One Health through alcohol prevention

2018 may be remembered as a watershed year in global health. Not one but two high-level meetings are to be held at the UN General Assembly in September to reinvigorate political commitment and spark renewed efforts by countries and the UN system to tackle tuberculosis and NCDs.

Tuberculosis is the leading cause of death worldwide from a single infectious agent and one of the top 10 global causes of death. In 2016, tuberculosis was responsible for an estimated 1.3 million deaths.

Globally, the tuberculosis mortality and incidence rates are decreasing annually at about 3% and 2%, respectively. However, by 2020, these annual rates of reduction need to be 4–5% and 10%, respectively, in order to reach the 2020 milestones of the End TB Strategy. Clearly, there is a need to galvanize the political commitment needed to step up the battle against tuberculosis and help the world and individual countries accelerate progress on the path to ending the epidemic,” wrote WHO Director General Dr Tedros in his recent report on the TB High-Level Meeting at the 71st World Health Assembly.

Premature mortality caused by NCDs and their four main risk factors is one of the biggest obstacles to sustainable development in the 21st century. Every year nearly 40 million people die due to NCDs Almost two-thirds of these deaths are linked to the four main risk factors. NCDs are the number cause of death and disability worldwide, accounting for 68% of global mortality.

Efforts to reach target 3.4 of the Sustainable Development Goals … require that the existing political commitments made at the United Nations General Assembly in 2011 and 2014 be implemented on a dramatically larger scale. Under a business-as-usual scenario (without significantly expanding efforts before 2020), the current rate of decline in the number of premature deaths from noncommunicable diseases is insufficient,” wrote WHO Director General Dr Tedros in his report on the NCDs High-Level Meeting at the 71st World Health Assembly.

It is clear that both high-level meetings are extremely timely. For NCDs it is the third iteration. After 2011 that generated the initial political commitments and momentum and 2014 that largely disappointed for lack of high-level attention, commitment and progress made, this year’s High-Level Meeting on NCDs is critical.

The challenge is now no longer to only gain political support, but one of investment and implementation. It is no longer one of arguing for greater priority, but one of being held accountable for delivery on agreed outputs and outcomes. It is no longer just proving the benefits of action, but one of reaping the benefits of evidence-based solutions,” wrote the WHO Independent High-Level Commission on NCDs in a think piece.

For tuberculosis, this is the first ever UNGA High-Level Meeting on the fight against TB. The infectious disease is responsible for more deaths than HIV and malaria, but has not received the same attention and political commitment. The first WHO Global Ministerial Conference on Ending TB, held in Moscow in November 2017, was a first step and the UNGA high-level meeting will be fundamental to drive efforts to end this top infectious killer.

To have global leaders pay attention to two global health topics during the UN General Assembly is a unique moment. Both high-level meetings are an excellent opportunity to discuss global health issues in the contexts of sustainable development and prosperity for all and to take important steps towards a One Health approach to human development and well-being. This One Health approach can be effectively facilitated through tackling cross-cutting risk factors for both diseases.

I hope that the parallel processes of preparation for and follow-up on both high-level meetings will lead to an elevation of global health as a central issue for world leaders in years to come.

Addressing alcohol as risk factor for TB and NCDs

Alcohol as a major risk factor for both tuberculosis and NCDs. Addressing alcohol as a cross-cutting risk factor provides a critical opportunity for synergies in responses and sustainable progress towards ending TB and NCDs.

While it is more commonly known that alcohol is a risk factor for NCDs, it is much less in focus in the response to the TB epidemic.

Evidence shows that alcohol use, alcohol dosage and alcohol-related problems are all associated with an increased risk of tuberculosis. In fact, alcohol use increases the risk of TB threefold, and is also a strong risk factor for poor TB treatment adherence. That simply means Alcohol is an important population level risk factor for TB, and it often is a common co-morbidity among TB patients.

Closing the treatment gap: addressing co-morbidities

In the spirit of the One Health approach, in IOGT International we work with a comprehensive approach across different diseases. For example, our first core strategy in tackling infectious and chronic diseases is to address co-morbidities by providing brief interventions and treatment.

For example, our members in Russia or in Uganda provide various forms of treatment and rehabilitation services to people struggling with alcohol use disorders. In Kampala, approximately every tenth patient our member organization treats is also infected with tuberculosis. Therefore, it is part of our community work to identify these co-morbidities and refer patients to relevant care providers. At the same time, we strive to link up with TB care facilities and help screening their patients for alcohol use disorders.

In short our first core strategy is about contributing to close the treatment gap and helping to provide comprehensive care packages by identifying co-morbidities and offering appropriate services.

Closing the awareness gap

Even our second core strategy is about closing a gap: the awareness gap. Our analysis shows that alcohol is an obstacle to sustainable development. It adversely affects 13 of 17 SDGs. Therefore, our second core strategy is to raise awareness about how and to what extent alcohol adversely affects specific Sustainable Development Goals. In that spirit, we work to empower cities, companies, civil society as well as decision-makers to understand and address how alcohol impacts their core mission.

We want to help create societies where everyone who is affected by alcohol harm is able to understand the burden and has the capacity and tools to craft and implement meaningful solutions in their context. In this way, we contribute to preventing and reducing TB and NCDs, but also violence against women or mental ill-health, to name a few.

Closing the funding gap

Our third core strategy addresses a third gap, the funding gap. Awareness is important. Screening, identification, brief interventions and comprehensive treatment and care is crucial. But there is no question that everything starts with the 3 best buys in alcohol policy – these are population-based measures that are scientifically proven, cost-effective and high-impact – especially when they are implemented in an integrated manner.

  • Banning alcohol advertising and sponsorships
  • Restricting alcohol availability, and
  • Increasing the price of alcohol, for example through taxation.

Alcohol’s harmful effects on NCDs, TB and other health and development problems cannot only be reduced but it can be prevented. Therefore, I think the alcohol policy best buys are best understood as prevention tools. Especially alcohol taxation is a powerful triple win measure. It helps to reduce alcohol harm, promotes health and it helps raise much needed domestic resources.

But make no mistake: The 3 Best Buys are not a silver bullet. They are powerful tools that are currently dramatically underutilized – and our work is about partnering with decision-makers on all levels to build capacity and provide concrete technical support for the implementation of well-crafted, evidence-based alcohol policies.

Making links and unlocking synergies

What our three core strategies show is that there are very real and evidence-based ways to link the conversations, communities and commitments for ending TB as well as NCDs. The essence of our core strategies is to close gaps through tackling alcohol harm systematically: the treatment gap; the awareness gap; and the funding gap. Both TB and NCDs have these gaps in common. And they have alcohol as a major risk factor in common – a risk factor that must be tackled to achieve the progress we all.

I’ve seen first hand and heard it from our members in communities around the world that working to address alcohol as risk factor helps to make links between TB and NCDs and helps to unlock synergies between care and treatment and prevention and (mental health) promotion.

With this understanding and experience, I hope that the parallel processes of preparation for and follow-up on both high-level meetings will elevate health and make it the priority it should be on the agenda of world leaders for years to come. Embracing 2018 as a potential watershed year and using the opportunity wisely matters a great deal for WHO and its (not so) new leadership; it matters for our collective efforts to achieve the Sustainable Development Goals and it matters for all the people, families and communities affected by alcohol, TB and NCDs.

Also published on Medium.

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