As Tedros Adhanom Ghebreyesus of Ethiopia takes the helm of the World Health Organization this week as its eighth Director-General, and the first from sub-Saharan Africa, he has set an ambitious agenda for the organization. During his campaign for the office and since his election, Tedros has consistently emphasized WHO’s important role as a guardian of equity — in particular ensuring that the world’s poorest populations have access to health care as a fundamental human right.

As practitioners and advocates for improving the health of the world’s poorest and most vulnerable people, we applaud Tedros and WHO for their commitment to assuring universal health coverage for all. At the same time, we want to call his attention to a critical gap in the global agenda for health equity and universal health coverage — the crushing but largely overlooked burden of noncommunicable diseases and injuries on the world’s poorest people and communities.

As Tedros said in his acceptance speech, achieving universal health coverage will require that WHO and its member states “focus our resources on the most vulnerable people in the most fragile contexts.” Currently, approximately 90 percent of the world’s poorest people live in sub-Saharan Africa and South Asia. The vast majority of them are young and live in rural areas. Most are involved in agriculture.


Enormous progress has been made over the past several decades in reducing mortality among people living in poverty from major infectious diseases and from maternal and child deaths during and after childbirth. But much more remains to be done. As the focus of global development and health priorities shifts from the Millennium Development Goals to the Sustainable Development Goals and universal health coverage, the poorest populations still suffer a heavy burden of preventable deaths and suffering due to conditions such as heart disease, cancer, mental health conditions, and trauma.

Throughout the process of framing the Sustainable Development Goals, WHO has asserted that universal health coverage must encompass noncommunicable diseases and injuries for it to be considered sufficient or complete. This reflects the reality of mortality and morbidity around the world.

Noncommunicable diseases such as heart disease, diabetes, asthma, and the like account for 70 percent of deaths worldwide; more than three quarters of those deaths occur in developing countries. But for universal health coverage to effectively cover noncommunicable diseases, we must first understand the epidemiology and risk factors for these diseases in the world’s poorest populations.

To date, noncommunicable diseases in developing countries have largely been framed as an epidemic of the same “lifestyle diseases” that are the leading causes of death and disability in the United States and other high-income countries, linked largely to unhealthy diets, lack of exercise, smoking tobacco, and drinking too much alcohol.

There is no question that developing countries confront a growing burden of conditions like coronary artery disease and type 2 diabetes fueled by unplanned urbanization and aging populations. This is a very real and important global health challenge. Yet much evidence suggests that the most vulnerable populations in the most fragile contexts also suffer from a very different set of noncommunicable diseases and injuries that are not related to behavioral risk factors. This includes diseases such as type 1 and malnutrition-associated diabetes, rheumatic and congenital heart disease, cervical and pediatric cancers, sickle cell disease, severe mental illness, burns, and trauma, to name a few.

As members of The Lancet Commission on Reframing Non-communicable Diseases and Injuries for the Poorest Billion, we have reviewed and conducted research to assess the devastating intersection between poverty and noncommunicable diseases and injuries. Preliminary results of that research confirm that noncommunicable diseases and injuries that can’t be attributed to typical lifestyle risk factors are responsible for at least one million excess deaths per year among the poorest children and young adults, and for driving millions into extreme poverty.

One of us has argued elsewhere for WHO to narrow its mandate to focus on three key areas — health emergency preparedness and response; continued technical assistance in areas where WHO has a core advantage; and setting standards and providing new technical assistance for the health-related sustainable development goals, including universal health coverage.

Tedros emphasized similar priorities when he summarized the key messages he had taken to heart after a year-long campaign in which he visited almost all of WHO’s 194 member states. “A key message is that you do not want an a la carte menu of technical assistance,” he said in his acceptance speech. “You want a holistic offering from WHO which helps you improve the health of your citizens.”

To provide a holistic offering that addresses the noncommunicable diseases and injuries of people living in poverty as a key to achieving universal health coverage, the organization will need to streamline and strengthen its capacity to develop guidelines for a number of the conditions that specifically cause excess mortality among people living in poverty, which it currently lacks. In addition, it should adapt its technical assistance strategy to support country-based priority-setting processes and not assume that globally produced, one-size-fits-all templates will be sufficient.

If WHO does this, there is an enormous opportunity to fulfill Tedros’s “most solemn commitment” to “save and improve the lives of our most vulnerable brothers and sisters.”

Gene Bukhman, M.D., is a cardiologist at Brigham and Women’s Hospital, director of the Program in Global Noncommunicable Disease and Social Change at Harvard Medical School, and co-chair of The Lancet Commission on Reframing Non-communicable Diseases and Injuries for the Poorest Billion. Chelsea Clinton is vice chair of the Clinton Foundation, co-author of Governing Global Health: Who Runs the World and Why? and a member of The Lancet Commission.

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