Love cities? This Valentine’s week, in my first-ever video blog, I explain why the World Heart Federation is calling for urgent action to protect children’s heart health in the world’s most populous cities. Click on the picture below to watch the video:
Johanna Ralston, CEO, World Heart Federation
When Member States met during September’s United Nations High Level Summit on Non-Comunicable Diseases (NCDs), one of the clear outcomes in the Political Declaration was their agreement to develop global targets to reduce the burden of NCDs by the end of 2012. Last week, the World Health Organization (WHO) Executive Board met here in Geneva and the commitments to targets and timeframes appeared in danger, as calls for more time and more targets threatened to undermine what Member States have committed to in the Political Declaration and further delay implementation with new deadlines for the creation of targets proposed for 2013 instead of 2012. Fortunately, leadership by key actors involved in negotiations and powerful statements by the NCD Alliance, other civil society organizations, and certain member countries, ensured that we will see those targets “completed” this year. Notably, Member States have agreed to “submit a substantive progress report on the development of a framework, including a set of indicators and targets, to the sixty-fifth World Health Assembly (May 2012) for consideration,” with “completion” committed to by the end of the year.
As the saying goes, “what gets measured gets done” and the discussions at the WHO Executive Board have brought us one step closer to being able to monitor and track progress made on NCDs. However, it is clear that controversy concerning how many and which targets will be presented at the World Health Assembly has not yet been resolved. The complexities include lack of a complete picture of available data and underlying surveillance systems that would be key in setting baseline measures against which to achieve targets. As well as limited and uncertain resources at a time when the major global organizations, including WHO and the Global Fund, are undergoing severe resource constraints and reform processes; and only an emerging recognition that achieving the commitments laid out in the Political Declaration and being debated in the targets process will require a different framework for policy, funding and partnership, what has been called a “new policy narrative.”
For the NCD and health community, this is the time to come together and build solidarity around which targets are needed to successfully reduce the global burden of cardiovascular disease and other NCDs. It is imperative that work on the global monitoring framework for NCDs is completed by the end of 2012, as agreed upon by member states at the WHO Executive Board last week. However, all of us will need to work together to ensure that the timeline laid out by last week’s resolution on NCDs is actually fulfilled.
The most critical goal included within the WHO proposed set of targets is one that has been championed by the NCD Alliance, that is to decrease the overall mortality from NCDs by 25% by the year 2025, using the mortality in 2010 as a baseline (and recognizing possible advantages in extending that goal to 2030 to align with development goals). In order to do this, all the major risk factors of NCDs must be addressed – including physical inactivity, which is noticeably missing from the current set of targets proposed by the WHO. There has been a push from many within the NGO community for the creation of a target for the reduction of physical inactivity, however some Member States feel that it does not sufficiently satisfy the WHO requirements regarding what should constitute a global target. A sticking point is an accurate indicator for physical activity. In other words, what measurement could governments use that would allow them to effectively monitor and track changes in physical activity levels? PAHO and GAPA have suggested legitimate and defensible indicators, as have many of our colleagues who submitted comments to the NCD Alliance prior to the Executive Board meeting, including the segmentation of targets based on age. The need for consistent data presents a legitimate challenge, yet to allow the targets process to continue without addressing physical activity seems a far greater problem.
Please weigh in: should physical activity be addressed in the global targets?
For more information
See the list of proposed WHO targets listed as table 2 in the following discussion paper
Download the statement made by the NCD Alliance at the Executive Board
Download the complete text of the WHO Executive Board Resolution on NCDs
Access full documentation from the 130th Session of the WHO Executive Board
Johanna Ralston, CEO, World Heart Federation
While we have been talking a great deal in recent months about the intersection of health and foreign policy, through the planning for the UN meeting and the ways in which our members have been targeting not just ministers of health but also ministers of foreign affairs in their advocacy, the discussions around cardiovascular disease and non-communicable diseases (NCDs) and trade have been less apparent. Yet trade can play a critical role and the World Heart Federation, through its role with the NCD Alliance, recently had the opportunity to participate in a high level meeting on the topic, at the World Trade Organization in Geneva.
Panel at the 5th High Level Symposium on Global Health Diplomacy
The 5th High Level Symposium on Global Health Diplomacy, organized by the Graduate Institute of Geneva at the WTO, assembled leaders from some of the top health and trade agencies in the world including the Directors General of the WTO, WHO and WIPO and the Executive Directors of UNAIDS, the Global Fund, and GAVI, among others. While the different panels highlighted some of the challenges faced at the intersection of health, trade and foreign policy, I was invited to bring to the conversations the issues related to NCDs and trade, with a particular focus on prevention and NCDs, including tobacco control, food policy and essential medicines. At the end of the session, our panel was summed up perfectly– it is time that the dichotomy between infectious and non-communicable diseases is toppled. For both, the prevention agenda is the trade agenda.
Sustainability will be at the core of our ability to deal long term with NCDs and to continue to address communicable diseases. Reports estimate that 9 billion people will populate the world in 2050. We have now surpassed 7 billion and that 7th billion person is more likely to die of an NCD than anything else. When we look at some of the key factors affecting health, one of the most significant is our built environment –or lack thereof – which is inherently political. Globalization and urbanization have brought with them many opportunities. Yet they have also facilitated access to many of the risk factors leading to NCDs – increased exposure to tobacco, unhealthy foods and alcohol – while also limiting access to many things needed for our health and wellbeing – safe spaces for activity, quality and affordable medicines, and access to health care workers. All in some way or another related to trade and foreign policy.
One point that was referenced only briefly is that of food – an area in which all of the above mentioned organizations will have a significant role to play. As we have seen the shift from rural to urban, we have witnessed more individuals surviving infectious disease related illness and more people with access to food. And yet, there are some startling facts out there. There are nearly 925 million people living with hunger and over 1.5 billion people obese. The conventional thinking is that these are separate issues, with undernutrition characteristic of low income countries and overnutrition a problem of high income countries . Yet, those most at most at risk are the poorest populations WITHIN each country, regardless of the country’s GDP, and often affecting the same populations – ie, undernutrition is increasingly recognized as another risk factor for overnutrition because of conditions associated with the former that are still poorly understood. Both over and under nutrition are battles being lost by the most vulnerable socio-economic groups in the world.
Within some of the most prosperous countries, such as the US, well over 10 percent of the population lives in poverty. As we make strides in addressing hunger, we seem to be creating a crisis of nutrition – studies show that prenatal exposure to under- nutrition leads to both impaired glucose levels and coronary heart disease later in life. While for those populations facing over-nutrition, the same is true. Conditions associated with increased urbanization also contribute to nutritional challenges – there may be more calories available in urban settings, but these are often not proportionally nutritious. Access to health – whether it be safe and affordable drugs, nutritious food, or health care workers – is the most glaringly difficult for the poorest populations. So what is the connection? Are there connections?
I say yes. Good health – sustainable health – depends on nutrition, which depends on agriculture; and agriculture is changing significantly. As climate change on the one hand and increasingly large agribusiness on the other change the food supply chain, the link between food source and consumer is more tenuous . Between farm and fork, there are many players – particularly if you live in urban centers. As we focus on producing as much food as possible, we are missing the crucial element of nutrition – which is getting lost in production lines. Is providing food – even if substandard – enough?
When I think about the players that came together to discuss trade, I can’t help but feel that the same issues will be raised in a decade, but not about medicines – about food. Lack of access, lack of partnerships, a dire need for leadership and sustainable solutions are needed now to ensure that we prevent future dilemmas in addressing health disparities. What are measures we can take now to ensure that addressing food insecurity and a sustainable food supply also take into account the quality of nutrients and taste, so that successes in reducing undernutrition are not eclipsed by challenges of overnutrition later on?
Johanna Ralston, CEO, World Heart Federation
With the introduction on 1 October of a “fat tax” in Denmark – a surcharge on foods with more than 2.3 per cent saturated fats – we asked our member organizations to give their reaction to this new law.
I am delighted to introduce this first guest blog, written jointly by the Danish Society of Cardiology and the Danish Heart Foundation, and congratulate their efforts on a national level to reduce the burden of cardiovascular disease (CVD).
Dr Inge Vestbo, MD, Managing Director, Danish Heart Foundation
Dr Christian Hassager, President, Danish Society of Cardiology
Obesity and overweight continues to increase in Western Europe as a result of unhealthy diets and low physical activity. Healthy diets are characterized by a high intake of fruit, vegetables, legumes, fibre, whole grains, nuts, vegetable oils, and fish; whereas unhealthy diets are characterized by a high intake of salt, red meat, processed meat, saturated fat, trans fat, refined grains, and refined sugars. Unhealthy diets greatly increase CVD incidence and premature mortality. Key problems are high salt intake, sugar sweetened beverages and saturated fat, each accounting for 10–15% of calories consumed by youth. Campaigns and public education programmes have not yet succeeded in changing these unhealthy lifestyles.
Changing dietary patterns from unhealthy to healthy will substantially lower cardiovascular risk. The causal linkage between consumption of saturated fat and risk of CVD is beyond discussion; the question is how to reduce consumption of saturated fat in the general population as well as those at increased cardiovascular risk. For those at increased cardiovascular risk, individual measures are needed but it is well recognized that small changes in risk of disease in the whole population can lead to greater reductions in disease burden than large shifts among those persons already at risk. Taxation is a widely used measure to regulate population behaviour: its efficiency has been shown in tobacco consumption, where fiscal measures are the most efficient in preventing smoking uptake in adolescents and reduce smoking in the less affluent. Although tobacco does not compare directly to food, taxation of unhealthy food content has the potential to modify food habits in a healthier direction. For this reason The Danish Society of Cardiology and the Danish Heart Foundation welcome this new tax on saturated fat.
Taxation of unhealthy food has been estimated to have the potential to reduce CVD deaths in the UK by 2%. Taxation of salty foods and sugar, including soda taxes, are already implemented in some countries. No substantial knowledge of the effect on consumption or obesity exists but tax is often lowered due to lobbying from industries. It is well recognized that the current “default” dietary patterns are pushed in the unhealthy direction by a number of conditions, including the ease of access to junk food, healthy choices being more expensive, marketing by the food industry and EU agricultural policy. Opponents to taxation of unhealthy food allege that taxation and other legislation will lead to a “Nanny state” that hinders the free choice of people but the fact is that free choice remains for the individual. Taxation of saturated fat just helps make the healthier choice the easier choice.
Inequality in health is increasing. Cardiovascular risk factors tend to accumulate in the disadvantaged. Whereas fiscal measures are more efficient in changing behaviour among the disadvantaged, the burden of the tax is also unequal. This is a paradox that has not been sufficiently addressed.
For now the Danish tax is mainly of symbolic value – it will result in relatively small increases in the price of meat, more in fatty meat, less in lean. It may have some impact on consumption of dairy products high in fat content, which the Danes still use a lot of when preparing traditional food. It will not hit whole milk, as only products with more than 2.3 per cent fat will be taxed. However, Danes use only 5 per cent of their income on food so the effect on their dietary habits and thus consumption of saturated fat is likely to be minimal. For taxation to have a real impact and translate into measurably reduced CVD and saved lives, the taxation has to be heavier. However, a principle has been established with wide political support and this is an important step in the right direction
Dr Inge Vestbo MD & Dr Christian Hassager
Managing Director, Danish Heart Foundation President, Danish Society of Cardiology
Should the global CVD community push for taxation of unhealthy food as a key source of revenue for addressing NCDs within health systems?
OR
Should we emphasize taxes on unhealthy foods as a means of changing personal behaviour around dietary choices, alongside our continued efforts to prioritize increased budget allocations for NCD prevention and control?
Johanna Ralston, CEO, World Heart Federation
When World Heart Federation board member Dr. Kingsley Akinroye spoke from the floor of the United Nations on September 20th, as part of a line-up of speakers that included heads of state, ministers of health and royalty, it was a moment in history for the World Heart Federation and the global CVD movement. Referencing his role as head of the African Heart Network, Kingsley noted that not only was cardiovascular disease an urgent health issue in Africa, but that there was much that could be done already to address it and other NCDs, from expanding smokefree laws that have successfully been implemented in South Africa, Mauritius and Nigeria, to increasing access to essential meds and addressing rheumatic heart disease (RHD). By countering scepticism about disease burden with the facts, and concerns about cost with solutions, Kingsley’s words achieved two of the goals of the meeting: raising awareness of NCDs as an urgent health issue, and demonstrating that many solutions are within our grasp, and are far more affordable than continuing along our current path of minimal primary or secondary prevention in most countries, and treatment largely limited to late stage, high cost intervention for those who can afford it.
In general, we are very pleased with the meeting, and proud that our members were so instrumental in ensuring its success, as marked by the attendance of 34 heads of state and a schedule that was extended by several hours to accommodate the numbers of Member States who wanted to make statements. We were delighted that both Russia and Australia made strong financial commitments to addressing NCDs in low and middle income countries, and that the reports by World Economic Forum and World Health Organisation on the costs of inaction and affordability of prevention and basic treatment were so well received. But now, the real work begins. The meeting was, as Sir George Alleyne – channelling Winston Churchill – describes it, “the end of the beginning.”
Next steps include, over the coming months, ensuring that targets and accountability initiatives that were not part of the final declaration are fully developed and agreed to. We will be communicating with our members and through the NCD Alliance on steps you can take. It is also critical that we start to advocate for inclusion of NCDs including CVD in the successors to the Millennium Development Goals; the current MDG’s expire in 2015 and plans for the next global set of development goals will start to be developed soon. As New Zealands’s Sir Peter Gluckman, Chief Science Advisor to the Prime Minister, noted, the “NCD and MDG agendas are inextricably intertwined.” Again, we will keep our members updated about the process and ways to get involved. In the meantime, we also need to continue to build evidence for what works at the country level, and to continue to support NCD plans, as well as national and regional alliances.
I’ll close with a quote from David Bloom of the Harvard School of Public Health, author of the World Economic Forum report on the cost of “business as usual” in addressing NCDs, who noted that NCDs are becoming “ a major impediment to economic growth and the mitigation of poverty. That finding, we hope, will be more than enough evidence for economic leaders to accord NCD prevention, screening and treatment much higher priority than they currently do.”
Question: What do you see as the most important next step for the CVD community following the Summit?
Johanna Ralston, CEO, World Heart Federation
Next week, global leaders will meet at the United Nations to take on some of the world’s greatest killers: cancer, diabetes, chronic respiratory disease, heart disease, and stroke. The UN High-Level Meeting on the Prevention and Control of Non-Communicable Diseases on September 19–20, has the potential to finally address these leading causes of death and disability, which until now have been largely ignored.
Yet when we wake up on Sept. 21, how much will have changed? Will there be a new Global Fund to fight noncommunicable diseases (NCDs)? Will key stakeholders, such as those involved in urban planning, agriculture, trade and current global health priorities, be as engaged as they need to be to realize ambitious goals of measurably reducing disease? Will the public even know what an NCD is — even though more than 60 percent of deaths worldwide are from noncommunicable diseases, the majority from cardiovascular disease?
The answer to all of these questions is: not yet. September 21 will be the start of the real work. The problems of NCDs are complex, but we have many opportunities to alter the course of what has become a global crisis.
There are a number of concrete steps that countries and health systems can take immediately to strengthen their commitment to reducing noncommunicable diseases. They can ratify and implement the Framework Convention on Tobacco Control, the world’s first public health treaty. Many countries already have the makings of NCD plans in existing cancer plans, tobacco control programs and strategies for diabetes and cardiovascular disease. They may also have specific programs to address respiratory disease, mental health and other issues. Health systems can make essential drugs, such as aspirin and statins, available immediately and at a low cost because many are off patent.
As leading researchers and public health officials said in an April 2011 Lancet article, “An effective response to NCDs requires government leadership and coordination of all relevant sectors and stakeholders, reinforced through international cooperation.”
In the end, we will need to make compromises and learn to share resources with people and institutions with whom we are not accustomed to collaborating. We will need to delay gratification and risk unpopularity in some of our choices. And we will likely not see the payoff in our lifetimes. But with time, effort and investment, we will see results.
Johanna Ralston, CEO, World Heart Federation
We were delighted to see well known chef Jamie Oliver call on the UN to address world obesity rates at the Summit later this month. In a speech made earlier this week in Zurich and covered by several news outlets Oliver noted that in low- and middle-income countries, “Diet-related diseases are two of the top five causes of premature death for people under 60 years old. They look set to create an absolute catastrophe over the next 30 to 40 years if nothing changes.”
His words were backed up by Sir David King in The Lancet, who noted that the epidemic is not about laziness or overeating but rather about the types of physical activity and food options that are available. Individuals’ options for what to eat are increasingly restricted to calorie-packed, low-cost “convenience” foods that are readily available, cooked in high fat oils and with lots of added sugar and salt for quick flavor and long-term preservation. As King notes, “Our biology has stepped out of kilter with society.”
We applaud Jamie Oliver for taking on this issue, and for drawing attention to the Summit. In particular, we know Oliver carries a message that resonates with a younger audience, empowering people to fight for the ability to choose what they eat and how they eat it – essential elements in the fight against cardiovascular diseases. At the World Heart Federation, we believe that, while options around early detection and treatment are of critical importance, the issue of having choices that may prevent heart disease and stroke in the first place are of utmost urgency. People deserve the right to have food options, access to safe places to move, and environments free from smoke and from marketing of tobacco and alcohol.
We believe that these types of choices become more limited in the crowded urban environments where most people live and work, especially in low and middle income countries. Limitations around food extend beyond fast food to what is often known as street food – cheap foods sold in markets and on sidewalks, that contain high fat oils, salts, and other ingredients that place heart health at risk. We were pleased to see the newest version of the UN outcomes document finally contain language on the need to restrict trans- and saturated-fats and sugars. We were sorry, however, that our target to reduce global salt consumption to less than 5 mg per day was not included.
The World Heart Federation agrees with Jamie Oliver’s view that in order to see change we must create an educated consumer. At the centre of all this should be children; research tells us that childhood nutrition strongly influences the chances of developing cardiovascular and non-communicbale diseases later in life. Furthermore, children are often the most vulnerable to marketing schemes. If fast food adverts and processed food packaging are targeted at children, health promotion materials must be targeted at children as well. The World Heart Federation has teamed up with the Union of European Football Associations (UEFA) to try to do exactly this through our Eat for Goals campaign, featuring well-know European football stars offering their favourite heart healthy recipes.
The global obesity epidemic, and cardiovascular disease which will often be the result, needs to be addressed and committed to by governments in the outcomes document at the Summit and beyond. We urge others with a voice and a platform to join Jamie Oliver in his fight to bring a Food Revolution to the UN. The world needs to be made aware of the Summit and the critical role it can play in fighting this new epidemic. With less than two weeks until the Summit, there is not much time and lots to be done. We thank Jamie Oliver for taking a lead on this and urge you to join his campaign by signing the Food Revolution petition today.
“Do you think there is need for a Food Revolution?”
Johanna Ralston, CEO, World Heart Federation
Many of our members have been reaching out to ask if we could please clear up all the confusion around salt. At the World Heart Federation we have been setting targets for years around reducing sodium intake, and recently consulted with our 192 member organizations to finalize cardiovascular disease (CVD) specific goals, including the reduction of salt intake to less than 5 grams per day by 2025. This target was a top priority for our members and was included in the NCD Alliance outcomes document to lobby for political support at the upcoming UN High-Level Meeting on Non-Communicable Diseases (NCDs). This goal is in line with both the World Health Organization’s recommendations and those made by The Lancet.
A recent Cochrane review has raised questions about whether sodium reduction really affects CVD mortality, based on a meta-analysis of seven randomized, controlled trials. Three of these trials were in people with normal blood pressure, two were in people with high blood pressure, one was in a mixed population of normal blood pressure and high blood pressure, and one was in people with heart failure. The purpose of the meta-analysis was to assess whether advice to reduce salt intake changed one’s risk of death or CVD. The review found that people with salt reduction had an overall decrease in blood pressure. However, mortality rates and cardiovascular events were not significantly lowered among either people with normal blood pressure or those with high blood pressure and patients with heart failure actually showed an increased risk for all-cause mortality after salt restriction. There have been interesting commentaries on this study at ProCor and “theheart.org” which raise important questions about the evidence presented in the study and salt reduction strategies. Addressing sample size, confidence intervals in the studies noted were wide enough to indicate that the studies may have lacked enough subjects to produce clear results. Finally, as Dr Nancy R. Cook from Harvard Medical School suggests, the studies included were not designed to test the effects of sodium reduction interventions on CVD events and mortality: an overall decrease in blood pressure is not the same as a reduction in cardiovascular events. It is much easier and more common to see reduction in blood pressure as a result of salt reduction approaches, than a reduction in myocardial infarctions (heart attacks) or death. And yet the study also looked at salt reduction in people with heart failure and came to a surprising conclusion: there was higher mortality among this group than among those without heart failure. Again, commentaries have noted that study size may have impacted this finding, and that a well designed longitudinal study on the topic using diverse populations is needed.
So, what do we make of all of this, other than that the evidence suggesting health benefits to sodium reduction far outweigh the downsides? Authors of a recent commentary in The Lancet have refuted the findings of the Cochrane Review. After reanalyzing the studies, they have concluded that a small reduction in daily salt intake (2g) does in fact result in a significant reduction in cardiovascular events (a 20% reduction), therefore supporting the recent Best Buy published by WHO. Despite the discrepencies, the Cochrane Review does raise two important points that we need to address by harnessing the advantages of the current political environment around NCDs: the need for more and better research; and the need to have a multi-sectoral approach to salt reduction. We need research that takes into account different populations and ethnicities, the extraordinary diversity of diets, and a host of other factors for which studies are either non-existent or too brief or small to give us informative and accurate data. More broadly, as the lead author suggests, salt reduction is not simply about telling people to reduce the amount of table salt they use. Other measures, including multi-sectoral partnerships that work with governments, NGOs and the private sector are key to effectively reducing salt intake, as the majority of salt consumed is “hidden” in processed and packaged foods. The upcoming UN High-Level Meeting on NCDs provides us the opportunity to address both of these issues: we need to develop and advocate for a strong research agenda for the years to come, and we need to develop and implement a comprehensive strategy to decrease the intake of “hidden” salt – which requires partnerships with both governments and the private sector. Thus, while we can do much with what we know now – and we do know enough to support salt reduction strategies, awareness and research is still needed to truly address salt consumption.
Question: What is the role of the private sector in addressing salt?
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Johanna Ralston, CEO, World Heart Federation
This week, our members stood up and stood out at the United Nations! Leaders from the Heart and Stroke Foundation South Africa, African Heart Network, Pan-African Society of Cardiology, Pakistan’s Heartfile, Danish Heart Foundation, Kenya Heart Foundation, Asia Pacific Heart Network, American College of Cardiology, the UK National Heart Forum, Emirates Cardiac Society, the American Heart Association and Heart and Stroke Foundation of Barbados, gathered in New York to meet with their mission ambassadors to the United Nations and to attend the civil society hearing to the UN. At the UN missions and in the general assembly, World Heart Federation members called for leadership by Member States and a strong outcomes document. Widely discussed was the growing burden of cardiovascular disease (CVD), the leading cause of death worldwide that claimed over 17.1 million lives in 2004, over four fifths of these in low- and middle-income countries.
Earlier in the week, our members and leaders also presented at the Global Health Council, where Bongani Mayosi a World Heart Federation rheumatic heart disease (RHD) expert, Sania Nishtar of Heartfile, Ileana Pina of American Heart Association, Srinath Reddy from Public Health Foundation of India and our President Sidney C. Smith Jr also presented on the global CVD burden and the work they are doing to fight RHD and other forms of CVD across the globe.
One remark that came up again and again, from UN mission staff, global health professionals and others, was “I had no idea – why don’t more people know about this?” Again and again our members shared the statistics, and stories of the people behind the death and disability. Again and again, the people we spoke to said they never knew CVD was so widespread across economic and social lines, and asked why this was not more widely known. In the coming weeks we will be hearing even more staggering numbers on the cost of cardiovascular disease globally. These numbers will reflect not just cost of treatment and lost productivity, but details on how treatment for CVD in low- and middle-income countries devastates families and forces people into poverty. And yet, the full extent of this disease is still unknown.
My question is, how do we get the message out about the consequences of CVD? How do we show that this is a disease that ravages at the individual and societal level? The time to be polite about this may have passed: how do we tell the world this is a crisis that belongs to all of us, and that now is the time to make noise?
Johanna Ralston, CEO, World Heart Federation
In New York, our members and friends are meeting with UN missions to ensure countries are briefed and on board, building on the technical materials they are receiving from WHO and their own country health and development colleagues. If you are based in the US, reach out and find out how you can support these efforts. As WHO Director General Margaret Chan noted yesterday in a special session NCDs, while this is a member-state driven process, the role of civil society organizations – like our members and the NCD Alliance – are critical and, in her words, “New York is extremely important to get the political support and attention of Heads of State”. This means that while WHO’s leadership has been vital in framing the NCD issue and harnessing global expertise to address it, the 125 days that remain between now and the Summit must focus on ensuring a strong response by UN missions and attendance by the leaders of Member States.
What are you doing to drive attendance from your Heads of State or Government? Or do you already have confirmation that they will attend the Summit, if so please share this excellent news with us here.
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