Volume 2, Oct-Dec 2019
Research Article:
Author’s Affiliation:
1- NCD Child Governing Council
2- Indonesian Pediatric Society
3- Department of Child Health, Faculty of Medicine, Universitas Indonesia
Received on: 04-Aug-2019
Accepted for Publication: 31-Dec-2019
Article No: 1983mE4193420
PDF - Full Text
We were all once young and it is our childhood and our adolescence thatlargely shapes the life we live, our health,and the opportunities we have. As an interconnected, global society, we must remember that today’s youth, are tomorrow’s leaders. Investing in a young person as a leader, educator, and owner of the Non-Communicable Disease (NCD) pandemic will ensure that NCDs do not continue to hinder the 2030 Sustainable Development Agenda.
Greta Thunberg, the 16-year-old, who has inspired an international youth movement around climate change, recognized that she couldn’t vote on issues that would impact on her future and that of future generations, so she rallied young people to tackle climate change by making their voices heard.  On 15 March 2019, young people did just that – they took to the streets all around the world to seek global attention, and fight for action, on climate change.  
This recent action by adolescents around the globeis a reminder of why the international community needs to listen to the voices of adolescents on issues that shape their lives and affect their future. This article will show case why the voices of adolescents need to be heard to tackle the NCD epidemic the world is facing. It will, inter alia: (i) introduce the NCD problem; (ii) provide the context for why adolescents matters and how they fit into consideration of the social determinants of health; and (iii) finally,address why the international community should be taking a human rights approach to the engagement of adolescents in the NCD discourse to progress this health agenda.
What is the NCD problem?
NCDs are non-infectious diseases that cannot be spread person-to-person, such as cancer, cardiovascular disease, diabetes, asthma, and mental disorders.1In 2012, NCDs were responsible for 38 million deaths – 40% of which were premature deaths.2 Traditionally seen as only an issue in adulthood, NCDs can occur or begin in childhood. Furthermore, 70% of preventable adult deaths from NCDs are linked to risk factors starting in adolescence.3 Therefore, children and adolescents represent the ‘age of opportunity’ for both prevention and management of NCDs.4
The international community recognised the severity and complexity of the NCD problem first at the UN High-level meeting on NCDs in 2011 and then momentum followed and NCDs were specifically included in the Sustainable Development Goals (SDGs). The SDGs set out a new framework of 17 goalsand are a universal call to action to end poverty, protect the planet and ensure that all people enjoy peace and prosperity.“These 17 Goals build on the successes of the Millennium Development Goals, while including new areas such as climate change, economic inequality, innovation, sustainable consumption, peace and justice, among other priorities. The goals are interconnected – often the key to success on one will involve tackling issues more commonly associated with another”.5
Goal 3 ensures that the global community “[e]nsure healthy lives and promote well-being for all at all ages,” and this was specifically included to build on the unfinished agenda of the Millennium Development Goals (MDGs). Four targets within Goal 3 are directly related to NCDs:
    • By 2030, reduce by one third premature mortality from non-communicable diseases through prevention and treatment and promote mental health and well-being;
    • Strengthen the prevention and treatment of substance abuse, including narcotic drug abuse and harmful use of alcohol;
    • By 2020, halve the number of global deaths and injuries from road traffic accidents; and
Achieve universal health coverage, including financial risk protection, access to quality essential health-care services and access to safe, effective, quality and affordable essential medicines and vaccines for all.
The Global Community, recognising the need for clarity on the implementation of these goals, provided four additional targets, which can be seen to be directly applicable to adolescent health rights and need:
    • Strengthen the implementation of the World Health Organization Framework Convention on Tobacco Control in all countries, as appropriate;
    • Support the research and development of vaccines and medicines for the communicable and non-communicable diseases that primarily affect developing countries, provide access to affordable essential medicines and vaccines;
    • Substantially increase health financing and the recruitment, development, training and retention of the health workforce in developing countries, especially in least developed countries and small island developing States; and
    • Strengthen the capacity of all countries, in particular developing countries, for early warning, risk reduction and management of national and global health risk.
With these targets in mind, countries and national stakeholders are encouraged tosupport a life-course approach to health, which promotes good health and healthy behaviors, prevention, early detection and diagnosis, management, rehabilitation, treatment and care. Data related to NCDs should be reported, disaggregated by age and sex, to ensure the specific needs of children and adolescents are considered. Civil Society should advocate for children and youth around NCDs and ensure that countries under their mandate are putting NCDs as a health priority and are aware of the new Global Goals.6
Why do adolescents matter?
The World Health Organisation defines “adolescents” as persons aged between the ages of 10-19 years.7 This temporal period of “adolescents” overlaps with the definition of “child” as provided for in the UN Convention on the Rights of the Child.8Accordingly, this overlap sees adolescents benefit from many of the rights afforded to children, by nature of their vulnerable status and special classification. It is these near universal rights provided for in the United Nations Convention on the Rights of the Child (UNCROC) that will be considered, along with other international legal instruments and global policy and strategy documents, in looking at NCDs from an adolescent perspective. This will also provide context as to why adolescents are entitled to special attention by virtue of their age and situation.
Adolescence provides a key window of opportunity to ensure the 2030 Agenda for Sustainable Development (SDGs) and its Global Strategy for Women’s Children’s and Adolescents’ Health are attained. Adolescents is a unique period as it sees, inter alia: (i) rapid physical, cognitive, social, emotional and sexual development; (ii) a widening gap between biological maturity and social transition to adulthood; and (iii) is a moment in an individual’s life where these is a need for balance between protection and autonomy.9Adolescent health is fundamental and central to the attainment of the SDGs and the related targets – “[a]dolescents can be a key driving force in building a future of dignity for all” (Ban ki-Moon, UN Secretary-General).
Given the unique period of an adolescence, listening to these young people is crucial and participation has been seen to, inter alia: (i) contribute to individual personal development; (ii) lead to better decision-making and outcomes; (iii) serve to protect children; (iv) contribute to preparation for civil society development, tolerance and respect for others; and (v) strengthen accountability.10 The WHO has recognized that investment in adolescents and their health, not only enables the young people to become healthy adults who can contribute positively to society, but such  “investment brings a triple dividend: benefits for adolescents now, for their future adult lives and for their children”.11
As will be discussed in more detail later in this paper, investing in adolescence does not only mean the provision of services that address the social determinants of health. Equally important, adolescents need to be empowered to participate in policy and decision making to ensure that their issues are best understood and the solutions provided actually address their needs.
What impact does NCDs have on adolescent health and the attainment of the SDGs?
The health of adolescents is affected by many factors at individual, peer, family, school, community, and national levels. Understanding individual risk factors and social contexts that affect health, commonly referred to as social determinants of health,will help the international community to focus onwhat measures and interventions will shape overall adolescents’ wellbeing. Moreover, adolescence is an important phase of transitions from dependency into self-care and responsibility. Improving adolescent health requires improving their daily lives with safe and supportive families, peers, schools, together with their communities and encouraging their own involvement and active participation throughout the process.12
The World Health Organization (WHO) defines social determinants of health as“the conditions in which people are born, grow, live, work, and age”; these conditions or circumstances are shaped by families and communities and by the distribution of money, power, and resources at worldwide, national, and local levels, and affected by policy choices at each of these levels.Two main levels at which the social determinants of health work are at the structural and proximal determinants levels. Structural determinants are defined as ways in which a society is set up based on social, economic, and political contexts. Proximal determinants are the circumstances of daily life that more directly influence a person’s attitudes and behaviors.6
Structural determinants are part of a complex web of family, peer, community, social, and cultural influences that affect present and future health and wellbeing. On the other hand, social connections as proximal determinants can either protect or increase exposure to risk behaviours. Violence, substance misuse, and sexual risk are dangers during adolescent health, whereas connectedness and social support are strong protective factors for adolescent health.6
In terms of the social determinants of health, there are disparities between and within regions around the world. Differences of population sector lead to different ability to gain access to healthcare services. In the Asia Pacific Region, particularly Indonesia, several determinants are involved, such as: i)family, school, peers, and community; ii) political events; iii) national priorities; iv) economic forces; v) norms and values; vi) natural events; and vii) historical events.6Technology and access to internet significantly increased during the past decade; becoming both a challenge and opportunity in shaping future of adolescents, including their health and wellbeing. Countries in the Asia Pacific Region become some of those who havethe highest number of internet users in 2018, such as 143 million users in Indonesia.13
There are different terms and languages about youth/adolescents among countries across Asia Pacific Region. Basic demographic data showed that there were 27.6millionyoung people/adolescents In Indonesia, 5.5 million young people aged 10-17 years in Malaysia, and 8.1 million teenagers aged 13-19 years in Japan.14
The WHO estimates that more than 1.2 million adolescents die every year, from largely preventable causes, mostly road traffic injuries, lower respiratory infections,and suicide. Specifically, the WHO hasemphasized that adolescents who suffered from mental health disorders, substance use, or poor nutrition could not obtain prevention and care services; either because they did not exist or because adolescents did not have access to the information.15
There is variable data regarding NCDs in children and adolescents in the South East Asia region. There are currently 1038 cases of type 1 diabetes in Indonesia (based on 2015 statistics); whereas its prevalence is 0.03/100,000 in Malaysia and 1.5-2/100,000 in Japan. Studies about cancer in children and adolescents showed 16.7 cases per million (solid tumor) and 26.7 per million (hematologic tumor) in Malaysia; 6.5/100,000 for solid tumor and 5.8/100,000 for hematologic tumor in Japan. The prevalence of congenital heart disease in Malaysia is 6.7/1000 and in Pakistan 2.5/1000. Data about chronic kidney diseases in Japan showed that its prevalence was 2.9/100.000.14
Risk factors of NCDs in adolescents are tobacco use (which is higher in boys than girls), unhealthy diet, physical inactivity, and childhood obesity. Approximately 80% of the population in the South East Asia region does not eat sufficient fruits and vegetables, but has a high consumption of salt and trans-fat.16,17In 2013, 42 million children were overweight or obese. Approximately 70 million young children will be overweight or obese by 2025 if the current trends continue. The rate of increase is 30% in low- and middle-income countries compared to that of developed countries.18 It was justified from data collected from countries in Asia Pacific Region, such as Indonesia, Malaysia, and Japan. A study in Indonesia showed that 8% of children were overweight or obese. Approximately 11.8% children in Malaysia were overweight and obese, and 13% of adolescents were obese. Another study showed that Japan had 10% of children with obesity.14
Childhood obesity is a major risk factor of adulthood obesity that leads to other metabolic syndromes, such as diabetes and cardiovascular complications. Pulungan et al found that 38% of adolescents with obesity in Indonesia had characteristics of insulin resistance.19There is no data on the current incidence of type 2 diabetes in Indonesia, however, there has been a significant rise in the prevalence of individuals being overweight and obesity. The Indonesian Pediatric Society has recommended dietary interventions, physical activity, metformin, blood glucose monitoring, and family support in type 2 diabetes management.
The human rights based approach to the engagement of adolescents in the NCD discourse
The right to health is provided for in various international legal instruments, including, inter alia, Article 25(1) of the Universal Declaration of Human Rights, which states: “Everyone has the right to a standard of living adequate for the health of himself and of his family, including food, clothing, housing and medical care and social services”.21 In terms of adolescents, the international community, in its near universal ratification ofUNCROC, has shown a clear commitment to specifically upholding and protecting the rights of children and adolescents.Article 24 of the UNCROC holds “States Parties recognize the right of the child to the enjoyment of the highest attainable standard of health and to facilities for the treatment of illness and rehabilitation of health. States Parties shall strive to ensure that no child is deprived of his or her right of access to such health care services”. As mentioned above, it is UNCROC that provides recourse for unpacking and understanding the special rights and entitlements adolescents have by virtue of the unique period in their lives.
While NCDs have historically been considered a “health” only issue that affects old people, health, as it relates to NCDs, is being more broadly recognized as closely related to and dependent upon the social determinants of health (SDOH) and the realization of other human rights.22Health was therefore considered to be broader than what was initially provided for in the preamble of the World Health Organisation Constitution and embraces a “wide range of socio-economic factors the promote conditions in which people can lead a healthy life, and extends to the underlying determinants of health, such as food, nutrition, housing, access to safe and potable water and adequate sanitation, safe and healthy working conditions, and a healthy environment”.23
In looking at advancing the NCD agenda, there is great benefit in reflecting on the interplay between NCD’s and the new SDG generation (adolescents). The SDG generation is made up of some 1.8 billion adolescents out there  - some 24% of the world’s population. In recent times, we have seen adolescence embracing social activism in relation to climate change. These young people realize that those in power won’t be around when the impacts of climate change will be felt by these adolescents. They want to have their say on the future their planet has. These adolescents are working to ensure that their right to be heard is recognized by the international community.
So, what does the right to be heard entail?
Article 12 of UNCROC holds that State Parties shall“assure to the child who is capable of forming his or her own views the right to express those views freely in all matters affecting the child, the views of the child being given due weight in accordance with the age and maturity of the child”.24These commitments need to be kept. Young people need to be represented at the table where decisions are being made that will impact on their future.  They can’t just be window dressing.
In addition to this right to be heard, there is further the obligation on State Parties to “ensure that all segments of society, in particular parents and children, are informed, have access to education and are supported in the use of basic knowledge of child health and nutrition, the advantages of breastfeeding, hygiene and environmental sanitation and the prevention of accidents”.25
Adolescent participation has been considered key not only from an operational perspective to ensure adolescent participation in decision making and policy formulation but it also “allows decision-makers to tap into adolescents’ unique perspectives, knowledge and experiences, which brings a better understanding of their needs and problems and leads to better solutions”.26Support for this ethical and human rights based perspective, in ensuring the right of adolescents to be heard in decision making processes is the best way to promote health equity.27
States have further been guided that they should provide a “safe and supportive environment for adolescents, that ensures the opportunity to participate in decisions affecting their health, to build life skills, to acquire appropriate information, to receive counselling and to negotiate the health-behaviour choices they make. The realization of the right to health of adolescents is dependent on the development of youth-friendly health care, which respects confidentiality and privacy and includes appropriate sexual and reproductive health services”.28
While NCDs are entrenched in SDG 3.4 and reflected in many other goals, in shifting the paradigm to ensure we include adolescents’ voices, it is important to reflect on the bold initiatives that member states took to highlight the importance of young people in the development agenda over the last few years. The SDGs: (i) put children and young people at the centre of discussions; (ii) committed to providing young people with the platform and knowledge to build momentum for the 2030 Agenda;and (iii) determinedto fulfillyouths unlimited potential.
While it is important that the right to be heard of adolescents is “respected, protected and fulfilled”, there is also a responsibility on the NCD Community, health leaders and policy makers - while young people are key agents of change and they can’t do it alone. They need leadership, empowerment, inclusion, and ownership over the policies and programs that will shape their future. The international community needs to be inspired by young people’s willingness to challenge the status quo and take bold steps.We have heard that issues children and adolescents face are a political win and can effect such change. So let’s win!
Adolescents need to be empowered to stand up for theirhuman rights – make their issues known, hold their governments accountable, and become activists for the promotion and protection of their rights. They know best what policies are needed to meet their needs. Further as the most interconnected, technologically advanced generation they are also able to easily share innovative solutions, information, and programs which are combating NCDs. This provides a great opportunity for governments to promote best practice, understand new solutions, and reconstruct policy to reflect dynamic ideas. Messaging is needed on NCDs from youth for youth.
Adolescents bring enormous passion and commitment that young people living with NCDs bring; they are committed to equity for all, our collective rights, not just attaining their own rights.International youth networks have amazing power. Young people are good at speaking with a unified voice – they recognise that the most important thing isthat UN member states and international organizations recognise the specific health needs of children, adolescents, and young people. This becomes their springboard to turn policy into action.
As the current SDG generation, this dynamic group of society recognises the important of transforming the development and health agenda as it is their future that is at stake. The future of humanity lies in the “hands of today’s younger generation who will pass the torch to future generations”.29
The World Health Organisation defines “adolescents” as persons aged between the ages of 10-19 years. However, equal definition of children and adolescents among countries particularly in Asia Pacific is still questioned. Consequently, inequalitiesofhealthcare in children and adolescents in this region should not be overlooked because it potentially exists between and within countries. In order to achieve the SDGs, greater attention and resources to adolescent health and the prioritization of young people in all national policy needs to be put front and centre of the health and development agenda. Visibility and knowledge base for adolescent health issues through better data collection and information systems, capacity building of healthcare providers, researchers, policy makers, and integration of research agenda are essential in ensuring adolescents health needs. Partnerships with stakeholders, governmental organization (particularly Ministry of Health) and private sectors are also needed to achieve SDGs together.
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    5. United Nations Development Programme. Sustainable Development Goals. Available from: https://www.undp.org/content/undp/en/home/sustainable-development-goals.html.
    6. NCD Child. Understanding NCDs. Available from: http://www.ncdchild.org/understanding-ncds/
    7. World Health Organization. Global Accelerated Action for the Health of Adolescents (AA-HA!): Guidance to Support Country Implementation. 2017. Available from: https://apps.who.int/iris/bitstream/handle/10665/255415/9789241512343-eng.pdf;jsessionid=BE6707025AA1E2CEFBDD14A843C21A36?sequence=1
    8. United Nations Convention on the Rights of the Child, GA Res 44/25, November 1989. Available from: https://www.ohchr.org/EN/ProfessionalInterest/Pages/CRC.aspx
    9. World Health Organization. Global Accelerated Action for the Health of Adolescents (AA-HA!): Guidance to Support Country Implementation. 2017. Available from: https://apps.who.int/iris/bitstream/handle/10665/255415/9789241512343-eng.pdf;jsessionid=BE6707025AA1E2CEFBDD14A843C21A36?sequence=1
    10. UNICEF and Save the Children. Every Child’s Right to be Heard: A Resource Guide on the Rights of the Child General Comment No. 12, 2100, pp. 5-12.
    11. World Health Organization. Global Accelerated Action for the Health of Adolescents (AA-HA!): Guidance to Support Country Implementation. 2017. Available from:  https://apps.who.int/iris/bitstream/handle/10665/255415/9789241512343-eng.pdf;jsessionid=BE6707025AA1E2CEFBDD14A843C21A36?sequence=1
    12. Viner RM, Ozer EM, Denny S, Marmot M, Resnick M, Fatusi A, et al. Adolescence and the social determinants of health. Lancet. 2012;379:1641-52.
    13. Internet World Stats. Internet users and 2019 population statistics. Available from: www.internetworldstats.com [Accessed 17 April 2019].
    14. Asia Pacific Pediatric Associations. APPA Internal Survey. 2018.
    15. World Health Organization. News release: more than 1.2 million adolescents die every year, nearly all preventable. 2017. Available from: https://www.who.int/news-room/detail/16-05-2017-more-than-1-2-million-adolescents-die-every-year-nearly-all-preventable [Accessed 17 April 2018].
    16. Proimos JP, Klein JD. Noncommunicable diseases in children and adolescents. Pediatrics. 2012;130:379-81.
    17. World Health Organization, Regional Office for South-East Asia. Noncommunicable diseases in the South East Asia Region. New Delhi: World Health Organization, Regional Office for South-East Asia; 2011. Available from: http://www.who.int/iris/handle/10665/205578 [Accessed 17 April 2019].
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    20. Pulungan AB, Affifa IT, Annisa D. Type 2 diabetes mellitus in children and adolescent: an Indonesian perspective. Ann Pediatr Endocrinol Metab. 2018;23:119-25.
    21. See also International Covenant on Economic, Social and Cultural Rights, Article 12(1); International Convention on the Elimination of All Forms of Racial Discrimination of 1965, Article 5(e)(iv); Convention on the Elimination of All Forms of Racial Discrimination against Women of 1979, Articles 11 and 12. The right is also provided in various regional instruments such as the European Social Charter of 1961, the African Charter on Human and Peoples’ Rights of 1981, and the Additional Protocol to the American Convention on Human Rights in the Area of Economic, Social and Cultural Rights or 1988.
    22. CESCR General Comment No. 14: The Right to the Highest Attainable Standard of Health (Art. 12), 11 August 2000, E/C. 12/2000/4, para. 3.
    23. CESCR General Comment No. 14: The Right to the Highest Attainable Standard of Health (Art. 12), 11 August 2000, E/C. 12/2000/4, paras. 4, 9, 11.
    24. UNCROC, Article 12(1).
    25. UNCROC, Article 24(2)(e).
    26. World Health Organization. Global Accelerated Action for the Health of Adolescents (AA-HA!): Guidance to Support Country Implementation. 2017. Available from: https://apps.who.int/iris/bitstream/handle/10665/255415/9789241512343-eng.pdf;jsessionid=BE6707025AA1E2CEFBDD14A843C21A36?sequence=1
    27. World Health Organization. Global Accelerated Action for the Health of Adolescents (AA-HA!): Guidance to Support Country Implementation. 2017. Available from: https://apps.who.int/iris/bitstream/handle/10665/255415/9789241512343-eng.pdf;jsessionid=BE6707025AA1E2CEFBDD14A843C21A36?sequence=1
    28. CESCR General Comment No. 14: The Right to the Highest Attainable Standard of Health (Art. 12), 11 August 2000, E/C. 12/2000/4, para. 23.
    29. Transforming our world: the 2030 Agenda for Sustainable Development, GA Res 70/1, 25 September 2015.  
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