Feature Non-Communicable Diseases

Will industry influence derail UN summit?

BMJ 2011; 343 doi: http://dx.doi.org/10.1136/bmj.d5328 (Published 23 August 2011) Cite this as: BMJ 2011;343:d5328
  1. Deborah Cohen, investigations editor
  1. 1BMJ, London WC1H 9JR, UK
  1. dcohen{at}bmj.com

In the run up to the UN summit on non-communicable diseases, there are fears that industry interests might be trumping evidence based public health interventions. Will anything valuable be agreed? Deborah Cohen reports

“I wish I had AIDS and not diabetes,” a man in Cambodia was heard to say. He was speaking to UN representative Princess Dina Mired of Jordan. The man was not commentating on the diseases themselves but highlighting the fact that with AIDS he could be treated for free in a modern facility whereas treatment for diabetes was unaffordable in his country.

Such is the plight of some patients with chronic diseases in low and middle income countries, that the UN general assembly unanimously voted to convene a special summit on non-communicable diseases—cancer, cardiovascular disease, respiratory illnesses, and diabetes—to be held in New York on 19-20 September.

Many hope that this meeting will force non-communicable diseases into the spotlight just as the first health related UN summit did for AIDS a decade ago. But non-communicable diseases do not have the high profile AIDS campaigners, gay activists, and celebrities ramping up pressure on governments to act.

The NCD Alliance, a group of international federations representing the four main non-communicable diseases, and public health professionals have quietly pieced together evidence for action on a group of chronic illnesses that the influential World Economic Forum has placed high on its list of global financial risks.1 One estimate is that $84bn (£51bn; €59bn) of economic output will be lost between 2005 and 2015 as a result of non-communicable diseases.2

But years of planning may be set to unravel. With only weeks to go before the summit, years of negotiations seem to be stalling. Discussions have stopped on the document that forms the spine of the summit, and charities are concerned that governments are trying to wriggle out of commitments.

With UN meetings, most of the ground work is done well in advance, and centres on drafting a declaration. By signing up to a declaration, governments make a commitment to its aims. But for governments to make such public pledges, they have to be sure they can deliver. Attention is paid to the precise wording; there can be no room for misinterpretation.

Heavily annotated draft documents have been circulating among the various member states for many months. Each change is marked with the names of the countries, flagging up where the fracture lines are. The latest version—dated 5 August—is being kept under wraps. The BMJ has, however, seen a copy.

An NCD Alliance meeting suggested that “member states are deeply divided on key issues,” including access to essential medicines and vaccines; control of risk factors; and resources to prevent and control NCDs. But the biggest worry is the lack of precise goals.

“Of particular concern are the “actions of the US, Canada and the European Union to block proposals for the inclusion of an overarching goal: to cut preventable deaths from NCDs by 25% by 2025,” the alliance said in a statement.

Risk factors

One argument for grouping together cardiovascular disease, respiratory illnesses, cancer, and diabetes is that they share common risk factors—namely, tobacco use, unhealthy diet, lack of physical activity, and misuse of alcohol. But there’s political disagreement on who experiences the greatest burden of disease and how much the various risk factors contribute.

The World Health Organization is clear that non-communicable diseases are diseases of poverty and that therefore social determinants of health need to be tackled.3 But a letter from Andrew Mitchell, the UK’s secretary of state for international development, in May this year shows that not everyone agrees.

“While there are many poor people affected by NCDs, and certainly, these diseases are an important and growing cause of impoverishment, the majority of sufferers tend still to be in the wealthier quintiles of the population,” said the letter.

This view was corrected by a commentary in the Lancet,4 but the misconception will undoubtedly be replicated elsewhere.

Economic climate and donors

As Richard Smith, professor of health system economics at the London School of Hygiene and Tropical Medicine, points out, there are winners and losers from every action and they are not as obvious as you might think. Reduced red meat consumption in the UK may have health benefits for the UK population but will also affect farmers across the world, potentially causing job losses and plunging people into poverty. The resulting health effects of poverty may exceed the benefits from reduced consumption of meat.

But protection of financial interests is a more important barrier to change. When traffic light labelling on food was discussed in Europe, companies tried to persuade members of the European Parliament that restrictions on the food industry would inevitably lead to job losses—among other things. And exactly as the tobacco industry had before, the food industry used sponsored science—placing articles in journals—to influence policy makers.5

The campaign was successful—traffic lights were not implemented in the EU. And in the current economic climate, this fiscal argument might carry even more weight. Some cash strapped EU governments and the US—among the chief donor countries—may not want to risk rising unemployment rates at the expense of fending off ill health in low and middle income countries.

Influence of industry

There are numerous examples of the powerful sway that the tobacco, alcohol, and food industries have over international governments and how this impedes effective health policy.

WHO director general, Margaret Chan, warned in Moscow this year that many threats to health come from powerful corporations, driven by commercial interests—and she should know. When WHO tried to provide guidance on restricting dietary sugar consumption in 2003 they were told in no uncertain terms to back off; their report was dismissed as “misguided” and “non-science based” by the Sugar Association.

And food is proving to be a sticking point again. Changes to language in the latest version of the draft document are subtle but clearly important. While the so called G77 group of lower income statesincluding India, China, Kenya, and Brazil—argue that saturated fat should be reduced in processed products, as well as sugar and salt, that recommendation is being resisted by the US, Canada, Australia, and the EU. A specific target of reducing population salt intake to less than 5 g per person per day has been considered but deleted.

“Omission of saturated fat follows the conflicted industry agenda,” claims the World Public Health Nutrition Association, a group of public health and nutrition professionals.6

And they’re not the only ones who are concerned that industry interests might be trumping evidence based public health interventions. Non-governmental organisations point to the draft document’s call for “partnerships” between industry and government on prevention and control of non-communicable diseases. They are not convinced that industry won’t strong arm its way into getting what it wants in public health plans.

The BMJ has learnt that this partnership approach—whereby governments work with other organisations such as industry and non-governmental organisations—is one of the most contentious points in the latest version of the draft outcome document.

In a letter to George Alleyne, the former director of the Pan American Health Organization, who is central to the discussions, Patti Rundall, policy director of Baby Milk Action, expressed concern that partnerships meant a “close” rather than “arms-length” relationship with business.

“We share the NCD Alliance concerns that there should be concrete actions to take the NCD issue forward and we all want industry to change—but we strongly believe that this proposed ‘partnership’ is entirely the wrong strategy.”

Over 100 non-governmental organisations and medical groups signed a petition in July saying that there needed to be a code of conduct with industry as there was a “lack of clarity of roles for the industry sector in UN health policy setting and shaping.”

At a UN meeting in New York for representatives of charities and the public (called “civil society” in global health) in June—staged to allow advocates to have their say on the final political declaration—many of the tabled speakers came from groups either representing industry or funded by industry. Speakers included representatives of the International Federation of Pharmaceutical Manufacturers and Associations, the International Food and Beverage Alliance, and the World Federation of the Sporting Goods Industry. A list of those attending the September summit on behalf of civil society also includes representatives of industry, the BMJ has learnt. GlaxoSmithKline, Sanofi-Aventis, and the Global Alcohol Consumers Group are included within the official US delegation. And drinks companies Diageo and SABMiller are coming from the UK.

Nevertheless, this hasn’t stopped Olivier Reynaud from the World Economic Forum—one of WHO’s main partners along with the NCD Alliance—from complaining that the private sector has no voice in the negotiations later that month. It perhaps comes as no surprise that, along with Tony Blair and Kofi Annan, Peter Brabeck, a former CEO and current chairman of Nestle, is a board member of the World Economic Forum.

Non-governmental organisations are concerned that industry does not represent “civil society” or the public interest. While non-governmental organisations and many public health professionals argue that legislation is needed for successful change, that is clearly not in the interests of industry.

Louise Kantrow, from the International Chamber of Commerce, who represent business interests globally, told the New York meeting in June: “Enterprises in all sectors in both the public and private domains are happy to play their part on a voluntary basis.”

Bill Jeffery, from International Association of Consumer Food Organisations, says that the UN and WHO need to put up firewalls between their policy making processes and the alcohol and food companies “whose products stoke chronic diseases” and the drug and medical technology companies “whose fortunes rise with every diagnosed case.”

“If national leaders embrace lame vendor-friendly voluntary ‘solutions’ instead of effective regulations governing advertising, product reformulation, package labelling, government procurement, and VAT reforms, public health and national economies will strain under the burden of NCDs for generations to come,” he said.

Nevertheless, the call for voluntary measures seems to be bearing fruit. The US is lobbying hard for a set of “voluntary” targets for the control of non-communicable diseases in the current draft of the political declaration, which the BMJ has seen. Non-governmental organisations worry that setting up a voluntary code will undermine any move towards tougher restrictions.

The draft documents show that Norway is trying to take a strong lead despite protests from the US. Morten Wetland, the Norwegian ambassador to the United Nations, acknowledges the role of regulation—and how it is proving to be a sticking point. There are several diseases caused by poor diet, drinking and smoking “which are largely untouched by the legislative power and the treaty making capacity of this House and we need to be prepared to have a serious discussion about that when we meet in the forum,” he said at the meeting in June.

But even when legislation has been implemented, history is replete with examples of how companies simply find another means of getting their message across.

Tobacco is already governed by legislation. And the tide is turning with alcohol. At a WHO meeting last year, several international governments proposed that there should be a legal framework for alcohol. But the political declaration contains no references to legislation surrounding the marketing and taxation of alcohol.

As one academic wrote: “Note that effective evidence based measures on alcohol (controlling price, availability and marketing) are being deleted, and industry favoured measures (partnership working, community actions, and health promotion) being substituted,” they said, adding: “These changes bear the mark of the drinks industry and are a result of heavy industry lobbying in New York.”

Even commitments to tackling tobacco use are being watered down. Although there are calls to use fiscal policies to prevent non-communicable diseases, Japan, the EU, US, and Canada are resisting all language on taxation. And in the latest draft, some tobacco producing G77 countries, such as Cuba and Indonesia, are refusing to acknowledge the “fundamental and irreconcilable” conflicts of interest between the tobacco industry and public health. Such countries have not signed up to the Framework Convention of Tobacco Control.

What the likes of Corporate Accountability, an international watchdog, are worried about is that if industry agree to a set of voluntary principles it will be little more than window dressing. For every motivated executive who is committed to improving a company’s corporate social responsibility, there are shareholders who will kick back if sales are falling.

When industry market share numbers came out in March this year, showing Pepsi-Cola slipped to number 3 in the sales stakes ranking—falling behind Coca-Cola and Diet Coke—Pepsi duly opted to spend 30% more on advertising. Indra Nooyi, chairman and chief executive officer of PepsiCo, is facing doubts from investors and industry insiders concerned that her push into healthier brands have distracted the company from some core products, the Wall Street Journal reports. 7

Nevertheless, PepsiCo have secured the prime side-event slot at the UN meeting: a breakfast event from 8-10 am on the morning of the summit.

If voluntary measures are put in place, who’s going to monitor and who’s really going to hold the various industries to account? In a letter to Ban Ki-moon, UN secretary general, this month, the NCD Alliance expressed concern that there has been “no clear decision to establish the means through which commitments can be followed up and coordinated at a global level. It asks the secretary general to provide options by the end of next year for further consideration.

“There’s an allergy to accountability,” Jorge Alday, associate director of the World Lung Foundation told the BMJ. “There is no clear timeline about what’s going to happen and there is push back from the US and EU for having a comprehensive review in 2014.”

The NCD Alliance agrees that preventive measures need to be put in place. However, there is concern that funding streams from some of its member organisations might limit the alliance’s ability to call for tighter controls on industry. One of the main members of the alliance, The World Heart Federation, accepts funding from Unilever8—owners of brands that make dairy produce and some fast foods.

In a statement to the BMJ , the federation said. “In the case of enterprises involved in manufacturing, distribution and sales of food and beverages, the World Heart Federation considers the important role they must play in product reformulation to eliminate trans fats, and reduce saturated fat and salt intake.”

The alliance is supported by 10 pharmaceutical and medical technology companies. The supporters have put out their own statement.

Governments should “validate and support the critical role of companies, across a broad variety of sectors, as value-adding partners to governments, civil society and other stakeholders,” it said.

However, the alliance stresses that “funds are applied at the Alliance’s discretion, with no influence or involvement from funding partners.”

Indeed, it is Japan who has been doing the bidding on behalf of the drug industry in negotiations. The country is keen to support the use of “high quality” medicines—a reference to branded as opposed to generic drugs; is pushing public-private partnerships and incentivising innovation; and, in line with drug industry requests, calls for “acknowledged public health best practices,” as opposed to cost effective interventions.

Other economic concerns

But while industries have their own interests to think about, so do politicians—which might well limit their responses. Donor countries have problems with non-communicable diseases on their own turf. There is no appetite for a new vertical or disease based initiative.

Professor Smith is concerned that non-communicable disease advocates have been doing a lot of talking among themselves. “Saying NCDs are bad and they affect people’s health is far too simplistic,” he says.

While health ministers might be convinced that “the health of the country is the wealth of the country” as one report argued,9 advocates have to persuade those occupying the powerful trade, industry, and budgetary offices in international governments. And they are yet to be convinced. The negotiations have stalled, in part, because there is a reluctance of donor countries to call for increased resources for non-communicable diseases.

Politics

According to Professor Smith, the issues are very diffuse, and it is hard to see what the political win is for some departments. Political short termism may well win out.

It was a point noted at a UK Chronic Disease Task Force meeting in December last year. Minutes said that they would need to “make the case for the government as to why it would be in their interest to be a champion.”

Sudeep Chand, global health fellow at Chatham House and a former adviser at the Department of Health—also says there needs to be sophisticated political thinking.

“Leaders need to think of votes—this usually goes down monetary lines and numbers of lives saved. There’s got to be a political gain particularly in democratic countries. How to deal with this long term in relation with other crises might be difficult. China could be better at doing this, for example. UK and US policy is often undermined by turnover of staff and an inability to implement long term plans,” he said.

One stumbling block for all those involved is the priority setting and the relationship between non-communicable and communicable disease. India, for example, has tacitly agreed to adhere to WHO’s code for marketing food to children—and the WHO calls on member states to sign up to it—but under-nutrition is seen as more of a current problem in India. Maybe, Professor Smith says, nutrition as a whole—looking at both poor diet and lack of food— should be tackled as one.

Even if the politics are overcome, tackling non-communicable diseases is a long term game. “The summit is a political platform to get a coherent strategy together—for leaders to acknowledge that this is an issue. It’s not a game changer, but it’s a start,” Dr Chand says.

Notes

Cite this as: BMJ 2011;343:d5328

Footnotes

  • Competing interests: The author has completed the ICJME unified disclosure form at www.icmje.org/coi_disclosure.pdf (available on request from her) and declares no support from any organisation for the submitted work; no financial relationships with any organisation that might have an interest in the submitted work in the previous three years; and no other relationships or activities that could appear to have influenced the submitted work.

  • Provenance and peer review: Commissioned; not externally peer reviewed.

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