Do the solutions for global health lie in healthcare?BMJ 2014; 349 doi: https://doi.org/10.1136/bmj.g5457 (Published 25 September 2014) Cite this as: BMJ 2014;349:g5457
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Conflicts of interest and global health and nutrition governance - The illusion of robust principles
In the run-up to the Second International Conference on Nutrition (ICN2), Jonathan Marks warned against downplaying the fundamental differences between the commercial interests of multinational food companies and those of public sector agencies. If public health officials do not acknowledge the divergent interests, he suggested, they risk harming their public health mission, institutional integrity and ultimately public trust.
Yet, the current discourse ignores the problem of involving food TNCs in public decision-making processes, acceptance of funds and resources in the name of partnership or stakeholder engagement. The trend to increase such engagement reduces and almost eliminates public policy spaces without corporations. Questioning of close relationships is frequently answered with reference to policies claimed to ‘mitigate’ the risks of such relationships.
For example, the ICN2 Framework for Action, which guides the implementation of the ICN2 Rome Declaration, urges governments to “strengthen and establish, as appropriate… multi-stakeholder mechanisms for food security and nutrition to oversee implementation of policies, strategies, programmes and other investments in nutrition” to create an “enabling environment for effective action.” While asserting that “such platforms may be needed at all levels” it refers to “robust safeguards against abuse and conflicts of interest.” (1)
The catch is that robust, comprehensive conflict of interest safeguards do not exist with respect to global food and nutrition governance. This lack became clear in the debates on the formulation of WHO’s Framework of engagement with non-State actors in January this year. (2)
Does the conflict of interest exercise of the Scaling Up Nutrition (SUN) initiative, initially introduced as a PPPPP - a “principled, people-public-private partnership” – at the World Economic Forum, fill this gap? Next week will see the celebration of SUN’s completed two-year project on conflicts of interest. This Gates Foundation-funded project designed “living documents on conflicts of interest,” presented as assisting governments in ‘SUN countries’ to prevent and manage conflicts of interest while the national nutrition arena is reshaped along SUN’s multi-stakeholder Engagement Principles.
At first glance, SUN’s definitions and interpretation of institutional conflict of interest seem congruent with those adopted by the U.S. Institute of Medicine:
"Institutional conflicts of interest arise when an institution's own financial [i.e. secondary] interest or those of its senior officials pose risks to the integrity of the institution's primary interests and missions." (3)
According to the project’s centrepiece Reference Note (4):
“An individual conflict of interest arises when the pursuit of the private or secondary interest of an individual has the effect of compromising, interfering with, or taking precedence of the joint endeavour.” (Para. 14)
An organizational or institutional conflict arises when the pursuit of an organization’s interest, whether ‘private’ or secondary, has the effect of compromising, interfering with, or taking precedence of the joint endeavour.” (Para.15)
Closer reading reveals profound differences with the IoM definition. The mandate of nutrition initiatives, i.e. the protection, promotion and respect of the right to adequate food and nutrition, is not taken as the ‘primary’ interest in either definition but the “joint endeavour”.
The primary purpose of SUN’s CoI exercise seems to be the protection of “establishing synergies between organizations …” by turning “stakeholders’ interest into converging interest.” (Para 10 & 19) As the Reference Note explains, the focus is on “inter-organizational conflicts…. that might arise in SUN countries and cannot easily be resolved through negotiation.” (Para 8).
The Reference Note, as well as the project’s Enhanced Learning Exercise, blurs crucial distinctions amongst:
• clashes or diverging opinions between actors; and
• the fundamentally differing fiduciary duties/mandates (primary interests) of market-led and public interest actors;
• “conflicts of interest” which relate to conflicting interests within a person or an institution; (5)
All appear in the Reference Note as ‘conflicts of interest.’ This blurred terminology hinders SUN participants’ understanding of the ultimate aim of conflict of interest policies: i.e. the protection of integrity, independence and public trust in persons and institutions serving public interests.
It obscures the fact that conflicts of interest are an important legal concept. Establishing conflict of interest policies are an integral part of UN agencies’ duty to establish the Rule of Law. According to the 2006 OECD Guidelines on Managing Conflict of Interest in the Public Service, public institutions should:
• ensure that effective procedures are deployed for the identification, disclosure, management, and promotion of the appropriate resolution of conflict-of-interest situations (comprehensive conflict of interest policies address CoIs, e.g. in public procurement, the revolving door problem, and the need for whistle-blower protection);
• support transparency and scrutiny; and
• create an organisational culture in which dealing with conflict-or-interest matters can be freely discussed and raised.
This does not seem to have been the focus of SUN’s CoI exercise. Its' Reference Note deters questions as to whether businesses should be invited as ‘stakeholders’ in public nutrition activities and empowered to shape nutrition agendas. Its basic assumptions are “good governance is inclusive” and actors in the nutrition arena should build “trust to permit such inclusiveness” (Para 9; cf. also Para 22.2.). There is no challenge as to whether the spirit of conflict of interest regulation is upheld when public interests are ‘aligned’ with those of corporate participants or TNCs are positioned in SUN’s Lead Group.
Critics who believe that those working in the nutrition arena should keep at arm’s length distance from food and beverage corporations and who advocate regulation of harmful marketing practices through legislation and naming-and-shaming are often ignored. The latest SUN Evaluation Report refers to persons with “phobias” and “hostile feelings” towards industry, who may “potentially sabotage the prospects of multi-stakeholder efforts to scale up nutrition.” (6)
Instead of sidelining and discrediting such voices, the SUN Secretariat may consider the integrity of their case and terminate the “Learning” exercise before SUN’s dilution of the meaning of conflict of interest contaminates the global nutrition arena. Otherwise, SUN’s exercise may cast doubt on governments’ and public interest actors’ understandings of CoI issues and cause a harmful redefinition of conflict of interest policies in the countries where SUN operates.
(1) FAO/WHO (2014). Second International Conference on Nutrition
Rome, 19-21 November 2014, Conference Outcome Document: Framework for Action, Doc. ICN2 2014/3 Corr.1; October 2014. Rome & Geneva, http://www.fao.org/3/a-mm215e.pdf
(2) WHO (2015). Study on practices of organizations of the United Nations system relating to conflict of interest in their engagement with the private sector. Geneva, World Health Organization & other relevant documents on http://www.who.int/about/who_reform/non-state-actors
(3) Lo, B. and M. Field, editors. Institute of Medicine (US) Committee on Conflict of Interest in Medical Research, Education and Practice, Eds. (2009). Conflict of interest in medical research, education and practice. Washington DC, National Academics Press.http://www.ncbi.nlm.nih.gov/books/NBK22942/
(4) For more information & Reference Note: Engaging in the SUN Movement: Preventing and Managing Conflicts of Interest, March 2014, cf. http://scalingupnutrition.org/about/principles-of-engagement-2/preventin... & http://gsogeneva.ch/?page_id=1456.
(5) Cf e.g. Peters, A. & L. Handschin eds. (2012). Conflicts of interest in global, public and corporate governance. Cambridge & New York, Cambridge University Press, p. 5 & 363 for some clarity on distinctions
(6) Mokoro, in cooperation with Valid International & FEC Consulting (2015). "Independent Comprehensive Evaluation of the Scaling Up Nutrition Movement - " FINAL REPORT Main Report and Annexes, 15 January
Competing interests: No competing interests
According to the Food and Agriculture Organization (FAO), the Second International Conference on Nutrition (ICN2), “may be the only opportunity in our lifetime to focus world attention on nutrition.” Given that the conference will take place in Rome next month, and that many issues will be determined in negotiations beforehand, a critique of trends in global health could not be more timely.
A central issue is the role of national and multinational food and beverage companies in efforts to address the so-called “double burden of malnutrition,” overnutrition and undernutrition. Governments and intergovernmental organizations (including the UN and the WHO) are relying increasingly on “engagement” with the private sector—in particular, public-private partnerships—to address obesity and non-communicable diseases (NCDs) more broadly.
The approach rests on the view that corporations, civil society, the academy, and government constitute “the golden quadrant,” and that they “need to agree upon finding effective and efficient policies, sustainable practices and food solutions.” The emphasis on agreement with industry comes at a price. As Jocalyn Clark notes, it creates opportunities for companies to influence policy agendas and ensure public health issues are framed and addressed in ways consonant with their interests.
In my own work, I emphasize the importance of considering how public-private partnerships—and industry interactions more broadly—may undermine the mission and integrity of government agencies and intergovernmental organizations. The commercial interests of multinational food companies inevitably diverge in fundamental ways from those of public sector agencies responsible for public health. We can recognize these divergent interests without demonizing industry, and we should do so. When public health officials downplay the divergence, they imperil their public health mission, and the integrity of their institution.
A distinct but related issue is how industry interactions may undermine trust and confidence in the public sector—including intergovernmental organizations. Several articles and letters in this and other medical journals have expressed concern about industry influence at the UN and WHO, and similar disquiet was expressed at the World Health Assembly meeting I attended in Geneva in May.
In the coming weeks, it will become apparent whether the full weight and implications of these concerns are recognized. In global nutrition policy, everyone may now be at the table. But who will determine what we get to eat?
1. Food and Agriculture Organization (FAO), The contribution of the private sector and civil society to improve nutrition. http://www.fao.org/fsnforum/forum/discussions/CS-PS-Nutrition
2. Clark, Jocalyn. Do the solutions for global health lie in healthcare?, BMJ 2014;349:g5457
3. Marks, Jonathan H. “Toward a Systemic Ethics of Public-Private Partnerships Related to Food and Health” Kennedy Institute of Ethics Journal, 24(3): 267–299 (2014) (revising and expanding http://ssrn.com/abstract=2268079)
Competing interests: No competing interests
As Jocalyn Clark outlines, the solutions for global health incontriversibly lie outwith healthcare. Then again, this is hardly surprising: so do the most pressing domestic health problems of today. The interplay of power, politics and health can be seen throughout debates from minimum alcohol pricing and e-cigarettes to healthcare rationing and NHS privatisation.
A firm conceptual understanding of public health, including the wider determinants of health, both on a national and international scale, have become fundamental attributes to the modern doctor's understanding of health. The post-2015 development agenda has great implications for health and medical professionals have an important voice in this debate.
The demand for global health education is there, yet here the content of current medical curricula falls considerably short; a set of Global health learning outcomes for medical students in the UK have been proposed which could form the framework for an adapted curricula.
Even as global health continues to attract cross-disciplinary contributors and collaborations, the medical profession continues to have an central role. Public health specialists may spearhead efforts, but population health is of relevance for all clinicians in order to best serve their patients. It is time all doctors were equipped with the skills they need to effectively tackle the great health problems of our day.
 Clark J. Do the solutions for global health lie in healthcare?. BMJ 349 (2014): g5457.
 Martineau F, et al. International health graduates—career path experience. The Lancet 379.9831 (2012): 2051-2052.
 Bhutta,A., et al. Education of health professionals for the 21st century: a global independent Commission. The Lancet 375.9721 (2010): 1137-1138.
 Johnson O, et al. Global health learning outcomes for medical students in the UK. The Lancet 379.9831 (2012): 2033-203
Competing interests: No competing interests