Author: Jo Jewell

Reflections on Progress to Reduce Non-Communicable Diseases

This week on Translational Global Health, regular blogger Jo Jewell – recently of the World Cancer Research Fund (WCRF) – offers an important reflection and summary on the progress thus far, in the global prevention and mitigation of NCDs. 

Flickr /  USAID_IMAGESIn September 2011, public health NGOs were gearing up for the High-Level Meeting of the United Nations on Non-Communicable Diseases (NCDs). This was only the second time that the UN General Assembly had met on a health issue. As such it was both a landmark occasion and an unprecedented opportunity to raise political awareness of the catastrophic impact of NCDs around the world.

Public health advocates wanted the meeting to bring a similar level of political attention and sense of urgency to NCDs as had previously been achieved for the HIV/AIDS epidemic. Critically, it was hoped that the Political Declaration that was to be agreed would secure much greater action worldwide on the prevention and control of NCDs. In so doing, all governments would set in stone their political ambition, commitment and accountability to addressing NCDs.

It was in this optimistic context that I joined the policy department at World Cancer Research Fund International. Thankfully, the Political Declaration was universally adopted by governments from around the world. In it they agreed a roadmap for international action. As such, my work at WCRF International has been influenced by the outcomes of this meeting. As I sadly prepare to leave WCRF International to take on a new career challenge, it seems like a good moment to reflect on the impact of that High-Level Meeting and what has happened during this exciting period for NCD policy worldwide.

Flickr / USC Global HealthAction since the UN Declaration on NCDs.

The UN Political Declaration has been instrumental in galvanising global action on NCDs. It has mandated international agencies such as the World Health Organization (WHO), Food and Agriculture Organization and the UN Development Programme to expand their work programmes on NCDs and to collaborate on this issue more than ever before. While there is still a need to ensure that NCDs are truly integrated in all the relevant areas – such as the ongoing discussions around the post-2015 global development agenda, it is undeniable that the profile of NCDs has risen as a result.

In the years since the Political Declaration, the WHO has successfully adopted a global policy architecture for NCDs, including a Global Action Plan, a set of global targets (designed to incentivise and drive action), a framework for monitoring progress, and a voluntary global target to reduce premature deaths from NCDs by 25% by 2025.

As a result, NCDs are well and truly established on the health policy map, and the WHO – as the lead agency on health – has articulated what it would like to see national governments do in terms of developing and implementing policies.

What has this meant for our work?

For World Cancer Research Fund International the new global policy architecture on NCDs galvanised our work advocating the wider implementation of effective policies for the prevention of cancer and other NCDs. We developed the NOURISHING Framework to bring together key areas where governments need to take policy actions to promote healthier eating and ultimately to help achieve the 25 by 25 goal. Having an agreed policy framework is critical because it allows the political discussion to move from the “what” to the “how”, which is where there is most potential to support national governments in developing policies.

Flickr / HealthGaugeAs part of NOURISHING we pulled together the policy actions that countries are taking around the world (e.g. on nutrition labelling) so we could see – and share with others – what countries are doing to implement these global agreements. What are other countries doing”? is a question we heard often from government officials. Even more, I used to hear “what is the evidence that policy is effective?” So we developed a plan to collate, review and interpret the evidence base. This is work I will be excited to see WCRF International develop into the future, and which I look forward to using in my new role at the WHO’s Regional Office for Europe.

Working internationally is different to working at the national level. Nationally, policy actions have to be tailored to contexts and populations; internationally, it’s about identifying the core elements of well-designed policy that are transferable globally. One of those elements inevitably involves the law, which is why we explored the role of law in obesity prevention in our first working paper, and collaborated with the McCabe Centre for Law and Cancer.

Where are we going next and what are the challenges?

By its very nature, public health evidence is complex. This is particularly the case for multi-factorial issues such as obesity.  As I leave World Cancer Research Fund International my hope is that it ultimately does for policy what it has always done so well in its science programmes (notably for Second Expert Report and now with the Continuous Update Project). That is, to ensure that all the evidence is brought together in a way that we can learn from it and take action. Communicating what has been learned to governments, including analysis of the real-world effects of innovative policies, should enable even more policy action on NCDs and a greater confidence in our understanding of the “how” part of the equation. This will be the true legacy of the Political Declaration.

This post was cross-posted from the blog of the WCRF. For more on this post and other blog posts by the WCRF, head to their website.

Jo Jewell has a background in European politics and has a Masters in Health Policy, Planning, and Financing. His experience mainly relates to food and alcohol policy, and his work has focused on advocacy at the European and global levels. He is a member of the Global Steering Committee for the Young Professionals Chronic Disease Network. 


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Health policy: nanny state or catalyst for change?

This week on TGH – regular blogger and NCDFREE change-maker Jo Jewell of the World Cancer Research Fund talks about health policy and its role in Global Health. 

It has become abundantly clear over the decades that there are sometimes major issues adopting policies to prevent people from becoming ill through non-communicable diseases (NCDs).  Starting with tobacco and now evident with alcohol, unhealthy diet and obesity, proposals for effective policy action – which centre on the need to reduce exposure to these risk factors –  often fail to make it onto the agenda, are repeatedly blocked in government, or are challenged in the courts of law. While this is down to a combination of factors, accusations of ‘nanny state’ have been at the forefront acting as a barrier to government action. 

Nanny State

Health police? 

It’s clear that the public cares a lot about health – the way in which governments choose to run our health care systems generates a lot of media coverage and is guaranteed to be a hot topic in the run up to any elections. Beyond health care, public health is often less visible, and the types of broader policies designed to influence public health appear to gain less immediate traction with the public. (Admittedly, public health can still hit the headlines and catch governments off guard, as is sometimes the case when the shocking extent of health inequalities within our countries is revealed). But it is when policies are perceived as being too interventionist, restrictive of choice or paternalistic that public health can really provoke headlines, controversy and debate (think ‘fat fascists’ or similar). At the forefront of opposition to these policies is the criticism that public health wants to ‘nanny’ the population – and, not wanting to risk public outcry, this can translate into a distinct lack of effective action by government.

An obstacle to progress

To illustrate the chilling effect this can have on policy, there are less than 5 countries worldwide with legislation or regulation on food marketing to children, and less than 10 using the price of food to improve health, despite the global epidemic of obesity. Similarly, plain packaging legislation in Australia is still being challenged in the courts, while David Cameron recently performed an outrageous u-turn on both plain packaging and minimum-pricing for alcohol. The insufficient implementation of effective policies globally is down to a combination of factors, but fear of nanny state is a core concern. We face these challenges in spite of the fact we have good evidence on what influences our behaviours and what policies are likely to be effective.

Why policy is critical

SAMSUNG DIGITAL CAMERALet’s reflect on the fact that the overarching aim of NCD prevention policies is to empower and enable people to lead healthier lives. It will achieve this by targeting those factors that influence our behaviours (i.e. who eats/drinks/smokes what, when, where and how much). From the evidence, we know that factors in our immediate environments, such as the availability, affordability, and promotion of products, are a major component in influencing our behaviour. We also know that our behaviour is being intentionally altered by the actions of companies in a way that fundamentally shifts our demand for their products and encourages the development of unhealthy habits. For example, in the food arena, companies intentionally market products in such a way that it encourages us to consume more of them, more often, and they then manipulate the characteristics and price of the product to reinforce this effect.6071330113_caf9a4240b_b

It cannot (or, should not) be implied therefore that consumers are somehow only fulfilling their desires. Nor should it be suggested that the inevitable downstream health effects are simply an unfortunate consequence that must be tolerated because people ‘want’ to be obese or ‘want’ to become addicted to tobacco. Our choices and actions – which determine our health – are rarely made on a completely rational or informed basis but are in fact influenced in large part by our external environment, and in ways over which we may have little control. I don’t therefore buy the short-sighted, hands-off argument that people should be allowed do as they please and just be a little more responsible. I don’t believe it is as simple as that.

What this means is that we in fact need a whole suite of stronger policies to respond. These policies should target the factors in the environment that influence our behaviours, and the objectives of policies should be carefully designed to achieve maximum benefit. For example, we know that children’s dietary behaviours are influenced by marketing, and that the amount of exposure is critical in shaping their preferences and food choices. So well-designed policies that broadly protect children by reducing exposure to all forms of marketing of unhealthy foods and place tough rules on the manipulative content of the marketing are entirely justified.

Opponents (whether in government, with industry, or people politically/philosophically opposed to ‘big government’) attempt to undermine such public health efforts in any way possible. First they claim the policy measures are an unfair restriction of freedoms, then they pull apart the evidence. For example, the NYC supersize soda restrictions proposed by Mayor Bloomberg were portrayed as being an unfair and an unjust restriction of choice that ‘coerced’ consumers. In fact, people would still have been able to order as much soda as they wanted but the default was simply changed to make it more difficult. In order to further stall the policy, opponents also cast doubt on the evidence. So wrapped up in the whole ‘nanny state’ debate is a second criticism that the proposed policies won’t be effective anyway, because people will continue to ‘seek out’ unhealthy food and drink, alcohol or cigarettes.

Changing the narrative

When people say that these sorts of interventions are nanny state, I ask: do you want to go back to a time when you breathed smoke for the duration of transatlantic flights, or risked your life driving at night because the driver coming towards you was blind drunk?

5934455616_9a4d6dec9b_oPolicies in these areas were once controversial, but have nowcome to be part of social norms and valued. My colleagues and I often reflect upon the fact that at some point in the future people will surely look back and think we were mad to ever let companies manipulate children through marketing junk food.

Through policy it will be possible to create new social norms over time, where people grow up valuing health and seek out opportunities to lead healthy lifestyles. But there is also an immediate task, which is to bring people with us on this journey – and the media needs to be a key ally, not an opponent, in promoting the benefits of public health policy. This way governments will have confidence that the public supports action. And, if they are then empowered to take a comprehensive approach, rather than piecemeal action here and there, we are much more likely to see impressive results over time.

Fruit_Stall_in_Barcelona_MarketI truly believe that accusations of ‘nanny state’ need to be re-examined. At its core this is a question about the role of the state and what the relationship between government, society and individuals should look like. This is by no means a new question and there has long been a debate in politics and philosophy around the ‘social contract’, legitimacy of state intervention, and what approach will produce the best outcomes for society.

When it comes to preventing NCDs, unnecessary deaths and disability, I feel that we – as a community – have a legitimate rationale to support intervention to protect and empower people. Particularly when it is so patently clear that industries with a completely different set of interests and motivations are allowed to interfere by influencing our behaviours. Very few public health policies have an ultimate aim of removing personal choice entirely – they are much more likely to focus on regulating the “worst excesses of manipulation” by private interests,  changing the environment and cues so as to tip the balance from unhealthy to healthy. It is the duty of the state to protect the population and we all need to do a better job at communicating this so that people are better able to judge for themselves whether the government is actually taking away freedoms or simply trying to re-empower its citizens.

This article was commissioned by NCDFREE, in collaboration with Remedy Healthcare and Local Peoples.

Jo Jewell is the Policy and Public Affairs Manager at World Cancer Research Fund International, based in London. He has a background in European politics and has a Masters in Health Policy, Planning, and Financing. His experience mainly relates to food and alcohol policy, and his work has focused on advocacy at the European and global levels. He is a member of the Global Steering Committee for the Young Professionals Chronic Disease Network. His contributions to this blog represent his own views and opinions.

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Global Trade: for healthy populations or healthy profits?

If we go back to the basics of epidemiology, it is abundantly clear that patterns of disease are converging globally, with NCDs emerging as the major threat to population health worldwide. Other threats of course remain – indeed low- and middle-income countries must now grapple with a potentially debilitating double burden of disease – but NCDs are ubiquitous. Tobacco smoking, alcohol consumption, unhealthy diet, physical inactivity and obesity are pervasive as risk factors globally. Last week’s launch of the Global Burden of Disease study confirmed this.

While it is clear in many cases that lifestyle behaviours associated with these risk factors are the immediate causes of disease, it is also clear that other underlying factors (or actors) must be driving this rapid convergence in behaviour and patterns of consumption. These changes have resulted in unprecedented levels of NCDs. Governments are indeed looking for solutions, but not always in the right place.

In this light, let’s explore the principle of ‘first, do no harm’, and examine it from a specifically global perspective – trade and globalisation.

The production line of (ill-) health

As many are aware, NCDs are largely preventable. In fact, the biggest opportunity (and challenge) is to reduce the contribution of risk factors such as tobacco smoking, alcohol consumption, unhealthy diet and physical inactivity to the rising burden of disease. In order to make meaningful progress in tackling NCDs, we need action that goes to the core of these risk factors by addressing supply-side factors and the environmental determinants. These are the push factors that drive trends towards increased consumption.

But what are supply-side factors and environmental determinants?

When we talk about supply-side factors and environmental determinants we immediately think about what is being produced (in what context and with which incentives); what is available; how much it costs; and, how it is marketed. An important factor in the obesity epidemic, for example, has been the availability, affordability and promotion of fast food, and the incentives along the food supply chain for its production and sale.

When faced with serious health challenges, government has a clear role to play in using these lever points for public benefit. But, as we will see, a government’s ability to take action to address this is sometimes limited by existing commitments to international trade.

Tobacco control policies are the most advanced in this field, and primarily aim to reduce demand by changing the environmental push factors. The Framework Convention on Tobacco Control (FCTC), the first and only global health treaty, sets out specific steps for governments to use taxation and pricing to reduce consumption; ban tobacco advertising, promotion and sponsorship; create smoke-free work and public spaces; use prominent health warnings on tobacco packages; and, curb illicit trade in tobacco products. This model has been hugely successful at empowering government and controlling the activity of tobacco corporations. Health advocates often look to the tobacco example to inspire policy action in other areas, including alcohol and food.

Trade, Globalisation and Health

Despite the many successes in tobacco control, it’s been far from plain sailing to this point. Since negotiations on the FCTC first opened, 63 million people (and counting) have died from tobacco-related diseases. Yet governments wishing to take regulatory action to tackle tobacco smoking still face an increasingly bitter fight from ‘Big Tobacco’ to protect their own interests. There has also been aggressive expansion to target new markets (women in established markets; new smokers in emerging low- and middle-income economies).

A recent high-profile example of this struggle against ‘Big Tobacco’ has been the introduction of plain packaging for cigarettes in Australia.

Congratulations to the Australian Government, who successfully defended their policy in the domestic courts. This was in spite of complaints from tobacco companies, working in unison, that the plain packaging infringed upon their brand ownership (intellectual property rights) and undermined trade investments. This month Australia rolled out its policy across the country, in a bid to further restrict the marketing activities of tobacco companies.

However, there are a number of international legal challenges that remain. These have been brought against the government by the tobacco industry, seeking new avenues to block regulatory action. As they lose clout with national governments, these companies increasingly tries to circumvent national policy through international trade law.

This new global dimension to public health policy reflects the structural dynamics that underpin both the supply side and the environmental determinants that affect demand – namely global integration of investment, trade and communication. Globalisation, to use a broader but more widely recognised term, has completely reshaped the policy playing field. The overhaul of the economic model, including trade liberalisation, has driven changes in the supply and promotion of consumer goods, with the emergence of transnational companies, retailers, foreign direct investment and global advertising. Global factors now stand right up there alongside national context in influencing the consumer environment.

But what does this new global playing field mean for health?

The World Trade Organization supervises the strict implementation of rules affecting global trade and commerce (chiefly international trade agreements), and provides a forum for complaints against countries considered to be ‘flouting the rules’.

One such legal challenge facing Australia over its bid to implement plain packaging comes via Ukraine, Honduras and the Dominican Republic (but financed significantly by the tobacco industry). The threat of such cases is a major disincentive for low- and middle-income countries looking to take policy action, as the legal costs to challenge such complaints can be astrononmical.

Another international legal challenge comes in the form of an investor-state dispute, whereby complaints can be made against a country deemed to be in contravention of bilateral trade agreements. Phillip Morris Asia claims that Australia is violating the terms of a 1993 trade pact between Hong Kong and Australia. In effect, they are seeking to block plain packaging as they frame it as a threat to trade.

The Australian government has since stated that, in addition to fighting this challenge, it will no longer support provisions in bilateral trade agreements that constrain its ability to implement national laws on social, environmental or economic matters. A clear sign that governments have concerns over the interplay between health policy and trade.

Other countries have faced down challenges and threats to national health policies from international trade agreements, including Norway when it introduced bans of retail display of cigarettes, and Denmark whose ban on trans fats in foods was scrutinised by the European Commission. The Scottish Government is currently awaiting an opinion from the European Commission as to whether its proposed policy on minimum unit pricing for alcohol contravenes EU trade rules.

Lessons for future health policy

The fact that a policy arena for NCDs is now operating at the global level means that policy-makers must consider the challenge of global trade when formulating national policy, but it also indicates that globalisation may be a significant factor (or amplifier) in the emergence and spread of the global NCD epidemic.

An expanding body of work suggests that the rate of increase in consumption of ‘unhealthy commodities’ (soft drinks, processed foods, tobacco and alcohol) is fastest in low- and middle-income countries, and that multinational companies have now penetrated these markets at similar levels to those seen in high-income countries.

Foreign-direct investment and free trade agreements are understood to be key factors behind this emerging trend, and that the heralded economic benefits of free trade are compromised by unexpected negative externalities (e.g. changing patterns of disease), and cost/benefits are not distributed evenly.

In 2002, the WHO and WTO prepared a joint report on the public health implications of trade. This found that trade agreements do take some account of health, permitting national measures that protect human health—but only those that are the least trade-restrictive relative to any other measure. The report emphasised the common ground between trade and health, but – recognising the potential for dispute – argued for health and trade policy ‘coherence’.

Certainly, trade policy continues to be one of the most contentious issues in global health.

Trade, globalisation & our new global health agenda

Global trade rules present genuine and substantial risk to health policies seeking to address supply side determinants and alter the consumer environment to reduce risk factors for NCDs. They affect what people eat and drink, and whether they smoke.

As it currently stands, when there are implications for trade, countries must construct a powerful case that demonstrates the relationship between the intervention and protection of public health – this requires capacity to construct a case and ability to participate fully in international policy-making to defend this case. Health policy can, and should, trump trade law, but this is not guaranteed and may come at very high cost to governments.
When faced with major global health challenges of a globalised nature, it seems counterintuitive that health policy is held hostage to trade policy (when we know that health is a pre-requisite to effective economic development…) and corporations are able to manipulate it to their own advantage. This is particularly frustrating when governments are trying to take upstream – pre-emptive – action on health, yet face barriers imposed by trade rules that seemingly serve the interests of big business.

Given these concerns, isn’t it time the health community tabled governance reforms to ensure this is no longer the case moving forwards?

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