After months of negotiations, lobbying from industry and NGOs and public health experts, international governments have finally agreed the political declaration that will form the spine of the UN’s summit on non-communicable diseases later this month.
The BMJ has seen a copy of the final declaration and for those who have been involved there are some highlights, lowlights and one or two surprises.
One plus, say campaigners, is that NCDs are finally in the public conscience and have reached the top international table—the UN. Whilst fervour has not reached the heights of AIDS, chronic diseases are starting to have a profile and they are starting to attract political and celebrity support. The PR savvy TV chef Jamie Oliver has added his voice to the issue, saying that diet-related diseases are two of the top five causes of premature death for people under 60 years old.
It has also brought the influential AIDS lobby together with the NCD lobby— some had previously feared they may have been pitted against each other over a potential diversion of funding.
Advocates will be pleased that there will be a follow up UN meeting in 2014—despite the best efforts of the EU to prevent this. (although the EU did win out when it said it didn’t want to commit extra resources or global targets in the reduction of deaths.)
The BMJ reported that governments have been representing the interests of industry. In earlier drafts it was disappointing for anti-tobacco campaigners when Western countries—with policies protecting their own citizens—were lobbying against imposing fiscal measures on tobacco. For smoke-free advocates, this battle has been won. The declaration says specifically that “price and tax measures are an effective and important means of reducing tobacco consumption.”
Another risk factor under terminal threat are trans fats. Having been described as “low hanging fruit” this is the first time any reference to transfats has appeared in the draft declarations circulating over the past few months. Now it makes specific reference to the elimination of “industrially produced transfats in foods.”
But for public health advocates there will be some disappointments. Whilst the declaration says: “Recognize that prevention must be the cornerstone of the global response to NCDs,” there are few specific targets. For example, the deletion of the 5mg target on salt per person per day that was in earlier drafts remains out. In its place are the promotion and initiation of “as appropriate, of cost-effective interventions to reduce salt, sugar and saturated fats.” And there are many references to “as appropriate” placed against health measures.
Of all the industries, it’s the alcohol industry, which will come out feeling happiest.
Alcohol industry representatives have been out in force visiting the country missions in UN headquarters in New York, and this has paid off. Efforts to get specific tough language on alcohol policy measures—taxation and restrictions on marketing— failed. Rather than restricting access to retailed alcohol; enforcing bans on alcohol advertising and raising taxes on alcohol, less restrictive measures have taken their place.
The declaration includes alcohol awareness campaigns targeting young people, which advocates point out, have been shown not to work—this is in stark contrast to wording on reducing the “impact of the marketing of unhealthy foods and non-alcoholic beverages to children.”
Governments have said they will “recognize” the “critical importance of reducing the level of exposure of individuals and populations to the common modifiable risk factors for non-communicable diseases.” But they will establish their own policies and involve “all relevant sectors.” And “appropriate domestic plans” may be drawn up with the alcohol industry themselves. Other than for tobacco, nowhere is it recognised that involving industry in health policy making is an inherent conflict of interest.
But the area of greatest tension was over intellectual property and flexibilities in trade agreements—known as TRIPS— where only after some intense horse trading was the final declaration agreed.
In 2001, against a backdrop of concern about the AIDS epidemic, countries agreed the Doha Declaration which stated that intellectual property should not prevent states from dealing with epidemics and public health crises. This meant UN agencies, charities and governments could buy far cheaper generic versions of drugs made in the likes of India and Brazil that were patented in the West .
As pharmaceutical industry representative are keen to point out, many drugs for NCDs are off patent. Many expensive cancer drugs and newer medicines, however, are still patented.
The BMJ understands that the perceived threat to intellectual property forced US like-minded countries—such as Japan, Australia, New Zealand, Canada and Switzerland— to form a group with the EU to protect their interests. They did not want the declaration to mention TRIPS, the Doha Declaration or even epidemics—a medical word with huge financial ramifications.
But it was the US who were taking a particularly hard line and they would have rather walked away from the discussions than concede any ground on intellectual property. In negotiations, the G77—the low and middle income countries— were pitted against each other with the US claiming that out of them, it was only Brazil, Mexico and India who cared about TRIPS.
Aware that the negotiation would stall, the EU stepped in to agree text. As a sop to Brazil, Mexico and India, the US like-minded groups have allowed the inclusion of TRIPS in exchange for no mention of the Doha Declaration or epidemics.
Campaigners point out this is a hypocritical stance saying that the US has invoked the Doha Declaration themselves for compulsory licenses NCDs medicines and technologies in the past. But also say that this diversionary tactic might not work—public health crises are also referred to in the declaration and countries can individually self-determine what constitutes a public health crisis in the first instance.
The real concern is that this will leave triggering of TRIPS flexibilities and the Doha Declaration open to interpretation—as many aspects of the declaration will. Country representatives are busy preparing their allotted five minute speeches for the meeting whilst lobby groups—all competing to make themselves heard— are drafting dossiers offering their interpretations to coincide with the summit start on 19 September.
Deborah Cohen is investigations editor, BMJ.