Monday 19 September. Day one

7.10 I arrive at the junction of 47 Street East and 2nd Avenue to meet the Pepsico people who are holding a breakfast meeting in the UN dining room. I meet several cronies that I haven’t seen for a long while and reflect traitorously that global health is maybe like medical ethics or medical history, places where ageing health figures go before they disappear altogether.

7.20 We head down to the UN meeting in a long crocodile. I’m walking with Patti Rundall, a woman who is very bothered about conflicts of interest and wants private companies excluded from policy setting. I tell her that I think Brits are much more, and perhaps disproportionately, concerned about this than other nationalities and how I’d counted up the origin of organisations on her list of those worried about conflict of interest. I saw evidence to support my hypothesis in that 28 were from the UK with no other country having more than six. I suggested that one of the reasons might be British class snobbery about those in trade. We have a spirited discussion, which passes the time as we wait in several long queues.

7.50 The UN dining room is right beside the East River, which is looking sparkling and inviting in the morning sunshine. Appropriately breakfast seems to be fruit and beans, but then I discover that the “beans” are in fact porridge with various fruits added. It amuses me that Pepsi is building a “porridge empire,” but I’m a purist when it comes to porridge. I don’t like it “sodded about,” the phrase my father used about any food that wasn’t simply meat and potatoes.

8.00 I sit down beside the minister of health from Guatemala and tell him at length of my experiences in Guatemala. After a while I realise he doesn’t understand a word. I tail off gracefully.

8.15 The session begins. The theme of the meeting is that agriculture is hugely important for health and yet, despite repeated calls from the UN, the worlds of agriculture, nutrition, and health have remained almost completely separate. The Chicago Council on Global Affairs, an organisation that doesn’t take a position on anything (Is the sea blue? Possibly), has produced a report—Bringing Agriculture to the Table: how agriculture and food can play a role in preventing chronic disease. The report is written by Rachel Nugent, a friend, and sponsored by Pepsico. It dawned on me a while ago (why not decades ago?) that agriculture is hugely important in health. Somehow we in health have forgotten food and concentrated far too much on drugs. One billion people in the world are undernourished and two billion overnourished, and many countries have both problems at the same time.

8.30 Gary Toenniessen, managing director of the Rockefeller Foundation, held my attention and that of everybody else when he described the “epidemiological transition” in terms of a family. Many farmers in the world grow about a ton of food a year on one hectare. Usually they grow cereals and legumes, rice and beans perhaps. They and their families eat what they grow, and they toil in the fields, using 4000 to 5000 calories a day. At harvest time they eat well and add a little fat. Before the harvest they are often hungry and lose the fat. Their diet is often short of micronutrients, and one of the later speakers—Shenggen Fan, director general of the International Food Policy Research—described how his vision was poor when he was growing up on a farm in China because of shortage of vitamin A.

Then the farmer might be given better seeds and fertilizer. His yield might increase to 2-3 tons per hectare, meaning that half of his farm could be diverted to fruit, vegetables, or livestock. Now he can feed his family on a better diet and sell some of his produce for cash. Perhaps too he now has a tractor, reducing his physical activity. Because everybody is producing more, the price of staple food falls, leaving even more money for richer foods, possibly processed foods dense with salt, sugar, and animal fat. He and his family may well now be the targets of marketing campaigns promoting unhealthy foods.

8.50 Fan was optimistic that those interested in agriculture, nutrition, and health were finally coming together. He’d been at several meetings that included all these people. Agriculture people, he said, were building health targets into their work, but he didn’t see many health people becoming more interested in agriculture.

9.05 David Nabarro, the UN special representative on food security and nutrition, agreed with Fen that people in agriculture were becoming much more interested in health. He’d been at a meeting of G20 ministers of agriculture and had never heard so much talk about health before from agriculture ministers. His main message was “Don’t wait for health professionals. It’s the economic arguments that make the difference.”

9.50 The meeting closes, and we start searching for the way out or the way to the overflow room.

10.35 After a very long and beautiful walk beside the river I arrive at conference room 4 in the North Lawn Building, the overflow room. It’s a huge room with rows of desks with each space having a microphone and headphones for listening to the speeches from the plenary in your language. At the front of the room are two giant screens where we can see the people in the plenary making speeches. The speeches are broadcast in English. The people in the far from full room mostly have their computers open. They are doing their emails, writing their blogs (like me), chatting, reading newspapers, or just sleeping. Hardly anybody is listening to the speeches. It reminds me very much of the BMA annual meeting on a global scale.

The first person I recognise is Richard Horton, the editor of the Lancet. I say hallo, and we retreat to the back of the room for a chat. Richard is very familiar with these global meetings, often speaking at them, chairing sessions, or helping draft outcome documents.

The outcomes document, which was shared publicly last week, has already been adopted. What then is the point of representative after representative making their three minute speech on what they are doing? At the moment a man from Israel is speaking, but since I arrived we’ve heard from Belgium, Guyana, the World Bank, and somewhere else that I missed. Perhaps it’s just the ritual that everybody has their say. The speeches are usually read and full of familiar material.

Richard tells me that he hasn’t seen a single head of state or government. Does it matter if they don’t turn up? I fear that it does. (Later I learn that the president of Brazil opened the meeting and that Robert Mugabe had spoken. Oh dear, Robert Mugabe, the global leader on NCDs.)

10. 54 Now it’s the turn of the woman from the International Food and Beverage Association that I just met at the Pepsico breakfast. At least she enunciates clearly. I wonder if somebody might shout her down, but I doubt it. There is no sense of a debate. Rather each country or organisation makes its contribution regardless of what previous speakers have said.

10.57 Andrew Lansley takes over the chair of the plenary session. Somewhere else a round table is taking place. What exactly is it trying to do? Maybe it’ll become clearer when I attend this afternoon’s round table. My hypothesis is that the plenary is about each country having its say, whereas the round table has presentations followed by discussion. (I was wrong. They seem to be indistinguishable, just speech after speech.)

11.10 Venkat Narayan tells me that the meeting reminds him of a Hindu wedding with lots of people making the same speech.

11.15 I head off for coffee and a chat. Just outside the room dozens of photographers are contained in a pen. Whom are they expecting? Suddenly we know: Mahmoud Abbas sweeps by at great speed and with a large entourage. Palestine applying to the UN is the story of the week.

12. 58 David Bloom tells the meeting that NCDs will cost the world $47 trillion over the next 20 years (see yesterday’s blog) and cracks the same joke as yesterday. No laughs but applause.

1.00 Lunch at last.

1.05 I have a conversation with a WHO colleague about the point of the meeting. He says it’s mainly for the publicity and the events that surround it. Trying to negotiate the document would be impossible. The diplomats, he says, do meeting after meeting. NCDs today. Desertification tomorrow. Fish farming on Thursday. And they trade: “I’ll support you on NCDs if you’ll support our proposals on green mussel supplements.”

1.50 Waiting to attend my “in the flesh” session, I wonder why the room is so empty. I look at my ticket, and it says 3.00 not 2.00. I find a hidey hole.

1.55 Outside the chamber feels much like Euston Station, people walking backwards and forwards, only perhaps with less purpose than at Euston. People there have a train to catch.

2.55 I meet Michael Marmot coming out of the loo. (For those who don’t know him, Sir Michael Marmot chaired the WHO Commission on Social Determinants of Health.)

3.05 I’m attending my one “in the flesh” session. I’m so far back that I might as well be in the overflow room. I’ve set up my computer and boldly I’m going to try and type rather than write notes. I’m not looking forward to the next three hours with great enthusiasm, but I’ve promised Christine Hancock from C3 that I’ll take notes. I plan to Tweet as well.

3.16 The chair talking over the crowd calls for the start of round table 2 of the meeting on “non-communication diseases,” a very appropriate malapropism.

4.05 I’ve now been taking notes on every speaker for nearly an hour. It’s like Pibroch, endless small variations on the same theme. NCDs are a serious health, social, and economic problem. We must do something. It’s good that the UN is holding a meeting.

4.45 Trying hard to detect any controversy, I can see that some countries are keener on regulating the food industry than working with it (Hungary, France) and some are uncomfortable about corporate profits being put ahead of access to essential drugs (Brazil).

5.15 People are beginning to drift away.

5.45 I’ve still managed to write something about every speech. Maybe I should think of this meeting as a huge quilt, stitched together from hundreds of small pieces that are insignificant in themselves.

5.55 Half the audience has gone.

6.01 Ann Keeling, chair of the NCD Alliance which now has 2000 member organisations, says how members of the alliance are “outraged.” Action is essential. Prevention is a good investment. “You [governments] lead, and we will follow.”

6.05 Now three quarters of the audience have left.

6.15 The translators leave. Now the meeting is only in English.

6.20 The last speaker, an Indian cancer surgeon, demands serious action on the tobacco industry. “They are laughing at us.”

6.25 I meet a French colleague who tells me that by the end of the meeting there were only two people in the overflow room.

6.30 I walk past dozens of policeman, noting how they can be short, fat, and wear glasses. Won’t Tony Soprano laugh at a policeman who just touches five feet?

6.50 I arrive at the Institute of Medicine meeting in the Grand Hyatt. I’m flagging. Over the next 90 minutes a succession of people appear in front of me and make speeches, but I’ve heard too many speeches. They are just part of the quilt.

11.25 I’m drinking a glass of Macallan (“No, not on the rocks”) with a friend on the roof terrace of a hotel with the skyscrapers all around us. She’s a member of one of the delegations. “I asked if I had to do anything. They didn’t seem to want me to do anything. They preferred that I stayed away and went to side meetings.”

11.50 I’m glad I’m not a diplomat.

Richard Smith was the editor of the BMJ until 2004 and is director of the United Health Group’s chronic disease initiative.