Embracing actors from any health harming industry is misguided given the scale of the current NCD crisis, argue Johanna Hanefeld and Benjamin Hawkins

The recent report of the WHO’s Independent High Level Commission on noncommunicable diseases (NCDs)[1]should be welcomed in so far as it recognises the political importance of this issue, and the need for cross-government approaches and political buy-in at the highest levels. However, the measures it advocates for tackling NCDs are completely inadequate to reverse current trends.

The commission was convened by the WHO director general to identify innovative ways to curb the world’s biggest causes of death. In announcing its launch, Dr Tedros stated, “We urgently need new approaches and action on a dramatically different scale if we are to stop people dying unnecessarily from noncommunicable diseases.”[2] Yet while the report was promisingly titled Time to Deliver, the “bold recommendations” it was commissioned with providing fail to materialise. Instead, this report represents a missed opportunity to shift the policy agenda decisively towards effective, evidence based approaches that would tackle this mounting threat to global health.

The report is remarkable in the extent to which it reproduces a pro-business agenda. Indeed, the authors openly admit they were unable to reach consensus on the most controversial issues, namely those involving taxation and curtailing corporate influence: “There was broad agreement in most areas, but some views were conflicting and could not be resolved. As such, some recommendations, such as reducing sugar consumption through effective taxation on sugar-sweetened beverages and the accountability of the private sector, could not be reflected in this report.” In keeping with this, it promotes an overtly pro-business approach, actively encouraging governments “to engage constructively with the private sector—with the exception of the tobacco industry.”

Research has consistently demonstrated that the most effective and cost effective interventions to prevent mortality and morbidity associated with conditions such as hypertension, cardiovascular disease, and various types of cancer, as well as obesity and overweight, are “upstream” measures designed to limit exposure to the “lifestyle factors” associated with these conditions.[3] This includes measures to reduce consumption of tobacco, alcohol, and hyper processed food.

Again, the evidence base is clear on how these reductions can be achieved: by placing restrictions on the availability and advertising of these products and increasing their price—for example, through tax increases.[4][5][6] For the public sector, and state funded health systems, these approaches are relatively inexpensive to implement. In fact, they may even have a positive fiscal impact. These should have been identified as “best buy policies” within the WHO report, yet it fails to prioritise these over less effective alternatives, or to set out the rationale for governments to pursue such measures.

We know that the industries that produce these products vehemently oppose these population level measures (including tax based approaches), fearing that reduced consumption will mean reduced sales and profits. Instead, they promote individual responsibility, targeted interventions, and, crucially, partnership between industry in developing and implementing policy responses.[7] Research evidence, however, suggests that these measures are likely to be the least effective in changing consumption patterns and thus reducing NCDs. Moreover, the partnerships advocated by industry actors, and too frequently entered into by governments, create significant conflicts of interest, which explain, in turn, the enduring persistence of the ineffective policy regimes they advocate. It’s disappointing therefore that the WHO report reproduces this familiar, industry favourable agenda.

One exception to this pro-industry policy agenda is the increasing marginalisation of the tobacco industry in recent years, which has contributed to the accelerated pace of tobacco control. The specific exclusion of tobacco industry actors from policy making has been justified by a logic of tobacco exceptionalism: that the product poses a unique threat to health and the tobacco industry constitutes a uniquely malign influence on policy. Yet this idea is becoming increasingly harder to justify as our understanding of the health effects of products such as alcohol and processed food—and the NCD time bomb they are fuelling—grows. That the market and political strategies employed by the associated industries closely mirror those of big tobacco further undermines the current approach.[8]

Increasingly, the exclusion of the tobacco industry is being used not as an example for policy makers and global health actors to follow in relation to other health harming industries, but as a rationale for their continued engagement. The tobacco industry are the bad “other” against which the alcohol and food industries differentiate themselves as legitimate participants in policy forums. For policy makers, the exclusion of “big tobacco” is often held up to counter suggestions of industry influence. Yet we should not be complacent on this point. Embracing actors from any health harming industry is misguided given the scale of the current NCD crisis and their role within this.

The report name checks various global responses to NCDs and laments the disappointing progress made in achieving the targets they set. Yet this is unlikely to change when the current policy discourse merely replicates the same, industry favourable policies and partnership-based approaches.

The forthcoming UN High Level Meeting on NCDs in September 2018 offers a perfect opportunity for the global policy community to redress this and change tack decisively on NCDs. Adopting clearer regulatory guidance—including for taxation of sugar, tobacco, and alcohol—should be the first decisive step towards a unified approach to tackling NCDs globally.

Johanna Hanefeld is associate professor in health policy and systems at the London School of Hygiene and Tropical Medicine. Her research focuses on health policy and systems in low and middle income countries, including issues of migration, health systems resilience, and antimicrobial resistance.

Competing interests: I have read and understood BMJ policy on declaration of interests and declare I have no conflicts of interest.

Benjamin Hawkins is assistant professor in global health at the London School of Hygiene and Tropical Medicine. His research focuses on the role of the corporate sector in the development and implementation of health policy at the national and global level.

Competing interests: I have read and understood BMJ policy on declaration of interests and declare I have no conflicts of interest.

References

[1] Nishtar S, Niinistö S, Sirisena M, et al. Time to deliver: report of the WHO Independent High-Level Commission on NCDs. Lancet 2018. https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(18)31258-3/abstract

[2] WHO statement to establish high-level commission on noncommunicable diseases. WHO 10 October 2017. http://www.who.int/news-room/detail/10-10-2017-who-to-establish-high-level-commission-on-noncommunicable-diseases

[3] WHO. Tackling NCDs: “Best buys” and other recommended interventions for the prevention and control of noncommunicable diseases. WHO 2017. http://apps.who.int/iris/handle/10665/259232

[4] Babor TF, Caetano R, Casswell S, et al. Alcohol: No Ordinary Commodity: Research and Public Policy. Oxford University Press 2010.

[5] Blake MR, Lancsar E, Peeters A, Backholer K. The effect of sugar-sweetened beverage price increases and educational messages on beverage purchasing behavior among adults. Appetite 2018;126:156-162. https://www.ncbi.nlm.nih.gov/pubmed/29627346

[6] Sugar, Tobacco, and Alcohol Taxes (STAX) Group. Sugar, tobacco, and alcohol taxes to achieve the SDGs. Lancet 2018;391:2400-1. https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(18)31219-4/fulltext

[7] Moodie R, Stuckler D, Monteiro c, et al. Profits and pandemics: prevention of harmful effects of tobacco, alcohol, and ultra-processed food and drink industries. Lancet 2013;381:670–9. https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(12)62089-3/fulltext

[8] Hawkins B, Holden C, Eckhardt J, Lee K. Reassessing policy paradigms: A comparison of the global tobacco and alcohol industries. Global Public Health 2018;13(1):1-19. https://www.ncbi.nlm.nih.gov/pubmed/26998944