Note: This post is a longer version of a correspondence that appeared in Lancet on August 13, 2011.
Alarmed that non-communicable diseases (NCDs), the world’s number one killer, now pose a growing threat to economic development, this September the United Nations General Assembly will convene its first High Level Meeting on NCDs in New York City. World leaders and public health officials will consider how to reduce the growing threat that cardiovascular disease, cancer, chronic respiratory disease and diabetes pose to population health, economic development and health care systems.
These conditions cause an estimated 35 million deaths annually; 80% occur in low and middle income countries and one quarter among people younger than 60 years of age. By 2030, NCDs will cause more than three quarters of all deaths in the world.
In preparation for the UN meeting, groups as varied as the NCD Alliance, a coalition of four global voluntary health organizations, the Commonwealth Heads of Government and theMillennium Development Goal Summithave proposed important but uncontroversial actions such as improving surveillance for NCDs, integrating NCD prevention and control into national health systems, making NCD prevention an economic development issue, and allocating more international assistance for NCDs.
The NCD Alliance has also recommended more controversial steps such as ratification and full and universal implementation of the WHO’s Framework Convention on Tobacco Control and the elimination of “all forms of marketing, particularly those aimed at children, for foods high in saturated fats, trans-fats, salt and refined sugars.” The most pressing question facing the UN meeting is whether participants will be willing to tackle the corporate practices of the tobacco, food, alcohol, automobile and pharmaceutical industries that have so significantly contributed to the global spread of NCDs.
How Corporations Promote the Spread of NCDs
A growing body of evidence demonstrates that how corporations create, market, retail and price their products has contributed to increases in NCDs. For example, food and beverage makers market products high in fat, sugar, salt and calories; increase portion size; target children with ads and video games promoting unhealthy food; lobby for policies that make unhealthy foods cheaper than healthier ones and export their least healthy products such as sugar-sweetened beverages, fast food, cereals and snack foods to low and middle income countries. The result has been rising rates of diet-related NCDs.
The alcohol industry advertises aggressively to young and problem drinkers, contributing to liver diseases as well as injuries and violence. The industry uses its political clout to stop excise taxes that would discourage youth and problem drinking and sponsors ineffective “responsible drinking” campaigns that compete with under-funded effective approaches and emphasize individual rather than social responsibility for discouraging problem drinking. The automobile industry produces cars that fail to use available pollution control technology, opposes stricter standards for pollution control, and resists policies that favor cleaner public transportation. Increasing evidence links auto pollution with chronic respiratory disease, heart diseases and cancer.
Tobacco is predicted to contribute to one billion premature deaths in this century. The tobacco industry manipulates nicotine levels to make cigarettes more addictive and promotes its products, especially to women and young people in developing countries, their emerging markets. By increasing the rate of women’s smoking through targeted advertising, the tobacco industry has helped to shrink the longevity benefit that women have long enjoyed over men, a perverse way of reducing inequities.
Finally, while the pharmaceutical industry has developed drugs that have helped to control NCDs, it also promotes inadequately tested or dangerous drugs to treat NCDs and invests in developing minor variations of patented drugs that are profitable rather than in cheaper, safer and more effective alternatives.
While NCDs have multiple causes, a growing body of evidence shows that their burden on global health are inextricably linked to the practices of a small number of global companies in industries that are becoming increasingly concentrated. Ten multinational food companies account for 80% of the global food and beverage advertising. The three largest tobacco companies sell close to two-thirds of the world’s cigarettes and a few companies produce most of alcohol the world drinks. Thus, altering the practices and policies of a few dozen corporations could substantially improve the prospects for preventing and managing NCDs but this requires political leaders to demand changes in some of the world’s most powerful corporations.
Making Corporations Accountable
To date, the business world has been remarkably successful in avoiding responsibility for its role in NCDs. It does this by exploiting or manufacturing several myths about chronic disease. First, many people see NCDs as the inevitable consequence of economic development and population aging, the collateral damage of progress. But many people now develop NCDs in early and mid-adult years, so their rapid growth is not simply a function of aging populations. China, Egypt, Jamaica and Sri Lanka have NCD mortality profiles similar to the US and other developed nations, contradicting the view that NCDs are the unique curse of better off countries. Business benefits from portraying NCDs as the unavoidable corollary of aging and development because this view spares closer scrutiny of the role of corporate practices.
Second, conventional wisdom posits lifestyle as the primary cause of NCDs: if only people ate better, moved more, smoked less and consumed less alcohol, the world could prevent many deaths and lower the costs imposed by NCDs. As a result, NCD prevention focuses on programs designed to change health-related behavior, often one person at a time. Of course individuals’ health behavior contributes to NCDs. However, no evidence demonstrates that the world’s population has recently become more gluttonous or susceptible to addiction. What has changed is the behavior of the organizations that shape the environments in which people make health decisions. Global expenditures for advertising increased from $50 billion in 1950 to $570 billion in 2005. In the last few years the number of corporate lobbyists working in the capitals of the United States, the United Kingdom, the European Union and wherever international trade negotiations occur has skyrocketed, giving business a disproportionate voice in the policy decisions that shape health and lifestyle.
Corporations and their political supporters insist that business has an important role in shaping NCD policies and promote a third myth that voluntary corporate codes are the most effective tool for changing their health-damaging practices. Last summer, UK Health Secretary Andrew Lansley invited Mars, Cadbury and Coca Cola to play greater roles in the national anti-obesity initiative and the development of new food regulations. Corporate health leaders at Pepsi Cola and other companies have called for more private-public partnerships to address NCDs. However, their claim that voluntary agreements for corporate social responsibility suffice to protect public health is not supported by independent assessments of such codes in the food, alcohol and tobacco industries.
Calls for public sector collaboration with businesses fail to acknowledge that many companies profit from promoting NCDs. Corporate managers are legally required to maximize profits and too often depend on business models that exploit biological vulnerabilities (e.g., a craving for high fat, sugar and salt diets), addictions, or social insecurities. Some companies may temporarily benefit from selling healthier food or promoting more responsible drinking but in the long run increasing consumption and market share usually require promoting disease rather than health.
In the final analysis, if the UN meeting is to make progress in stopping the rise in NCDs, participants will need to find the backbone to stand up to corporate propaganda and lobbyists. Specific policies that could put a dent in the incidence of NCDs include: tighter restrictions on advertising unhealthy products; laws and taxes that discourage companies from transferring or externalizing the health costs of their products onto consumers or tax payers; legal corporate codes of conduct that require global companies to disclose known health effects of their products and practices; and stronger restrictions corporate lobbying and campaign contributions in order to provide health advocates with a more level political playing field. Absent forceful political mobilization by social movements, local governments and health professionals and their organizations, it is unlikely that businesses will agree to such a platform but will instead argue for the incremental, ineffective approaches they have advanced so far. Stay tuned for further developments.
For Further Reading
Beaglehole R, Bonita R, Horton R, et al. Priority actions for the non-communicable disease crisis. Lancet. 2011;377(9775):1438-47.
Cecchini M, Sassi F, Lauer JA, Lee YY, Guajardo-Barron V, Chisholm D. Tackling of unhealthy diets, physical inactivity, and obesity: health effects and cost-effectiveness. Lancet 2010;376 (9754):1775-84.
Freudenberg N, Galea S. The impact of corporate practices on health: implications for health policy. J Public Health Policy. 2008;29(1):86-104.
Geneau R, Stuckler D, Stachenko S, et al. Raising the priority of preventing chronic diseases: a political process. Lancet. 2010;376(9753):1689-98.
Monteiro CA, Levy RB, Claro RM, de Castro IR, Cannon G. Increasing consumption of ultra-processed foods and likely impact on human health: evidence from Brazil. Public Health Nutr. 2011;14(1):5-13.
World Health Organization. 2008-2013 Action Plan for the Global Strategy for the Prevention and Control of Noncommunicable Diseases, 2008.
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