PHM-Exch> Pub hlth nutrition professionals’ comments on Time to Deliver: WHO Indep High Level Commission on NCDs

[Claudio Schuftan]

FYI

4 August 2018



Public health nutrition professionals’ comments on

Time to Deliver in 2018: WHO Independent High Level Commission on
Noncommunicable Diseases (NCDs)





Ahead of crucial negotiations at the United Nations High Level Meeting on
NCDs (UN HLM) to take place in New York in September 2018, we, the
signatories of this letter, researchers, civil society members and
advocates, would like to voice our concerns with the report “Time to
Deliver” launched 1 June 2018 in Geneva (
http://www.who.int/ncds/management/time-to-deliver/en/).

We wish to raise concerns regarding both the content of the report and the
private sector’s interference in the report’s development.

We write this letter to provide a civil society perspective that is not
adequately represented by the Civil Society Statement put forward 5 June
2018 by the NCD Alliance (
https://ncdalliance.org/news-events/news/ncd-alliance-statement-of-concern-poltical-declaration-un-hlm-on-ncds).
Although some of the concerns voiced in the NCD Alliance letter are similar
to our own, the NCD Alliance has a governance structure that is
compromised, thus limiting the power of the arguments it makes. The NCD
Alliance is engaged with pharmaceutical and other transnational
corporations that are at odds with the aims and objectives of public health
nutrition.  At least 46% of the NCD Alliance budget comes from the
pharmaceutical industry and related industries. This puts the Alliance in a
conflict of interest situation in much of its work. Therefore, with this
letter, we wish to outline our concerns separately.



We are concerned with several of the recommendations made in the
report “Time to Deliver”, We also want to draw attention to
well-supported recommendations that have been offered by other
institutions, even by WHO itself, that were not considered in Time to
Deliver Annex 1 highlights specific comments on the document, and
Annex 2 provides our recommendations for future work of the
Commission.



We would also like to raise questions about the private sector´s influence
on and possible interference with the Commission and its outputs. We are
particularly concerned about the participation of representatives on the
High-Level Commission who have previously been linked with the sugary drink
industry and representatives from the World Economic Forum which partners
with 100 companies.  We are also concerned that the NCD Alliance, an
organisation that, as we explain above, is seriously compromised, should be
the only organization tasked with representing public interests on the
Commission.



Public-interest civil society groups have raised concerns previously about
the private sector´s influence in the NCD-related work of WHO, for example,
when launching the Conflict of Interest Coalition during the 1st UN General
Assembly on NCDs, demonstrating the concern of 161 NGOs to keep policy
setting free from commercial influence.  Additionally, some of us have also
stressed (in a letter in May 2017) serious concerns over the membership of
the Working Group convened by WHO as part of the preparatory process for
the 27 September 2018 High-level Meeting on the prevention and control of
non-communicable diseases (NCDs).

In conclusion, we recommend that there should be a zero-tolerance policy
with regard to the involvement of food and beverage industry, tobacco,
alcohol or pharmaceutical industries or members and organizations with
conflicted interests, especially within the membership of the Commission
and the Working Group.  And, when referring to engagement with the private
sector, all the work of WHO’s Independent Commission on NCDs should be
aligned with previous recommendations.



The “*Framework Convention of Tobacco Control”* (FCTC) is a good starting
point to highlight the relevant risks of engaging with the private sector
and can serve as a model for NCD prevention in terms of how to address the
risks of engaging with the tobacco, alcohol and Big Food and Beverage
industries. Guidelines on how to perform a risk assessment, including due
diligence in interactions with the private sector, must be explicit parts
of the report “Time to Deliver” as a minimum standard.



The signatories strongly believe that if guidance on this matter is not
clear and vested private sector interests continue to prevail in the public
health policy arena, it will seriously hamper efforts to achieve the NCD
targets in most of the Member States.



Finally, as signatories, we are appalled that the Report does not mention
the right to adequate food and nutrition as a central issue in the NCDs
debate and in its key role in the years left of Agenda 2030.



1. Alejandro Calvillo, El Poder del Consumidor, Mexico

2. Alessia BIGI, IBFAN-GIFA, Switzerland

3. Angela Carriedo, Communications secretary, World Public Health Nutrition
Association, UK

4. Arun Gupta, Regional coordinator IBFAN Asia, India

5. Barbara Nalubanga, Cochair IBFAN Global, Uganda
6. Barrie Margetts, Emeritus Professor, Faculty of Medicine, Southampton, UK

7. Beverley Ann Lawrence Beech, Past Hon Chair, Association for
Improvements in the Maternity Services, UK

8. Carlos Monteiro, Professor of nutrition and public health, University of
Sao Paulo, Brasil

9. Claudio Schuftan, External affairs secretary, World Public Health
Nutrition Association, member steering council PHM, Vietnam

10. David Sanders, Emeritus professor, University of Western Cape, and
global co-chair PHM, South Africa

11. Elizabeth Sterken, Co-chair IBFAN Global and Secretary World Public
Health Nutrition Association, Canada

12. Flavio L. Schieck Valente, FIAN International and Universidad de
Pernambuco, Brasil

13. Geoffrey Cannon, Center for Epidemiological Studies in Health and
Nutrition, University of Sao Paulo, Brasil

14. George Kent, Emeritus Professor, University of Hawaii, USA

15. Helen Crawley, First Steps Nutrition Trust, UK

16. H.P. Sachdev, Pediatrics and Clinical Epidemiology, Sitaram Bhartia
Institute of Science and Research, India
17. Hooi Choo, International Code Documentation Center, Malaysia

John Mason, Professor Emeritus, Tulane School of Public Health and TM, USA

18. Jorge Vega Cardenas, Health Workers for All Coalition, Netherlands

19. Kaleab Baye, Director, Center for Food Science and Nutrition, Addis
Ababa University, Ethiopia

20. Katherine Pettus, International Association for Hospice and Palliative
Care, USA

21. Laura Michéle, FIAN International, Germany

22. Margaret Miller, President, World Public Health Nutrition Association,
Australia

23. Maria Alvim Leite, doctoral student, University of Sao Paulo, Brasil

24. Marisa Macari, El Poder del Consumidor, Mexico

25. Marta Trejos, IBFAN Latin America and the Caribbean, Costa Rica

26. Mira Shiva, Initiative for Health Equity in Society, India

27. Nicholas Freudenberg, City University of New York School of Public
Health and Health Policy, USA

28. Olivia Yambi, Policy and Projects Secretary, World Public Health
Nutrition Association, Tanzania

29. Patrick Durisch, Health program coordinator, Public Eye, Switzerland

30. Patti Rundall, Baby Milk Action and IBFAN UK, UK

31. Radha Holla, Independent researcher, India

32. Regina Keith, Treasurer, World Public Health Nutrition Association,

33. Roger Shrimpton, Adjunct Professor, Tulane School of Public Health and
TM, Portugal

34. Sabrina Ionata Granheim,  Independent consultant, Norway

35. Sara Gardunio, Membership secretary, World Public Health Nutrition
Association, Kuwait

36. Ted Greiner, Editor of World Nutrition, World Public Health Nutrition
Association, Brasil

37. Valerie McClain, writer, USA
38.Vandana Prasad, Public health Resource Network, India











ANNEX 1 Comments on specific recommendations made in the report





·       “Time to Deliver” does not provide a clear focus on an action plan
on priorities for the global south. This, as the 40 million deaths
attributed to NCDs every year, are driven by the influence of the permanent
and expanding presence of unhealthy food and beverage industries, even in
the poorest areas lacking basic needs such as clean drinking water.  These
deaths are wrongly attributed in the report to “*accidents of geography and
poverty that are tragically cutting lives short*”. This, of course, implies
that such deaths are natural and unavoidable rather than being driven in
large part by the unhealthy eating practices ultra-processed food
industries promote and profit from and that poverty is inevitable and not
an effect of a system that reproduces inequality and exclusion.

·      Among the recommendations made to member states (MS) to introduce
cost-effective interventions, there is no explicit recommendation made for
a 20% sugar-sweetened beverage (SSB) tax to reduce SSBs consumption,
despite established evidence of the relationship of sugar consumption to
diabetes and obesity and evidence of widespread excessive consumption far
above WHO recommendations. In 2016, WHO published a recommendation to
include fiscal measures to limit the consumption of sugary drinks as one of
several interventions to tackle obesity and diabetes.  We believe this
recommendation must be explicitly re-stated as a cost-effective
intervention in this document, as it has been proven to be so in modelling
studies and in countries where it has been implemented.

·      Recommendation 2 (p.19) mentions that MS should set NCDs as a
priority on national agendas but does not prompt or highlight the “best
buys” priorities for the NCDs on the agenda mentioned in previous UN and
WHO documents which have explicitly highlighted the relevance and
importance of reducing the harm of unhealthy diets as a major contributor
to NCDs.

·      Access to health care and improved health systems is highlighted (p.
21), but access (incl. physical and economic) to healthy, natural or
minimally processed foods and culinary preparations (that promote
traditional diets), as well as sufficient and affordable water and
sanitation --that are key determinants of healthy diets and good
nutrition-- are not mentioned explicitly in the recommendations. This
ignores the accumulating evidence of the effect these factors have on NCDs.
 Attention to food systems and the policies shaping them, from production
to consumption, is crucial for producing changes in diets, preventing
different forms of malnutrition--including overweight and obesity--and
reducing NCDs.  The report is silent on the major policy reforms needed in
this area, including those policies that support and protect small and
medium scale producers who produce the foods that form the base of
traditional diets and culinary cultures.

·      We believe that WHO’s role should be to guide policy makers on
regulations and other public health policy measures to prevent NCDs/promote
healthy diets, and to ensure that interactions with the private sector are
appropriate.  We strongly disagree on how recommendation 4 numeral I (p.
24) is presented in the document: “*WHO should support governments’ efforts
to engage with the private sector for the prevention and control of NCDs…”*.

·      Recommendations are made to create a forum with investors to shift
health portfolios that “*should include attention to agriculture and food
production, the introduction of health and nutrition impact measures of
investment and the role of public investment to shape private investments*”
(p.27).  We believe this recommendation is a loophole that invites COI
situations, as private corporations are given a green light to influence
private and profitable priorities in ways that may override or ignore any
public health intervention.

·      Contrary to recommending the concomitant establishment of a forum
with other organizations with academia, foundations and public interest
civil society organizations (and other actors with non-commercial
interests), we merely find a suggestion of setting up a forum (“*could be
created*”- p.27).  This undermines the importance of the role of
public-interest actors in supporting governments in the design of
preventive policy packages.

·      The mechanisms to increase financing on NCDs are said to
include a “*Global
Solidarity Tobacco and Alcohol Contribution*” under recommendation 5,
numeral B (p.27).  We do not believe any of these industries should be
involved in financing NCDs prevention, as their primary interests (i.e., to
increase profitability and returns on investment to shareholders), are in
conflict with prioritizing public health and NCDs prevention

·      The recommendation on exploring the establishment of a multi-donor
trust fund to catalyse financing should explicitly outline safeguards that
adequately protect policy setting and implementation from conflicts of
interest (recommendation 5, page 27).  The report only bans the tobacco
industry in such mechanisms but promotes the inappropriate involvement of
corporations such as non-alcoholic beverages, pharmaceutical, food and
alcohol industries.

·      Recommendation 4 addresses engagement with the private sector,
academia and civil societies, with appropriate mechanisms to promote
transparency and accountability.  Engaging with the private sector with the
exception of the tobacco industry is recommended: “*Governments should be
encouraged to engage constructively with the private sector—with the
exception of the tobacco industry*” (p. 23).  It remains painfully unclear
to us how such guidelines or “*engagements*” will bring about transparency
and accountability as mentioned and suggested.  It considers “*fresh
relationships should be explored with the food, non-alcoholic beverage…
industries*” (recommendation 4, Numeral I, p. 24). As mentioned, we believe
none of these industries should be included, particularly after pointing
out that progress in reducing NCDs has been particularly slow because of
the huge influence these industries have over policy makers.

·      The report explicitly calls for involving industry in policy making
including regulatory measures: “*governments should work with: food and
non-alcoholic beverage companies in areas such as reformulation, labelling
and regulating marketing*” (recommendation 4, numeral C, p. 23).  This is
highly problematic and should be removed.

·      Additionally, this recommendation mentions:  “*Governments could
also encourage economic operators in the area of alcohol production and
trade to consider ways in which they could contribute to reducing the
harmful use of alcohol in their core areas, as appropriate, depending on
national, religious, and cultural contexts*” (recommendation 4 Numeral C.
p.23).  This, in our view is not strict or adequate enough to prevent
problems associated with advertising and promotion that encourage the
consumption of alcohol, which is harmful to mental health and contributes
to other NCDs. Government regulations to protect public health is to be
paramount and cannot be replaced by industry self-regulation.

·      Recommendations on including multi-stakeholder mechanisms, such as
NCDs commissions and “*equivalents of the Global Coordination Mechanism*”
open the door to undue influences in policy setting. They fail to address
power imbalances and conflicts of interest as has been demonstrated by the
case of the SUN initiative.

·      The engagements proposed with industry will definitely undermine the
recommendation given: “*Governments should employ their full legal and
social powers to achieve public health goals and to protect their
populations. This includes policy and legislative and regulatory measures
that minimize the consumption of health-harming products and promote
healthy lifestyles.*” (recommendation 4, numeral I p.24). The proposed
engagements with food corporations will undermine and risk legal and social
powers, as industry participation on the agenda setting for a given
regulatory proposal might water down the legal and social instruments (e.g.
reducing the amount of a SSBs tax, procure auto-regulation measures, ease
nutrient criteria parameters) or the implementation process (by
volunteering or participating in its evaluation).

·      Furthermore, the specific recommendations at the end of the document
do not include targeted recommendations to reduce alcohol use. They do not
address issues of food and nutrition literacy for people living with
diabetes or heart disease and are focused on pharmacological treatments
only.

·      For the recommendation on preventing NCDs through early nutrition
interventions, reducing the consumption of ultra-processed foods by infants
and young children, including through effective marketing regulations,
implementing the International Code of Marketing of Breastmilk Substitutes
and subsequent relevant WHA Resolutions is essential.

·      The documents to monitor and evaluate progress do not include a
reference on how to address COI and including, accountability and
transparency indicators of interactions and engagements with the private
sector.



ANNEX 2.  General recommendations



Reformulation of products as a voluntary strategy by industry is *not* a
solution. It helps industry white-wash its image, while keeping consumers
hooked on ultra-processed foods.



Private-public partnerships as a mechanism to go forward are highly
problematic in that they water down public health policies and erode
accountability of governments to people.



Addressing NCDs also requires fundamental reform of the current trade and
investment regime, including the Codex Alimentarius, to ensure that public
health and the environment, rather than corporate profit are the primary
focus. For example, simple food labelling strategies have been highly
contested in several member states by companies under investment treaties.



Recommendations on how to perform a risk assessment of all interactions
with the private sector, due diligence of potential partnerships, and
safeguards that ensure arms-length relationships with the food and beverage
industry must be explicitly part of the Report as a minimum standard.  Although
the document titled: “*Safeguarding against possible conflicts of interest
in nutrition programmes. Draft approach for the prevention and management
of conflicts of interest in the policy development and implementation of
nutrition programmes at country level*”, (
http://www.who.int/nutrition/consultation-doi/comments/en/) has been an
initial attempt to guide MS on how to manage engagement with the private
sector, we believe it is still insufficient.  Engagement with the private
sector risks bringing potential vested interests to the strategies proposed
by MS on their NCDs policy. Therefore, explicit wording to this effect must
be included in the Report.
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