UN Summit on Non-Communicable Diseases
Who’s in charge?
Two battles that WHO needs to win: Breastfeeding to 2 years and beyond
and control of advertising of processed products to children (right)
Geneva. Senior World Health Organization officials are in a tight spot. They are determined to ensure that the UN Summit on Non-Communicable Diseases (to be held at UN headquarters in New York this coming September), will uphold and strengthen WHO's policy positions on control and prevention of major chronic diseases, including diabetes, cardiovascular disease, and common cancers. These positions record the agreements made by all UN member states convened by WHO at its annual World Health Assemblies. Nevertheless, some could be undermined in New York. .
Two of these agreements, the basis for the UN Global Strategy on Infant and Young Child Feeding, and for current UN policy in the marketing of ultra-processed food and drink products to children, are briefly summarised in Box 1 and Box 2, below. These two are chosen here because both concern the health of young children, which tracks to adolescence and throughout life.
Breastfeeding: Lifelong protection
WHO maintains its position that breastfeeding is in all normal circumstances crucial for the health of the child, at the time and throughout life. This includes specifying that infants and young children should be breastfed exclusively for 6 months, and that breastfeeding should continue until 2 years of age and beyond, with suitable complementary food. This is illustrated by the picture above, left, of a 2 year-old looking forward to his meal of fresh food.
Pressure from the baby food industries, to dilute or divert messages on breastfeeding, remains intense. These include recruitment of UN officials as industry executives. Also in recent years UNICEF, the lead UN agency concerned with the health of children and their mothers, has paid more attention to ready-to-use therapeutic food, to treat and prevent malnutrition, and comparatively less attention to breastfeeding. Further, a number of recent publications have doubted the need or wisdom of extended exclusive breastfeeding. Given the scale of the infant formula and baby food industries, $US billions every year are at stake.
The UN Global Strategy on Infant and Young Child Feeding, agreed by WHO and UNICEF in 2003:
Positions breastfeeding as: 'An unequalled way of providing ideal food for the healthy growth and development of infants';
Supports employed women to: 'Be helped to continue breastfeeding by being provided with... for example paid maternity leave, part-time work arrangements, on site crèches, facilities for expressing and storing breast milk, and breastfeeding breaks.'
States that: 'Virtually all mothers can breastfeed, provided they have accurate information and support within their families and communities and from the health care system.'
WHO needs to maintain its position on infant and young child feeding, on paper and in reality, most of all in impoverished regions of the world where food supplies are insecure and water supplies are unsafe. In winning battles on breastfeeding, WHO officials may decide to yield ground at the New York Summit to conflicted industry on issues seen to be of somewhat less crucial importance to human health.
Why may WHO be undermined at the New York Summit? 'The most obvious reason is that WHO is starved of resources' says Association publications secretary Geoffrey Cannon, who has served as a member of the UK, and then the Brazilian, government delegations, to WHO meetings at which global nutrition and food policies are determined. He added: 'The current WHO senior officials in our area are excellent, committed, and independent, in the best tradition of the international civil service. But the WHO department of non-communicable diseases has only pitiful amounts of discretionary funds'.
He added 'This is one compelling reason why WHO, in common with other UN agencies, has espoused "public-private partnerships" including with conflicted transnational industry. These "partnerships" give industry powerful leverage, but so far have been a source of misery and frustration to UN officials'. Thus, the distinguished public health advocate Janet Voûte, having been hired by WHO to work at the highest level brokering partnerships with industry, left after a couple of years to become the global head of public relations for Nestlé.
A related issue was explained by Association Council member Fabio Gomes, a member of the editorial team responsible for these briefing notes. 'The colossal food and drink corporations, now often known as Big Snack, whose products are causing obesity and related diseases, have literally billions of dollars or euros at their disposal. They use their power skilfully, to make friends and influence people, and also to win over key players to their cause. Their position is that their products are harmless or good for public health. Alternatively, they say that if there is any problem, they will solve it themselves, without any disagreeable and divisive statements from the United Nations, let alone legislation from national governments. However, there is no good evidence that voluntary agreements made by industry are having any discernable effect on the incidence of obesity and of chronic diseases'.
WHO protects children from food marketing
A fundamental issue, in work to control and prevent overweight and obesity and associated diseases, is the advertising and marketing of energy-dense and other unhealthy food and drink products to children. This is illustrated by the packets of two ready-to-eat sugared breakfast cereals in the pictures above, right. The examples shown are as marketed in Latin America. Here, WHO has taken a strong lead.
Ala Alwan ,WHO Assistant Director-General of Noncommunicable Diseases and Mental Health, has stated that: 'The marketing of foods and non-alcoholic beverages with a high content of fat, sugar or salt reaches children throughout the world. Efforts must be made to ensure that children everywhere are protected against the impact of such marketing and given the opportunity to grow and develop in an enabling food environment — one that fosters and encourages healthy dietary choices and promotes the maintenance of healthy weight.'
This follows a Resolution of member states at the 2010 WHO World Health Assembly. The Resolution endorsed the WHO Action Plan for the Global Strategy for the Prevention and Control of Noncommunicable Diseases. In the Action Plan, member states are enjoined to
'Prepare and put in place, as appropriate, and with all relevant stakeholders, a framework and/or mechanisms for promoting the responsible marketing of foods and non-alcoholic beverages to children, in order to reduce the impact of foods high in saturated fats, trans-fatty acids, free sugars, or salt'. Also:
'Given that the effectiveness of marketing is a function of exposure and power, the overall policy objective should be to reduce both the exposure of children to, and power of, marketing of foods high in saturated fats, trans-fatty acids, free sugars, or salt.'
'Governments should set clear definitions for the key components of the policy, thereby allowing for a standard implementation process... When setting the key definitions, Member States need to identify and address any specific national challenges so as to derive the maximal impact of the policy.'
'Governments should be the key stakeholders in the development of policy and provide leadership... for implementation, monitoring and evaluation. In setting the national policy framework, governments may choose to allocate defined roles to other stakeholders, while protecting the public interest and avoiding conflict of interest.'
Here, WHO has gone probably as far as it could, in indicating that national governments must take the lead. WHO stops short of specifying that statutory legislation, including policies affecting price and availability – as used with cigarettes and alcoholic drinks – are a necessary part of overall policies to control advertising to children. Such a position would have been opposed by a number of powerful member states. But the WHO statement does state that the statutory approach needs serious consideration. The transnational food and drink manufacturing and associated industries are determined to stay in control, in a climate very strongly inclined to partnerships that include them as key actors in policy discussion and determination.
The positions agreed by UN member states at WHO assemblies on breastfeeding and food marketing to children, link with WHO's overall Global Strategy on Diet, Physical Activity and Health. This is designed to enable national governments and all other actors – including industry – to prevent chronic diseases and to promote good health and well-being, nationally and worldwide. The scientific basis for the strategy is an expert report, Diet, Nutrition and the Prevention of Chronic Diseases, published in 2003. The chair and vice-chair of the committee of scientists responsible for this report were Association members Ricardo Uauy and Shiriki Kumanyika. It was preceded by a report with the same title published by WHO in 1990. Chair of the expert panel responsible for this earlier report was Association founder member Philip James.
Current WHO public policy positions have a solid scientific foundation. This has however been constantly undermined by those sectors of industry whose products, consumed regularly, are harmful to personal and population health. A summary of attacks on the 2003 expert report is contained in the book The Republican War on Science This gives an account of the combined pressure of the 2000-2008 US administration and transnational industries, to discredit the 2003 report and thus the WHO Global Strategy.
Will the Obama administration support WHO at the New York Summit in September? Will WHO itself be able to withstand external and internal pressures to compromise its key policies? Can UN secretary-general Ban Ki-moon afford to oppose industry on any significant matter? In one form and another, Big Food and Big Drink will be present at the Summit, and in massive force, in the UN headquarters building. Will they also be sitting at the tables where new policies are agreed? This seems likely. WHO has a big battle ahead.