Nicholas Freudenberg

For public health advocates, the Rio+20 environmental summit last week was an important opportunity to connect better health with sustainability.  The government negotiators from 188 nations and the thousands of activists from around the world who attended the three-day meeting went home with mixed reviews of their success in moving towards “the future we want,” the conference slogan.

The Director-General of the World Health Organization (WHO), Dr. Margaret Chan, called Rio+20 a “victory for health” and said of the final report: “This focus on the links between health and sustainable development is critical. Healthy people are better able to learn, be productive and contribute to their communities. At the same time, a healthy environment is a prerequisite for good health.”  Chan also released a new WHO report, Our Planet, Our Health, Our Future. Human Health and the Rio Conventions: Biological Diversity, Climate Change and Desertification, that describes the links between health and sustainable development. Many nations made commitments for future action or financial support. For instance, the United States agreed to partner with more than 400 companies, including Wal-Mart, Coca-Cola and Unilever, to support their efforts to eliminate deforestation from their supply chains by 2020.

On a more negative note, Greenpeace executive director, Kumi Naidoo, said that, “Rio+20 has been a failure of epic proportions. We must now work together to form a movement to tackle the equity, ecology and economic crises being forced on our children. The only outcome of this summit is justifiable anger, an anger that we must turn into creative, thoughtful and meaningful action.” A coalition of NGOs wrote of their opposition to the final agreement, “The Future We Want is not to be found in the document that bears this name. The Future We Want is not what resulted from the Rio +20 negotiation process. The future that we want has commitment and action, not just promises. It has the urgency needed to reverse the social, environmental and economic crisis, not postpone it. It has cooperation and is in tune with civil society and its aspirations, and not just the comfortable position of governments.”

In my post on Rio+20 last week, I wrote that creating a healthier, more sustainable future will require a willingness to reconsider the role of multinational corporations in today’s world. At first read, the final summit document The Future We Want didn’t provide much hope on this front.  It did, however, address non-communicable diseases directly, an improvement over earlier drafts. 

The report acknowledges “the global burden and threat of non-communicable diseases (NCDs) constitutes one of the major challenges for sustainable development in the twenty-first century.” And, according to the NCD Alliance, a global coalition of NGOs concerned about non-communicable diseases, the report:

• committed  to strengthen health systems toward the provision of equitable, universal coverage and promote affordable access to prevention, treatment, care and support related to NCDs,
• committed to establish or strengthen multi-sectoral national policies for the prevention and control of non-communicable diseases, and
• reaffirmed the right to use TRIPS (trade-related intellectual property rights) flexibilities to protect public health and promote access to medicines for all, and encourage the provision of assistance to developing countries.

But while the 53 page report used the words “health” or “healthy” 54 times, it used the term “business” only eight times and the words “corporation” or “corporate” only twice. When business was mentioned, it was described as one more partner in global alliances for sustainability. Yet as I noted last week, the Third World Network, an NGO in Malaysia, said in their Rio+20 briefing paper, “If governments want to enable sustainable development, then they must regulate transnational corporations who are drivers of unsustainable development.” As at so many global conferences, multinational corporations remained largely invisible in Rio, immune from the scrutiny needed to reform their unsustainable and unhealthy practices.

One way that environmental and public health activists can move from speeches into action is to identify the specific ways that corporations undermine the environment and health. A good place to start might be to focus on the role of Big Agriculture and Big Food in contributing to human induced climate change and the rise of NCDs.  In a new series on Big Food and Health PLoS Medicine is publishing several articles that outline the health side of the challenge. An introductory editorial notes that “big multinational food companies control what people everywhere eat, resulting in a stark and sick irony: one billion people on the planet are hungry while two billion are obese or overweight.” A recent article in Lancet describes some of the environmental consequences of Big Agricultural practices and a recent report by Deutsche Bank estimates that agriculture accounts for 25 percent of greenhouse gases. What might be the common goals that could bring activists in these two sectors together?  Here are some suggestions for starting points:

1.  Support global, national and local efforts that nurture smaller scale agriculture, subsidize fruit and vegetable production, and reduce meat consumption. 

2.  Restrict advertising and promotion of unhealthy products such as fast food, sugar-sweetened beverages and processed snacks.

3.  Challenge companies that use philanthropic support of environmentalism and sustainability (e.g., Pepsi, Coke and Dr. Pepper, as described in one of the PLoS Big Food articles) to achieve “innocence by association” and to divert attention from their other harmful practices.

4.  Protect science and universities from corporate penetration and establish standards of integrity that prevent corporations from using science and scientists to defend their harmful practices and deliberately create doubt to thwart public health policy. (For a useful description, see the Union of Concerned Scientists report  Smoke, Mirrors & Hot Air.)

5. Affirm the precautionary principal (that requires products or corporate practices to be demonstrated to be safe before widespread dissemination) as a way of protecting public health and the environment.

6. Strengthen agricultural and food trade agreements to protect health and the environment.

Already environmental and public health activists around the world are working on each of these goals.  By developing a global common agenda and bringing together activists, scientists, local and national governments and local, national and global NGOs, we can begin to create the world we want for our children and grandchildren. 

 

Image Credits:

1. JorgeBRAZIL via Flickr.

2. World Resources via Flickr.

Last week, the World Health Assembly, the governing body of the World Health Organization, voted in Geneva to adopt a new global target of a 25% reduction in premature mortality from noncommunicable diseases such as cardiovascular disease, cancer, diabetes and chronic respiratory diseases by 2025. All governments will now be obliged to collect data on diabetes and NCD deaths, and report regularly on progress to the United Nations. According to WHO officials, this mandatory target has the potential to drive significant action on heart disease, diabetes, cancer and chronic lung disease across all countries.

Timothy Armstrong, coordinator of Surveillance and Population-based Prevention in the Department of Chronic Diseases and Health Promotion at the WHO, said, “This is a landmark decision on the prevention and control of NCDs. For the first time, we are moving away from aspirational goals to an action-based approach that will be anchored in quantifiable targets.”

Representatives of non-governmental organizations (NGOs) also celebrated this new resolution. Ann Keeling, Chair of the NCD Alliance and CEO of the International Diabetes Federation declared: “The adoption of this bold and ambitious target is a landmark event in the fight against NCDs. For the first time all governments will be accountable for progress on NCDs. The NCD Alliance and its members and partners around the world have worked tirelessly for nearly a year for this. On behalf of the hundreds of millions of people with NCDs, we are delighted to see this result.”

While the vote is a step forward – at the UN High Level Meeting on NCDs in New York City last September, governments concerned about austerity and fiscal constraints and representatives of the food, tobacco, alcohol and pharmaceutical industries worried about threats to profits from a determined global campaign to prevent NCDs joined forces to delay any specific targets for reductions in NCD deaths.

Several daunting challenges face effective action to prevent premature deaths and avoidable illnesses from NCDs. Currently, the provisions of trade agreements negotiated through the World Trade Organization or bilateral or multilateral agreements among nations often preclude the effective regulation of the tobacco, alcohol and food industries that have played a prominent role in creating the current burden of NCDs.  Ron Labonte and his colleagues explain these relationships in a recent report on international trade and chronic disease.    

In addition, these agreements protect the intellectual property rights of pharmaceutical companies, making it more difficult for emerging and low income nations to produce and distribute at affordable prices the medications that can help prevent complications from heart disease, cancer or diabetes. As a public health commentator in Australia asked about last week’s agreement, “Will World Trade Organization (WTO), World Bank and International Monetary Fund (IMF) policies help or exacerbate the problem?” In the past, these organizations have often promoted corporate-managed trade at the expense of public health protection. Another obstacle to effective action is the determined efforts by multinational corporations to avoid public health oversight. In the United States and the United Kingdom, two countries with a long history of public regulation, the food and beverage industries have recently launched mostly successful campaigns to thwart stronger regulation of the products most associated with diet-related chronic conditions. If the governments of two of the wealthiest nations are unable to stand up to special interests, what are the chances for many poorer nations?

In addition, new worries about economic growth in India and China, two countries with the largest number of people predicted to come down with NCDs in coming decades, may limit resources for public health prevention and further tilt these governments to adopt pro-market policies that contribute to NCDs.  As I noted in an earlier post, Coke, Pepsi and fast food companies have targeted China as their next growth area, ensuring a new generation of people with diet-related chronic diseases. 

Some have also questioned whether the UN has the backbone or muscle to stand up to special interest.  WHO is itself going through a complex re-organization, distracting top officials at least to some extent.  Some critics have also warned about the growing dependence of WHO on corporate and philanthropic funding, trends which might compromise its ability to speak clearly for health.

The resolution on NCDs passed by the UN General Assembly in September 2012 requires countries to develop and report back to the UN their national NCD plans in 2014. What can public health professionals do to ensure progress by that date?

One concrete starting place is the Rio plus 20 United Nations Conference on Sustainable Development to be held in Rio de Janiero on June 20-22.  At this meeting and in its aftermath, activists and governments can strengthen the ties between organizations and constituencies concerned about sustainable development and those concerned about NCDs.  Solutions to each require charting a new path that ends the promotion of patterns of consumption that threaten the planet’s future and create new epidemics of NCDs.  Charting policies that discourage the corporate promotion of unhealthy and unsustainable lifestyles and strengthening the capacity of governments and international organizations to act to protect public health and the environment are the broader goals of such an alliance.  Such an agenda can begin to catalyze the movements that will have the passion and power to suggest that another road to human development is possible.

Different nations have the potential to play different roles in creating a new ethic of healthy and sustainable consumption.  The wealthiest nations in North America and Europe can find new ways to re-create past successes in public health protection and apply them to the twenty first century challenges of growing inequality, persistent poverty and unsustainable consumption.  Emerging nations like China, India, Brazil and South Africa can experiment with new approaches to bringing the benefits of prosperity to large sectors of their populations without imposing on them the burden of premature mortality, preventable illness and unaffordable  health care costs now observed in many Western nations.   Finally, the poorest nations have the most to gain by continuing progress in reducing infectious diseases without going down the road that will bring them to high levels of NCDs.  All nations will encounter the determined resistance from  the multinational corporations that continue to profit from current patterns of NCDs.  Finding new ways to confront that force will determine whether counting NCDs, as now required by the World Health Assembly, can be a first step towards preventing them.

 

Image Credits:

1. UN Radio and Media

2. Dave Proffer via Flickr

A new report to be published in the American Journal of Preventive Medicine estimates a 33 percent increase in obesity prevalence and a 130 percent increase in severe obesity prevalence over the next two decades. By 2030, according to this forecast, 42 percent of Americans will be obese and 11 percent severely obese. The authors conclude that “if these forecasts prove accurate this will further hinder efforts for healthcare cost containment.” The authors also conclude that if obesity rates stayed at the 2010 levels, the combined savings in medical expenditures by 2030 would be $549.5 billion.

Another new report published in the Journal of Health Care Economics estimated that the total cost of health care associated with U.S. obesity is now $190.2 billion a year, or 20.6 percent of total U.S. health spending – twice as much as previously reported.

Last month, the US House of Representatives voted to eliminate the Prevention and Public Health Fund in order to pay for legislation dealing with student loans. Although the measure is not expected to pass the Senate and President Obama has vowed to veto it, by this vote the House proposed to eliminate one of the few streams of funding to support preventive measures to reduce obesity and other health problems that contribute to diabetes, heart disease and cancer.

Last week Public Citizen and the National Association of Consumer Advocates released a report called Justice Denied One Year Later. The report notes that in the one year since the U.S. Supreme Court’s decision in AT&T Mobility v. Concepcion, consumers have regularly been blocked from pursuing class-action cases. In its Concepcion decision, the court vastly expanded the reach of arbitration by ruling that corporations could block the consumers they force into arbitration from pursuing cases as a class.

According to the report:

Since Concepcion, judges have cited the case in decisions that stopped at least 76 potential class-action lawsuits from going forward. Several judges have expressed frustration that the decision has forced them to stop consumer actions that are best suited to proceed as class actions. Class-action lawsuits historically have provided a means to combat illegal payday lending practices, contest poor business practices and confront discriminatory auto lending. But Concepcion has left many consumers without a means to pursue redress.

In the case of tobacco, public health experts agree that class action lawsuits played a vital role in strengthening public health protection against a tobacco industry determined to make profits even at the expense of their customers’ health.

Whatever the intentions, by seeking to de-fund one of the few federal funding streams for prevention of obesity and other diet-related diseases and by denying consumers a powerful tool to change food industry practices that have been shown to contribute to obesity, the House of Representatives and the Supreme Court have voted to endorse the status quo of rising obesity rates.

 

Image Credits:

1. allgoodprovisions.com

In 1842, the United Kingdom and the Qing Dynasty of China signed the Treaty of Nanjing to end the first Opium War. A few years earlier, concerned about its trade imbalance with China, Great Britain began to export opium from India to China in order to cover its growing trade deficit generated by British imports of Chinese silk and tea. China resisted by confiscating Britain’s opium. In response, the British navy attacked China in 1839 and three years later China was forced to sign a treaty that required it to allow the importation of opium, an important precedent in global trade and China’s subsequent struggles with opium addiction.

Coke and Pepsi Expand

Last month, Muhtar Kent, Chairman and CEO of The Coca-Cola Company, inaugurated the opening of its 42nd bottling plant located in Yingkou, Liaoning, the largest Coca-Cola production facility in China. The new plant represents a US $160 million (1 billion in Chinese renminbi) investment in China, a small part of a three-year, US $4 billion investment plan announced last year. “China is a vast growth market for Coca-Cola. As we work to double the size of our global business in this decade, China will play a critical role,” said Kent. At its completion, the Liaoning plant is expected to reach an annual production capacity of more than 5 billion servings of sparkling and still beverages, including Coca-Cola, Sprite, Minute Maid and Ice Dew.

Sprite, one of Coca Cola’s 500 branded products available in China

Coca Cola, the world’s largest beverage company, offers its customers more than 500 sparkling and still brands including Coke, Diet Coke, Fanta, Sprite, Coca-Cola Zero, vitaminwater, Powerade, Minute Maid, Simply, Georgia and Del Valle. These beverages refresh consumers in more than 200 countries who drink more than 1.7 billion servings of its products a day. Coca Cola’s global beverage portfolio includes 15 brands that generate more than one billion dollars annually.

Nor is Coca Cola alone in expanding in China. In March, PepsiCo, Inc., the world’s second-largest food and beverage business (after Nestle) and the owner of 22 billion-dollar-a-year brands, announced a new partnership to create “a strategic beverage alliance” with the Tingyi (Cayman Islands) Holding Corp, one of the leading food and beverage companies in China.  As part of the alliance, a Tingyi subsidiary – Tingyi-Asahi Beverages Holding Co Ltd (TAB), one of China’s leading beverage manufacturers – will become PepsiCo’s franchise bottler in China.

In 2010, PepsiCo announced plans to invest US $2.5 billion in its China business over the next few years. Later this year, Pepsi plans to open its largest research and development center in Asia and a pilot plant in Shanghai, reports China Daily. The research center will employ more than 100 scientists who will develop new food and beverage products for China and the rest of Asia.

“China will soon surpass the United States to become the largest beverage market in the world,” said PepsiCo Chairman and CEO Indra Nooyi. “As a result of this new alliance with Tingyi, PepsiCo is extremely well positioned for long-term growth in China. Tingyi is an outstanding operator with a proven track record of success. By leveraging the complementary strengths of each company, we’ll be able to significantly enhance our beverage business in China, reach millions of new consumers throughout the country, and create value for Tingyi and PepsiCo shareholders.”

Pepsi for sale in a Chinese supermarket

US Soda Sales Go Flat

Together, Coca Cola and PepsiCo accounted for more than one quarter of the global beverages industry in 2010, according to Datamonitor, a global business research group. In the United States, however, reports Beverage Digest, soda consumption is going flat. Throughout most of the 1990s, soda sales in the United States grew about 3 percent annually but started to slow in 1999. Since 2005, sales have been in decline as consumers concerned about health turn to options they see as healthier, such as bottled water, juice and tea. In 2011, US soda consumption fell 1 percent. According to Beverage Digest, the top four sodas — Coke, Diet Coke, Pepsi-Cola and Mountain Dew — all saw declining sales last year. Of those, Coke’s market share was flat, while the other three lost share. In part, then, Coke and Pepsi’s enthusiasm for the China market is a response to this fizzling market for sugary beverages in the United States and Europe.

To boost sales and profits, Coke and Pepsi are aggressively marketing their sugary beverages in China.  Coke hired Knicks basketball superstar Jeremy Lin (actually born in Taiwan) to sell its products both in New York and overseas. In early March,reports Bloomberg News, about 100 million people in China watched the Knicks-Dallas Mavericks game on TV, offering Coke the opportunity of associating its Chinese logo with a rising sports star.  “For a global marketer like Coca-Cola,” Mark O’Brien, an executive with the advertising firm DDB, told a WNYC radio reporter, “you’ve expanded your audience reach from maybe amounts that are in the millions to amounts that are in the tens to hundreds of millions.”

Coke’s new salesman in China: Jeremy Lin

In its agreement with the Chinese company Tingyi, PepsiCo will retain control of branding and marketing its drinks while Tingyi is to oversee manufacturing, sales and distribution in China. As CEO Indra Nooyi said, “The strength of both companies will help make the products available for Chinese consumers in an affordable way.” In other words, PepsiCo’s global advertising savvy will be used to seek to bring a few hundred million Chinese into the Pepsi Generation.

Health Impact of Rising Soda Sales

From one perspective, growing the market for sugary beverages in China makes perfect sense. It offers two leading American companies an opportunity to grow as sales decline in their domestic market. In theory, it offers the United States an opportunity to balance its trade deficit with China, a perennial concern for American businesses and politicians. In practice, however, Coke and Pepsi do not make the drinks they sell in China in the US and in China, they hire mostly Chinese workers. Some portion of the profits does return to the United States and this constitutes a growing share of both companies’ revenues and return on investment.

But from a health perspective, the new trade in sugary beverages constitutes a disaster. In a 2010 article in the New England Journal of Medicine, Yang and colleagues estimated that 92.4 million adults in China have diabetes with an age-standardized prevalence of diagnosed and undiagnosed diabetes of 9.7 percent and of prediabetes, a precursor condition, of 15.5 percent. Moreover, like other countries around the world, China is experiencing rising rates of child obesity. In 2005, the prevalence of child obesity and overweight in big northern coastal cities in China reached 32.5 percent for boys and 17.6 per cent for girls, prevalence rates similar to many developed nations. One recent study concluded, “China is undergoing a remarkable, but undesirable, rapid transition…characterized by high rates of diet-related non-communicable diseases.”

While many factors contribute to rising rates of diabetes and obesity, increased consumption of sugar sweetened beverages (SSBs) plays an especially important role in these conditions and makes a logical target for intervention. A recent literature review by researchers at the Harvard School of Public Health concluded that “higher consumption of sugar-sweetened beverages is associated with development of metabolic syndrome and type 2 diabetes” as well as weight gain. The authors noted that “these data provide empirical evidence that intake of SSBs should be limited to reduce obesity-related risk of chronic metabolic diseases.” To increase production and marketing of sugary beverages in a country struggling with epidemics of overweight and diabetes is like pouring gasoline on a fire.

In assessing the impact of the Opium Wars and the Treaty of Nanjing, the eminent U.S. China scholar John K. Fairbankdescribed the British opium trade as “the most long-continued and systematic international crime of modern times.” Clearly, caffeinated sugary beverages are different from opium, although a new body of research does note the similarity between “hyperpalatable foods” such as fast food and sugary beverages and the neuronal pathways activated by opioid addiction. And clearly Coke and Pepsi’s new agreements with China violate no current laws or international standards of corporate conduct.

But it is also evident that the expanded production and marketing of sugary beverages in a country caught in the throes of epidemics of obesity and diabetes dooms many, many millions of people to premature death and preventable illnesses. Soda marketing will also impose huge burdens on China’s health care system, diverting resources from other national goals such as environmental protection and improved education.

In the 1970s and 1980s, health professionals and public health advocates succeeded in dramatically reducing tobacco use in the United States and other developed nations, preventing millions of deaths. But the unintended consequences of these public health victories were to push the tobacco industry to accelerate its marketing in developing nations. In the twentieth century, 100 million people died prematurely as a result of tobacco use, but in this century it is estimated that tobacco will cause one billion premature deaths, mostly in Asia, Africa and Latin America. Now it looks like Coca Cola, Pepsi and other multinational beverage makers will follow the tobacco play book, building markets in nations that have not yet begun to turn away from sugary beverages. In the next century, will our failure to prevent this assault on health rank as “the most long-continued and systematic international crime” of our times?

 

Image Credit for photo 3:

Teamstickergiant via Flickr.