healthy caribbean coalition global ncd epidemic and civil society responses

Healthy Caribbean Coalition

Global NCD epidemic and civil society responses

Population 6,000,000,000

Total deaths per year 54,000,000 (0.9%)

Cardiovascular death 17,000,000 (31%)

44% coronary heart disease31% stroke78% in low income countries

AIDS 3,000,000Tuberculosis 1,000,000Malaria 1,000,000 (mostly in Africa)

Global causes of death

from Murray & Lopez The Global Burden of Disease 1996

0 500 1000 1500

Established market economies

Former socialist economies

India

China

Other Asia

Sub-Saharan Africa

Middle Eastern Crescent

Latin America

Coronary heart disease

Cerebrovascular disease

Number x 103

Regional differences in cardiovascular disease in 1990

Global trends• Increasing and inexorable increase in the

global burden of the avoidable chronic diseases

• We are united by common challenges and solutions

• Collective solutions• International determinants of health and

disease• Previously unintended consequences of

development• No excuses now! Public health has grown

up – un-natural experiments.

Global developments and trends• WHO commission on the social

determinants of health (2009)

• The causes of the causes and inequalities

• Social determinants of health – economic, ,fiscal, market, commercial, environmental, social ,cultural and civic

• Lifestyles shaped by determinants

• Necessary but not sufficient conditions

Global developments and trends

• Unsustainable demands on health and social services

• Breakdown of the intergenerational contract

• Public health is about the influencing the control of the determinants

• HIE’s and the spread of chronic diseases to MLIE’s

• Absence from the MDG’s

Global developments and trends • Tobacco, food and alcohol culture and

economy

• Consumption industries

• Globalisation

• Power of the vested industries

• The games they play

• Health creating culture an economy

• Light touch self regulatory world

• Regulatory challenges

Global developments and trends • CNCD”S have been neglected especially

ion low and middle income economies and by development organisations and Governments

• Global economic and social polices are driving the chronic disease pandemic

• Political failure not a technical failure-low cost effective solutions available

• Political opportunities for progress are available

Global developments and trends

• Political opportunities for progress are available –ECOSOC, UN high level summit

• WHO NCD strategy• WHO recommendations on the marketing of

foods And non alcoholic beverages to children

• WHO salt• FCTC• WHO commission - social determinants

Summary:

The evidence matters•Importance of social justice.•Empowerment at the heart

•Material – income•Psychosocial – control•Political- having voice

•Evidence•Social determinants.•Social gradient.

•Action•Improve daily life•Tackle distribution power, money and resources.•Understand problem

Population level determinants of lifestyles• Social

• Environmental

• Economic

• Cultural

• Commercial and market

• Global/EU

• Civic

• POLITICAL

The Public Health Challenges

• Commercial determinants of health

• Changes in (over) consumption largely driven by unfettered marketing

• Dietary and market transitions – UK phenomena last 25 years. Changing faster elsewhere in the world - accelerated by globalisation and growth in neo liberal market economies

• Market and regulatory failures

• Public health failures

The Public Health Challenges

• Challenging the domination of self regulation – a mostly flawed concept

• Challenging the soft paternalistic responses which widen health inequalities

• Protecting children and young peoples health

• No longer unintended consequences – collateral damage

• Policy convergence – joining forces e.g. the Lisbon agenda - sustainable equitable economic development

Main prevention trends over 1980’s onwards

• Integration of chronic disease prevention policy and action –ACD’s

• Lifestyle - Primary risk factors

• New population level risk factors - obesity

• Changing intergenerational risks

• Ecological approach – tackling the social, economic and environmental determinants

• Inter-sectoral

What levers are available and who is the honest broker?

Get ahead of the curve and do not repeat mistakes made elsewhere and learn fast via a connected of global civil society community

The role of civil society in promoting the publics’ health• Sustainable social change

• Trusted

• Independent

• Non ideological

• Advocacy – voice amplified by powerful alliances

• Voice of the less well reached

• Keeping public health a public good

• Population health measures

The role of civil society in promoting the publics’ health

• Countervailing force for the excesses of industry and unhelpful and unproven ideologies

• Champion of the public interest

TOBACCO CONTROL

The UK food culture and economy

FOOD AND PHYSICAL ACTIVITY LINKS

THE FUTURE

After a two-year tour of the United States, Michelangelo's David is returning to Italy...

His tour sponsors were:

Why a project on obesity?1994-96 1997-99 2000-02

Source: IOTF

Male

Female

Data shown for England and Scotland

Foresight

Tackling Obesities: Future Choices

Project key messagesMost adults in the UK are already overweight.

Modern living insures every generation is heavier than the last – “Passive Obesity”.

By 2050 60% of men and 50% of women could be clinically obese. Without action, obesity related diseases will cost an extra £49.9 Billion per year

The obesity epidemic cannot be prevented by individual action alone and demands a societal approach.

Tackling obesity requires far greater change than anything tried so far, and at multiple levels; personal, family, community and population.

Preventing obesity is a societal challenge, similar to climate change. It requires partnership between government, science, business, and civil society.

Humans are

endowed with an

ANCIENT

PHYSIOLOGY

moulded by

famine ...

… especially when we do so little!

.... and ill equipped to

handle our modern food

environment ….

Parallel to Climate Change• Complex problem

• Challenge for whole of society

• There is a danger that the moment to act radically and coherently will be missed

• A market failure

Synergies with other policy areas

Healthy Weight, Healthy Lives

Architecture and characteristics

Cross government

Multi-sectoral

Environmental determinants

Population and individual

Whole systems impact

Multiple interventions

Natural experiments

Lifecourse

The big Five – the foods that most concern us

Snacks

Fast foods

Confectionery

Sweetened cereals

Soft drinks

Energy-dense and salt rich foods: contribute high proportion of calories to the dietencourage passive over-consumptionoften displace other healthier foods.

The recommended diet vs the advertised diet

Around three-quarters of food advertising to children is for sugary, fatty and salty foods. For every £1 spent by the WHO promoting healthy diets, £500 is spent by the food industry promoting unhealthy foods

The processed food culture and economy

Cadbury’s – chocolate for sport?

1 netball = 20,000 kcal

1 volleyball = 72,000 kcal

2 net posts = 1,200,000 kcal

How popular Pepsi is!

Marketing to children

Give them your phone numberDownload their ring-tones

Marketing methods candy counting books

Equip the team...with McDonalds

Nutritional food labelling

Colour coded front-of-pack labelsQuick and easy for all social groupsEnables shoppers to accurately assess and compare products One universal scheme on all brands in all shopsPressure / praise for retailers and companiesFrame the arguments for EU regulation?

Outcomes• Product reformulation• Nutrient profiling established• Industry wide adoption of front of pack

nutrient signpost labelling• Industry behaviour publicly exposed• Opposition to industry’s flawed labelling

schemes to force a proper debate at EU level and set the scene for the review of the EU labelling directive

GDA report – February 2007

Real change in behaviour

Sales of Sainsbury’s Ham and Pineapple thin and crispy pizza 335g down by 55% (One red, two amber and two green - WoH)

Sales of Sainsbury’s Ham and Pineapple Pizzeria 356g up 42% (All green - WoH)

NICE - IPTFA’s –policy goal

Ensure all groups in the population are protected from the harmful effects of IPTFA’s

IPTFA’s - Natural experiments• Voluntary action

• Mandatory action – content and labelling

• Content – Denmark (at source) and New York

• Labelling – Canada, USA and PAHO (plus tax incentives)

• Labelling promotes product reformulation and substitution

• Marks and Spencer

Effect on bad LDL cholesterol

Effect on good HDL cholesterol

Saturated fat Raise ~

Trans fat Raise ~

Plant sterols and stanols

Lower Raise

Polyunsaturated fat Lower Raise

Oily fish and omega 3 oils

Lower Raise

Mono unsaturated fat Raise Raise

Effect of different fats on cholesterol

Bad

fa

t

Good

fat

Evidence summary:Country Time period Intervention Outcome

Finland 1972 – 1995 Mixed, incl.Low fat dairyAgriculture

Tot chol ↓ 17%

Norway 1975 - 1993 Mixed, incl.SubsidiesHealthy food

Tot chol ↓ 10%

Mauritius 1987 – 1992 Cooking oil switch

Tot. chol ↓ 0.82mmol/L

Poland 1990 - 1999 Veg. cooking oils & spreads

CHD ↓ 26%

Civil Society contributions• Advocacy - provide leadership where absent

from Government or accelerate the achievement of National goals

• Monitoring – self regulation codes

• Canvass public opinion

• Champion the public interest

• Counter industry distortions in partnership forum

• Essential democratic element –proxy citizen/ consumer group

• Policy research and development

Article in The Grocer – 17 March

The Healthy Food Code: what it brings

In home and

out of home

Addresses supply and

demand

All food – diet, meals,

snacks, caterers …

Healthier food

choices

The health and food

‘ask’ in one place

Action for all and

industry leaders

What is a health-creating economy?

• An economy that minimises the risks of avoidable chronic diseases that arise from the business practices of companies, and by government/EU policies that govern or influence their behaviours

• Focus on food, tobacco, alcohol & transport

Supply and demand policy levers

SOME KEY UPSTREAM POLICY LEAVERS THAT SHAPE THE CULTURE AND MARKET

FOOD MARKETING

FOOD LABELLING

FOOD REFORMULATION

NUTRIENT PROFILING

SCHOOL FOOD

COMMON AGRICULTURAL POLICY

PUBLIC FOOD PROCUREMENT

SOCIAL MARKETING

What other policy leavers?Taxes and subsidies

Socially responsible investment

Independent monitoring particularly of industry based self regulation

HIA fully integrated in RIA’s and wider economic appraisal

Statutory regulation of marketing

Product standards

Agricultural policy

NICE - Common Agricultural Policy

• 2013 reforms

• Public health enshrined in EU law as a public good

• CAP spending – health comprehensively factored into impact assessments

• Shift from pillar one to pillar two mechanisms –nutritious foods such as fruit and vegetables whole grains and lean meats

PUSH… and PULL…

Taxes and levies

Statutory regulation

Monitoring corporate practices

Engaging NGOs ↔

Incentives & subsidies

Voluntary controls

Socially Responsible Investment (SRI)

Engaging NGOs

Adam Smith The wealth of nations 1776

Sugar, rum and tobacco are commodities which are nowhere necessities of life, which are become objects of almost universal consumption and which are extremely proper subjects of taxation.

2000s: solid evidence

“The scientific evidence is compelling. Physical activity not only contributes to well-being, but is also essential for good health.”

Professor Sir Liam DonaldsonChief Medical Officer,Department of Health

Transport and health

Take action on active travel asks

100 plus organisations

Ambitious targets for walking and cycling

10% transport budget – create safe attractive conditions

Make 20 mph or lower the norm for residential streets

Health check all transport an dland use decisions

Tackle bad driving

Reports

A life-course approach eg. changing the nutritional balance of the diet

Rigorous food procurement/provision standards in public institutions

0-6 months 

Breast feeding

6-24 months

Improved weaning advice

0-4 years 4-16 years 16-65 years 60+   

Nutritional standards for pre-schools

Transformation of school food

Guidelines for workplace canteens

Nutritional standards for elderly care

The hazards associated with upstream measures

Dogma dilemma's• “What evidence and who care’s”

• Informing not lobbying –language political discourse

• David and Goliath

• Nanny state

• Children

• Public and professional support

• Precautionary principle

• Human rights

Dogma dilemma's

• Cost savings

• ST benefits

• Co-benefits

• Comprehensively understand markets and different forms of regulation-do not be out smarted

• Nuffield ladder of interventions

Covert consumption industry goals and behaviour

Grow the market, increase profits and shareholder value

Slow down regulatory reforms

Seek Government: Industry partnerships and seek to exclude civil society groups

Capture civil society organisations-set up BINGO’s

Sponsor government relations work

Industry strategy continued:

Maintain existing markets and grow new ones

Work in self regulatory cartelsObsfucation of issues - produce industry

bias researchDiscredit PINGO’sCreate counter marketing on nanny state

issuesCSR –commercial propaganda

Industry strategy continued:

Threaten to move industry base

EU and Global levels – protect unfettered commercial rights as absolutes and maximise the supremacy of these freedoms

Government and civil society responsesOnly establish tripartite partnerships

Combine HIA with RIA and wider economic appraisals

Adopt “polluter must pay” principle

Commission independent comprehensive monitoring

Secure independent industry technical expertise

Support international governance solutions

Continued

In short term - secure enabling international legislation

Utilise human and civil rights legislation

Establish highly responsive broadly based consumer and health advocacy alliances

Greater utilisation of civil society advocacy as part of the social marketing mix

Concluding remarks

• CNCD’S trends unsustainable

• We have the public health know how

• Industry and ideological interests

• Determinants of ACD’s and inequalities

• Transformational role of civil society

The National Heart Forum

• Membership- 70 national organisations

• Chronic disease charities, professional, consumer and social policy organisations

• Policy development, advocacy and information

• Predominant focus on upstream national and international level policy and action

• Ecological, determinants based, social justice and health promoting approach

NHF functions

AnInternational/

National Centre of Excellence

Policy Research

Information Services

Consultation/Representation

Policy Development

Members Forum

Co-ordination/Collaboration

Diagram one

NHF scope of work

Primary prevention of

Avoidable Chronic Diseases

Cancer

Stroke

DiabetesObesity

CHD

Hypertensive diseases

Disease and Health Inequalities

Health andWellbeing

Diagram two

NHF strategic partnerships

NHF Members and

Partnerships

ConsumerOrganisations

Government

Chronic DiseaseCharities

Academia/Research

Social PolicyOrganisations

InternationalGovernmental Organisations

andNGOs

ProfessionalOrganisations

Diagram three

NHF Values and Principles

• Expert and evidence based

• All work underpinned by pursuit of equity and social justice

• Promoting early intervention and throughout the life course

• Tackling the root causes

• Maximizing social, economic, environmental co –benefits wherever possible

•

NHF Values and Principles

• Remain independent of commercial and party political interests

• Act in the public interest and with the publics’ support

• Scale and seriousness of the epidemic means focus on high impact interventions

What probably makes a civil society network successful ?• Integrity

• Independent of vested and ideological interests

• Dialogue not partnership that sells the soul

• Shared values and goals

• PINGO’s and BINGO’s

• Connected – nexus - real time information

• Become a player- “plugged in” where it maters- act on the inside and the outside

What probably makes a civil society network successful?• Movers and shakers-public health hero’s -

calculated risks

• Non compromised charities, professional, consumer, social policy and academic groups

• Powerful individual members and patrons

• Common issues

• A social movement

• Strategic –smart and tactical

• Focus and clarity about goals

What probably makes a civil society network successful?• Advocacy – clarity – always be the voice of

reason and reasonableness – acting in the public interest –advocacy bullets

• Public opinion• Play to strengths of different advocacy

styles across membership• Media links –salience• Ability to respond quickly• Handling controversy• Forum - hot topics – common positions

What probably makes a civil society network successful?• Respect differences and have caveats to

not necessarily represent everyone• Handling controversy –rapid responses• Human rights and freedoms• Policy acumen• Upstream high impact work downstream

support• Don’t delude your self – do things that

matter-do not get sucked downstream instead remove the sewage

What probably makes a civil society network successful?• Marshalling and promulgating evidence

and expertise

• Argue cost effectiveness and cost savings

• Rock solid ethics

• Leadership and co-ordination- clear priorities

• Cross sector and cross government

• Productive and respectful links to senior civil servants

What probably makes a civil society network successful?

• Mandates for change- social marketing mix - professional and political mandates

• Good governance: Wise governance –keep organisations and people linked

• Good organisation

• Work together- play each other in - trust-solidarity

• Legal protections- cover your back

• Quality

What probably makes a civil society network successful?• Representation

• Consultations- voice

• Transparency and openness

• Membership surveys - sensitive close working links

• Democratic working

• Collective bids

• Gossip, intelligence and ideas

What probably makes a civil society network successful?• Power of a public interest alliance

• Energy, enthusiasm and passion

• Develop political acumen – nanny state arguments, children, ST benefits, cost savings, co-benefits

• Cross party political support for issues

• The hallmark/touchstone of an effective functioning democracy

Political literacy – new lexicons?

• Lifestyle necessary but not sufficient

• Behavioural determinants-population level interventions

• Nudge theory – supply and demand side incentives – default choices

• Choice architecture

• Nuffield ladder of interventions

• Upstream diversions

“Walk before you can run but always stand up high”

To subscribe e-mail Nicola Schmidt at nicola.schmidt@heartforum.org.uk

Beyond smoking kills

TobaccoNew strategy focus children and inequalities

– beyond Smoking Kills

Tobacco free society

Ban smoking in all public places -5 years

Total ban -10 years

Reintroduce above –inflation price escalator for tobacco products

Abolish prescription charges- NRT

Tough new targets for tobacco smuggling