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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 [email protected]
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