Due to a rapid rise in rates, non-communicable diseases (NCDs) have become a major concern in the global health community. The World Health Organization (WHO) recognizes four main NCDs: cardiovascular (including heart disease and strokes), cancers, diabetes and chronic respiratory disease (WHO, 2018). Although NCDs have become a top issue in global health, they have received minimal funding compared to other diseases. Council of Foreign Relations Senior Fellow for Global Health and Seton Hall University Professor, Yanzhong Huang, explains, “In 2008, NCDs became the leading causes of death in the world, with roughly 80 percent of NCD-related deaths occurring in low- and middle-income countries. Yet according to an Institute of Health Metrics and Evaluation report, only 1.7 per cent of development assistance for health (DAH) went to NCDs in 2014, compared to the 61 percent set aside for MDG priorities—HIV/AIDS (30.3 percent), MNCH (26.9 percent), and tuberculosis (3.8 percent)” (Huang, 2016).
Policymakers have often overlooked NCDs because they are associated with lifestyle choices and are difficult to categorize. Causes can vary between poor diet, a sedentary lifestyle, substance abuse, high stress, and environmental pollution. NCD rates, however, have been “outpacing the improvement of developing country governments’ health and regulatory systems. As a result, more people are falling susceptible to NCDs faster and suffering more chronic disability than expected” (Bollyky, 2013).
The rapid increase in NCDs has posed a challenge to state and non-state actors in how to respond to the global health problem. Indiana University Law Professor David P. Fidler argues there is a lack of governance architecture and an “open-source anarchy” that impacts any global health strategy. He identifies a plethora of state and non-state actors who don’t have a cohesive approach to solving global health issues. Separate actors have their own set of priorities which can compete with another’s, and no party welcomes restrictive policies. “The process of bringing order to unstructured plurality confronts the resistance of both States and non-State actors to have their prerogatives and freedom of action restrained” (Fidler, 8). Yet, a potential reframing of global health leadership occurred in 2016 when the United Nations introduced seventeen Sustainable Development Goals (SDGs). The SDGs were intended to replace the Millennium Development Goals (MDGs) and are much larger in scope. They emphasize domestic funding vs. donor charities, which reiterates the state as the leading actor in global health governance.
The state, however, has been hesitant and ill equipped to take on such a major global health role. “The existing governance structure is such that nonstate actors would resist attempts to significantly restrict their freedom of action…[and] given the resource constraints faced by all countries in achieving their health-related SDG targets and their reduced dependence on donor support, public-private partnerships in financing and delivering health services become all the more important” (Huang, 2016). Yet, in the midst of open-anarchy, there is a dire need for the state to assertively manage global health actors, especially on the NCD front.
Although the state relies on public-private relationships and funding, a conflict of interest arises when private sector agendas fail to align with global health strategies. Some private industry practices have been linked to rising NCD rates, with the food industry as a main example. According to a 2018 joint report issued by the WHO and United Nations Development Programme (UNDP), agricultural and seafood production, crop cultivation, livestock management, and the sugar industry bear directly on this problem. “The food and agriculture sector is inextricably linked with NCDs…‘Big food’, ‘big sugar’ and ‘big beverage’ industries try to obscure proven links between unhealthy diet, obesity and poor health…It is important that governments are not unduly influenced by these industries when developing policies” (WHO, 2018). Industry brands are often household names, and only a few corporations own the major international food companies: “Nestlé, PepsiCo, Coca-Cola, Unilever, Danone, General Mills, Kellogg's, Mars, Associated British Foods, and Mondelez each employ thousands and make billions of dollars in revenue every year” (Taylor, 2016).
Although there is a consensual consumer relationship and a free market component, food industry practices surrounding certain ingredients and environmental pollutants have been directly linked NCDs and population sickness. The WHO and UNDP stated that “particular attention must be given to livestock practices because livestock, primarily cattle, is responsible for deforestation and almost 15 percent of human-induced greenhouse gas emissions. The inappropriate use of antibiotics in animals is also a leading cause of rising antimicrobial resistance. Pesticides and chemicals used in food production are underlying causes of various cancers in farming-communities and consumers. Biodiversity loss due to industrial agricultural practices threatens nutritional diversity and health” (WHO, 2018).
Additional NCD research reveals that “unhealthy diets, malnutrition, and NCDs are closely linked…foods with salt, sugars, saturated fats, and trans fats have become cheaper and more widely available.Furthermore, global demand for and supply of meat, dairy products, sugar sweetened drinks, and processed and ultra-processed foods has increased dramatically” (Branca et al., 2019).
Major food industry practices have a direct impact on health and NCD rates, while corporate funding directly influences global health policy. The World Health Organization “came under pressure to withdraw and water down measures it was proposing in its Global Strategy on Diet, Physical Activity and Health, as they were perceived as threatening to the sugar industry. The sugar industry had written several strong letters to the Director General of the WHO…and threatened to lobby Congress to withhold US contributions to the WHO” (Elbe, 118).
Despite clear WHO measures, such as “restricting marketing of unhealthy foods to children, taxing sugar sweetened drinks, or banning industrial trans fats” (Branca et al., 2019), less than one third of countries have integrated WHO recommendations into policy. “Commercial interests, including the agri-food and drink industries, have large budgets to use on a variety of tactics—from lobbying decision makers to stirring public resistance—to undermine public health policy…The challenges of achieving policy coherence and implementing multisectoral action across governments—in the face of competing priorities and budgetary constraints, short term political gain, and lack of accountability—should also be acknowledged, along with the challenges of collecting reliable data to inform policy and report on progress, or its lack” (Branca et al., 2019).
Food industry budgets have also been known to influence research released to consumers.JAMA Internal Medicine revealed the sugar industry paid three Harvard scientists to publish a 1967 review on the relationship between sugar, fat and heart disease (Kearns, 2016). The publication downplayed the link between sugar and heart disease while redirecting attention to fats. The studies were handpicked by the sugar industry, which point towards evidence that the industry has shaped health research for the last several decades.
A 2015 New York Times article reported that “Coca-Cola, the world’s largest producer of sugary beverages, had provided millions of dollars in funding to researchers who sought to play down the link between sugary drinks and obesity. In June, The Associated Press reported that candy makers were funding studies that claimed that children who eat candy tend to weigh less than those who do not” (New York Times, 2016).
How can the state help prevent private sector economic agendas from affecting global health progress and research, primarily when it comes to NCDs? Research and recommendations have already been provided by the United Nations Decade of Action on Nutrition (2016-2025), the 2030 Sustainable Development Agenda and Goals, the Paris Agreement, Agenda 2030, and the 2014 Rome Declaration of ICN2. These entities and agendas “present an unprecedented opportunity to transform food systems, eliminate malnutrition in all its forms, prevent diet related NCDs, and realize the human rights to food and health” (Branca et al., 2019). Strategies outlined in the 2018 joint WHO-UNDC report include:
1. Import/export duties to make nutritious foods (e.g. fruit, vegetables and fresh fish) more affordable, and foods that are high in fat, sugars and/or salt less affordable.
2. WHO’s Global Strategy on Diet, Physical Activity and Health, the International Code of Marketing of Breast-milk Substitutes, and WHO’s recommendations on the marketing of foods and non-alcoholic beverages to children.
3. School feeding programmes/lunches that are safe and nutritious with limits or bans on products high in fat, sugar and/or salt. Linking local farmers and suppliers to schools.
4. Eliminating/replacing trans-fats from the food supply and supporting efforts to reduce the population’s intake of salt.
5. Increasing excise taxes on energy-dense and nutrient-poor foods and beverages.
Some countries have begun to implement stricter food industry regulations: “Mexico’s sugar tax has reduced consumption of sugary drinks, while generating over US$ 1 billion in government revenue. Consumption declined most in low-income Mexicans, who are most vulnerable to NCDs and their consequences. Thailand has a new excise tax on sugary drinks as of September 2017.Tonga has, year-on-year, extended increased import duties on tobacco, SSBs, alcohol, and food high in fat” (WHO, 2018). The state is inevitably in the spotlight when it comes to upholding global health strategies and combatting NCDs. Countries who have begun to engage and regulate food companies have taken an important step in recognizing core causes of NCDs. As the leader in global health funding, however, it will be important for the United States to make similar changes if NCD rates are going to diminish. As Fidler notes, “Good governance is governance that gets beyond ideas and good intentions and engages in the heavy lifting of applied ideology” (Fidler, 15).
Bollyky, Thomas J. “Big Data, Better Global Health.” Council on Foreign Relations. Council on Foreign Relations, February 21, 2013. https://www.cfr.org/expert-brief/big-data-better-global-health.
Branca, Francesco, Anna Lartey, Stineke Oenema, Victor Aguayo, Gunhild A Stordalen, Ruth Richardson, Mario Arvelo, and Ashkan Afshin. “Transforming the Food System to Fight Non-Communicable Diseases.” The BMJ. British Medical Journal Publishing Group, January 28, 2019. https://www.bmj.com/content/364/bmj.l296.
Elbe, Stefan. Security and Global Health: toward the Medicalization of Insecurity. Cambridge: Polity, 2010.
Fidler, David P. “Architecture amidst Anarchy: Global Health’s Quest for Governance.” Global Health Governance, December 31, 2012. http://blogs.shu.edu/ghg/fidler_architecture-amidst-anarchy-global-healths-quest-for-governance_spring-2007/.
Huang, Yanzhong. “How the SDGs Will Transform Global Health Governance.” Council on Foreign Relations. Council on Foreign Relations, January 28, 2016. https://www.cfr.org/expert-brief/how-sdgs-will-transform-global-health-governance.
Kearns, Cristin E. “Sugar Industry and Coronary Heart Disease Research.” JAMA Internal Medicine. American Medical Association, November 1, 2016. https://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2548255.
O'connor, Anahad. “How the Sugar Industry Shifted Blame to Fat.” The New York Times. The New York Times, September 12, 2016. https://www.nytimes.com/2016/09/13/well/eat/how-the-sugar-industry-shifted-blame-to-fat.html.
Taylor, Kate. “These 10 Companies Control Everything You Buy.” Business Insider. Business Insider, September 28, 2016. https://www.businessinsider.com/10-companies-control-the-food-industry-2016-9/.
“What Ministries of Agriculture Need to Know: Non-Cummicable Diseases.” United Nations Development Program. The World Health Organization and The United Nations Development Program , 2018. https://www.undp.org/content/dam/undp/library/HIV-AIDS/NCDs/Agriculture English.pdf.