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Three representatives of 'civil society' at the UN NCD summit last month: heavy hitters from AstraZeneca, PepsiCo, and the World Economic Forum

Have you heard the one about the English upper-crust tourist and the Irish peasant? It goes like this. The scene is a long, winding, rutted country road, whose signposts are broken, missing or in Gaelic. Tourist brakes his latest model saloon, consults a map, scratches his head. Paddy approaches. Tourist: 'I say, you fellow, tell me, is this the right road to Galway?' Paddy: (after a long pause) 'Well sor, (begob begorrah), if I was wantin' a right road to Galway, I wouldn'a be goin' from here'.

Was the summit a fiasco?

In a recent editorial, The Lancet foresaw that the UN High-Level Meeting on non-communicable diseases, whose Political Declaration was approved and published on 19 September, would be a fiasco – a disgraceful and dishonourable failure. Disagreeing, the Association sees the meeting as a first stage. But observers of the processes leading to the meeting, and of the event itself, including those with open hearts and minds, have had plenty of reason to agree with the Lancet prognosis.

There is no space here to give all the main reasons for gloom and despondency. To start, here in some detail, is just one. See the pictures above. They are of people who were billed in the official agenda of the UN High-Level Meeting as leading representatives of civil society, positioned as giving keynote statements at 'round tables' designed to guide policies. So who are they? On the left is David Brennan, chief executive officer of the pharmaceutical transnational corporation AstraZeneca. In the middle is Donna Hrinak, who after stints as US ambassador to the Dominican Republic, Bolivia, Venezuela and Brazil, is now vice president, global public policy and government affairs, at PepsiCo, the world's biggest manufacturer of ultra-processed snack products. On the right is Børge Brende, previously minister of trade in a Norwegian centre-right government, now managing director for 'government relations and constituents engagement', at the World Economic Forum. the champion of big deals between government and business, which involve the trashing of public interest regulations.

Some mistake? Not at all. The official list of civil society representatives invited to the Meeting included public interest organisations such as the Center for Science in the Public Interest, Consumers International, and Action on Smoking and Health. It also included health professional interest groups such as the International Diabetes Federation, the European Respiratory Society, and the American Cancer Society. Further, it included industry representative and risk management organisations, such as the International Federation of Pharmaceutical Manufacturers Associations (hence David Brennan), the International Food and Beverage Alliance (hence Donna Hrinak), as well as the World Economic Forum (hence Børge Brende).

You may think it is absurd to imagine that the Alcohol Prevention Youth Initiative, the National Heart Forum, and the Global Alcohol Producers Group, might sing from the same hymn-sheet, or could ever freely agree policies on say, access to and price of booze in supermarkets, and you would be right. You might also think that 'civil society' is a term that refers to charitable and non-profit organisations that in some way represent citizens, consumers, communities, and the public interest.

Here you might once have been right, but this notion is now evidently rejected as fuddy-duddy. Further, there is a rationale for what an innocent mind will see as a dishonourable and disgraceful coupling of big business with public interest groups. Access civil society on Wikipedia, and you will be referred to the London School of Economics (LSE) Centre for Civil Society, maybe the pole position think-tank on the topic. The Centre proposes that society as a whole is made up of the state, the market, and civil society. To quote: 'Civil society refers to the arena of uncoerced collective action around shared interests, purposes and values. In theory, its institutional forms are distinct from those of the state, and market... Civil societies are often populated by organizations such as registered charities, development non-governmental organizations, community groups, women's organizations, faith-based organizations, professional associations, trade unions, self-help groups, social movements, business associations, coalitions and advocacy groups'.

So what about the Mafia and Murder Incorporated, which are coalitions, self-help groups and business associations, if not faith-based in a conventional sense? Criminal organisations are not allowed. Oh, okay. But what this concept means, is that while Big Pharma, Booze, Sugar or Snack, in the form of individual corporations, are in 'the market' and not 'civil society', any time a bunch of corporations form an organisation to represent their collective interests or as a damage limitation exercise, preferably in non-profit form, hey presto, they are 'civil society'. To put this another way, take away government, and 'the market' (Newspeak for 'industry') and also remove bandits, and the rest is 'civil society'. Is the United Nations acknowledging and adopting this way of thinking? It looks like it, yes.

Is Big Booze good for public health?

Mind you, this does not entirely explain the composition of the UN High-Level meeting 'civil society' list. It also includes Big Pharma companies Novo Nordisk, Bayer Health Care, Hoffman La Roche, GlaxoSmithKline Oncology, and Sanofi Aventis, and Big Booze companies Diageo, SAB Miller, and Molson Coors Brewing. Various plenary speakers in New York identified the purpose of the High-Level meeting as 'health care', which may explain the identification of the drug industry as philanthropists. Positioning Big Booze as 'civil society' is trickier to rationalise. Perhaps they supplied the hospitality for the High-Level Meeting happy hours.

There is a serious question here. Does the United Nations and its relevant agencies agree that the interests of the alcohol industry are against the public interest, and that of public health? Yes, or no? If yes, why is Big Booze sitting round the UN table, briefed to help formulate global public health policies? If no, why not?

Watch our concepts

Now, let's return to the encounter between the upper-crust motorist and the Irish peasant. Finding where the right road begins, and finding the way not to Galway but to the 2012 and 2014 deadlines for concrete progress agreed at the High-Level Meeting, requires examination of the assumptions, and indeed the terminology, of the process so far. The sad story told above is one example. What is 'civil society'? What is 'the private sector'? When do interests conflict?

Big Tobacco is excluded from public health policy-making, because its interests are conflicting. Indeed they are. But why does this salutary thinking not apply to Big Booze? Why is Big Snack, the giant purveyors of energy-dense fatty sugary or salty ultra-processed products and sugared drinks, accepted as a full partner in policy-making designed to prevent obesity and related chronic diseases? And why no representation of business outside the food, drink and associated industries? And why within the food industry, are there no producers or indeed even retailers represented? Issues like these need addressing, otherwise the NCD prevention and control convoy will end up not where it wants to go, but in the drink. Fiasco, indeed.

With these thoughts in mind, Box 1 anatomises the current UN NCD roadmap. It expands the table we published last month. This time it shows some of the roads that are most as well as least travelled, in the final Declaration. As you will see, the superhighways, the concepts constantly mentioned, are partnerships between multisectoral stakeholders that lift burdens and speed the development of developing countries. No mention is made of the fact that so far at any rate, 'development' means, among other things, the displacement of traditional and established food systems by ferociously and recklessly marketed energy-dense fatty, sugary or salty products manufactured by transnational manufacturers. Indeed, no mention is made of transnational manufacturers, globalisation is mentioned once as an opportunity (for whom?) and 'the private sector' is simply positioned as a partner.

Sherlock Holmes once remarked that the solution to a knotty case was to be found in the fact that the dog did not bark. Indeed, what remains striking in the whole process leading to the High-Level Meeting is what is not in the final Political Declaration. As you can see from the red NO entries, indicating the paths that are absent – or ripped up, rather like the railways replaced by motorways – primary producers, rural economies, retailers, food systems and supplies, fish stocks, water, dietary patterns, meals, and specific food groups are not mentioned, and the one reference to cooking is use of smoky fuels. Fresh food? No. Food processing? One reference to industrially generated trans-fats. Energy density? No. Soft drinks? No. Quantified goals to prevent and control disease? Absent. Fat, saturated fat, sugar? With one exception, mentions of these are in the context of marketing to children, or processed food labelling. Any indication of what is meant by healthy diets? Only in references to WHO reports. Regulation and legislation? Apart from their use in tobacco control, mentioned only and 'as appropriate', as an option for governments.

Watch our language

In finding the right road, language needs to be watched. As Philip James indicates in his magisterial commentary published in WN last month, to limit NCDs only to those diseases of professional interest to the NCD Alliance is wrong, and this has been addressed rather well in the Political Declaration. But an explicit new definition is needed. Also, the term 'non-communicable diseases' needs a re-think. This is not a phrase that will get the juices of any politician flowing. A better phrase, albeit technically less accurate, is 'chronic diseases like diabetes, heart disease, and cancer'. All heads of government are likely to have a parent or sibling or child who has suffered or is suffering from these and other chronic diseases, if not themselves. The message gets across. Worse, is the acronym 'NCD', which feels like 'MOU' or 'E&OE' or 'RCT'. Will a producer of a prime-time television programme feature 'NCDs' on the backdrop of a crucial studio debate? No, obviously not. 'Obesity, diabetes, heart disease, cancer'? Yes.

While on the topic of misleading words and phrases, it is time to eliminate the terms 'developing' and 'developed' countries. It is absurd and insulting for instance, to label China, a country with four thousand years of continuous civilisation and culture, as 'developing' merely because the average income of its people is relatively low, whereas Saudi Arabia, ruled by people who were nomads a few generations ago, is 'developed' because of oil money. (No disrespect to tent-dwellers intended).'High-income' and 'lower-income' at least make clear what the term is referring to, although these terms give no indication of relative prosperity or impoverishment within any country. On this point, the Irish peasant's advice applies with special salience to the assumption made throughout the High-Level Meeting process, that global economic development is crucial. Joined-up thinkers will point out that more and more capitalisation, flow of money, and use of natural and physical resources, will turn the world into desolation. Rates of diabetes and cancer may be low in the Sahara and Gobi deserts but these are not the destinations to which we should be travelling.

Determinants of health and disease

The Political Declaration now agreed and issued, refers to the economic, social, political and environmental determinants of health. This is new, and is enlightened. Work on the implications of this conceptual framework is needed. The social determinants field is now cultivated. But, for example, what impact does the 'market' ideology, a political construct, have on world food systems and thus health, and risk of chronic diseases? And as one piece of a bigger environmental picture and thinking of all forms of malnutrition, bearing in mind the achievements of Wangari Maathai, who died last month, what impact does tree cover, availability of wood as fuel, and of accessible water tables, have on food and nutrition security and sustainability at local level and on malnutrition in all its forms, including childhood diabetes? Or, to glimpse the whole picture, what are the most important social, political, economic and environmental determinants of health and thus risk of chronic diseases? Work has been done on this but as yet there is no general agreement. There needs to be.

There is much work to do, to find a right road.

Acknowledgement and request

Readers are invited please to respond. Please use the response facility below. Readers may make use of the material in this editorial if acknowledgement is given to the Association, and WN is cited

Please cite as: Anon. Down from the UN NCD Summit. The right road. [Editorial] World Nutrition, October 2011, 2, 9: 458-464. Obtainable at www.wphna.org

The opinions expressed in all contributions to the website of the World Public Health Nutrition Association (the Association) including its journal World Nutrition, are those of their authors. They should not be taken to be the view or policy of the Association, or of any of its affiliated or associated bodies, unless this is explicitly stated.

2011 October. WN2. Editorial
Down from the UN NCD Summit: The right road

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