Access pdf of this editorial here
Access pdf of editorial on conferences here
Access pdf of commentaries on the use of law in Latin America
Access pdf of commentary on the use of law in New York City here

Public health champions from the UN, Mexico, Brazil, Costa Rica, Chile:
Is this now the dawning of a new age for our profession and for our cause?

This editorial introduces the series of commentaries published in this issue of World Nutrition. These surely mark a significant stage in moving the principles of public health nutrition into policies and actions in the public interest. The commentaries have been commissioned by Enrique Jacoby of the Pan American Health Organization in Washington DC, pictured left in the strip immediately above, who has recently acted as the deputy minister of health of Peru.

The commentaries have Latin America as their focus: appropriate this month, which is the occasion of the triennial conference of the society of Latin American nutrition societies (SLAN) being held in Havana, Cuba, between 11-18 November. President of the Havana conference is Manuel Hernández Triana, left in the picture at the top of this editorial, together with his predecessor Eduardo Atalah, president of the previous 2009 SLAN conference held in Santiago, Chile.

Partnerships in the public interest

The stories told in the commentaries can be applied to other continents. Their lessons are global. They are written by leaders of the public health movement in Latin America. Four of the seven are Association members. In the picture strip above they are, after Enrique, Juan Rivera and Sonia Hernández Cordero of the Mexican National Institute of Public Health, a branch of Mexico's national government; Fabio Gomes of the Brazilian National Cancer Institute, a branch of the Brazil's national government; Leonardo Garnier, Costa Rican minister of education; and from Chile, Cecilia Castillo, who has worked within government and now is a civil society leader, and Marcela Reyes of the Chilean National Nutrition and Food Technology Institute, part of the University of Chile which is linked with the national government.

Implicit in the commentaries is the theme of this editorial. This is that the partnerships needed now throughout the world, to confront, control and prevent obesity and related chronic non-communicable diseases, are public-public partnerships. Strategies to prevent disease and to promote good health and well-being, need to be worked out and agreed between actors with no conflicted interests. The role of that sector of industry whose interests conflict with those of public health is of course crucial in the stage of implementation, once strategies, including the wise use of law, are agreed. Food is not tobacco, but the same general principles now well understood for tobacco control, apply also to the control of energy-dense fatty, sugary or salty ultra-processed products (1-3).

Obesity: an uncontrolled pandemic

The specific context of the commentaries is the need to control and prevent childhood overweight and obesity. This is now a worldwide epidemic – a pandemic – that is out of control, as now is early-life diabetes in many countries. Young people with diabetes will live with the disease for perhaps half a century or more, and the costs of its treatment in countries like India are projected to exhaust the total of all health care public funds by or before 2025.

A reason for the so far irresistible rise of obesity in children is of course the very rapid rise in production and consumption of energy-dense fatty or sugary processed food and snack products and sugared drink products (1-4). In turn, to go deeper, the cause of what has become a phenomenal change in the global food system, is of course the still dominant 'free trade' ideology, which has created the modern version of 'red in tooth and claw' capitalism practiced by vast transnational food and drink product manufacturers. Meanwhile, as the UN Food and Agriculture Organization and Oxfam have recently pointed out, nearly a billion people remain food and nutrition-insecure and often hungry. A reason for this is food price rises and fluctuations, of which one cause is speculation in staple foods, now treated as a commodity like any other (5,6).

The duty of governments

The commentaries all emphasise the need for national governments to do their duty to protect public health, specifically by regulating and restricting the advertising and promotion by transnational and other food and drink product corporations of what in Chile is known as comida chatarra – junk food – to children. They also amount to a wake-up call for everybody committed to working in the public interest, in ways that among other things will support and encourage socially responsible food producers, manufacturers, distributors and caterers.

Superficially, the stories told in the commentaries, with the partial exception so far of the central American republic of Costa Rica, are depressing. In their detail, what they show, are attempts by dedicated champions of public health at national level, from universities, civil society organisations, and government departments, overworked and often even working in their free time, to counter transnational corporations with vast resources and global strategies. The picture is of scattered groups of people with pea-shooters confronting armies possessing nuclear power.

The commentaries show that the strategy of the transnational food and drink corporations is the same the whole world over. Leading food and drink product manufacturers are superficially competitive with one another. But they have the same general plans, which they agree at meetings with their representative organisations, and then enact.

One of these plans is to offer to reformulate their ultra-processed food and drink products according to their own criteria, so that the products contain somewhat less fat or saturated fat or sugar or salt. In return, the manufacturers gain the right to advertise and promote these somewhat less unhealthy products as healthy, often with 'premium' prices (3). Another is to insist on their right to make their own rules and set their own timetables on reformulation of what are intrinsically unhealthy products, and to set and strongly influence the agenda of discussions nominally convened by UN agencies or national governments, graced with the name of 'public-private partnerships'.

Big Snack makes friends

A further policy of the transnational food and drink product manufacturers, also known as Big Food or Big Snack, is to give financial and other material support to the public institutions they seek to influence. As one of innumerable examples that could be given, last year McDonald's in Brazil partnered with the Brazilian federal ministry of health, to produce a guide to fitness and health aimed at children, as shown here. The point here is not about McDonald's specifically. It is one example of the way in which the transnational food and drink product corporations seek to make friends with and to influence powerful people, such as ministers of national governments.

Brazilian health minister Alexandre Padilha and McDonald's CEO Marcelo Rabach launch Brazilian official health messages that promote burgers

The photograph above shows a promotion launched in May last year for which the Brazilian health ministry and McDonald's were jointly responsible. Brazilian federal Health Minister Alexandre Padilha (left) and McDonald's Brazil CEO Marcelo Rabach (right) are holding up a poster. This includes various tips designed to encourage children towards 'health and balance', by running, dancing, playing football, sleeping well, staying out of the sun, eating vegetables and fruits, and in the centre at the bottom of the poster, an advertisement for McDonald's. On the other side is information not originated by the health ministry. This is a list of the nutrients contained in many McDonald's products. These are compared with Brazilian 'day to day' foods, such as traditional snacks, pizza, and the Brazilian national weekend dish feijoada. McDonald's in Brazil have used the poster as table-mats in their Brazilian outlets, indicating that burgers are endorsed as healthy by the Brazilian government.

'Public-private partnerships'

Such informal 'public-private partnerships' involve technical skills and resources and visibility supplied by the private corporations whose products collectively are harmful to public health. They make it hard for public servants working in government who are concerned with the impact of energy-dense fatty, sugary or salty ultra-processed snacks and sugary drinks on public health, to persuade ministers that among other things, rocketing rates of childhood overweight and obesity amount to a crisis that requires regulation and restriction of unhealthy food and drink products.

The same point applies to the formal 'public-private partnerships' that in this century have been endorsed and officially welcomed by United Nations agencies and national governments. In principle, alliances between public bodies inside and outside governments, and industry, are right. But in practice, the partnerships now established are not with industry as a whole, nor with the food and drink industry as a whole. The private 'partners' are transnational food product manufacturing corporations whose products collectively are harmful to health, and whose formal duty is to protect their sales, profits and share price, which they do by aggressive advertising and promotion of their branded ultra-processed snack, drink and other products.

The way the transnationals work is more evident in the global South than in the global North, whose high-income countries are already saturated with ultra-processed ready-to-consume products. For the transnationals the action is in the global South, where they plan and project and are achieving, 'double-digit' growth, meaning 10 per cent plus increase in sales every year. One result is displacement of traditional or long established food systems and dietary patterns suitable for local climate and terrain. Another result is even more evident: rapid rise in overweight and obesity and in related chronic non-communicable diseases (1-4).

Transnational muscle

Their ways to achieve this also follow a general plan, evident from accessing their annual reports and the trade press. One part of the plan is to take over national industries. Another is to buy land to grow the raw materials for their products. Another, as shown in our commentaries, is to mount legal challenges to any right of national governments to protect the health of their people. In this respect the judgement of the Costa Rican constitutional court, reported in the commentary by education minister Leonardo Garnier, is of special and international value:

'The State should safeguard the health of its inhabitants, especially children… Freedom of trade is secondary to more relevant interests, such as supporting students in their comprehensive formation, which implies not only education in the sciences and arts, but also in good eating habits that form to a great extent the basis of human health'.

But as warned in all the commentaries, including that from Brazil by Fabio Gomes and from Chile by Cecilia Castillo and Marcela Reyes, decisions taken by legislators in national governments can be overturned as unconstitutional in national courts, and even then, when upheld as in Costa Rica, can be challenged as impediments to free trade by invocation of the international rules of the World Trade Organization. Leading food and drink product transnationals have annual sales figures equivalent to the gross domestic product of middle range countries.

So what can be done, in the public interest and for the public good? Perhaps the first reason for hope, is that the cause of all those concerned to control and prevent childhood obesity, with all this implies, is just. A second reason for hope, as Enrique Jacoby says, is that there is not much serious doubt about how to achieve this. The right approach is what is being attempted in Latin America and countries throughout the world. This is to reform food systems, so that healthy fresh and minimally processed food is relatively cheap and more available, and so that ultra-processed energy-dense fatty, sugary or salty products are relatively expensive and less available. For children, this means restriction and even prohibition of ultra-palatable snacks and drinks in schools and other places of education.

One of the lessons evident in the commentaries is that at the moment, as indicated above, the transnational corporations 'hunt as a pack'. They use the same arguments and strategies everywhere. By contrast, leaders in governments and professional, civil society and other non-government organisations are scattered. This month a move is being made to correct this, with a special meeting convened by Juan Rivera on 25-26 November, together with the Chilean National Institute of Nutrition and Food Technology and the Latin Parliament. As stated, 'the purpose of the meeting is to strengthen the movement throughout Latin America to agree rational and effective regulations designed to control overweight and obesity in children. Participants in the meeting will include politicians and civil servants, lawyers, public health and civil society organisations, educators and journalists'.

What our profession can do

Above, Nestlé, Coke lovelies at the Latin American conference in Santiago, Chile. Now is the time for the nutrition profession to be fully independent

Another reason for hope is that our own profession of public health nutrition is now alerted to the big issue of conflicts of interest. As readers know, in April this year the Association, in partnership with Abrasco (the Brazilian national public health organisation) achieved our Rio2012 conference. This, we believe for the first time ever for an international conference, was funded and supported solely from public funds and with the dedicated work of volunteers and a professional conference organising company also committed to avoiding conflicts of interest. Rio2012 has proved that conferences can be 'public-public partnerships'.

This period of time in our field is undoubtedly one of global crisis. Are health professionals generally, including nutritionists, having a profound and lasting impact on the state of public health? Are they becoming as effective as were the public health leaders in the mid-nineteenth century who were confronted by the crises that followed reckless and ruthless industrialisation? The energy and determination of those founders of the modern public health movement indicates the scale of vision and action that is needed now. The series of commentaries in this issue of WN suggest some ways forward.

References

1. Stuckler D., Nestle M. Big Food, Food Systems, and Global Health. PLoS Medicine. 2012; 9(6): e1001242.
2. Stuckler D, McKee M, Ebrahim S, Basu S (2012) Manufacturing epidemics: the role of global producers in increased consumption of unhealthy commodities including processed Foods, alcohol, and tobacco. PLoS Med 2012; 9 (6): e1001252
3. Monteiro CA, Cannon G. The Food System. Ultra-processed products. Product reformulation will not improve public health. [Commentary]. World Nutrition, September 2012, 3,9, 406-434. Obtainable at www.wphna.org
4. Monteiro CA, Gomes FS, Cannon G. The snack attack. Am J Public Health 2010, 100, 975-81.
5. The Food and Agriculture Organization of the United Nations. The State of Food Insecurity in the World 2012. Rome: FAO, 2012.
6. Oxfam. Food Price Rises Doomed to Repeat. Oxford: Oxfam, 2012.