Rethinking Global Health Challenges: Towards a 'Global Compact' for ...

Public Health 123 (2009) 265–274

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Rethinking global health challenges: Towards a ‘global compact’ for reducing the burden of chronic disease R.S. Magnusson* Sydney Law School, University of Sydney, NSW 2006, Australia

a r t i c l e i n f o

s u m m a r y

Article history: Received 7 October 2008 Accepted 27 December 2008 Available online 10 March 2009

Chronic diseases, including cardiovascular disease, diabetes and cancer, are the leading cause of death and disability in both the developed and developing world (excluding sub-Saharan Africa). At present, the global framework for action on chronic disease is strongly ‘World Health Organization (WHO)centric’, defined by two WHO initiatives: the WHO Framework Convention on Tobacco Control, and the Global Strategy on Diet, Physical Activity and Health. This paper explores the difficulties of developing a collective response to global health challenges, and draws out some implications for chronic disease. It highlights how political partnerships and improved governance structures, economic processes, and international laws and standards function as three, concurrent pathways for encouraging policy implementation at country level and for building collective commitment to address the transnational determinants of chronic disease. The paper evaluates WHO’s initiatives on chronic disease in terms of these pathways, and makes the case for a global compact on chronic disease as a possible structure for advancing WHO’s free-standing goal of reducing mortality from chronic diseases by an additional 2% between 2005 and 2015. Beneath this overarching structure, the paper argues that global agencies, donor governments and other global health stakeholders could achieve greater impact by coordinating their efforts within a series of semi-autonomous ‘policy channels’ or ‘workstreams’. These workstreams – including trade and agriculture, consumer health issues and workplace health promotion – could act as focal points for international cooperation, drawing in a wider range of health stakeholders within their areas of comparative advantage. Ó 2009 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.

Keywords: Global health governance International law Non-communicable disease Chronic disease Global health policy Tobacco control Obesity Public health nutrition

Introduction One of the most important challenges in global health is how to address the epidemic of chronic, non-communicable disease, despite the unfinished agenda of perinatal health and communicable disease, as reflected in the Millennium Development Goals (MDGs). The MDGs contain three specific health goals: reduce child mortality; improve maternal health; and combat human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/ AIDS), malaria and other diseases.1 Together, these account for 32% of global mortality.2 By 2001, however, non-communicable diseases accounted for 59% of global mortality; nearly 54% of deaths in low- and middleincome countries, and 87% of deaths in high-income countries.3 Cardiovascular disease (CVD) is the leading cause of death in all

* Tel.: þ61 2 9351 0211. E-mail address: [email protected]

regions except sub-Saharan Africa. It accounts for over one in four deaths in high-income countries, and over one in five deaths in low- and middle-income countries where it causes nearly twice as many deaths as tuberculosis, HIV/AIDS and malaria combined.3 CVD mortality rates in working-age populations are substantially higher in emerging economies, undermining productivity and the benefits of the lower dependency rates enjoyed by countries with younger populations.4 Worldwide, there are more than 1.1 billion adults who are overweight, and 312 million of these are obese.5 Diabetes is expected to double from 171 million to 366 million cases over the period 2000–2030. Developing countries will shoulder the burden of this problem (especially India, China, Southeast Asia and the Western Pacific), with incidence peaking in those aged 45–64 years.6 The transition towards chronic diseases reflects many factors including the ageing of the population (due to declining fertility rates and improved infant survival), the relative success of efforts to control communicable diseases, and the globalization of risk factors for chronic diseases. Driven by income growth, direct foreign

0033-3506/$ – see front matter Ó 2009 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.puhe.2008.12.023

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R.S. Magnusson / Public Health 123 (2009) 265–274

investment in supermarkets and heavily marketed, processed foods, there has been a ‘nutrition transition’ towards diets richer in fats, sugar and salt.7–9 Other factors include greater participation of women in the workforce, urbanization and the accompanying trend towards more sedentary lifestyles, and the global marketing of tobacco. Chronic diseases are not confined to affluent countries, nor do they only affect those who have consciously chosen unhealthy lifestyles.10,11 Due to rising rates of cancer, CVD and chronic obstructive pulmonary disease, deaths from chronic disease are expected to increase by 17% over the period 2006–2015, accounting for nearly 70% of global deaths by 2030.12 For all these reasons, global health advocates have argued that donor governments and global agencies with a stake in health should direct a greater share of resources and policy attention to the looming ‘lifestyle epidemics’ of the 21st Century, particularly CVD, cancer, diabetes and tobacco-related diseases.4,10,11,13–19 This paper reviews current policy initiatives for global action on chronic diseases, with a particular focus on the role of obesity and nutrition. Chronic diseases call for policies and programmes across a variety of sectors and this necessarily implies a degree of complexity at national level. There is growing interest in the role that the law can play in implementing national policies on chronic disease prevention, including the prevention of population weight gain.20–26 In addition, however, the looming burden and shared challenge of chronic disease in developing countries, together with the transnational factors contributing to their spread, call for a ‘global response’. But what, exactly, does this mean? At global level, since no single government, international institution, foundation or other funder has the resources, expertise and influence to write the script for a comprehensive national response to chronic disease in low- and middle-income countries, the cooperative provision of technical and financial assistance is required. The management of global health issues at transnational level is no longer the sole preserve of nation states, or international agencies controlled by nation states. Private foundations and public–private partnerships wield significant economic power, and ‘moral networks’ embracing a wide range of health issues have leveraged the political influence of non-governmental organizations (NGOs) and civil society generally.27–29 New political groupings, such as the G8, and World Economic Forum, are also assuming major significance in placing global health issues on the agenda.30,31 Fidler has coined the term ‘open source anarchy’ to describe the challenges to governance in this constantly evolving and non-state-centric environment.32,33 According to Fidler, the global health environment is one of ‘unstructured plurality’; a ‘diversity of actors, interests, norms, processes, initiatives, and funding streams’.32 This paper provides one way of conceptualizing a response to these challenges. It highlights how: (i) international legal norms; (ii) economic processes; and (iii) collective political will formalized through governance structures and partnerships between governments, global agencies, private funders and civil society groups can function as three, concurrent pathways for advancing policies and programmes on chronic disease. The paper evaluates the World Health Organization’s (WHO) initiatives on chronic disease in terms of these pathways, and proposes a global compact on chronic disease as a possible structure for advancing concrete goals for reductions in mortality rates from chronic disease. Chronic disease and the challenge of global health governance A feature of global challenges of any sort is that there is often no suitable agency, organization or government with the resources, technical capacity, credibility, and legal and political mandate to act as a catalyst for global action, liaising between stakeholders and

helping to coordinate a truly effective global response. This challenge is especially stark in the case of chronic diseases. At transnational level, actions are required by global agencies, governments, transnational businesses, NGOs, professional associations and academia, while at national level, policy initiatives are required from governments, not-for-profit bodies and the private sector.34–37 The policies required to address the national and global determinants of chronic disease extend well beyond the boundaries of health departments and national healthcare systems. For example, policies are required that engage with the food system (primary production, manufacture, retail, catering and advertising of food), agriculture and trade, transport and urban development, the education system, finance and taxation, while also challenging some of the entrenched norms and customs of modern, sedentary and increasingly urban lifestyles.34,35 The capacity of any one organization to shoulder the burden of global leadership – providing the resources, technical support and wielding the political influence necessary to stimulate changes across all these sectors at country level – is limited. In fact, the need to show results and to demonstrate aid effectiveness has tended to narrow the horizons of development organizations, constraining their activities to areas of ‘comparative advantage’.29 It is not surprising, then, that the need to better coordinate the activities of the major players has become a major challenge. Public health lawyers are accustomed to thinking about the contribution that law and regulation can make to patterns of death and disease in the population. At global level, however, not only is there no health ‘regulator’, but the pre-eminence of national sovereignty means that the place for legal norms, and especially enforcement mechanisms, is heavily contested.38 International health law, where it exists, takes the form of international agreements whose substantive obligations nation states have signed on to voluntarily, following a process of negotiation in a multilateral forum [an important exception is the International Health Regulations (IHRs), which bind members of the World Health Assembly on an ‘opt out’ rather than an ‘opt in’ basis].39,40 What international law brings to global health governance is the normative pressure of the international community, including civil society, brought to bear upon signatory states to develop their capabilities to ensure particular forms of state practice, or to otherwise implement the substantive obligations of international agreements through domestic laws and policies. International law depends heavily on both the willingness and capacity for states to implement their international obligations into domestic laws and thereafter to enforce them. On the other hand, the development of international norms also provides opportunities for advocacy and political action by NGOs and professional groups, as the work of the Framework Alliance illustrates in connection with the WHO Framework Convention on Tobacco Control (FCTC).41,42 WHO is acknowledged as the lead agency with capacity to shape global health policies, through its strong knowledge base, convening powers and capacity to identify and disseminate best practice. WHO has a constitutional mandate to propose conventions, regulations and recommendations about international health matters (Article 2). WHO’s recent achievements in international health law – the IHRs39 and the FCTC41 – have been widely and justly celebrated.43,44 However, debate persists over the extent to which global agencies, such as WHO, have the capacity to intervene independently to set the governance agenda for global health (one extreme), or whether they merely provide a secretariat through which member states pursue their own interests (the opposite extreme).45,46 As the evolution of the FCTC illustrates, the truth may lie somewhere in the middle.19 The political pressures that major powers impose upon WHO and other agencies with a stake in health represent real-world


constraints in the use of international law and multilateral treaties as a channel for collective action in response to shared health threats. Much of the influence of WHO, the World Bank and other bodies arises through the technical assistance that these bodies provide to various levels and sectors of government in the recipient state, and through the normative impact of policy recommendations, guidelines and strategy documents. At the same time, there are challenges to identity and influence as a result of new private and public/private funding sources, and the increasingly diverse and cluttered environment of global health efforts.47 Responding effectively to the ‘fragmentation, duplication and lack of coordination’ of global health efforts has been identified as one of the ‘grand challenges’ of global health law.38 There is a growing literature that proposes new governance structures or ‘architecture’ for addressing these problems. Recent proposals include a new framework convention on global health to secure the basic survival needs of vulnerable populations48,49; a new committee of the World Health Assembly to foster better coordination and information transfer between the key stakeholders in global health50; and the allocation of a fixed percentage of funding from vertical, disease-specific initiatives to support health systems strengthening, with an international research organization to monitor accountability and outcomes.51 Other proposals include a multilateral ‘global noncommunicable disease partnership’ drawing in the resources and capabilities of the United Nations (UN) and other agencies and synchronizing their efforts,52 and a new global goal for the reduction of chronic disease to supplement the MDGs.10,13 Global processes Developing a global response to transnational health problems poses challenges in terms of the content of policies that aim to address the transnational determinants of disease. Defining these policies and achieving agreement on them – from global norms on tobacco control to the rules of international trade – is never easy. Beyond the content of policies themselves, however, is the challenge of finding effective processes for stimulating commitment to a collective response, and the policy agenda it implies. How, for example, can global health stakeholders best encourage political ‘ownership’ of the problem of chronic disease in order to ensure that policies and programmes are funded and implemented at country level? This paper directs attention to three global processes, implicit in the reform proposals listed above, for responding to global health challenges in a formalized and collective way (Table 1). Firstly, through partnerships, cooperation agreements and governance structures linking governments, global agencies, foundations, transnational corporations and civil society groups, global health stakeholders can – collectively – improve the quality and coordination of development assistance and generate greater technical capacity and political momentum for effective policy making. Secondly, law-making and norm-setting processes at global level can create legal and normative pressures for domestic policy changes. Thirdly, donor agencies and governments can provide economic support and impose economic pressures for domestic policy change through funding conditionality and related strategies. Given the vast number of important issues already dominating the agendas and claiming the resources of governments and stakeholders in global health, there may be no single initiative – no brilliant new strategy or piece of global architecture – that will transform the political landscape and propel chronic disease to the top of the global health agenda. Global responses, much like national responses, are likely to be incremental. The institutionalization of the policy changes needed at domestic level is unlikely to happen all at once, and different aspects of a global response may

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be advanced in different ways through legal, economic and political channels. Legal, economic and political processes provide concurrent and overlapping possibilities for progress and action. For example, experimentation with new structures for the delivery of development assistance in health has been driven by demands for ‘aid effectiveness’.27 The need to improve the effectiveness of funding provided to advance the MDGs has stimulated new partnerships including the ‘International Health Partnership’ signed in September 2007 by a coalition of donor and recipient countries, international agencies and other funders.53,54 This partnership emphasizes the need for health development to be country led, to strengthen the whole health system, to permit greater flexibilities in use of funds, as well as ‘shared appraisal, funding and reporting mechanisms’.53 The International Health Partnership, in turn, represents one attempt to put into practice the Paris Declaration on aid effectiveness, a statement of principles having normative (albeit non-legal) force.55 The International Health Partnership has since developed its own unique governance structure.54 Notwithstanding the benefits of concurrent action, described above, it is argued that the priority for improving health outcomes for chronic disease lies in seeking to improve the quality and intensity of partnerships between global agencies and other donors that have the capacity to influence the global and domestic policies (and budgets) that impact on chronic disease. This paper proposes the idea of a global compact on chronic disease, comprising a statement of goals and policy channels within which development assistance agencies, foundations, corporations and other stakeholders could collaborate by ‘opting in’ and contributing resources and expertise within their areas of comparative advantage. A balance will need to be struck between the need for coordination, through a ‘top down’ response that would define the key policy channels and seek to formalize the commitments and responsibilities of key stakeholders, and the flexibility needed to permit ‘bottom up’ initiatives as stakeholders within each channel restructure their activities in innovative ways and evolve a collective response. Although WHO might be the appropriate agency to monitor progress towards the goals of the compact as a whole, the overarching aim of the compact would be to make the challenge of chronic disease look less like a WHO strategy and more like a ‘shared project’ of the global community. This is important if chronic diseases are to achieve an international profile commensurate with their threat to global health. The chances of achieving high-level political leadership and ongoing commitment to multisectoral action at national level depends on increasing the range and depth of contacts between national governments (especially finance ministries), global agencies and other health stakeholders. While WHO’s role is vital, therefore, chronic diseases are too complex, and cut across too many sectors, for any one agency to have a proprietary grip over vision, strategies, policies and programmes. At the present time, the most ambitious example of a global health partnership is the MDGs; a package of development outcomes that heads of government have committed to achieve, collectively, over the period 2000–2015.1 By locating the executive and coordinating functions directly within the UN Secretariat, the MDGs found a high-profile ‘political champion’ and became the pre-eminent global development programme. Progress depends both on the technical expertise and resources of partner agencies who have committed to the goals, including WHO and the World Bank, and on the actions of governments themselves in implementing effective policies. Daunting challenges remain in progress towards the MDGs.56,57 Close alignment between the goals of each agency and the goals of the broader partnership is necessary if each agency is to willingly contribute its resources, especially where overall strategic control is located elsewhere. Nevertheless,

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Table 1 Global processes for seeking to improve the impact of technical assistance and to mobilize support for policy changes

Pathway Political

Process

Impact

Partnerships between key stakeholders (international agencies, governments, transnational corporations, private funders, NGOs)

Improved capacity for development assistance; greater political commitment and momentum for domestic policy change

Governance structures Global “architecture”, including targets & goals Legal

Treaties, conventions Resolutions, declarations International norms & guidelines

Legal and normative pressure for domestic policy change

Economic

Economic & material support

Economic pressure for policy change and implementation; material resources for programs & policies

Funding conditionality Informal pathways

Advocacy by thought leaders & “issue champions” Popular movements in civil society, academia

Normative pressure for global & domestic policy change

Media campaigns mobilizing popular opinion

partnerships have the capacity to multiply the technical, financial and human resources available for advancing partnership goals and to expand opportunities for policy influence at country level. Some partners are uniquely positioned to act in the legal channel, driving the development of global standards that provide the normative environment for domestic laws and policies.19 Where are we now? A potted review of global initiatives on chronic disease WHO and the World Bank Collective action at global level is required if countries are to respond successfully to transnational factors influencing rates of smoking, patterns of diet and nutrition, and physical activity.13 Hitherto, the global framework for action on chronic diseases has been largely embodied in two WHO initiatives: the FCTC41 and the Global Strategy on Diet, Physical Activity and Health (GSDPAH).34 Further impetus has come from several influential WHO reports.58,59 The tobacco initiative is significantly different to the strategy on diet and nutrition. The FCTC entered into force on 27 February 2005 and currently has 157 signatories. It sets out transnational legal norms on tobacco control, together with a process for reporting and for the development of additional protocols in specific areas, through the Conference of Parties (COP).60 Through the COP, WHO is negotiating a separate protocol on illicit trade in tobacco, and there are guidelines under development on advertising, promotion and sponsorship; packaging and labelling; and tobacco product testing, measuring, regulation and disclosure.60 As transnational tobacco companies seek to grow markets and extract concessions from governments, international legal instruments, such as the FCTC, have been recognized as ‘global public goods’ that strengthen national capacity to protect against threats to health sovereignty.44 The longer-term impact of the FCTC was substantially strengthened by a 2-year gift of $125 million from New York City Mayor Michael Bloomberg to assist the implementation of tobacco control programmes in low- and middleincome countries.61 In 2008, the Bloomberg Foundation pledged a further $250 million over 4 years, while the Bill and Melinda Gates

Foundation pledged $125 million over 5 years. This level of funding is unprecedented in tobacco control.62 In contrast to the FCTC, the GSDPAH, approved by WHO on 22 May 2004, adopts a facilitative, advocacy-based approach.34 It synthesizes evidence for action and outlines a multisectoral strategy that countries are urged to implement, with support from WHO and partner agencies, civil society and the private sector. Governments have a broad role that encompasses coordination of policy across various sectors and ministries; the provision of accurate information and regulation of marketing, labelling and health claims; fiscal and agricultural policies; and promotion of physical activity. The GSDPAH positions the processed food industry as an important ally in reform efforts, given its capacity to develop more nutritional products and to promote healthier diets. In April 2007, WHO pointed out that although 70% of countries now have a policy on chronic diseases, ‘the proportion of the health budget spent. on prevention and control of noncommunicable diseases remains very small’.63 The FCTC and GSDPAH have hitherto overshadowed a brief strategy document on non-communicable diseases that was affirmed by the World Health Assembly in 2000.64 More recently, however, WHO has built on this strategy – and on the FCTC and GSDPAH – by drawing up an action plan for ‘leading and catalyzing an intersectoral and multilevel response’ to non-communicable diseases.65 This action plan, endorsed by the World Health Assembly in May 2008,66 points to the role of tobacco, lack of physical activity, unhealthy diet and alcohol misuse in causing 35 million deaths in 2005 from CVD, diabetes, cancer and chronic respiratory diseases.65 There are important benefits for governments in adopting an integrated approach in their budgeting and policy development that recognizes the combined impact of these lifestyle risks on the leading causes of disease burden. Not only are these lifestyle risks commonly co-located in individuals and populations,67,68 but in each case, harmful consumption (tobacco) or overconsumption (alcohol, foods high in fat, salt and/or sugar) reflects the success of global business enterprises that seek to manipulate consumer behaviour for profit and to resist measures that could reduce consumption. WHO recognizes that effective action on noncommunicable diseases calls for policy responses across multiple


sectors and ‘across all government departments’.65 International, regional and national partnerships are required. Importantly, WHO’s action plan recognizes that governments must themselves evolve new structures (‘a high-level national multisectoral mechanism’) for driving policy changes outside of the health sector.65 WHO’s initiatives in chronic disease come at a time when global development assistance in health has been transformed by the entry of private foundations and global funds operating outside of treaty processes and international agencies such as WHO. Much of this new funding has been directed to priority communicable diseases (HIV/ AIDS, malaria, tuberculosis) or other vertical programmes (vaccinations, essential medicines), rather than the strengthening of healthcare systems or the multisectoral policies required to make a sustained impact on chronic diseases.29,47 Over the period 1997– 2006, the World Bank’s share of total financing for health, nutrition and population (HNP) activities – through lending and disbursements – continued to shrink. Although annual HNP financing stands at approximately US$1.5 billion, the magnitude of the World Bank’s impact on health development depends increasingly on the quality of its policy advice and technical dialogue with client countries.29 The World Bank’s recent HNP strategy recognizes the ‘formidable challenge’ of chronic diseases caused by tobacco and obesity, and emphasizes the World Bank’s comparative advantages in the health sector. These include its global experience, strong country focus and capacity to adopt a multisectoral approach through regular engagement across multiple sectors with government agencies at national and subnational levels.29 Strengthening healthcare systems remains the core priority for HNP development under the new strategy, given that the absolute number of people with chronic diseases will continue to rise, regardless of prevention efforts, due to population ageing and the relative success of efforts to reduce communicable diseases.29,69 At the same time, the World Bank’s policy agenda on chronic disease foreshadows an expanded role for the bank in assisting countries to integrate policies for chronic disease prevention within their health and development strategies, through an approach that engages multiple sectors.69 The private sector Changes in global business practices are vital if we are to achieve improved outcomes for chronic disease, given the role of the business sector, including transnational corporations, as employers, and as manufacturers and marketers of consumer products. Recently, WHO and the World Economic Forum have highlighted the workplace as a critical setting for addressing risk factors for chronic disease, advocating the development of workplace health promotion programmes for improved productivity, reduced healthcare costs for business and improved corporate image.31,37 Workplace health promotion would be an important workstream within a global compact on chronic disease, providing opportunities for participation and influence by a range of agencies including the International Labor Organization, the Organization for Economic Cooperation and Development, WHO, the World Economic Forum, the World Bank and other agencies. The most effective way of achieving improvements in the consumer products that contribute to chronic disease (tobacco, food and beverages) remains a matter of debate. There has hitherto been a consensus among public health advocates that the tobacco industry is not a credible partner in tobacco control efforts, and that the best way for governments to ‘engage’ with the industry is by enacting and enforcing legislation to implement the FCTC.70 Some cracks in that consensus are appearing as the tobacco control community debates how best to progress the knowledge base for tobacco harm reduction policies.71 There is less consensus about the merits of regulatory versus collaborative engagement with the food and beverage industry.72–76 Judging by well-publicized efforts by the USA – acting

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on behalf of its sugar industry – to weaken the GSDPAH during its development, a regulatory approach to diet and nutrition appears unlikely to have been feasible.77 At the same time, it is unclear whether industry has the capacity, through unilateral action alone, to reshape consumer preferences and to improve the nutritional quality of processed foods to the degree required to have an impact at the population level. There is also the risk that voluntary commitments will predominate in markets where change is demanded by affluent populations and an engaged media, with ‘business as usual’ elsewhere. An uneven response from the food manufacturing sector could exacerbate existing disparities in risk factors for chronic disease. In 2002, 77% of global food sales were of processed foods and beverages, giving processed food manufacturers and large retailers massive influence over global diets.78 A study of 25 global food manufacturers, retailers and food service companies carried out in 2006 found that only a minority had altered their business practices in response to the GSDPAH.79 In Europe, the European Union Platform for Action on Diet, Physical Activity and Health provides a forum for the food industry, and medical and consumer groups, to make public commitments to measures to reduce obesity and to improve diet and physical activity.80–82 In November 2006, nine soft drink makers won high praise for agreeing not to target soft drink advertising to children aged 11 years and under.83 In the USA, the Alliance for a Healthier Generation, a joint initiative of the American Heart Association and the William J. Clinton Foundation, announced voluntary agreements during 2006 with three large beverage makers, and five large snack food makers, to comply with new beverage and competitive food guidelines governing their marketing to 123,000 schools.84,85 Future possibilities for global action on chronic disease As suggested by the GSDPAH and WHO’s action plan for noncommunicable disease, a comprehensive response to chronic disease at national level is necessarily complex. It includes capacity building, strengthening the primary healthcare system, policies addressing the behavioural, socio-economic and environmental determinants of disease in a variety of sectors and settings, surveillance and monitoring of the burden of disease, the promotion of research capacity, and attention to health inequalities.34,36 Complexity is a feature that chronic disease shares with other emerging public health threats, such as global warming.86 An analogy can be drawn with the task that an orchestra faces in playing a symphony, in the absence of a conductor, in circumstances when many players lack an individual score. The difficulty goes well beyond developing individual policies (or scores) at the domestic level; it extends to evolving new processes for developing transnational policies, and generating commitment and capacity to implement policies at all levels. Despite the fact that chronic disease calls for multisectoral, whole-of-system change, this paper argues that a global response will be more effective if the core stakeholders share responsibility for key dimensions of the problem within appropriate ‘policy channels’ or ‘workstreams’. In each case, the capacity of different stakeholders to advance a global response through legal, political and economic strategies will vary. Some stakeholders, such as WHO and the World Bank, could play an anchoring role across multiple workstreams. The remainder of this paper aims to stimulate debate about the opportunities that legal, political and economic processes present to global health stakeholders for evolving incremental responses to chronic disease. Legal processes: should there be global standards on diet and nutrition? Legally binding international standards, as well as ‘soft law’ resolutions, declarations and guidelines, provide a range of

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opportunities for health stakeholders seeking to advance discrete parts of the policy agenda on chronic disease. Trade and agriculture is an important policy channel that deserves greater attention. The impact of trade liberalization on economic growth, and follow-on effects upon diet, nutrition, obesity and chronic disease is complex and not well understood.7,35,87 In general terms, domestic and international trade laws and policies should support the production, availability and consumption of fresh fruits and vegetables, and other foods that contribute to a healthy diet. Flexibilities are needed, however, to permit countries to respond to dietary imbalance at population level caused by overconsumption of saturated fats and refined sugars. This should be seen as a core principle of ‘health sovereignty’. In many Pacific Island countries, for example, cheap, processed and high-fat imports have substantially displaced traditional foods. One result is that local fishing and agriculture, and other traditional sources of a healthier diet have become economically non-viable, replaced by products including turkey tails and mutton flaps that are not considered edible in the exporting countries.88,89 In Europe, Lloyd-Williams et al argue that subsidies for the production of meat and dairy under the European Union’s Common Agricultural Policy (CAP) result in approximately 9000 additional deaths per year from heart disease and stroke within Europe.90 In addition, however, CAP has been a stimulus for the dumping of high-fat and high-sugar exports, with detrimental impacts on diets in third countries.91 Sensitive trade issues are involved here; the development of legal flexibilities to support health sovereignty and to prevent hazardous forms of dietary dependency are a longer-range goal that scores high on the ambition scale. It is difficult to imagine fundamental change, however, without the collaboration of the World Trade Organization (WTO), the Food and Agricultural Organization (FAO), WHO and the World Bank in strategies to audit the impact of trade patterns on healthy nutrition, and the introduction of flexibilities to permit domestic and regional solutions without fear of retribution from foreign investors, trading partners or foreign aid donors. Lo points out that bilateral and regional free trade agreements (FTAs) are increasingly dealing with many issues beyond trade, and progressively undermining the impact of WTO rules.92 While Lo regards FTAs as a vehicle for implementing the IHRs, they could also provide the basis for regional and bilateral cooperation with respect to the impact of food trade on patterns of diet and on risk factors for chronic disease. There are novel yet important opportunities for ‘frame alignment’ with policies designed to reduce demand for animal products, thereby reducing the substantial impact of livestock production on global greenhouse gas emissions.93 Consumer protection is another important policy channel or workstream that provides opportunities for legal interventions. Developing global standards on diet and nutrition does not mean trying to replicate the FCTC with a comprehensive treaty on food. While some scholars have supported this proposal,75,76,94 the politics of achieving it may be insurmountable.72 Nevertheless, regulatory measures could complement the current advocacybased strategy of the GSDPAH in four key areas.19 Firstly, there is no justification for failing to ensure that consumers everywhere have adequate information for making informed, rapid and healthy food choices. Global standards for health claims made in relation to food, rules for labelling the nutritional values of a food and the profile of a particular food within a healthy diet, and fair warning of health risks, could stimulate the development of healthier recipes, and hasten the removal of ‘less healthy’ products from the market.95,96 Secondly, there is an established relationship at population level between blood pressure and salt intake, between cholesterol and dietary fats, and between blood pressure and weight.97 Evidencebased standards in these areas could influence the activities of national and multinational food producers, retailers and food

service companies; their implementation into domestic legislation could also create standards for product reformulation and moderate the intake of saturated and trans fats, salt and free sugars at population level. WHO has acknowledged that regulatory approaches to salt reduction are justified in countries ‘where for years voluntary approaches have proved ineffective’.98 Thirdly, there is growing acceptance that the vulnerability of children supports protective regulation. WHO’s International Code of Marketing of Breast-milk Substitutes – a rare example of an international standard for public health nutrition – stands as an important precedent in this area.99 Whether voluntary commitments will successfully defuse calls for government regulation of food marketing to children remains to be seen.26,100–102 International standards on food marketing to children could provide consistent standards for the marketing activities of food companies, irrespective of their country of origin or area of operations. NGO advocacy, such as the ‘Sydney principles’ developed by a Working Group of the International Obesity Taskforce, is continuing to build momentum.103 The final area for global standards relates to surveillance of risk factors for chronic diseases, and the obligation to report on progress in implementing effective policies at country level. Surveillance data are important for galvanizing political commitment for public health policies, and in the longer term for evaluating policy interventions taken at country level. WTO compliance International standards on diet and nutrition could have a positive impact on global health by serving to ‘WTO proof’ domestic and regional responses to chronic disease. The General Agreement on Tariffs and Trade and subsequent WTO agreements prohibit countries from adopting laws and policies that discriminate between domestic goods and imports, and between the imports of different countries.104–106 However, domestic laws and policies (referred to as ‘measures’) that impose restrictions in order to protect human health are permitted when the content of those measures is based on international standards.107,108 The WTO’s Agreement on the Application of Sanitary and Phytosanitary Measures (SPS Agreement) applies to a range of measures including those applied to protect human life and health from additives, contaminants, toxins or disease-causing organisms in food and beverages.107 On the other hand, domestic laws and policies imposed for public health purposes outside these specific contexts, as well as domestic measures imposed to prevent deceptive practices, will fall for consideration under WTO’s Agreement on Technical Barriers to Trade (TBT Agreement).108 The line of division between the SPS and TBT Agreements was considered by the WTO Panel in the EC-Biotech case, which concerned European restrictions on the import of genetically modified foods.109 The Panel distinguished between foods that pose a danger to a consumer’s life and health, and those that were nutritionally disadvantageous due to the quality or quantity of their nutrients. The Panel made it clear that the SPS Agreement only applied to the former. The Panel also adopted an interpretation of ‘food additive’ that would seem to exclude sugar, salt or fat. For these reasons, it is likely that domestic laws and policies implementing legal standards aimed at improving diet, and at improving the nutritional quality of food, would fall for consideration as TBT measures, rather than SPS measures. The TBT Agreement provides that domestic measures that are based on international standards, applied in order to protect human health or to prevent deceptive practices, will be ‘rebuttably presumed not to create an unnecessary obstacle to international trade’.108 WTO rules support the international flow of goods and services within a contestable market. Domestic laws or policies that impact on international trade will therefore need to be consistent with that


country’s obligations under WTO agreements. In principle, there is nothing to prevent countries from choosing a particular, national level of health protection and thereafter subjecting both domestic and imported goods to identical manufacturing and regulatory standards to ensure that health objectives are met. However, in response to a complaint that a country’s domestic policies constitute a de facto barrier to imports from another country, the responding country would need to justify its TBT measures, or its SPS measures within the terms of the relevant agreement. The strategic benefit of the FCTC and, potentially, international standards on diet and nutrition is to provide a clear legal mandate for the introduction of domestic laws that address the transnational determinants of chronic disease. Provided that domestic laws for public health nutrition are based on international standards, they will gain protection, even if their effect, in the circumstances, is to discriminate against certain imports. While they provide no immunity from political and economic pressures, international public health laws do, at least, provide a basis for countries to re-assert their health sovereignty and to overcome ‘regulatory chill’; the reluctance of governments to address public health threats for fear of provoking a trade dispute. Rethinking partnerships and governance structures for chronic disease The political pathway directs attention to the role of partnerships and governance structures – ‘global architecture’ – in responding to transnational health threats. Two important challenges arise. The first is to identify the stakeholders who have the greatest potential to contribute to a transnational response and to draw them into appropriate workstreams. The second is to identify effective governance structures for coordinating and monitoring efforts across all workstreams. The GSDPAH envisages a partnership of agencies, headed by WHO, to develop comprehensive intersectoral strategies on diet and physical activity, to mobilize resources, advocate policy reforms and cooperate in research.34 There are clear synergies between WHO, WTO and FAO with respect to improving the supply, affordability and consumption of fresh fruit and vegetables, and with UNICEF around children’s diets, nutrition education and food marketing. As children’s nutrition comes to be framed increasingly in terms of a tension between corporate profits and human rights, UNICEF’s influence as a moral champion for children’s health will be enhanced, as it was during the development of the International Code of Marketing of Breast-Milk Substitutes.99 WHO anticipates an important role for the Codex Alimentarius Commission in implementing the GSDPAH through the development of international standards, particularly with respect to nutrition labelling, health claims and food composition standards.110 This presents a challenge for Codex, which – like domestic food standards agencies – have traditionally focused on food safety, rather than public health nutrition. Elsewhere, the author has argued that rather than delegating control to Codex, it may have been wiser for WHO to make a virtue out of Codex’s technical and more limited role, seeking its input while nevertheless reserving for itself the role of standards development.19 It remains unclear to what extent Codex will be capable of developing progressive global standards, given its reputation for being dominated by industry, and the politicization of its role that comes from Codex–WTO linkages.111,112 After a slow start, WHO and FAO have prepared an action plan which sets out the assistance that the Codex Committee on Food Labelling and the Codex Committee on Nutrition and Food for Special Dietary Uses could provide in implementing aspects of the GSDPAH. The focus is on nutrition labelling, health claims and the development of nutrient reference values.113,114 In addition, Canada has prepared a discussion paper on the possible revision of guidelines to introduce

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provisions on nutritional quality into Codex texts.115 It seems doubtful that Codex processes will be able to advance other issues originally flagged for Codex in the GSDPAH, including measures to mitigate the impact of marketing on unhealthy diets, and production standards for the nutritional quality and safety of food. The World Bank is an important stakeholder in chronic disease prevention, given its more extensive resources, strong country experience, and the fact that it is low- and middle-income countries that have the greatest need for development assistance in this area. The World Bank’s work on the economic benefits of tobacco control, including tobacco taxes, complements the policy expertise of WHO.116 Important opportunities remain for partnerships to support the implementation of the FCTC. The World Bank has staked out nutrition as a priority117; it also acknowledges the economic impact of chronic diseases, and the stress they will cause to health systems.69 Like WHO, the World Bank could play a valuable ‘anchoring role’ across multiple workstreams. While partnerships with international agencies primarily enhance links with government, NGOs and civil society networks have a broader role. Governance structures that facilitate direct contact and collaboration between governments, global agencies, corporations and NGOs are critical. Besides pressuring governments to introduce healthy policies, the role of civil society extends to sharing information, pressuring the food industry to improve the nutritional quality of food, and influencing consumers directly in ways that reduce lifestyle risks and shape market demand. As noted previously, the global response to chronic disease is largely ‘WHO-centric’, despite the acknowledged role of partnerships in WHO’s GSDPAH and action plan.34,65 Greater ownership of the aims of WHO’s chronic disease strategy may come from decentralizing, and sharing control of various strategic issues with health stakeholders whose resources and/or capacity for influence at national level could strengthen the response overall. In structural terms, a global compact for the prevention of chronic disease could reflect a ‘holonic structure’, in which each workstream constituted a semi-autonomous structure for global cooperation and development assistance, with different agencies and stakeholders taking

Box 1. Some functions performed by a global compact for the prevention of chronic disease. A call to action: synthesizing the evidence and stating the case for collective action A conceptual map: stating and defending a conceptual approach to chronic disease prevention; identifying core values to support greater ‘health sovereignty’ Core ‘workstreams’: identifying key policy channels for coordinated action. These may evolve over time, but could include: B Trade and agriculture B Consumer health protection B Economics of policy investment B Programme financing B Workplace health promotion B Tobacco control Collaboration and coordination: signalling opportunities for a collaborative approach involving international agencies, private foundations, public/private funding organizations, governments, the private sector, civil society, non-governmetal organizations and academia Reporting and monitoring: identifying mechanisms for coordination across workstreams, monitoring and reporting on progress in appropriate international forums

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anchoring or participating roles.118 Key workstreams could include: trade and agriculture; consumer health protection; the economics of policy intervention; and workplace-based health promotion (Box 1). Tobacco control can be considered a cross-cutting workstream. New workstreams might evolve over time. Linking global targets with funding and economic strategies The realization that chronic diseases are a neglected epidemic have led to calls for new targets to be bolted on to the MDGs. This could occur by inserting new targets and indicators under Goal 6, which aims to ‘combat HIV/AIDS, malaria and other diseases’, or by expanding Goal 4 (‘reduce child mortality’) and related indicators to include adult mortality and morbidity.58,119,120 Advocates have also emphasized the role of tobacco control in reducing hunger and poverty, and advancing the other MDGs.2,119 Efforts to recast the MDGs midway through their intended lifetime are unlikely to be successful, and could undermine the status these goals have achieved as focal points for UN-led development efforts, aggravating existing difficulties in achieving them. Maintaining political commitment to the MDGs is a grand challenge in itself, and the UN Secretariat is unlikely to assume new responsibilities around chronic disease. Public health advocates, and WHO, have also advocated a freestanding goal of reducing chronic disease death rates by an additional 2% on top of projected age-specific mortality rates for 2005–2015, resulting in 36 million fewer deaths by 2015.10,58 This is a worthy goal, but one unlikely to get beyond the pages of public health journals without appropriate global architecture to support efforts towards its achievement. Goals must be linked to resources; advocates must therefore ‘sell’ the need to fund the policies, programmes and capabilities that are required in order to meet the goal. Doing this means more than just producing statistics and arguing the importance of chronic disease to governments and funding agencies; it requires the case for funding to be made within the context of the budgetary resources required by countries and regions to meet their share of the goal. Global health funding, through G8 and private foundations, still overwhelmingly favours communicable diseases and the MDGs. The economic case for investing in chronic disease prevention and the development of health systems capable of treating chronic disease is perhaps the most powerful frame there is for seeking to nudge funding agencies towards action. However, the economic benefits of investment in chronic disease prevention must also be made to recipient governments. The structural adjustment policies imposed on faltering economies by the International Monetary Fund (IMF) during the 1990s have given funding conditionality a bad reputation.121 Since 1999, however, a different form of funding conditionality has arisen. In order to encourage greater participation and country ownership of development strategies, the World Bank and IMF now require countries seeking debt relief or concessional assistance to prepare Poverty Reduction Strategy Papers (PRSPs) that identify longerterm development goals, and the policies, programmes and resources needed to achieve them.122 The World Bank and IMF exercise considerable real-world influence over these country-level priorities. In 2005, a joint review echoed a call by the UN Development Program for the PRSP process to be used as an operational framework for scaling-up country-level efforts to achieve the MDGs.122,123 The PRSP process also provides a vehicle for linking chronic diseases to country funding strategies. More ambitiously, a global compact on chronic disease could provide the ‘architecture’ for cooperation among agencies and other funders in order to work towards concrete goals for reductions in the burden of chronic disease. A concrete goal is the

beginning; political processes are needed to ensure that global stakeholders ‘own’ the goal, care about it, understand the need for it, contribute their resources towards it, and collaborate together effectively. Given the many factors that contribute to poor diet and sedentary lifestyles, alcohol misuse and tobacco use, the goal of reducing chronic disease death rates by 2% is a difficult goal to ‘own’. In addition to establishing the key workstreams for a global response, a global compact could provide the structure for linking the goal with the political and economic commitments needed for progress towards it. Conclusion Fidler argues that efforts to develop ‘new architecture’ for coordinating global health efforts fail to understand that global health is no longer ‘the house that WHO built’, but has evolved to become ‘an integrated global public good’ with strategic relevance to multiple areas of governance.32 According to Fidler, in a global environment of ‘unstructured plurality’, both states and non-state actors may resist governance solutions that aim to centralize and systematize the multiplicity of cross-cutting health initiatives.32 Fidler’s argument has a particular resonance for chronic disease, and other challenges – such as global warming – that call for a multisectoral, indeed transgenerational response. It is prudent to acknowledge the limits of influence of any one health stakeholder (while remembering the advantages of partnerships); the fact that no single initiative is likely to be enough, but that opportunities do exist for incremental progress towards shared goals. With this in mind, a global compact for the prevention of chronic disease provides both structure and flexibility (Box 1). It seeks to draw on the resources of global health stakeholders who would coordinate their activities within semi-autonomous workstreams. It also provides an overarching conceptual framework for renewing political commitment, securing funding and monitoring progress towards a free-standing goal for reducing mortality rates from chronic disease. Ethical approval None sought. Funding Australian Research Council (ARC) Discovery Project Grant DP0667271.

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