In 2003, 168 countries signed the world’s first public health treaty: the Framework Convention on Tobacco Control (FCTC). The FCTC legally bound countries to enforce major tobacco control measures, ranging from tobacco taxes to regulations on public smoking. Through a massive international effort, the FCTC has assisted countries to improve their tobacco prevention programs, and the treaty continues to be a basis for many new programs that are implementing evidence-based tobacco control strategies.
In an article in today’s PLoS Medicine, we publish new data showing that the food and beverage industry’s activities in low- and middle-income countries parallel that of the tobacco industry in years past; moreover, as cardiovascular disease and diabetes rates rise in poor nations, junk food, soda, and alcohol are statistically the major factors giving rise to deaths among working-age populations, and the newest evidence suggests that educational programs alone aren’t effective when markets are drowned by imports of cheap, unhealthy food and readily-accessible booze. So should the public health community push for a nutritional treaty or governance structure that parallels the successful introduction of the FCTC, but addresses “unhealthy commodities” like junk food? If so, what would such a structure look like?
Zooming out from the debates about soda taxes and similar public health controversies that pit individual freedom against public health desires to reduce disease rates, there are really a few core public health problems now facing global food systems: (1) that undernutrition and famine persist as over-nutrition (malnutrition in the direction of obesity) has appeared in the same poor households in many countries; and (2) that climate change has forced us to think about how to produce food for the world’s 9+ billion people in a manner that is environmentally sound (as highlighted in our recent discussion of Oxfam’s GROW campaign).
Proceeding with the status quo would lead us to continue having several terrible outcomes: the poor being unable to pay for nutritious food, whether that means adequate food to prevent underweight and stunting because local grain markets are rocked by market volatility and inadequate food stores, or quality food to prevent obesity and metabolic disease; and the industrial farming sector continuing to produce products that are cheap to make and easy to sell for high profits despite having devastating health and environmental implications such as the loss of water supplies, increased methane production and energy consumption from the production of meat, and loss of arable land.
Essentially, since everyone is responsible for perpetuating these problems, no one is really responsible for addressing them. Numerous non-governmental organizations and medical bodies have highlighted what they believe needs to be done to support small-scale agriculture that is equitable to poor communities, improvements in large-scale food production to bring people healthier products with less of an environmental footprint, and market regulations and nutritional production policies to reduce exposures to hidden unhealthy agents like transfats and high-salt foods. But these efforts affect one another: demand for food inherently drives supply, but we have also seen that supply and associated marketing also generates its own demand (as Steve Jobs said “people don’t know what you want until you show it to them”, and since the 1970s the marketing of fast foods has generated new demand for products that were not yet desired); environmental changes and changes to agricultural production may alter the resilience of some areas to natural disasters and famines as well as storing food that is healthy; and changes to the human body itself—in the form of obesity, chronic heart disease and diabetes—affect the demand on medical resources and shift the nature of human productivity, petroleum use from medical interventions, and the prioritization of public health efforts that are currently increasingly splitting between undernutrition and obesity.
Can we coordinate?
There are really three areas that could be addressed by an FCTC-like treaty on nutrition: (1) the creation of a nutrition research body to address pressing research questions that affect the nexus between health, industry and the environment; (2) the generation of a governance body to negotiate guidelines and hopefully ultimate regulatory efforts once nutritional science establishes clear “global bads” (e.g., a global ban on transfats would already be supported by existing research); and (3) define clearly what level of international financing would be needed to support such efforts in order to coordinate those programs that require capital infusion.
Of course, such a proposal is ripe with politics and would likely be highly imperfect due to the nature of global power. We would not be surprised to hear of industry efforts to undermine or radically-alter the process. But if public health institutions could establish the FCTC in the face of the massive tobacco industry efforts to derail regulation, they can certainly continue to challenge the ongoing efforts of the food industry to do the same.
But there are some potential benefits to coordinating through such an international body. First, the research in this realm requires an international perspective and data that can only be generated through coordination to answer questions like how specific global trade provisions facilitate or discourage the production and trade of the unhealthiest products (almost the opposite issue to the global access to medicines trade disputes); will changing agricultural subsidy policies such as the US biofuel policy result in significant stability in food prices and prevent both dumping and inappropriate encouragement of high-fructose corn-based products; and what do international nutritional support programs need to look like in order to address but undernutrition and overnutrition in the same households (e.g., changing flour aid to ready-to-use therapeutic foods but also preventing pre-packaged crap-food from entering poor communities and displacing produce).
Secondly, it’s not clear that without reinvigorating a World Food Council, we would really be able to make the equivalent of large-scale decisions around food that need to take place, just as tackling HIV necessitated a Global Fund both to finance initiatives to improve disease outcomes but also to determine what an international scale-up on these efforts would look like and describe what change is needed. Just as it was deemed unacceptable to allow HIV-infected persons to die without medicine access, not the question is whether we will allow people to die from both undernutrition and overnutrition; again we’re faced with the same question of whether to blame victims for poor governance or poor “lifestyle choices” or engage in a public health agenda that recognizes the social and economic forces behind epidemiological change. A council for food initiatives would no doubt include not only nutritional experts and representatives of governments, non-government organizations and major global agencies like the UN; the real debate will likely take place about the role of industry on such a council, as well as the role of private foundations and financial institutions.
We’ve seen so many published reports and held so many conferences about the global food situation—about food prices, famines, agricultural and climate change, junk food and alcohol importation—that the question is whether we will translate these statements into a meaningful body that can implement solutions that are already available. The recommended strategies to initiate some basic nutritional regulations have already been outlined, based on specific evidence; now the momentum needs to be generated to initiate some legislation beyond New York City.