Ethical considerations on public-private engagements for public health

LSHTM, 13 April 2016

Dr Modi Mwatsama, Director, Global Health & Registered Nutritionist

Key messages

1. Public-private partnerships (PPPs) promoted by the

WHO & UN

2. Partnerships with Big Food can be problematic

3. Big Food corporations deliberately weaken public

health efforts to improve diets

4. Need to raise awareness, generate evidence &

develop guidance on avoiding COIs in nutrition

“Encourage and promote effective public, public-private

and civil society partnerships, building on the

experience and resourcing strategies of partnerships”Goal 17.17

http://www.un.org/ga/search/view_doc.asp?symbol=A/RES/70/1&Lang=E

“The private sector needs to be part of effective

multisectoral action on NCDs”

UN political Declaration on Non-Communicable Diseases, 2011

“Big Food”

Products rather than food

Higher profit margins from processed foods

£11.20 per kg £0.47 per kg

24x more profitable

Food marketing: Recommended diet vs the advertised diet

Margaret Chan World Health Organisation

WHO Director-General

“Research has documented these tactics well. They include front groups, lobbies, lawsuits, promises of self-regulation, & industry-funded research that confuses the evidence and keeps the public in doubt”June 2013~ http://www.who.int/dg/speeches/2013/health_promotion_20130610/en/

“It is not just Big Tobacco anymore. Public health must also contend with Big Food, Big Soda, & Big Alcohol

All of these industries fear regulation, and protect themselves by using the same tactics.”

Front groups

Courtesy of Professor Simon Capewell, The University of Liverpool

Global Energy Balance Network: leaked emails –out of the tobacco industry playbook

Leaked emails show $110M dollars from Coke

Deliberately selecting studies that would help deflect

attention from soda & buy silence:

– Coke: “large and expensive study but could be a game changer. We need this study to be done.”

– “Avoid the image of [Coke] being a problem in people’s lives…”

– “Akin to a political campaign, we will develop, deploy and evolve a powerful and multi-faceted strategy to

counter radical organizations and their proponents.”Courtesy of Professor Simon Capewell, The University of Liverpool

Self regulation & partnershipsUK Responsibility Deal distribution of interventions

Upstream: More effective Downstream: Less effective

Courtesy of Dr Cecile Knai, LSHTM

PPP risks: reciprocities & framing, reputation

Marks, Jonathan H. 2014. “Toward a Systemic Ethics of Public-Private Partnerships Related to Food and Health.” Kennedy Institute of Ethics Journal 24 (3): 267–99.

Nutrition governance project

• Aim: to support efforts to address governance gaps

on COIs

• Key informant interviews & literature review

• Workshop at Rockefeller Foundation Bellagio centre

• Outputs: report, publications, Casebook initiative

• Collaboration between UKHF & Canadian Institute of

Health Research – Institute of Population & Public

Health

Recommendations for tackling COIs

1. Generate evidence on COIs & PPP challenges in public health

2. Assessment & evaluations of PPPs: health & systemic effects (eg Brazil products, policies & practices tool)

3. Raise awareness, capacity building & opportunities to share & learn on COI and PPP challenges

Essential components of an

ethical framework

• Independent 3rd party assessment of the ethical

implications

• On-going reviews to assess PH impacts & efforts to

address COIs

• Considers wider systemic effects (not constrained to

those within the partnership)

• Includes exit mechanisms

Thank you!

NGOs letter to WHO Executive Board,

January 2016

1. Review the adequacy and implementation of existing

WHO policies to establish whether FENSA

strengthens or weakens safeguards.

2. Develop a comprehensive and effective COI policy

for WHO.

Promote production & consumption

of plant-based foods

http://www.groundswellinternational.org/sustainable-development/ghana/promoting-local-food-and-nutrition-in-ghana/

http://bvsms.saude.gov.br/bvs/publicacoes/dietary_guidelines_brazilian_population.pdf

Pepsico’s health goals

Products goal (2010)

“Increase the amount of whole grains, fruits, vegetables, nuts, seeds and

low-fat dairy in global product portfolio”

Source: Acharya T et al (2012) Activities of the Private Sector, Part 1 in Stucker D. & Siegel K Sick Societies: Responding to the global challenge of chronic disease.Jamba Juice http://www.jambajuice.com/menu-and-nutrition/menu/jamba-kids-meal

Jamba juice (2013):

“Now You Can Have Your Whole Grains and Drink Them Too”

10 different F&V6g fibre

34g sugar

Conflicts of Interest

Margaret Chan, Director General, WHO:

• Efforts to prevent NCDs go against the business interests

of powerful economic operators…

• It is not just Big Tobacco. Public health must also contend

with Big Food, Big Soda, and Big Alcohol… They fear regulation & protect themselves with the same tactics.

• See Profits & Pandemics, the Lancet NCD series 4: no

evidence that public-private partnerships are effective.

Margaret Chan speech WHO Health Promotion Conference 2013, www.who.int/dg/speeches/2013/health_promotion_20130610/en/

Profits and pandemics: prevention of harmful effects of tobacco, alcohol, and ultra-processed food and drink industries

http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(12)62089-3/abstract

Market expansion

UN NCDs Declaration called for

“The intensification of efforts to curb harmful use of alcohol in young people…”

Tequila (alcohol)

Youth-oriented marketing key to "opening up the

emerging market floodgates…"

Source: Euromonitor international (trade press blog, 15 December 2011)

MALI TURKEY

MEXICO USA

http://foodmatters.tv/articles-1/what-the-world-eats-shocking-photos

Coca Cola park lives

COI definition

An institutional conflict of interest arises when a public-

interest institution creates a situation in which it

enters into a collaborative interaction with a private

sector organisation in a manner that puts the

interests of the private sector organisation

(secondary interests) above the interests of the

public-interest institution.

Adapted from: UN Standing Committee on Nutrition, Private Sector Engagement Policy, 2006

Sowing doubt through science

Sowing doubt through science

Beneficial industry collaborations:

eg UK labelling

Coop supermarket &

Coronary Prevention Group

• “High Medium Low” scheme

(traffic light labels precursor)

• Consumer research

• Labelling campaigns

Series on Chronic Disease and Development

Mass media camp

Worksite interv.

Physician couns.

School-based int.

Food labelling

Fiscal measures

Food advert reg.

Disability-adjusted life years (thousands) Life years (thousands)

China India Brazil Russia England Mexico South Africa

Source: Ceccini et al. Tackling Unhealthy Diets, Physical Inactivity and Obesity: Health Effects and Cost-Effectiveness. The

Lancet, Nov 2010

Global analysis: Effects of obesity interventions (average effect per year)

Upstr

eam

Dow

nstr

eam

Food taxes: Industry lobbyingexpenditure in the US ($)

Source: WilsonD and Roberts J (2012) Special report: Howe Washington went soft on childhood obesity. Reuters. http://www.reuters.com/article/interactive/idUSBRE83Q0ED20120427?view=small

Responsibility Deal: illustrates the

syste ic co seque ces of PPPs

• Reciprocities: policies favourable to industry

• Framing effects: adoption of industry’s framing of the problem & solutions

• Reputational damage: perceptions of lack of

integrity, credibility & trust

Marks, Jonathan H. 2014. “Toward a Systemic Ethics of Public-Private Partnerships Related to Food and Health.” Kennedy Institute of Ethics Journal 24 (3): 267–99.