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.