We can all, in general, expect to live a little longer than our grandparents did – and, until recently, many of us have had expectations to live to an older age than our own parents. In addition to living longer, our risks of disease and causes of death are changing.
Data from the 2010 Global Burden of Disease survey showed that all around the world populations are shifting away from infectious diseases towards non-communicable diseases (NCDs). NCDs represent a wide range of conditions, among which the most common are heart disease, strokes, and lung diseases.
Long thought of as diseases of the rich world, they are rising everywhere: by 2030, NCDs will be the most common cause of death in Africa.
Among the top ten global risk factors for disease identified in the 2010 survey, at least half were associated with “consumer lifestyle” – tobacco smoking (ranked number two), alcohol use (number three), low consumption of fruit (number five), high body mass index and high plasma glucose (numbers six and seven, respectively). The number one slot was occupied by high blood pressure – with its multitude of drivers and causes.
The institutions that co-ordinate global responses to health problems – most notably the World Health Organisation – were established many decades ago, in an age when the main dangers to health were predominantly infectious diseases (tuberculosis, respiratory infections, diarrhoea, polio, and so on).
At the time, they tended to see the biggest transnational threats to health arising from the potential spread of infection across national borders – a problem which grew in prominence as the world globalised, and cross-border movement (of people and animals) became more widespread.
Countries developed mechanisms for co-operating to control the spread of infectious diseases, both within their own borders and beyond, and had marked success against a number of pathogens (for example, smallpox, SARS, and polio until recently).
A 21st century response
However, the current threats to health and well-being pose a very different set of challenges. While the WHO and its sister institutions had some success in regulating international health policy in an era characterised by infections and epidemics, can they succeed in promoting and protecting the health of the public where threats to health are now associated with exposure to the products of big business?
Transnational threats to health in the early 21st century arise predominantly from private sector companies selling tobacco, alcohol and manufactured foods and drinks (the consumption of highly processed foods typically high in salts, fats, sugar and additives may be displacing fresh foods among some populations.
Regulating these threats to health is no longer as (relatively) simple as thinking about how to monitor, control and treat infectious pathogens. Instead, the “guardians of global health” are now faced with the challenge of negotiating with interests whose very existence depends on the sale of products that can be actively harmful to human health.
Regulation or co-operation?
If governing states has proven challenging for international organisations, the prospect of constraining private sector interests through the same mechanisms is a distant dream. Given this, what model could negotiations take? Should the global health community promote regulation, or co-operation? Can we legislate our way out of a public health crisis, or can we rely upon informed consumers to make the right choices?
The rise of NCDs has highlighted a serious regulatory blindspot, and raised important questions about who is capable of protecting global health.
The challenge is vast. In 2011 the World Economic Forum (WEF) said NCDs posed one of the greatest threats to economic development and state stability. The problem – like our waistlines – is not getting any smaller. The WEF estimated that NCDs will cost poorer countries an average US$500 billion a year to tackle.
At first glance, the balance of negotiating power seems heavily stacked in favour of private sector industries, as the chart below illustrates. In terms of financial resources, the private sector has wealth beyond the wildest dreams of those concerned with health promotion and protection.
And as Margaret Chan, director-general of the World Health Organisation so succinctly put it in 2013: “market power readily translates into political power.”
People, not financial, power
Financial resources are just one aspect of power. In the past few decades, democratic and social movements have also brought about changes in the landscape of global health negotiations. From organisations demanding access to HIV medicines in the global south, to co-ordinated global protests against the promotion of infant formula feeding, global health has a strong history of civil society movements bringing about changes in the way the private sector (for example pharmaceutical companies and manufacturers of baby milk) does business.
For now we don’t have strong movements of citizens demanding changes to the way sugar is promoted to children, while young people are encouraged to associate alcohol with the positive imagery of sex, sport and good times.
But this may change. If life expectancies fall (as predicted), and the full extent of the costs to society of tackling the negative health consequences of – for example – drinking alcohol, are finally calculated, will civil society demand action, and will decision-makers listen?
Within living memory we have moved from an era of death and disease transmitted by infection, to death and disease associated with consumerism and choice. Understanding how to reduce risks in this this changing environment means, at heart, asking fundamental questions about the nature of global health and society and who will hold private sector companies to account for the impact of their actions. At its heart will be whether profit and public health can co-exist in an equitable society.