Corporate power is one of the major barriers to improving global health, according to Dr Margaret Chan, the Director General of the World Health Organization.
In a strong opening address last week to the 8th Global Conference on Health Promotion in Helsinki, Finland, Dr Chan also highlighted concerns about inequalities, between and within countries, which “are now greater than at any time in recent decades”.
“We increasingly live in a world of rich countries full of poor and sick people. The rise of noncommunicable diseases threatens to widen these gaps even further,” she said.
Efforts to prevent noncommunicable diseases go against the business interests of powerful economic operators, she said, and “this is one of the biggest challenges facing health promotion”.
Dr Chan said public health did not only have to contend with Big Tobacco:
“Public health must also contend with Big Food, Big Soda, and Big Alcohol. All of these industries fear regulation, and protect themselves by using the same tactics.
Research has documented these tactics well. They include front groups, lobbies, promises of self-regulation, lawsuits, and industry-funded research that confuses the evidence and keeps the public in doubt.
Tactics also include gifts, grants, and contributions to worthy causes that cast these industries as respectable corporate citizens in the eyes of politicians and the public. They include arguments that place the responsibility for harm to health on individuals, and portray government actions as interference in personal liberties and free choice.
This is formidable opposition. Market power readily translates into political power. Few governments prioritize health over big business. As we learned from experience with the tobacco industry, a powerful corporation can sell the public just about anything.
Let me remind you. Not one single country has managed to turn around its obesity epidemic in all age groups. This is not a failure of individual will-power. This is a failure of political will to take on big business.”
Dr Chan said WHO believed that the formulation of health policies must be protected from distortion by commercial or vested interests.
“When industry is involved in policy-making, rest assured that the most effective control measures will be downplayed or left out entirely,” she said. “This, too, is well documented, and dangerous.”
Health in All Policies (HiAP) was the theme of the conference, and some interesting insights emerged about what can help facilitate such approaches.
Presentations highlighted the importance of central leadership (heads of government rather than health ministers are best placed to lead HiAP), regulation, and an HiAP workforce with the ability to negotiate complexity, to facilitate social change, and to create conditions that promote favourable political decisions.
The invitation-only conference was co-organised by the World Health Organization and the Ministry of Social Affairs and Health of Finland.
Below is a wrap of some conference highlights, including an article from Professor Fran Baum reflecting upon the implications for Australia. Beneath her post are summaries of some key presentations.
Lessons from Helsinki for local, state and federal governments
Fran Baum writes:
The first message is that health and its distribution (health equity) should stand alongside GDP as a measure of how well a society is doing.
This was also the message from the Commission on the Social Determinants of Health whose relevance to Australia has been reinforced by the Senate Standing Committee on Community Affairs.
Health in All Policies is a vital mechanism to implement action on social determinants and is one that should be adopted by local, state and the Federal government.
Australia has some history of doing this through Healthy Cities projects and a formal Health in All Policies initiative in South Australia. The consensus feeling was that Health in All Policies should be lead from the Head of Government (Mayor, Premier or Prime Minister) but that the health sector has a vital technical support role.
Health promotion matters
A crucial stand out message for us from Helsinki is: why on earth are our state governments cutting back their spending on health promotion?
This conference over and over again stressed the need for all health systems to have a strong health promotion effort and that Health in All Policies was one part of this but that local health promotion through primary health care is also vital.
Yet both South Australia and Queensland have been busy making very significant cuts to their health promotion effort.
It is particularly strange for South Australia, which has such a strong record in the area and whose Health in All Policies work has been recognised internationally and at this conference. Luckily HiAP in SA appears to have survived the cuts so far.
Australian governments should be aiming to increase their investment in health promotion. Over and over again the economic sense of this investment was stressed.
For instance, if we don’t ensure that all children have a healthy childhood then the whole of society will bear the future costs through the health, criminal justice and welfare sectors.
For Australia to make cuts to health promotion at any level of government is long-term economic madness.
Standing up to industry
There were also key lessons about dealing with the impact of industry on health.
The adverse consequences of Big Food, Big Soda and Big Alcohol were laid out plainly by WHO Director General Dr Margaret Chan when she said:
“In the view of WHO, the formulation of health policies must be protected from distortion by commercial or vested interests,” whose tactics “include front groups, lobbies, promises of self-regulation, lawsuits, and industry-funded research that confuses the evidence and keeps the public in doubt.”
Frances Fitzgerald, the Irish Minister for Children and Youth Affairs, also talked of the need to make the lobbying tactics of industry transparent and to ensure that health promotion advocates have the same access to politicians as industry representatives.
It is so easy for industry to paint their influence as benign and even helpful to health while ignoring adverse health impacts (including tax evasion).
A representative from the World Economic Forum made such a presentation and I tweeted (@baumfran) it as a “healthwash” akin to the dubbing of questionable industry environmental credentials as “greenwash”.
Delegates spoke of the need for industry regulation and the importance of dealing with the ideological battle whereby measures to protect health are derided as the “nanny state” in action and as interfering with individual rights.
Australia was congratulated at the conference for its tobacco plain packaging legislation and there were frequent references to the ways in which industry have tried to undermine it.
There was also much discussion about the post-2015 Millennium Development Goals agenda and a strong feeling that the Health in All Policies approach is very relevant.
Health equity and development
Over and over again delegates stressed that the post-2015 agenda had to include health equity as a goal and pay attention to the very real differences in health status within countries.
The structural unfairness of the world’s economic system was also discussed and there were calls for it to become fairer and increase regulation for global public health.
The final session included a call for development assistance budgets of rich countries to be at 0.7% – an important message for Australia.
The final conference statement was strong on recognition of the problems HiAP faces, yet disappointly weak in terms of its recommendations. This was especially true given DG Chan’s powerful opening speech.
In response, a group of us from the People’s Health Movement are working to develop a stronger Call to Action.
Australia could benefit by considering our recommendations on the importance of progressive taxation, on the need for Health in All Policies to be led by heads of government in order to eliminate the policy incoherence that undermines population health and exacerbates health inequities, and the need to regulate other health-damaging industries in the way we have tobacco.
Overall, the 8th Global Conference on Health Promotion has greatly reinforced the absolute importance of concerted government action to ensure that the conditions of our everyday lives – at home, work and in our communities – as much as possible create supportive environments for health.
Far from being the actions of a “nanny state”, this is the way in which the right of all of us to be as healthy as possible is realised.
• Fran Baum is a professor of public health. She is the director of the Southgate Institute of Health Society and Equity, Flinders University, Adelaide, Australia, and is a member of the Global Steering Committee, People’s Health Movement. She is an Australian Research Council Federation fellow. Follow her on Twitter: @baumfran
• Here is Fran Baum’s presentation on the evaluation of HiAP work in SA, where Health in All Policies has been promoted as a strategy to address complex problems and has strong across government support. She said that implementation is mediated by organisational culture, capacity and priorities, power relationships, political will and resources.
• Fran Baum also blogged for the BMJ on the conference:
On Finland’s primary healthcare system which provides free accessible multidisciplinary primary healthcare services to all its population, the need to use fiscal measures to control risk factors for chronic disease, and an observation that “failed childhoods are very costly to society”.
On how governments can get Big Food to stop addicting us to sugar and fat (and what we can learn from Finland on this re the importance of regulating the food supply, and from Thailand’s approach to HiAP and progressive health policies)
On Ecuador’s impressive progress on health and social spending, and reducing inequities through multisectoral action. The conference also heard Canadian Greg Taylor cite Danny Broderick, senior policy officer in HiAP, South Australia as saying “Intersectoral action can sometimes be like a tug of war. HiAP has different logic—let go of the rope.”
On the globalisation of unhealthy lifestyles and suggestions about how to create the political will for HiAP.
In brief…some other presentations
Subra Subramanian, Professor of Population Health and Geography from the Harvard School of Public Health, said that the levels of income and wealth inequality that we are witnessing now – both within and between countries – is unprecedented. Health and social problems are worse in more unequal countries. If recent global and national economic trends provide any indication, research and action on income inequality and its potential effects on health will probably be more, and not less, important.
Pekka Puska, Director General of the National Institute for Health and Welfare in Finland and President of the International Association of Public Health Institutes, spearheaded the famous North Karelia Project which reduced cardiovascular mortality. He said that healthy policy decisions are usually the result of complex political power play with conflicting interests and interest groups. Sustained changes in population health can only take place with permanent changes in people’s lifestyles and environments, and represent a long term social change process. He said: “We should not blame the patient or the population but need to create social change to create conditions that promote favourable political decisions. Policymakers and private sector are much influenced by the opinions of the people.”
Ilona Kickbusch, Director of Graduate Institute of Development and Development Studies in Switzerland, said the challenge for health promotion is to develop capacity at various levels of governance to address the key determinants of health – political, social, economic, commercial environmental and behavioural – and to contribute to sustainable growth and development. She cited Margaret Chan on the globalisation of lifestyles as being a political, trade and foreign affairs as well as a public health issue. Capacity building includes intersectoral training opportunities in cooperation with schools of public health, business, diplomacy, foreign policy, and public policy. She also noted that complexity science and political science are essential to understanding HiAP processes because policy processes are chaotic and political. HiAP is an ever moving target and its work is never done. Stakeholder and network analysis and management, and negotiation are also crucial skills for HiAP. Learning systems are required where people can experiment and make mistakes and so keep their courage for challenging the status quo. She also said the core skill for public health will be the management of the interfaces between varied groups with v different interests, legitimacy and power. The health in all policies strategist must “evolve from a master who gives the orders to a facilitator who makes the process work”.
Ilona Kickbusch also tweeted a link to the Fair Tax Mark campaign,which she described as an HiAP tool. This civil society campaign, which recently launched in the UK, ranks companies for tax transparency, tax paid and use of tax havens.
Their website says: “We use the Fair Tax Mark methodology to publish credible assessments of whether large companies are acting transparently and paying fair tax in the UK. We marshal public support to campaign for the specific changes that will lead to more companies paying fair tax.”
This presentation included this evocative image – anyone for an HiAP boardgame, snakes and ladders style?
And, finally, this post from the HiAP blog asks whether Helsinki will prove to be “history in the making”.
Perhaps at least some of the answer lies with whether the public health community can effectively engage the general community and wider health sector (perhaps via social media et al) in creating political pressure for change.