Time to Deliver in 2018: WHO Independent High Level Commission on Noncommunicable Diseases (NCDs)

We write this letter to provide a civil society perspective that is not adequately represented by the Civil Society Statement put forward 5 June 2018 by the NCD Alliance (https://ncdalliance.org/news-events/news/ncd-alliance-statement-of-concern-polticaldeclaration-un-hlm-on-ncds). Although some of the concerns voiced in the NCD Alliance letter are similar to our own, the NCD Alliance has a governance structure that is compromised, thus limiting the power of the arguments it makes. The NCD Alliance is engaged with pharmaceutical and other transnational corporations that are at odds with the aims and objectives of public health nutrition. At least 46% of the NCD Alliance budget comes from the pharmaceutical industry and related industries. This puts the Alliance in a conflict of interest situation in much of its work. Therefore, with this letter, we wish to outline our concerns separately.

Public health nutrition professionals' comments on Time to Deliver in 2018: WHO Independent High-Level Commission on Noncommunicable Diseases (NCDs) Ahead of crucial negotiations at the United Nations High Level Meeting on NCDs (UN HLM) to take place in New York in September 2018, we, the signatories of this letter, researchers, civil society members and advocates, would like to voice our concerns with the report "Time to Deliver" launched 1 June 2018 in Geneva (http://www.who.int/ncds/management/time-to-deliver/en/). We wish to raise concerns regarding both the content of the report and the private sector's interference in the report's development.
We write this letter to provide a civil society perspective that is not adequately represented by the Civil Society Statement put forward 5 June 2018 by the NCD Alliance (https://ncdalliance.org/news-events/news/ncd-alliance-statement-of-concern-polticaldeclaration-un-hlm-on-ncds). Although some of the concerns voiced in the NCD Alliance letter are similar to our own, the NCD Alliance has a governance structure that is compromised, thus limiting the power of the arguments it makes. The NCD Alliance is engaged with pharmaceutical and other transnational corporations that are at odds with the aims and objectives of public health nutrition. At least 46% of the NCD Alliance budget comes from the pharmaceutical industry and related industries. This puts the Alliance in a conflict of interest situation in much of its work. Therefore, with this letter, we wish to outline our concerns separately.
We are concerned with several of the recommendations made in the report "Time to Deliver", We also want to draw attention to well-supported recommendations that have been offered by other institutions, even by WHO itself, that were not considered in Time to Deliver Annex 1 highlights specific comments on the document, and Annex 2 provides our recommendations for future work of the Commission.
We would also like to raise questions about the private sector´s influence on and possible interference with the Commission and its outputs. We are particularly concerned about the participation of representatives on the High-Level Commission who have previously been linked with the sugary drink industry and representatives from the World Economic Forum which partners with 100 companies. We are also concerned that the NCD Alliance, an organisation that, as we explain above, is seriously compromised, should be the only organization tasked with representing public interests on the Commission.
Public-interest civil society groups have raised concerns previously about the private sector´s influence in the NCD-related work of WHO, for example, when launching the Conflict of Interest Coalition during the 1st UN General Assembly on NCDs, demonstrating the concern of 161 NGOs to keep policy setting free from commercial influence. Additionally, some of us have also stressed (in a letter in May 2017) serious concerns over the membership of the Working Group convened by WHO as part of the preparatory process for the 27 September 2018 High-level Meeting on the prevention and control of non-communicable diseases (NCDs).
In conclusion, we recommend that there should be a zero-tolerance policy with regard to the involvement of food and beverage industry, tobacco, alcohol or pharmaceutical industries or members and organizations with conflicted interests, especially within the membership of the Commission and the Working Group. And, when referring to engagement with the private sector, all the work of WHO's Independent Commission on NCDs should be aligned with previous recommendations.
The "Framework Convention of Tobacco Control" (FCTC) is a good starting point to highlight the relevant risks of engaging with the private sector and can serve as a model for NCD prevention in terms of how to address the risks of engaging with the tobacco, alcohol and Big Food and Beverage industries. Guidelines on how to perform a risk assessment, including due diligence in interactions with the private sector, must be explicit parts of the report "Time to Deliver" as a minimum standard.
The signatories strongly believe that if guidance on this matter is not clear and vested private sector interests continue to prevail in the public health policy arena, it will seriously hamper efforts to achieve the NCD targets in most of the Member States.
Finally, as signatories, we are appalled that the Report does not mention the right to adequate food and nutrition as a central issue in the NCDs debate and in its key role in the years left of Agenda 2030. ANNEX 1 Comments on specific recommendations made in the report • "Time to Deliver" does not provide a clear focus on an action plan on priorities for the global south. This, as the 40 million deaths attributed to NCDs every year, are driven by the influence of the permanent and expanding presence of unhealthy food and beverage industries, even in the poorest areas lacking basic needs such as clean drinking water. These deaths are wrongly attributed in the report to "accidents of geography and poverty that are tragically cutting lives short". This, of course, implies that such deaths are natural and unavoidable rather than being driven in large part by the unhealthy eating practices ultra-processed food industries promote and profit from and that poverty is inevitable and not an effect of a system that reproduces inequality and exclusion. • Among the recommendations made to member states (MS) to introduce cost-effective interventions, there is no explicit recommendation made for a 20% sugar-sweetened beverage (SSB) tax to reduce SSBs consumption, despite established evidence of the relationship of sugar consumption to diabetes and obesity and evidence of widespread excessive consumption far above WHO recommendations. In 2016, WHO published a recommendation to include fiscal measures to limit the consumption of sugary drinks as one of several interventions to tackle obesity and diabetes.
(http://apps.who.int/iris/bitstream/handle/10665/250131/9789241511247eng.pdf?sequence=1) We believe this recommendation must be explicitly re-stated as a cost-effective intervention in this document, as it has been proven to be so in modelling studies and in countries where it has been implemented. • Recommendation 2 (p.19) mentions that MS should set NCDs as a priority on national agendas but does not prompt or highlight the "best buys" priorities for the NCDs on the agenda mentioned in previous UN and WHO documents which have explicitly highlighted the relevance and importance of reducing the harm of unhealthy diets as a major contributor to NCDs. • Access to health care and improved health systems is highlighted (p. 21), but access (incl. physical and economic) to healthy, natural or minimally processed foods and culinary preparations (that promote traditional diets), as well as sufficient and affordable water and sanitation --that are key determinants of healthy diets and good nutrition--are not mentioned explicitly in the recommendations. This ignores the accumulating evidence of the effect these factors have on NCDs. Attention to food systems and the policies shaping them, from production to consumption, is crucial for producing changes in diets, preventing different forms of malnutrition-including overweight and obesity--and reducing NCDs. The report is silent on the major policy reforms needed in this area, including those policies that support and protect small and medium scale producers who produce the foods that form the base of traditional diets and culinary cultures. • We believe that WHO's role should be to guide policy makers on regulations and other public health policy measures to prevent NCDs/promote healthy diets, and to ensure that interactions with the private sector are appropriate. We strongly disagree on how recommendation 4 numeral I (p. 24) is presented in the document: "WHO should support governments' efforts to engage with the private sector for the prevention and control of NCDs…". • Recommendations are made to create a forum with investors to shift health portfolios that "should include attention to agriculture and food production, the introduction of health and nutrition impact measures of investment and the role of public investment to shape private investments" (p.27). We believe this recommendation is a loophole that invites COI situations, as private corporations are given a green light to influence private and profitable priorities in ways that may override or ignore any public health intervention. • Contrary to recommending the concomitant establishment of a forum with other organizations with academia, foundations and public interest civil society organizations (and other actors with non-commercial interests), we merely find a suggestion of setting up a forum ("could be created"-p.27). This undermines the importance of the role of public-interest actors in supporting governments in the design of preventive policy packages. • The mechanisms to increase financing on NCDs are said to include a "Global Solidarity Tobacco and Alcohol Contribution" under recommendation 5, numeral B (p.27). We do not believe any of these industries should be involved in financing NCDs prevention, as their primary interests (i.e., to increase profitability and returns on investment to shareholders), are in conflict with prioritizing public health and NCDs prevention • The recommendation on exploring the establishment of a multi-donor trust fund to catalyse financing should explicitly outline safeguards that adequately protect policy setting and implementation from conflicts of interest (recommendation 5, page 27). The report only bans the tobacco industry in such mechanisms but promotes the inappropriate involvement of corporations such as non-alcoholic beverages, pharmaceutical, food and alcohol industries. • Recommendation 4 addresses engagement with the private sector, academia and civil societies, with appropriate mechanisms to promote transparency and accountability.
Engaging with the private sector with the exception of the tobacco industry is recommended: "Governments should be encouraged to engage constructively with the private sector-with the exception of the tobacco industry" (p. 23). It remains painfully unclear to us how such guidelines or "engagements" will bring about transparency and accountability as mentioned and suggested. It considers "fresh relationships should be explored with the food, non-alcoholic beverage… industries" (recommendation 4, Numeral I, p. 24). As mentioned, we believe none of these industries should be included, particularly after pointing out that progress in reducing NCDs has been particularly slow because of the huge influence these industries have over policy makers. • The report explicitly calls for involving industry in policy making including regulatory measures: "governments should work with: food and non-alcoholic beverage companies in areas such as reformulation, labelling and regulating marketing" (recommendation 4, numeral C, p. 23). This is highly problematic and should be removed. • Additionally, this recommendation mentions: "Governments could also encourage economic operators in the area of alcohol production and trade to consider ways in which they could contribute to reducing the harmful use of alcohol in their core areas, as appropriate, depending on national, religious, and cultural contexts" (recommendation 4 Numeral C. p.23). This, in our view is not strict or adequate enough to prevent problems associated with advertising and promotion that encourage the consumption of alcohol, which is harmful to mental health and contributes to other NCDs. Government regulations to protect public health is to be paramount and cannot be replaced by industry self-regulation. • Recommendations on including multi-stakeholder mechanisms, such as NCDs commissions and "equivalents of the Global Coordination Mechanism" open the door to undue influences in policy setting. They fail to address power imbalances and conflicts of interest as has been demonstrated by the case of the SUN initiative. • The engagements proposed with industry will definitely undermine the recommendation given: "Governments should employ their full legal and social powers to achieve public health goals and to protect their populations. This includes policy and legislative and regulatory measures that minimize the consumption of health-harming products and promote healthy lifestyles." (recommendation 4, numeral I p.24). The proposed engagements with food corporations will undermine and risk legal and social powers, as industry participation on the agenda setting for a given regulatory proposal might water down the legal and social instruments (e.g. reducing the amount of a SSBs tax, procure auto-regulation measures, ease nutrient criteria parameters) or the implementation process (by volunteering or participating in its evaluation). • Furthermore, the specific recommendations at the end of the document do not include targeted recommendations to reduce alcohol use. They do not address issues of food and nutrition literacy for people living with diabetes or heart disease and are focused on pharmacological treatments only.
• For the recommendation on preventing NCDs through early nutrition interventions, reducing the consumption of ultra-processed foods by infants and young children, including through effective marketing regulations, implementing the International Code of Marketing of Breastmilk Substitutes and subsequent relevant WHA Resolutions is essential. • The documents to monitor and evaluate progress do not include a reference on how to address COI and including, accountability and transparency indicators of interactions and engagements with the private sector.