Prioritization of Noncommunicable Diseases in the Global Health Policy Agenda

The 21^st century has seen a dramatic transformation of the global disease burden. Noncommunicable diseases (NCDs), including cardiovascular diseases, cancers, chronic respiratory diseases, and diabetes are now the leading causes of mortality globally, with an estimated 41 million deaths per year [1]. More than seventeen million of these deaths are premature, affecting people when they are productive and most likely to have dependents—between the ages of 30 and 69—placing a heavy social and economic toll on societies and threatening sustainable development. Over 86% of premature deaths are taking place in low- and middle-income countries (LMICs), where the health systems are least prepared to provide access to optimal treatment and care [1]. While NCDs are largely preventable, a complex interplay of social, economic, cultural, environmental, and commercial determinants keeps driving the rise of the NCD pandemic.

The rapidly increasing prevalence of NCDs has gained global political prominence following the three United Nations General Assembly High-level Meetings (UNGA HLMs) on the Prevention and Control of NCDs in 2011, 2014, and 2018. At these meetings, there was a broad consensus that the magnitude of the challenge required collaboration with “non-health actors and key stakeholders, where appropriate, including the private sector and civil society, in collaborative partnerships to promote health and to reduce NCD risk factors [2].” The same documents highlight that public policies need to be protected from undue influence from industries that profit from the sale of unhealthy commodities.

Acknowledging the impact of commercial factors on societal health, governments have called on the private sector to strengthen its commitment to national NCD prevention and control efforts by promoting and creating safe and healthy working environments; encouraging reductions in the use of alcohol; taking concrete steps toward eliminating marketing, advertising, and sale of alcoholic products to minors; producing and promoting food products consistent with a healthy diet; reducing children’s exposure to marketing of unhealthy foods and beverages; and improving access to effective medicines and technologies aimed at preventing and controlling NCDs [3].

With the adoption of the 2030 Agenda for Sustainable Development, heads of state and government and other high-level representatives reaffirmed that NCDs are a major barrier to achieving nations’ health and development objectives. The Agenda includes SDG target 3.4 on the reduction of premature mortality from NCDs by one-third and enhanced mental health and well-being by 2030 [4]. Other NCD-related targets encompass strengthening policies and programs to address the use of alcohol and other psychoactive substances and treatment for substance use disorders. These include achieving universal health coverage; scaling up the implementation of the WHO Framework Convention on Tobacco Control; ending all forms of malnutrition, including obesity; supporting research and development; and improving access to vaccines and essential medicines for NCDs. In addition, the 2030 Agenda incorporates SDG 17 on means of implementation, specifically in targets 17.16 on “Global Partnership for Sustainable Development, complemented by multi-stakeholder partnerships that mobilize and share knowledge, expertise, technology, and financial resources” and 17.17 on public, public-private, and civil society partnerships.

The United Nations’ growing emphasis on multistakeholder partnerships and governance, now embedded in the Sustainable Development Goals (SDGs), opened up new opportunities for the private sector to participate in the policy-making processes. Public-private partnerships have become more common in the health sector, as governments and multilateral institutions are applying these arrangements to address diverse health issues [5]. However, the private sector is not homogenous, and a blanket approach to the engagement of the private sector, particularly for NCD prevention and control, may unduly influence the public health agenda [6].

While recognizing that there are many different types of private commercial sector entities playing a significant role in public health, this paper seeks to (i) describe the key industry actors shaping the NCD landscape; (ii) highlight the impact of unhealthy commodities’ production and trade on health and the growing burden of NCDs; and (iii) outline challenges and opportunities associated with engagement with the private sector to reduce the exposure to unhealthy commodities to address NCD prevention and control both globally and nationally.

Key Industries Shaping the NCD Landscape

The private sector has been defined as ‘organizations that engage in profit-seeking activities and have a majority private ownership, including transnational companies, micro-, small- and medium-sized enterprises, cooperatives, individual entrepreneurs, market vendors, and farmers, who operate in the formal and informal sectors [7]’. The private sector also refers to corporate commercial healthcare providers, which have a large and growing role in health systems worldwide. In some countries, private providers are contracted by governments for basic care towards universal health coverage, such as private general practitioners in the United Kingdom or non-governmental organizations in Bangladesh to provide primary healthcare services. In other systems, private providers deliver additional, beyond-basic healthcare services for those who can afford to pay for them [8].

Apart from the private health service providers, a wide range of industries in both the health and non-health sectors can directly or indirectly influence public health. For example, the contribution of healthcare companies to the research and development of medicines and technologies to prevent, diagnose, treat, and manage health conditions is well established. The industry has both the expertise and business interests in supporting the NCD agenda. As a result, in recent years there has been a significant increase in the number of access to medicines and other global health initiatives involving pharmaceutical companies and their foundations [9]. Other industries, such as sporting goods and fitness, design, and built environments, consumer goods, foods and beverages, health insurance, and media and information technologies are also increasingly becoming pervasive in the health marketplace. For example, personalized health technologies, including wearable devices and smartphone apps, are targeting various chronic diseases and their risk factors, including adherence to medications, remote monitoring, smoking cessation, and mental health [10].

While public-private interactions can address some of the diverse challenges related to NCDs, concerns arise when it comes to agreements between governments and industries that produce products that are negatively associated with health [11]. Commercial determinants of health, here defined as the private sector activities that affect people’s health positively or negatively, come into complex interplay with the social determinants of health, including intermediate determinants (e.g., education, occupation, income, ethnicity, race, access to healthcare) and structural determinants (e.g., socio-economic and political context), and affect health inequities and individuals’ health throughout the life course [12].

In this context, a major challenge for NCD prevention and control is the influence of transnational corporations that directly or indirectly profit from the consumption of their products (tobacco, alcohol, and unhealthy foods and beverages) proven to influence the NCD risk factors and worsen the populations’ quality of life and health outcomes. Ultimately, the rise of NCDs is a manifestation of a global economic system that currently prioritizes corporate wealth creation over health creation. Many problems and solutions to address the risk factors for health lie outside the health sector, in the domains of finance, trade, agriculture, and investment policies [13].

Understanding that immense threats to health in the modern era cannot be tackled by governments alone, and also recognizing the challenges of reconciling public and private interests, in 2011, Michael Porter and Mark Kramer introduced a new approach for businesses to highlight the importance of creating shared value by identifying and addressing societal challenges, including in the areas where health outcomes intersect with business. The shared value framework seeks to “create new opportunities for companies, civil society organizations, and governments to leverage the power of market-based competition in addressing social problems [14].”

From the NCD perspective, “Big Tobacco,” “Big Alcohol” and “Big Food” are the major industries associated with the production of unhealthy commodities affecting NCDs. The transnational corporations in these sectors operate at all levels (local, national, regional, and global) and have tremendous economic power at their disposal to influence policy processes [15]. Many of them are economies larger than those of national states [16]. For example, the combined revenues of ten large food corporations (Nestlé, PepsiCo, Unilever, Mondelez/Kraft, Coca-Cola, Mars, Danone, Associated British Foods, General Mills, and Kellogg’s) reached more than a billion dollars a day in 2017–2018: in the same period, annual sales of Nestlé, with its over 2000 brands, amounted to USD 91.2 billion, which is roughly the same as the gross national products of Sri Lanka or Kenya [17]. The breastmilk substitute marketing industry is worth $55 billion [18] and the value of the global tobacco and alcohol markets is even more staggering; in 2017, the tobacco industry was estimated to be worth around US$785 billion (excluding the world’s largest tobacco company, China Tobacco) while the global 2021 alcoholic drinks market size was estimated to be valued at around $1.5 trillion and projected to nearly double by 2028 [19, 20].

Not surprisingly, large corporations in these spheres are increasingly shaping the complex global NCD landscape while the demand for their products continues to grow in LMICs. Given the significant contribution of these products and associated practices to NCDs, is there room for public-private interaction to create shared value and promote population health?

Unhealthy Commodities’ Impact on Health and the Growing Burden of NCDs

Tobacco continues to be one of the leading causes of premature mortality globally, killing over 8 million people each year. More than 7 million of those deaths are the result of direct tobacco use, while around 1.2 million are due to non-smokers being exposed to second-hand smoke. All forms of tobacco are harmful, and there is no safe level of exposure to this product. Almost half of all children globally regularly breathe air polluted by tobacco smoke in public places, and 65,000 die each year from illnesses attributable to second-hand smoke [21].

Alcohol-related harm has a significant impact on global health. The World Health Organization estimates that alcohol consumption contributed to three million deaths in 2016, of which 1.7 million were related to NCDs, including mental health disorders [22]. Consumption of even one alcoholic drink per day increased the risk of various cancers, including female breast, oral cavity, pharynx, and esophagus [23]. The health, social, and economic risks of alcohol consumption go beyond NCDs. Alcohol use is also linked to violence, injuries, infectious diseases, and harm to others [24]. Recent evidence has questioned the claim that there is an “optimal” level of alcohol consumption for cardiovascular health, suggesting that previously reported risk reductions from light alcohol consumption may be better explained by genetics and other behaviors [25]. The preponderance of evidence suggests that the optimal level of alcohol consumption for most demographic groups is zero alcohol consumption [26].

The synergistic effects of tobacco smoking and alcohol consumption on cancer mortality have also been well documented. Combined consumption of tobacco and alcohol has been linked to a greater effect on cancer than consuming either of these products alone. Heavy drinking also appears to be a risk factor for heavy smoking and vice versa [27].

Unlike tobacco and alcohol, the influence of the food and beverage industry on health is not necessarily negative. Healthy nutritious food is essential for life. Many foods need to be processed to some extent to make them safe and widely available to consumers e.g., drying, packaging, chilling and freezing, and pasteurizing. The challenge is the rapid penetration of global markets by highly-processed foods and drinks that are made from industrially processed substances derived from high-yield crops, such as hydrogenated oils and fats, refined sugars, syrups, and starches, protein isolates, and remnants of intensively reared animals. These foods are often energy-dense products, low in dietary fiber, micronutrients, and phytochemicals [28]. However, they often look, smell, and taste good due to a combination of flavors, colors, thickeners, sweeteners, emulsifiers, sodium, and other additives that make them appealing to consumers, particularly children [29].

Approximately 8 million global deaths annually are attributable to unhealthy diets (Figure 1) [30]. Consumption of highly-processed foods and carbonated and other sugary drinks have been linked to the deterioration of the overall nutritional quality of diets and associated with obesity, gastrointestinal disorders, metabolic syndrome, hypertension, diabetes, cardiovascular diseases, various cancers, depression, and other chronic conditions. This is well documented in studies from Brazil, Chile, Columbia, Mexico, the USA, Canada, the UK, France, Belgium, Australia, New Zealand, and Japan [15]. Added sugars in particular, such as fructose-containing sweeteners, sucrose (table sugar), high-fructose corn syrup, maple syrup, and agave nectar, are the most addictive components driving the NCD risk. It is estimated that sugar-sweetened beverages are associated with 184,000 deaths every year globally [31]. In addition, the synergy of high fat with high sugar is extremely effective at stimulating the overconsumption of certain types of foods, especially fast foods. In the USA, 56% of the diet consists of highly-processed foods, and some form of sugar has been added to 74% of the items in American supermarkets [32].

The problem is not confined to Western countries alone. Once high-income country market saturation happens, the food industry tends to shift to lower-income countries. For example, from 2002 to 2016, sales of highly-processed foods increased from 20% in the Latin America and Caribbean region to around 90% in South and Southeast Asia [33]. Young children in Nepal are consuming unhealthy snack food and beverage products in alarming amounts: On average these foods contribute to nearly 25% of the dietary energy intake for children 12 to 23 months, with the highest consumers receiving nearly 50% of their calories from these products [34].

Challenges

Reducing the harms brought about by tobacco use, unhealthy diets, and alcohol consumption worldwide continues to be a major challenge, particularly in LMICs. It is well documented that transnational corporations use similar tactics and strategies to enhance their sales and undermine public health interventions [20]. Some of these strategies include:

1. Sophisticated marketing techniques—Like Big Tobacco, the Big Alcohol industry has substantially expanded its market in LMICs in the past decades, owing in large part to their successful marketing strategies targeting population groups that typically have lower levels of alcohol consumption, including women and young people. For example, a study of 11- to 16-year-old students in Zambia found that students who reported ever receiving a free alcoholic drink from an industry representative had more than 40% higher odds of experiencing alcohol-related behavioral problems (e.g., skipping school or engaging in fighting) and drinking to intoxication versus students who have not received a free drink [35]. Another example refers to an alcoholic beverage that was developed exclusively for women as a ‘stylish’ alternative to beer. The company in question also designed mini liquor bottles to make sure the small size and lower price were attractive to young people and were also easier to transport to rural areas [35]. There is documented evidence that 22% of five-year-old children in Brazil, India, Nigeria, Pakistan, China, and Russia were able to correctly identify a major Philip Morris International brand [36]. A study in Uganda showed that there is widespread advertising of unhealthy foods and beverages around primary and secondary schools (with 86% featuring unhealthy products) [37].

2. Interference in public policy-making processes—The tobacco industry’s interference in public health policies is an issue in rich and poor countries alike. For example, Switzerland, which is not a party to the WHO FCTC, allows tobacco company employees to be elected as members of the Federal Assembly while keeping their jobs. Similarly, the governments of Bangladesh, India, and Malaysia continue to hold their shares in tobacco companies. These practices contrast with the decision of the Norwegian government’s pension fund, which stopped investing in tobacco after introducing the fund’s ethical guidelines. Overall, five countries that remain non-parties of the WHO FCTC—Argentina, the Dominican Republic, Indonesia, Switzerland, and the USA—faced more interference from the tobacco industry in undermining national tobacco control efforts than party states [38]. Highly-processed food industry actors also attempt to influence public health policy through coalition management, involvement in policy formulation, legislative preemption, cooption of the policy process, and information management [39, 40]. Work by Allen et al. has found that countries with the greatest legislative opportunities for corporations to use their financial resources to directly influence policymaking have the lowest levels of NCD policy implementation, and Corporate Financial Influence explains a fifth of the overall variance in global NCD policy implementation [41].

3. Opposing evidence-based practices and biasing research evidence—Unhealthy commodities industries often use evidence to undermine public health and oppose regulation. For example, published articles sponsored by the food and beverage industry are four to eight times more likely to have conclusions favorable to the financial interests of the sponsoring companies [42]. The ultra-processed food and beverage industry claims that regulation to address diet-related NCDs does not have the desired effect. It also questions the links between sugar consumption and obesity and a range of NCDs, despite the mounting evidence that the opposite is true [43].

4. Creating the illusion of corporate social responsibility or shared value—The WHO FCTC is clear that the tobacco industry cannot be seen as a partner in health-related matters. Recognizing the “fundamental and irreconcilable conflict between the tobacco industry’s interests and public health policy interests,” the Treaty calls on Parties, among others, to “reject partnerships and non-binding or non-enforceable commitments with the tobacco industry [44].”

To shift attention away from the protection of public health and improve its public image, the tobacco industry uses ‘corporate social responsibility’ (CSR) strategies such as supporting tobacco farmers or donating funds to COVID-related activities, poverty alleviation, disaster relief, and sponsoring sports events [28]. Phillip Morris currently holds a one-third stake in a company that is producing a COVID vaccine [45]. Actors within the food industry are also increasingly framing themselves as “part of the solution,” whilst continuing to pursue corporate strategies that prioritize profits over health [46].

In South Africa, the alcohol industry established an Association for Responsible Alcohol Use and is actively sponsoring events such as educational workshops and initiatives to stop underage drinking. Similarly, major food manufacturers in South Africa have active CSR programs focusing on nutrition education [47].

The situation is further compounded by the fact that transnational corporations operate at all levels from global to local and benefit from the opportunities that globalization, trade liberalization, and digitization bring [48]. Irrespective of this fact, governments have a range of valuable tools at their disposal to counter the unhealthy commodity industries’ efforts to advance their business interests at the expense of public health.

Opportunities to Reduce Exposure to Unhealthy Commodities

Conclusions

NCDs are the leading cause of global death and disability, with the tobacco, alcohol, and food and beverage industries playing significant roles in shaping this unfolding slow-motion pandemic. Despite the growth of public-private partnerships in the health sector to promote development objectives, governments need to remain vigilant about not compromising public health interests when engaging with the private commercial sector. For the most part, shared value can only be attained when both parties have something to gain, i.e., health improvements and increased shareholder value through financial returns, although sometimes shared value can be less financially explicit for corporations (e.g., through reduced reputational risks). For that reason, it is absolutely clear that there is no possibility of creating shared value with the tobacco industry. Whilst the alcohol industry appears keen to engage around themes of “responsible drinking,” it is also becoming clear that alcohol consumption is always associated with health risks. As such, inherent conflicts of interest should preclude partnerships and collaboration with governments and health actors in the development of alcohol policies and high-impact strategies and interventions to reduce the harmful use of alcohol.

Engagement with the food and beverage industry needs more careful examination to assess the health impact of their actions and engagements. As highly-processed food producers are quick to point out “there is no such thing as unhealthy foods, only unhealthy diets [59].” The food industry defies binary categorization (friend nor foe), and we would argue that industry actors can be involved in specific public health actions given that essential safeguards are put in place [60].

Beyond the food, tobacco, and alcohol sectors, there are multitudes of commercial actors whose business models do not inherently conflict with public health goals. If carefully handled, there may be huge scope for increasing engagement to tackle NCDs and address broader sustainable development issues—and the SDGs recognize this fact [61]. With the right governance mechanisms, regulatory frameworks, and geographically, politically, and culturally specific policies responsive to disease burden, creating a shared value to address NCDs and their risk factors is a goal for all relevant actors to strive for.

Data Accessibility Statement

All data used in this article are publicly available.