Under the hashtag #beatNCDs (Non-Communicable Diseases, such as cancer, diabetes, and cardiovascular disease), the Third United Nations General Assembly High-level Meeting, held in the late September 2018, claimed for NCDs control and prevention. The first meeting occurred in 2012 and was the initial demarche of NCDs discussion in the UN General Assembly. These meetings are noteworthy because of NCDs’ relevance in the contemporary agenda of global challenges (e.g., the Sustainable Development Goals). In spite of the increased attention in the global agenda, NCDs were responsible for 71% of all deaths worldwide in 2016 and over three-quarters of them occurred in low- and middle-income countries (WHO, 2018). Especially in the last decades, NCDs have risen dramatically mainly due unhealthy diets, which include the excessive consumption of ultra-processed foods (UPF), which are those “hyper-palatable, cheap, ready-to-consume […], energy-dense, fatty, sugary or salty and generally obesogenic” edible products (Monteiro et al., 2013, 21).
UFP has become central in global debates due to its political economy and public health drivers. Among the formers are the strong relation between transnational companies and national regulation. This relation is sometimes fuzzy and marked by the prominence of private interests over public health concerns. Public health drivers, for instance, are those related to excessive UFP consumption that influences public health directly (e.g., high obesity rates, diabetes, cardiovascular diseases, etc.). To target the excessive consumption of UPF worldwide, some actors of the UN system (ECOSOC, PAHO/WHO, and UN General Assembly) enacted resolutions to encourage countries to adopt their national regulation to control UFP and to prevent NCDs related to unhealthy diets. Though the march of internalization of international resolutions into the domestic arena is not automatic, we argue that this process is part and parcel of Global Health Diplomacy (GHD).
Conceptually, GHD comprehends a multi-level perspective in which several stakeholders influence – yet do not act as the ultimate decision maker – the negotiation processes, the policy outcome, and the agenda setting. These stakeholders (e.g., NGOs, industry, international organizations, academia) come together “to influence the decisions taken by the members’ states on public health and be part of the negotiation process” (Kickbusch, 2011, 1). Moreover, GHD is a non-linear process since each state – the decision unit – has differences in how each public health issue will be translated into national policies.
GHD starts at the global action arena, in which actors interact to make policy-related decisions (Jones et al., 2017) but do not end when the final international resolution is adopted. A “[…] successful conclusion to international negotiations is part of a process, not the end” (Smith and Irwin 2016, 4); hence GHD finishes when the policy design is implemented. This policy design is also known as the National Policy on Global Health (NPGH) outcome. In this sense, GHD that should be seen as a process not as an end in itself, with a crucial domestic step of policy design.
Thus, maintaining the GHD as a process enable us to highlight the barriers and opportunities in the implementation action at the national context (e.g., identifying the role played by the full range of actors, especially the transnational companies, relational power, resources). Moreover, this concept offers methodological questions such as how international agreements are implemented in the domestic level and how to assess the impact of global health diplomacy in the national health systems. Then, the level of analysis change from the international arena to the domestic environment, as proposed by the Observatory of International Regulation on Risks Factors Associated to NCDs carry out by the Centre of Studies on Bioethics and Health Diplomacy of Fundação Oswaldo Cruz/Brasília (NETHIS, online).
The Chilean labeling laws enacted in 2012 to regulate UFP illustrates an example of GHD as a process. Chile took steps to implement the FAO and PAHO/WHO on obesity prevention recommendations and became a global model to UPF regulation (FAO & PAHO, 2017). The so-called Chilean Labelling Law (Law n. 20.606/2012) sets provisions to reduce the total quantity of critical nutrients (sodium, sugar, and saturated fat) of the population’s consumed food.
The GHD process started at Chile’s international and national commitment, but also by considering obesity as a public health problem in Chile. Then, GHD has four main drivers in the Chilean case. First, the public health driver. 74.2% of Chileans have overweight (3.2% with morbid obesity), and a high sodium consumption: 98.4% of the national population eat more than 5g of salt per day, which is more than de recommended by the World Health Organization (WHO). In 2016, Chile had one of the ten highest obesity rates in the world and the highest one in Latin America and had the highest sweetened beverages consumption in the world (IPSUSS, n.d.). Moreover, Chile’s economic growth also led to changes in the population nutritional profile in the last two decades by reducing fruits and vegetable consumption and increasing energy-dense foods (Corvalán et al., 2013). In this regard, as identified by the Observatory of International Regulation on Risks Factors Associated to NCDs (NETHIS, online), the government of Chile enacted 26 national regulations (laws, decrees and resolutions) from 2005 to 2018 to control UPF consumption in order to reduce the Chilean high obesity rates. Second, in 2010, the WHO recommended the restriction of all sort of food advertising to children and adolescents (Resolution WHA63.14 and Resolution WHA63.23) (Corvalán et al., 2013). In this sense, Chile took on a national sanitary objective to reduce 10% the obesity prevalence in children above 6 years old (Chile, 2010).
The third driver that fostered the implementation of WHO resolution on UPF in Chile was the leadership and personal commitment of Guido Girardi, a physician and Senator who was the author of the national law on food labeling. Last but not least, the fourth driver was the human rights dimension: the strategy used by the transnational corporation to sell junk food (e.g., advertising to entice children and presenting ingredients in an unintelligible list) was flagged as a violation against human rights, according to Girardi (FAO, online).
The internalization process of PAHO/WHO recommendations on obesity control through the national law also entails the relational power among Ministries and federal agencies. Overall, Chile’s Ministry of Health has the competence to enact regulations on UFP. Data show that, from 2005 to 2018, 53% of UFP regulations laid down by this Ministry and the inspection has been made by Ministerial Regional Departments (NETHIS, online).
Furthermore, a GHD process requires a high degree of policy coherence as well as political and economic synergies among stakeholders to elaborate national policies on global health design with coordinated political responses. Regarding the need of multisectoral response to cope with UFP issue, the Chilean Ministry of Health and the Ministry of Education have been worked together. From 2002 to 2018, the Ministry of Education enacted 18 curricular guidelines on healthy eating (from pre-school to secondary school) to increase the children and adolescents awareness about obesity and UPF as recommended by the WHO (Resolutions WHA63.14 and WHA63.23). For instance, Chilean success of implementing the #beatNDCs initiative was, among other things, a coordinated effort from Ministry of Health, Ministry of Education and Ministry of Finance, since the 2012’s law affects consumer rights and tax returns.
Finally, despite Chile’s protagonist role as a global model of UPF regulation, the Chilean national law on labeling is not an epiphenomenon. In a broad sense, this law is an essential element of Chile’s GHD on NCDs and a significant case to clarify how global health issues are tackled in national contexts. From global arena to national policy design, this case also sheds light on the importance of multisectoral coordination to implement international organization’s recommendations by understanding, in epistemological terms, that the GHD process overlays both national and international decision-making process, resources, rules, and institutions.
CHILE. Ley 20.606 de 06 de julio de 2012. Sobre composición nutricional de los alimentos y su publicidad. Biblioteca del Congreso Nacional de Chile, 2012. Available at: https://www.leychile.cl/Navegar?idNorma=1041570. Access 29 July 2018.
CHILE. Metas 2011 – 2020: Estratégia Nacional de Salud. Para el cumplimiento de los Objetivos Sanitarios de la Década 2011 – 2020. Santiago: Gobierno de Chile, 2010. Available at: http://www.minsal.cl/portal/url/item/c4034eddbc96ca6de0400101640159b8.pdf. Access 1 August 2018.
CORVALÁN, C, REYES, M, GARMENDIA, L, UAUY, R. Structural responses to the obesity and non-communicable diseases epidemic: the Chilean Law of Food Labeling and Advertising. Obesity Reviews 2013 Nov; 14 (Suppl. 2): 79-87.
FAO & PAHO. Aprobación de nueva Ley de Alimentos en Chile: Resumen del proceso. Santiago, 2017. Available at: <http://www.fao.org/3/a-i7692s.pdf>. Access October 22, 2018.
INSTITUTO DE POLÍTICAS PÚBLICAS EN SALUD (IPSUSS). Chile: pimer lugar en obesidad infantil en América Latina y sus consecuencias físicas, psicológicas y en salud de la sociedad. Available at: http://www.ipsuss.cl/ipsuss/actualidad/obesidad/chile-primer-lugar-en-obesidad-infantil-en-america-latina-y-sus/2016-01-26/171149.html. Access 22 October 2018.
JONES, Catherine M.; CLAVIER, Carole; POTVIN, Louise. Adapting public policy theory for public health research: A framework to understand the development of national policies on global health. Social Science & Medicine, [s.l.], v. 177, p.69-77, mar. 2017. Elsevier BV. http://dx.doi.org/10.1016/j.socscimed.2017.01.048.
KICKBUSCH, I.. Global health diplomacy: how foreign policy can influence health. Bmj, [s.l.], v. 342, n. 101, p.1-1, 10 jun. 2011. BMJ. http://dx.doi.org/10.1136/bmj.d3154.
NETHIS. Observatório de Regulação Internacional de Fatores de Risco Associados às Doenças Crônicas Não Transmissíveis. Available at: < https://bioeticaediplomacia.org/observatorio/ >. Access 23 October, 2018.
SMITH, Richard; IRWIN, Rachel. Measuring success in global health diplomacy: lessons from marketing food to children in India. Globalization And Health, [s.l.], v. 12, n. 1, p.1-4, 16 jun. 2016. Springer Nature. http://dx.doi.org/10.1186/s12992-016-0169-5.
MONTEIRO, C. A. et al. Ultra-processed products are becoming dominant in the global food system. Obesity Reviews, [s.l.], v. 14, p.21-28, 23 out. 2013. Wiley. http://dx.doi.org/10.1111/obr.12107.
WORLD HEALTH ORGANIZATION. World Health Statistics 2018. Geneva: WHO, 2018. Available at: http://apps.who.int/iris/bitstream/handle/10665/272596/9789241565585-eng.pdf?ua=1. Access 22 October 2018.
WORLD HEALTH ORGANIZATION resolution 63.14. Marketing of food and non-alcoholic beverages to children (21 May 2010). Available at: http://apps.who.int/iris/bitstream/handle/10665/3088/A63_R14-en.pdf?sequence=1. Access 22 October 2018.
WORLD HEALTH ORGANIZATION resolution 63.23. Infant and young child nutrition (21 May 2010). Available at: http://www.who.int/nutrition/topics/WHA63.23_iycn_en.pdf. Access 22 October 2018.
GOODY, Jack. Industrial food: towards the development of a world cuisine. Cooking, Cuisine And Class, [s.l.], p.154-174, 1982. Cambridge University Press. http://dx.doi.org/10.1017/cbo9780511607745.007. GOODY, Jack. Industrial food: towards the development of a world cuisine. Cooking, Cuisine And Class, [s.l.], p.154-174, 1982. Cambridge University Press. http://dx.doi.org/10.1017/cbo9780511607745.007. GOODY, Jack. Industrial food: towards the development of a world cuisine. Cooking, Cuisine And Class, [s.l.], p.154-174, 1982. Cambridge University Press. http://dx.doi.org/10.1017/cbo9780511607745.007. GOODY, Jack. Industrial food: towards the development of a world cuisine. Cooking, Cuisine And Class, [s.l.], p.154-174, 1982. Cambridge University Press. http://dx.doi.org/10.1017/cbo9780511607745.007.and Culture. Routledge: London, 1997, pp. 338–356.
About the authors
Tiago Tasca, MSc. in International Relations and Researcher at Center of Studies on Bioethics and Health Diplomacy (NETHIS/Fiocruz) (firstname.lastname@example.org).
Roberta Freitas, PhD in Global Health and Deputy Coordinator of Center of Studies on Bioethics and Health Diplomacy (NETHIS/Fiocruz) (email@example.com).