On May 18, 2004, when governments of 192 World Health Organization (WHO) member countries gather at Geneva for the world health assembly, one Mrs Sharma in one town, Jabalpur perhaps, will be making her way purposefully to the new swanky fast food joint in Sadar Bazar. As she delightfully feeds upon the Rs 149.99 combo meal of a regular burger and an extra large chilled cola, the assembly will be debating WHO's 'global strategy on diet, physical activity and health'.
While Mrs Sharma's bulging body adjusts to the additional pound of adipose tissue, the WHO shall have made it emphatically clear -- obesity is a disease and it's responsible for more than 60 per cent of all deaths caused by non-communicable diseases (NCDs) in the world.
Supper done, Mrs Sharma shall drive home to rest a bit. WHO would have by then put forth its global strategy to combat obesity: reduce sugar consumption and reform agriculture and trade practices worldwide to promote such diets. While Mrs Sharma sleeps bellyful, a bitter fight shall break out on the strategy. The strategy is not binding on countries, but still each word in it will be argued over. The US will say food is a matter of personal choice, you can't blame any industry for somebody being overweight. Mauritius will complain that the strategy targets sugar, the lifeblood of its economy. India, like Mrs Sharma, might be caught napping or worse still prevaricating.
As hired lobbyists of the sugar and food industry try to prove that any link between obesity, disease and food is bad science, Mrs Sharma would have reached Jabalpur's flashiest fitness centre and joined a Rs 20,000-per-month body-firming and figure-shaping slimming course. While she huffs and puffs on the treadmill, civic groups will be protesting worldwide that the strategy has been weakened because of pressure from the US and industries.
While Mrs Sharma spends her thousands, the assembly of nations would have fought over business estimated to be worth trillions of dollars. At the end, there may emerge a global strategy to prevent every Mrs Sharma from being force-fed into obesity. There may emerge a strategy to ensure that public health wins the battle against trade interests.
Maybe.
Obesity has become a worldwide concern because people in each and every nation are falling prey to it. WHO defines obesity as a body mass index (BMI) of at least 30 kg/m2 and overweight as a BMI of at least 25 kg/m2 (BMI is calculated by weight in kg divided by the square of a person's height in metre). Around one billion adults in the world are overweight and around 300 million of them are obese.
Diabetes, hypertension, cardiovascular diseases, gallbladder ailments, cancer, psycho-social problems, breathlessness, sleep disorders, asthma, arthritis, weak bones and reproductive hormone abnormalities are just some of the NCDs which are more likely to affect obese and overweight people. WHO's surveillance of risk factors (SuRF) report, which came out in 2003, says diet, lack of physical activity and obesity are common risk factors for NCDs. The World Health Report 2003 says that in all continents except Africa more people die of NCDs than communicable diseases. WHO estimates that by 2020, 73 per cent of all deaths will be caused by NCDs.
The governments of several developing countries like India claim that obesity and NCDs aren't their problems. But the fact is NCDs are increasing even in developing countries (see table: No place safe). Of the 16.6 million people who died of cardiovascular diseases (CVDs) all around the world in 2001, around 80 per cent were from low- and middle-income countries. It's feared that by 2010, CVDs would be the leading cause of death in developing counties. India, China, Indonesia, Pakistan and Brazil are among the top 10 countries affected by diabetes. At least 19.4 million Indians had diabetes in 1995 and the number rose to 31.5 million in 2000.
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This massive obesity epidemic is eating up the money countries spend on healthcare, and it's also wasting their human resources. Industrialised countries could be spending 2-7 per cent of their healthcare on obesity. United Kingdom in 1998 spent 9.5 million (US $17 million) on obesity treatment and 470 million (US $ 840 million) on treating diseases caused by it, says a study done by Stephen Morris, a researcher at the economics department of London's City University. Lost earnings due to deaths attributed to obesity amounted to 830 million (US $ 1.5 billion) and lost earnings due to sickness were 1.3 billion (US $ 2.3 billion).
As many as 40,000 years of working life were lost due to the 31,000 deaths attributed in 1998 to obesity, which also cost the nation 18 million days of sickness. UK's health service directly lost half-a-billion pounds (US $ 894 million) due to the disease and 2.5 billion (US $ 4.5 billion) indirectly. If the trend persists, obesity could cost the UK 3.5 billion (US $ 6.2 billion) by 2010.
The US spends an average 6.8 per cent (US $70 billion) of its total health expenditure on obesity. USW businesses spend US $12.7 billion on expenditure attributed to obesity which includes insurance and paid sick leave.
For all these diseases and the money spent on treating them, researches conducted all over the world blame sugar- and fat-rich food. Jim Mann, professor of human nutrition and medicine at University of Otago in New Zealand, has reviewed several studies which found that:
• When people were asked to cut down intake of sugars and replace it with starchy foods such as potatoes for five months, they lost weight
• When overweight people were asked to reduce fat consumption, they lost weight
• People eating high-fat or high-sugar diets gained weight. The weight gain in people having high sucrose diet was double that gained by people on high fat diet
• Children drinking soft drinks rich in sugars gained weight with each serving of a drink
• Food and drinks rich in sugar have higher energy and lead to weight gain as compared to low energy, artificially sweetened food
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Struggling with non-communicable diseases, the WHO and Food and Agriculture Organisation (FAO) set up a study group in January 2002 to discuss the problem with health and agriculture experts. The result was TRS 916, a technical report. It says that calories from sugar should form 10 per cent of the daily diet; and high intake of energy-rich and micronutrient-poor foods, sugar-sweetened drinks and fruit juices, large portion sizes of food in restaurants and extensive marketing of such foods are some of the causes for obesity.
With TRS 916 in hand, the WHO team started meeting other UN organisations, non-governmental organisations, consumer groups and industries in order to have a global strategy to prevent obesity. The strategy came out in November 2003, and said changing agriculture, fiscal and regulatory policies, strengthening surveillance systems and consumer education can prevent NCDs. Growing more fruits and vegetables, subsiding healthy food and educating people about food were some of the options countries can use to fight obesity, the strategy said.
These suggestions irked several countries and the food and sugar industries. They realised that what they had presumed would be a harmless health policy went much further and hurt their interests. WHO had in 1990 suggested a similar plan, which recommended the kinds of food people should eat. That plan was never implemented, but the new strategy was again raising debates on agriculture policy, subsidies, consumer education, nutrition and marketing. (see chart: Step by step... to healthy world?)
The 192 member countries of WHO were first given time till January 2004 to comment on the strategy and then the deadline was extended till February 2004 because governments wanted more time to study the suggestions. A total of 68 countries including India have now sent their comments on the strategy, which will become a policy if it's endorsed at the World Health Assembly (WHA) (see box: A taste of who's dish).
The strategy's draft, which will be presented at the WHA, was issued on April 19, 2004, but consumer groups allege that it has been diluted. They say a passage urging states to offer incentives for producing, marketing and transporting fruit, vegetables and other healthy food has been deleted and other changes have been made, weakening the policy.
This strategy isn't going to become an international treaty, but big businesses however fear that if they don't act soon the strategy will become a success like the Framework Convention on Tobacco Control. WHO has repeatedly said that food is not tobacco and it wants to cooperate with the industries. But the industries don't want any restriction on intake of sugar and high-energy food.
The US sugar industry is one of the most pampered and powerful in the world. Domestic sugar price in the US has remained three times that of world prices in the last decade. USA's Sugar Act of 1934 restricts imports and ensures that the government stores excess domestic production. Americans pay US $2 billion annually in inflated sugar prices because of this policy. Using its massive profits, the sugar lobby since 1990 has donated more than US $18 million to Democrats and Republicans. It has given US $490,000 -- a trifle compared the profits -- to the congressional and presidential candidates for the 2003-2004 elections. This lobbying has always worked. During the January 2004 trade talks with Australia, the US refused to open up its sugar market. In December 2003 the US agreed to import one per cent of the sugar it needs from five Central American countries, but its sugar industry has teamed up with the wheat and maize industry to oppose the agreement.
Like in the US, the common agricultural policy of the European Union (EU) protects the sugar market in the continent. Not just the US and EU, even Mauritius, which exports its entire sugar production to EU due to preferential trade arrangements, feels threatened by WHO's strategy. With the EU's sugar policy ending in June 2006 and the US Farm Bill ending in 2007, this is hardly the time for WHO to say that the world should consume less sugar.
Sharing the same boat with sugar is the fast food industry. Since 2000, several studies have warned the fast food business to get rid of its obese image. A study done by Morgan Stanley, an investment consultant group, in 2003 shows that four out of five consumers in UK, USA and France in are trying to give up candies, snacks, fast foods, carbonated and non-carbonated soft drinks and ice cream because they consider them to be unhealthy. Morgan Stanley has also told the industry that presently court cases against it will find it difficult to pinpoint what causes obesity, but that could change if WHO's strategy is approved.
This industry's plan has been to pressure for new laws which make choosing what food to eat a personal responsibility (see box: US says you're what you eat). Two Acts designed to protect the food industry have recently been passed by the House of Representatives. Lobbyists like Dan Spiegel, a former US ambassador to Switzerland and supporter of the Grocery Manufacturers of America, are currently coordinating efforts by the food industry to delay the strategy. "The US food industry is fighting rather than cooperating with efforts to deal with obesity, much as the tobacco industry did for years. This is a self-destructive strategy because public opinion may turn against the industry," says Kelly D Brownell, director, Yale Center for Eating and Weight Disorders, USA.
Helping these two industries is the confusion and division among WHO's member countries over the strategy. At the WHO executive board meeting of member countries on January 21, 2004, a debate on the strategy proved inconclusive. Of the 34 nations who commented on the strategy, only UK, Canada, New Zealand, Spain and South Africa accepted it. India asked for more time to study the strategy. Pakistan asked for more scientific evidence. USA wanted more focus on personal responsibility, and India and 12 other countries said they "agree with the US".
Several developing countries like Mauritius, Philippines, and India have written letters to the WHO and told it that they believe that the strategy exclusively focuses on overeating and it should also consider "under-eating". Bosnia and Herzegovina supports the idea that if people are given good food it will take care of under-nutrition, Belgium believes that personal responsibility concept cannot be applied to children and the Czech Republic doesn't agree that people would make healthier choices if 'bad food' is made expensive.
Sugar-growing countries like Mauritius, Barbados and Cuba opposed limiting consumption though their health guidelines restrict calorie intake. Mauritius advises its citizens to have less than 50 gm of sugar per day (less than 10 per cent of the diet), but it won't support WHO's global strategy on restricting calories.
The London-based International Sugar Organisation sent a memo to members (sugar companies from around the world) on February 17, 2004 informing them with glee that FAO has not accepted TRS 916.
The basis for this statement was a FAO meeting in Rome on February 9-10, 2004 during which G77 countries and the China Group had raised concerns on whether TRS 916 will affect agriculture. The International Sugar Organisation, however, told its members that using this concern among G77 nations, they could ensure that the strategy isn't adopted at the WHA. Experts say that with consumer groups putting pressure on their government, the US is finding it difficult to stall the strategy and therefore has put the developing countries on the forefront to fight its battle.
"They (sugar industry) have questioned the scientific basis of the expert findings and generated fear that sugar production could be affected if the WHO's recommendations are observed. This is evidently undermining the confidence of some developing countries as evidenced by the G77 response at the FAO meeting in Rome," says Neville Rigby, director, policy and public affairs, International Obesity Task Force, London.
"Lobbying groups are exerting pressure on governments to support corporate interests over public health. The WHO report has nothing new in its dietary recommendations, particularly the one suggesting no more than 10 per cent of calories from added sugars. The reason why the report is causing trouble is that it actually recommends methods for achieving this doing something about it," says Marion Nestle, professor of public health, New York University.
"The main thing is to have the strategy approved. It shouldn't be blocked by commercial lobbying, especially from the sugar industry," says Pekka Puska, director general of National Public Health of Finland and former member of the team which drafted the strategy. Right now it's unclear what stand countries would take at the WHA. Among G77 countries, Brazil and Pakistan haven't decided; India doesn't accept all aspects of the strategy (see box: India's strategy: keep waiting) and Mauritius wants to avoid it. At Geneva, officials at WHO's headquarters feel that they have done their best and all that they can do now is wait and watch. "We have taken into account all of the additional comments we received by the deadline, and made relevant changes in the strategy. It will now be up to our member states at the WHA to consider endorsing the strategy," says Amalia Waxman, project manager for the global strategy.
WHO has time and again said that the strategy is based on scientific evidence, successful campaigns against NCDs in several countries and on recommendations from health and nutrition experts from across the globe. But the sugar and food industry and their lobbyists have tried to discredit the strategy by saying that any link between obesity and diet is bad science. Civic groups say the same tactic is used by the tobacco industry, which says there is no clear evidence to show smoking affects health.
In this propaganda, the industry cries 'bad science' and then scares countries by reeling out the consequences of following WHO's strategy. Riaz Khan, director general of the London-based World Sugar Research Organisation (WSRO), at FAO's Rome meeting gave a presentation which said that if the strategy is accepted, sugar consumption would decrease by 20 million tonnes and world trade drop by 3.5 to 6.5 million tonnes.
But the truth is that if the world sugar market were to be opened up, net imports would increase by 15 million tonnes every year and create employment for nearly one million workers in developing countries. World sugar prices would increase by at least 40 per cent, and prices in countries like USA that protect their industry would drop. For example, Brazilian producers would earn US $2.6 billion per year from this open market. It's true that this open market would mean Brazilian consumers will have to pay one billion dollars more for sugar, but this still leaves the country with a profit of US $1.6 billion. If the US were to open its market, developing nations' annual export earnings would rise by about US $1.5 billion.
Oxfam, a British non-governmental organisation, in April 2004 claimed in a paper, The Great EU Sugar Scam, that the EU's common agricultural policy grants enormous subsidies (an estimated US $976 million) to European sugar companies, who then dump their excess production in poorer countries. EU sugar companies are guaranteed minimum price, which is two to three times the world market price, but developing countries are kept out of the European market.
Sweden has suggested a solution that the EU should decrease export refunds and tariffs on fruits and vegetables and open up the European market to the outside world. "The Swedish government has just sent a letter to the EU-Commission concerning this issue. We are now informing our public health colleagues all over the EU so that they discuss this with their ministries of agriculture ahead of the common agricultural policy reform in 2006," says Liselotte Schfer Elinder, research manager, National Institute of Public Health, Sweden.
But WSRO, which has Coca-Cola and Pepsi among its members, wouldn't like a debate on open markets. Experts say closed sugar markets hamper plans to control obesity and NCDs worldwide. "As the US refused to open its market during the trade talks, the Australian industry will now not allow its government to limit sugar intake in the country or in any other country which buys Australian sugar," says Geoffrey Leigh, clinical director, Australian Institute of Biological Medicine in a letter to the British Medical Journal.
The US government is framing a new food pyramid which will suggest to its citizens that their daily diet should have 8 per cent sugar. WHO's strategy says it should be less than 10 per cent sugar. The US says fat should form 20-35 per cent of daily diet; WHO says 15-30 per cent. The US surgeon general has called for examining the marketing practices of the fast food industry, ensuring that healthy foods are available in schools, keeping students away from vending machines and creating laws and policies that promote healthy lifestyles. Why won't then the US government let WHO recommend similar strategies?
The reason, consumer groups allege, is that USA wants to keep its people healthy, but ensure that its industries can sell their junk food to developing nations (see box: Consumer Power). Developing countries is where the money is -- Coca-Cola earns over 70 per cent of its profits outside the US. The value of Coke's brands increased from US $68.95 billion in 2001 to US $69.64 billion in 2002 because of growing sales in developing countries. By the end of 1993, one third of McDonald's stores were overseas and accounted for half of its profits. Four out of every five new McDonald's restaurants are now opening abroad rather than in the US.
The world has lot to gain if it switches to a healthy diet. "If the strategy is accepted, diabetes is likely to decrease by forty to sixty per cent worldwide," says Nigel Unwin, medical officer, diabetes programme, WHO. "Traditional risk factors like smoking, unhealthy diet and physical inactivity explain 75 per cent of the cardiovascular diseases. If these risk factors are addressed, cardiovascular diseases can be halved within the next 10 years," says Shanti Mendis, coordinator, cardiovascular diseases, WHO. "The questions on what kind of food pyramids, what kind of nutrition education, what kind of food labelling will have to be decided on national levels. If the strategy will be adopted, further international work particularly on regional basis would be needed," says Puska.
Why then are developing countries like India spending their precious resources on treating these diseases and not following a plan which would prevent them? Because you don't just feed yourself, that sugar and fat in your food is making profits for nations and industries. They want you to keep eating.
With inputs from Lopamudra Banerjee Dhar in USA
Elections always teach lessons. The outcome of the 2004 polls is still a few days away but we have already learnt from media reports that the water scarcity has left a countrywide imprint. The crying need for water reverberates in villages of the water-stressed regions in central India, in rainfall abundant villages of states like Kerala and Meghalaya and in cities across India. Reports suggest that the scarcity of water is crippling much of our country. We know that each time rural communities suffer a drought, it further erodes their ability to cope and makes them weaker. It leaves them incapable of dealing with the vagaries of the monsoon, making the drought a permanent reality. A perpetual drought then eats away at the very insides of the country. To avoid this snare people across the country are demanding that their politicians deliver on this one promise: provide water to drink and to irrigate.
So when candidates go sparring with each other in the relatively rich suburbs of Mumbai, the one thing the voter is keen to know: where is the water to drink. Politicians, off course, have a readymade counter plan. Accuse the opponent for delaying the sanction of the large water project. Blame environmental concerns for impeding the project. And, finally make the grand promise: vote us in and we shall veto the environmental regulations out.
This is not surprising. Most political leaders view environmental concerns as constraints that impede the pace of development. They are blind to the fact that environment has already become a key issue in the ongoing polls. I say this because besides water scarcity, the two other big, all India issues -- captured in the media, in surveys and opinion polls -- are unemployment and power. All three issues are clearly linked to abysmally poor resource management and governance.
Too often we forget that the shortage of power shortage is linked to the shortage of water. The households and the industry need power, but the agricultural sector's need is dire. Channelling groundwater into irrigation ensures over 80 per cent of Indian agricultural produce. With water tables falling precipitously, farmers need more electricity to pump the water out. More importantly, they need assured electricity at the right time: when crops need water.
Unemployment may not be directly linked to environmental degradation. But the solutions to unemployment lie in the better management of natural resources -- land, forests and water. Let us be clear. India's formal industrial sector has never been the provider of employment. As the sector achieves greater economies of scale and mechanisation in the years to come, its employment rates will only plummet. The service sector -- outsourcing included -- will grow but it cannot really absorb jobseekers in a country the size of India. The key to employment lies in building productive and sustainable livelihoods based on natural resources. The potential is enormous. Plant trees for pulp, rear animals, run dairy farms, rear worms for silk or grow medicinal plants for pharmaceutical industries -- these are but a few livelihood generating methods to break India Shining's growth-without-jobs syndrome.
But, even if we agree that these are election issues, the question is will these issues also determine the result? That is a difficult one to answer. Politicians learn too fast. The pre-election rhetoric may be full of the 'development' word, but I would argue, development is still not on the election agenda.
I say this because, very little has yet been done to deliver on the promise of development -- the promise of food, employment, water, education or health services. Politicians know that real development requires serious reform of the way in which we do business. They also know they face a serious governance crisis. The abilities of the state to deliver meaningful change have been consistently and successfully disabled. Politicians also realise that they don't have the ability to handle our rigid and won't-do bureaucracies. The resolution of this institutional crisis is essential for development, they know.
For instance, they know that solving the water crisis demands policies and practices that optimise the water endowment of each region, so that the water management system at the level of each settlement harvests the maximum and uses the precious resource in the least wasteful way. This can only be done if local communities are involved. But building local interests and institutions requires serious and effective institutional reform. Governance has to be put into the hands of people. That is a formidable task. So the politicians instead promote a futuristic project to link Indian rivers, which even by their own estimations will 'solve' water problems in over 10-15 years.
There is a pattern to selling the 'idea' of development as a dream. To bypass the problem of governance, politicians are now working with private capital, focussing on what is mutually beneficial -- power stations, software parks, industries and large roads. This way, politicians tide piggyback on efficiencies of the private interests and market themselves as effective. But private interests do not produce societal goods so this 'feel good' is limited to areas of mutual convenience and not societal good.
But elections, as I said before, have a habit of teaching us lessons. Whoever wins this election, let me forewarn them. When the next election comes around pani, bijli and kaam (water, electricity and work) will be more exigent. Delivering on them will require greater reform, not less.
-- Sunita Narain