There is now broad acceptance that the future success of global health depends to a large extent upon sound nutrition and physical activity policies. Work with colleagues while at the WHO convinced me that such policies need to be developed and implemented in partnership with the corporate food sector if they are to achieve maximum impact. Soon after accepting my position at PepsiCo, Ricardo Uauy, President of the International Union of Nutrition Sciences, invited me to share my early views with colleagues in the hope of stimulating dialogue that would lead to health gains.
I have spent the last two decades in community-based research and policy development in the public sector. For a decade I was involved in the development of South Africa’s epidemiological and public health capacity, before moving to WHO in 1995. There I led the development of a renewed global health policy entitled ‘Health for All in the 21st Century’ that updated and anticipated future changes not considered at Alma Ata in 1978. Among these were the need for a stronger focus on responding to the reality of globalization, the rise of chronic diseases and the importance of engaging partners from outside governmental, WHO and World Bank institutions. In contrast to several aspects of acute infectious disease control, including smallpox and polio eradication programmes, I saw that these emerging challenges demanded new forms of partnering that draw upon many sectors and would require resolving many competing development priorities. This is particularly important as we seek ways to effectively tackle the complexity of nutrition transition.
Evidence about the negative epidemiological and economic consequences of unhealthy diets and a lack of physical activity on health increases every year. It now conclusively shows that, without attention to these areas, global gains in health brought about by declines in infectious diseases will be eroded by the rapid emergence of chronic diseases(Reference Yach, Hawkes, Gould and Hofman1–Reference Adeyi, Smith and Robles3).
The WHO and FAO have responsibilities between them for developing international norms and standards for food and nutrition policy. They do this by working closely primarily with national governments. Their statements and documents have an impact on national priorities and policies. For example, WHO Technical Report Series no. 916 of 2003(4) provided the science base for implementation objectives outlined in the Global Strategy on Diet, Physical Activity and Health which was adopted by all governments in May 2007(5). Several of the objectives required changes in the composition of foods, in the way they are marketed and the priority that should be given to physical activity. These changes are well beyond the scope of WHO, FAO, non-government organizations (NGO) or governments to implement alone, and many fall directly within the ambit of food companies and other corporations.
Food and beverage companies have the resources and the reach, not to mention a strong profit motive, to make products and conduct their business in ways that benefit their consumers. Taste, convenience, price and health are all elements that determine what consumers eat. Leading food and beverage companies are increasingly being judged by investors and consumers on the basis of how they meet all these consumer needs, including health aspects, and not just on sales. Worldwide, health concerns like obesity have emerged as major drivers of which products are sold and how they are sold. NGO, legislators and consumers seek authentic action by the companies they support that shows how the company is responding to nutrition needs by changing its product portfolios and the way those products are marketed.
When we look back a decade, the notion of private–public partnerships in health has not been broadly accepted. In fact, deep ideological differences led to academics who partnered with corporations (then mainly pharmaceutical companies) being subject to hostile responses. Despite this, public–private partnerships have led to new pharmaceutical products being developed and priced in ways that allow for better control of many infectious diseases; and to new ways of working in communities(Reference Quam, Smith and Yach6).
The time has come to apply knowledge of what works best to keep such partnerships focused on achieving practical outcomes for obesity and related health concerns. However, unlike so many other major public health threats, there still is no example of a sustained decline in obesity in a large population outside a war or famine. The trend lines in developed and developing countries remain upward. We all have our views about what would work best. We need to maintain a reasonable degree of humility about what will really work. And be open to testing different solutions.
I have always sought to work where the potential for health gain is great. It was a privilege to be at WHO when we had support to move the public health agendas on tobacco, mental health and then diet and physical activity ahead. The process of developing WHO’s first treaty, the Framework Convention on Tobacco Control (FCTC), showed the potential power of governments, NGO and UN agencies working together when effective interventions exist and outcomes are well defined(Reference Yach and Wipfli7). The FCTC was preceded by 30 years of norm development, backed by reasonable funding, and focused on a very specific set of products with no health benefits. In contrast, WHO’s 192 Member States adopted a resolution on diet and physical activity at WHO without adequate resources to move ahead rapidly; without a science base that demonstrated what works to reduce obesity in large populations; and without any experience of the vast complexity of the food industry and its potential to hamper or help WHO and governments.
I joined PepsiCo at a time of profound transformation for the company. For the last few years it has steadily moved to develop ways of addressing those aspects of the nutrition crisis that it has the power to influence. PepsiCo’s CEO, Indra Nooyi, has inspired the company to focus on ‘Performance with Purpose’. Performance refers to the financial and business aspects of the company. Purpose is defined in terms of human, environmental and talent sustainability(8). A Blue Ribbon Advisory Board provides high level and independent inputs to the CEO about major health and wellness policies. It includes Gro Harlem Brundtland, my previous boss (!) and Director General of WHO, and David Kessler, previously Director of the US Food and Drug Administration. Internally, all business units within the globally distributed array of companies are moving towards accepting a common set of objectives that would influence the levels of nutrients in all products, portion size, marketing and partnerships to promote physical activity. Specifically, there are significant investments occurring in relation to the nutrition profile of current products, with healthier oils replacing older versions and levels of sodium and sugar being steadily reduced. In addition, the company has acquired new products that further enhance the health profile of the portfolio(9).
There is no longer a need to make the case for food and beverage companies to change. Leading food companies accept the need to:
• remove trans-fatty acids from the food supply;
• reduce the levels of salt, sugar and saturated fat in their products;
• increase the availability of products based on fruit, vegetables, nuts, grains and legumes;
• use their marketing excellence to promote more physical activity and fruit and vegetable consumption, especially among children.
Further, many companies accept that their responsibility to nutrition must include partnering with international organizations, NGO and academics to tackle continued high levels of undernutrition and micronutrient deficiency in the world. In fact, I have been struck by how seriously leading food companies have addressed areas of the WHO Global Strategy that fall within their remit(10). This stands in contrast to the slow pace of action by many governments in tackling their areas of responsibility. Part of the reason for this is that many governments are still too poorly resourced to tackle chronic diseases and nutrition in general. Resource constraints also hamper rapid action in addressing chronic diseases and nutrition within the WHO, World Bank and FAO.
The magnitude of the changes required to slow down and reverse trends in all forms of malnutrition cannot be achieved without strong, new and effective partnerships. The most powerful untapped opportunities for partnerships involve public–corporate interaction. My experiences over the last decade suggest that significant support for change will not come from traditional sources of health development finance such as government development agencies or the major private foundations. These partnerships need to be embedded in new business models that promote better health and are profitable.
While each player with an interest in nutrition continues to do what they do best, more opportunities need to be created for large-scale interventions aimed explicitly at harnessing resources to show what works best. Such initiatives exist for AIDS, malaria, many infectious diseases and micronutrient deficiencies. For this to happen, groups who continue to disagree about the principle of working together need to look at the consequences of their inaction for health and business, and work out how to overcome these differences.
As we move forward we need to develop appropriate mechanisms of accountability for our actions. The future will judge whether the commitments and promises made by the public and private sectors have been fulfilled. No sector has the monopoly of what works best and what is in the public interest. We must learn to work together and responsibly. At the end of the day, consumers as citizens will hold us accountable for our actions or inactions.
I have been privileged to work with the most committed colleagues in the public sector. Now I am finding equally committed colleagues in the corporate sector who share the public health community’s desire to make a difference to the lives of their consumers. Let us work together to make that difference.
