Fat, Fate, and Disease : Why we are losing the war against obesity and chronic disease (35 page)

This is not to say that some current programmes should be discontinued. Among all the adult interventions there can be no doubt that the campaign against smoking has been highly successful and has had major effects in reducing the risk of cardiovascular disease, lung disease, and lung cancer. There have been major advances in many countries in reducing smoking through a mixture of strategies—social marginalization of the smoker, legislation to restrict where they can smoke, vilification of the tobacco industry, and taxation to increase the price of tobacco products. We need to keep reinforcing these approaches.

It remains a tough battle. One of the best ways to reduce cigarette smoking is to stop advertising. This has been achieved on television in many countries. Another way to do so is to insist that cigarettes are sold in plain packages. The Australian government is trying to do this but the tobacco lobby is rich and aggressive. The tobacco industry is even threatening to reduce the price of cigarettes if the government carries through their plan.

And what should we do about a country such as Malawi, where the economy is almost entirely dependent on tobacco growing? There is plenty of water in Lake Malawi which could be used to irrigate other crops, but is the international community prepared to provide the assistance that Malawi would need to switch from tobacco growing?

When we are fighting a war on many fronts, and losing, it can be a good strategy to combine forces to achieve greater penetration on a smaller number of fronts. This is exactly what is needed in the fight against chronic disease. We need to integrate our approach to the problem across the life-course, from conception to maturity and middle age, by making it part of education, primary care, welfare,
women’s and children’s support, and so on. The list is not short, but each of these domains currently operates with its own bureaucracy and its own goals and priorities. If we are to make real progress we will have to join up these activities. Not only will this make success more likely, and probably save money too, but it will ensure sustainability.

After all, one of the critical differences between the ‘epidemic’ of non-communicable disease and other truer epidemics of infectious disease is that the problem will not be solved all in one go. An epidemic of a new strain of swine flu can be stopped in its tracks—permanently—by developing the appropriate vaccine and using it effectively to prevent new cases occurring. We are safe then, until the next epidemic strain appears. But with diabetes and cardiovascular disease we will have to keep up our endeavours to hold them at bay for generations to come, no matter how effective we are in reducing them right now. That is, unless some genius invents a time-machine which will allow us to rerun our evolution so that we remain naturally healthy in an obesogenic world. Or unless we all wake up tomorrow and decide that we don’t want to live sedentary lives in warm accommodation and have easy access to tasty food … neither of these possibilities seems very likely.

When we turn to the developing world, the need for a more unified approach to chronic disease prevention becomes even more obvious. We know that the problem will not be fixed quickly because, unlike in the developed world, it is only just beginning. We have not yet seen its full impact in this generation and the one immediately following, let alone come to grips with what will be needed to keep such disease at a reduced level. On an international scale the large organizations such as the World Health Organization, which should be able to take a long-term view, have relatively little funding to invest. More and more health interventions depend on the contributions of large philanthropic organizations such as the Bill and Melinda Gates Foundation. Regrettably, however, these large
philanthropic organizations have not yet really engaged with the challenge of chronic disease prevention, even though they are strongly committed to reducing infectious disease, reducing poverty, and promoting socio-economic improvement.

Why is this? It is not through lack of information, because several representations have been made to such organizations at the highest level by influential scientists and doctors. We think that the reason for this lack of response comes from the very nature of philanthropic organizations. To a large extent they are driven by the vision and the desires of a small number of individuals, very often the wealthy individuals who established the organization or their initial scientific advisers. At least in the first instance such people—and this is no discredit to them whatsoever—naturally want to make a difference and to see the effects of the funding they provide in a relatively short period of time. Moreover, and particularly in times of financial duress, they are cautious about becoming involved in schemes which might have to run for many years in order to produce a sustained difference.

The lessons learnt in the 20th century from food aid programmes in the developing world are still fresh in many people’s minds. The answer to starvation is not simply to provide food—not unless we are ready and willing to provide it for an indefinite time. Sooner or later we will have to stop, and know that we leave behind a problem unsolved as we walk away. Replacing food aid with sustainable agricultural and light industry schemes was the answer, in the hope that populations could become self-sufficient. For diabetes and cardiovascular disease it may be even more difficult and we are only just beginning to see what the longer-term sustainable solutions might be.

So it is easy to see why organizations such as the Gates Foundation have focused on infectious disease prevention. If they can send a team of health workers into a part of the world such as rural India and vaccinate young children against polio with a few drops of vaccine on the tongue at the cost of only a few dollars each, then we
can see how attractive such a scheme might be. One can divide the total amount in dollars that one is willing to spend by the cost per child of vaccination and come up with a figure of the number of lives saved—of people who will not get polio, ever, during their life. If one does the calculations right, it may even be possible to eradicate the disease entirely in the region, and thus deal with the sustainability issue as well. After all, this is what has been achieved for smallpox in many developed countries.

Infectious disease prevention is an extremely worthy venture and one which we should not belittle, and we can see why it might take priority over investing the same amount of funding in a long-term campaign to prevent chronic disease, for example, by educating young girls in the same part of rural India. We can’t simply move in and set up a school and educate children for a year or two and then get back into our vans or helicopters and leave, as we could for a vaccination programme. Education is a long-term business and nothing much will be achieved from a short-term programme that cannot be sustained.

The Gates Foundation spends so much on prevention of maternal and infant mortality—which is linked to Millennium Goals 4 and 5—and it is but a small extension of that magnificent effort to also invest in those same mothers and infants for the longer term. Surely this makes sense and would build on their contributions to date. We know enough to see specific actions that could make a difference—keeping girls in school, nutritional education and support for women and infants, promoting family planning: these are simple measures that could make a real difference.

There is another dimension to this issue too. In comparison to government-funded bodies, philanthropic organizations are relatively unaccountable. They take advice from experts, whom they choose independently, and evaluate the success or otherwise of the programmes which they fund in their own particular ways. We can see why they do this—it’s their money after all—but it risks giving a
bias to the work. The charity or philanthropic organization may have a board of trustees to satisfy and a scientific advisory board which it must convince, but otherwise it operates in a relative vacuum. This is the traditional way in which philanthropy has operated for well over 100 years, but given the influence which charities now have over international bodies, we need a new form of more aligned strategic planning involving both agencies and the donors.

There is general agreement that we need integrated action at the global level, although there may be disagreement about the shape of that action. As the epidemics of obesity and chronic disease take hold and spiral out of control in countries like India and China while continuing unabated in the West, we see grave risks ahead. Many developing countries will simply not be able to handle the burden of disease and we will have the nightmare scenario of economic development leading to rising expectations at the very time when the productive section of the population becomes unwell. This will damage development and have global consequences. And beyond that there is the risk that these countries will blame the West for their ill health. It results, they might argue, from the Western-controlled multinational companies encouraging them to adopt more Western lifestyles for financial reasons. The geopolitical consequences could be very unfortunate.

By the time this book is published the United Nations General Assembly will have held a special high-level summit for world leaders to address the issue of non-communicable disease, with particular emphasis on the developing world. This is only the second time since its formation that the United Nations has convened a summit to address a specific health issue—the previous summit addressed HIV-AIDS. It has been informative to watch the build-up for this summit. Different countries and interest groups came to it with very
different motives and agendas. There were those for which this represented an opportunity to sell high-technology medicines and health systems to developing countries. Some of the companies manufacturing these have been pilloried in the past for not providing such treatments and systems at low cost to developing countries. Now they can envisage improving their reputation while still retaining a profitable business, if inexpensive generic drugs or equipment can be developed in conjunction with government and philanthropic support, to be sold in vast quantities in the developing world. As with the food industry, there is nothing inherently wrong in this, but the potential conflict of interest has to be recognized.

Other groups lobbying the delegates of the United Nations summit were those for which this was an opportunity to ram home the ‘gluttony and sloth’ message and to continue aggressively with the failing blame-the-individual agenda of the West. Some of these groups wanted to use the opportunity to attack the food industry; others wanted to focus on specific interventions or solutions, following the anti-smoking model. Some, again with good reason, argued that many chronic diseases such as cancer have their origins in infection, and so approaches similar to that used successfully to prevent infectious disease should be the priority. And there were representations from faith groups, from ethnic minorities, and from other civil society organizations, all of whose voices had to be heard. Incorporating the views of all these disparate groups into some coherent and achievable action plan was an unenviable challenge.

The World Health Organization took responsibility for coordinating the delivery of whatever plan was drawn up at the summit, although in reality, of course, it had been decided to a large extent beforehand. The World Health Organization had to grapple with this by involving a large range of organizations in the preliminary discussions. But when we wrote this in May 2011, time was very short. It was disappointing to see how dominant the World Health Organization itself had been in this initiative, with the manifestation of its own
internal politics, to the exclusion of other agencies in the build-up to the meeting. We believe that a much more integrated approach was needed, involving many agencies, from the UN Development Programme, UNESCO, and UNICEF to the UN Women programme and the Food and Agriculture Organization. And beyond the United Nations there are many other agencies that have an important role to play, such as Christian Aid, Save the Children, Médecins sans Frontières, Oxfam, and so on. And then there are the big foundations: Gates, Ford, and Rockefeller; the big charities such as the Wellcome Trust; and the private sector. We can only hope that the World Health Organization is up to this challenge.

It seems to us that the problem is of sufficient magnitude for a new agency of the UN to be needed—there are perhaps too many vested interests operating now for one to get a coherent view. And however the UN takes the lead, it must do so informed by science rather than by politics.

Our leaders may decide that the issues are too complex and too intractable and that the political fallout from addressing them will be too great. They may be deterred by the cost of the action needed now on a global scale, despite the argument that the investment will pay off enormously in the future. They may conclude that we need much more research—which is true enough, but only if it is directed towards evaluation of action.

The kind of science upon which action should be based is sometimes called ‘post-normal’ science. This is science which is complex and where there are, and will remain, many uncertainties. Such science cannot be fully separated from issues of societal values and attitudes. Yet the matters involved are urgent and action is needed. Climate change is an example of such science, as is food security, as well as infectious and non-communicable disease. The philosopher of science Heather Douglas in her recent book
Science, Policy, and the Value-Free Ideal
points out that in such situations the first question has to be whether there is enough evidence of sufficient quality to act,
while acknowledging that this evidence will not be complete. Even more importantly, there may be errors in the available evidence. The question then boils down to the risk of doing harm from acting prematurely on the basis of evidence which turned out to be flawed, versus the risk of doing nothing when the available evidence indicated that action should be taken. This can be a tough decision.