To whom it may concern,
The Draft First Report of the World Health Organization (WHO) Independent High-Level Commission on Non-Communicable Diseases (NCD) begins an international dialogue for the 2030 Agenda for Sustainable Development, which aims to “reduce one-third of premature mortality from NCDs through prevention and treatment and promote mental health and well-being.” While this is a laudable undertaking, the assumptions and arguments used in the report undermine global best practices to combat NCDs. As a taxpayer-funded sub agency of the United Nations, the WHO has a duty to choose their health agenda wisely. As a government watchdog and taxpayer advocate, the Taxpayers Protection Alliance has outlined its concerns with the First Draft Report below.
In the report, it is stated that, “lack of political will and capacity to overcome the economic, market and commercial factors that contribute to the burden of NCDs” and a “lack of priority setting” is a critical impediment to NCD efforts. While this is undoubtedly true in many stable middle-income countries, there remain many countries with active civil conflicts nonetheless targeted in the WHO’s NCD efforts. In war-torn countries such as Syria, we believe it imperative for the WHO to maintain focus on communicable diseases such as tuberculosis and infectious hepatitis. Long-run, comprehensive interventions to reduce cardiovascular disease require the cooperation of a unified central government; nutritional/lifestyle guidelines simply cannot be effectively imposed within a warring state.
In Recommendation 1, the WHO calls on countries to prioritize “cost-effective interventions that have been endorsed by the World Health Assembly,” such as reducing sodium and eliminating artificial trans- fat and implementing comprehensive tobacco-control programs. While the WHO is correct that trans-fat has been shown to increase the risk of cardiovascular problems, the implications of national bans are far from clear. Replacement costs will likely be large, prompting increased restaurant and food manufacturing costs and shifting food consumption elsewhere. Any enforcement of new food regulations will likely hit establishments more heavily than street vendors, whose activities are harder to track.
Millions of street vendors in cities such as Delhi, India are not even licensed in the first place, and attempts to incorporate them into the formal sector have not been successful. But these merchants are responsible for a large degree of food preparation throughout Asia and Africa, and street vendors rely heavily on partially hydrogenated cooking oils that harbor trans-fats. Writing in the Journal of Nutrition Education and Behavior, Gupta et al (2016) find that “food environments in low-SES communities in India are saturated with energy-dense street and snack foods containing high amounts of TFA and saturated fat.” It is unclear how strict guidelines permeating from the WHO can change these practices, as the government of India struggles to bring these communities into the legal fold.
While the WHO recommends banning trans-fats entirely, sodium should only be “reduced” as a part of a comprehensive global strategy. This accords with wider WHO advocacy on targeted taxes on foods with unhealthy ingredients. But what would this look like in practice for member-states? The experiences on Mexico and Hungary allow a glimpse at the results of targeted taxation. Faced with low life expectancies, high per-capita salt consumption, and a majority-overweight population, officials in Hungary implemented a targeted tax on unhealthy eats in 2011. Products in certain categories deemed to have excessive levels of salt and sugar were slapped with a 4 percent tax. The stated two-fold aim was to encourage healthier choices and raise money for public health. Mexico put a simpler program in place in 2014, charging an 8 percent tax on packaged products with at least 275 calories per 100 grams, which included some healthy foods.
As several years have passed since these reforms, researchers have attempted to measure the effects on waistlines and reported habit changes. In summarizing the results of the Hungarian experience, the WHO concluded in a research brief that people bought fewer unhealthy products because their price was higher. This, however, is simply not consistent with the evidence. In fact, statistics from the Hungarian government show that unhealthy food consumption in fact increased in the couple of years since the introduction of the tax.
Using regression analysis, University of Edinburgh researcher Anikó Bíró found evidence that expenditures of untaxed sweets went up in the aftermath of the tax. In other words, customers are simply removing taxed products from their baskets and adding untaxed products that aren’t necessarily any healthier. But any sort of analysis trying to isolate the effect of one policy on bottom-line results inevitably runs into trouble. Even if researchers could reasonably claim to have evidence of changing behavior after 2011, they would also need to account for the drastic price increase of imported sugar around that time. In the case of Mexico, concurrent policy changes put strict limits on junk food advertisements on television. The main examination of Mexico’s efforts fails to take this into account, and makes no attempt to measure any sort of substitution away from targeted, packaged foods.
In addition to recommendations concerning high-trans-fat and sodium products, the WHO focuses on alcohol and tobacco products. As a part of Recommendation 3, the WHO urges national governments to “increase prices of and taxes on tobacco and alcohol.” This effort would be part of comprehensive efforts to “conduct full-cost accounting, which factors in the true cost to societies of policies that have a bearing on NCDs.”
But these policy proposals are unlikely to reduce NCDs for a variety of reasons. Taxes on conventional tobacco products have been shown by research to result in the substitution to more tar-intensive products. In a study published in the RAND Journal of Economics, scholars William N. Evans and Matthew C. Farrelly found that cigarette smokers responded to higher tax rates in American states by switching to brands with higher-tar-and-nicotine contents. Due to the carcinogenic properties associated with tar, the net increase in tar consumption associated with tax changes may actually increase the danger associated with tobacco products.
There is simply little real-world evidence that higher tobacco taxes result in reductions in usage. As pointed out by economics writer Adam Creighton in The Australian, “The number of smokers in Australia has increased for the first time since anti-smoking campaigns ramped up a generation ago, casting doubt on the effectiveness of further taxes on cigarettes. An unexpected standstill in the national smoking rate since 2013, combined with rapid population growth, has pushed up the number of regular smokers by more than 21,000 to 2.4 million according to Colin Mendelsohn, an expert in public health at the University of New South Wales, who says Australia’s ‘punitive and coercive’ policies to curb smoking have ‘run out of steam’.”
The “full-cost accounting” called for by the WHO needs to take substitution effects into account, and consider the impact of electronic tobacco products that can provide an “exit ramp” off of conventional smoking. A research team led by Dr. Reto Auer of the University of Bern in Switzerland examined the level of carcinogens emitted from an electronic puff, compared to the traditional cigarette brand Lucky Strike. The team found that amounts of polycyclic aromatic hydrocarbons (PAH) found in smoke from an electronic product were far lower than for cigarette smoke. Of the thirteen PAHs studied for which output data is available, only one PAH (Acenaphthene) contains a per-cigarette dosage over 10 nanograms (ng). By way of comparison, ordinary cigarette smoke contained doses of over 100 ng for the majority of PAHs studied.
As the result of this research, the WHO should emphasize the role that electronic tobacco devices have in mitigating NCDs around the globe. Additionally, encouraging regulators to allow these innovative products would lead to less contaminants in the air (also covered under Recommendation 3).
Ambitious goals that will likely be set forth under the “Countdown to 2030” envisioned by the WHO will only succeed if the right public policy options remain on the table. Further, appropriate regulations that incentivize the private sector will help the WHO achieve its NCD goals by creating a responsible and competitive environment.
Lastly, scientific evidence must be considered before member-nations raise taxes on products; regulators and elected officials must carefully weigh trade-offs. Working with and educating consumers, vendors, manufacturers, government employees and the general public on the causes of NCD remains a better path forward than restricting and eliminating “problematic” products.