In an interview with the NCD Alliance, Maisha Hutton, Executive Director of the Healthy Caribbean Coalition (HCC), responds to new research that highlights six key strategies used by junk food companies and the alcohol and tobacco industries to avoid regulation.

From your experience in the Caribbean do the three industries - tobacco, alcohol and sugar-sweetened beverages (SSBs) - use the same types of strategies to try to avoid regulation?

Yes, more or less these three industries try to use the same types of strategies to avoid regulation. However, I would agree with the research article that (industries making) ultra-processed food products (UPFS)/ SSBs and alcohol have greater access to policymaking spaces and are more likely to be engaged in relationships with the public sector that raise questions around conflict of interest. In general, however, the tactics are the same — passed down from global transnational giants to regional and national industry actors, the very same strategies are deployed to dilute, delay and derail public health policy.

In small developing settings such as those in the Caribbean, rules of engagement with these actors can be difficult to define and boundaries blurred. Identifying, preventing and managing conflicts of interest present significant challenges in our setting where, for example, small markets necessitate that one entity manufactures both healthy and unhealthy product lines. And to complicate matters, this handful of corporate entities are major economic drivers in already vulnerable economies, the power imbalances in favour of industry are exaggerated, professional and political relationships overlap, and powerful industry actors are often intricately connected to political decision-makers at the highest levels.

In the Caribbean the private sector has formed an umbrella association which has gained recognition at the highest policymaking level in the region, thereby creating a situation where the voice of industry is significantly contributing to public health decisions in an environment where there is insufficient emphasis on conflict of interest. The impact of this is presently apparent in public health policy relating to trans-fats and front of package warning labelling, where the tactics of dilute, delay and derail are evident.

The referenced private sector association, have, in their efforts to frustrate the regional adoption of a labelling standard which promotes ‘High In’ in warning labels, challenged existing science on the labels and sought to create their own science, which unsurprisingly draws conclusions in favour of industry. As part of the regional consultative processes to arrive at a consensus on a regional labelling standard, some representatives of the private sector also questioned the normative role and authority of regional public health agencies such as PAHO (Pan American Health Organization) and CARPHA (Caribbean Public Health Agency).

Post-COVID-19 do you think that industries are better or worse positioned to avoid regulation?

In some ways, health-harming industries are better positioned to avoid regulation and in other ways, they are not.

The private sector is largely perceived to have done ‘good’ during the pandemic in our region, where COVID has created needs that the public sector was/ is not always able to fill. Governments, due to lack of fiscal space, occasioned and worsened by COVID, have often leaned on the private sector. The private sector has stepped in, filling gaps and simultaneously leveraging the opportunity to build brand visibility and loyalty.

The ultra-processed food sector has maximised opportunities to donate products, supplies and cash during COVID — again generally branded. As mentioned, some private sector actors have also very effectively undermined the potential introduction of strong regional front-of-package warning labels — one of the arguments has been that the introduction of these labels would significantly undermine the ability of the private sector to contribute to economic recovery in the region.

We have seen examples of this in particular with alcohol, most recently where the Ministry of Health and Wellness in Jamaica announced that they would no longer be accepting donations from the alcohol sector and there was an audible outcry amongst some in the public questioning the policy as the ministry had recently accepted donations for a COVID ward at a local hospital. Some also quite justifiably pointed out that the public sector did not have the funds and that these companies were responding to a need. (Indirectly related — encouraging health-neutral or health-supporting industries to step up and play these roles is an area where more work is needed).

The major negative economic impact of COVID has strengthened the hand of industry, further deepening the power imbalance between industry and public health. This was on show recently after Barbados announced its intention to double its SSB tax to 20% and regional leaders in the beverage industry descended on the country, united with the local manufacturers to try to influence the government into delaying implementation. Needless to say, the attempt failed but it illustrated the power of the industry and the extent to which it will go.

The Barbados example also highlights how COVID has potentially weakened the ability of unhealthy commodities industries’ to avoid regulation. In many ways, the pandemic has deepened the resolve of governments to address NCDs. The increased COVID vulnerability of those living with obesity or NCDs has significantly heightened public awareness and increased opportunities for amplification of advocacy by civil society organisations (CSOs) for NCD prevention and control policies.

Or coming at this question from the other direction: will governments post-COVID-19 be better equipped to regulate industries?

Overall yes in our region, governments are better equipped to regulate industry than they were before the pandemic. Governments are better informed about the need for regulation because of the increased focus on NCDs arising out of the pandemic. HCC and CSOs across the region have maximised the opportunity created by the pandemic to promote NCD policies such as taxes on sweetened beverages, front-of-package nutrition warning labelling and regulating the sale and marketing of ultra-processed foods in schools.

In Barbados, the Heart and Stroke Foundation of Barbados and the Barbados Childhood Obesity Prevention Coalition has been effectively advocating for healthy food policies, including an increase in the SSB tax rate. The nationwide multi-faceted campaigns have effectively used the pandemic to highlight the obesity/NCD crisis and the need for policies, which resulted in public understanding and an appetite for action.

So while I provided an example above with front-of-package warning labels in which COVID may have actually made it more challenging for governments to support healthy food policy and regulate the unhealthy food industry, the Government of Barbados very recently drew in part on the experience of COVID —heightened awareness and acknowledegment of the crisis of NCDs facing Barbados and its massive potential to undermine current and future human capital and development — and pushed forward with SSB taxation.

An important step in regulating these industries is developing mechanisms to ensure that political decision-making is unencumbered by conflicts of interest and resulting interference. There is increased political awareness about the factors and actors which undermine strong healthy food policy including conflicts of interest and industry interference. HCC and partners have been heavily invested in work around the management of conflict of interest targeting policymakers including sharing data on instances of industry interference in the region.

Jamaica provides another example where civil society efforts have not only increased public awareness through national campaigns but also heightened public sector accountability. To their credit, the Heart Foundation of Jamaica has very skilfully used the media to spotlight inconsistencies and possible interference in the local food labelling standards deliberations processes. They leveraged the pandemic to build a case for urgent and transparent policy action on healthy food policy in particular – warning labels – thus playing a key supportive role for the Ministry of Health and Wellness.

The study says that "Except for tobacco, the public health community continues to disagree about ethical terms of engagement for unhealthy commodities industries. This is concerning for several reasons. Policy change can be facilitated by cohesion and divisions limit public health movements. Accordingly, there is an urgent need for the public health community to generate consensus for how to limit corporate autonomy in industries that harm health.” Do you agree with that statement and do you think the public health community is aware of the need to and is working toward, generating consensus?

I am in full agreement with this statement. The absence of consensus and thus dearth of guidance on engaging with the alcohol and UPFS/ SSBs industries has resulted in vulnerabilities which have been and will continue, to be leveraged by these industries.

The FCTC (WHO Framework Convention on Tobacco Control) has been very effective in defining the rules of engagement with the tobacco industry and the impact of this strong global guidance is clear. In contrast, in the area of UPFS and alcohol, industry actors have exploited this gap to their advantage. In fairness, however, this is an extremely complex area and a one-size-fits-all solution will not work. Some of the boundaries which can be drawn with alcohol, for example, in other settings simply cannot be drawn in the Caribbean, where many companies are heterogenous manufacturers, distributors and retailers of alcoholic and non-alcoholic beverages, including healthy product lines.

Personal and professional connections, limited financial resources and weak conflict of interest policies and industry regulation are fertile ground for companies seeking to promote their products and build their brands. There are real cultural issues and economic realities which make it difficult to highlight the vested interests and negative tactics of these industries in the eyes of the public — especially in circumstances created by COVID where the public sees these entities as saviours meeting critical public needs when governments are unable to play this role. Even if we remove some of these unique challenges seen in small communities, this is a highly complex area.

There are, however, some recent developments which point towards greater awareness and investment in seriously addressing commercial determinants of health (CDOH), including building a consensus on how to protect policymaking from these actors. WHO recently launched a workstream on CDOH; prior to this, PAHO launched a toolkit for member states on preventing and managing conflicts of interest in country-level nutrition programmes; and organisations like the NCD Alliance are tracking industry interference.

In the Caribbean, HCC has been working closely for some time with PAHO and most recently supported by the Global Health Advocacy Incubator to develop resources for CSOs and the public sector to assist in the identification, prevention, mitigation and management of conflict of interest in NCD policymaking. We have developed tools and held training sessions for CSOs and the public sector looking at managing conflict of interest in public health decision-making as a critical element of good governance.

HCC has also been monitoring instances of industry interference and marketing of unhealthy commodities to children since 2018 and this data is used to inform our advocacy. Despite all of this, however, our impact will continue to be limited when actors in the unhealthy commodities industry can exploit a divided public health community where mixed messages abound both locally and atthe top levels of global public health norm-setting.