Sleeping with the enemy: the United Nations Development Programme and its position on the non-communicable disease epidemic

Authors


Abstract

The United Nations Development Programme's (UNDP) position on non-communicable diseases (NCDs) is undermined by a key issue at the global institutional level. Fundamentally, the nature of the relationship between international development agencies and the tobacco industry is at odds with the professed public health priorities of the former. At its core, the business model of the tobacco industry is premised on the sale of addictive and disease-causing substances that fuel NCDs in the first place. The role of the United Nations system and, in particular, UNDP is to ‘build nations that can withstand crisis’, not to collaborate with entities that profit from crises. This simple and well-established fact cannot be overlooked. We outline an array of conflict of interests. If the effects of NCDs are ever to be reversed, then international agencies such as the UNDP ought to adhere to ethical standards in choosing partners and avoid conflict of interests. In the absence of this, the UNDP may well compromise its own agenda and proliferate NCDs rather than containing them.

Introduction

Clark (2013a) has stated the United Nations Development Programme (UNDP) position on non-communicable diseases (NCDs) in her article in a well-regarded scientific journal. The authors have contested these assertions (Lal et al. 2013). Our contention is this: United Nations (UN) agencies routinely partner with and accept funds from the tobacco industry and their front groups, which fundamentally undermines concerted global efforts to combat NCDs.

Globalisation has led to a range of increasing interdependencies across the world. With decreasing communications and transportation costs, greater financial integration and capital mobility, multinational companies have a greater degree of access to demographically burgeoning growth markets – the bulk of which are in low- and middle-income countries (LMICs). As in the case of the proliferation of tobacco use, the degree of increase in consumption of soft drinks and processed foods high in salt, fat and sugar is very high in LMICs, surpassing that of higher income countries (Stuckler et al. 2012). One study asserts that the ‘higher intake of unhealthy foods correlates strongly with higher tobacco and alcohol sales, suggesting a set of common tactics by industries producing unhealthy commodities’ (Stuckler et al. 2012). These unhealthy commodities are leading risk factors for various NCDs, and manufacturers including tobacco companies are focusing on increasing sales of their products in developing country markets. Although tobacco use has been highest in high-income countries, sustained marketing efforts in LMICs have proved to be very effective. In fact, the consumption of tobacco has shifted at a higher rate to LMICs. Between 1990 and 2009, when cigarette consumption in Western Europe dropped by 26%, it rose by 57% in Africa and the Middle East (Eriksen et al. 2012).

A compelling matrix of facts highlights the relationship between international development agencies and the tobacco industry, which is at odds with the public health priorities of the agencies. At its core, the business model of the tobacco industry is premised on the sale of addictive and disease-causing substances that fuel NCDs in the first place. This simple and well-established fact cannot be overlooked. Therefore, the UNDP must at the least consider this embedded conflict of interests and clearly distinguish its negotiables from its non-negotiables, if the trajectory of reversing the effects of NCDs is ever to be achieved.

The UN system and the tobacco industry

Since the early 1990s, UN agencies have been encouraged to generate resources from the private sector. Owing to a lack of exclusion criteria and standards for partnership and participation, companies largely responsible for causing the NCD epidemic have ironically become development partners with UN agencies. This has not gone unnoticed.

In 2009, the UN's platform for industry engagement, UN Global Compact, recognised WHO's fight against tobacco but expressed its inability to exclude the tobacco industry – ‘Since tobacco is a legal product whose use UN Member States have not yet outlawed, the Global Compact Office is not able to exclude tobacco companies from the initiative if they still wish to join’ (UN 2008a). So, India's largest cigarette manufacturer, ITC Limited (UN 2008b), tobacco leaf growers Souza Cruz of Brazil (UN 2009) and Limbe Leaf Tobacco Company, Malawi (UN 2007a), plus diversified tobacco companies (Kraft Food Mexico) (UN 2007b) are now active participants engaging in global policy development across sectors – facilitated by the openings provided by UN Global Compact.

Another UN body – the UN Framework Convention for Climate Change (UNFCCC) – provides assistance to industry through the Clean Development Mechanism (CDM), directly benefiting British American Tobacco-affiliated (BAT) and other major tobacco companies in India, Pakistan and China (UNFCCC 2013). This continues despite incontrovertible evidence that tobacco cultivation causes massive environmental degradation (Geist & Lambin 2002). As a result of this willingness to ignore such hard facts, perverse incentives end up becoming an effect of institutional design. The UNDP's involvement with the tobacco industry can be similarly illustrated through a few examples. The Global Environment Facility (GEF), jointly hosted by the UNDP and the World Bank, has the tobacco industry formally partnering with it. Several UNDP-led projects in the Philippines (GEF 2005), Uganda (GEF 2005) and Tanzania (GEF 2005) have received financial support from tobacco companies such as Philip Morris and BAT. In Tanzania, for example, the GEF supported a reforestation programme with the aim of sustaining the long-term benefits to tobacco farmers by providing them fuel for curing tobacco, where deforestation was actually caused by tobacco curing.

The tobacco industry endorsed as a partner by the UN has set a precedent by which a seriously problematic partnership has become prevalent practice. Today, influential non-governmental organisations and think-tanks, such as the World Wide Fund for Nature, World Economic Forum, the Energy Research Institute, Earthwatch and the Eurasia Group (Eurasia Foundation 2007), actively partner with tobacco companies.

Tobacco money directing public health programming

Public health is one arena where the implications and consequences of such a perverse partnership stand out. The tobacco industry offers substantial financial assistance to public health initiatives, being cognisant of the significant political mileage these partnerships bring (Philip 1982). For instance, the UN and WHO work closely with the Global Business Coalition against HIV/AIDS, which includes several tobacco companies such as British American Tobacco (GBCHealth 2008), Imperial Tobacco Group (GBCHealth 2010) and SABMiller Breweries (GBCHealth 2006), a Philip Morris International subsidiary.

The leverage gained by the tobacco industry through such associations has instrumentally diluted the WHO's intent to fight tobacco. An internal memo of British American Tobacco recorded that WHO was reluctant to expand its Tobacco or Health programme for fear of offending the United States. BAT noted that the American tobacco industry was well positioned within the US Congress and went on to describe the latter as ‘a body that loses no opportunity to threaten the UN system with cuts in funding’ (BAT 1991). BAT paid large consultancy fees to Paul Dietrich, former head of WHO's Latin American division, Pan American Health Organization (PAHO), who successfully diverted the focus away from tobacco to vaccination and HIV/AIDS (WHO 2000). Dietrich was working for the interests of the tobacco industry during his tenure at PAHO, a fact that is amply documented by the WHO's Tobacco-Free Initiative (WHO 2001) and peer-reviewed journals (Muggli & Hurt 2003). The Scientist (Godlee 2000) states that British American Tobacco ‘… give [Dietrich] credit for PAHO's decision that year to strike tobacco control from its budgetary priorities, in favour of immunisation and cholera campaigns’.

In the 1970s, Philip Morris took immunisation services to children in Guatemala (Philip 1971); WHO, UNDP and the United States Agency for International Development (USAID) partnered with India's largest cigarette maker, which distributed condoms and family planning services in hard-to-reach regions from 1992 to 1997 (USAID 1992; BAT 1993). These examples indicate that the relative openness of the UN system has afforded the tobacco industry an opportunity to gain currency and respectability at the global level and ironically influence health priorities. By partnering with the tobacco industry, the UNDP confers upon it an undeserved legitimacy, while facilitating the industry better access to global policymaking and subsidising the production of tobacco products using international aid. This inevitably calls into question the organisation's commitment to its agenda of combating NCDs.

Conclusion

By virtue of associating with the UN system, tobacco companies enjoy an undeserved aura of respectability. This fundamentally distracts the focus that the global public health community needs to maintain on the growing epidemic of NCDs from which these companies profit. Through the influence that the multilateral system exerts on national governments, tobacco companies effectively influence health policy at a global level while obfuscating the focus from their responsibility for aspects of the NCD epidemic.

In our view, the essence of the problem is located at an institutional level. How do institutional arrangements deal with fundamental conflict of interests and how are these to be assessed? How can we ensure that potential negative effects on global public health, which are certain to arise from such conflict of interests inherent in financial and institutional networks be averted, preferably before the fact?

Consider a salutary example of dealing with industry after the fact: in the USA, for example, the Master Settlement Agreement imposed a huge fine for the deceit and the damage caused by the tobacco industry over several decades. The financial costs imposed on the industry do serve a critical purpose and serve as a commitment device to ‘lock in’ the tobacco industry's responsibility to American society at large. It is, however, high time to look beyond the imposition of liabilities for damages caused and scrutinise structural arrangements to work towards the prevention of such damages in the first place.

These are intricate and complex issues, of course. Ideally, the range of potential conflict of interests is infinite – and our contention would be simply to ensure that potential conflict of interests should be prevented from distorting science and public health outcomes in the first place. The framing of our views is more focused on diagnosing mission-critical inconsistencies at the institutional level rather than merely in terms of the sectoral or substantive characteristics of the entities (companies, foundations or donor organisations) that may fund these arrangements as such. For the purposes of argument, we do not, ceteris paribus, see a fundamental difference between the dangers of greater tobacco consumption or fast food consumption. But the scope of dealing with such a contention would not only be substantively larger and methodologically deeper, but beyond the scope of the argument that we are presenting in this article. Our overall focus is more immediate- and medium term. We argue that when institutional arrangements that attempt to combat NCDs actually accept funding from (and thereby confer respectability on) the tobacco industry, which has clearly known about the dangers of the product that it sells, then there is a clear conflict of interest that can be dealt with without very much concerted effort. In this sense, the purpose of our contention is public health outcome-oriented.

The need for strong leadership is also clear. Eminent scholars have urged that ‘strong leadership from heads of state is needed to meet national commitments to the UN political declaration on NCDs and to achieve the goal of a 25% reduction in premature NCD mortality by 2025’ (Bonita et al. 2013). This is quite unlikely to happen given the current reluctance of the UN and other international agencies to disassociate themselves from a range of implicit conflict of interests.

Clark (2013a) has stated in her response that the UNDP is finalising a new ‘due diligence policy to assess its work with the private sector’ and that this includes ‘a series of exclusionary clauses that identify areas of industry that UNDP will not partner with, including … any tobacco company or organisations dependent on the tobacco industry’. This is a step in the right direction. Nevertheless, one proposition is inescapable: public health advocates across organisations, independent of location, need to be cautious and attentive to public health priorities. Any strategy to advance NCD control will be effective only if a principled and strict position is taken on tobacco industry participation within the UN, with public health and human rights advocates as monitors. Genuine leadership entails matching intent with action, preferably in lockstep proximity.