Chapter 1 1

4.5 Influencing international policy

Tim Lang and Martin Caraher

Objectives
This chapter will help you understand:
- the relationships between international policy and local policy action
- why public health practitioners should build an international
dimension into their work
- how to influence and advance public health internationally, even
through local action.

The chapter uses examples (many from the world of food and health
policy on which the authors work) to illustrate more general points
about the structures and processes of engagement you are likely to
consider.

Why is this an important public health

issue?
Delivering public health requires understanding of the different actors,
bodies and processes, and how they interact at multiple levels.
Effective public health demands interdisciplinary intelligence. It also
requires support and co-ordination between actors at each level. This
co-ordination function can test your firm but delicate negotiation
skills, as tensions between local, national, regional and global levels of
health governance may be exposed.

The international dimension of public health work is today essential,

not least because the world is complex. The drivers and shapers of ill-
health today may be far away both in terms of physical distance but
also in terms of the policy drivers.

Even the most local of actions may have international ramifications

and even the best of local or national interventions can be improved by
inspection from afar.

Many of the policies influencing health may not be directly health-

related. It is now realised, for example, how trade regulations may
influence tobacco and food availability just as much as national
policies. The infrastructure of health – issues such as food, transport,
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housing, water, energy, air, and climate - may all be shaped by the
actions and interactions of giant companies, powerful countries and
seemingly distant institutions. It can sometimes feel as though public
health services pick up the pieces scattered by others.

All this is why public health needs strong advocates and organization
across borders. Public health proponents have to think and act both
internationally and locally.

Why do we need an international consciousness?

Reasons for an international focus in public health work include:
- the international dimension adds to and can alter analysis of
problems
- drivers of communicable diseases and NCDs can be international
and distant from where the effects are manifest
- ill-health crosses borders in new ways in the modern globalised
world with ‘vectors’ being cultural as well as biological
- this new scale of movement of people, goods, ideas and services has
implications for international public health institutions

In the modern globalised world, actions in one place can have

profound impacts elsewhere, sometimes unforeseen. Campaigns to
improve healthy eating in rich countries, such as calling for increased
fruit consumption, need to be aware of how this has an impact of
supply chains. In Germany, for example, health advice to drink fruit
juice has meant an increase in long-distant fruit, notably oranges from
Brazil. A study by the Wupperthal Institute in Germany calculated that
80% of Brazilian orange production was consumed in Europe. Annual
German consumption occupied 370,000 acres of Brazilian productive
land, three times the land given over to fruit production in Germany. If
this level of German orange juice consumption was replicated world-
wide, 32 million acres would be needed just for orange production. In
addition, the levels of income to the growers in Brazil are small with
most of the profits going to intermediaries such as producers and
retailers. And in Brazil, local crops were replaced by crops for export.
(1) The simple health education message thus had complicated
consequences internationally.

- Disease knows no boundaries

Infectious diseases constantly migrate, borne by human exchange.

There is nothing new about this. The mediaeval plagues in Europe
were fearsome and one of the worst killers in the 20th century was
influenza. Non communicable diseases (NCDs) cross borders in
different ways and through different mechanisms, typically involving
social and economic changes which have an impact on new lifestyle
decisions and changes.
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Epidemics of both communicable and NCDs travel within and

between countries. HIV/AIDS, for example, has caused millions of
deaths. Prevention strategies require the sharing and spreading of
knowledge. Swinburn and Egger have argued that population weight
gain is shaped by changes in the environment far beyond the
immediate control of health actors.(2) The WHO now also relates the
increase in mental disorders to increases in poverty, urbanisation,
aging populations and the pace of life, all factors which are shaped by
international forces – economic, political, and cultural.(3)

NCDs used to be judged as rich society diseases, but today the

incidence of coronary heart disease, strokes, diabetes, some cancers
and obesity have spread round the world, associated with changes in
diet, physical activity and lifestyle. These are shaped by international
forces as populations shift towards a more ‘Western’ lifestyle – eating
different foods, taking less exercise, spending time in front of screens
and not just aspiring to, but achieving, western patterns of
consumption.(3) Obesity now coexists with malnutrition in developing
countries. And in developed countries obesity rates has created a
culture where historically abnormal body mass indices are accepted as
normal.

This more complex globalised world raises questions for public health:
- Are your local and national public health systems tapped into
international health organizations which monitor and share best
practice on disease?
- Does your planning system include any health or social impact
measures on possible international impacts?
- Have you any means for feeding data and thinking back into
national and international public health systems?
- Have you created or got access to early warning systems?
- Do you have multi-disciplinary networks which give broad-based
sources of information at the international level? Conversely, is your
information available beyond your area to add to international
intelligence?
- Do you know how your locality’s profile fits into international
comparisons?
The scaling up of economic activity has implications for health
The history of public health is full of lessons how cross-border activity
may occur in different forms: people, ideas, goods, plants, animals.
The acceleration of international economic activity has had big
implications for health. Rising incomes are beneficial for health,
although the effects appear to level off, and are affected by relative
levels of equality within societies. Public health bodies and thinking
are having to monitor the effects from new as well as old industries.

Mass tourism is relatively new industry, and is a big employer which

benefits health. Yet it is one way ill-health can also spread. In 2008,
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there were an estimated 922 billion tourist trips taken worldwide, up

from 639 in 2001. Tourism is very big business, generating receipts of
$944 billion in 2008.(4) For international health, what matters is that
approximately one seventh of humanity is crossing borders and
potentially both spreading and catching diseases. It has been estimated
that tourists run an estimated 20-50% risk of contracting a food-borne
illness.(5) Travel itself can be a significant contribution to
environmental damage and air transport is associated with atmospheric
pollution.

Ideas cross borders. Historically, human progress has depended on,

and been deepened by, the spread of ideas but the consequences can
also be mixed. Advertising, marketing and the internet can be positive
media by which human understanding is increased or the means by
which behaviour change occurs without the health infrastructure or
counter-balances being in place. Multi-media sources of information
can give opportunities for solid evidence to be made more widely
available or can allow urban myths and misinformation to “go viral”.

Goods cross borders too. The removal of barriers to trade at the 1994
General Agreement on Tariffs and Trade (GATT) talks accelerated
emerging patterns of trade. A new body was created, the World Trade
Organization (WTO) as the international secretariat to facilitate the
spread of goods and services. Food came under this international
economic regime for the first time; as a result, the Nutrition Transition
was accelerated. For developing countries, this has meant the arrival of
western fast food chains and soft drinks but for rich consumer societies
it has meant retailers sourcing globally. A new world food order has
emerged where foods out of season, and control other people’s land
and food space alter the drivers of health. This has restructured power
relations between health organizations, governments, companies and
consumers (see the example above on orange juice). The effects can be
debated – some see it as progress, others as subversion of national
health governance. Most immediately, it revises and exposes the
interdependency of quality and hygiene controls. Failures in one
country may have consequences far away. International frameworks
become ever more important for health.

It is not only goods that cross boundaries but people too. An example
of the need for health professions to have excellent representation in
international trade talks was the General Agreement on Trade in
Services (GATS), which was agreed alongside the 1994 GATT. GATS
set up rules for the regulation of services, including healthcare and the
growth of transnational companies providing health care for whole
countries or regions has followed. In addition, the free-flow of labour
across national boundaries has considerable impact, with concerns
about qualified staff being attracted to developed countries in pursuit
of better wages and conditions. Migration is one of the key public
health issues of the twenty first century. Migration of skilled labour
from the global south to the global north has many implications for
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health care, not the least of which is the denuding of a country of its
health care skills and expertise. But migration within countries from
rural to urban areas also has many public health implications including
the loss of land, work and income.

Globalised mass supply systems have relocated and altered work.

Sophisticated just-in-time managerial controls, based on how factories
work, assembling ingredients and delivering products to supermarket
shelves just when needed. Logistics and computerized informatics are
central to this efficiency and to profitability and competition. For
public health, there must be systems of traceability and accessible
paper-trails to enable audits if there are break-downs and recalls of
unsound products. Companies are sensitive to this but their concern
may be in brand value and product reputation rather than public health.
These extended and mass scale supply chains introduce many more
points for possible contamination or err, and has led to the introduction
of risk assessment and management systems such as Hazards Analysis
Critical Control Point (HACCP) approaches.

21st century public health protection probably needs to go further than

HACCP and reconnect with lessons from the 19th century health
movements which asked about the social distribution of health
benefits, not just the economic ones. Who and what wins and loses
from the new world order (see the box on coffee)?

Box: Who makes money from coffee? Winners

and losers
 Grower in Africa gets 9p per kilo for green coffee beans
 Exporter buys it for 17p
 Transport to port for grading etc for 29p
 Importer in UK pays 34 p per kilo
 Roaster in Oxfordshire pays 41p (new price is £1.06, with
moisture loss)
 Supermarket, having paid for processing, packaging,
distribution and marketing now charge £17.11 per kilo—
that is, between farm gate and shopping trolley, price goes
up by 7,000% (6).

Concentrations of power
With unequal distribution of wealth from economic activity in
international supply chains, there is increasing interest among health
bodies about how to ensure positive health impacts. The 2008 report of
the WHO Commission on the Social Determinants of Health was one
response to this problem.(7)
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Broader questions touch on the relative power and influence of public

health professionals in fiercely competitive commercial environments:
- can public health interests compete with powerful economic forces?
- is our job just to pick up the pieces rather than prevent problems?
- how can we use crises (when they happen) to promote health
protection measures?
- are our professional bodies actively involved in international policy-
making to ensure public health is fully acknowledged in policy
frameworks?

If there is a breakdown in health controls:

- Are you clear where the product came from?
- Where did its constituent parts / ingredients come from?
- Was this a problem of a particular batch or supplier?
- How or where in the distribution process were the risk points?
- What is the legal responsibility and who has it?
- Why are we acting after the event? Could we have been proactive in
setting up prevention controls?

Getting organized
In an ideal world, public health policy and practice would be evidence-
based but the reality is that the relationship between evidence, policy
and practice can be tortuous.(8) Health considerations are often not
represented at the policy table where critical decisions are taken.
Getting organized means getting a place. And that can mean a lot of
work.

Public health professionals must ensure they have good voice. We

cannot assume that political and institutional frameworks for
addressing the ‘transnationalisation’ of health patterns are either
adequately resourced or fit to keep abreast of economic, social and
cultural change. Public health work and institutions tend to be locally
and nationally focused and based, partly due to funding and tax-
collection systems, but economic and social changes are increasingly
trans-national. The long struggle to achieve some leverage over
international trade in tobacco is an important case study of the value of
international work (see Case Study 4.51). There is much to learn from
the long, frustrating process of trying to control the scourge of
tobacco. A key lesson is that a local focus is not sufficient to get
change. Local initiative needed international links. Another lesson was
to ensure consistent messages. Being well organized internationally
helps the process of incremental change, too. A gain in one country
can be replicated and exceeded elsewhere. This needs international
liaison and trusted forums. At the time of writing the Australian and
probably Irish attempts to introduce plain packaging on cigarette
packet is being challenged in the courts by the tobacco companies. The
irony is that the challenges are economic and framed within a barrier
to trade argument and not on a public health basis. This is not
dissimilar to food and nutrition areas where the companies rarely use
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or challenge public health initiatives in the courts, although they may

well lobby about them. This happened in the late 2000s when attempts
to get optimum front-of-pack nutrition labeling failed in the EU.
Heavy and sustained lobbying by some (but not all) giant food
industry interests swayed the European Commission not to act for
optimum health.

Case study 4.5.1. Tobacco control

Tobacco control has been a public health success but required
extended effort, very strong evidence, and clarity of purpose and
strategy. The history of tobacco control has been slow: half a century
from the first firm evidence to ‘leaps’ such as bans on smoking in
public places and the Framework Convention on Tobacco Control
(FCTC). A combination of action by many organizations was needed,
and global funds. While national campaigns introduced restrictions on
tobacco promotion, international funding has been used to tackle
structural issues such as growing practices and not just spent on health
education campaigns in the countries that grow tobacco but used to
subsidize changes in growing practice to help farmers during the
change from tobacco to other cash crops. The FCTC, which came into
force in 2005, was the first international treaty driven and negotiated
under the auspices of the World Health Organization. It has become
one of the most widely embraced treaties in UN history(1). It was
developed in response to the globalization of the tobacco epidemic and
is an evidence-based treaty reaffirming the right of all people to the
highest standard of health. The Convention represents a milestone for
the promotion of public health and provides new legal dimensions for
international health co-operation.

Public health practitioners learned, when the GATT 1987-94

negotiations were underway, that health could be seen as a ‘threat’
while trade is perceived as an ‘opportunity’.(9) Yet there is still an
opportunity here to address public health under the banner of the
precautionary principle and for the protection of vulnerable groups
such as children. Not that long ago, children were seen as legitimate
targets for food advertising now the cultural attitudes to this has
shifted and even the advertising industry accepts the need for limits
(10). Conventions and global agreements should be reflected in local
and national plans. The advertising industry does this for its own
interests, via its own international codes and practices. Public health
groups, too, can get organized to create sounder international codes. In
the late 2000s, for example, ‘Sydney Principles’ were created to
protect children’s health in relation to advertising, usable
internationally.(11) Local policies could and should reflect such
international public health consensus.
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Too often, health lags behind forces driving economic restructuring. In

Europe, years of negotiation preceded the creation of the 1987 Single
Market but it was not until bovine spongiform encephalopathy (BSE)
‘jumped’ to humans in the mid 1990s that the EU recognized and
implemented stronger preventive public health measures. A Food
Safety White paper was created in 2000 and the European Food Safety
Authority in 2002, under Regulation EC 178/2002 January 2002. A
Rapid Alert System was created alongside a new Directorate-General
for consumers and health (DG Sanco). Almost two decades passed
between the economic moves to facilitate cross-border trade and the
creation of proper public health measures and institutions to ensure
health is protected. The point here is about the opportunism of public
health in times of crises to lever policy change. While the BSE crises
was one of food safety and public confidence it also provided an
opportunity for discussions on broader remits of food policy at all
levels from the local to the global.

Achieving health-promoting change at any level requires good

organization, dedicated to:
- Identification of causes , both overt and underlying
- Clarification of necessary interventions
- Debate about different courses of action
- Good liaison with international (perhaps regional rather than global)
bodies
- Refinement of arguments to win ‘hearts and minds’
- Alliances to help deliver change
Alliances to help deliver change
Alliances are essential for effective championing roles in the public
health. They may take different forms: within professions, between
professions, in wider society, e.g. with civil society and NGOs, across
government, and with pro-public health sections of commerce (see
also Chapter 7.3 Elston).

Key issues for effective international work by health practitioners

include:
- How to develop potential allies – who might help?
- Continual analysis of barriers – where might difficulties or
opposition come from?
- How to combine short- and long-term perspectives
- Building up trust relationships across borders;
- Creating trusted teams and networks;
- Allowing for difficulties of diverse languages, traditions, cultures,
expectations and styles.

One way of influencing global policy involves you or your

organization joining campaigning groups or non-governmental
organizations and becoming part of regional and global networks. See
Case Study 4.5.2 on Baby Milk Action for an example of such an
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approach; for further example see Chapter 6.8 Gray and Chapter 4.4
Chapman.

Case Study 4.5.2. International Baby Foods Action Network

The International Baby Foods Action Network (IBFAN) involves over
150 citizen groups in over 90 countries. In 1977 a boycott of Nestlé
was launched in protest at the company’s selling of breastmilk
substitutes. IBFAN came together in 1979 to promote the boycott, to
monitor company infractions, to deliver policy commitments to
promote breast-feeding, and to reduce ill-health and deaths from
inappropriate infant feeding. It spawned moves among Health
Ministries to create the International Code of Marketing of Breastmilk
Substitutes (ICMBS). This was Resolution WHA34.22, adopted by the
World Health Assembly in 1981 as a "minimum requirement" to
protect infant health. The WHA, WHO’s democratic meeting of
Member States, agreed that the ICMBS should be implemented "in its
entirety." IBFAN has become an active global network to strengthen
independent, transparent and effective controls on the marketing of
baby foods. Where water is unsafe, a bottle-fed child is up to 25 times
more likely to die as a result of diarrhoea than a breastfed child and the
WHO and UNICEF estimate 1.5 million infants die every year because
they are not breastfed. Companies continue to violate the provisions of
the ICMBS and IBFAN’s work is a reminder of the need for public
health vigilance and good monitoring, as well as the value of having
NGOs that can concentrate on full-time campaigning and working with
professionals. IBFAN helps national campaigns by providing
illustrations of best-practice, lobbies international forums, and has
helped deliver resolutions at WHA every two years. It won the Right
Livelihood Award (often called the alternative Nobel Prize) in 1998
for this work. (See further resources, below, for more details.)

The 1990 WHO-Unicef Code on Breastfeeding (the Innocenti

Declaration) agreed the goal that “all women should be enabled to
practice exclusive breastfeeding and all infants should be fed
exclusively on breast-milk from birth to 4-6 months.” (Unicef 2005) It
committed national governments to implementing a wide range of
policies such as taking action on the marketing of breast-feeding
supplements and to promote breast-feeding for instance in hospitals.
Implementation has been challenging due in part to failures of
governments, hospitals and services to address the issue and in part to
systematic attacks by business. Breast-milk substitute manufacturers
have looked to developing countries as new markets subject to fewer
controls than developed economies.

Refining arguments to win ‘hearts and minds’

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It is wrong to think good and effective public health action

internationally only needs facts, evidence and risk assessments. These
are essential but may be insufficient for success. We must also think
about arguments that can:
- Persuade the faint-hearted (see chapters 4.4 and 6.4)
- ‘Sell’ the issues to a wider public through media advocacy
- Win over key decision-makers
- Recognize that the discussions over health policy happen in arenas
such as trade and finance and factor these in to our deliberations
- Recognize but overcome opposing arguments.

Public health advocacy should be built into campaigns to bring about

change and raise awareness of issues incorporating aspects of global
impact and agreement (see Chapter 4.4 Chapman). The general public,
and even public health practitioners, are often unaware of global issues
that have an impact on health and of the complex impact their actions
can have on the health of populations in the developing world. The
Fairtrade movement provides an example of how purchasing decisions
can contribute to the health and incomes of those in developing
countries.
Global Institutions: what levers do we have?
Many institutions – governmental, non-governmental, and commercial
– operate on a global level (see Table 4.5.1). They were created
throughout the 20th century. You could create your own list of key
bodies for your interests, and build contacts with and within them,
either yourself or through a professional body.
TABLE 4.5.1 Global institutions involved in health
Remit Examples of Organizations
Public health WHO, Food and Agriculture Organization (FAO),
Children and health UNICEF, UNESCO
Global economic World Bank, International Monetary Fund, World Trade
bodies with health Organization (WTO), Organization for Economic CO-
impact operation and Development (OECD)
Intergovernmental Bio-safety Convention, International Conference on
Agreements with a Nutrition, Basel Convention on hazardous waste
health impact
Emergency aid World Food Programme, International Committee of the
Red Cross / Crescent
Environmental health Global Panel on Climate Change, UN Conference on
Environment & Development (UNCED), International
Maritime Organization
Commercial interests Transnational Corporations, International Federation of
Pharmaceutical Manufacturers Associations, World
Economic Forum,
Regional bodies with European Union, Regional Offices of WHO and FAO
health role
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Trade Associations International Hospitals Federation

Networks to promote Healthy Cities Network [WHO], International Baby Food
public health ([UN] Action Network (IBFAN), Pesticides Action Network,
indicates UN support) Tobacco Free Initiative [WHO]
Professional Health Action International, International Union of Health
associations Education, World Public Health Association,
Non-Governmental Friends of the Earth, Oxfam, Médecins sans Frontières,
Organizations World Federation of Public Health Associations

Many international bodies have resolutions, reports, conventions and

agreements which have implications for public health at the local
level. Knowing and being able to cite these can be very helpful in local
and national policies. National governments and firms might not like
to be measured against international statements.

Table 4.5.2 gives illustrations of some conventions and international

agreements supporting public health action. There are many others.
Some are ‘soft’ commitments and not given binding power at national
or legal level (eg Declarations). Some are criticized as being remote or
undemocratic. Others have been made important by being used as
yardsticks for health improvement (eg binding agreements which have
to be ratified by national governments, turned into national laws).
They can legitimate local or national actions, and people working
inside bodies set up to service international commitments can be useful
allies. Take legal advice.

In relation to any such agreement it is important to ask:

- How strong is it? Is it binding?
- Has your national professional body a position or statement on the
issue?
- Has your government ratified it (i.e. put it into national law)?
- If not: why? What are the lessons to be learned? Was it how it was
done? Who did it? Find out!
Table 4.5.2 Examples of international commitments with public health
relevance
Occasion Date Relevance
Universal Declaration of Human Rights 1948 Right to health
Stockholm Conference on the Human 1972 Environmental
Environment protection

World Food Conference (Universal 1974 Eradication of

Declaration on the Eradication of Hunger malnutrition
and Malnutrition)
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Ottawa Charter on Health Promotion 1986 Health promotion

‘Health for All’

Convention on the Rights of Child 1989 Children

Innocenti Declaration on Breastfeeding 1990 Breastfeeding
Kyoto Protocol 1997 Climate change
Millennium Development Goals 2000 Global poverty and
inequality reduction
targets by 2015

Good public health depends on practitioners and researchers finding

new ways to win arguments, build evidence, and improve policy and
practice. International links can help generate new methods and
approaches. An example of how methods can be refined and improved
is the growth of Impact Assessments, including Health Impact
Assessments and Environmental Impact Assessments (HIAs / EIAs;
see Chapter 1.5 Scott-Samuel and Chapter 3.2 Taylor). If HIAs and
EIAs were accompanied by Social Impact Assessments public health
might have the information needed to tackle multi-level, multi-sectoral
problems.
Conclusions
The international dimensions of public health will continue to be
addressed by organizations such as the United Nations but there are
now many international bodies besides governments all competing for
policy attention and influence on health. They include commerce,
sectoral / special interests, professions, and civil society. Sound public
health protection can get lost as various interests tussle. That is why
public health practitioners need to be – and to remain – well organized,
informed and funded internationally. This must not be an afterthought.
It is not a luxury.

The causes of health problems are complex. Having an international

perspective was always useful; today it is essential. Alliances, across
sectors as well as regions, are key ingredients for success.

Influencing health at the international level means the following:

- It is part of the modern multilevel approach, combining the local,
national, regional, and global
- Allowing time for good advocacy and building the international case
- Being well resourced and organized
- Using existing international health institutions while also
strengthening, supporting and sometimes cajoling them
- Being prepared to enter complex terrain where there are existing
powerful interest groups
- Thinking and working in alliances
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Further Resources
Lee K (2003). Globalization and Health: An Introduction. Palgrave:
London.
Lang T, Barling D, Caraher M (2009). Food Policy: integrating
health, environment and society. Oxford University Press: Oxford.
Labonte R, Laverack G (2008). Health Promotion in Action: from
Local to Global Empowerment. Palgrave: Basingstoke.
Rayner G, Lang T (2012). Ecological Public Health: re-shaping the
conditions for good health. Eathscan-Routledge: Abingdon
Unicef (2005). 1990 – 2005 Celebrating the Innocenti Declaration on
the Protection, Promotion and Support of Breastfeeding: Past
Achievements, Present Challenges and the Way Forward for Infant
and Young Child Feeding. Unicef, Innocenti Research Centre:
Florence.
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