New models for old

As was outlined above in the discussion on Boyd Orr, the dominant model for food policy dates back to the post World War II period. The model centered on an analysis that

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                                                                       Increased

                                                                                 production Distribution Health

Capital

Figure 4.1 Food’s impact on health – the mid 20th century model.

Science                                          Increased

                                                      Production                 Distribution

Health

Health

Capital                                                                 education       

Figure 4.2 Food’s impact on health – the mid to late 20th century model.

underproduction was the primary policy failure. If science could only unleash nature’s productive capacity and if capital investment could be suitably made, then farming could increase output and nutritional deficiencies could be alleviated. As long as there was efficient distribution and a welfare safety net to “catch” failures in personal income, then improved public health would surely be the outcome. The model is schematically represented in Fig. 4.1. By the 1980s, with rising evidence of degenerative diseases, another “box” was inserted into the package in the form of health education (Fig. 4.2).

The problem with this approach was that it made a number of assumptions which events proved to be unwarranted. Firstly, it assumed that increased supply would improve health when in fact rising incomes, urbanization, and changed nature of sup-ply allowed (or arguably encouraged) the rise of degenerative diseases such as coronary heart disease, the diet-related cancers, diabetes, and obesity – all the diseases associated with and highlighted in the nutrition transition.

Secondly, the model assumed that the era of contagion was over when in fact theopening up of food systems removed barriers to the spreading of diseases. Thus, if food traveled across continents and if processors and retailers purchase globally, new opportunities and routes for cross-contamination and spreading of diseases were created. Key causes of disease include Salmonella, Campylobacter, Escherichia coli, and new ones such as bovine spongiform encephalophathy (BSE). Thirdly, changes in the nature of production and distribution opened new chances for diseases to spread further and faster. Tourism, for instance, turns more than 600 million people each year into disease carriers.

Food Policy

Figure 4.3

WHO European Region model for food and health policy (reproduced from WHO Regional Committee for Europe, 2000, with permission).

Fourthly, the model assumed that the “old” banes of food policy, such as adulteration and contamination, would be consigned to the history books when in fact they have changed. Some forms of contamination and adulteration have been successfully controlled whereas new ones such as contamination from pesticides, additives, and nitrates have been introduced or greatly enhanced.

 What is now required is a much more complex and multidimensional model. The 51 member states of the WHO European Region in 2000 agreed to a new simple model (Fig. 4.3). This suggests that to meet health goals, public policy should give equal emphasis to building three pillars: nutrition, food safety, and sustainable food supply. Unless they are equal, the roof – health – under which all humans can shelter would tilt and not last. This model is highly appropriate to present this new message, being simple and intelligible. But it can be argued that in reality, the model ought to be more multifactoral; there should be many more pillars and understanding required needs to include many sciences. Figure 4.4 shows a more appropriate model, even though this might be hard to sell to politicians, who famously are both busy and need to be “sold” simple messages.

If public policy is to be built on a comprehensive rather than a partial analysis, it should integrate the goals of achieving individual, population, and ecological health.

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Institutions

Institutions

 When the General Agreement on Tariffs and Trade (GATT) was signed by over 100 countries in 1994, it was to have profound direct and indirect implications for public health in

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Figure 4.4

Food’s impact on health: the complex model (from Waltner-Troews and Lang, 2000) with permission.

general, and for food and agriculture in particular. It created the immensely powerful World Trade Organization (WTO) which not only monitors trade rules but runs a system of arbitration which is de facto a new jurisprudence. This mattered for public health for a number of reasons.

The institutions through which public health has expressed its views in the post-war period have been quietly marginalized (Labonte, 1998). A new system of world governance, much commented on by its non-governmental organization (NGO) critics, is emerging in parallel to, and more powerful than, the formerly more democratic institutions of the United Nations (Navarro, 1999). The WTO (or the World Bank) is more significant in framing the conditions for public health than the WHO (Banerji, 1999). The WHO is informed by a World Health Assembly, yet there is no parallel citizen’s voice for the WTO. Economically, there is no contest as to which is more significant, the UN system or the new trade system.

The GATT is a key, if not the key, structure in the architecture of the new era of globalization. Within the many hundreds of pages of the full GATT agreement, public health barely registers, except when implied as a threat to free trade. A fear that health is a fig-leaf for protectionism stalks the neoliberal halls, whereas to proponents of public health, the notion of “protection”, like prevention, carries positive rather than negative connotations. In the GATT’s Agreement on Agriculture much effort was put into ensuring that national governments cannot set food standards or restrict entry of foods unless they have “sound scientific” justification. This seems reasonable, although in practice subject to subjective interpretation and commercial pressures.

Research conducted in 1991–93, before the 1994 GATT was signed, suggested that Codex was not in a fit democratic state to carry public confidence about its processes (Avery et al ., 1993). Codex is a large system of around 20 committees, which has many participants at meetings around the world. These working parties are usually hosted by rich countries and meet over two years and make recommendations to the bi-annual full meeting of the Codex Commission. Over the full 1991–93 cycle of meetings there were a total of 2758 participants. Codex is theoretically a meeting of governments but the study found that nearly a quarter of participants were from large international companies – the same for whose products were being set standards. Reviewing a full two-year cycle of Codex meetings, the

Cracking the Codex study found that:

• 104 countries participated, as did over 100 of the largest multinational food and agrochemical companies;

•The vast majority (96%) of nongovernmental participants represented industry;

• There were 26 representatives from public interest groups compared to 662 industry representatives;

• Nestlé, the largest food company in the world, sent over 30 representatives to all Codex committee meetings combined, more than most countries;

• Most representation came from rich, Northern countries: over 60% came from Europe and North America with the poor countries of the South dramatically under represented – only 7% from Africa and 10% from Latin America;

• Of the participants on the working group on standards for food additives and contaminants, 39% represented Transnational Corporations (TNCs) or industry federations, including 61 representatives from the largest food and agrochemical companies in the world;

• Of the 374 participants on the committee on pesticide residue levels, 75 repre- sented multinational agrochemical and food corporations, 34 from the world’s top 20 agrochemical companies; only 80 participants represented the interests of developing countries;

• The USA sent more representatives to Codex than any other country (50% of them representing industry) and almost twice as many as the entire continent of Africa.

Following the publication of this report and despite requests to “clean up” this inadequacy, the GATT secretariat declined to act. In subsequent years, officials and companies became sensitive to these criticisms, which have been pursued by the consumers’ movement. Some countries now hold tripartite national premeetings with industry, consumers, and government officials before going to Codex meetings. However, this left practice at the Codex meetings themselves unchanged. One review in 1997 concluded that little has changed (McCrea, 1997). At the 1997 Codex food labeling committee, for instance, the US delegation comprised eight government officials, three from NGOs and ten from industry. Reform is now, happily, beginning, but why so late?

Particularly sensitive is the issue of scientific judgment. The GATT stipulated that disputes would be arbitrated on grounds of “sound science”, yet consumer groups argue that science is not the only salient feature, nor indeed is science quite the straightforward arbiter it is assumed to be. Whose is the research? Who funded it? Is it publicly available? What questions framed the analysis? The argument between the USA and the EU over hormone use in meat fattening illustrates the sensitivity of the issue. Since the early 1980s, the EU has implemented a ban on the use of hormones. This was con-tested by the US, keen to sell its beef in Europe’s rich markets. The dispute was referred to Codex and the long-awaited WTO decision was announced in early 1998. Both the US and EU claimed vindication of their positions (EC, 1998; USTR, 1998). The EU’s Scientific Committee on Veterinary Measures then argued that further studies suggested scientific evidence warranting a continued ban (European Commission, 1999).

 The food trade issue is now particularly sensitive. For the last few years there has been a steady stream of high profile cases where food-exporting nations fight over the right to export surpluses to each other and to markets they deem their own. There have been wars over lamb between Australia and New Zealand and the USA (International Centre for Trade and Sustainable Development, 1999); over beef hormones between the EU and USA; over genetically modified foods between the USA and many countries but especially the EU. The notion that food security stems from growing most of one’s food within one’s country (what used to be called self-reliance) is being eroded by the notion that security stems from being able to purchase food on the open world markets (WHO-Europe, 1995).

Food security is a concern for most developing country governments whereas rich countries are more troubled by consumer-driven food safety issues. As the WHO Regional Office for Europe’s (1999) Food and Nutrition Plan recognizes, from a public health perspective, both are important and both re ect changes in methods of production and distribution and in the food system (Tansey and Worsley, 1995; Lang, 1997). The Norwegian Government was rare among rich nations in openly criticizing the drift of the new GATT talks. It should know. Its citizens voted in the early 1990s against joining the EU, in part from hostility to the Common Agricultural Policy undermining the national nutrition and food policy in place since 1976 (Royal Norwegian Ministry of Agriculture, 1976). Yet Norway by signing onto the 1994 GATT began to erode exactly the very same national policy.

In a paper prepared in June 1999, Norway laid down a clear policy challenge: food security is too important to be left to the vagaries of trade (Royal Ministry of Agriculture, 1999). Under the Plan of Action agreed at the 1996 World Food Summit, as at the earlier 1992 International Conference on Nutrition, Governments agreed they have a moral responsibility to ensure their citizens have adequate food, are free from hunger and achieve food security (World Food Summit, 1996). The GATT perspective favors the market approach to food security. Tacitly, it argues that the cheapest food is best. The new public health perspective suggests that the West’s food revolution has intensified food production such that when food is cheap, other costs are being externalized onto the environment (Lang, 1999b). In this intellectual context, Norway’s position was pioneering. It argued that the new Round should agree on rules to safeguard national food security. When wheat or maize prices can rise by 50% in just two years, as happened in 1993–95, reliance on being able to buy one’s food in the world marketplace is a form of security only open to the af uent. (Norway, as a small population with immense oil wealth is ironically one such country.) What are the poor to do in such circumstances: tighten their belts? As Sen (1981b, 1997) and others have shown, hunger follows poor purchasing power and is not necessarily a function of food availability.

The new WTO structures are designed to facilitate cross-border economic activity and to reduce national control over capital  ows, competition and even cultural control. In the age of the internet, information knows few boundaries yet vast new corporations are emerging which dominate almost everything humans do or consume. The irony about the new GATT is that it is based upon the free trade model of globalization just when evidence about its negative effects is mounting up. According to the tenth annual UN Human Development Report, the richest 20% of the world now account for 86% of world GDP, while the poorest 20% have just 1% (UNDP, 1999); 200 of the world’s richest people have doubled their net worth in the last four years. The richest three people in the world have assets greater than the combined Gross National Product of all the least developed countries in the world, 600 million people. There is little chance of health for all in such a socially divided world.

Another reason for public health involvement in trade talks and debate concerns the work of public health monitoring itself. Public health action has to be based on a good understanding of the real world. Perspective is in order. Postwar development has brought astonishing gains for billions of people, but equally, as the Human Development Report documents, the scale of contemporary inequality and poor healthcare defies sanity. The Human Development Report itself came into existence because a decade ago, UN administrators, social scientists, and politicians were critical of the convention of measuring development through indicators such as Gross Domestic or National Product. They disguise intranational inequalities and fail to convey the quality of life issues. The Human Development Index was created to fill this gap. The Human Development Report shows that 80 countries have incomes lower today than a decade ago; 1.3 billion people, over a fifth of humanity, exist on less than US$1 per day. However it is measured, the gap between the richest and poorest is widening. In 1960, the gap between the richest fifth and the poorest fifth was 30:1. In 1990 it was 60:1. In 1997 it was 74:1 (UNDP, 1999). In this context, it is clear that epidemiologists as much as physicians and health activists have to ask themselves how their work does or does not confront this obscene accrual of wealth and power. And does the nutrition transition call for new health indicators? Almost certainly, yes!

The Human Development Report , however, argued that globalization is unstoppable and that all good people can do is try to give it “development with a human face”. It is true that proponents of unfettered free trade are more defensive than in 1987–94. Faced by growing opposition and the sheer weight of evidence of harm, the architects of inequalities in health now plead that we should still trust them and that (their version of) growth must continue by a different path (Wolf, 1999). Inequalities may be bad, they admit, but now is the time to target resources on the poor. We should ignore, they imply, the accrual of power by the rich as they are the motor force of the new global economy.

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Conclusion

The nutrition transition raises immensely important challenges for food policy. This chapter argues that these need to be accompanied by sensitivity to other challenges raised by contemporary globalization.

Table 4.5 Different Food and Health Policy Frameworks: fragmented or systemic solutions?

Fragmented approach Systemic approach

Food policy focus on productionism &  Food policy seeks sustainability & citizenship

consumerism

Marketing appeal to individual health Population approach to public health

Reliance on technical fixes  Diet-based approach to preventive health

(drugs, functional foods, etc.)

Marginalization of health from supply  Health central to economics

chain thinking

Separation of safety and nutrition Policy linkage between safety, nutrition and

sustainable food supply

Intensification Diversification

Health costs externalized Health costs internalized

Poor links between global, regional,  Multilevel governance

national and local governance

Competing frameworks within government  Integrated policy across government and food

and corporate sector supply chain

There is a strong case for action on food and health. Interventions much cited in the literature, such as the North Karelia experiment in Finland, are often rooted in an era of more interventionist government action. Finland produced a 55% decline in male mortality due to coronary heart disease in the period 1972–92. So even in the con-temporary policy climate, interventions can work. As has been illustrated by Thailand, which engineered a decline in childhood malnutrition from 50% in 1982 to 10% by 1996. The key, according to the Commission on the Nutrition Challenges of the 21^st Century (2000) reporting to the UN, is a combination of political will, health planning, and community focus.

The good news is that awareness of health as a central element of development is growing. Pressure to enable the new ecological public health approach is building up. Policy options and the implications of choices are becoming clear, but much more coordinated thinking, research, and health action is needed if enormous changes such as the nutrition transition are to be steered in positive rather than negative directions.

Table 4.5 summarizes some of the policy goals that need to be reviewed and analyzed more clearly and carefully. The case argued here is that unless such issues are included in the discourse about the nutrition transition, there is a danger the transition will be seen as immutable and inevitable. The context presented here reminds us that the nutrition transition is not an isolated phenomenon. Economic, political and cultural transitions accompany, facilitate and frame the nutrition transition. It is an indicator of a wider restructuring of society and lifestyle, part driven by strong forces, part pulled by aspirations, immensely complex.

Now that so much is known about the nutrition transition, the challenge is to widen debate to include what to do about it. There are strong forces who argue that the transition is unimportant, a policy deviation, a side-show in the onward march of social progress, a matter for consumer choice. They argue that it is beyond governance. One strand of modern thinking on governance agrees with this analysis, arguing that the state and public thinking are too diffuse or weak to act on mega-trends such as the nutrition transition. We know better. The history of public health suggests that there have always been such siren voices. Good people, armed with evidence, informed governments like Thailand’s or Finland’s and together with progressive forces in the food supply chain acted with imagination and persistence to improve public health. The nutrition transition is an awesome challenge. It requires new alliances, new political will and new thinking. And since when were public health challenges easy?

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Demographic Trends

Hania Zlotnik

Over the past four centuries the population of the world has increased tenfold, rising from about 580 million persons in 1600 to slightly over six billion in 2000 (Biraben,1979; United Nations, 2001a). Most of that growth occurred during the 20th century when the population nearly quadrupled (Fig. 5.1). Thus, whereas it took three centuries – from 1600 to 1900 – for the population to increase from 0.6 billion to 1.6 billion, between 1900 and 2000 a further 4.4 billion persons were added to the world population. Such rapid population growth, unprecedented in human history, resulted largely from the major reductions of mortality that occurred during the 20^th century. Between 1900 and 2000, life expectancy at the world level nearly doubled, reaching 65.5 years by the end of the century. Almost universally mortality reductions preceded changes in fertility. In populations where mortality had been traditionally high, women had to bear large numbers of children to ensure that enough of them survived to adulthood. As mortality declined, populations did not immediately adjust their fertility levels to match the reduced risks of death. As a result, populations grew rapidly when high fertility persisted even as mortality declined. The more developed countries of today were the first to experience sustained declines of mortality. Starting in the 18th century, better hygiene and improving standards of living contributed to reduce mortality rates in those countries. Between 1750 and 1850, for instance, life expectancy in a number of European countries increased from 25 years to 35 years (Vallin, 1989) and during the 19th century, as mortality reductions accelerated, a widespread fertility decline began as well. Although even for Europe the data available on fertility trends over the 19th century are partial, it would appear that fertility in the continent declined from about 5–5.5 births per woman in the early part of the 19th century to about four children per woman in the early part of the 20th century (Clark, 1968). The process whereby reductions of mortality are followed by reductions of fertility sufficient to ensure that overall population growth remains low is known as the demo-graphic transition. During the 20th century, most developing countries embarked on the demographic transition. Indeed, with the discovery of antibiotics and other means

The views and opinions expressed in this chapter are those of the author and do not necessarily represent those of the United Nations.

The Nutrition Transition

Copyright © 2002 Elsevier Science Ltd

ISBN: 0-12-153654-8

All rights of reproduction in any form reserved

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Figure 5.1

Long-term population increase, _BC400 to 2000_AD.

to combat the spread of the infectious diseases endemic in developing countries, rapid reductions of mortality were achieved in those countries after 1945–1950. As in the more developed countries earlier, the continuation of high fertility as mortality declined gave rise to very rapid population growth, but fertility reductions in the developing world have been occurring more rapidly than in the more developed countries. The availability of modern contraceptives has facilitated such developments. By the end of the 20th century, most developing countries had initiated the transition to lower fertility. According to United Nations (2001a) estimates, by 1995–2000 only 16 developing countries had not yet shown signs of a fertility reduction and they comprised just 3% of the world’s population. Not only did the 20th century witness a rapid rise of population but, in addition, it saw the distribution of the population between rural and urban areas change dramatically. Indeed, although the existence of populous cities with urban attributes dates back several centuries if not millennia depending on the region under consideration, the vast majority of the world’s population has lived in rural settings during most of human history. Even as late as 1800, only 5% of the world population lived in urban areas and by 1900 that proportion had increased to just over 13% (United Nations, 1980). But over the course of the 20th century the proportion urban more than tripled, reaching 47% by 2000 (Fig. 5.2). The process of widespread urbanization started earlier in the more developed regions than in the developing world. Already by 1900 one out of every four inhabitants of more developed countries was an urban dweller whereas in the developing world the equivalent proportion was one in fifteen. Although levels of urbanization have risen markedly in developing countries, by 2000 less-developed regions are still about half as urbanized as more-developed regions. Thus, whereas 76% of the population of the latter lives in cities, just 40% of the population of less-developed countries is made of urban dwellers. This chapter describes in more detail the evolution of the size and growth of the world population and the dynamics of the process of urbanization in the major regions

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Figure 5.2

Percentage of population in urban areas, 1800–2030.

of the world since 1950. It also discusses future prospects and their implications. The data presented were derived from the 2000 Revision of estimates and projections of national populations prepared by the United Nations Population Division (United Nations, 2001a,b) and from the 1999 Revision of World Urbanization Prospects (United Nations, 2001c). To ensure consistency between the two sets of data, estimates and projections of the urban and rural populations were derived using the national populations produced by the 2000 Revision and the proportions residing in urban areas as estimated and projected by the 1999 Revision of World Urbanization Prospects.

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