The views expressed are those of the author and do not necessarily reflect the position of FORESIGHT Global Health.
People don’t usually imagine lawyers on the front line of public health, but laws can be a powerful tool to prevent NCDs and facilitate support for those affected by them. They can set societal norms; hold accountable the industries driving NCD risk factors like tobacco use, alcohol consumption and unhealthy diets; protect people’s rights; and ensure effective oversight of health systems.
Don’t take a lawyer’s word for it, though. The importance of law in achieving better health outcomes is clear in major international frameworks for health and sustainable development like the 2030 Agenda for Sustainable Development and the 2018 United Nations Political Declaration on NCDs. While those of us in the NCD community are familiar with SDG target 3.4 – to reduce premature mortality from NCDs by one-third – the SDGs are also underpinned by Goal 16 on peace, justice and strong institutions, which acts as an enabler for all goals. The SDGs also include universal health coverage as Target 3.8, which is the practical expression of the right to health.
Effective use of law is a crucial element in achieving 2030 targets aimed at reducing premature mortality from NCDs by one-third. As part of the global NCD agenda, the World Health Organization’s (WHO) 2018 Montevideo Roadmap recognises the need for law and legal expertise in the NCD response, and WHO’s cost-effective NCD policy responses – known as “Best Buys” – are full of legal interventions. Further strengthening implementation of the first treaty negotiated under the auspices of the WHO, the WHO Framework Convention on Tobacco Control (WHO FCTC), is target 3.a of the SDGs.
Yet, even before the pandemic’s effects were fully felt, in 2020 only 31 countries were on track to meet target 3.4 of reducing premature mortality from NCDs by one-third. We need to make better use of law.
LAW AS A PUBLIC HEALTH PRIORITY
The WHO “Best Buys”—such as increasing excise taxes on tobacco and alcohol, implementing plain packaging for tobacco products, banning tobacco and alcohol advertising, and taxing sugar-sweetened beverages —are all enabled by laws, and are all making an impact around the world. Countries can select from the list of Best Buys and other recommended interventions, based on their national context, for options which best suit them.
In Australia, for example, the world’s first tobacco plain packaging laws, which require that cigarettes be sold in drab packages without corporate logos, is estimated to have led to 100,000 fewer smokers within its first three years. And research suggests that people in the United Kingdom consumed less sugar from soft drinks after the country introduced a tax on sugary beverages.
Law and regulation should not be considered as separate to the development of a country’s NCD policies, but as fundamental parts of it. Law, as a public policy tool, can translate evidence and normative guidance into action.
SHIFTING SIDES IN THE PACIFIC
If the full scope of the NCD epidemic was overlooked globally before 2011, it has been impossible to ignore in Pacific Island countries.
This unique, diverse and scattered region of islands covering 15% of the Earth’s surface has been called the NCD capital of the world. Pacific leaders declared an NCD crisis in 2011, with about 75% of mortalities in the region caused by NCDs, fuelled largely by unhealthy diets that rely increasingly on imported, processed foods. NCD-related co-morbidities have been a major contributor to severe outcomes in the waves of COVID-19 in Pacific countries, such as Fiji. Trade and movement restrictions triggered by the pandemic have further impacted availability and accessibility of healthier foods, and increased reliance on unhealthy foods.
The Pacific region is also feeling the disproportionate impact of another great global challenge: climate change. Five of the top 15 nations considered most vulnerable to climate change impact are in the Pacific. Climate change impacts health in diverse ways, from deaths and illnesses linked to increasingly frequent extreme weather events contributing to food insecurity, to undermining the social determinants for good health, such as livelihoods, equality and access to health care and support.
Yet Pacific countries are drawing on their rich history of commitment to health and sustainable development and acting as leaders in the international negotiations on climate change and its intrinsic link to health. With well-established regional support mechanisms and collaborative bodies, Pacific countries are highlighting the systems changes required to address both NCDs and climate change, such as reform to trade, energy, transport, built environment and agriculture, and exploring coordinated approaches to address these.
Indeed, some of the most important work using law to tackle NCDs is happening in the Pacific. When the region published its own NCDs roadmap in 2014, two of the four strategic priorities – strengthening tobacco control and reducing the consumption of unhealthy food and drinks linked to obesity, heart disease and diabetes – required countries to advance laws that are context-driven.
The Pacific Monitoring Alliance for NCD Action (MANA) dashboard tracks progress against the roadmap. It shows that more than three-quarters of Pacific Island countries and territories, such as Fiji and Nauru, have laws taxing sugar-sweetened beverages, and several others are advancing tobacco control laws. Samoa’s 2019 tobacco control amendment bans the sale of tobacco products by people aged under 15 years and also bans promotional discounts on tobacco products. Niue was recognised by WHO for its 2018 law that raises the minimum age to buy cigarettes to 21 and bans the manufacturing of tobacco for commercial purposes – some of the strongest tobacco control policies in the world.
Regional initiatives such as the MANA dashboard provide a useful accountability mechanism to track progress and gaps on the implementation of NCD policy and law at both the national and Pacific level, which could be emulated in other regions.
BUILDING CAPACITY FOR SUSTAINABLE CHANGE
Though it’s important that we celebrate good news in the Pacific and around the world, there is still a long way to go to meet NCD targets by the end of this decade. And the path ahead is obscured by the ongoing pandemic.
The COVID-19 pandemic is diverting funding and public health resourcing away from NCD initiatives, while the high prevalence of obesity, diabetes, and other chronic diseases has been a major contributor to high COVID-19 death tolls, particularly in the United States, Europe and Latin America.
At the same time, the industries behind NCD risk factors, such as tobacco, alcohol and unhealthy foods, have seized on the pandemic to market themselves as ‘socially responsible’ and to partner with governments, international agencies and NGOs, hoping to influence policy in their favour.
Countries are able to accelerate progress on NCDs by advancing laws in line with the WHO Best Buys and the WHO FCTC. Laws must also be protected from industry influence and conflicts of interest by leveraging article 5.3 of the WHO FCTC, which requires Parties to act to protect public health policies from the commercial and vested interests of the tobacco industry, and by other conflict of interest measures.
Over the next two years, WHO is presenting updates to a range of NCD plans and policies which will rely on effective use of law. This includes an updated ‘implementation roadmap’ to encourage countries to meet updated NCD targets by 2030, which was recently presented at the WHA Executive Board. A strategic direction within this roadmap is to prioritise and scale up the implementation of the most impactful and feasible interventions in the national context. The WHO Best Buys will be further updated in 2023.
While law is an important part of global efforts to address noncommunicable diseases, no one sector can have an impact on its own. That’s why it is so important to work with government representatives from different sectors, civil society groups, health professionals, and people affected by noncommunicable disease to identify areas where law can make a difference and implement these.
As lawyers, we’ll never perform a life-saving surgery or develop a breakthrough treatment. Yet by working together, we can be champions for evidence-based laws which protect and ensure public health and safety.
HOW CAN WE SUPPORT BETTER LAWS?
Good public health laws don’t draft, pass and implement themselves. A whole lot of hard work, technical knowledge and political commitment goes into making laws that are effective and enforceable. And it’s unfair to expect health officials to also be experts in the law, or to ask all government lawyers to be well-versed in public health.
That’s where we in the global health community need to step up. We need to continue supporting countries to strengthen their capacity to develop, pass and enforce public health laws. We need to provide training and technical support, reaching across sectors and across borders to foster networks where people working on NCD laws can share knowledge and build on successes.
For example, following Australia’s lead, we’ve seen 19 more countries implement tobacco plain packaging laws, with others to follow. The vibrant tobacco control sector has facilitated knowledge-sharing to enable this progress, from workshops and technical support offered by the WHO FCTC Secretariat and its Knowledge Hubs, international conferences and academic research, as well as involvement and coordination from civil society actors. These activities have given crucial opportunities to exchange ideas with the leaders, lawyers and policy-makers who are working for change, to review and adapt strategies for local conditions and to have quiet conversations to prepare for the inevitable challenges from industry.
Because the only way to take meaningful action against an epidemic that kills 41 million people every year is by working together.
TEXT – Hayley Jones is the Director of the McCabe Centre for Law & Cancer, based in Melbourne, Australia. The McCabe Centre is a joint initiative of Cancer Council Victoria, the Union for International Cancer Control and Cancer Council Australia.