The path to putting people before commercial interests
Europe’s uniquely high levels of alcohol harm result in large part because regulation fails to safeguard citizens from the harms of a commercial activity. And this is true not only for alcohol.
“Health does not begin in clinics or hospitals any more than justice begins in law courts or peace starts on the battlefield,” Tedros Adhanom Ghebreyesus, Director General of the WHO wrote in the Lancet in March. “Rather, health starts with the conditions in which we are born and raised, and in schools, streets, workplaces, homes, markets, water sources, kitchens, and in the very air we breathe.”
“We must acknowledge that commercial companies play an important role in public health,” said Nicolás Gonzalez Casares MEP opening the event which he was hosting, alongside co-hosts MEP’s Erik Poulsen and Michele Rivasi. “We must address this problem head on.” Mr Poulsen highlighted the importance of the work of the SANT Subcommittee on Public Health, on which he sits. He reminded delegates of a forthcoming SANT report on tackling NCDs, currently in draft phase.
The 150 attendees to a Eurocare event, supported by the Lancet, were asked to do just that, being asked whether the EU is facilitating an industrial epidemic in its failure to regulate commercial interests? To help answer the question delegates were first introduced to the idea of commercial determinants of health (CDoH). The lack of adequate alcohol labelling regulation in the EU provides a stark example, which Eurocare addressed with the launch of its new position paper on the matter.
Health is not healthcare
“Health is often conceived of doctors, nurses, hospitals, but they are what happen when health goes wrong,” said Dr Nason Maani of Edinburgh University’s Global Health Policy Unit, setting out the broader origins of health and drivers of ill-health. Tobacco is not exceptional, as many think, he said. A similar business model is followed by other health harming industries, like unhealthy food, fossil fuels, gambling and the gun industry.
“For NCDs we should be able to move forward, we need to get beyond tobacco exceptionalism,” said Professor Anna Gilmore, Professor of Public Health and Director of the Tobacco Control Research Group at the University of Bath, drawing on a piece published in the Lancet. One of the key lessons from looking at commercial determinants of health more broadly as a system problem, she said, is that voluntary arrangements with industry do not work. The commercial goals of companies in these areas conflict with improving health.
Combatting commercial interest
The EU is one of the biggest lobbying centres in the world, coming second perhaps only to Washington DC, delegate heard from Koen Roovers of the Office of the European Ombudsman, which investigates complaints about maladministration and looks into broader systemic issues. “The Ombudsman is where the rubber meets the road in terms of the commercial determinants of health,” according to Roovers.
Commercial interests constantly interfere in the EU policy making process where proposals for legislation are first drawn up by the European Commission before being agreed by the Council of the EU and the European Parliament. “It should not come as a surprise that special interest representatives seek to influence the Commission’s proposal before it is tabled,” Roovers said.
The Ombudsman faces an uphill battle in combatting this interference. “We are a small institution with a large remit,” he said. It currently has 75 staff with a “few more” expected to join the team in the coming years. The European Commission alone, meanwhile, has 32,000 people working for it. “We’re fairly busy,” said Roovers. “Civil society organisations and NGOs are among our most frequent complainants.”
But it does not stop at EU level, commercial pressures are seen at the national level too. “About 20 minutes after launching an alcohol plan we got feedback from the alcohol industry,” said Tina Van Havere, an advisor to the cabinet of Belgian Minister of Health Frank Vandenbroucke. “We need to protect policymaking from the interference of industry. It is very obvious.” The industry has a different perspective on the topic, “We will have to agree to disagree.”
Globally commercial interference presents a barrier to the WHO’s target of reducing alcohol consumption in the European region by 10% by 2025. “There are so many ways that the process can be influenced,” said Dr Carina Ferreira-Borges, Programme Manager for Alcohol, Illicit Drugs and Prison Health for the WHO Regional Office for Europe. “Ministers have lost their position because of opposition from the alcohol industry.”
Learning from tobacco
The battle to have effective graphic warning labels on tobacco shows just how successful industry delaying tactics can be, with the first tentative warning labels appearing in America back in 1966. Rob Cunningham, Senior Policy Analyst at the Canadian Cancer Society, outlined the twists and turns since then. But the long struggle was worth it, because, “The packet is the perfect means to do public education.” Plain packaging is now increasingly becoming the norm, while Canada will provide warnings on each cigarette next year.
“Warnings are a good and cheap way to inform citizens on the harm of consumption of alcohol products,” said Professor Karine Galopel Morvan from the University of Stirling. But what makes warnings effective? Size is important. And positioning too, with warnings being more effective when at the top of a label. Including pictorial elements helps too, whether they are pictograms or photographs. Meanwhile the messages must be very specific and clear, with around a dozen messages rotating to keep them “fresh”. The warning is also most effective when combined with a positive cessation message.
The alcohol industry’s half-hearted voluntary efforts at alcohol labelling are predictably poor, given they conflict with the pursuit of sales. They use QR codes which require anyone interested to scan them with their mobile phone. This means barely anyone ever sees the content. “Why is it that a can of coke has to have info on label but not a ready-mix whisky and coke?” asked Camille Perrin of the European Consumer Organisation BEUC, introducing a video showing how the seldom-used QR codes are woefully unreliable.
A commercial victory?
Has the commercial lobby won on alcohol labelling, the panel in the closing session was asked? No, not in the case of Ireland said Sheila Gilheany is CEO of Alcohol Action Ireland and a Eurocare board member. Ireland is moving forwards with labelling on its own, with its law now making its way through the World Trade Organisation. Commercial interests are busy there too. “The objections from member states are not really from member states but from the alcohol industry,” she said. Alcohol labels would be a crucial step in informing the consumers, Sıla Gürbüz, outlining the position of the European Medical Students' Association.
“Labelling is just a matter of fairness,” said Nikhil Gorkani, chair of the Eurocare’s international labelling expert group. But at the EU level, however, the long-delayed matter alcohol labelling appears to have stalled once again. It was put on the EU’s legislative agenda in the Commissions’ Europe’s Beating Cancer Plan in February 2021, but the Commission is already eight months late in delivering a proposal. This means it has now missed the chance to be considered within the current election cycle. Gorkani said, nevertheless, he was still “hopeful” the EU would ultimately follow Ireland’s example on labelling.
Ensuring alcohol labelling happens may mean scrutinising the policy making process as well as the facts. A complaint to the European Ombudsman was not out of the question, said Eurocare’s Secretary General Florence Berteletti. “We call on MEPs to declare who they meet,” she said. “This will allow us and voters to see who they are influenced by. If MEPs meet 20 or 50 industry representatives and then us once, then that is not enough.”
Commercial interests deploy significant financial resources to influence policy making, often successfully. Health advocates, meanwhile, operate on scant resources. But health advocates and those overseeing the lobbying process can, in time, ensure policy makers see the facts that should shape policy. Tobacco has already shown that doing this better serves the interests of Europe’s citizens. Tobacco is no exception; it is an example policy makers should study closely and apply elsewhere.