‘Risk Factors’ or ‘Determinants’ – The NCD Debate

By Claudio Schuftan

Since the WHO’s adoption of the “Global Strategy on Diet and Physical Activity” in 2004, recommendations have been made concerning how populations should eat and exercise in order to reduce the risk of obesity, diabetes and other non-communicable diseases (NCDs). Unfortunately there has been a singular lack in emphasis on the harmful marketing practices of the food and beverages industry, which determine what many of us eat. In 2012, the World Health Assembly passed a resolution endorsing the strategy and urged member states to put into practice a Comprehensive Implementation Plan (CIP) on maternal, infant and young child nutrition.

The case of non-communicable diseases is an example of how profitable solutions are applied to problems that have a potential for profit. It is striking that problems that should be addressed through binding regulations and/or legislation are being timidly addressed in a framework that seeks ‘cooperation’ from the industry’s and/or adhesion to ‘voluntary’ codes of conduct.

The 1993, World Health Report of the WHO started the trend of viewing health as a key input to increase productivity. This concept has, since attained a ‘respectable’ status in mainstream discourse. Consequently, a number of documents promoting action on NCDs have gone even further: they call on the private sector to see health and nutrition as market opportunities. Not surprisingly, the ‘hard sell’ of actions to tackle NCDs continues skew the debate on NCDs and ignores their social and economic determinants while focusing almost exclusively on changing risk factors related to individual behaviour.

Obesity is a normal response to an abnormal environment. The more urbanised the environment, the more obesogenic pressure is exerted on its population. Asking people to make better choices whilst the current against them flows faster and faster, is futile as well as condescending. The environmental pressures that make the healthy choice the difficult choice mean that many people are growing up in a world where healthy behaviours are rarely encountered and they are slowly yet surely learning, practicing and reinforcing how to be unhealthy1. In other words, big tobacco, alcohol, sugar, trans-fats and fast-food and beverage transnational corporations are 'vectors of disease' that need monitoring in the same way as other vectors in public health.

The structural causes of disease and of poverty are of no interest to the rich and powerful. On the contrary, the highlighting of these causes represents a threat to the status-quo as they address extreme and growing inequalities which bring this privileged group so many rewards both in geopolitical and economic terms. It is time to question the use of the term ‘risk factors’ in NCDs and indeed the whole concept of risk. The term tends to imply individual agency and responsibility, i.e., as if people had the ability to fully control their lives and their environment. It ignores the critical distinction between risks taken and the risks imposed by the different manipulations of the market place that result in the skewed corporate power relationships we all know about. The terms, ‘contributing factors’ or ‘determinants,’ are more neutral than ‘risk factors’. Using them to identify causal pathways, rather than ‘risk factors’ allows the real causes to be identified and analyzed without prior assumptions (or subtle suggestions) about the individual or structural origin of the causes.

Nothing really effective is being done to stem the global epidemic of obesity and non-communicable diseases because, like Big Tobacco has done, Big Food and Big Beverage control the agenda and, through corrupt lobbying, ensure governments only implement programs based on individual behaviour changes.

A more comprehensive discussion on the NCD's policy debate is inlcuded in the latest edition of the Alternative World Health Report, Global Health Watch 4, under the title Non-communicable diseases: is big business hijacking the debate?

1 http://www.wmc.uk.com/wp-content/uploads/2011/07/UK-Obesity-Epidemic.pdf