It’s Time for a Conversation about Conflict of Interest and Public Health in the Caribbean – Maisha Hutton, Executive Director Healthy Caribbean Coalition, 3 December 2021
The Healthy Caribbean Coalition (HCC) is a regional alliance of civil society organisations mobilized around the prevention and control of non-communicable diseases (NCDs), advocating for, contributing to, and supporting the development and implementation of evidence-based policies and regulations that enable people to live healthy lives.
We note with concern, weak or absent mechanisms to address conflicts of interest which have the real or perceived potential to undermine sound public health decision-making and regulations. Recent regional examples involving health ministries and the alcohol sector highlight that the time is overdue for a regional conversation on protecting public health policy from vested interests.
Public health institutions, including ministries of health or their equivalents, and public health officials, including ministers of health, chief medical officers, directors of health services, doctors, nurses, and other health professionals, must all have a commitment – whether formal or informal – to place the health of people above all else in discharging their duties.
Non-communicable diseases such as diabetes, cancer, heart disease and respiratory diseases are the leading causes of death and disability in the Caribbean. They are responsible for 76% of premature deaths in the region, which has the highest NCD mortality in all of the Americas. One in three children are overweight or obese and, in some countries, almost 1 in every 2 adults are obese. Putting aside the tremendous health and social impacts of such untenable levels of disease, the economic costs are significant and unsustainable. Barbados spends 32 million US dollars annually on diabetes and cardiovascular disease and incurs indirect costs of 81 million US dollars annually due to lost productivity.
NCDs themselves are caused by five key modifiable risk factors – tobacco use, harmful use of alcohol, physical inactivity, air pollution and unhealthy diets. Therefore, the tobacco, alcohol, ultra-processed foods (high in sugars, unhealthy fats and sodium), and fossil fuel industries produce a category of products often referred to as unhealthy commodities, which have a significant negative impact on the health of Caribbean people.
Given the acknowledged link between these products and NCDs, the tobacco, alcohol, ultra-processed foods industries are often considered incompatible or ‘at odds’ with public health objectives, and, by extension so too are partnerships between these industries and public health. Collaboration between entities charged with protecting health and entities connected to products which harm health raises serious questions around conflicts of interest. For example:
- Should a senior executive of a tobacco company sit on a national NCD commission? How will this impact decision making around tobacco legislation?
- What about a senior health official sitting on the board of a company that manufactures soft drinks? How might this affect deliberations around raising sugar taxes, a recommended policy option for prevention of overweight and obesity?
- Should a manufacturer of ultra-processed foods sit on a committee that determines whether or not to introduce nutrition warning labels on ultra-processed foods and beverages? Will that person’s inputs be influenced by their vested interests?
- What about a country working towards reduced carbon emissions? Can a local fossil fuel company which stands to lose millions from emission regulations contribute to defining emission thresholds?
For some, the answers to these questions will be an unequivocal “no”. However, others may argue that the answer is not always so evident – there are grey areas, not only black and white. This is further complicated in the region’s small developing states, where many of these private sector actors manufacture, distribute, or market a wide portfolio of products, including both healthy and unhealthy items and are often represented on government and regulatory boards.
Another complicating factor is the role that these actors often play in filling key funding gaps, especially in times of need. This has been particularly evident over the course of the COVID-19 pandemic, where the private sector has stepped up and played substantial roles, providing significant funding for health care services, supplying personal protective equipment and sanitizers, and donating food. These donations are often heavily branded and made in the public arena, so while they meet critical needs, they also present opportunities to build brand visibility and loyalty. This becomes potentially questionable and problematic when considering donations of ultra-processed foods to children and older persons, or alcohol-branded sanitizers to secondary school students.
These examples raise fundamental questions around public health partnerships with the tobacco, alcohol and ultra-processed food industries. Two recent interactions between ministries of health in the region and the alcohol industry highlight the complexities around how public health institutions view and manage conflict of interest in their relationships with unhealthy commodity industries.
Conflict of interest is common, almost normal in any relationship and here we point out the problem at the individual level. In evaluating the conflicting interests, individuals must decide which interest must take precedence over the other. Both public health and the alcohol have interests, but by definition they are in conflict and incompatible. Thus, the public health professional cannot retain a position as guardian of the public’s health and simultaneously serve the interests of the alcohol industry.
An October 31, 2021 Op-ed in the Jamaica Gleaner entitled ‘A dangerous cocktail of alcohol and public health’ written by the Dr. the Hon. Christopher Tufton, Minister of Health and Wellness of Jamaica. presented his justification for an internal memo to his Ministry restricting acceptance of donations from the alcohol and tobacco sector. The Minister wrote:
‘Alcohol abuse is one of the leading causes of non-communicable diseases, sickness, and death. Its promotion directly or indirectly represents a clear conflict of interest and undermines the role that public health must play in driving policies for healthier-lifestyle practices, including acceptable levels of alcohol consumption.’
Minister Tufton went further:
‘Parading on hospital compounds with giant figurative cheques to show gifts in cash or kind from alcohol companies may serve the interests of the alcohol brand, and even the needs of a particular hospital deficit at a point in time, but it undermines the legitimacy of public health to champion the need for a reduction in alcohol abuse, which is a major issue in our country. With due respect to those who defend the grand public gifting, the greater principle of controlling alcohol abuse is not served, but undermined, in this instance.’
The Op-ed closed with a reminder of the need for principled positions from our public health institutions and indeed more broadly from our governments: ‘Given the alcohol-attributable death rate, alcohol-related illnesses, alcohol-caused motor vehicle accidents, and other social ills associated with the misuse of alcohol, public health must lead the charge in representing good health and lifestyle practices. It cannot optimise this responsibility if we are providing a platform for alcohol brands. Public health has to stand without ambiguity on this issue.’
For regional and global public health advocates, Minister Tufton’s stance was a bold and courageous step towards protecting public health policymaking from the potentially negative impact of commercial interests which seek to increase profits—which is always the primary goal—rather than to safeguard health.
Trinidad and Tobago
On November 21, 2021, the Trinidad Daily Express reported that Principal Medical Officer (PMO) Dr Maryam Abdool-Richards was appointed to the board of rum and bitters manufacturer Angostura Holdings Ltd (AHL) effective November 16, 2021. The article went further to state that Dr Abdool-Richards felt that ‘there was no conflict with her being appointed to the AHL board and managing the parallel health care system on behalf of the Ministry of Health’.
According to a November 22, 2021 Trinidad and Tobago Newsday Article , the appointment was supported by Minister of Health, the Honourable Terrence Deyalsingh, who indicated that there was ‘nothing debarring principal medical officer (PMO) Dr Maryam Abdool Richards from sitting on the board of Angostura.’ Despite this, the move was met with criticism on social media and a strong statement from the Trinidad and Tobago NCD Alliance (TTNCDA) urging the PMO to reconsider her decision, noting ‘great concern’ as ‘The use of alcohol is one of the risk factors for NCDs, the priority being addressed by the Ministry of Health for improving the health of our population.’ The statement noted that ‘Dr Abdool-Richards’ directorship of a global beverages company which promotes the sale and consumption of alcohol with its adverse effects on physical and mental health cannot be reconciled with her role as PMO’.
Dr Karen Sealey, President of the TTNCDA, highlighted potential issues around the perceived or actual ‘championing [of] the consumption and sale of alcohol while concurrently advocating for greater personal responsibilities and public health measures to combat COVID-19 and its NCD comorbidities’. As we recognize HCC’s annual Caribbean Alcohol Reduction Day (CARD) on December 3, 2021, HCC’s Alcohol Policy Advisor, Professor Rohan Maharaj, expressed his full support for the TTNCDA statement and cautioned against the dangerous precedent this appointment could set.
This tale of two ministries serves to bring to the fore much needed reflection and dialogue around conflicts of interest in public health in the Caribbean and the need to implement conflict of interest policies as key elements of good governance. At a recent regional webinar promoting the introduction of front-of-package warning labels, Sir George Alleyne, Director Emeritus of PAHO and HCC Patron, stated in relation to regional policy on front of package nutrition warning labelling (FOPWL) that ‘the decision-making architecture of public health in the region is broken’. This observation is in part due to the non-transparent and porous nature of public health processes, which are not sufficiently firewalled from powerful vested interests. At the moment there is a multitude of examples of partnerships and relationships across the region in ministries of health and more widely in other government sectors, which raise ethical questions as to who is driving decision making and how much impact this is having in diluting and delaying critical evidence-based public health policies.
Evidence-based policies, proven at global, regional, and national levels, are essential if our health services are to address adequately both the treatment of disease and the more cost-effective prevention of disease. These policies lead to health-supporting environments which do not encourage tobacco and alcohol use, and overconsumption of unhealthy, heavily processed foods. It is clear that those who profit from tobacco, alcohol, ultra-processed foods, and fossil fuels should not be making or influencing policies which have the potential to impact negatively on health.
This is not simply an issue of ethics it is also one of human rights. Governments, including all government sectors, not only ministries of health, have a duty and an obligation to ensure that citizens achieve the highest attainable standard of health and to do everything in their power to protect, fulfill, and respect this right. The former United Nations Special Rapporteur on the Right to Health maintained that in fulfilling this role, ‘States should decisively counter undue influence of corporations on government decision-making by strengthening legal frameworks and safeguard the policies that protect the right to health’.
This challenge is not unique to the Caribbean. Countries are grappling with these types of decisions across the globe, and while excellent guidance exists for dealing with the tobacco industry through the World Health Organization (WHO) Framework Convention on Tobacco Control (FCTC), guidance for partnerships with ‘Big Alcohol’ and ‘Big Food’ are weak. The WHO recently launched a welcome workstream on the Commercial Determinants of Health private sector activities that affect people’s health positively or negatively) in order to strengthen the evidence base; develop tools and capacity to address the commercial determinants; convene partnerships and dialogue; and raise awareness and advocacy.
The HCC is committed to promoting whole-of-society and whole-of-government approaches to NCD prevention and control. However, these multisectoral, health-in-all-policies approaches must ensure that actors in health-harming industries are not seated at the policymaking table and that they are prohibited from influencing those who are developing and implementing public health policies. This is not an easy task, but our leaders must begin to take conflict of interest in public health seriously and put in place policies and mechanisms to identify and manage it, if the Caribbean is to make progress in reducing the burden of NCDs.