Measuring success in global health diplomacy: lessons from marketing food to children in India

India comprises both very rich and very deprived populations, and obesity prevalence varies considerably by geography and socio-economic status. Childhood obesity is increasingly prevalent in children of higher socio-economic status, particularly the urban wealthy [9, 10]; between 2002 and 2007 there was an increase from 16 % to 24 % in urban children in Delhi, largely felt to be due to increased eating at fast food venues and television viewing [9, 10]. However, obesity often takes second place to the importance of under- and mal-nutrition and addressing childhood obesity is seen as somewhat of a ‘luxury’.

This creates potential dissonance between national and global priorities. This is exemplified in the idea that for most of India more calories rather than less is desirable, which is the antithesis of the Set of Recommendations. For instance, the Set of Recommendations refers to nutritional labels, with the idea that those high in calories and fat may be discouraged. However, as one respondent from the private sector indicated, in India ‘Diet Coke’ cans are printed with a warning label that they are not for children because the government does not feel that it would be appropriate for a child to consume a beverage with no calories. In another example, a respondent from a research institute stressed that there is a perception, particularly in Northern India, that it is healthy to be obese because ‘thin children die.’

Thus the Set of Recommendations were felt not to address the specific social and cultural factors relating to India, which is a significant barrier to successful implementation, as well as their engagement with the drafting process. When asked about risk factors for childhood obesity, respondents listed a number of issues they perceived to cause obesity: as more women enter the workforce, there is the perception that women are choosing convenient (less healthy) options for family meals; western-made goods, which are highly processed and less healthy, are seen as superior, and often safer, with one respondent stating that ‘it is in the Indian psyche…will do anything to substitute the natural’; increasing emphasis on academic performance at school was also felt to perhaps limit access by children to sport and physical activity as households become wealthier; the increased popularity of processed food, use of formula in infancy, lack of choice in school canteens, unhealthy packed lunches and consumption of fried street food, which is high in transfatty acids, are also all major changes in Indian lifestyles. (See also [9]).

It was also felt that there was inadequate consideration in the Set of Recommendations of obesity in India as being concentrated in the wealthy. One respondent from a research institute remarked that the scientific community – both inside India and externally – was ‘in a rut’ and ‘trapped in the thinking that India equalled poor and malnutrition.’ Similarly, a respondent from the private sector noted that there was little data on the issue and what existed was unmatched, unpublished and ‘scattered.’

Indeed, negotiations in global health diplomacy are highly reliant on clinical or epidemiological evidence and the quality or type of evidence can either constrict or expand policy options. The experience of low-and-middle income countries was missing from much of the process of the Set of Recommendations. For example, the WHO ad hoc expert group considered two systematic reviews on The Extent, nature, and effects of food promotion to children [11, 12]; the more recent document was an update of the first. In these, one hundred fifteen studies met the inclusion criteria. Of these, only ten studies included a component on countries outside of Europe, the US, Canada or Antipodes, four of which examined India.

The authors of the studies were well aware of this limitation and tried to mitigate it. For example, in the first review, researchers conducted supplemental desk research using business and marketing press, journals and commentaries from non-governmental organisations to map the marketing environment in low-and-middle income countries In the latter review, there is an entire section devoted to ‘food promotion and marketing in developing and middle income countries’ which pulls out more detailed data from the 10 applicable studies. Additionally, there was geographic diversity in the ad hoc expert group.

This lack of input from low and middle-income countries was also found in the countries and organisations represented in the stakeholder dialogue, few of whom had experience in low or middle-income countries. There is a sense that global representation is a goal at the WHO, but there are few health issues that are evenly distributed across the globe. Cairns et al. found that food companies in middle-income countries used similar marketing techniques as in high-income countries, but had very little data on low-income settings. This meant that in the final version of the Set of Recommendations there was greater focus on television and Internet advertising and less on advertising methods in low incomes countries, such as billboard, print and point-of-sale.

There was concern that using a ‘Western’ view of the problem was inadequate for interventions, which related to wider critiques about the drafting process focussing on the experience of high-income countries. For instance, because of the disparity in wealth, firms target different classes in different ways, and several respondents gave the example of firms selling “5 rupee” products – products that are packaged in smaller portions and sold at more affordable prices, which parallels the experience in tobacco sales. Thus any policies concerning food and food sales would need to consider the many ways in which food is sold. Further, India reflects starkly the reality that any country is several markets rather than one, with a wide variety of types of marketing – including those that may reach children. Thus, limiting marketing via television, radio and mobile phones may address the types of sponsorship found in wealthy areas, but not those more common in poorer areas, including billboards or sponsorship of schools or sporting events.

Overall, respondents felt that the disparity in importance of the health burden to most of the population, and in the legislative capacity, and indeed priority, to tackle what is seen as a minor issue, made the Set of Recommendations feel of less, if any, relevance to government. Non-communicable disease in general has only recently reached the political agenda, and the Ministry of Health is just now rolling-out its first non-communicable disease programme (based on the WHO’s Global Strategy for Diet, Physical Activity and Health). Although at the time of the study, respondent reported that the Ministry planned to hire a number of people at headquarters and throughout the country who would be associated with this programme, until then non-communicable disease is dealt with on a national level with by a team of 4–5 people in a country with over one billion inhabitant. According to a Ministry representative, there is a wide disjuncture between the global context within which the Recommendations were formulated, and the specific national context; an expression of a more general limitation of global health diplomacy that no one policy will be fully applicable to all country contexts