On 21^st June 2019, the Healthy Caribbean Coalition hosted their second webinar in their childhood obesity series. This webinar series aims to empower organisations in the Caribbean who are advocating for the introduction of policies to tackle childhood obesity.

This webinar focused on the Caribbean experience of implementing front-of package nutrition labels (FOPL), a key strategy in tackling childhood obesity by ensuring that consumers are provided with a quick and easy of way of assessing the nutritional content of the foods they purchase so they can make healthy choices.

Speakers included:

• Fulgence St Prix, the Technical Officer at the CARICOM Regional Organisation for Standards and Quality (CROSQ), who discussed the revision of the standard for the labelling of pre-packaged foods to include FOPL. He provided an overview of the consultation process, the timeline for the development of the standard, the next steps and recommendations for the standard’s successful implementation.
• Dr Fabio Da Silvia Gomes, Regional Advisor in Nutrition at PAHO, who gave an insightful presentation on the rationale behind the introduction of FOPL, the best strategy for assessing the most effective type of front-of-package label for Caribbean countries, compared different types of labels and summarised the evidence on the effectiveness of FOP.
• Dr E. Arthur Phillips, Senior Medical Officer of Health (NCDS), Ministry of Health and Wellness Barbados, who provided a health perspective
• Luis Galicia, Ministry of Health Uruguay, who summarised their experience of implementing FOPL explaining their strategy, the resources they developed, how they addressed imported products and the challenges they experienced
• Vonetta Nurse, Advocacy Officer at the Heart Foundation of Jamaica, discussed all the great work they’ve been doing to advocate for FOPL in Jamaica
• Lawyer, Nicole Foster,  who discussed the trade and practical considerations of FOPL as this is a major concern of industry who argue that FOPL may have trade implications. This presentation explored the WTO’s Technical Barriers to Trade agreement and how this agreement speaks to the balance between trade and protecting the health of a country’s population so that policies like FOPL are not more trade-restrictive than necessary.
• Maisha Hutton, the Executive Director of the Healthy Caribbean Coalition who summarised the work that the HCC has been doing to support the introduction of FOPL regionally

If you missed this very informative and insightful webinar, you can watch the recording below and for more information, please visit the HCC’s website.

Welcome to part two of our ‘Discussions on Managing Conflict of Interest’ blog. In part one we provided some background to conflict of interest (CoI) and the challenges faced by those aiming to tackle NCDs in the Caribbean. Here, in part two, we’ll be providing highlights from the Health Caribbean Coalition’s (HCC) conflict of interest meeting which we attended a couple of weeks ago.

The HCC’s Meeting

The HCC’s CoI meeting was a two-day regional event held on 26^th and 27^th March 2019 that had a focus on conflict of interest in the prevention and control of non-communicable diseases (NCDs) in the Caribbean, and the overall aim of the meeting was to begin to build regional capacity to identify and manage conflict of interest.

Regional Experiences of Conflict of Interest

The meeting started with an interesting and insightful look at regional experiences of CoI from both civil society and the public sector. From civil society, we heard from the Heart Foundation of Jamaica, the HCC and the Trinidad and Tobago Heart Foundation, and from the public sector, we heard from representatives from the Ministries of Health in Antigua, the Bahamas and Jamaica.  Collectively they touched on industry interference and conflict of interest. Some interesting points that were raised included:

• In the Caribbean, in most instances, we have to live with CoI and so approaching this area from the point of view of managing CoI is a more practical and realistic approach
• The difficulty of dealing with the “smallness” of the Caribbean – everyone knows each other and in our professional lives, in tackling NCDs, we may have to fight against people we know and respect
• Absolutes are unlikely to work except with the tobacco industry where globally the public health community does not partner with tobacco companies. For other industries, like the food and beverage industry, we must explore degrees of conflict of interest (low, medium and high) and degrees of partnership or engagement. Not every engagement will be detrimental to public health and we must understand how to manage conflict of interest whilst getting the most benefit out of any relationship or partnership
• What happens after a conflict of interest has been identified? What is the process for review? Is it an actual, potential or perceived CoI? What is the process for recusal?
• Should an organisation’s CoI policy be generic or specific?
• Some good practice with respect to disclosure forms:
  • All CoI policies should have a supporting disclosure form
  • Disclosure forms are valid for a year
  • The obligation is on the person who is disclosing to report any changes within that year
  • Have a process for checking the accuracy of a completed disclosure form
• Managing conflicts of interest – ensure that if you’re going into a partnership with industry that a lawyer reviews the MoU and any non-disclosure agreements to prevent any CoI issues; don’t be afraid to negotiate so you can minimise any risks or exposures.

WHO/PAHO Tool for Preventing and Managing CoI In Nutrition

A core part of the HCC’s meeting was to explore the tools and support that could be offered to organisations to identify and manage conflict of interest in order to build regional capacity. Therefore, during the meeting, attendees were introduced to WHO’s draft tool for preventing and managing CoI, including an abbreviated ‘scoping’ version of this tool developed by PAHO,  and a draft of the HCC’s CoI guide and policy.

The PAHO scoping tool provides a simple method to evaluate potential engagements and is divided into three areas that enable organisations to reflect on important issues before deciding on whether to enter into an engagement with an external entity.  These areas include:

• Actor alignment
• Engagement profile
• Assessing the risk and benefits

Additionally,  this scoping tool complements the more comprehensive decision-making tree developed as part of the WHO draft tool. This is a 6-step process that takes the user through a structured process for analysing a potential engagement to identify and manage conflict of interest. The steps include:

• Exploring the rationale for engagement
• Profiling, due diligence and risk assessment of the external actor and the potential engagement
• Balancing risks and benefits
• Risk management
• Monitoring, evaluation and accountability
• Transparency and communication

Both resources provide users with an objective and comprehensive method of identifying and assessing conflict of interest, whether an engagement should be pursued and if so, what measures can be introduced to manage any conflicts of interest.

The HCC’s CoI Guide and Policy

Finally, the HCC presented their draft CoI guide and policy which is aimed at their staff, volunteers, board members, advisors, interns and consultants. Their policy and guide aims to prevent, identify, avoid and manage CoI. It also aims to serve as a general guide for civil society organisations and individuals as they develop their own CoI policies, the idea being that CSOs can simply adapt the HCC policy to suit local needs and situations.

Our Thoughts

We thought this was an excellent meeting which gave us a lot of food for thought.

Conflict of interest is an area that we considered on a simple level, but this meeting allowed us to explore this subject in depth and fully appreciate the risks of not properly analysing the relationships that we seek to enter.

The meeting was very timely as over the past few months we’ve started to explore organisations that we can approach to support some of our activities and during this process, we have found it challenging to determine whether we should pursue forming relationships with an organisation that promotes both healthy and unhealthy food and beverages. Attending this meeting has given us some clarity and by using the knowledge we have gained from this meeting and the PAHO tool we believe we can make a better decision.

Conclusion

We encourage Caribbean civil society organisations working in the NCD field to explore developing an approach to tackling conflict of interest to safeguard the credibility and integrity of their work, and for further information, please do reach out to the Healthy Caribbean Coalition

On 26^th and 27^th March 2019, we joined representatives from across the Caribbean in attending the Healthy Caribbean Coalition’s workshop on conflict of interest (CoI). This event had a special focus on conflict of interest in non-communicable disease (NCD) prevention and control in the Caribbean.

This is going to be a two-part blog and in today’s piece we’re going to provide some background to conflict of interest and in part two we’ll provide some highlights from the HCC’s CoI meeting.

What is Conflict of Interest?

The World Health Organisation describes conflict of interest as:

“…circumstances where there is potential for a secondary interest to unduly influence, or where it may be reasonably perceived to unduly influence, either the independence or objectivity of professional judgement or actions regarding a primary interest.”

They also explain that:

“The existence of conflict of interest in all its forms does not as such mean that improper action has occurred, but rather the risk of such improper action occurring. Conflicts of interest are not only financial but can take other forms as well.”

Another definition of CoI comes from Public Health and Food and Beverage Industry Engagement: A Tool to Guide Partnership Opportunities and Challenges. They define CoI as:

“… where one engages in any private, personal or business undertaking or other activity in which one’s private or personal interest conflicts with one’s duties or responsibilities…”

For further clarity around the concept of CoI further explanations have been offered which categorise CoI into perceived, potential and actual and these are defined as follows:

• An actual conflict of interest occurs when there is a direct conflict between a person’s professional duties within an organisation and a competing interest or obligation, whether personal or involving a third-party.
• A potential conflict of interest arises where a person has an interest or obligation, whether personal or involving a third-party, that could conflict with their professional duties and responsibilities in the future.
• A perceived conflict of interest occurs where it could reasonably be perceived, or give the appearance, that a competing interest could improperly influence a person’s professional duties.

Additionally, CoI may be seen at the individual, institutional and structural levels.

By understanding and reflecting on these definitions we can recognise if we, or our organisation, may be conflicted. This will allow us to take steps to address this to ensure we are serving our primary interest – this is the one we committed to serve at the outset of our professional journey (in our case, improving the public’s health).

Conflict of Interest, the Caribbean and NCDs

Small Island Developing States (SIDS) like the Caribbean are presented with a unique set of circumstances which make the area of conflict of interest particularly challenging. The circumstances in question relate to the very small populations creating an unavoidable, overlapping, intertwined social and business environment. This means that individuals and organisations may have multiple competing interests.  Therefore, staff working in organisations aiming to prevent and control NCDs may, at some point, find themselves in a number of difficult situations when it comes to CoI. This may include:

• Having a family member, friend or close associate working in an industry that produces products that are risk factors for NCDs
• Being offered funding, sponsorship or resources from companies that produce unhealthy products in a landscape where there are very limited funding and sponsorship opportunities
• Exploring a partnership with a company that produces both healthy and unhealthy products
• Being invited to take part in health campaigns by companies who produce products that are risk factors for NCDs (with there being no other companies to partner with to reach such a large audience)
• Developing NCD prevention and control policies with individuals and entities who have competing interests

In larger countries there are multiple options when there is a need to partner with individuals and organisations to  implement projects to prevent and control NCDs so many of the above situations can be avoided. Therefore, their approach to conflict of interest centres on prevention.

In Small Island Developing States, many of these conflicting situations cannot be avoided so not-for-profit entities (as well as government departments) have to start to re-think their approach to conflict of interest, focusing on strategies to effectively manage conflict of interest.

The HCC’s Conflict of Interest Meeting

Historically, conflict of interest, in many cases, has been addressed with a global blanket approach that doesn’t delve into the complex, overlapping business and personal relationships as well as the challenging funding environment that exists in the Caribbean. A more bespoke approach is needed for the Caribbean and hence the HCC’s conflict of interest meeting brought organisations together for in-depth discussions on this issue. Time was also set aside to explore solutions through the review and testing of a new conflict of interest tool being developed by WHO/PAHO as well as the review of a conflict of interest policy and guide being developed by the HCC. This meeting was very informative and we were delighted to have attended.

Coming Up Next Time

In part two of this blog we’ll summarise the highlights from the meeting, but in the meantime, for further information on conflict of interest you can explore the documents in our reference list below. We also encourage anyone working in public health in a Small Island Developing State to develop an approach to managing CoI to ensure the  credibility and integrity of their organisation remains intact.

References

1. The Healthy People and Communities Steering Committee’s Multi-Sectoral Partnerships Task Group, 2014. Public Health and Food and Beverage Industry Engagement A Tool to Guide Partnership Opportunities and Challenges, Ontario, Canada: The Healthy People and Communities Steering Committee’s Multi-Sectoral Partnerships Task Group, May 2014.
2. University of Southern Queensland. Conflicts of Interest. [Online]. Available at <https://www.usq.edu.au/hr/empcond/conflicts> [Accessed on 3^rd April 2019]
3. WHO, 2016. Framework of Engagement With Non-State Actors. [Meeting Proceedings] 28^th May 2016. Sixty-Ninth World Health Assembly.
4. WHO, 2015. Addressing and managing conflicts of interest in the planning and delivery of nutrition programmes at country level. Report of a technical consultation convened in Geneva, Switzerland, on 8–9 October 2015.

We’re so delighted to have been invited to take part in a panel discussion at the Healthy Caribbean Coalition and the Heart and Stroke Foundation of Barbados’ event on childhood obesity.

This event will take place at the beautiful Hilton Hotel in Barbados on 20th November in recognition of Universal Children’s Day and the official end of the HCC’s childhood obesity prevention campaign.

One of the key parts of this campaign was the HCC’s childhood obesity prevention petition which called on our Heads of Government to enact any of the following policies and legislation which have been demonstrated as effective measures to combat childhood  obesity:

• Imposition of a tax of not less than 20% on Sugar Sweetened Beverages (SSBs) and use tax revenue for NCD prevention and control.
• Banning the sale, promotion and marketing of SSBs, and unhealthy foods and beverages in and around schools.
• Mandatory physical activity in all primary and secondary schools
• Adoption and application of regional standards for nutritional and front of package labelling of foods and beverages.
• Banning the marketing of unhealthy foods and beverages to children (includes non-school environments)
• Enacting legislation related to The International Code of Marketing of Breast-milk Substitutes.

This event will officially close the petition and campaign by bringing together a wide cross section of national and regional stakeholders to celebrate the achievements of the campaign and to chart the way forward.

The meeting will provide a unique opportunity for organizations across the Caribbean, who took part in the campaign, to discuss the progress made over the course of the campaign and share national and regional successes and lessons learned in childhood obesity prevention advocacy platforms.

This one-day forum will also serve to leverage the energy and momentum of the past seven months and redirect it towards focussed evidence-based advocacy in support of creating healthy school environments across the Caribbean.

Lake Health and Wellbeing, as participant of the campaign and a member of the campaign’s civil society action team has been invited to take part in a panel discussion on the importance of coalitions and CSO collaboration around critical issues such as childhood obesity.

We’re very much looking forward to taking part in this very important event and are honoured to have been invited to participate – a big thank you to the HCC and HSFB for the invitation.

 

We were delighted to e-attend the Healthy Caribbean Coalition’s Civil Society Action Team’s inaugural meeting on 20th April .  The main objective of the action team is to ensure that the Caribbean public becomes aware of the challenges of childhood obesity and supports the call for policy changes and other educational approaches that will create a supportive environment for the reduction of this growing problem which places children at risk of developing diabetes and hypertension as well as  cancer and heart disease in their adult life

During this inaugural meeting of the action team, the HCC shared its communication plan for their childhood obesity prevention petition and discussed ways in which organisations could play a part in their local area. This included liaising with the media and encouraging  members, corporate partners and other social and parenting groups to sign the petition at www.toomuchjunk.org.

This was a really interesting meeting and we were delighted to meet representatives from a number of Caribbean organisations and we look forward to implementing the ideas discussed in the meeting in our local area here in St Kitts.

Wednesday 4th April, 2018

Today, we touch on the Healthy Caribbean Coalition’s new childhood obesity prevention campaign, why this campaign is important, what policies the HCC is encouraging governments in the Caribbean to introduce to tackle childhood obesity and how you can get involved.

The Healthy Caribbean Coalition has launched their Childhood Obesity Prevention Petition as part of their Civil Society Action Plan for 2017-2019.

The aim of the petition is to raise awareness of childhood obesity in the Caribbean and to influence the region’s leaders to champion and implement critical policies that will improve the health of our children, reduce childhood obesity and prevent the associated non-communicable diseases.

The Healthy Caribbean Coalition plans to present their petition at the CARICOM Heads of Governments Conference in Jamaica in July, which presents the perfect opportunity to raise this issue.

With 1 in 3 children in the Caribbean being overweight or obese urgent action is needed and therefore the HCC needs your help. Please add your voice to the HCC’s call for action to be taken on childhood obesity by signing their petition and encouraging your contacts to do so too.

We can all make a difference and improve our children’s health, and this petition is just the first step.

Thank you for your support. For more information on this campaign and to sign the petition, please visit: www.healthycaribbean.org/yourvoicematters

We are delighted to announce that we are now a member of the Healthy Caribbean Coalition, an organisation that we admired from afar when we were based in the UK.

The Healthy Caribbean Coalition is a civil society alliance established to combat non-communicable diseases, their associated risk factors and conditions. In the Caribbean the four main non-communicable diseases are diabetes, cancer, cardiovascular disease and chronic respiratory diseases and their four main common risk factors are smoking tobacco, high alcohol consumption, an unhealthy diet and being physically inactive. These are the issues that the HCC are tackling in the region.  Additionally, the Caribbean has the highest mortality rate in the Americas from NCDs in the Americas causing three out of every four deaths, this is cause for concern and the HCC is working tirelessly to address this through prevention, early detection and influencing government policy.

We’re delighted to have become a member of the Healthy Caribbean Coalition and look forward to working with the HCC and its member organisations to tackle NCDs in the Caribbean.

For more information on the Health Caribbean Coalition you can visit their website here

Friday 17^th November was the second annual Caribbean Alcohol Reduction Day. This year’s theme was: Drink Less, Reduce Cancer and to mark the day the Healthy Caribbean Coalition, in collaboration with PAHO, CARPHA and CARICOM, hosted a webinar on Alcohol and Cancer in the Caribbean.  This was a very informative and interesting webinar which featured three speakers:

• Dr Kevin Shield – Alcohol Consumption and Cancer in the Caribbean
• Dr Maristela Monteiro – Alcohol Policies in the Caribbean
• Dr Rohan Maharaj – Alcohol use among the elderly in the Eastern Caribbean: Associations with NCDs and psycho-social issues

Alcohol Consumption and Cancer in the Caribbean

The first presentation was delivered by Dr Kevin Shield. He started by providing some background into cancer in the Caribbean explaining that the latest data, from 2012, shows that in the Caribbean about 21,000 new cancer cases are diagnosed every year and just over 13,000 deaths per year in the region are due to cancer.  When we look at the number of cancers in the Caribbean caused by alcohol, it is estimated to be 650 cancer cases per year or put another way 3.1% of all cancers diagnosed in the Caribbean are due to alcohol consumption. Looking at the number of cancer deaths in the Caribbean due to alcohol, 2.9% of all cancer deaths are due to alcohol consumption or 387 deaths per year.

Dr Shield  stated that in the Caribbean, on average, an adult consumes 1.2 alcoholic drinks per day, but there is a difference amongst countries with some countries drinking less and other drinking significantly more.

Dr Shield explained the  link between cancer and drinking stating that numerous studies have been conducted that have determined how drinking causes cancer. Data suggests that alcohol causes cancer in the following ways:

• By our bodies converting alcohol into a cancer-causing chemical (i.e. a chemical that can damage our DNA)
• By affecting our hormone levels and various pathways in the body

Through research links have been found between alcohol and cancers of the mouth, upper throat, food pipe, voice box, breast, bowel and liver.  The number one cancer impacted by alcohol is breast cancer.

Based on all of these factors the  International Agency for Research on Cancer  has classified alcohol as a type 1 carcinogen, which means there is the highest level of evidence to suggest that it does cause cancer. So drinking is a major problem.

The question then is: how can we prevent the cancers that are caused by alcohol? The solution is to reduce alcohol consumption and Dr Shield stated that there are three cost effective and feasible approaches that can be taken:

• Restrictions on access
• Banning advertising
• Increasing excise taxes

This presentation ended on a fairly positive note highlighting that many Caribbean countries have not fully introduced these three measures which means that there is potential to make a huge difference in tackling alcohol and cancer in the Caribbean.

Alcohol Policies in the Caribbean

We then heard from Dr Maristela Monteiro who gave an overview of alcohol policies in the Caribbean. She started by explaining that as part of the voluntary global non-communicable diseases target for 2025 there is a goal to reduce harmful use of alcohol by 10%.  WHO and PAHO, in consultation with a number of organisations, developed a global strategy to reduce harmful use of alcohol and they provided recommendations on 10 policy areas and countries are to try to implement as many as possible. They describe particular recommendations as “best buys” especially for low to middle income countries and these were the three areas mentioned by the previous speaker (restrict access to alcohol, enforce bans on advertising and raise taxes on alcohol).

Dr Monterio then went through each of these three policy areas giving an assessment of how successful Caribbean countries have been with their implementation. She started first with whether countries have a national alcohol policy in place.  Out of the 14 Caribbean countries that they looked at only three had some form of national policy.

Dr Monterio then looked at policies to restrict access to alcohol:

• Licensing: most Caribbean countries have a licensing system, 12 out of the 14 countries. Licensing systems restrict access by imposing rules and penalties to those who wish to sell alcohol such as not selling to minors, the license also has a fee and this may limit the number of businesses who choose to sell alcohol.
• Restrictions on hours, locations and days of sale of alcohol: only three Caribbean countries were fully compliant in this area.
• Minimum drinking age: most Caribbean countries have a minimum drinking age, only three don’t.  The majority of countries in the Caribbean with a minimum drinking age have set this at 18, some have set this at 16.  It was felt that 18 was a relatively low age restriction and this could be increased to 21 to have more of an impact.

Dr Monteiro then discussed taxation. She stated that in the Caribbean most countries have some taxation of alcohol, but these taxes were introduced many years ago and have not been adjusted for inflation. This means that taxation is not having the impact that it should as taxes are fairly low and are not acting as a deterrent.

Finally Dr Monteiro discussed restrictions on advertising and explained that this was the least developed area of policy in the Caribbean.  She explained that this is a major problem as 20% of students are exposed to alcohol advertising daily and research has shown that this is associated with an increase in alcohol consumption. She explained how persuasive these advertising campaigns are and some of the tactics used to encourage people to drink –  companies focus on alcohol as an antioxidant, that consuming alcohol causes weight loss and improves your mood (this communicates the message that alcohol is healthy)  and equating drinking alcohol to business success.

Action needs to be taken to address advertising as research as shown that youths are more exposed to advertising than adults so there is a concerted effort by the alcohol industry to reach young people and make them life-long drinkers.

Alcohol Use and the Elderly

Finally we heard from Dr Rohan Maharaj who summarised a very interesting piece of research carried out across four Caribbean countries on alcohol use and the elderly.  The research consisted of participants from Puerto Rico, Barbados, the US Virgin Islands and Trinidad. The data was collected from April 2013 to May 2015 and they determined whether people were ever-drinkers, current drinkers, problem drinkers or heavy drinkers and related this to various psycho-social and health issues.  Their main conclusions were:

• Generally there was wide use of alcohol across all participants
• 5-6% of participants were involved in potentially harmful alcohol use
• Males were more likely to be problem or heavy drinkers
• There was an association between alcohol use and stage 1 hypertension
• There was an association between alcohol use in ever-drinkers and cancer
• A higher proportion of those with lower educational achievement admitted to alcohol use
• Those who were employed were more likely to be drinkers (thought to be because they had more disposable income)
• Those who reported earlier initiation of sexual activity reported heavy drinking
• Those who had issues with domestic violence (current or past) had reports of problem drinking
• Heavy and problem drinkers tended to be lower educated males, living in Trinidad, married, physically active and employed with high rates of hypertension and being diabetic.

Dr Maharaj and his team will be doing a follow up study with participants in the next 2 to 3 years and this will give them the opportunity to further explore the link between alcohol use, cancer and other non-communicable diseases.

Conclusion

This was a very informative webinar  and it’s so important that we get some of this information out to the public as we know that many people are not aware of the link between cancer and alcohol consumption.

For more information you can listen to a recording of the webinar here

The Healthy Caribbean Coalition published an excellent report on non-communicable diseases (NCDs) and trade policy in the Caribbean. This briefing document discusses how trade policies affect the public’s health and what needs to be done to ensure that policies have a positive effect on the health of countries’ citizens.

The report clearly explains, with examples, how specific policies can influence our health. For example, low taxes on items like sugary drinks, alcohol, tobacco and processed foods lowers their cost enticing the public to purchase them. The consumption of these items, over time, increases our risk of developing non-communicable diseases such as  type 2 diabetes, cancer and cardiovascular disease. The report details how policies like this in the Caribbean have had a detrimental effect with families shifting from a traditional plant-based, home-made diet to a processed, meat-based diet.

The report states that the Caribbean shockingly has the highest mortality due to NCDs in the Americas,  the Caribbean has some of the highest rates of obesity and there are significant levels of tobacco use and binge drinking.  There is an urgent need to address these issues and exploring trade policies is just one strategy that can be introduced to improve the public’s health.

The Healthy Caribbean Coalition’s report explores policies around three main areas:

• Unhealthy/healthy food
• Alcohol
• Cigarettes

These recommendations are based on global approaches such as the WHO Framework Convention for Tobacco Control, the WHO strategy to reduce alcohol consumption and the ICN2 Framework for Action. The HCC’s recommendations for the Caribbean are illustrated below.

This report was an excellent, comprehensive, clear and informative report that gives concrete actions that can be taken to tackle NCDs through policy changes.

You can download the report below.