25 years GCSP: Health and Inclusion – Episode 1

Ms Ashley Müller: Welcome to episode 1 of this mini-series on Health and Inclusion. I’m your host Ashley Müller with the Geneva Centre for Security Policy and in this episode, Fleur and Johanna look at health and inclusion.

Fleur Heyworth: So today, I'm delighted to be joined by Johanna Ralston, who is the CEO of the World Obesity Federation, and also a GCSP Associate Fellow, Global Fellowship Initiative, she has delivered a health security course and has a very strong curriculum vitae, which is available on our website, including having led the NCD Alliance. So Joanna, a very warm welcome. You specialise in NCDs, non-communicable diseases from heart disease through to obesity. Casting our minds back to a year ago, before we were dealing with COVID every day, what were the health challenges you were most concerned about?

Johanna Ralston: Thank you, Fleur. And it's a pleasure to be here. So a year ago, today, I was most concerned about the fact that the epidemic of non-communicable diseases or NCD’s, which includes cancer, diabetes, heart disease, and obesity, among others, were not getting the adequate attention and resource that they required, they were still, we were still struggling to get attention for them as challenges of particularly low and middle-income countries, where they have in fact, surpassed infectious disease and other health challenges   as the main drivers of death and disability in the majority of countries. What and particularly the burgeoning obesity challenge which now there are more than 1 billion people worldwide living with obesity. And yet it's poorly missed, you know, understood as a matter of personal weakness and failure when it's far from that. Those were the real issues that were concerning me. I've been working in the NCD space for over two decades and was previously running World Heart Federation and I helped get NCD Alliance off the ground. And, and also ran the global program for a large cancer organisation in the US.

Fleur Heyworth: So I hear you saying that often being symptoms of wealth, these are actually symptoms of poverty, is that fair to say?

Johanna Ralston: Very much so. And I think that that's the pattern that we've seen in higher-income countries as well. Now we see that for example, obesity is very much associated in the US and in the UK, with lower socioeconomic status. And as we know, of course, that's had an impact in our current situation. The same is true also for, for heart disease for diabetes, India is now known as the diabetes capital of the world. And while it tends to start as an association with wealth, because as people are able to eat, you know, sort of more westernised diets, that's initially associated with wealth, but now with the cheapening of the food system, the commodification of food, it becomes more increasingly associated with poverty.

Fleur Heyworth: Gosh, and so have these concerns changed in the midst of this pandemic? I noticed it in a recent Lancet article COVID-19 was described as a syndemic rather than a pandemic. Could you explain what this means?

Johanna Ralston: It’s a fantastic word. It's nice, in a way introduce a word that gives people pause. It's syndemic is really a co-occurrence of pandemics. So it's, it's multiple, you know, sort of major health challenges across geographies that are co-occurring in time and space. And in fact, in this case, as we see worsening one another, the same is true for the the syndemic of obesity under nutrition and climate change, that each of those influences the other and in fact, worsen the other The same is true here where we see the syndemic  of COVID-19 associated with NCD. So, finally, and in a very terrible, heartbreaking and unnecessarily painful way we've seen NCDs start to to be elevated on the global agenda, because of their correlation with COVID-19 And in fact, the sort of syndemic of COVID-19 and NCDs that we're experiencing now, that means that really NCDs, like obesity, like heart disease, like even cancer, diabetes have a significant impact on outcomes of COVID-19. There's far, far greater complications of it, far greater mortality from it among people with pre existing NCDs. It's complete, you know, that the evidence accumulates every day. We don't know why that is. There's lots of good theories why, but we do not know exactly why. But it speaks to the fact that ncds were an overwhelming burden that now has escalated and expanded the COVID-19 pandemic.

Fleur Heyworth: Are you able to give us any recent statistics on the percentage of people affected or the outcomes that you mentioned?

Johanna Ralston: You know, the first data from France, I think, said something like 99, notepro, sorry, from Italy, apologies, said something like 95 to 99% of people who were, who were, you know, sort of affected by COVID-19. There were underlying NCDs, in the case of obesity, early data showed that, I think, two thirds of all people in an ICU in the UK had severe obesity, so the numbers continue to accumulate around that in different geographies. But, it's overwhelmingly, the majority of COVID of cases of COVID. And with particularly with COVID complications, I want to add, so meaning, the worst outcomes are highly correlated with NCDs and underlying conditions.

Fleur Heyworth: So I'm really interested in this from a genuine inclusion perspective. And when the COVID outbreak really started to take hold back in March, in April, we hosted a series of webinars, the International Gender Champions, and the first one we looked at was respond don't react. And we're seeing that the responses of governments are becoming more differentiated according to different regions and different zones, different cities. But do we need to get even more responsive in the way that we're directing resources in this pandemic?

Johanna Ralston: I think we do. And frankly, I think we need to look at it from a few different angles, which is so so very much in the US where I'm currently based. There you know, we saw quite quickly that COVID was affecting people of lower socioeconomic status. And so there was no biological difference. There was this lower socioeconomic status that was sort of playing into this and that includes things like, you know, few, you know, health systems, the availability of good and quick and effective health care, plays a factor in this and more people were dying of, you know, who were in categories of lower socioeconomic status. So we need a differentiated response, in that respect, we need a differentiated response, of course, when there are underlying conditions, like obesity or like diabetes. But I want to actually take that one step further and think about some of the ideas around sort of how we appropriately value, women's roles and how that plays into this, to sort of put the gender lens on this and think about, you know, do reproduction and care work, and even environmental work that sustains us? Do those have appropriate value? Well, we know that they don't, and we know that, that issues like NCDs also have are about in some strange way a misalignment of values, because one of the biggest risk factors for all of the common NCDs, particularly diabetes, particularly obesity, is unhealthy diet and high diet and high intake of ultra-processed foods.

Fleur Heyworth: Johanna, you said that we production care work the environment and appropriately valued. I just want to go deeper here. We know that women are routinely trapped in time-consuming unpaid domestic tasks, and are globally less likely to access higher education, well paid employment or business opportunities and are more likely to live in poverty. They've also been disproportionately impacted by school closures and domestic violence during confinement. Are women also therefore more impacted by COVID from a health perspective because of their access to nutritious food? What's the bigger picture here?

Johanna Ralston: So people who therefore have a high diet and intake of ultra-processed foods, are going to be more vulnerable to the complications of COVID-19. Why is this happening?  It's happening because on the surface food is cheap. And so people from lower socioeconomic status have access to cheaper food. Well, that cheaper food is unhealthy. And the reality is, it actually isn't cheap when you look at the overall societal costs of unhealthy diets of ultra processed foods because they're based on sort of monocrops, loss of diverse, localised food and the end sort of industrial agriculture, which has through through you know effective and innovative means, reduce the the sort of the number of major crops that are produced that into things like corn, wheat and soy are the main crops worldwide and that contributes to a global food system that is very underverse in its offerings, very cheap and accessible and in order to be globally available, heavily processed, so as to be edible by the time it reaches the last mile the final customer, but, has a has a very sort of deleterious effect on the individual driving obesity driving, heart disease driving diabetes, I'm not sure if that link is is clear, but it's incredibly important to understand that that, that our food system is driving a lot of this. And our food system is artificially inflated through sort of subsidies and cheap prices by the end-user to appear to be cheap, and to be a chair to be an opportunity for people of lower socioeconomic status to be able to, to eat. And yet that what is being eaten turns out to be very unhealthy and driving these sorts of underlying conditions that are in turn driving COVID-19. From a little road there, from your initial question about sort of the sort of differentiation, try to think about and understand what is that person presenting, in-hospital presenting, dying quickly of COVID-19? What are the conditions that have driven their vulnerability to COVID in the first place, and it has a huge and complex system behind it?

Fleur Heyworth: Absolutely. And some of these solutions aren't going to be quick fixes overnight. And clearly, there's a need to contain the spread of COVID, as much as possible to limit the vulnerability of these people in the short term, but in the longer term and as we start to think, what if we're devaluing the environment? If we're devaluing the people that are involved in that system of production and reproduction? And what shifts do we need to make in terms of the way we approach policymaking? And how do we fix this? How do we improve and play our part in trying to rebalance this system?

Johanna Ralston: So I think we need to, you know, use this slightly overused phrase of building back better, we do need to think about what were those systemic issues that that meant that the poorest people are also the sickest people, and chronically sick, not just sick due to infectious diseases, but having underlying chronic conditions, which is very much now what we're seeing. So I think it is, you know, building, you know, we revisiting food systems, of course, revisiting, even built environment, I think that plays an incredibly important role as well as agricultural systems, and even things like housing, and, and sort of the environment. But to answer it more, simply, I think we have to take a long and a short view and the short view are obvious, there, there are things we can do to to make health systems work more effectively, and to be more accessible to all but then we need sort of longer-term reconstruction of both our food and our health systems to help protect against this happening in the future, which it most probably will. I think, if nothing else, this is a dress rehearsal for a future pandemic. And we need to have health systems that speak to each other more effectively across borders. We very much see that fragmented communication of health systems to one another was impeded both by misalignment of those health systems, but also by, of course, you know, the political barriers and then that food systems and other systems work better to serve the individual with healthy and nutritious diets, which in turn, the probably the simplest thing is to say greater sovereign diets is certainly part of the solution. 

Fleur Heyworth: When you say sovereign diets, do you mean diet and food produced within a country for the country?

Johanna Ralston: Yes, to the to the extent possible, while recognising that there are also tremendous benefits of the availability of, for example, fresh fruits and vegetables year-round in a food system that does allow for cross border production and distribution but that part of the issue is that much local farming is a wild oversimplification. Here, but there's a preponderance of local farming that supports industrial agriculture, rather than local communities. And those types of things, you know, sort of transformation of those systems play an important role.

Fleur Heyworth: And you can see local empowerment playing a huge role here. My colleague Anna Brach published a policy brief on human empowerment as a key tool in inclusion, and really trying to create an environment whereby those local communities are equipped with the resources they need and the knowledge they need to take ownership over some of this production and this innovation.

Johanna Ralston: Absolutely, I think that's such an important point. But I think local empowerment, and I would say one step further, is around individual power empowerment, which requires sort of the affected individuals at the table at the outset. So I think it's sort of flipping the script on this kind of large global systems, which, quite frankly, are designed in places, you know, like Geneva, like New York, like, you know, sort of that kind of flipping the script is really, really important. 

Ashley Müller: That's all we have now for this episode. Thank you to Ms Fleur Heyworth and Johanna Ralston for this important conversation on health and inclusion. Keep this mini-series rolling and listen to our next episode on diversity and policy. In the meantime, don’t forget to subscribe to us on Apple iTunes, follow us on Spotify and SoundCloud. Click the next button to get the next episode!

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