World Health Organization : The mandate of a specialized agency of the United Nations

Noncommunicable diseases[1] represent an increasing and significant burden on public health. In 1990, the 41% of the global burden of disease was due to noncommunicable diseases, whereas the 44% was dependent on communicable, maternal, perinatal disease and nutritional disorders. In 2020, noncommunicable diseases are expected to be responsible for over 60% of the global burden of disease and 73% of the deaths in the world[2].

In 2001, noncommunicable diseases caused 58.5% (33.1 million) deaths in the world, far more than the 32.5% (18.4 million) due to communicable diseases, maternal and perinatal conditions and nutritional deficiencies[3].

In particular, in developed countries, 95% of the global burden of disease in 2001 is attributable to 15 leading causes. The top is occupied by neuropsychiatric disorders, cardiovascular diseases and injuries[4].

On the contrary to what one could think, noncommunicable diseases affect also low- and middle-income countries, where they add up to communicable diseases. In 1998, 77% of the total number of deaths attributable to noncommunicable diseases occurred in developing countries, and 85% of the burden of disease was borne by low- and middle-income countries[5]. Nowadays, the percentage has already raised till 79%[6]. Anthony Rodgers of the University of Auckland, New Zealand, a consultant for the World Health Report 2002, comments that "conditions like high blood pressure and high cholesterol are much more prominent in developing countries than previously thought and contribute significantly to their overall disease burden […] The whole world once thought of cardiovascular diseases as a Western problem, but this is clearly not the case"[7]. Dr Brundtland recognises the gravity of the situation in developing countries, where "it places a double burden on national health systems which must simultaneously deal with the infectious diseases found primarily in these countries as well as newer cardiovascular diseases"[8].

Noncommunicable diseases, therefore, seem to be a problem, both in developed an developing countries, even though under different shapes. For example, in poor countries there are 170 million underweight children, whereas worldwide more than one billion are overweight and at least 300 million are clinically obese[9]. As Dr Brundtland warns, what it is true is that "the world is living dangerously; either because it has little choice or because it is making the wrong choices about consumption and activity"[10].

The good thing when speaking of noncommunicable diseases, however, is that they are mainly preventable, as they are linked to risk factors related to lifestyle.

In this respect, the World Health Report 2002, 'Reducing risks, promoting healthy life', represents an extremely interesting document, as it describes "the amount of disease, disability and death in the world today that can be attributed to a selected number of the most important risks to human health"[11]. A risk is defined as "a probability of an adverse outcome, or a factor that raises this probability"[12]. The Report individuates more than 25 major preventable risks and, among those, it finds that the top 10 globally are: childhood and maternal underweight; unsafe sex; high blood pressure; tobacco; alcohol; unsafe water, sanitation and hygiene; high cholesterol; indoor smoke from solid fuels; iron deficiency and overweight/obesity (Figure 1).

Figure 1: Global distribution of burden of disease attributable to 20 leading selected risk factors

As far as it concerns noncommunicable diseases, - in particular cardiovascular disease, cancer, chronic obstructive pulmonary disease, diabetes, obesity - they are strongly connected to risk factors related to life style. These factors are tobacco use, alcohol, unhealthy diet and physical inactivity[13]. To give an example, inactive lifestyle, tobacco use and low fruit and vegetable intake account each for 20% of cardiovascular disease[14].

As noncommunicable diseases are strictly linked to such risk factors, the World Health Organization is responsible for convincing member states, their governments and people, that it is necessary to act on such risk factors in order to obtain a change in the burden of disease. The second day of the Meeting of Interested Parties 2002 (MIP) was dedicated to the topic 'Tackling risks to health'[15]. In this occasion, participants agreed on the evident effect that risk factors have on noncommunicable diseases. For this reason, Ms Janet Voute, from the World Hearth Federation, declared the importance of increasing the 'share of mind' about the positive influence that an action on risk factors could have on reducing noncommunicable diseases.

As Dr Pekka Puska, Director of the Department of Noncommunicable Disease Prevention and Health Promotion, and Dr Derek Yach, Executive Director of the Cluster of Noncommunicable Diseases and Mental Health, proposed in their presentations[16], the action to be taken shall regard both individuals and the supportive environment in which they live[17]. Therefore, the requested change is both a change in lifestyle and in behavioural habits, as well as a change in environmental, social, economic and cultural conditions.

People and governments of member states are to be convinced that it is worth to take any kind of intervention direct to address risk factors. With the purpose of this contribution, I assume an intervention to be "any health action – any promotive, preventive, curative or rehabilitative activity where the primary intent is to improve health"[18]. During the MIP, it was defined the importance of the action that the WHO should take at country levels, both on governments and on the public. The WHO should provide policy-makers with the scientific evidence in order to increase the confidence to invest in health promotion[19]. The governments of the countries are to be principal actors, as they have "a key leadership role in developing the legislative and economic environment needed to allow people to make healthy choices and to stimulate the market to promote health"[20]. Furthermore, the people should receive the right information, in order to have the opportunity to change their habits[21]. As Dr Derek Yach said, "the WHO is for personal choice. We simply want to make sure that these choices are made by fully informed consumers. We want these choices made in an environment in which it is easy for people to make healthy decisions about what to eat and how much physical activity they get"[22].

The action taken by the WHO to control and reduce noncommunicable diseases should, therefore, primarily focus on addressing the risk factors in an integrated manner.

Once described the challenge that the World Health Organization has to face, I will take into consideration one of the main initiative started by the Organization, and in particular by the Department of Noncommunicable Disease Prevention and Health Promotion[23] within the Noncommunicable Diseases and Mental Health Cluster[24], in order to tackle certain risk factors.

With the purpose of the present contribution, I will not deal with the action taken against tobacco use, namely the Tobacco Free Initiative and the Framework Convention on Tobacco Control[25]. The interest of this chapter will rather focus on other two abovementioned behavioural risk factors, that are unhealthy diet and physical inactivity.

The attention of the WHO towards diet and physical activity raises in 2000, as a consequence of an increasing consideration for the noncommunicable disease issue.

In 1998, the WHA adopted a resolution, endorsing "the proposed framework for the integrated prevention and control of noncommunicable diseases, including the support of healthy lifestyles, the provision of public health services and the major involvement of health, nutrition and other relevant professions in improving the lifestyles and health of individuals and communities"[26]. The Assembly, therefore, requested the Director-General to develop a global strategy for the prevention and control of noncommunicable diseases.

The strategy was developed during 1999, and it was presented to the WHA in May 2000. The 53rd WHA adopted the 'Global strategy for the prevention and control of noncommunicable diseases'. For the first time, it was stated that an action at the risk factor level, in particular tobacco use, unhealthy diet and physical inactivity, was required in order to prevent the most prominent noncommunicable diseases, specifically cardiovascular disease, cancer, chronic obstructive pulmonary disease and diabetes[27].

During the 54th WHA, in May 2001, in the context of health promotion, member states considered that the WHO should, among the other risk factors, step up its work on effective and global strategy for nutrition and physical activity, key factors in preventing noncommunicable diseases[28].

As a response to such a request, the Secretariat started to work on a report on Diet, physical activity and health[29]. This Report was presented to the 109th EB in January 2002 which recommended the 55th WHA to adopt a resolution with this regard[30]. According to this report, "unhealthy diet and insufficient physical activity are among the major causal risk factors in coronary heart disease, cerebrovascular strokes, several forms of cancer, type 2 diabetes, hypertension, obesity, osteoporosis, dental caries and other conditions. A healthy diet and physical activity reduce the risk of fatal diseases through their influence on blood lipids, blood pressure, thrombosis, body weight, glucose tolerance, insulin resistance and other demonstrated metabolic changes […] Physical activity also reduces stress, anxiety and depression. Consumption of vegetable and fruit, the amount and quality of fat ingested, and the intake of salt are the most important elements of a diet for prevention of both cardiovascular diseases and cancer. Maintaining normal weight and adequate physical activity throughout the life span are the most effective ways of preventing diabetes and many other chronic diseases"[31].

Figure 2: Attributable DALYs in 2000 by undernutrition and diet-related risks and physical inactivity

In May 2002, the 55th WHA discussed the Report by the Secretariat and recognised the importance of the framework for action on diet and physical activity within the integrated approach to prevention and control of noncommunicable diseases. As a consequence, the WHA approved a resolution which requested the Director-General to develop a Global strategy on diet, physical activity and health[32]. Diet is addressed in the strategy as it relates to prevention of chronic noncommunicable diseases. Therefore, it does not only concern overnutrition (overweight and obesity), but also other consequences of unbalanced nutrition (e.g. through blood pressure, blood lipids, glucose tolerance)[33]. Physical activity includes all activity undertaken during discretionary (leisure) time, at work, at home, and for transportation[34].

With this purpose, the WHO Secretariat[35] has been engaged since September 2002 with a process aimed to develop a Global strategy on diet, physical activity and health[36] to be presented to the 57th WHA in May 2004[37]. The aim of the overall strategy is "to improve public health through healthy eating and physical activity"[38]. Through such a document, the WHO wants to convince countries, their governments and people, that to act on risky behaviour, as unhealthy diet and physical inactivity, will guarantee the prevention of noncommunicable diseases, and therefore their reduction. In this sense, the Global strategy on diet, physical activity and health can be intended as an advocacy document aimed at convincing policy-makers.

The process for the development of a Global strategy on diet, physical activity and health can be subdivided in three different phases (Figure 3).

Source: WHO Process for a Global Strategy on Diet, Physical Activity and Health, p. 8

As a consequence of the resolution of the EB which called for the development of a strategy on diet, physical activity and health for the prevention and control of noncommunicable diseases[40], WHO and Food and Agriculture Organization (FAO) convened in Geneva for the Expert Consultation on Diet, Nutrition and the Prevention of Chronic diseases from 28 January 2002 to 1 February 2002[41]. The aim of the consultation was to update the existing recommendation on diet, nutrition and prevention of chronic diseases taking into account the new scientific evidence and lessons learned from implementing national intervention strategies.

According to the Diet and physical activity project team, such a report should constitute the scientific basis for the strategy, even though the strategy is to be conceived a much wider document than the issues treated during the Consultation[42].

The consultation resulted in a draft report which basically discussed obesity, cardiovascular diseases, cancer, diabetes, dental diseases and osteoporosis, and updated recommendations on population nutrient intake goals.

The draft report was submitted to comments from all interested organisations, member states and individuals until the deadline of 15 June 2002. After this, the chairs and rapporteurs of the consultation reviewed the comments and prepared a final report based on their scientific judgement to be circulated for comments and approval to all the experts during September 2002. This process has been very long and problematic, as it had to coordinate opinions and findings of 60 different experts. A final draft report was, however, completed in November 2002. The report is expected to be finally published in April 2003.

II. Process for stakeholder consultation on a WHO global strategy on diet, physical activity and health.

The second phase of the process moves from the fact that "in a world filled with complex health problems, the WHO cannot solve them alone. Governments cannot solve them alone. Nongovernmental organisations, the private sector and foundations cannot solve them alone. Only through new and innovative partnerships can we make a difference"[43]. Therefore, the WHA requested the Director-General to develop the Global strategy in consultation with members states, with the bodies of the UN system and professional organisations concerned. It also required a strengthened collaboration with other partners, including other UN organisations, international nongovernmental organisations and even the private sector[44].

In response to this, a 18-month consultation process with the abovementioned stakeholders has started in order to provide the content basis for the strategy. In November 2002, a draft outline of the strategy was prepared by the Secretariat and by a reference group, composed of internationally recognised experts, to be used as a basis for the consultation meetings.

As the WHO acts first of all for the member states, it is essential to involve them in the formulation of a strategy[45]. The WHO is actually pursuing such a strategy because, as Dr Derek Yach said, "our members have asked us to act. The member states are the main shareholders of the Organization, and in resolution WHA55.23 they requested the Director-General to develop a Global strategy on diet, physical activity and health"[46].

The purpose of the regional consultations with member states and the European Union is "to provide information on the extent of the problem associated with diet, physical activity and chronic diseases, and appropriate prevention strategies for their particular countries"[47].

Regional consultation will provide recommendations and feedback to the draft of the Global strategy on diet, physical activity and health. They will also contribute to regional work in such a field through a review of the extent of the noncommunicable disease problems related to diet and physical activity in the region, and sharing of experiences of various strategies, policies and programmes that are being implemented in countries and in the regions[48]. They will represent unique occasions to share experiences about how to face the same common problem.

Consultations with the six regional offices are supposed to be convened between March and April 2003[49]. With this purpose, the discussion paper, which will be used as basic document for the regional consultation, has been prepared. In addition, countries are expected to provide a country paper, based on a model provided by the Regional Office in collaboration with headquarters[50].

The concerned UN agencies should also be involved in the consultation. They are FAO, UNICEF, WB, UNESCO, World Food Programme, UNEP and regional development banks. The technical meeting with UN agencies will be held in Geneva, in May 2003, with the aim to make "concerned technical officers in the agencies to be actively involved in the regional consultations. This will also help to ensure that concerned government agencies in the regions can contribute to the regional consultations"[51].

Civil society organisations (CSOs) have more frequently entered into relationships with WHO in the past years[52]. Even in the context of the Global strategy on diet, physical and health, the WHO finds enriching to act in collaboration with not-for-profit consumer organisations and professional and lay health organisations with specific interest in the field.

For this reason, the WHO has started an informal consultation process which will lead up to the consultative meeting and roundtable with the Director-General to be held in Geneva right before the 56th WHA, in May 2003[53].

A meeting between representatives of international NGOs[54] and WHO was convened at the World Cancer Research Fund in London on 29th October 2002. The CS representatives agreed to be part of a loose strategic alliance and, together, they will prepare a document advocating for the Global strategy[55]. In addition, it was underlined the need for better global coordination among NGOs concerned with food, nutrition, physical activity and the prevention of chronic diseases, and associated fields such as sustainable use of resources and environment impact. For this reason, it was proposed to create a 'contact group' of relevant international organisations to provide better coordination and networking, and as a basis for strategic policy development and effective programmes and campaigns[56].

The outcomes of the consultative meeting and the Director-General-civil society roundtable will be known between April and May 2003.

The WHO wants to involve in the process also the private sector[57]. The Organization is aware of the important role played by the food, sport and advertising industries in the area of diet, physical activity and health[58]. Dr Derek Yach underlines that the WHO and the private sector have clearly two different functions. The first one "is a public sector organisation charged with protecting and promoting public health. The private sector's role involves issues such as business development, increasing market share, enhancing brand value, as well as legislative compliance. However, there is quite a wide area in which we share common goals, and where our interest converge: we both have self-interests in the health and well-being of the public. You want them as customers to come back to your restaurant, or into the supermarket, and purchase your products and services. For that, people must be healthy, and need to trust that none of the products consumed will harm their health"[59].

For this reason, the WHO has started a consultation process with the private sector. This process is organised at two levels: "one will focus on trust building and identifying positive common ground for collaboration"[60] and the second one "will be a formal consultation aimed at commenting on the discussion paper"[61].

A central event at the first level was a meeting between private sector representatives[62] and WHO, on 28 October 2002, in London[63]. The meeting was convened by the Prince of Wales International Business Leaders Forum (IBLF)[64]. During this meeting, some action areas were individuated: to develop a common message on diet, physical activity and health that could be adopted by all companies in the sectors; to share and advance strategies for using the information environment to advocate the goals on diet, physical activity and health; to share information on research and development of innovative products; to promote diet, physical activity and health through the workplace itself[65].

The formal consultation and the Director-General-private sector roundtable will be held in May 2003.

This phase of the process is aimed at presenting the final document of the strategy to the 113th EB in January 2003 and to the 57th WHA in May 2004. With this purpose, a reference group has been constituted to advise WHO in the development of the strategy. The first working meeting of the expert reference group was held in Oslo on 18-19 November 2002. During this time the international experts agreed on a draft, on which they will still have to work.

Once the strategy is formulated, it will have to be implemented. As Dr Derek Yach says, "we have to implement the strategy with the support of the various stakeholders involved. We aren't simply working on another dry document. We want to create a momentum behind that strategy so that it works to better the health of people worldwide"[66].

Once outlined the action taken by the World Health Organization for the development of a Global strategy on diet, physical activity and health, one could wonder why the WHO is involved in pursuing such a strategy, and if it fits at all with the Organization's mandate.

First of all, does such a strategy have anything to do with the role that the Organization plays in development? I have previously underlined how noncommunicable diseases were mainly a Western problem in the past, and how they have been recently increasing also in low- and middle-income countries. Since noncommunicable diseases are becoming of great concern also for developing countries, an action addressed to basic risk factors, such as diet and physical activity, should be carried out there as well. The poorest countries are to be a target of the Global strategy. Prevention and control of noncommunicable diseases will be an additional means to achieve development, even though there is no direct reference to them in fundamental documents for the world development, such as the Millennium Development Goals[67].

On the contrary, it seems to be clear the connection that such a strategy has with the constitutional objective of the WHO, which "shall be the attainment by all peoples of the highest possible level of health". Health is here considered as a complete state of well-being rather than the mere absence of disease. Therefore, such a vision takes into consideration the human being as a whole, and his health as a consequence of multiple variables, among which his behaviour. As a consequence, the Global strategy on diet, physical activity and health has to do with WHO constitutional mandate because it has to do with basic determinants of health, as behavioural risk factors.

Moreover, along this line, the strategic direction number 2 of the corporate strategy for the WHO Secretariat is "promoting healthy lifestyle and reducing health risk factors that arise from environmental, economic, social and behavioural causes". The Global strategy seems to be shaped exactly on the basis of this guideline.

The Global strategy does also take into account the efficacy of reaching out other actors that Dr Brundtland has particularly stressed in her five-year term. For this reason, the process for the formulation of the strategy is based on a long period of consultation with different stakeholders, from other UN agencies to the civil society and to the private sector.

As long as it concerns the second tool for the implementation of the WHO constitutional objective, the budget shows that there has been an increase of the resources allocated to the two Clusters involved with the strategy. The process for the Global strategy has adopted a cross-sectoral approach tackling as a target more than one issue. The Clusters involved are, therefore, the Sustainable Development and Health Environment and the Noncommunicable Diseases and Mental Health. Yet it is difficult to be able to understand from the proposed programme budget the resources which are actually allocated to the Global strategy.

However, if one looks at the programme budget for the biennia 2000-2001[68], 2002-2003[69] and 2004-2005[70] (Table 1), one can still observe that the amount is much inferior to that one gave out to communicable diseases.

Nevertheless, just to recall all the features, I said that in 2001 noncommunicable disease caused more deaths in the world than communicable diseases, and that, maintaining this trend, by 2020, this type of ill-health will be responsible for over 60% of the global burden of disease. The decision depends on the priorities' choice.

[1] Some of the most prominent noncommunicable diseases include cardiovascular diseases, cancer, diabetes, obesity and chronic respiratory diseases.

[2] The percentages are calculated in DALYs (disability-adjusted life years). See Noncommunicable diseases, mental health and injuries, WHO, Document WHO/NMH/EXR/02.1

[3] Presentation from Dr Pekka Puska, Director of noncommunicable disease prevention and health promotion, to Health Promotion Conference in Israel, Health promotion and disease prevention to meet the global public health challenges. Source: World Health Report 2002.

[4] ibid.

[5] Tullao, T.S., The impact of economic globalisation on noncommunicable diseases: opportunities and threats, in Noncommunicale disease prevention and health promotion, Globalisation, diets and noncommunicable diseases, WHO Geneva, 2002

[6] Presentation from Dr Pekka Puska, Director of noncommunicable disease prevention and health promotion, to MIP, Diet, physical activity and health – a global response.

[7] Poor countries face growing burden of heart disease, strokes, says UN, Agence France Presse, 18 October 2002.

[8] ibid.

[9] This is the shocking contrast between the haves and haves not in the world. The World Health Report 2002, Reducing risks, promoting healthy life, WHO, Geneva, 2002 (WHR2002), p.4

[10] ibid.

[11] ibid., p. 7

[12] ibid.

[13] Brochure of the Department of noncommunicable disease prevention and health promotion, WHO, Geneva, 2002

[14] The World Health Report 2002, Reducing risks, promoting healthy life, WHO, Geneva, 2002 (WHR2002), p. 60

[15] We participated to the Meeting of Interested Parties 2002, 7 to 11 October 2002, Geneva. See www6.who.int/mip2002

[16] ibid.

[17] The reference is again to definition of health as a human right at two levels: freedom and entitlement. See The right to the highest attainable standard of health, CESCR General Comment No. 14, E7C.12/2000/4 (11/8/2000). See Part II, Ch. 3, p. 120

[18] The World Health Report 2002, Reducing risks, promoting healthy life, WHO, Geneva, 2002 (WHR2002), p. 8

[19] Presentation from Ms Ferro-Luzzi, 'From science to policy', during Meeting of Interested Parties 2002, 8 October 2002, Geneva

[20] Speaking notes prepared for the Prince of Wales International Business Leaders Forum (IBLF) dialogue with WHO in London, 28 October 2002, by Dr Derek Yach, Executive Director of the Noncommunicable disease and mental health cluster, see www.who.int/hpr/nutrition/who.principles.htm. Dr Derek Yach also quotes the Health and Human Services Secretary, Tommy Thompson, "more choices and healthier choices on their menus, and advertising campaigns to eat healthy".

[21] Ms Isabelle Moncada, from the Panel: communicating risk to health: public perception and policy development: 'Danger is real, but risk is socially constructed – defining risk in an exercise in power', during Meeting of Interested Parties 2002, 8 October 2002, Geneva. This panel focused on the importance of the media and of advocacy in circulating scientific information.

[22] Speaking notes prepared for the Prince of Wales International Business Leaders Forum (IBLF) dialogue with WHO in London, 28 October 2002, by Dr Derek Yach, Executive Director of the Noncommunicable disease and mental health cluster, see www.who.int/hpr/nutrition/who.principles.htm.

[23] Department of Noncommunicable Disease Prevention and Health Promotion, available at www.who.int/hpr

[24] Noncommunicable Diseases and Mental Health Cluster, available at www.who.int/noncommunicable-disease

[25] See Framework Convention on Tobacco Control, www5.who.int/tobacco

[26] Noncommunicable disease prevention and control, WHA resolution, Document WHA51.18

[27] Global strategy for the prevention and control of noncommunicable diseases, Report by the Director-General, Document A53/14 and Prevention and control of noncommunicable diseases, WHA resolution, Document WHA53.17

[28] Health promotion, Report by the Secretariat, Document A54/8

[29] Diet, physical activity and health, Report by the Secretariat, Document A55/16

[30] Diet, physical activity and health, EB resolution, Document EB109.R2

[31] Diet, physical activity and health, Report by the Secretariat, Document A55/16

[32] Diet, physical activity and health, WHA resolution, Document WHA55.23

[33] Presentation from Dr Pekka Puska, Director of Department of Noncommunicable Disease Prevention and Health Promotion

[34] The World Health Report 2002, Reducing risks, promoting healthy life, WHO, Geneva, 2002 (WHR2002), p. 61 and see Physical Activity, available at www.who.int/hpr/physactiv/index.shtml and Move for Health, available at www.who.int/hpr/physactiv/move.for.health.shtml

[35] Dr David Nabarro, Executive Director of the Cluster Sustainable Development and Healthy Environment has overall coordinating responsibility for revitalising WHO's work on diet, food safety and human nutrition. The Global strategy on diet , physical activity and health is a key component within this initiative and it is under the direct responsibility of Dr Derek Yach, Executive Director of the Noncommunicable Diseases and Mental Health Cluster. The overall coordination of the project is in the hands of a cross-cluster steering committee chaired by Dr Derek Yach. The project team is led by Dr Pekka Puska, Director of Department of Noncommunicable Disease Prevention and Health Promotion. Core staff includes a policy and strategic project manager responsible for the implementation of the process and stakeholder relations, nutrition scientists, professional and administrative support and a media officer. See WHO process for a Global strategy on diet, physical activity and health, Document WHO/NMH/EXR.02.2, WHO, September 2002, p. 5

[36] Since such a process has been just recently started, the information about it was gained mainly by first-hand experience, thanks to the participation to the weekly core group meeting for the development of the strategy. I found extremely fascinating to gain an inview of the actual process for the formulation of a WHO strategy, and to meet the people involved with it.

[37] See www.who.int/hpr/global.strategy.shtml

[38] WHO process for a Global strategy on diet, physical activity and health, Document WHO/NMH/EXR.02.2, WHO, September 2002, p. 1

[39] ibid.

[40] Diet, physical activity and health, EB resolution, Document EB109.R2

[41] See www.who.int/hpr/nutrition/ExpertConsultationGE.htm

[42] From a conversation with a member of the WHO secretariat involved with the process.

[43] Brundtland, G., Address to the fifty-fifth World Health Assembly, Geneva, 13 May 2002

[44] Diet, physical activity and health, WHA resolution, Document WHA55.23

[45] With respect to the relationship that the WHO should have with its member states, it was also interesting to take part to the Mega Country Health Promotion Network Meeting on Diet, Physical Activity and Health, from 11 to 13 December 2002, in Geneva. The target of this meeting are countries with a population higher than 100 million people. As Dr Pekka Puska, Director of Department of Noncommunicable Disease Prevention and Health Promotion, said at the opening, "the main purpose of this meeting is to understand how the WHO can help member states: you do not come here to listen what we ask you to do! You come here with your 'shopping list' and we see what we can do about that. We beg you to share your experience with us and with the other countries, and we will think of what kind of practical initiatives we can start together. The aim is not the WHO, but the member states". Therefore, referring to the Global strategy on diet, physical activity and health, "the WHO does not create a strategy on its own and then it wants the member states to implement it. Member states take part to the consultation, they say what they needs are and the WHO tries to give a response to their requests".

[46] From a presentation at the Mega Country Health Promotion Network Meeting on Diet, Physical Activity and Health, from 11 to 13 December 2002, in Geneva.

[47] WHO process for a Global strategy on diet, physical activity and health, Document WHO/NMH/EXR.02.2, WHO, September 2002, p. 3

[48] From a conversation with Dr Pekka Puska, Director of Department of Noncommunicable Disease Prevention and Health Promotion.

[49] During my internship, I had the possibility to observe how difficult it was for the headquarters to have the Regional Offices to agree on dates and places for such consultations. It was interesting overall taking into account the decentralisation topic that more than once has been treated in this dissertation: has Dr Brundtland really succeeded to make WHO, One WHO?

[50] With this aim, a questionnaire to be submitted to countries was being prepared while I was in Geneva. The purpose of this document was to make countries start working on the issue and get ready for the formal consultations to be held in March and April 2003.

[51] WHO process for a Global strategy on diet, physical activity and health, Document WHO/NMH/EXR.02.2, WHO, September 2002, p. 3

[52] For further information on civil society, See Part II, Ch. 3, p. 141

[53] WHO process for a Global strategy on diet, physical activity and health, Document WHO/NMH/EXR.02.2, WHO, September 2002, p. 3

[54] To have an idea, some of these are: European Hearth Health Initiative, European Hearth Network, Health Enhancing Physical Activity Network, International Diabetes Federation, International Obesity Task Force, International Union of Nutritional Sciences, World Cancer Research Fund, World Federation of Public Health Organizations, World Health Policy Forum, International Association for Sport of Higher Education, International Association of Consumer Food Organizations, International Baby Food Action Network, Stakeholder Form, Sustain.

[55] As from the WHO representatives' report.

[56] From the report of the meeting with nongovernmental organisations.

[57] For further information about the private sector in general, see Part II, Ch. 3, p. 144

[58] For further information about the role that the private sector can play in this field, see Hawkes, C., Marketing activities of global soft drink and fast food companies in emerging markets: a review, in Globalisation, diets and noncommunicable diseases, WHO, Geneva, 2002

[59] Speaking notes prepared for the Prince of Wales International Business Leaders Forum (IBLF) dialogue with WHO in London, 28 October 2002, by Dr Derek Yach, Executive Director of the Noncommunicable disease and mental health cluster, see www.who.int/hpr/nutrition/who.principles.htm

[60] WHO process for a Global strategy on diet, physical activity and health, Document WHO/NMH/EXR.02.2, WHO, September 2002, p. 4

[61] ibid.

[62] To have an idea, some of these were: Coca-Cola Company, Kellog's, McDonald's Corporation, Nestlé, PepsiCo, Procter&Gamble, Starbucks, Swiss Re, Unilever, World Federation of Advertiser.

[63] The following meeting with private sectors representatives was expected to be convened on 10 February 2003.

[64] As of the WHO representatives' report, "this meeting constituted the beginning of the dialogue between the global strategy team and industry representatives. It was a positive meeting which facilitated open discussion among all participants, and there was full attendance for the entire day. There was a range of positions among the industry representatives going from aggressively against the global strategy goals to openly for the global strategy goals".

[65] From the report of the meeting with the private sector.

See also www.iblf.org/csr/csrwebassist.nsf/content/b1q2.html

[66] Speaking notes prepared for the Prince of Wales International Business Leaders Forum (IBLF) dialogue with WHO in London, 28 October 2002, by Dr Derek Yach, Executive Director of the Noncommunicable disease and mental health cluster, see www.who.int/hpr/nutrition/who.principles.htm

[67] At the 111^th EB, in January 2003, it was interesting to hear the discussion of the Report by the Secretariat concerning the role of WHO in the achievement of the MDGs. Some countries, such as Saudi Arabia, criticised the absence of noncommunicable diseases in the document, although they represent a very heavy burden for the world population.

A further example which provoked me is that in China's rural areas (more than 800 million people), noncommunicable disease now account for more than 80% of deaths, whereas communicable diseases less than 3%. See Speaking notes prepared for the Prince of Wales International Business Leaders Forum (IBLF) dialogue with WHO in London, 28 October 2002, by Dr Derek Yach, Executive Director of the Noncommunicable Disease and Mental Health Cluster, see www.who.int/hpr/nutrition/who.principles.htm

[68] Proposed programme budget 2000-2001, available at

policy.who.int/cgi-bin/om_isapi.dll?infobase=PPb2000e&softpage=Browse_Frame_Pg42

[69] Proposed programme budget 2002-2003 , available at

policy.who.int/cgi-bin/om_isapi.dll?infobase=pb02-e&softpage=Browse_Frame_Pg42

[70] Proposed programme budget 2004-2005, available at

policy.who.int/cgi-bin/om_isapi.dll?infobase=PPB04e&softpage=Browse_Frame_Pg42