THANK YOU! GRACIAS!

1. Creating a tipping point to stop the epidemic of chronic diseases in Chile: the need for transformational partnership(s) between government, private sector, and civil society Presentation to the Cumbre de nutricion y Salud, Valparaiso, Chile, Marzo 25, 2008 C. James Hospedales Jefe, ENT, OPS/OMS

2. THANK YOU! GRACIAS!

4. Vision General • Sufficiency of evidence regarding the chronic disease epidemic – perspectiva global • Why we need everyone together and how do we do it • Regional Strategy and Partners’ Forum on the Prevention and Control of Chronic Diseases

5. Suficiencia de la evidence – perspectiva global

6. “Planet Doctor”

8. Planet has a fever (global warming) Population: about 7 billion humans - dangerously close to the limit of the Earth’s available resources About 1 billion are living in desperate poverty, with most in the middle, while relatively few are very rich – very unjust, unfair …Y otros problemas An amazing amount of new knowledge, technology and information systems, military powers invented

9. How did this happen? • One species that is very intelligent (at least in some ways), has become the dominant species. They emerged about 10,000 years ago, having invented agriculture, and the villages and political systems that soon followed. Up to that point, people had wiped out a few of the Earth’s largest animals, but left most of the land surface and all the oceans intact. People then used all means they could to convert the resources of the Earth and the seas into wealth, and they did so at an amazing rate, consuming the hydrocarbon fuels, land, forests, water, fish, food, destroying completely thousands of species in the process. And as a Planet doctor, realizing this made me feel very sad, because you see we are taught that the Creator God made the Earth, and when He did so, “He saw that it was good”.

10. How did this happen? • They invented ways of overcoming various epidemics and problems like small pox, plague, tuberculosis, through vaccines, water and sanitation, housing, etc. In the last 100 years or so, they became much less physically-active, with urbanization and the invention of cars and mechanized things. And even where some wanted to be more active, they could not because the environment was not safe anymore, or had become very polluted. And the continued increase in the use of fossil fuels has begun to warm the planet.

11. Que Pasa? • They invented ways of producing nitrogenous fertilizer (double the capacity of nature) to force the Earth to produce even more food, and invented pesticides, and other chemicals to control the pests. In the last 100 years, a large percentage took up smoking tobacco (and for this crazy habit, you see why I question their intelligence). Harmful use of alcohol also became more widespread and contributed to much chronic disease and injury and social harm.

12. Que Pasa? • And excessive consumption habits spread to food where high fat, high sugar, high salt foods became widespread and cheap, marketed and distributed by an efficient private sector so that even the children are now becoming often becoming fat and unhealthy. And ironically, more and more of the cheap, calorie dense, non nutritious food became consumed by the poor, worsening the gaps in the society.

13. Muy Importante • This set of circumstances (global warming, pollution, deforestation, over fishing, over-population, intensive agriculture, urbanization, despeciation) is all happening at the same time, and is all inter-connected, unlike our tendency to study or focus on one thing at a time. And the consequences of the interactions we cannot predict from our reductionist approach to science.

14. Conclusion 1 • The epidemics of obesity and cardiovascular disease, diabetes, cancer, respiratory diseases, are symptoms of our development paradigm gone astray • Costs to governments, families, and business are huge and increasing, and no sostenible • Symptoms of the deeper problems of a sick planet. • The roots of obesity and chronic disease problem lie deep, deep in the way the species, our species, lives on this planet.

15. Conclusion 2 • Although our entry point in this Summit is obesity and chronic diseases, the discussions will lead to the fight against poverty, the fight to restore environmental balance, the fight to stabilize the population. • It is a very complex problem. • The evidence is compelling that we need to redesign our social and economic policies before we completely wreck this planet and the future of the people, and our children. • And thus we must come together, politicians, business, media, academia, etc., in a new way.

16. Faith, Hope and Love • I have Faith in the science. • I have Hope at the awakening awareness, as evidenced by this Summit, and tools and partners available. • What we need is Love …

17. Sufficiency of Evidence • Preventability – 80% heart disease and diabetes preventable, 40% cancer preventable and another 30% curable – the challenge is in the application; • “Discovery-delivery gap” or 20, 30, 50+ years: how to shorten? How to apply the evidence? What policies? What changes in Global and regional market forces?

18. Sufficiency of Evidence • Importance of comprehensive, integrated action combining population-based and individual measures; small changes in levels of several risk factors can have major impact. • Lancet, December 2007: 32 million deaths can be avoided over the next 10 years by a combination of 15% reduction in salt consumption and comprehensive tobacco control (14 million deaths avoided) at a cost of $0.40 per person per year, and scaling-up of treatment with aspirin, and drugs to lower high blood pressure and cholesterol (18 million avoided) at a cost of $1.10 per person per year.

19. Why we need everyone together and how do we do it

20. Transformational Partnerships Niveles: Local National Regional Global Public Sector Private Sector Civil Society Science-Based

21. Why do we need everyone together? • Creating Tipping points • From physics, popularized by Gladwell’s book; seeks to explain and describe enormous and "mysterious" sociological changes that mark everyday life • Tipping Points are "the levels at which the momentum for change becomes unstoppable” • A sociological term "the moment of critical mass, the threshold, the boiling point“ • "Ideas and products and messages and behaviors spread like viruses do.“ Examples of such changes in his book …

22. Creating positive social “epidemics” • "The success of any kind of social epidemic is heavily dependent on the involvement of people with a particular set of social skills." • Connectorsare people who "link us up with the world ... people with a gift for bringing the world together" • Mavensare "information specialists", or "people we rely upon to connect us with new information." They accumulate knowledge, especially about the marketplace, and know how to share it with others • Salesmenare "persuaders", charismatic people with powerful negotiation skills. They tend to have an trait that goes beyond what they say, that makes others want to agree with them • From the book, Tipping Point, by Malcolm Gladwell

23. Why do we need everyone together? • The problem is very complex • Many countries and organizations have developed many initiatives, policies, promotion and prevention programs…. But the response is fragmented • Partnership/collaborations are the stage that everyone needs for action, to create needed synergy between initiatives, to create a “tipping point(s)” for the epidemic in the short to medium term

24. Why do we need everyone together? • Governments can make policies that help reduce risks, scale up provision for those affected and minimize final catastrophe for families and individuals, but they need the support of the private sector and an empowered civil society • Regional and global market forces are major determinants of chronic diseases and health, but private sector needs government policies to level the playing field, and informed consumers to generate markets for healthier products • Civil society cannot do it alone; they need an environment that makes the healthy choice the easy choice, which flows from government and private sector policies.

25. No es facil! • “We chose to go to the moon and do other things, not because they are easy, but because they are hard, because the goal will serve to organize and measure the best of our energies and skills, because that challenge is one we are willing to accept, on we are unwilling to postpone, and one which we intend to win, and others, too.” (John Kennedy)

26. How do we do it? • Global perspective, with local actions • Inclusive • Cooperative • Environmentally aware • Science-based Jeffrey D. Sachs: “Common Wealth; Economics for a Crowded Planet” Penguin Press, 2008

27. How do we do it? • Inclusive • Who is not here at this Summit that will feel that they should be here, and who we need to have on board for success? • What happened that the private sector is not well represented? • Which is the biggest NGO in the world; very important in Chile? Are they at the Summit? • Who feels that they should have been part of the planning of the Summit, and were not?

28. And if you were not involved or invited? • Maybe it was not intentional • Forgive the organizers and join the effort! • En la Biblia: "Lord, how many times shall I forgive my brother when he sins against me? Up to seven times?"  Jesus answered, "I tell you, not seven times, but seventy-seven times” Matt 18: 20-21

29. How do we do it? • Cooperative • “Each of you should seek not only to your own interests, but seek also to the interests of others”. Philippians 2:4

30. Some Useful Tools

31. Some Useful Tools Interest-BasedNegotiation Conflict Management Group, Cambridge, Mass, USA Mercy Corps Int’l, Seattle

32. Some Useful Tools Communication & Relationship Keys to the “circle of power” Clarify Interests Identify Options for mutual success Criteria of Fairness Agreement & Commitment

33. How to do it? • We have to connect our interests to the interests of others • Learn to speak the language of other groups sectors • Connect our health metrics to social justice, to profits and productivity, to environmental concerns, to security interests, to spiritual interests, etc

34. How do we do it? Some useful tools • THE SEVEN HABITS OF HIGHLY EFFECTIVE PEOPLE • Habit 5 -- Seek First to Understand • Then to be Understood • Principles of Empathic Communication • Stephen Covey, and the Covey Leadership Institute

35. Some Useful Tools

36. Some Useful Tools

37. How do we do it? • “If your colleague does something to offend you, go and show him his fault, just between the two of you. • If he listens to you, you have won your colleague over. • If he will not listen, take one or two others along, so that the matter may be established by the testimony of two or three witnesses..” Matthew 18: 15-16

38. How do we do it? • Persevere: the most important thing • See the movie “Amazing Grace” about how the British slave trade was ended through the efforts of Member of Parliament, 1789-1906, William Pitt • “After the final No, there comes a Yes, and on that Yes the future depends”, Poet, Wallace Stevens

39. People will say, “No” • No, we need not change; we have always done this • No, we cannot change; it is too hard • No, we will lose profits… or prestige • No, we cannot make peace with that group… • ….

40. Private sector interests • Profits and productivity • Customer satisfaction • Increasing share holder value • Quality and competitiveness • Controlling costs (workplace wellness) • New market opportunities • Avoiding future litigation • Image and reputation • Corporate Social Responsibility • Etc

41. Private Sector; not homogenous • Food Companies • Media and telecommunications • Arts and entertainment • Travel and tourism • Finance and banking • Insurance companies • Auto industry • Farming and agriculture • Etc

42. Private Sector: business opportunities in health • Food Companies – “5-a-day” frutas y verduras • Sports companies – Ciclorecreovias – bicycles, sports drinks • Media, Arts and entertainment – wellness programs • Telecommunications – cellphones for RF surveys? For health education with text messages? • Arts and entertainment – integrate good health behavior into telenovelas? • Travel and tourism – health spas, health tourism • Finance and banking - healthy people earn and save • Insurance companies – healthy populations can pay premiums • Auto industry • Farming and agriculture – fruits and veg, low fat meats

43. Private sector and cholera • In 1991, cholera threatened to spread to the Caribbean islands from Col, Ven, Guyana and governments, private sector and NGOs responded • Private Sector Response against the Cholera Threat in Trinidad & Tobago. • Hospedales J, Holder Y, Deyalsingh I, et al. Bull Pan Am Health Org 1993; 27:331-6 • Private sector had spent five times more than the government in education the public about preventing cholera!

44. Steps to establish a Tourism and Health Partnership in Caribbean • 1995 “Prevention of diarrheal disease in travel industry  • 1996 “Prevention of foodborne disease”  • 1996 “Reducing cost impacts of health and disease problems”  • 1997 “Improving profitability through attention to health and hygiene” !! (Inter-American Travel Congress, Costa Rica) • Quality Tourism for the Caribbean (QTC): joint public-private partnership Caribbean Hotel Association-Caribbean Epidemiology Center (CAREC/PAHO), 1998 $BID $CDB

45. A private Sector Perspective • “Dr Hospedales, we have demand for healthy food products from Europe and North America, but we have no demand from South America; why should we change? We will lose money to our competitors and I don’t want to commit financial suicide’ (Vice President, XXXX Foods; en la casa de Don Franscisco, Miami, 2007) • What are the interests and concerns in this statement? What options for working together?

46. A private Sector Perspective • “Dear Dr Roses, I want to congratulate you on the work of your team in diet and physical activity. It has inspired me to do a special show on obesity. You will be pleased to hear that the show broke viewership records” • Don Franscisco, letter to Director, PAHO, January 2008 • What can we learn here from a Univision perspective? An issue in health is good for business!

47. http://www.dpaslac.org/

48. Partnership between “Prevention and Treatment” – comprehensive approach • “The value of medical care to health promotion’, Sir Douglas Black, President, UK Royal College of Physicians, 1974 • Integrating prevention into medical care, preventive exams screening for smoking, BMI, cervical cancer, etc., es muy importante. Clinical and Public Health Ethical responsibility • Largest decrease in Relative Risk of all cause mortality due to physical activity is in patients who have diabetes, hypertension, overweight (3-5 fold) • In a diabetes quality-of-care project, advice to patients to eat healthy more likely to succeed if we to make healthy foods more accessible and affordable

49. Interests of the Church • Spiritual health • Salvation of people’s souls • Spreading the kingdom of Jesus Christ • Caring for the sick and disabled • Fostering reconciliation between people; peace making • Preventing sins of gluttony and sloth and drunkeness • “Do you not know that your body is a temple of the HolySpirit, who is in you, whom you have received from God?” • -> Look after your body; take care not to pollute it with tobacco and drunkeness

50. Partnership Government-Civil society-PAHO • CARICOM Heads of State special summit on chronic diseases, September 2007; resulted in high level political commitment and healthy public policy directions • Case study of Critical success factors: • Partnership PAHO-CARICOM Secretariat • Evidence of human and economic cost from Caribbean regional health institutions and Universities • Involvement of countries in planning and preparing for the Summit • Involvement of the media in raising awareness