International public health lawyers are increasingly called upon to formulate and advise on legal interventions to tackle noncommunicable diseases (NCDs) in low- and middle-income countries. From smoke-free place laws, to taxes on sugar-sweetened beverages, to zoning laws that encourage active transport, legal interventions are important tools to address NCD risk factors such as tobacco use, harmful use of alcohol, unhealthy diet, and physical activity.
Using laws to address NCDs can be especially challenging in low- and middle-income countries, where health and justice systems tend to be weak, there may be limited local and/or regional evidence to support these non-traditional uses of the law, and priorities such as under-nutrition and infectious diseases compete for lawmakers’ attention. In this context, it is not enough to draft technically sound laws. We must tailor laws for the local context, provide economic analysis and scientific evidence, build public support and political will, and increase local capacity to ensure successful implementation and administration.
This tough mandate goes beyond the capacities of most public health lawyers. In addition to local governments and regional offices of the World Health Organization (WHO), it is essential for public health lawyers to work closely with local experts, experts in development, medical doctors and scientists, economists, civil society organizations, and experts in communication.
Medical doctors and scientists
Our first partners for tackling NCDs are medical doctors and scientists. Doctors and scientists play a key role in the formulation of legal interventions to address NCDs by conducting studies that build the evidence base to justify the interventions and the funding to implement them. We can draw upon different types of evidence to make the case for legal interventions to address NCDs, including:
- Evidence linking NCD risk factors (e.g., tobacco use, harmful use of alcohol, unhealthy diet, physical inactivity), physiological indicators of disease (e.g., elevated glucose, obesity), and disease itself;
- Evidence linking the NCD intervention in question (e.g., tax on sugar-sweetened beverages) with a reduction in prevalence of the NCD risk factor (e.g., consumption of sugar-sweetened beverages); and
- Evidence linking the NCD intervention to improved health outcomes.
In addition to scientific justification, decision-makers are keenly interested in the costs and outcomes associated with the adoption of NCD interventions. Economists can calculate the short, medium, and long-term costs of implementing NCD interventions, as well as the outcomes that flow from health improvements. Drawing upon evidence from other countries, as well as modeling, economists can forecast:
- Economic burdens of NCDs (i.e., cost of treating NCDs and productivity losses);
- Costs of implementing NCD interventions; and
- Outcomes (e.g., reduced treatment costs, increased productivity).
In-country experts and experts in development
Working together, lawyers, development experts, and local experts can maximize the likelihood of successful outcomes by tailoring NCD interventions to the local context. Local experts contribute essential knowledge of the social, cultural, economic, legal, and political context in which the intervention will be implemented. Experts in development can assist to adapt international NCD interventions for implementation in this local context.
To give the best chance of successful implementation, lawyers, development experts, and local experts can seek to understand and address gaps or weaknesses in local implementation capacity. We can incorporate “good governance” mechanisms within interventions, including monitoring, evaluation, and reporting requirements to promote transparency.
Civil society organizations can influence the policy agenda, advocate for development and adoption of strong NCD interventions, increase public and political support for interventions (through education and information campaigns, and by highlighting negative industry activities), and monitor, evaluate, and report on implementation and outcomes. Civil society organizations also provide invaluable resources and support for public health lawyers including by collecting and analyzing good practice public health laws and policies that can be adapted for other countries. The Campaign for Tobacco Free Kids’ Tobacco Control Laws database, for example, provides a wealth of information on tobacco control legislation and litigation. The World Cancer Research Fund International’s NOURISHING framework collects examples of policies that promote healthy diets and reduce obesity.
However, in many low- and middle-income countries civil society is emerging, but remains small in scale and has limited capacity to exert influence. As Ghaus-Pasha notes, variation in the nature and scale of civil society in different countries is influenced by the social, cultural, historical, and political environments . Impediments to growth include authoritarian political control, limited resources, and the absence of the right to “organize (Ghaus-Pasha, 2004). In these circumstances, civil society organizations may not play a significant role in agenda-setting and advocacy, but engaging such organizations in the development of NCD interventions may build the capacity of civil society to monitor implementation and play a bigger role moving forward.
Communications experts can also help ensure successful implementation of legal interventions to address NCDs in low- and middle-income countries. Lawyers and policy-makers can work with communications experts to promote legal interventions as an important tool to address NCDs. They can assist us to tailor this message to the different stakeholders, including politicians and decision-makers, the public, and industry.
Perhaps even more importantly, communications experts can develop mass media and educational campaigns to complement legal interventions. Such campaigns can improve effectiveness of laws by publicizing their existence, incentivizing compliance, and building capacity to comply. By way of example, the World Lung Foundation’s Mass Media Communications Campaign develops country-specific mass media campaigns to educate the public on the harms of tobacco use and second-hand smoke. These media campaigns reinforce the tobacco control message and complement tobacco control laws.
Law is an important tool to ban, disincentivize, and de-normalize unhealthy behaviors, as well as to promote healthy diets and physically active lifestyles. Partnering with local experts, doctors, scientists, civil society, economists, and communications experts, public health lawyers can realize the law’s full potential to tackle the burden of NCDs in low- and middle-income countries.