Though different in their history, political institutions, and cultures, in recent years the emerging nations of Brazil, China, and India have witnessed a burgeoning growth—of obesity and diabetes cases. The product of ongoing economic growth, trade, increased consumption of fatty foods, and sedentary lifestyles, the presence of these epidemics support the notion that the rise of obesity and diabetes cases correlates with economic growth and prosperity.


Despite their similar health challenges, these nations have varied in how they have responded, in terms of both prevention as well as access to medicine and treatment. Brazil was the only nation to pursue prevention, access to medicine and treatment for obesity and diabetes, while China and India, in contrast, have only recently begun to address obesity prevention. With respect to diabetes, China and India’s governments still fall short of ensuring access to medications as well as treatment.

But why was Brazil so successful? The case of Brazil shows that successfully responding to obesity and diabetes requires that nations simultaneously strive to increase their international reputation as governments capable of eradicating disease and build upon preexisting institutions and policies guaranteeing the universal distribution of medicine
while working closely with civil society. Geopolitical aspirations, historical institutions, and a rich history of social health movements therefore constitute important contextual factors facilitating this process. Geopolitically, Brazil has always been sensitive to international criticisms and pressures when it came to health. When international agencies and the media began to pressure Brazil for a stronger response to obesity and diabetes, the government escalated its policy response in order to strengthen the government’s reputation as a modern state capable of eradicating disease; China shared similar views and incentives, but India did not. In contrast to these other nations, moreover, Brazil had a long history of creating a centralized bureaucratic and policy response to epidemics while dovetailing this with constitutional commitments guaranteeing access to medication as a human right. These preexisting institutional traditions and commitments were absent in China and India.


Brazil

In Brazil, obesity began to emerge as an epidemic by the late-1980s, mainly as a result of heightened economic growth, the import of processed foods, changes in dietary habits, and increased migration to urban centers. By the mid-2000s, the number of obese burgeoned, growing from 11.4 percent of the population in 2006 to 15.8 percent in 2011. Interestingly this occurred amidst ongoing malnutrition, causing a “dual nutrition” problem. But by 2010 Brazil’s Health Minister, Jose? Tempora?o, commented that, “the problem of Brazil is no longer malnutrition but childhood obesity and the increase in weight.” According to research conducted by Maria Teresa Torquato in 2003, diabetes—primarily Type 2—as a health ailment also began to emerge during this period and was generally attributed to obesity. By 1998, researcher Sandhi Barreto found that 4.9 million adults had diabetes, with a projected increase to 11.6 million by 2025.



Despite a transition back to democracy in 1986, the government was slow to respond. The presence of multiple diseases, preexisting commitments to decentralization, and limited funding for nutritional programs generated a lack of attention and policy response. Despite the Congress organizing several hearings on better nutrition and education through The National Congress of Nutrition (No Congresso Nacional de Nutric?a?o) and the National Policy on Nutrition (Poli?tica Nacional de Alimentac?a?o) in 1999, endeavors which improved the provision and quality of foods, accurate data and reporting, promotion of healthy eating and research, there were no prevention and treatment policies for obesity and diabetes.

In response, the international community began to criticize and pressure the Ministry of Health (MOH) for a more aggressive response. Theses pressures emerged with the World Health Organization’s (WHO’s) publication in 2004, The 2004 Global Strategy on Diet, Physical Activity, and Health. This report singled out Brazil, as well as India and China, for failing to adequately address obesity, diabetes, and other chronic illnesses (such as high blood pressure and cancer), while providing policy suggestions such as the regulation of fatty foods and a snack tax.




Instead of ignoring these pressures, the President and MOH positively responded. Under President Luiz Ignacio “Lula” da Silva, in 2010 the Congress heightened its response to both epidemics by creating the National Plan of Strategic Action in Response to Non-Communicable Chronic Diseases (Plano de Ac?o?es Estrate?gias para o Enfrentamento das Doenc?as Cro?nicas Na?o Transmissi?ves – DNST). Through the DNST the MOH created guidelines for the implementation of anti-obesity initiatives for 10 years. In 2007, the MOH created the Health Program for Schools (Programa Sau?de nas Escolas – PSE). And in 2009, the MOH provided funding to schools for healthier lunches through the Program of Direct Money to Schools (Programa Dinheiro Direto na Escola – PDDE), which also required the purchase of food from agricultural producers.

With respect to diabetes, the government also heightened its response to quell international pressures. The MOH committed itself to diabetes prevention as early as 1988 through the National Program of Diabetes Education and Control (PECD), which entailed setting up clinics and “diabetes teams” for treatment. Despite a decline in PECD funding during the 1990s, by 2001 a National Plan of Assistance of Diabetes and Hypertension was created, as well as a MOH campaign to detect diabetes cases. Since the creation of the 1988 constitution, when access to universal healthcare was deemed a human right, the MOH has also been committed to providing free medications for diabetes. The MOH has viewed the provision of insulin and other oral medications (such as metformin and glibenclamide) as “essential medicines,” on par with drugs for HIV/AIDS.



According to estimates conducted by Professor Luciana Bahia, in 2007, out of a total estimated per capita cost of 1000 individuals totaling US$747,000, the government paid for 75.4 percent of these expenses (roughly US$563,506), while the rest was paid for by patients in private hospitals.

But where did the impetus for this commitment to prevention and medical treatment come from? Brazil’s commitment reflects its history of centralized bureaucratic and policy responses to disease prevention and treatment, a history that dates back to the early 20th century. When obesity and diabetes emerged, the MOH essentially adhered to prior traditions of providing information for prevention and medications. But the commitment to universally distributing diabetic medication also stems from the government’s constitutional commitment to providing medicine as a human right. During the drafting of the 1988 constitution, politicians passed an amendment requiring that medications be available for anyone in need. Since then, this constitutional right has forced the government to fund all types of medications as well as treatment services in public hospitals.

But civil society also played an important role. Building on a tradition of social health movements responding to diseases, which also dates back to the early-20th century, the social movement for diabetes has a long history. According to Laerte Damaceno, President of the Brazilian Diabetes Society (Sociedade Brasiliara do Diabetes - SBD), beginning in the 1940s in the city of Rio de Janeiro, doctors, healthcare workers, activists, and family members organized themselves to form the SBD in order to increase government and social awareness. Currently comprised of over 3,000 members, the SBD organizes bi-annual conferences while being funded through voluntary contributions. SBD leaders travel throughout the states to increase awareness, meet with other SBD chapters, while working with local governments to provide prevention and treatment services. SBD, as well as community groups working on obesity awareness, has been successful in not only helping keep the MOH accountable, but also for increasing awareness while pressuring the government for policy reform.




China

Similarly to Brazil, the Chinese obesity and diabetes epidemics emerged as a product of escalating economic growth, the government’s one-child policy, heightened migration to urban cities, the introduction of fatty foods, and sedentary lifestyles. The growth in obesity cases has mainly impacted children. A study conducted by Federick Balfour in 2010 claims that nearly 8 percent of Chinese children in major cities are obese, while an estimated 40 percent of children in Beijing are overweight and obese.

And as in Brazil, Type 2 diabetes has also been attributed to the rise of obesity. Scientists note that China has now overtaken India to have the highest number of diabetes cases in the world. In 1980, Professor Frank Hu of the Harvard School of Public Health stated that approximately 1 percent of the population had diabetes; this increased to 10 percent by 2008. Furthermore, this year’s estimates conducted by the International Diabetes Federation found that there are approximately 92.3 million diabetics in China. Running parallel with the childhood obesity epidemic, the rate of diabetes cases among children has essentially tripled in recent years.

However, like Brazil, China’s MOH did not immediately respond to obesity and diabetes. MOH officials and the governing communist party believed that there were too many health threats and that obesity and diabetes were not among the most serious. Childhood obesity was also seen as something positive, connoting good health and nutrition. When combined with pre-existing commitments to decentralization, there were no incentives for the government to respond immediately.



China’s government confronted a series of international criticisms and pressures. While researchers from the WHO had been organizing conferences in China since 2001, underscoring Beijing’s need to address obesity and diabetes, the aforementioned WHO 2004 Global Strategy report claimed that China joined India in having the largest number of Type 2 diabetics in the world. Scores of media outlets, such as the BBC, The Guardian, as well as the scientific community added to the WHO’s criticisms and pressures.

China responded positively, for like Brazil, the government wanted to prove to the world that it could curb the spread of obesity and diabetes, in turn revealing its developmental potential. This kind of reputation-building response has a long history in China. In 2009, an editor for the Sydney Morning Herald, Jason Lee, described China as being the world’s most “self-conscious superpower,” incessantly worried about its international image. Over the years, in response to SARS, HIV/AIDS, and now obesity and diabetes, China would once again use health policy reform as a means to bolster its international reputation.

Not surprisingly, China increased its commitment to combating obesity and diabetes. While China had already established a National Plan to Prevent and Control Diabetes and Cardiovascular Diseases in 1996, beginning in 2010 a National Health Plan for the Promotion of Diabetes Management was created in order to further increase awareness. What’s more, in 2008 the MOH launched a month-long public media campaign. To curb obesity, by 2005 the government announced plans to create laws and regulations for improved nutrition. The following year, the government authorized passage of the Sunshine Physical Education Policy. In 2008, the Ministry of Education mandated one hour of running in all schools, while in 2010 the MOH passed the Regulation to Improve Nutrition.




In contrast to Brazil, however, China’s MOH has not been as committed to scaling up its prevention and treatment programs. Despite the government’s preexisting recognition of the obesity and diabetes epidemics, no federal programs have been introduced providing grants for healthier foods in schools. While local governments in large cities, such as Beijing, have financed gyms and playgrounds to help reduce childhood obesity, nothing else has been done to help local governments. Diabetes patients have also failed to receive adequate medication and treatment. An increasing number of diabetics, especially in rural areas, do not have access to insulin and oral medication. There is also a lack of adequate healthcare staff and clinics needed to provide diabetic prevention and treatment services, as well as screening. This challenge has recently prompted the government to implement a three-year “pilot” program to train local doctors on how to screen and treat diabetics.

But why did China respond this way? History and human rights provides insight into this question. Unlike Brazil, China does not have a long history of creating an aggressive, centralized response to disease containment. Instead, local governments and community groups often responded to diseases and other social welfare needs on their own. Second, access to medicine was never incorporated into the Chinese constitution, thus engendering no binding commitment to ensuring the universal provision of diabetes medication as well as other essential medicines.

The historic absence of social movements and NGOs in response to disease also helps explain the government’s response. Unlike Brazil, a social movement and/or community-based organizations mobilizing, criticizing, and pressuring the government for a response to disease never existed. Confucian religious principles of respect for the state stunted the growth of civil society organizations; consequently, no tradition of state-civil societal partnerships to contain the spread of disease emerged. When combined with the Communist cultural revolution of the 1960s and 1970s, proactive social health movements were practically impossible.



When the obesity and diabetes epidemics emerged, then, no civic groups formed to respond. While there has beeen a Chinese Diabetes Society since 1991 that is part of the Chinese Medical Association, it is mainly driven by the MOH. The Chinese Diabetes Society also concerns itself mainly with research and publishing guidelines for better screening and diabetic treatment. Other organizations, such as the Beijing Diabetes Prevention Association, were created in 1996 to increase awareness and combat diabetes discrimination in schools and the workplace. But in contrast to what we saw in Brazil, neither the government nor any of these NGOs has attempted to work with each other for policy reform.

India

Like Brazil and China, India has also seen the emergence of an obesity and diabetes epidemic. By the late-1990s, obesity mainly emerged in congested urban centers, gradually spreading out to rural areas. According to Y. Wang of Johns Hopkins University, when measured in terms of a BMI (Body-Mass-Index) score greater than 30 (which




indicates obese), the rate of obesity among adults in major cities escalated between 1998-99 to a high of 9.2 percent in New Delhi, 3.8 percent in Kerala, 2.7 percent in Tamil Nadu, 4.3 percent in Goa, and 4.4 percent in Gujarat. The heightened import of fatty foods, increased migration to cities, sedentary lifestyles, and a general lack of awareness about good nutrition has been the factors attributed to this growing health problem.

At the same time, cases of Type 1 but especially Type 2 diabetes have burgeoned, mainly as a consequence of increased numbers of the overweight and obese. According to researcher Kavita Venkataraman, in 2004 there were a total of 37.6 million diabetics in India, increasing to 41 million in 2007, while researcher Stephan Bjork projected the number of diabetes cases to increase to 80.9 million by 2030.

Similar to Brazil and China, India’s government also did not immediately respond to obesity and diabetes. Initially politicians reasoned that they were “diseases of luxury,” relegated to the richer classes, individuals that could easily take care of themselves. Politicians believed that most of the population was poor and malnourished (which is true), while the country was riddled with a host of other health challenges deemed as a greater priority. At the same time the government was committed to healthcare decentralization and expected the local governments to bear most of the policy responsibility.

India was also criticized and pressured by the international community. In addition to media articles alluding to India’s rising obesity and diabetes problem, as mentioned earlier, the WHO’s 2004 Global Strategy singled out India as leading the world in the total number of Type 2 diabetics. The following year, the WHO followed up with yet another report criticizing India for essentially ignoring its policy recommendations. By 2006 medical journals such as the Lancet also alleged that India had the highest number of obese and diabetic cases in the world.


In contrast to Brazil and China, however, India’s government did not respond as positively to these criticisms. For instance the government criticized the WHO’s 2004 Global Strategy for its suggested reduction in daily sugary intake, claiming that manual day laborers need the energy for work. The government also claimed that, biochemically, Indians were more predisposed to weight gain and diabetes, given their higher production and storage of fatty cells. But India’s government was also never concerned about creating a more aggressive health policy response in order to bolster its international reputation. This foreign policy belief stemmed from the days of Jawaharlal Nehru (India’s first Prime Minister, 1947-1964), and for the most part reflected the government’s history of viewing itself as a global power.



Consequently there were few incentives for the government to create an aggressive response to obesity and diabetes. With respect to obesity, no national prevention programs were created. While in 2006 the Parliament and the Ministry of Health & Social Welfare (MHSW) published a report stating its intention to monitor the spread of obesity, no policy interventions followed suit. It was not until 2008 that legislation was implemented by the Ministry of Women and Children’s Development (MWCD), which launched a nutritional program focused on diet and better exercise. In contrast to Brazil, however, no federal campaign to increase awareness was ever created, nor did the center provide grants to schools for educational materials, gyms, or partnerships with agricultural producers.

And with respect to diabetes, despite international criticisms and pressures, little effort was made to implement prevention and treatment policies. In contrast to what we saw in Brazil, no national census survey was ever taken to collect data on the prevalence of diabetes cases. While the MHSW did try to increase monitoring and the treatment of diabetes through the creation of a National Rural Health Mission in 2005, increase awareness, as well as the provision of medications, the government has not effectively pursued these endeavors. And finally, in 2008 the MHSW created a pilot program called the National Program for the Prevention and Control of Diabetes, Cardiovascular Disease, and Stroke. Despite the program’s intention to monitor the spread of diabetes, insufficient data has been collected. Some also question its success at increasing social awareness and prevention.

When it comes to providing medication, India pales in comparison to Brazil. In the absence of a universal healthcare system, access to insulin and oral medications is limited. Without government support, most of the costs for medications are borne by the patients themselves. And even those that can afford private medical insurance have found that companies are unwilling to cover diabetes-related tests and medications.

But why has the government not been committed to guaranteeing the universal distribution of medication? In contrast to what we saw in Brazil, it seems that part of the problem is the absence of an ongoing tradition of state intervention and the universal provision of medications. Notwithstanding a centralized healthcare system under British Raj, since political independence the government has sought to decentralize healthcare responsibilities. Furthermore, at no point has the government institutionalized its commitment to the universal distribution of medicine as a human right within the constitution, or any other federal law, despite referring to diabetic drugs as “essential medicines.” Without this commitment, the government has had no incentive to live up to its commitment of ensuring the provision of diabetes medication.




And finally, while civil society’s response to obesity and diabetes has been strong, it has operated in complete isolation from the government. According to Dharini Krishnan of the Heinz Corporation in India, NGOs have been responding to rising obesity and diabetes cases mainly in large urban centers, striving to increase public awareness, education in schools and among families, while helping local governments improve nutrition and daily exercise in schools. But in contrast to what we saw in Brazil, Paleru Jagannivas and Sheela Krishnaswamy of the Heinz Corporation note that despite pressures on the government to strengthen its response, NGOs have essentially been ignored, while the MHSW has not tried to work with them. In this context, civil society has worked on its own, while having few incentives to collectively pressure the government for a response.

Conclusion

As the emerging nations of Brazil, China, and India modernize, prosper, and seek greater global economic integration, obesity and diabetes cases will continue to rise and pose not only detrimental health conditions, but also threaten the economy and national security. When compared to each other, however, it seems that Brazil has been the most successful responder, implementing new prevention policies while guaranteeing access to essential medicines and treatment for its growing diabetic population.

But what can the case of Brazil teach us? First, while government sensitivity to international criticisms, pressures, and interest in reputation building are important catalysts for reform, this is by no means sufficient for ongoing policy reforms to occur: governments must also be interested in listening to and working with civil society, incorporating it into the policy-making process. Second, governments must formally commit to universally distributing medications, either by institutionalizing this commitment through a constitutional amendment or by creating federal laws that guarantee the provision of medication. As we saw in India, it is not enough to verbally claim commitments to universally distributing essential medications. Brazil shows that politicians need to formally institutionalize their commitments, and that they are willing to face the specter of law suits should they renege on their promises. This helps to create incentives to provide essential medicines, regardless of the costs.

As Brazil, China, and India develop their economies, in order to ensure ongoing growth and prosperity, they must also become innovative and committed to ongoing health challenges, such as obesity and diabetes. More than ever, policy makers in these nations need to learn from each other and find common ground on the types of interventions that will succeed in safeguarding their citizens’ health and prosperity. Achieving this outcome will require them to take international opinion and policy recommendations seriously, while establishing clear and effective channels for working with the medical community, healthcare workers, volunteers, and families to address these silent but ever so deadly diseases.