Public health

From the University of Essex to the United Nations: Evidence about social security, healthcare, and protection and assistance to the family in the UK

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By Dr Koldo Casla

Dr Koldo Casla, project lead of Human Rights Local, has submitted evidence to the UN Committee on Economic, Social and Cultural Rights for their inquiry into the state of socio-economic rights in the UK. Socio-economic rights include, among others, the right to housing, food, education, social security, health, access to work and good working conditions, all of which are recognised in the 1966 International Covenant on Economic, Social and Cultural Rights (ICESCR).

Launched in 2020, Human Rights Local is a project of Essex Human Rights Centre to make human rights locally relevant in the UK.

Every few years, the 170+ states that have ratified ICESCR ought to report to the UN Committee on Economic, Social and Cultural Rights (CESCR) on the policies they are implementing to respect, protect and fulfil socio-economic rights. For the UK, the last review was completed in 2016. The current one began in 2022 and will end with a UN report, known as ‘concluding observations’, that will probably be published around mid-2025. This report will be based on information provided by the UK government and devolved administrations, as well as evidence from three National Human Rights Institutions (the Equality and Human Rights Commission, the Scottish Human Rights Commission and the Northern Ireland Human Rights Commission), and evidence from NGOs and academics. On 13-14 February, the UN Committee will meet with civil society groups and NHRIs in Geneva, and it will also hold a ‘constructive dialogue’ with UK government representatives.

As part of Human Rights Local, Dr Koldo Casla has provided support to community groups and people with lived experience of poverty so they could provide their own evidence to the UN and their recommendations to bring about the necessary changes to improve their lives. This is part of GRIPP (Growing Rights Instead of Poverty Partnership), of which Essex Human Rights Centre is a founding member.

In addition, Dr Casla has also conducted research for Amnesty International about the extent to which the UK’s social security system (Article 9 ICESCR) meets international standards in relation to the right to social security. The study will be published later this year, but beforehand Amnesty International will rely on the evidence and the recommendations in their advocacy with the UN Committee on Economic, Social and Cultural Rights.

Dr Casla has also co-authored two submissions for the UN Committee. One of them identifies a series of concerns about the level of enjoyment of the right to health (Article 12 ICESCR) among Gypsy, Roma and Travelling communities in the East of England. It is based on qualitative evidence in the form of testimonies gathered in 37 peer-to-peer interviews conducted by four partner organisations – COMPAS, GATE Essex, Oblique Arts, and One Voice 4 Travellers – between June and August 2023. The evidence was part of the project “Building a community of practice to identify strengths, barriers and prioritise solutions to the right of access to healthcare for Travelling Communities”, led by colleagues in the School of Health and Social Care, and funded by the National Institute for Health and Care Research, between February 2023 and August 2024. The qualitative evidence compiled in the document is the unreserved confirmation that the UN’s concerns persist in relation to stigma, prejudice, discrimination, lack of informational accessibility and lack of cultural acceptability of healthcare for Gypsy, Roma and Traveller communities. This is reflected in the lack of cultural awareness in availability of suitable health professionals, lack of non-English language provision, problems of trust due to lack of cultural competence, lack of understanding of issues around literacy, and ongoing social exclusion, particularly digital exclusion.

The second submission goes hand in hand with the anti-poverty human rights NGO ATD Fourth World. It examines the impact of child protection services on families in poverty. Creating a social security system that guarantees the essentials in life, regulating for-profit children’s homes, and extending peer-parent support are among a list of recommendations to preserve the right to protection and assistance to the family (Article 10 ICESCR) for households living in poverty. 

As argued by Dr Casla and Lyle Barker in a paper published in the Journal of Human Rights Practice in 2024, lived experience brings both epistemic and instrumental value to human rights research. In relation to the former value, in a peer-led process, people with lived experience of poverty do not simply provide evidence, data and information. Instead, they rank their concerns, frame their grievances in their own terms and decide about their priorities and the research methodology. This approach intends to address the epistemic injustice that silences people in poverty and dismisses their knowledge. In relation to the second value, the instrumental one, lived experience can help detect the real impact of the distinguishing features of specific human rights. For example, in relation to child protection services, a peer-led and participatory action research with families showed that one of the instrumental values of putting lived experience first is that it can reveal the true nature, prevalence and damage of povertyism – the negative stereotyping of people in poverty – on people in poverty.

For more information lease contact Dr Koldo Casla @ Koldo.casla@essex.ac.uk

Booze, Bottles and Brussels: Member States’ Dilemma on Alcohol Health Warnings

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By Dr Nikhil Gokani, Lecturer in Consumer Protection and Public Health Law, Essex Law School

Nikhil is Chair of the Alcohol Labelling and Health Warning International Expert Group at the European Alcohol Policy Alliance, Vice President of the Law Section at the European Public Health Association, and member of the Technical Advisory Group on Alcohol Labelling at WHO.

This blog is a condensed version of N Gokani, ‘Booze, Bottles and Brussels: Member States’ Dilemma on Alcohol Health Warnings’ (2024) 13(2) Journal of European Consumer and Market Law 97-102. The full article is available here. An open access version is also available here.

An example of an alcohol health warning. Pictured here as used in the Yukon Study.

Alcohol and the need for effective alcohol labelling

Alcohol is a causal factor in more than 200 diseases, injuries and disabilities. Even at lower levels of consumption, alcohol is associated with increased risks of heart diseases and stroke, liver cirrhosis, cancers and foetal alcohol disorders. In the EU, alcohol consumption causes between 255,000 and 290,000 deaths per year. Beyond health, alcohol results in significant social and economic losses to individuals and society at large.

Despite negative consequences of drinking alcohol, consumer awareness of its harms is low. The World Health Organization (‘WHO’) has repeatedly called on States to provide consumers with essential information through alcohol labelling. The EU has itself acknowledged the importance of consumer alcohol information, reflecting the foundation of EU consumer protection policy that consumers can be empowered through becoming well informed.

EU level regulation of alcohol labelling

Current EU rules in Regulation 1169/2011 on the provision of food information to consumers (‘FIC Regulation’) require alcoholic beverages with a content over 1.2% alcohol by volume (‘ABV’) to include alcohol strength on the label. Similar health-related information, including ingredients list and a nutrition declaration, which are required on the labels of most food products, are exempt for alcoholic beverages above 1.2% ABV. EU law does not require other health-related information to appear on the label.

Member State developments on alcohol labelling

Health-related warnings are not explicitly addressed under EU law and several Member States have introduced national mandatory labelling rules. These have focused on two forms on messaging: mandatory label labelling relating to the age of consumption and messaging against drinking during pregnancy.

In October 2018, Ireland signed into law its Public Health (Alcohol) Act 2018. In May 2023, Ireland signed into law as its Public Health (Alcohol) (Labelling) Regulations 2023. From May 2026, non-reusable alcohol containers will be required to include the following labelling.

While feedback from civil society organisations representing public health and consumer protection expressed strong support, industry bodies from across the globe responded opposing the measure. The feedback questioned the compatibility of the Irish Regulations, and warning labelling in general, with EU law in three key ways, which are addressed in turn below.

Legal objection 1: The Irish rules constitute a discriminatory barrier to free movement

Alcohol labelling is harmonised at EU level. National labelling rules fall within the scope of the FIC Regulation. National alcohol warning labelling rules are allowed under two different sets of rules in the FIC Regulation – depending on whether or not warning labelling would be considered to be “specifically” harmonised by the FIC Regulation.

On the one hand, health warnings are not specifically mentioned in the FIC Regulation. This suggest that health warning labelling is not “specifically” harmonised. Under this interpretation, Member States may introduce national rules. This is allowed providing that these are not contrary to general EU Treaty provisions.

On the other hand, the full list of mandatory labelling particulars (eg list of ingredients, use by date) have been listed in the FIC Regulation. This suggests that the mandatory labelling has been “specifically” harmonised. Under this interpretation, Member States may not introduce national rules unless the FIC Regulation includes a derogation. The FIC Regulation does indeed include a derogation. Article 39(1) allows Member States may adopt rules requiring additional mandatory particulars justified on public health or consumer protection grounds. This is allowed providing that Member States do not undermine the FIC Regulation and that the national rules are not contrary to general EU Treaty provisions.

Therefore, irrespective of the different interpretations of the FIC Regulation, Member States seem able to move forward with national warning labelling.

Legal objection 2: The Irish rules are not consistent with existing EU harmonisation

The FIC Regulation requires that Member States may not undermine its base protection in Article 7. Therefore, national labelling shall be “accurate”, “clear and easy to understand” and “not be misleading”.

Accurate: Taking the Irish labelling as case study, this labelling is accurate according to scientific consensus. Evidence that “Drinking alcohol causes liver disease” is well-stablished. The evidence on the dangers of drinking during pregnancy is also clear. No amount of alcohol is considered safe during pregnancy. There is also well-established evidence that “There is a direct link between alcohol and fatal cancers”. Alcohol is classified as a group 1 carcinogen by the WHO International Agency for Research on Cancer.

Clear: The requirement that information is “clear” relates to legibility and visibility. The Irish warnings meet this requirement not least as they appear against a white background, are within a black box and have a minimum size.

Not misleading: The Irish labelling is also not misleading. In line with broader consumer protection in the internal market, compliance with information rules is assessed against the behaviour of the “average consumer who is reasonably well informed and reasonably observant and circumspect taking into account social, cultural and linguistic factors”. This notional average is an active player in the market who reads information, has background knowledge, is critical towards information, does not take information literally, and will not be misled easily if sufficient information is available. This average consumer is likely to understand the meaning of the Irish labelling. The pregnancy warning simply advises women not to drink during pregnancy as per national health guidance. The message that “There is a direct link between alcohol and fatal cancers” communicates association with fatal cancers but does not go as far as communicating a direct causal relationship notwithstanding the well-established evidence on causation. The warning that “Drinking alcohol causes liver disease” is not misleading as liver disease occurs with even relatively lower levels of consumption.

Therefore, the Irish rules appear compatible with existing EU harmonisation.

Legal objection 3: The Irish rules are not proportionate

National alcohol labelling must also be proportionate, which it is when it is suitable and necessary to achieve its objective.

Legitimate objective:The primary objective for warning labelling is to inform consumers. It is also a part of a broader, secondary objective of reducing consumption and harms. As the Irish Regulations have been introduced under the Article 39 derogation, the objectives are limited to “the protection of public health” and “the protection of consumers”. Alcohol control clearly falls within these broad grounds as the CJEU has consistently held.

Suitability:Under the suitability limb of proportionality, it is necessary to determine whether the proposed labelling can attain its objectives of informing consumers and contributing to a reduction in consumption as part of a broader suite of measures. In respect of the primary objective, evidence demonstrates that there is a deficit of knowledge about the health consequences of alcohol consumption and labelling informs consumers. Studies show that alcohol health warnings leads to increased knowledge of health risks. Indeed, EU law already requires certain food products to be labelled with health warnings. As regards the secondary objective, evidence shows the contribution of labelling to reduction in harms and consumption.

Necessity:Under the necessity limb of proportionality, it must be determined whether a less intrusive measure can be equally effective as the proposed labelling to attain the objectives. Other measures are not equally effective. Labelling is available at both the point of purchase and point of consumption. Labelling is available on every container. It is targeted so that everyone can see the label when they see alcohol, but its visibility is in proportion to the number of containers a person consumes. It mitigates the effect of promotional marketing messaging on labelling. Ongoing costs are minimal.

Therefore, the Irish rules appear proportionate.

Moving towards effective alcohol health warning labelling

The objection raised by industry, that EU food law is a barrier to national alcohol health warning labelling rules, are demonstrably wrong. Therefore, in the absence of EU level action, Member States must take responsibility for moving forward independently. Let us hope the rest of the EU follows Ireland’s lead.

Nevertheless, EU institutions must support Member States to tackle alcohol-related harm. Tides appeared to be turning with Europe’s Beating Cancer Plan, in which the Commission committed to introducing proposals on alcohol health warning labelling by the end of 2023, but the deadline passed with no action. Let us also hope the EU decides to prioritise the health of consumers over the interests of economic actors.

Alcohol labelling and warnings: how progress at the Codex Alimentarius Commission can help States overcome challenges at the World Trade Organization

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By Nikhil Gokani, Lecturer in Law, Essex Law School, University of Essex

In this post, Nikhil Gokani writes about the work he is involved in on developing international standards, which can help countries navigate challenges under the rules of the World Trade Organization. Nikhil works on food and alcohol labelling regulation in the UK, EU and globally. He is chair of the Alcohol Labelling and Health Warning International Expert Group at the European Alcohol Policy Alliance (Eurocare). He is also a member of the Technical Advisory Group on Alcohol Labelling at WHO.

Alcohol-related harm and consumer protection

Consuming alcohol is a causal factor in more than 200 diseases, injuries and other health conditions. Alcohol consumption affects other people, such as family, friends, colleagues and strangers. Globally, about 3 million deaths each year result from the use of alcohol. Beyond health, there are significant social and economic burdens.

Consumers do not have sufficient knowledge about the content and effects of alcoholic beverages. Most consumers are unaware of the energy and nutrition values (such as amount of carbohydrates) and ingredients. Few consumers are aware of the health risks, such as alcohol causing at least seven cancers.

Alcohol labelling and global progress

Alcohol labelling is an important source of information for consumers. Labelling is unique in providing information at both the point of purchase and consumption. Labelling improves knowledge. It is an effective measure to help ensure consumers are well-informed and not misled. Increasing evidence also shows that health information can empower consumers to make healthier consumption decisions, including drinking less.

Unfortunately, few countries in the world require that consumers are given essential facts on labelling, such as ingredients lists and nutrition declarations. Even fewer countries require beverages to be labelled with information warning consumers about the hazards of drinking alcohol.

The most recent success was in Ireland where new rules will require alcohol packaging to display warnings that “Drinking alcohol causes liver disease”, “There is a direct link between alcohol and fatal cancers” and a pictogram showing that alcohol can harm the unborn child if drunk during pregnancy. Countries like Ireland, unfortunately, face international legal challenges, particularly under international trade law.

International trade law and international standards

International trade law can constrain the regulatory autonomy of States. Significant to alcohol labelling is the World Trade Organization (WTO) Agreement on Technical Barriers to Trade (TBT Agreement). Most significantly, Article 2.2 of the TBT Agreement states that technical regulations, including rules on alcohol labelling, shall not create “unnecessary obstacles to international trade”. Technical regulations shall not be “more trade-restrictive than necessary to fulfil a legitimate objective”. Preventing alcohol-related harm is indeed a legitimate objective. However, many States trying to introduce better alcohol labelling rules have been challenged because other States have argued that labelling rules go beyond what is more trade-restrictive than “necessary”.

When a WTO State’s rule about alcohol labelling is challenged, international standards can either help or hinder them.

On the one hand, Article 2.4 of the TBT Agreement states that where “relevant international standards exist” States “shall use them…as a basis for their technical regulations” except when this would be ineffective or inappropriate Therefore, where international standards are not aligned with public health interests, they can make it harder for States to introduce effective national rules.

On the one hand, Article 2.5 of the TBT Agreement provides a powerful defence mechanism. It states that, when a technical regulation is “in accordance with relevant international standards”, there is a rebuttable presumption that the national rule does not create an unnecessary obstacle to international trade. Simply stated, where the State complies with a relevant international standard, they have a potentially strong defence for their labelling rules. Therefore, good international standards can be very powerful to help countries defend their national labelling policies.

Codex Alimentarius

An international standard is one which is made by a recognised body and compliance is voluntary. For alcohol labelling, there is indeed an international standard: the Codex Alimentarius is a collection of standards, guidelines and codes adopted by the Codex Alimentarius Commission.

Where alcohol labelling is in compliance with relevant Codex standards, States could use this as a defence under WTO rules. This underlines the importance of having good Codex standards that support effective national rules on alcohol labelling.

Significant progress has been made at the Codex Alimentarius Commission. Alcohol labelling was discussed at four Sessions of the Codex Committee on Food Labelling (CCFL). The Report of the 46th Session of CCFL noted “there was common ground on which to proceed with the work” but little further progress has since been made in recent years. At that Session, the Committee agreed that Russia, European Union and India with assistance from WHO and Eurocare would prepare a discussion paper for consideration at the next meeting. In fact, this was the first time this Committee included an NGO in the preparation of a discussion paper, which is a testament to the global leadership by Eurocare in this field.  Unfortunately, however, no discussion paper was submitted by Russia. Therefore, WHO and Eurocare each submitted their own discussion paper to keep the matter moving forward. The WHO representative spoke objectively and convincingly at the 47th meeting of CCFL. These efforts led to alcohol labelling remaining on the Codex agenda – something which several States, no doubt under the influence of the powerful alcohol industry, had resisted.

The Codex Alimentarius Commission has now started a new consultation process. It issued a Circular Letter which asks State members and Observers to comment on how work on developing alcohol standards should proceed.

For this consultation process to work best for public health and consumer protection, we need everyone to contact their governments (emails here) to demand effective progress at Codex. Please join us in these efforts!

Front-of-Pack Nutrition Labelling: Time for the EU to Adopt a Harmonized Scheme 

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By Dr Nikhil Gokani (Essex Law School) and Prof Amandine Garde (School of Law and Social Justice, University of Liverpool)

Nutri-Score label as published by Santé Publique France

In its Farm to Fork Strategy, published nearly 3 years ago in May 2020, the European Commission committed to ‘propose harmonised mandatory front-of-pack nutrition labelling’ (‘FoPNL’) to ‘empower consumers to make informed, healthy and sustainable food choices’ by the fourth quarter of 2022. This commitment was repeated in Europe’s Beating Cancer Plan in February 2021. The deadline has now passed and the promised proposals do not seem forthcoming. This is all the more disappointing considering there is strong support for the implementation of an EU-wide harmonized FoPNL scheme, as demonstrated by the results of the EU consultation on ‘Food labelling—revision of rules on information provided to consumers’ published in December 2021.

Such support is not surprising considering the significant advantages that the adoption of a harmonised FoPNL scheme has for consumers, traders, Member States and the EU alike.

  • From the perspective of consumers, an effectively designed FoPNL scheme helps inform them of the nutritional composition of food. Informing consumers lies at the heart of the EU’s consumer protection strategies and reflects its long-held view that regulating food labelling empowers consumers to make healthier choices whilst promoting the objectives of market integration. At present, the EU only mandates a small table of nutrition information on the back of food packaging. This is often hard to see and difficult to understand, whereas effectively designed FoPNL can provide easy-to-see and easy-to-understand information on the front of food packaging thus supporting healthier food choices.
  • From the perspective of traders, harmonized FoPNL will create a level playing field by reducing regulatory fragmentation, which will also increase legal certainty and lower labelling costs. There are currently 7 national FoPNL schemes recommended across 15 EU Member States. Further industry-led schemes are used, although they have not been officially endorsed by any Member State. While some manufacturers have adopted FoPNL, many have not, and others are using multiple different schemes.
  • From the perspective of Member States, a mandatory, EU-wide FoPNL scheme will contribute to improving diets and health outcomes. Current EU rules prohibit the adoption of FoPNL schemes which are interpretive, and do not facilitate the adoption of FoPNL schemes which are easy to use. They also prevent Member States from making FoPNL mandatory.
  • From the perspective of the EU itself, a harmonized FoPNL scheme will promote the proper functioning of the internal market in line with the EU’s mandate to ensure a high level of health and consumer protection in all its policies. Moreover, it will facilitate the compliance of all its Member States with the commitments that they have made at international level to promote healthier food environments.

The choice of any single scheme must be guided by evidence. The Commission’s Joint Research Centre reviews, published in 2020 and 2022, identify what makes FoPNL effective:

  • colour-coded labels draw consumer attention through increased salience, are preferred by consumers, are associated with increased understanding and encourage healthier food purchases;
  • simple labels require less attention to process and are preferred and more easily understood by consumers; and
  • consumers prefer and better understand consistent and simple reference quantities.

In its Inception Impact Assessment of December 2020, the Commission put forward four types of labels as contenders for a harmonized, mandatory EU-wide scheme: graded indicators (e.g. Nutri-Score); endorsement logos (e.g. Keyhole); colour-coded (e.g. Multiple Traffic Lights); and numerical (e.g. NutrInform). It is clear that of the four schemes considered in the Inception Impact Assessment, Nutri-Score is the only one meeting the criteria above, and its effectiveness is strongly established. Not only does it attract consumers’ attention, it is favourably perceived and well understood. It also has a positive impact on the nutritional quality of purchases. Additionally, the nutrient profiling model underpinning Nutri-Score has been extensively validated and shown to be associated with improved health outcomes. Even if no scheme will ever be described as ‘perfect’ by all stakeholders, its developed evidence base and adoption by a growing number of Member States, makes Nutri-Score the only viable option for the timely implementation of a mandatory, harmonised FoPNL scheme in the EU.

Growing rates of obesity and other diet-related diseases increase the urgency for the EU to act. We, therefore, call on the Commission to propose legislation requiring food to be labelled with Nutri-Score on a mandatory basis across the EU, as it has committed to do.

This post was originally published as an invited editorial in the European Journal of Public Health in June 2023. It is available here.

Nikhil Gokani is an expert in the regulation of front-of-pack nutrition labelling in the EU and globally. Please click here for his profile and contact details.

Front-of-Pack Nutrition Labelling: Experts Come Together to Discuss National, Regional and Global Challenges for Regulation

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Photo by Penn State on Flickr

In this post, Dr Nikhil Gokani (School of Law, University of Essex), an expert on regulating food labelling, writes about a major conference he organised with partner institutions.

On September 9 and 10, 2021, the Health and Medical Humanities Hub at the University of Essex, the Law & Non-Communicable Diseases Unit at the University of Liverpool and the Global Center for Legal Innovation on Food Environments of the O’Neill Institute for National and Global Health Law at Georgetown University jointly held a major online conference on the national, regional, and global regulatory implications of front-of-pack nutrition labelling (FoPNL).

Unhealthy diets are a leading cause of death and a significant factor in the development of non-communicable diseases (NCDs) as they are associated with an increased risk of overweight, obesity, and diet-related NCDs such as diabetes, cardiovascular diseases and cancers. To tackle the growing burden of poor nutrition, the World Health Organization (WHO) recommends that states implement FoPNL as part of a comprehensive approach to healthy diets. FoPNL displays simplified, at-a-glance graphical information on the front of food and beverage packaging. It helps consumers understand the nutritional quality of foods and beverages easily and more quickly, and can lead to healthier purchasing decisions, especially with members of lower socioeconomic groups. Even though the evidence base is still developing on how specific forms of FoPNL can best meet consumer needs, FoPNL is most effective when it is interpretive and makes an evaluative assessment about the nutrition quality of food and beverage products.

Many states have now introduced, or are considering introducing, a variety of voluntary or mandatory FoPNL schemes within their respective jurisdictions. These schemes differ in objectives and, consequentially, in design. In particular, the level of public health protection offered by these different schemes varies, not least as the ease of understanding, and the level of interpretation required by consumers to understand the nutrition composition of the food is different for each scheme. In light of the proliferation of national schemes, discussions are being held at the regional and global levels on the harmonization of FoPNL. At the same time, these developments face strong opposition from powerful food and beverage businesses.

In this context, the conference brought together global actors. It gathered over 250 participants from 39 countries, from Antigua to Vietnam, and provided a discussion forum where academics from various disciplines, international civil society organizations, and government and public health agency representatives discussed a range of overarching issues relevant to the regulation of FoPNL. The conference was organized into six panels.

Panel 1 began the event with a discussion on the importance for states of adopting FoPNL, and in particular interpretive FoPNL. Panellists discussed the rationale for FoPNL and the scientific evidence supporting this intervention, including the role of FoPNL in building healthier food environments and reducing health inequities, as well as the support it has received from the international community. Panellists explored states’ obligation under international human rights law to uphold the right to the enjoyment of the highest attainable standard of health and other related human rights, such as the rights to adequate food, information, and the benefits of scientific progress, through the implementation of FoPNL.

Panel 2 focused on national experiences. In particular, panellists discussed the development, adoption and implementation of legislation mandating warning signs on certain foods and beverages in the Americas – with case studies form Mexico and Uruguay – and government-endorsed schemes in Europe – not least the Nutri-Score which originated in France and UK multiple traffic light labelling. This panel highlighted the importance of gathering evidence and galvanizing public support, in addition to raising key questions concerning the different objectives that different FoPNL schemes pursue, as well as the nutrient profiling models underpinning them.

Panel 3 concluded the first day by looking at how national schemes had been – and could be – contested at the World Trade Organization (WTO) Technical Barriers to Trade (TBT) Committee and, were a formal legal dispute to arise before the WTO Dispute Settlement Body or an international arbitration tribunal, what arguments could be made and how they could be addressed. Ultimately, all panellists agreed that the question was not so much the lawfulness of FoPNL but its implementation. Under this framework, it is indeed possible for states to adopt effective FoPNL schemes, but they will be more equipped to do so well if they are mindful of their obligations under international trade and investment law and if they anticipate potential legal disputes (even if these disputes never do arise). In fact, linking the discussions of Panels 1 and 3 together, while states have some degree of discretion as to how to regulate FoPNL, it is clear that they have an obligation to do so under international human rights law.

One the second day, after discussing national experiences, the focus moved to regional harmonization and global standards. Panel 4 focused on the experience of the European Union (EU) and the anticipated developments following the European Commission’s repeated announcements that it would publish a proposal for an EU-wide FoPNL scheme in 2022. The discussions highlighted the limits of EU law as it currently stands, preventing Member States from mandating FoPNL at national level. After hearing the plans of the European Commission, panellists analysed the imperative for the EU to adopt a regulatory framework introducing an EU-wide, mandatory, interpretive FoPNL scheme, or, at the very least, a framework that does not prevent Member States from adopting mandatory FoPNL at the national level in the absence of enough political will to act effectively at regional level.

Panel 5 focused on the experience in Latin America and the Caribbean, bearing in mind that an increasing number of countries have already regulated or are in the process of regulating FoPNL, and that regional bodies, such as MERCOSUR and CARICOM, are reflecting on common rules. In the case of South America, panellists stressed that trade-related arguments were often used to halt or delay national FoPNL measures, though MERCOSUR empowers countries to take unilateral measures to protect public health. In the case of the Caribbean, panellists emphasized the flaws in CARICOM’s process, including due process concerns related to the food and beverage industry’s disproportionate influence in policy decisions. They also addressed the use of inaccurate trade-related arguments as a barrier for regional progress on FoPNL. In turn, in North America, panellists echoed the above concerns on the use of trade agreements as barriers to achieving health-related goals, inspiring contradictions in policy decisions as a result of political swings that endanger the sustainability of public health policies.

Finally, panellists expanded the discussions from the regional to the global plane. Panel 6 concluded the proceedings with a discussion on the role that Codex Alimentarius standards could play in promoting or hindering effective FoPNL schemes. In particular, panellists discussed what the international community could do to promote better consumer information through the adoption of common standards on FoPNL, not only at a regional but also at a global level. They also reflected on how to ensure that these standards were an effective tool of public health protection, rather than subservient to the food and beverage industry’s interests, and more specifically how the voice of public health could be better heard in this joint commission of the WHO and the UN Food and Agriculture Organization.

Having discussed the national, regional, and global regulatory implications of FoPNL, with a particular focus on the policy debates in the Americas and Europe, this conference made clear that comparisons between different FoPNL schemes should indeed be drawn with caution, paying particular attention to the objectives each of these schemes set out to achieve. The devil lies in the detail, and the law and public health communities need to tread cautiously if they are to resist the opposition from powerful food and beverage industry actors and ensure that FoPNL schemes effectively serve the interest of consumers and the protection of public health.

Realising the Right to Health

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Photo by Marcelo Leal

The right to health, or ‘the right to the enjoyment of the highest attainable standard of physical and mental health’ to give it its full name, is a fundamental human right which extends beyond a right to healthcare to include a range of pre-conditions for a healthy life.

According to the Office of the United Nations High Commissioner for Human Rights (OHCHR), ‘every State has ratified at least one international human rights treaty recognizing the right to health. Moreover, States have committed themselves to protecting this right through international declarations, domestic legislation and policies, and at international conferences.’

Yet evidence from around the world suggests States’ commitments to ‘progressively realise’ the right to health are yet to lead to practical progress.

What is required, then, to help States move from treaty signing to practical action?

The challenge

While most countries have signed up to treaties containing binding obligations in relation to the “progressive realisation” of the right to health, a lack of clarity on the scope of the right to health and historical confusion regarding appropriate indicators and benchmarks has created ambiguity, which some have used to sidestep their commitments.

What we did

Drawing on the fields of international human rights law and public health governance, research led by Judith Bueno de Mesquita, from our School of Law and Human Rights Centre, has sought to look at the expectations, or norms, in relation to the right to health, in the context of specific health issues, with a particular focus on sexual and reproductive health and rights (SRHR).

In a field that has been dominated by discussions of constitutions and legislation, this research focuses on the framework of regulations and policies required at national level, for implementation.

Bueno de Mesquita was appointed as a consultant by the United Nations Population Fund (UNFPA) to work with two national human rights institutions, the Commissioner for Human Rights, Azerbaijan, and the Ombudsperson Institution of Kosovo. In this consultancy role, she led the research required for national assessments looking at sexual and reproductive health.

These consultancies allowed her to apply her research to country contexts, and assess the degree to which the legislative, regulatory and policy environments were compliant with international human rights standards in the area of SRHR.

What we achieved

In Azerbaijan, the resulting report contributed to the Government taking sexual and reproductive health and rights more seriously, and provided valuable advocacy tools. The report was used to lobby the Azerbaijan Parliament to incorporate sexual and reproductive health issues into the State Program on Demography and Population Development and to develop the National Action Plan on Gender-Based Violence to ensure effective implementation of the 2010 law on domestic violence prevention.

The report was also showcased as a case study in the United Nations Population Fund’s ground-breaking guidance (UNFPA: 2019, pp. 76-78).

In Kosovo, Bueno de Mesquita’s recommendations were contained in the Ombudsperson Institution’s 2016 report, resulting in life-changing impact for rights-holders, including:

  • the provision of free contraceptives to vulnerable groups
  • the supply of low-cost condoms via vending machines
  • a decision to retain contraceptives on the essential drugs list
  • an increase in health inspectorate staffing, with human rights integrated into this organisation’s work
  • steps taken to make maternal death audits consistent with World Health Organisation guidelines
  • and the adoption of a rights-based national HIV action plan.

The impact in Kosovo is ongoing, with the report continuing to inform the next cycle of Azerbaijan’s Reproductive Health Strategy.

In both countries, the research of Judith Bueno de Mesquita has successfully bridged the gap between theory and implementation, supporting significant progress and providing useful examples of how national legislative and policy frameworks can help realise States’ commitments in relation to the progressive realisation of the right to health.

This impact case study was first published on the website of the University of Essex and is shared here with permission and thanks. Read the original story here. You can follow Judith Bueno de Mesquita on Twitter here.

Front-of-pack nutrition labelling in the EU: proposals for a mandatory EU-wide label

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Dr Nikhil Gokani, Lecturer in Law, University of Essex.

The European Commission published its Farm-to-Fork Strategy on 20 May 2020. In this, the Commission declared that to ‘empower consumers to make informed, healthy and sustainable food choices’, the Commission will propose harmonised mandatory front-of-pack nutrition labelling (FoPNL) by the fourth quarter of 2022.

As part of these plans, the Commission published an inception impact assessment and published two initiative Roadmaps: “Food labelling – revision of rules on information provided to consumers” and “Facilitating healthier food choices – establishing nutrient profiles”. Feedback on these opened on 23rd December 2020 and will close on 3rd February 2021.

In this post, Dr Nikhil Gokani, whose research explores the regulation of FoPNL, which was also the topic of his PhD, briefly sets out his views on how the EU should proceed with the regulation of FoPNL. To further develop the understanding of the regulatory issues involved, and bearing in mind the Commission’s target for legislative proposals, Dr Gokani and Prof Amandine Garde (Law & Non-Communicable Diseases Unit, University of Liverpool) are organising a conference on FoPNL – to explore the national, EU and international regulatory issues – which is provisionally scheduled for September 2021.

Back-of-pack nutrition labelling (BoPNL) does not sufficiently contribute to informing consumers, promoting healthier diets or tackling the rise in overweight, obesity and diet-related non-communicable diseases.

Evidence is clear that consumers find BoPNL confusing. They do not perceive nor understand BoPNL well, and they are unable to use this type of labelling effectively to help them make healthier food purchasing and consumption decisions. This is particularly so for consumers of lower socioeconomic groups.

Interpretive front-of-pack nutrition labelling (FoPNL) is an evidence-based intervention to inform consumers, help them make healthier food purchasing and consumption decisions, whilst encouraging manufacturers to reformulate products to make them healthier.

Effectively presented FoPNL is better perceived relative to BoPNL. Surveys have shown high levels of use, and research on various FoPNL schemes has shown improved trolley outcomes. FoPNL has a statistically significant effect in steering consumers’ choices towards healthier products, whilst encouraging product reformulation.

Interpretive FoPNL has consistently been shown to be most effective in improving health-related understanding, reducing processing time and improving purchasing intentions, with simpler schemes generally being better understood.

The EU should introduce a mandatory, interpretive EU-wide FoPNL scheme.

EU law, as it stands, precludes Member States from adopting mandatory FoPNL at national level (Regulation No 1169/2011 on food information to consumers and Regulation No 1924/2006 on health and nutrition claims) and does not effectively promote the voluntary adoption of evidence-based FoPNL schemes.

To be most effective, FoPNL should be mandatory for all food products. Any exceptions should be limited and only permitted where there are clear evidence-based justifications. The introduction of a mandatory pan-EU FoPNL scheme in the EU would help ensure a high level of consumer protection and public health while improving the functioning of the internal market. Moreover, this would be consistent with the EU’s obligations to protect consumers and their health, and to comply with fundamental rights as mandated by the EU Treaties and the EU Charter.

FoPNL should be: developed in a transparent manner; based on effective stakeholder engagement with conflicts of interest managed; effective in improving outcomes for all population sub-groups; supported by well-resourced education campaigns; encourage product reformulation; permit the comparison of products within and between food categories; monitored and evaluated for effectiveness; and reviewed periodically.

The presentation of EU-wide FoPNL

The evidence base supports the introduction of a mandatory, interpretive pan-EU FoPNL scheme. Hence, the EU should not move forward with FoPNL option 0 (“Baseline” ie business as usual) nor FoPNL option 1 (“Nutrient-specific labels – numerical” eg NutrInform). With FoPNL option 3 (“endorsement logos” eg Keyhole), consumers tend to over-estimate the healthiness of products, and there is insufficient research on the effectiveness of this type of FoPNL. By contrast, research has shown that option 2 (colour coded eg Traffic Light Labelling) and option 4 (graded indicators eg Nutri-Score) are effective in meeting public health objectives of increasing salience, improving understanding and improving purchasing intention as well as actual purchasing decisions.

Relative to other schemes in use in the EU, Nutri-Score presents a number of advantages which favour its adoption across the EU. Firstly, Nutri-Score is widely supported by a broad range of stakeholders, including many public health organisations and consumers themselves. Secondly, Nutri-Score has been evaluated in several large-scale studies evaluating perception and comprehension in French populations. It has been shown to improve understanding and lead to better basket outcomes, particularly with consumers from more vulnerable populations. Thirdly, the scheme has been adopted by several Member States, which would facilitate its extension to other EU Member States.

The nutrient profiling model underlying EU-wide FoPNL

It is a prerequisite that the development of interpretive FoPNL is based on an evidence-based nutrient profiling model. This model should encourage consumption of fruit, vegetables and wholegrains and other health-promoting food categories and ingredients; and discourage the consumption of fat (especially trans and saturated fatty acids), sugar (especially free sugar) and salt. Smaller portion sizes, energy density, level of processing and artificiality of ingredients may also be reflected in the model. The model, and the way FoPNL displays the classification derived from the model, should permit meaningful comparisons in order to encourage healthier substitutions both within and between categories.  The model should classify food based on a scoring system which provides continuous gradations of healthiness of the food in order to encourage continuing reformulation. It should be based on uniform reference values (100g/ml)

Nutri-Score is based on a nutrient profiling model which was originally developed in the UK and was found to be largely consistent with French nutrition recommendations. A diet, which is consistent with recommendations derived from the model, was found to result in improved health markers amongst the population. There is evidence that the Nutri-Score nutrient profiling model would also be effective for diverse European populations.

However, the model would need to be altered to address certain criticisms. To this end, EFSA should be tasked with developing an objective, evidence-based model free from undue industry interference. Alternatively, noting the Commission’s failure to adopt nutrient profiling for the purposes of Article 4(1) of Regulation No 1924/2006, the development of this nutrient profiling should be tasked to a scientific committee of independent experts from across the EU.

In the absence of a mandatory pan-EU FoPNL scheme, the EU should not prohibit mandatory national schemes.

The controversies surrounding the adoption of Regulation 1169/2011 and Regulation 1924/2006 have shown that reaching consensus across Member States is likely to be extremely difficult. There is a real risk that, in the absence of sufficient political will, the EU may fail to adopt a single pan-EU mandatory FoPNL scheme. It is therefore important that the Impact Assessment anticipates these difficulties and contains an additional FoPNL option exploring the implications of a partial harmonisation scheme whereby EU law would permit Member States to introduce effective mandatory national schemes, as noted in the Presidency Conclusions on front-of-pack nutrition labelling, nutrient profiles and origin labelling of 15 December 2020.

The nutrient profiling model should also be used to regulate the use of health and nutrition claims more effectively, as mandated by Regulation No 1924/2006.

The controversies surrounding the adoption of Regulation 1169/2011 and Regulation 1924/2006 have shown that reaching consensus across Member States is likely to be extremely difficult. There is a real risk that, in the absence of sufficient political will, the EU may fail to adopt a single pan-EU mandatory FoPNL scheme. It is therefore important that the Impact Assessment anticipates these difficulties and contains an additional FoPNL option exploring the implications of a partial harmonisation scheme whereby EU law would permit Member States to introduce effective mandatory national schemes, as noted in the Presidency Conclusions on front-of-pack nutrition labelling, nutrient profiles and origin labelling of 15 December 2020.

The use of health and nutrition claims is a marketing tool intended to encourage consumers to purchase certain products. As claims lead to an increase in consumption and overall energy intake, it is important that they do not mislead consumers and, in particular, that they do not mask the overall nutrition profile of food products. Under Article 4 of Regulation No 1924/2006, the Commission should have adopted an EU-wide nutrient profiling model to restrict the use of food claims on unhealthy products by 19 January 2009. The Commission should finally fulfil this obligation as a priority to ensure that businesses operate within a level playing field and consumers are finally protected from the most misleading forms of commercial food information. It would be logical for FoPNL and food claims to be based on the same underlying nutrient profiling model.

The EU should extend mandatory back-of-pack and mandatory front-of-pack nutrition labelling to alcohol.

It is extremely concerning that alcoholic beverages containing more than 1.2% by volume of alcohol are exempt from the requirement of displaying a nutrition declaration. Even when such a declaration is provided on a voluntary basis, it can be limited to an energy-only declaration in a non-tabular format.

There is increasing evidence that there is a deficit in consumer knowledge and understanding of the nutritional content of alcoholic beverages and the consequences of their consumption. Moreover, consumers are interested in alcohol nutrition labelling across Member States. In any event, the exemption is illogical bearing in mind that EU consumer law, and the EU Alcohol Strategy of 2006 more specifically, aims to ‘provide information to consumers to make informed choices’.

Human Rights, Childhood Obesity and Health Inequalities

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Photo courtesy unsplash.com (Brett Jordan)

Dr Nikhil Gokani, Lecturer in Law, University of Essex, has co-authored a new book chapter on human rights, childhood obesity and health inequalities with Dr Marine Friant-Perrot.

The prevalence of childhood obesity, and its rapid increase, is not distributed equally across populations. Some groups of children are more likely to live with obesity than others, with childhood obesity being strongly associated with belonging to socioeconomic groups consuming more energy-dense diets. These health inequalities are largely systematic, and are mostly the result of the social, political and economic environment in which children live and play.

Despite the creation of a health-promoting environment for all children being recognised by the international community as a matter of societal responsibility, inequalities in childhood obesity are growing. Within legal frameworks, social, cultural and economic rights are well placed to help reduce the prevalence of obesity. These human rights are inspired by the principle of solidarity and, as they are conceived as instruments of social transformation, they aim to provide corrective measures to economic liberalisation. As their essence is to protect everyone equally, the reduction of health inequalities in childhood obesity can be articulated within this human rights discourse.

This book chapter argues that, through helping to restore a real capacity for choice in food consumption, and thereby supporting healthier diets for every child, the right to non-discrimination on the basis of socioeconomic status and the principle of equality can be thought of as a foundation for realising social rights, in particular the right to health and the right to food. Moreover, it explores the implications of a human rights approach grounded in the right to non-discrimination for reducing health inequalities in childhood obesity prevention strategies. It calls for State implementation of restrictions on the marketing of unhealthy food to children as an evidence-based method to reduce inequalities and help better fulfil children’s right to non-discrimination and protect them from unnecessary commercial influences.

This book chapter was co-written with Marine Friant-Perrot (University of Nantes) and published in Amandine Garde, Joshua Curtis and Olivier De Schutter (editors), Ending Childhood Obesity: A Challenge at the Crossroads of International Economic and Human Rights Law (Elgar, December 2020).