Re-thinking obesity

Re-thinking obesity: The Global Syndemic and complex adaptive systems

The Global Syndemic

The original concept of a syndemic was largely applied to diseases at the individual level — two or more diseases clustering in time and place, interacting with each other and having common, societal determinants.429 A subsequent extension of the concept used syndemics to describe health problems that synergistically affect population health in the context of economic and social inequalities.30 To date, the main applications of the extended syndemic concept have been in relation to HIV/AIDS and its associations with substance abuse and violence,431 the clustering of hepatitis C, alcohol abuse, and hepatocellular cancer,3132 and poverty, depression, and diabetes among low-income populations.30

The Commission proposes that the definition of syndemics should be further extended to the pandemics of obesity, undernutrition, and climate change. We consider climate change a pandemic because of its dynamic nature, its rapid rise, and its predicted catastrophic impact on human health. The interactions between these pandemics occur at both the individual and population levels (figure 2B). The Commission calls these three pandemics The Global Syndemic to emphasise the major global importance of this cluster of pandemics, which are now, and will be into the foreseeable future, the dominant causes of human and environmental (ie, planetary) ill-health. Recognition that these synergistic pandemics constitute a syndemic provides a more comprehensive view of their interactions, and promises common systemic actions that can unite previously disparate stakeholders.

Obesity, undernutrition, and climate change cluster in time and place

The prevalence of obesity has risen globally in the past four decades including an 8 times increase in girls to 5·6% and a 10 times increase in boys to 7·8% in 2016.33 The rise in obesity prevalence in adults in the same period has also been relentless, increasing to 14·9% in women and 10·8% in men, in the same time period.1 In 2015, excess bodyweight was estimated to affect 2 billion people worldwide, and accounted for approximately 4 million deaths and 120 million disability-adjusted life-years.34 The estimated costs of obesity are about US$2 trillion annually,3536 representing 2·8% of the world’s GDP.36 The increase in the prevalence of obesity accounts for the rapid increase in diabetes, which now affects almost 9% of the world’s population.1

The Global Burden of Disease data suggest that, by 2025, nearly 268 million children and adolescents in 200 countries will be overweight, 124 million will have obesity, and almost three-quarters (72·3%) of NCD-related illness and deaths will occur in LMICs.34

The prevalence of undernutrition has been declining for decades, although it is still highly prevalent in many LMICs. The Global Hunger Index (1992–2017) showed substantial declines in under-5 child mortality in all regions of the world but less substantial declines in the prevalence of wasting and stunting among children.24 In 2008, stunting, severe wasting, and intrauterine growth retardation were estimated to account for 2·2 million deaths and 21% of disability-adjusted life-years in children under 5 years of age.37 In 2018, the Global Nutrition Report found that 155 million children were stunted and 52 million children were wasted.28 2 billion people have a micronutrient deficiency, and 815 million people are chronically undernourished. Undernutrition disproportionately affects children and adults in low-income countries, particularly those in eastern and middle Africa and south-central Asia.37 Because the prevalence of undernutrition has been declining, the prevalence of child and adolescent obesity might exceed moderate and severe undernutrition by 2022.1 Estimates of the costs to the global economy from undernutrition, micronutrient deficiencies, and overweight are up to $3·5 trillion annually.23

Although malnutrition in all its forms is by far the largest cause of health loss in the world, it will be compounded by the health effects of climate change in the near future.38 The health gains achieved in the past 50 years of global economic development could be reversed by 2050 due to the consequences of climate change.39 Estimates of the future costs of climate change are 5–10% of the world’s GDP, with costs in low-income countries in excess of 10% of their GDP.40

LMICs that produce the fewest greenhouse-gas emissions are more affected by climate change than those countries that produce the highest greenhouse-gas emissions. Furthermore, climate change will have a disproportionate effect on agricultural production and consequently human health in LMICs. The resultant population displacement might already account for increased global migration patterns in Africa and other regions.39

Obesity, undernutrition, and climate change interact with each other

Many interactions occur among the components of The Global Syndemic. The World Economic Forum’s annual risk reports include the global risks of climate change, NCDs, food crises, failures of governance, and failures of urban planning.41 The report’s interconnections map shows the interdependency of these risks. The UN’s IPCC predicts that the biggest threat to health from substantial climate change will be undernutrition.4243 Phalkey and colleagues44 provide an example of a causal loop diagram showing the systemic interconnections between climate change and food security (appendix p 3).

Climate change affects food systems in many ways. Small-scale, low-income farmers will likely be most affected, although environmental change will affect all producers exposed to storms, floods, drought, coastal erosion, warming oceans, and rising sea levels. A small degree of global warming might benefit some crops in some areas, taking into account the carbon fertilisation effects. However, global warming will lead to lower yields especially in tropical regions. Furthermore, climate change might reduce the protein and micronutrient content of plant foods.43 Although not all crops are equally affected, elevated levels of carbon dioxide have been shown to decrease protein concentrations of wheat, barley, rice, and potato crops by 10–15% and soy by 1·4%.45 These changes in nutrient value will further contribute to undernutrition, particularly in children. All of these changes will also increase the prices of basic food commodities,464748 and are expected to lead to increases in nutrient deficiencies and chronic undernutrition among the most food-insecure population groups.4950 Food insecurity could be exacerbated further by climate mitigation efforts associated with land sparing.50

Food production is one of the largest contributors to climate change. Agriculture directly contributes about 15–23% of all greenhouse-gas emissions, which is comparable to transportation. But when land conversion and the wider downstream food system processes, including food waste, are taken into account, the total contribution of food to emissions can be as high as 29%.5152 Livestock alone account for 12–19% of greenhouse-gas emissions.53 The types of food produced have differing effects. Both meat and dairy products require more resources and generate larger emissions of methane than plant-based alternatives.5455 Additionally, non-seasonal fruits and vegetables produce substantial emissions when grown in greenhouses, preserved in a frozen state, or transported by air.54 The energy required for the production, harvesting, transportation, and packaging of wasted foods also generates more than 3·3 billion tonnes of carbon dioxide annually, making food wastage the third top emitter after the USA and China.56

The globalisation of food systems has depended on cheap energy from fossil fuels for intensive large-scale agricultural production and long-haul transportation that has transformed the diets of the world’s population. Increased urbanisation has exposed people in these environments to markets for mass-produced, processed food and beverage products.

The interactions between climate change and obesity are also numerous but less certain. Increasing ambient temperatures could contribute to obesity through reductions in physical activity.57 Additionally, the effect of climate change on fruit and vegetable production will make these products more expensive, and might prompt shifts in the eating patterns of populations towards processed food and beverage products that are high in, fats, sugars, and sodium.57 Increased food and agricultural production to meet the needs of a growing population with a high prevalence of obesity will increase the food system’s greenhouse-gas emissions. Another mechanism by which obesity could contribute to climate change is through the increased costs of fossil fuels related to transporting populations with a high prevalence of obesity.57 This added contribution to greenhouse gases attributed to obesity is very small relative to other greenhouse-gas emissions5458 and emphasising this pathway risks placing further blame on people with obesity — not only for their own condition but also for climate change. Because periodic, but not severe, food insecurity is associated with increased risks of obesity in high income countries,59 increased food insecurity could theoretically increase the prevalence of obesity.

Obesity and undernutrition also interact. Undernutrition in early life is a predictor for later obesity. Biological and social mechanisms that explain this relationship include the contribution of fetal and infant undernutrition, food insecurity, and poor diet quality characterised by a low variety of healthy foods.60 Many middle-income countries, especially in the Middle East and north Africa, are facing a double burden of undernutrition and overweight or obesity. For example, Iran, Morocco, Oman, Saudi Arabia, Syria, and Tunisia are all in the top tertile of countries for both the prevalence of adult female obesity (>27% with body-mass index [BMI] >30 kg/m2)1 and female child and adolescent underweight (>18% with a BMI Z score <1 standard deviation; appendix p 4).61 Indeed, the co-occurrence of stunting (low height-for-age) and obesity (high BMI for age) is not uncommon within the same country, village, family, and even individual.23 LMICs carry the greatest triple-burdens of malnutrition. In LMICs, the prevalence of overweight in children less than 5 years of age is rising on the background of an already high prevalence of stunting (28%), wasting (8·8%) and underweight (17·4%).36 The prevalence of obesity among stunted children is 3% and can be more than 10% in some middle-income countries.62 Countries cannot afford to prioritise their nutrition policies to focus only on reducing undernutrition while costly obesity-related NCDs, such as type 2 diabetes, are overwhelming their national health systems.

Obesity, undernutrition, and climate change have common systems drivers

The shared societal determinants for obesity and climate change have previously been noted in the published literature.6364 Both are driven by the high consumption of cheap energy sources (foods and fossil fuels) and car-oriented transportation systems. The consumptogenic economic systems that promote excessive and unsustainable consumption patterns value GDP growth and overlook its role in damaging the health of people, the environment, and the planet.65 In economic systems in which the vested interests of powerful transnational corporations produce financial benefits that are maximally privatised, the social and environmental costs or externalities fall to consumers, taxpayers, ratepayers, and future generations. The major risks to society and economic development in the future are heavily neglected.57

The balance of power between actors within the governance mechanisms determines how the levers of power are used. Those levers include policies (eg, laws and regulations), economic incentives and disincentives, and societal norms and expectations. Although governance occurs at all levels, macro-level governance (usually national governments) creates the operating conditions for the major systems that drive The Global Syndemic — the food, transportation, land use, and urban design sectors. These macro systems, in turn, flow through the meso systems or settings in which people interact, such as schools, workplaces, retail outlets, and community spaces. They, in turn, influence the micro systems or social networks, such as families and social groups, affecting their behavioural patterns.

The power balance within the governance structures determines, for example, whether agricultural subsidies support monoculture crops and beef and dairy farming over more sustainable agricultural systems with fewer environmental effects and greater health benefits, whether funding for transportation infrastructure prioritises roads over mass transit and active commuting, whether periurban horticultural lands are zoned for housing and industry, whether economic policies promote consumption-driven growth, whether regulatory systems allow or constrain marketing of unhealthy food and beverage products to children or breastmilk substitutes to mothers, and whether cultural and religious codes of dress and behaviour, especially for girls and women, constrain their ability to be physically active and fully engaged with society. The sociocultural nature of some of the systems is important to note. A population’s values, beliefs, attitudes, religious expectations, and social practices shape the types of foods people eat, how they use food for hospitality, the status attributed to particular foods, and their vulnerability and exposure to targeted commercial marketing that exploits these attitudes and values.

Key aspects of the political economy have been recognised as the deep drivers that shape the very nature of the systems creating The Global Syndemic. For example, economic power has become increasingly concentrated into fewer and fewer transnational corporations, and this is certainly true in the food sector.666768 According to the former Director General of WHO, this “market power readily translates into political power”.69 Specifically, the transnational corporations lobby for fewer regulations that apply to them (eg, no regulations on marketing unhealthy food to children or warning labels on processed foods), promote regulations that apply to other sectors (eg, trade and investment agreements that bind governments to protect corporate investment interests), resist or reject taxes that apply to their products (eg, taxes on sugary drinks and energy-dense, nutrient-poor foods), and lobby policy makers for subsidies that benefit their businesses (eg, agricultural and transportation subsidies).68 The fossil fuel and food industries that are responsible for driving The Global Syndemic receive more than $5 trillion in annual subsidies from governments.70

Complex adaptive systems

Close examination of the contributors to The Global Syndemic reveals the role of complex adaptive systems operating at each of its levels (figure 2B). Systems, such as health systems, schools, or families are complex because the inter-relationships are multiple, change over time, and involve several interacting, reinforcing, and balancing causal feedback loops, as well as the fact that non-linear associations exist between causes and effects. Reinforcement of feedback loops leads to virtuous or vicious cycles, depending on the outcome, although balancing feedback loops counteract the directions of change that form the basis of homoeostasis and policy resistance in complex adaptive systems. For example, a new food launched into the market might accelerate profits for its manufacturer, which in turn supports more marketing and wider distribution that make more profits in a reinforcing feedback loop. However, the product’s growth in sales and profits are not infinite because market saturation and competition act as balancing feedback loops that counteract the reinforcing feedback loop driving the initial growth.71 Understanding the dynamics of the major feedback loops within a system is, therefore, crucial to identifying how to reorient the systems towards better outcomes.

The systems are also adaptive. Any change in one part of the system will lead to changes in the implicit and explicit rules of the actors in other parts of the system, generating new, emergent dynamics. Changing the reimbursement structure within a health system, changing governance structures in a school, or changing the structure of a family through marriage or separation, for example, can lead to the adaption of actors by changing the rules in how they respond to each other and their environment, and push a system toward a new equilibrium or system instability.

Taking a system dynamics approach to The Global Syndemic provides new insights into three critical questions: why are systems, including food systems, the way they are? Why do they need to change? Why are they so difficult to change?72

Five sets of feedback loops

The Commission considered that five crucial feedback loops (figure 2C) need to be assessed within the food, transportation, urban design, and land-use systems as the drivers of The Global Syndemic: the business, supply and demand, governance, ecological, and health feedback loops. The feedback loops are described in more detail below with reference to the food system, but they also apply substantially to transportation systems, urban design, and land use.

The business feedback loops reflect the market-based food systems that combine the profit motives of businesses with the demands of their customers. Market-based food systems are remarkably robust enterprises for getting food from its source in farms or the sea to people in the centre of megacities or in remote rural outposts. The food value chain, rather than supply chain, better describes the system because as food travels one way from one private operator to another along the chain, money and profits flow back the other way as a set of intersecting positive feedback loops that ensure that the system incentivises the flow of food to people. The underlying imperative of adding value along the chain intrinsically leads to more processed and ultra-processed foods. Milk as a basic food has less added value (in profit terms) than baby formulas, yoghurts, and ice cream. These products fulfil consumers’ desire for taste, variety, choice, and shelf life, and create greater profits for the food providers. Unfortunately, such a focus also results in a food supply that is high in ultra-processed foods and is associated with higher rates of chronic diseases.737475 Negative health and environmental outcomes are not factored into the current business model which has a major role in creating and sustaining The Global Syndemic. As we discuss later, new 21st century business models are needed to ensure that food systems contribute positively to all four global outcomes of health, sustainability, social equity, and prosperity.

The supply and demand relationship through market mechanisms efficiently matches food supply with consumers’ wants and needs and their ability to pay. However, consumers themselves have biological, psychological, social, and economic vulnerabilities that industry exploits through food environments that influence people’s preferences, which increases the demand for energy-dense and nutrient-poor food and beverage products and feeds back into increased supply.2 Some government measures, including regulations for the marketing of unhealthy food and beverage products to children, front-of-pack warning labels, fiscal policies such as soda taxes, and consumer protection laws can help to constrain this supply-driven consumption of unhealthy foods. However, demand-driven consumption of unhealthy or environmentally damaging foods can occur if the foods are considered part of familiar or aspirational cuisines. For example, cheap, fatty mutton flaps exported from New Zealand or turkey tails from the USA have become part of the standard cuisine in some south Pacific countries,76 which in turn affects supply and demand for those unhealthy products.77

Red meat consumption is widely consumed in high-income countries and, as countries develop economically, the demand for red meat as a high status food also increases.78 Reducing the consumption of red meat is a cornerstone for healthy, sustainable diets, but achieving this will be formidable given the current supply and demand dynamics. Western-style fast foods might also be part of aspirational diets for some populations in low-income countries.79 Dietary patterns are relatively conservative and tend to change slowly over decades, often with new generations, immigrant cuisines, or new information on the health effects of specific foods providing the stimulus for change.

Although correcting market failures due to negative externalities on health and the environment is a core task of governments, policy inertia affects their implementation, as has already been noted and is explained within the set of governance feedback loops. Powerful lobby forces often prevent government policy making for public good.6880 Although the collective voice of small farmers is a political force in some countries, the concentrated power of the large food corporations is the most powerful source of policy inertia for actions that create healthier food environments.68 Additionally, the governance structures in many countries are weak or corrupt, making them even more susceptible to influence. Transparent and accountable governance structures are needed that are free from conflicting interests, inclusive of civil society groups, and responsive to the needs of citizens.

Feedback loops related to natural systems help explain why the business, supply and demand, and governance structures cannot be maintained under existing operating conditions. Current food systems are degrading the environment beyond the capacity of natural ecosystems to repair. The forces of over-extraction and pollution of natural environments are not balanced by built-in constraints on those business or consumer activities that damage the environment through greenhouse-gas emissions, pollution of waterways, deforestation, reduced food biodiversity, water over-extraction, soil degradation, or food waste.68 Eventually, a degraded natural environment will have a negative feedback on businesses and consumers, but this is often a delayed effect on health (shown by the parallel lines across the arrow in figure 2C) that will be felt by future generations of land and business owners, consumers, and citizens.

Human health feedback loops also explain why the existing systems cannot continue. The development of the current food systems has substantially improved human health in the past century, but now, paradoxically, these same food systems have become a major contributor to the global epidemics of chronic diseases. Better nutrition and food security have helped increase life expectancy, but, at the same time, poor diets have become the biggest contributor to the global burden of disease (figure 1). The effects on health represent another major negative externality of the food system, with delayed feedback from the health problem to the food system. For example, there has been a considerable delay between the recognition of the adverse health effects of sugary drinks and the creation of policies to reduce their consumption.

Levers to convert policy inertia into policy traction

These five sets of feedback loops need to be examined in more depth from a systems perspective to identify the types of levers that might create traction for implementing policies to reduce the ecological and health damage. Many of the systemic levers will be double-duty or triple-duty actions for mitigating obesity, undernutrition, or climate change.

The feedback loops that protect the environment need to be strengthened. Carbon pricing, pollution regulations, water levies, consumer education, and environmental food labelling are examples of such measures. The feedback loops that constrain the production and marketing of foods and beverages that promote ill-health also need to be strengthened. These efforts include taxation, front-of-pack signposts such as warning labels for products high in sugar and salt, and consumer education and social marketing campaigns. Other strategies include gaining commitments from food companies to create healthier food environments and holding them to account for fulfilling such commitments using monitoring and public ratings systems. At the same time, strategies that promote availability, accessibility, and affordability of healthy foods must be implemented across the food system. The imperative for food systems to provide the basis for healthy diets should be articulated in all policies that shape them, from agricultural production through to retail. Strategies to increase the demand for healthy foods, such as education, social marketing, government procurement, taxes, and subsidies can send the signals back through the value chain, creating alternative sources of value.

Strengthening governance, managing conflicts of interest, and creating social demand for change are all important strategies to counter the current detrimental influence of vested interests on public food policies. Additionally, new business models are needed to reduce the negative externalities created by incentives in the current economy. Corporate social responsibility efforts, which are too often marketing exercises, need to evolve into a stronger accountability model, in which targets and performance criteria are independently specified, monitored, and publicly shared.

Changes to fundamental values, guiding philosophies, and principles (eg, human rights, polluter pays, agriculture for better nutrition, and improved infrastructure for public and active transportation) will have more powerful, systemic effects than more visible changes (eg, school food programmes, food labelling, and pricing policies), because values that permeate the whole system create more fundamental and sustained changes.

The role of individuals

The idea that individuals personally carry the responsibility for their own health-related behaviours is common, especially in Western, individualistic societies. The recognition that people’s health-related behaviours are heavily influenced by the environments around them is the first step in implementing effective policies to support health. For example, poverty severely restricts people’s capacity to make healthy choices, and obesogenic environments dominated by fast food outlets and unsafe neighbourhoods severely restrict the healthy choices available. Affluence and health-promoting environments create a positive health effect.

As previously noted, the socioecological model concept of the person–environment interaction is centred on the individual. The model shows how individuals are products of their personal attributes and the environments and influences around them. In our framework, individuals populate all layers of the human systems and continuously interact with the natural ecosystems (figure 2D). They do not and cannot exist in isolation of the natural and human systems. By depicting individuals in this manner, the three parts of the person–environment interaction become more apparent. The first part is the personal agency individuals have in making their choices from the environments available. The second is the influence the environment has on those choices. The third is the influence that the individual has on changing the environments and systems around them.

People live in networks of influence. Their influence is greatest at the micro level with family and social circles, but people also interact in and influence many settings — eg, workplaces, schools, universities, shops, recreational settings, villages, and local communities. Even at the macro level, being a consumer, using mass media, or working in government or other macro systems provides an opportunity to create influence. Individuals also have a voice in governance, especially within democracies that are not overshadowed by money and corruption.

This depiction of individuals as network agents provides an important basis for action. The two things that flow across human networks to create change within a system are knowledge (an understanding about the nature of the problems and how to apply actions) and engagement (the energy, enthusiasm, and commitment for change).81 For individuals, actively disseminating knowledge and engagement through networks is a central mechanism for reorienting existing systems, especially at the community level (discussed in the Community-based actions section).

One broad strategy for addressing The Global Syndemic is, therefore, to give people the capacity to take personal responsibility for their own health by reducing poverty, strengthening education, and reducing structural and social prejudice on the basis of gender, religion, and race. A second is to make the healthy and sustainable choices the easy and default choices through strong public-interest policies. A third is to activate people’s network agency so that society’s human systems reorient to promote the four essential global outcomes: environmental health and wellbeing, human health and wellbeing, social equity, and economic prosperity.

The nature of double-duty or triple-duty actions

The 2015 Global Nutrition Report first used the term double-duty actions to describe programmes and policies that could potentially reduce the burden of both undernutrition and NCDs related to overweight, obesity, or diet.82 This concept has been crucial in starting to bring together each form of malnutrition under the umbrella term of malnutrition in all its forms.83 Examples of double-duty actions provided in the Global Nutrition Report included actions to promote breastfeeding in workplaces, urban planning for healthy food outlets and discouraging outlets for unhealthy food, ready access to clean water, and universal health care.

The 2017 Global Nutrition Report proposed that triple-duty actions could have positive effects on all of the 17 SDGs.23 Examples included: diversifying food production systems to provide a nutritious food supply, ecosystems benefits, and empowerment of women to become innovative food value chain entrepreneurs; increasing access to efficient cooking stoves to improve nutritional health, reduce respiratory disease from indoor smoke, preserve forests, and reduce greenhouse-gas emissions; and providing school meal programmes that could reduce undernutrition, prevent the risk of developing obesity, provide income to local farmers, and encourage children to stay in school and learn better when at school. As already noted, the SDGs are highly interconnected and many actions can have several benefits across SDGs. In this report, we use the concept of double-duty or triple-duty actions to discuss those actions that address two or three aspects of The Global Syndemic (appendix p 11).

Drivers have most in common at the governance and macro levels (figure 2B and 2C). Some triple-duty actions such as dietary guidelines and nutrition education to address obesity, undernutrition, and environmental sustainability, can be delivered at the meso level (eg, through schools) or micro level (eg, through social marketing), but they are developed primarily at the macro and governance levels. For example, when the USA and Australia tried to include sustainability in their national dietary guidelines, vested interests from food industries leaned heavily on their governments to eliminate sustainability from the terms of reference.8485 Brazil, which has a much more democratic governance structure for food policy development,86 kept vested interests at bay and produced the first dietary guidelines with explicit sustainability recommendations.87

As articulated in the first Lancet Series on Obesity,88 interventions that involve changing its societal determinants are much more difficult and have much less direct evidence of their effects, but they are much more important than programmatic and educational approaches to complex problems. Because these societal determinants are the deep drivers of The Global Syndemic, the Commissioners believe that they should be central to the debate about solutions. The following actions would support policies on The Global Syndemic, but all require fundamental shifts in societal beliefs and priorities and will face repeated resistance: reducing the effects of vested interest lobbying on public policy development, internalising the costs of a product’s effects on the environment and human health into its price, redistributing wealth to alleviate poverty, reducing corruption in governments, and elevating the education, power, and status of women. The certainty that any particular lever for system change will have the desired outcome is low within the hierarchies of evidence commonly used in health. However, if achieved, the effects can be expected to be felt across the spectrum of The Global Syndemic.

Many authoritative reports from WHO, other UN agencies, and groups of independent experts contain specific recommendations for actions on obesity and undernutrition by countries, international bodies, the private sector, development agencies, civil society, and academia. The same is not the case for reports on climate change. The most authoritative body for climate change, the UN’s IPCC, has produced many reports that provide evidence-graded statements about the underlying science of the problems and potential actions, but lack recommendations for specific actors.

To test the idea of double-duty or triple-duty actions, we sourced the most recent, comprehensive authoritative reports on recommendations for action for nutrition and physical activity and assessed the potential that these recommended actions might have for climate change mitigation and adaptation (appendix p 13). These preliminary assessments, presented in the following sections, show the existing overlaps across nutrition, physical activity and climate change action areas, and therefore the value behind more combined efforts. If the deep drivers of The Global Syndemic are going to be changed, independent movements, such as those that address poverty reduction, environmental sustainability, climate change, food sovereignty, social equity, hunger prevention, liveable cities, safe neighbourhoods, healthy food environments, rights of the child, and good governance, will need to be more coordinated, more coherent in their communications about the multiple benefits, and more forceful in their demands for deep change.

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