Behind two days of talks at the United Nations and a unanimously adopted 13-page document about the need to fight noncommunicable diseases around the world is a fierce struggle between commercial and health interests that has only just begun.

Some of the issues, and some of the partisans, are the same ones at the heart of two other huge health campaigns in the past 20 years — the battle against smoking and the effort to bring AIDS drugs to poor countries. But the stakes here are much bigger, given the number of lives and sums of money at play.

That’s because noncommunicable diseases — heart disease, stroke, cancer, diabetes and emphysema — are deeply entangled with important global industries, not only tobacco but also food, pharmaceuticals, advertising, transportation and construction. And they are the globe’s biggest health problem, responsible for 63 percent of all deaths each year, with incidence growing steeply in the low-income, rapidly urbanizing nations of the world.

At issue are two questions: Will assaulting obesity-driven ailments require attacking the food companies the way assailing tobacco companies has driven efforts against smoking? What is the responsibility of rich countries, and the pharmaceutical companies located in them, to improve medical care in poor countries, where 40 percent of deaths from noncommunicable diseases occur before age 60?

The food industry, which is responsible for much of the sweet, salty, high-fat food that experts view as a problem, for the moment is considered a “partner” in the new campaign. It will not be treated as a pariah industry like tobacco, whose companies are barred from meetings like this.

The 13-page “Political Declaration” under intense negotiation since June and adopted Monday contains more than a dozen “partner” references. It telegraphs a message that voluntary changes in salt, fat and calories in food and in marketing directed at children are the preferred route to slowing the rise in obesity, hypertension, high cholesterol and inactivity that underlies many of the diseases.

Activists hungry for more

It is a position that has left many activists unsatisfied.

“Our position is that partnership isn’t the right word. It implies trust and respect,” said Patti Rundall, who helped run the campaign against infant formula sales in Africa 30 years ago and today is working to limit the marketing of processed food in the developing world. “The allegiance of the food companies is to create profits. Their voluntary commitments are only good for as long as they want to keep them,” she said.

Laurent Huber, 41, a Swiss exercise physiologist who works for an anti-smoking group, said, “The fast-food industry and the junk-food industry cannot be engaged in the policy process. They are part of the problem. This conflict of interest needs to be looked at.”

Nevertheless, many companies have agreed to slowly reduce salt in processed food, remove trans fats and remake restaurant dishes so they contain less fat. This month, the company that owns the Red Lobster and Olive Garden restaurants promised to take that last step.

The bigger issue in preparing the document, however, was how much to invoke the international trade agreements that indirectly have helped bring life-saving antiretroviral drugs to nearly 7 million people with HIV infection in low-income countries in the last decade.

In 2001, the World Trade Organization’s agreement on intellectual property, known informally as TRIPS, was amended in Doha, Qatar, to help developing nations gain access to AIDS drugs. The Doha Declaration said a poor country could force pharmaceutical companies to let manufacturers make generic drugs for use in low-income countries, in exchange for a small royalty.

This option helped persuade U.S and European drug companies to voluntarily let offshore companies make versions of their high-priced drugs long before the patents expired. This prevented “compulsory licensing,” as the Doha mechanism is called, from becoming common practice.

The Doha Declaration referenced HIV, tuberculosis, malaria “and other epidemics.” Whether that might cover “epidemics” of noncontagious diseases such as diabetes and hypertension wasn’t mentioned — or probably even considered.

The document from this week’s U.N. meeting doesn’t mention the Doha Declaration, although it does mention “full use of TRIPS flexibilities.” It also doesn’t describe the noncommunicable diseases as epidemics; it calls them “a challenge of epidemic proportions.”

Many experts and activists interpret these omissions as evidence that rich countries don’t want their drug companies to be pressured into repricing cancer and heart medicines for the developing world as they were for antiretrovirals. There are far more drugs for noncommunicable diseases; many are pricier than AIDS drugs; and there are hundreds of millions more patients who could use them.

“We really believe that Doha was not meant to be so narrowly interpreted, that it was intended to address all public health crises,” said Krista L. Cox, a lawyer for Knowledge Ecology International, a four-person organization with offices in Washington and Geneva that campaigns for global health equity.

Pharmaceutical Research and Manufacturers of America takes a different view.

“Compulsory licenses are intended to be used to address health emergencies and to provide urgent access in situations where there is little or no availability of existing effective medicines,” said Jay Taylor a vice president of the trade group. “This situation is clearly not the case in the context of the growing burden of noncommunicable diseases . . . there are hundreds of low cost generic medicines to treat NCDs in low-income countries that simply are not getting into the clinics and pharmacies or into the hands of the patients that need them most.”

The organization’s member companies would work to provide those to needy countries, he said.

A summary of the negotiations, made available to The Washington Post on the condition it not be quoted directly, shows that U.S. negotiators at one point threatened to scuttle the document if it mentioned either TRIPS or Doha. A compromise was reached in which the former was included but not the latter, and also no reference to “epidemics.” This was viewed as giving future negotiators more flexibility in issues of compulsory licensing.

A U.S. government official familiar with the talks had a different account. The official said there was little debate over a Doha reference and that its absence from the final document is insignificant because Doha is part of TRIPS. As for “epidemics,” the official said, negotiators simply stuck to the medical definition, which requires contagion.

Asked about the Doha omission on Tuesday, the director-general of the World Health Organization, Margaret Chan, took a similar position: “Any member of the WTO can exercise the TRIPS flexibility, and that’s it.”