How Mexican Public Health Advocates Fought Big Soda and Won | Civil Eats

How Mexican Public Health Advocates Fought Big Soda and Won

The new film ‘El Susto’ documents efforts to tax soda in Mexico at a time when Coca-Cola was more accessible than water and Type 2 diabetes was the leading cause of death.

Coca-Cola billboard

A Coca-Cola billboard at the entrance to the Mayan community of San Juan Cancuc in Chiapas, Mexico. (Photo credit: Thomas Aleto)

When Karen Akins signed up to volunteer for a medical mission to Mexico in 2008, she knew very little about the impact of type 2 diabetes on the country. She had no idea that rates of the disease had doubled between 2000 and 2006, that Mexico’s healthcare system was ill-equipped to handle chronic conditions, nor that, for a time, it was the leading cause of death there.

Akins traveled to remote rural villages where the Coca-Cola logo was painted on elementary school walls and bottles of soda were cheaper than water. There, she and her team delivered the dreaded diagnosis over and over. She learned that soda consumption had doubled among Mexican adolescents between 1999 and 2006, mirroring diabetes rates, and began to get angry about what she—and everyone else—hadn’t known.

“Occasionally we would test people, and when they heard that they had diabetes, they would go, ‘Oh, El Susto.'”

“I was concerned about people on the ground that were suffering,” she said. So she decided to make a film about what she had learned.

About a decade later, despite having no filmmaking experience, Akins finished El Susto (The Shock), a documentary that follows Mexico’s type 2 diabetes public health crisis, tracks the soda industry’s role in that crisis, and looks at how a group of advocates and politicians challenged the industry and passed a federal soda tax there in 2013.

Since the soda tax passed in 2013, data have shown sales of the taxed drinks went down. Recent research also shows more Mexicans are drinking less soda as a result of the tax.

El Susto movie graphic

Akins finished the film in 2019, but the pandemic slowed the rollout. This month, it became widely available in the U.S. (and around the world) for the first time, via Apple TV, Amazon Prime, and On Demand (via select cable providers).

El Susto documents how Coca-Cola and other soda brands became ever-present throughout Mexico over time. It tracks their ubiquity even in remote, rural places (where nutrition education is often lacking), as well as their inescapable branding, and the companies’ ties to politicians, health organizations, and media outlets. It also shines a light on the dire impacts of type 2 diabetes on Mexicans—from blindness and amputations to more than 100,000 deaths annually.

At a moment when battles over soda taxes are being fought all over the world, Civil Eats spoke to Akins about what she saw through her lens and what she hoped to convey about soda taxes, public health, and Big Soda on screen.

“El Susto” refers to an Indigenous belief that shock, caused by a trauma, can cause illnesses like type 2 diabetes. Why did you decide to make it your title?

Occasionally we would test people, and when they heard that they had diabetes, they would go, “Oh, El Susto.” We kept hearing it. Later on, when I started delving into attitudes, I [realized that I] didn’t understand how prevalent the [belief] was throughout Mexico and Central America. But the film’s name works on several levels. It works on the economic level, where you’ve had an influx of processed foods that has shocked the whole culinary culture. And it also has another level of meaning: the unseemly tactics that the companies used are another level of shock and horror. I was interviewing this academic down at the University of Texas, Austin—Dr. Pilar Zazueta—and an hour and a half into the interview [I asked her about] El Susto and she got super serious and gave this unbelievable explanation. She said that this could be a way that people make sense of how their lives are being disrupted.

La Patrona mural (Thomas Aleto)

A mural featuring Pepsi logos at a shop in Santa Ana Zegache in Oaxaca, Mexico. (Photo credit: Thomas Aleto)

In some of the rural places you filmed, the fact that safe water wasn’t always available contributed to soda consumption. Can you speak about the ways economics and lack of infrastructure in Mexico contributed to Big Soda’s ability to become so ingrained in the culture?

There have been fairly recent cholera outbreaks in Mexico, so the fear [of drinking the local water] is not unfounded in some places. A lot of people just don’t want to take the risk, and they know that if they drink a Coke it’s going to be fine.

I’m not an expert on Mexican water policy, but there was some corruption inside the Mexican government when Vicente Fox was president, and he was a former Coca-Cola executive. He had one of his former colleagues as the head of the department in charge of water, and then they started giving out water rights to bottling companies. And maybe it was just meant to create jobs. It certainly did, but it was also taking a public resource, privatizing it, and letting people profit off of it. And then it enabled them to do things like produce bottled water and Coke and set the price of Coke at less than the water, which incentivizes drinking it. They had all kinds of tactics, including a heavy marketing presence everywhere.

We’ll bring the news to you.

Get the weekly Civil Eats newsletter, delivered to your inbox.

We would hear from some of the women working with the Indigenous communities that when they would say, “You shouldn’t put Coke in the baby’s bottle” [they didn’t always have the option not to]. Well, the children got the calories that they needed so that they weren’t wasting away. It’s the same thing with the construction workers that take a two-liter bottle of Coke with them to the job site for the day for their sustenance. It’s a cheap, convenient way to provide energy. It really speaks to poverty, and I don’t think there’s a simple fix. But the soda companies certainly took advantage of all of the weaknesses in the food system there.

DOD protest (photo credit: El Poder del Consumidor)

Public Day of the Dead altar erected to bring attention to the 500,000 people who died from diabetes from 2007-2012 in Mexico. The protest event was organized by Consumer Power, El Poder del Consumidor, the leading NGO advocating for public health policies to combat the diabetes and obesity epidemics.

What do you think sparked the start of the campaign for a federal soda tax?

They had been trying to tax soda in Mexico since the ‘30s or ‘40s. I’ve seen some of the campaigns. So, there is a long history . . . and it never ever went anywhere. The spark, I think, was when the type 2 diabetes numbers spiked. They needed to figure out something to do quickly that would be effective. If you do an education  campaign it may take a generation to change people’s habits. But the soda tax was something that could be implemented quickly, and I think it coincided with the World Health Organization coming out with good data about taxes and the likely reduction in consumption, right about that time.

Also, there was such an economic need at that moment. Mexico was really suffering, and the health system was on the verge of collapse from having to take care of all the consequences of chronic diseases. I think we have a line in the movie [about how] the health system had been set up for infectious diseases like cholera . . . it just wasn’t quite set up to deal with what they were seeing. So, I think the economic incentive to do it cannot be overlooked. And it was good timing, there was a change in government. A lot of things came together all at once.

You spend a lot of time in the film showing the tactics that the industry used to fight the proposed tax. Which actions stood out to you? 

I think we’re used to industry setting up trade associations and lobbying under those trade associations’ name. Or creating front groups to go out and do your bidding so that your company isn’t associated with something. But the thing that bothered me the most personally was [the industry’s] use of science. Hiring their own scientists and doing really bad studies that were not peer-reviewed and that were done for the purpose of casting doubt on good science. Because when policymakers . . . start to get conflicting information, they freeze. They don’t know what to do because they’re not experts.

I think the fact that the company funded those kinds of things was really disingenuous. It’s creating confusion. It’s disinformation.

Snacks offering (photo credit: Marcus Brooks)

Snacks, Coca-Cola, and beer are offered at an altar. (Photo credit: Marcus Brooks)

At the end of the day, the tax passed. Public health advocates were successful there, unlike a lot of other places where people have tried. Why did they succeed?

Every single person in Mexico has somebody with type 2 diabetes in their family, who they see suffering. I don’t have any proof that that fed into it, but I think at some level, there was this underlying concern about the health of the country. If it wasn’t the country with the highest diabetes rates in the world, maybe it would have been harder. But it was also a perfect storm of economic need and then also the fact that the nonprofit groups got very organized. And I don’t want to bring Bloomberg into it, but he did put a lot of money in and still continues to put money into this issue all over the world. That’s not to minimize the great people that were on the ground figuring out how to push for it and make it happen. It’s still a miracle that had happened, and I think that they probably couldn’t believe it after.

Thank you for being a loyal reader.

We rely on you. Become a member today to read unlimited stories.

How do you see this film influencing efforts that are happening around soda taxes in the U.S. and in other countries?

We premiered in December 2019, months before the pandemic. I thought that we would have a bunch of community screening tours in different places where they were discussing taxes. It turned out we did lots of virtual screenings. We ended up doing them all over the world . . . and we’ve been involved when [groups in different places have been] pulling together their coalition to push for a tax. People are using the film to educate a lot of people very quickly. And that’s what I was aiming for.

El Susto - Diabetes test (Photo credit: Katarina Zvarova)

Diabetes testing (Photo credit: Katarina Zvarova)

Can you share an experience you had while filming that really stuck with you?

We were in this remote Mayan village, and we were testing some people there for diabetes. I was out in the van waiting for people to finish up. And there were these three little girls. I was playing with them and dancing with them. One little girl just wouldn’t smile at all; she would give a sort-of closed-mouth smile. And then I realized that all of her teeth had rotted. This wasn’t diabetes, but when you see how her life is already being affected, that her confidence was taken away . . . It was a very visible effect of what was happening. Would Coke executives be proud of that?

This interview has been edited for length and clarity.

Lisa Held is Civil Eats’ senior staff reporter and contributing editor. Since 2015, she has reported on agriculture and the food system with an eye toward sustainability, equality, and health, and her stories have appeared in publications including The Guardian, The Washington Post, and Mother Jones. In the past, she covered health and wellness and was an editor at Well+Good. She is based in Baltimore and has a master's degree from Columbia University's School of Journalism. Read more >

Like the story?
Join the conversation.

More from




Senator Cory Booker Says FDA Proposal Could Worsen Antibiotic Resistance

A farmworker feeds cows in a barn.

Are Companies Using Carbon Markets to Sell More Pesticides?

a tractor sprays pesticides on a field while hazard symbols fade into the distance. (Civil Eats illustration)

In Brazil, a Powerful Law Protects Biodiversity and Blocks Corporate Piracy

An overhead shot of the Atlantic Forest in Brazil. (Photo credit: FG Trade, Getty Images)

Bringing Back Local Milk, Ice Cream, and Cheese

Foggy Bottoms Boys co-owner Cody Nicholson-Stratton pictured with his son. (Photo courtesy of Foggy Bottoms Boys)