“Food deserts”—evidence and assumption in health policy making
BMJ 2002; 325 doi: https://doi.org/10.1136/bmj.325.7361.436 (Published 24 August 2002) Cite this as: BMJ 2002;325:436
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Absolutely true!. Accepting repeated assertions as received truth,
and formulating policies based on them, is pervasive of all sorts of
health care systems. This is another expression of what the late Petr
Skrabanek called 'the Bellman's fallacy'[Skrabanek], after the famous
declamation of the Bellman in 'The hunting of the snark':
"Just the place for a Snark!" the Bellman cried,
As he landed his crew with care;
Supporting each man on the top of the tide
By a finger entwined in his hair.
"Just the place for a Snark! I have said it twice:
That alone should encourage the crew.
Just the place for a Snark! I have said it thrice:
What I tell you three times is true." [Carroll]
Those health care systems with more restricted budgets, particularly
in low and middle income countries, need to do a special effort to resist
adopting policies based on 'factoids', sometimes pushed forward by
commercial interests, sometimes by the good-will of aid organisations
based on OECD countries. Let us be aware!: repeated assertions posing as
truth are everywhere (and I have said it twice!).
Dr. Rodrigo A. Salinas
References
Carroll, L. The hunting of the snark. London: Penguin Books, 1967.
Skrabanek, P. Follies and fallacies in medicine, third edition.
Withorn: Tarragon Press, 1999.
Competing interests: No competing interests
EDITOR – Cummins and Macintyre use the term ‘factoid’ to describe
“assumptions or speculations reported and repeated until they are
considered true” and discuss this in terms of the apparently uncritical
acceptance of the concept of ‘food deserts’ by the current UK government
(1).
Doubtless there are numerous factoids circulating in all areas of
both policy and research. In particular, we believe that many current
ideas concerning social capital, health and socio-economic inequalities in
health (SEHI) are factoids and that, like the concept of food deserts,
these have been incorporated into government policy without the support of
suitable research evidence.
For example, there is still considerable disagreement over the
definition of social capital, at what level it should be conceptualised
(e.g. individual or community), how it can best be measured and the exact
relationship between social capital, socio-economic status and health
(2,3). Furthermore, there is little evidence concerning methods of
building or regenerating social capital or that this has a beneficial
effect on the population’s health. Despite these rather fundamental
problems, both the UK government (4) and the World Bank (5) have
repeatedly emphasised the importance of social capital in terms of
improving population health.
In common with Cummins and Macintyre’s analysis of food deserts, we
do not dispute the possibility that social capital is an important
determinant of health or that variations in social capital may be one
explanation of current SEIH. However, the jury is still out and further
evidence is needed before significant amounts of public money are invested
in what remains a controversial area.
We agree with Cummins and Macintyre’s conclusion that “when making
health policy decisions, we need to move away from an unquestioning
acceptance of conventional wisdom…and cast a more critical and objective
eye over the facts”. It is the responsibility of good scientists to
provide evidence that helps us differentiate between seductive ideas and
actual facts and the responsibility of good policy makers to interpret
this evidence carefully. We are concerned that, by accepting and
promoting particular theories which are far from confirmed, governments
and policy makers may be hastening the development and propagation of
factoids and that these stifle much needed further research and debate.
(1) Cummins S, Macintyre S. “Food deserts” – evidence and assumption
in health policy making. BMJ 2002;325:436-438
(2) Baum F. Social capital: is it good for your health? Issues for
a public health agenda. Journal of Epidemiology and Community Health
1999;53:195-196
(3) Macinko J, Starfield B. The utility of social capital in
research on health determinants. The Milbank Quarterly 2001;79(3):387-427
(4) http://www.cabinet-
office.gov.uk/innovation/2001/futures/main.shtml (accessed 30 August 2002)
(5) http://www.worldbank.org/poverty/scapital/ (accessed 30 August
2002)
Competing interests: No competing interests
Having recently (a) read that the BMJ is going to produce an American
version, and (b) come back from the ‘Grossology’ exhibition at the Science
Museum, I wonder how the editors are going to deal with the translation of
Factoid in the article by Steven Cummins and Sally Macintyre?
The Grossology exhibition is 'on tour' from the USA. Throughout the
exhibition viewers are presented with ‘Factoids’. I asked the ‘attendants’
on the door what the word meant and the answer was 'little fact'. A quick
look at some web pages using the word 'Factoid' shows that some seem to
use it as ‘little fact’ (e.g. 2-3) while others (e.g. 4) do use it as
defined by Cummins and Macintyre. Given the confusion over the meaning of
the word, Conway and Budewig are probably right to argue its use is
unhelpful.5
1. Cummins S, Macintyre S. "Food deserts" - evidence and assumption
in health policy making. BMJ 2002; 325: 436-438
2. http://www.beach.com/surfrider/cfactoid.asp
3. http://www.nps.gov/yell/technical/fire/factoid.htm
4. http://www.mincava.umn.edu/papers/factoid.htm
5. Conway D, Budewig K. Get your factoids right. BMJ rapid response,
29/8/2002.
Competing interests: No competing interests
Response to Cummins S., Macintyre S. “Food deserts” – evidence and
assumption in health policy making. BMJ. 2002; 325: 436-438.
Cummins and Macintyre are right to emphasise the problems of
“unquestioning acceptance of conventional wisdom” in public health and
social policy1. It contributes to the important debate of evidence based
public health practice2,3,4.
The main point we feel compelled to comment about is the misleading
nature of the article. The authors introduce the term ‘factoid’ and define
it as simulated or imagined facts. The use of this neologism is unhelpful
and does not add to the article’s transparency.
On the first page in the summary box, the following is stated: “the
assumption that in the United Kingdom there are poor urban areas where
residents cannot buy affordable, healthy food (‘food deserts’) is a
factoid”1. Applying the above definition of factoid to the statement, it
translates into “the assumption that there are food deserts is an imagined
fact”. However, the authors conclude by stating that the relevant research
is conflicting. And then they go on to reassure the reader they "are not
suggesting that food deserts do not exist in the United Kingdom"1,
although the above summary point does exactly that.
There is a lack of clarity in the arguments and the structure of the
article. In our view it would have been necessary to comment on the
difference between inconclusive evidence and evidence against the
existence of food deserts.
Cummins and Macintyre have put themselves at risk of being
misunderstood as a recent article in a Scottish national newspaper
demonstrated. The Herald’s medical correspondent reported: “According to a
report published today the so-called ‘food deserts’ which have driven
policy for 10 years are a myth”5. We doubt that this interpretation was
intended by Cummins and Macintyre.
Issues associated with health improvement and inequalities are
complex socio-political processes. Their clear presentation and analysis
are therefore of paramount importance. To choose such an area of public
policy to highlight the use of “factoids” does nothing to help tackle the
issue of “food poverty” - a very real challenge which the authors have
acknowledged5. This paper only undermines the holistic approach that is
required to tackle food poverty in the United Kingdom that must address
the infrastructural requirements of access to healthy food in terms of
local availability, relative affordability in addition to food culture,
selection and preparation6.
Finally, we agree with the authors that the Food Poverty Eradication
Bill7 should be welcomed. However, in the context of a holistic approach
to this policy we cannot accept that the concept of “food deserts” should
be excluded.
References
1. Cummins S, Macintyre S. “Food deserts” – evidence and assumption
in health policy making. BMJ. 2002; 325: 436-438.
2. Davey Smith G, Ebrahim S, Frankel S. How policy informs the
evidence. BMJ. 2001; 322: 184-185.
3. Rychetnik L, Frommer M, Hawe P, Shiell A. Criteria for evaluating
evidence on public health interventions. Journal of Epidemiology and
Community Health 2002; 56: 119-127.
4. Healthy Public Policy Network. The Possible Scot. The Scottish
Council Foundation, 1998.
www.scottishpolicynet.org.uk/scf/publications/paper_7/frameset_splash.shtml
(accessed on 28 August 2002).
5. MacDermid A. Healthy food deserts ‘a myth’. The Herald. 23.8.2002.
6. The Scottish Office. Eating for health - A diet action plan for
Scotland. Edinburgh: The Scottish Office Department of Health, 1996.
7. Food Poverty (Eradication) Bill.
www.joeshort.net/foodjustice/thebill.html (accessed on 28 August 2002).
Competing interests: No competing interests
Sir
Cummins and Macintyre highlight a common problem which potentially
seriously undermines the development of quality healthcare services
throughout the UK.
Factoids exist in many arenas (not just health) but in healthcare
they appear at the forefront when it comes to development of both local,
and national strategies on healthcare service configuration. Innovative
emergent local strategies are in danger of being overlooked because of
this attachment to "dogma" - which can be adhered to by the most eminent
of clinicians when the facts are clearly not there. Government and local
srategists and our patients deserve better.
It would prove more healthy (and transparent) if college documents
(often, in the UK , the source of the "primary" factoid) came with an
unambiguous statement as to whether conclusions within are based on
unequivocal fact or not. In this way decisions in healthcare could be
seen to be made around manpower issues or other issues pertaining to
quality rather than factoids. As a result local factors could relevantly
be factored in hence ensuring that the quality framework of a new
initiative was enhanced by local
conditions.
In healthcare there is rarely "one size fit all" and recognising and
acting on the presence of factoids to take into account local factors adds
to, rather than detracts, from quality.
Competing interests: No competing interests
Let's get the evidence first.
Sir,
Cummings and Macintyre raise a very important issue and we hope that
their article will rekindle debate in an area in which views have become
increasingly entrenched. The concept that low-income groups have a poor
diet primarily because of the three ‘A’s: Access, Availability and
Affordability is in danger of becoming accepted dogma in nutrition, public
health and political circles. The frequent usage of these words in
Government documents (e.g. NHS Cancer Plan[1] and the National School
Fruit Scheme[2]) and reports from organisations such as Sustain[3] and the
National Heart Forum[4], etc. is extensive. And, laying aside the minor
technicalities raised in the response to this article by Conway[5], we
wholeheartedly agree with the central strand of Cummings and Macintyre
that there is not yet the weight of empirical evidence to support the
Three ‘A’s dogma.
We currently have two empirical refereed papers in press reporting
studies undertaken with a low-income cohort[6,7] in which “classical”
access and affordability problems were NOT major barriers to healthy
eating for this cohort. Our studies (perhaps not surprisingly) revealed
that the causal factors of consuming inappropriate diets are many and
interacting. How people perceive health, their personal values and
histories, the degree of social stress encountered and many other factors
all interact to drive what they eat. Employing simplistic “cause-and-
effect” relationships offers many attractions for policy makers, and
concepts like “food deserts” and the Three ‘A’s make for good sound-bites,
but as with many social “problems” causality is frequently messy. We
accept that simple access and affordability issues are part of the
“problem” for some people in some areas, as indeed our own research has
shown. The key issue is that the extent of these barriers nationwide has
still to be determined. This is where the Food Standards Agency’s
nutritional survey of low-income groups (LIDNS[8]), currently underway,
should provide more empirical evidence for the debate.
The danger of exaggerating causes way beyond the supporting evidence
is that much needed resources can be channelled into areas that are not
major problems. Once influential “actors” in the arena become attached to
the “hype”, status and reputations become entwined with the beliefs, which
can make it difficult to challenge the established orthodoxy.
References
1. Department of Health. The NHS Cancer Plan. London: The Stationery
Office, 2000.
2. Department of Health. The National School Fruit Scheme
http://www.doh.gov.uk/schoolfruitscheme/ (accessed 10 September 2002)
3. Cottee, P. (ed) “Tackling inequalities in health and diet related
disease” A publication by Sustain, the alliance for better food and
farming. London: KKS Printing; 1999.
4. National Heart Forum. At Least Five a Day: Strategies to Increase
Vegetable and Fruit Consumption. London: The Stationery Office;1997.
5. Conway D, Budewig K. Get your factoids right. Bmj.com 29 Aug 2002.
6. Dibsdall L, Lambert N, Frewer L. Using Interpretative Phenomenology to
Understand the Food-Related Experiences and Beliefs of a Select Group of
Low-Income UK Women. Journal of Nutrition Education and Behavior 2002 (in
press).
7. Dibsdall L, Lambert N, Bobbin R, Frewer L. Low-income consumers’
attitudes and behaviour towards access, availability and motivation to eat
fruits and vegetables. Public Health Nutrition 2002 (in press).
8. Dowler E, Draper A, Nelson M, Thomas R, Dobson B. Scoping study for a
proposed national dietary and nutritional survey of people living on low
incomes in the UK. MAFF report no. AN1060, 1998.
Competing interests: No competing interests