Can we leave industry to lead efforts to improve population health? NoBMJ 2013; 346 doi: https://doi.org/10.1136/bmj.f2426 (Published 17 April 2013) Cite this as: BMJ 2013;346:f2426
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The BMJ recently ran a poll asking if we can leave industry to lead efforts to improve population health (April 17th 2013). In his book ‘Bad Pharma’ Ben Goldacre asserts that research into life-styles will never have the prominence accorded to drugs because it does not have the backing of a $600 billion pharmaceutical industry (1). Reluctantly, at least in regard to physical activity I agree and find it perplexing that the UK Government has failed to even use the data it has.
Approximately 80% of GP consultations are for Long-term Conditions (LTCs). The benefits of physical activity are well known. These include helping to prevent and manage over 20 chronic conditions that impact upon the UK healthy life-expectancy (2) and an approximately 30% risk reduction in all-cause mortality. Small wonder it was described by the previous Chief Medical Officer as a ‘wonder drug’ (3). If a drug were invented that had the same effect it is hard to imagine the demand (or profit) that would ensue.
Unfortunately physical activity can be free (gardening, housework etc) or as active travel even cost-saving (4) and therefore does not have the commercial incentives afforded to pharmaceutical solutions except where it can be commercialised e.g. gyms, leisure centres etc. The lack of emphasis on active travel is emphasised by the reaction to the recent London Mayor’s Vision for Cycling by cycle campaigners. Pledging £913 million over the next 10 years to make cycling a ‘normal part of everyday life’ it was described by the London Cycle Campaign as ‘ground breaking’ and the national cycling charity CTC as ‘breathtakingly ambitious’. However, this represents approximately 1/50th of Transport for London’s annual £5 billion budget. Similarly, the Sports England Active People Survey perpetuates and reinforces this by only reporting on physical activity within Local Authorities that is “for the purpose of health, recreation, training or competition not to get from place to place” (5). Accordingly someone who cycles or walks to work everyday (known as active transport) is reported as less active than someone who plays competitive bowls once a month. Although active transport data is recorded the Active People survey, now in its seventh year, does not report it, nor release it without agreement to a data user license.
In terms of population health this is a missed opportunity. If you are interested in how physical activity may be incorporated into everyday life google bicycle parking at any Dutch railway station. In the face of a financial and obesity crisis this would seem to be a policy own-goal.
(1) Goldacre B. Bad Pharma. How drug companies mislead doctors and harm patients. 1st ed. London: Fourth Estate; 2012.
(2) Murray CJL, Richards MA, Newton JN. UK health performance: findings of the Global Burden of Disease Study 2010. Lancet 2013 5th March 2013;doi:10.1016/S0140-6736(13)60355-4.
(3) Department of Health. 2009 Annual Report of the Chief Medical Officer. 2010.
(4) Cavill N, Kahlmeier S, Rutter H, Racioppi F, Oja P. Economic analyses of transport infrastructure and policies including health effects related to cycling and walking: A systematic review. Transp Policy 2008 09;15(5):291-304.
(5) Sport England. Explanation of the different sport participation indicators. Available at: http://www.sportengland.org/idoc.ashx?docid=d65addc2-db76-473f-92b5-12ae.... Accessed 10th March, 2013.
Competing interests: Reading for a Doctorate in Public Health (DrPH)
Why go for taxation that is largely punative when there are easier and likely more successful strategies through tax incentives? Over three quarters of food sales go through 5 supermarket chains and loyalty cards are in common use. Data mining companies routinely extract shopping data to generate profit through incentives. Why not look at this in a different way?
Governments could draw up a list of healthy foods and provide tax breaks to supermarkets if they could show that they had sold a high enough percentage of these. Rather like a food QOF. If the incentive was attractive enough, all of the marketing and advertising would be geared to this effort. Supermarkets would have to choose their suppliers based on healthy food and redesign their stores around this incentive.We would see a different type of supermarket based on promoting healthy food, advertising and marketing would drive this change. Legislation would be light. Tax is negotiable after all. Some successful UK companies pay no tax at all. And far better to spend tax money on prevention rather than treatment, which is estimated to cost several billion pounds a year. League tables would further drive the incentive.
The last sentence in the last paragraph of the article by Derek Yach pretty well sums up where we need to go with this. As a GP who has an interest in preventative health and has worked with a large supermarket chain to provide a weight management scheme, I can only say that the legislative approach through mostly punitative taxation is reactive and doomed to fail. It seems to have been effective with smoking and attempts are being made with alcohol, but diet and lifestyle are too complex to handle in this way. The example in Denmark where taxation on fat has been dropped and future legislation on sugar shelved should give us an idea how difficult all of this is. The food industry lobbying around European food labelling shows us the power of the industry to protect it's interests. And why not? It is all within the law. The industry spin about responsibility is in my opinion more about going for profitable market share than any concern about health. If they were truly bothered they would design their stores differently. There is huge talent in the food and advertising who would love to take this challenge on. What I have suggested is a pragmatic and practical way of harnessing this power and put it to use in a positive way.
Competing interests: No competing interests
There is no such thing as population. Consumption is a matter of personal preferences.
Ultimately, the obligation to maintain and improve one's health lie with the individual. The proof is obvious: despite what the author sees as "market manipulation" millions of ordinary people consciously eat reasonably healthy food and conduct reasonably active lifestyle taking care of their bodies and minds in parks, recreational and fitness centers.
Industry is well positioned to cater to these people.
Apart from rare genetic differences, the chief reasons why many people in developed countries are unhealthy are their individual preferences. Whether these preferences can be improved, or whether an objectively "better" set of preferences even exists, is a philosophical or an anthropological question, certainly a better one than "can we allow the industry to serve its customers?".
The author writes "...around 90% of lung cancer can be attributed to smoking. Why should manufacturers be allowed to produce and market (at all) a product with such predictable consequences and wash their hands of any responsibility". Perhaps its because, as every smoker can attest, cigarettes serve other useful purposes in the smoker's life, for example, improving his or her concentration, or saving him or her from depression. If the smoker is prepared to take the risks - why should anybody else be allowed to deny him or her this choice, considering the fact that the majority of smokers are likely to die early and their net burden on the society is therefore near zero?
Moreover, why should we trust the government to decide which product should be allowed to be produced and marketed? Is government somehow magically protected from incentives to manipulate and be manipulated, to deceive and be deceived, and to mislead and be misled? How do we know that government-approved choices are better for individuals - considering all the costs, benefits and risks arising from the centralized choice-making?
Competing interests: No competing interests