Should action take priority over further research on public health?
BMJ 2018; 360 doi: https://doi.org/10.1136/bmj.k292 (Published 01 February 2018) Cite this as: BMJ 2018;360:k292
All rapid responses
The argument between action or more research on behaviour is a false dichotomy - both are indispensable [1]. After all, we need to be coming in at all levels of any given issue to truly effect change [2]. So, although more action is clearly needed, Aileen Clarke is right to suggest that "research is vital" on many aspects of our lives. That said, we must not forget the extent to which vested interests already have very advanced research and evidence on how to influence behaviour [3]. The manufacturers and retailers of food, alcohol and other commodities that harm health are already experts at understanding human behaviours in relation to manufacturing, promoting and selling their wares. Not only commercial interests but also scientific research, are well aware of the effect on consumption of the artificially salty, fatty or sweet taste of foods and drinks, the relative cost per calorie, the convenience, the psychological appeal behind the marketing and advertising of such products [4]. Similar knowledge and strategies have been demonstrated amply through tobacco control and exposure of tobacco industry strategies over recent years [5].
What is needed, is a change in the mind set of governments that place so much importance on economic health at the expense of that of individuals. We need pushback against industries fighting for anything beyond the mildest, voluntary agreement theoretically designed to improve public health but in practice dominated by commercial interests [6]. This requires bold moves by politicians on factors such as changes to the incentives such companies face, regulatory frameworks or at least stricter consequences of not following voluntary agreements. The soft drinks industry levy is one such bold start - even the announcement had industry scrambling to reformulate and reconsider its strategies [7]. We need to challenge a media environment that brands as "nanny statism" or "petty diktat" attempts to curb industry excesses and improve public health, while failing to highlight the subtle control marketing and branding experts exert over us all [8]. Consumers, and the media that inform us, ought to be more outraged at the corporate stealth tactics that control our behaviours than at the so-called "petty" concerns over harmful levels of salt in our food.
There is a great deal of knowledge on behaviour - on why people eat or drink unhealthily, why they smoke, gamble and fail to exercise. Changing the determinants of those behaviours - most of which are under corporate and government control - is needed to truly improve public health. Individual behaviour change is the wrong framework for a system in which individuals are responding to clever behavioural incentives used by industry; there is evidence enough to act now. To prioritise gathering more information on individual behaviour is to admit corporate imperialism has triumphed and all we can do is react.
References
[1] S. Capewell, P. Cairney, and A. Clarke, "Should action take priority over further research on public health?," Bmj, vol. 360, no. 10, p. k292, 2018.
[2] H. Rutter et al., "The need for a complex systems model of evidence for public health," Lancet, vol. 6736, no. 17, pp. 9-11, 2017.
[3] D. A. Cohen and S. H. Babey, "Contextual influences on eating behaviours: heuristic processing and dietary choices," Obes. Rev., vol. 13, no. 9, pp. 766-779, 2012.
[4] D. Stuckler, M. McKee, S. Ebrahim, and S. Basu, "Manufacturing Epidemics: The Role of Global Producers in Increased Consumption of Unhealthy Commodities Including Processed Foods, Alcohol, and Tobacco," PLoS Med, vol. 9, no. 6, p. e1001235, 2012.
[5] G. J. Fooks, A. B. Gilmore, K. E. Smith, J. Collin, C. Holden, and K. Lee, "Corporate social responsibility and access to policy élites: An analysis of tobacco industry documents," PLoS Med., vol. 8, no. 8, 2011.
[6] K. Buse, S. Tanaka, and S. Hawkes, "Healthy people and healthy profits? Elaborating a conceptual framework for governing the commercial determinants of non-communicable diseases and identifying options for reducing risk exposure," Global. Health, vol. 13, 2017.
[7] K. Hashem and J. Rosborough, "Why Tax Sugar Sweetened Beverages?," J. Pediatr. Gastroenterol. Nutr., vol. 65, no. 4, 2017.
[8] http://www.telegraph.co.uk/news/health/news/12207571/Revealed-Britain-is...
https://www.theguardian.com/media/greenslade/2011/mar/31/dailyexpress-da...
Competing interests: No competing interests
Like many specialists in public health, Aileen Clarke remains focussed on “ways to change and sustain our individual behaviour".
With dietary problems, for 30 years, all over the world, in poor countries as well as rich ones, that has meant trying to get people to make "healthier choices". That strategy has failed. The global obesity epidemic is the real world evidence.
Happily, the UK government has moved on. The key programme at the heart of the Childhood Obesity Plan is the reformulation of nine categories of popular, mass market foods, to reduce their sugar content.
This is a major strategic development: changing foods as well as changing people. Structural as well as behavioural change.
This strategy has numerous advantages. As Public Health England says, “These approaches to sugar reduction do not rely on individual behaviour change” [1].
And more: reformulation benefits everyone, even those who resent the whole idea of healthy eating advice as the Nanny State in extremis.
And not least of its advantages in these straitened times is that most of the cost of reformulation is paid by the food industry, not the public purse.
When the government is so practical, it is time for public health specialists to recognise the point -- it is possible to have nutritional improvement without behavioural change.
Jack Winkler
Emeritus Professor of Nutrition Policy
London Metropolitan University
jtw@blueyonder.co.uk
[1] Public Health England (2015), Sugar Reduction: The evidence for action
Competing interests: No competing interests
Capewell and Cairney, in their ‘Yes’ argument say that ‘A delayed response to evidence can be damaging’ and that ‘when scientists refer to “insufficient evidence” they may naively help opponents of policy change, including vested interests. They also argue that “Insufficient evidence” is an excuse for dither and deaths.
In March 2014 – four years ago - the BMA Board of Science carried out research into ‘Prescribed drugs associated with dependence and withdrawal’. The results of this research were formally published 18 months later, October 2015 (1) . There followed stakeholder meetings hosted by the BMA and follow-up. In October 2016 the BMA announced a formal call for ‘better support systems for patients suffering because of dependence or withdrawal’ stating that ‘In the absence of robust data, we do not know the true scale and extent of the problem across the UK. However the evidence and insight presented to us by many charity and support groups shows that it is substantial. It shows us that the 'lived experience' of patients using these medications is too often associated with devastating health and social harms.’(2)
Public Health England has very recently announced that it will carry out a ‘public-health focused review of commonly prescribed medicines, authorised for adults who have non-cancer pain, anxiety, insomnia or depression’ (3). This review is planned to take place over 2018 and to report in early 2019, so will be 5 years from the time that the BMA Board of Science research evidence was collected and indicated alarming issues with these prescribed medicines..
Meanwhile countless patients have been, and continue to be, harmed and disabled by these prescribed drugs, affecting lives, families and society and contributing to poverty and deprivation. Many patients have suffered terribly and died prematurely.
Cases of ‘medically unexplained’ illness and disability are rising inexorably. The evidence is clear, if only we look and take notice.
The All Party Parliamentary Group for Prescription Drug Dependence, and previously APPGITA, have been calling for action on these issues for many years.
Patients in Scotland and Wales (4) are in the process of petitioning their respective parliaments and calling for action. Individual patients are providing the clearest evidence of what has happened and is happening: being disbelieved and dismissed by their doctors when they are suffering serious harm by medicines ‘taken as prescribed’. Powerful and harrowing written evidence is in the process of being sumitted and published on the webpage of the Scottish Parliament Public Petitions, reference PE01651 (5).
At the recent Committee evidence session at the Scottish Parliament (18 January 2018) the Principal Medical Officer and the Minister for Mental Health Scotland stated that they did not ‘recognise’ the premise of the petition: ‘that there are people who were not given proper advice about the consequences of taking these prescriptions, put on those drugs, not given other supports and left on them; also that the GP does not know how to support them through the withdrawal of the drugs’. They conceded only that the petitioner ‘felt’ that there is an issue.
It would seem that the behaviour changes referred to by Aileen Clarke as being needed ‘to improve the public health of our patients, families, and communities' are actually at the level of medical advisers to politicians and influential members of the medical profession and institutions - who are clearly very powerfully wedded to their own beliefs.
The evidence is clear.
(1) http://bmaopac.hosted.exlibrisgroup.com/exlibris/aleph/a23_1/apache_medi...
(2) https://www.bma.org.uk/collective-voice/policy-and-research/public-and-p...
(3) https://www.gov.uk/government/news/prescribed-medicines-that-may-cause-d...
(4) http://www.senedd.assembly.wales/mgIssueHistoryHome.aspx?IId=19952
(5) http://www.parliament.scot/GettingInvolved/Petitions/PE01651
Competing interests: No competing interests
Public wealth vs public health.
The debate about action vs research for public health may have missed the wood for the trees.(1)
The pro for action rightly declared “the huge current burden of avoidable disease is a scandal” but wrongly scapegoated “corporations producing harmful commodities such as tobacco, alcohol, junk food, or sugary drinks routinely oppose regulation.”(1) The pro for research rightly questioned “if the causes of ill health are clear … why hasn’t this happened?” but ignored the obvious.(1)
Facts are simple. Corporations are only doing their job, to sell their products. Politicians, elected by citizens, can choose public health or the public wealth (i.e. economy). In France, since 1998, a small group of “wise” persons has questioned candidates for the presidency about their public policies and published an evaluation. In 2017, French citizens elected the one ranking just before the last.(2)
However, politicians’ choice is not the sole issue. The US Department of Agriculture school meal and competitive venue standards, an effective public policy to improve student nutrition and health, has been implemented in only 2% of middle schools and in less than 1% of high schools.(3) Bureaucratic inertia cannot be overlooked, but why are parents not concerned by the implementation of policies aimed at improving their children’s health?
Sadly, the worst is yet to come. Italy, Spain and the UK were among the first to fulfil 2014 Eurostat’s call to include illegal drug traffic in Gross Domestic Product. France just followed.(4) Smoking provides the most robust evidence of social benefit to the economy. Smokers pay large amounts of taxes (80% of the retail price) and as they die an average of 10 years earlier than non-smokers: a) total medical expenditures are lower as they increase with age; no long-term nursing care for elderly; c) cost savings in pension payments.(5) Who benefits the most from smoking? The tobacco industry or the department of budget? The dealer is the state and reversing the taxes approach (paying the tobacco industry to end its business) is not a paradox.(6)
Citizens’ empowerment is a prerequisite for public health as it is for patients for care. However, the public is not in interested in health but in wealth. Ibsen warned in an 1882 play, “An Enemy of the People”. Dr Stockmann who discovered the huge bathing complex, crucial to the economy, is seriously contaminated … has alienated everyone. However, bye-laws (local laws) may allow dedicated politicians to act. New York City has been a beacon, with great results from a most comprehensive tobacco control program since 2000 (clean indoor air law, the highest state tobacco taxes in the US, increased access to cessation services, laws that restrict minors' access to tobacco a with robust implementation). Berkeley too with its tax on sugar-sweetened beverages.(7)
1 Capewell S, Cairney P, Clarke A. Should action take priority over further research on public health? BMJ 2018;360:k292
2 http://www.securite-sanitaire.org/reponses2017/LeMonde11avril.pdf
3 Terry-McElrath YM, O'Malley PM, Johnston LD. Potential impact of national school nutritional environment policies: cross-sectional associations with US secondary student overweight/obesity, 2008-2012.JAMA Pediatr 2015;169:78-85.
4 http://www.lemonde.fr/les-decodeurs/article/2018/02/01/comment-l-insee-v...
5 Braillon A. Smoking-attributable medical expenditures: Time biases and smokers' social role. Prev Med 2015;81:294.
6 Braillon A. Reversing the taxes approach for a win-win tobacco control policy. Addiction 2011;106:2047.
7 Silver LD, Ng SW, Ryan-Ibarra S, et al. Changes in prices, sales, consumer spending, and beverage consumption one year after a tax on sugar-sweetened beverages in Berkeley, California, US: A before-and-after study. PLoS Med 2017;14:e1002283.
Competing interests: No competing interests