WPHNA Building Healthy Global Food Systems Day 1: Summary Day 2: Policy Provocations Simon Capewell Professor of Clinical Epidemiology LIVERPOOL UNIVERSITY, UK Oxford, Tuesday 9th September 2014
WPHNA Building Healthy Global Food Systems
Day 1: Summary
Day 2: Policy Provocations
Simon CapewellProfessor of Clinical Epidemiology
LIVERPOOL UNIVERSITY, UK
Oxford, Tuesday 9th September 2014
WPHNA Building Healthy Global Food Systems
Day 1: Summary
Day 2: Policy Provocations
Simon CapewellProfessor of Clinical Epidemiology
LIVERPOOL UNIVERSITY, UK
Oxford, Tuesday 9th September 2014
Thanks: Barrie Margetts, Phil James, Jane Landon, Susanne Logstrup Klim McPherson, Mike Rayner, Paul Lincoln, Graham MacGregor Robert Lustig, Aseem Malhotra, Katharine Jenner, Martin McKee Helen Bromley, Martin O’Flaherty, Robin Ireland, Julia Critchley, Ffion Lloyd-Williams, Ann Capewell
Funding: MRC, EU, BHF, NHS, L&G, NIHR, NIH
Declaration of commercial interests:
I have nothing to declare
Day 1: Food policy PROBLEMS
WPHNA Building Healthy Global Food Systems
Day 1: Summary
• Global BURDEN of poor nutrition
• Economic COSTS: people, populations, productivity, healthcare
• Global Food SYSTEMS: UPPs, Nutrient profiles, laws?
• SUSTAINABILITY: agriculture versus environment ?
• CLIMATE CHANGE, population increases & food crises
Are major interventions justified?
Day 1: Food policy PROBLEMS
WPHNA Building Healthy Global Food Systems
Day 1: Summary
• Global BURDEN of poor nutrition
• Economic COSTS: people, populations, productivity, healthcare
• Global Food SYSTEMS: UPPs, Nutrient profiles, laws?
• SUSTAINABILITY: agriculture versus environment ?
• CLIMATE CHANGE, population increases & food crises
Are major interventions justified? YES!
Day 1: Food policy PROBLEMS
WPHNA Building Healthy Global Food Systems
Day 1: Summary
Day 2: Food policy SOLUTIONS
WPHNA Building Healthy Global Food Systems
(Day 1: Food policy PROBLEMS)
• DEMAND & food systems: people, society, governments
• Food System COSTS: Food security, affordability & trade
• POLITICAL challenges & Big Food: Overcoming Vested Interests
• SOLUTIONS & Global Exemplars:
France, Mexico, Brazil, Peru, South Africa
Day 2: Food policy SOLUTIONS
WPHNA Building Healthy Global Food Systems
(Day 1: Food policy PROBLEMS)
• Why focus on healthy food?
• Effectiveness of individual versus population approaches
• Opposition from powerful vested interests
• Past history of public health triumphs
• Ethical duties of public health scientists ??
My Talk now: Policy Provocations
WPHNA Building Healthy Global Food Systems
Day 1: Summary
Day 2: Food Policy SOLUTIONS
Why focus on healthy food?
FIRSTLY
WPHNA Building Healthy Global Food Systems
Day 1: Summary
Day 2: Policy Provocations
Burden of disease attributable to 20 leading risk factors in 2010
expressed as a percentage of global disability-adjusted life-yearsGlobal Burden of Disease Group. www.thelancet.com 2012 380 2245
Burden of disease attributable to 20 leading risk factors in 2010
expressed as a percentage of global disability-adjusted life-yearsGlobal Burden of Disease Group. www.thelancet.com 2012 380 2245
Burden of disease attributable to 20 leading risk factors in 2010
expressed as a percentage of global disability-adjusted life-yearsGlobal Burden of Disease Group. www.thelancet.com 2012 380 2245
Diet ≈ 40%
Burden of disease attributable to 20 leading risk factors in 2010
expressed as a percentage of global disability-adjusted life-yearsGlobal Burden of Disease Group. www.thelancet.com 2012 380 2245
Diet bigger than
Tobacco+Alcohol+Inactivity
Effectiveness of individual approaches versus
population strategies?
- Equally effective ??
SECONDLY
WPHNA Building Healthy Global Food Systems
Day 1: Summary
Day 2: Policy Provocations
Nuffield ladderof public health interventions
2007
(Ayres & Braithwaite Responsive Regulation 1992)
(Interventions that are higher up the ladder are more intrusive and therefore require a stronger justification)
Nuffield ladderof public health interventions
• Eliminate Choice
• Restrict Choice
• Guide Choice
–
–
–
• Enable Choice
• Provide information
• Do nothing
(Interventions that are higher up the ladder are more intrusive and therefore require a stronger justification)
Nuffield ladderof public health interventions
• Eliminate Choice eg isolate patient with nasty infectious disease
• Restrict Choice eg remove toxins from drinking water
• Guide Choice
– through disincentives eg tobacco tax, congestion charging
– through incentives, eg tax breaks for cycling to work
– Changing default, eg side dish routinely salad, chips optional
• Enable Choice eg provide free fruit at schools, free gyms etc
• Provide information, eg campaigns walking or eating fruit
• Do nothing, or simply monitor situation
(Interventions that are higher up the ladder are more intrusive and therefore require a stronger justification)
19
An Effectiveness Hierarchyfor Public Health?
The apocryphal story about “upstream”
and “downstream” prevention
20
“Downstream” prevention interventions
targeting individuals
consistently achieve a smaller public health impact
than
“upstream” policies such as regulation or taxes...
21
An Effectiveness Hierarchyfor Public Health?
Downstream Upstream
Joosens & Raw 2008
Tobacco Control Score (TCS)Estimated effects of different policy options
Joosens & Raw 2008
Downstream Upstream
0
5
10
15
20
25
30
35
Tobacco Control Scale (Joossens & Raw)
TCS points
Joosens & Raw 2008
Tobacco Control Score (TCS)Estimated effects of different policy options
Effectiveness HierarchyEffects of different policy options (evident for tobacco control, alcohol control, dietary salt & transfats etc)
24
Downstream UpstreamSiz
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ea
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be
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fit
INTERVENTIONS
Prevention can work fast
Evidence for rapid effects
Capewell & O’Flaherty Lancet 2011
Prevention can work fast
Evidence for rapid effects
• DIET: Poland, Czech, E Germany, Cuba
• BP & CHOLESTEROL: tablet trials (6 months)
• cholesterol effect (1- 5 years) Law BMJ 1994
• MONICA analyses Lancet 2000
• 1940s Hunger Winters (1- 2 years)
• PrediMed RCT (Mediterranean diet RCT (3 months)
Capewell & O’Flaherty Lancet 2011
• Effectiveness of individual versus population approaches
• Scientific evidence → public health policy decisions
- A rational, linear path ??
THIRDLY
WPHNA Building Healthy Global Food Systems
Day 1: Summary
Day 2: Policy Provocations
• No: Lois Orton et al
• No: Kathryn Oliver et al
• No: Sally MacIntyre
From scientific evidence to public health policy decisions
- A rational, linear path ??
• Individual approaches or population policies? - Equally effective?
• From scientific evidence to public health policy decisions - A linear path ?
• Opposition from powerful vested interests
FOURTHLY
WPHNA Building Healthy Global Food Systems
Day 1: Summary
Day 2: Policy Provocations
Opposition from powerful vested interests
- Inevitable?? Insurmountable??
• Moodie (Lancet)
• Big Food series (PLoS)
• Vectors of Disease (Anna Gilmore)
• Denialism (McKee)
• SLEAZE (Capewell)
These 10 Corporations Control Almost Everything We Buy
These 10 Corporations Control Almost Everything We Buy
Industrial Corporations prioritise PROFIT, not public health
Rob Moodie, David Stuckler, Carlos Monteiro,
Nick Sheron, Bruce Neal, Thaksaphon Thamarangsi,
Paul Lincoln, Sally Casswell,
on behalf of
The Lancet NCD Action Group
Lancet February 2013
Non-Communicable Diseases 4
Profits & Pandemics: prevention of
harmful effects of tobacco, alcohol, &
ultra-processed food & drink industries
Rob Moodie, David Stuckler, Carlos Monteiro, Nick Sheron, Bruce Neal, Thaksaphon Thamarangsi,
Paul Lincoln, Sally Casswell, on behalf of The Lancet NCD Action Group
Profits & Pandemics: prevention of harmful effects of tobacco, alcohol, &
ultra-processed food & drink industries
Lancet February 2013
Non-Communicable Diseases 4
Transnational corporations •major drivers of non-communicable disease (NCD) epidemics
•profit from ↑ consumption of tobacco, alcohol, processed food & drink
Rob Moodie, David Stuckler, Carlos Monteiro, Nick Sheron, Bruce Neal, Thaksaphon Thamarangsi,
Paul Lincoln, Sally Casswell, on behalf of The Lancet NCD Action Group
Profits & Pandemics: prevention of harmful effects of tobacco, alcohol, &
ultra-processed food & drink industries
Lancet February 2013
Non-Communicable Diseases 4
Transnational corporations •major drivers of non-communicable disease (NCD) epidemics
•profit from ↑ consumption of tobacco, alcohol, processed food & drink
Alcohol & ultra-processed food & drink industries
•use similar strategies to tobacco industry
to undermine effective public health policies & programmes
Rob Moodie, David Stuckler, Carlos Monteiro, Nick Sheron, Bruce Neal, Thaksaphon Thamarangsi,
Paul Lincoln, Sally Casswell, on behalf of The Lancet NCD Action Group
Profits & Pandemics: prevention of harmful effects of tobacco, alcohol, &
ultra-processed food & drink industries
Lancet February 2013
Non-Communicable Diseases 4
Transnational corporations •major drivers of non-communicable disease (NCD) epidemics
•profit from ↑ consumption of tobacco, alcohol, processed food & drink
Alcohol & ultra-processed food & drink industries
•use similar strategies to tobacco industry
to undermine effective public health policies & programmes
Unhealthy commodity industries deserve NO role in NCD
prevention policies
•Current fashion for industry self-regulation & public–private partnerships
is foolish, not effective & does NOT improve public health
Rob Moodie, David Stuckler, Carlos Monteiro, Nick Sheron, Bruce Neal, Thaksaphon Thamarangsi,
Paul Lincoln, Sally Casswell, on behalf of The Lancet NCD Action Group
Profits & Pandemics: prevention of harmful effects of tobacco, alcohol, &
ultra-processed food & drink industries
Lancet February 2013
Non-Communicable Diseases 4
Transnational corporations •major drivers of non-communicable disease (NCD) epidemics
•profit from ↑ consumption of tobacco, alcohol, processed food & drink
Alcohol & ultra-processed food & drink industries
•use similar strategies to tobacco industry
to undermine effective public health policies & programmes
Unhealthy commodity industries deserve NO role in NCD prevention
policies
•Current fashion for industry self-regulation & public–private partnerships
is foolish, not effective & does NOT improve public health
The only evidence-based mechanismsto prevent harm caused by unhealthy commodity industries
are public regulation & market intervention
Martin McKee & Pascal Diethelm
How the growth of denialismundermines public health
BMJ 2010 341 c6950
Tobacco, alcohol & food companies typically denyscientific evidence of harm by using SLEAZE tactics:
• S Scientific conspiracies i
• s
• L Logical flaws
• p
• E Evidence selected
• A Absolute perfection demanded
• Z Zany arguments & distractions
• r
• E Experts bought by industry
S Capewell & A Capewell BMJ 2010 341 c6950
Tobacco, alcohol & food companies typically denyscientific evidence of harm by using SLEAZE tactics:
• S Scientific conspiracies are alleged (rather than admitting
this is a solid scientific consensus);
• L Logical flaws in their arguments (but which may initially
sound plausible);
• E Evidence severely selected to suit their case, (all
conflicting facts ignored);
• A Absolute perfection demanded of the public health
advocates, (eg "why no RCT for passive smoking and cancer?");
• Z Zany arguments. Distractions, to take attention away
from the main issue, (& use scarce public health resources to refute);
• E Experts bought by the rich industries, to undermine good
science, or publish conveniently contradictory findings. (see Google)
S Capewell & A Capewell BMJ 2010 341 c6950
• Past history of public health triumphs
- Lessons for today??
FIFTHLY
WPHNA Building Healthy Global Food Systems
Day 1: Summary
Day 2: Policy Provocations
• Safe drinking water
• Sanitation
• Slavery abolition
• Immunisation
• Road safety
Past history of public health triumphs - Lessons for today?
JAMA 2011 306 38
• Safe drinking water
• Sanitation
• Slavery abolition
• Immunisation
• Road safety
• Seat belts
• Air pollution control
• Tobacco advertising bans
• Smokefree legislation
• etc etc
Past history of public health triumphs - Lessons for today?
JAMA 2011 306 38
VISION
STRATEGY
ACTION
Learning from the slavery abolitionistsR Smith BMJ 2012 345 e8301 A Hochschild 2005. Bury the chains: the British struggle to end slavery
BMJ 2012 345 e8301
VISION
Learning from the slavery abolitionistsR Smith BMJ 2012 345 e8301 A Hochschild 2005. Bury the chains: the British struggle to end slavery
BMJ 2012 345 e8301
VISION
•Leaders & followers need deep belief in the cause
•Successful movements have different sorts of leaders with
different skills,
but they must work together
•What seems impossible can be done - & rapidly
•Progress is unlikely to be smooth
(two steps forward, one step back… )
•A champion can be very useful (An important person, perhaps a politician needing an issue for their own
advancement)
Learning from the slavery abolitionistsR Smith BMJ 2012 345 e8301 A Hochschild 2005. Bury the chains: the British struggle to end slavery
BMJ 2012 345 e8301
STRATEGY
Learning from the slavery abolitionistsR Smith BMJ 2012 345 e8301 A Hochschild 2005. Bury the chains: the British struggle to end slavery
BMJ 2012 345 e8301
STRATEGY
•Pick an achievable aim, & be business-like
•Must connect the issues with peoples’ everyday
lives
•Need shrewd tactics
•Need continuous actions on many fronts
•Boycotts can be powerful
•Success is unlikely to be complete
Learning from the slavery abolitionistsR Smith BMJ 2012 345 e8301 A Hochschild 2005. Bury the chains: the British struggle to end slavery
BMJ 2012 345 e8301
ACTION
Learning from the slavery abolitionistsR Smith BMJ 2012 345 e8301 A Hochschild 2005. Bury the chains: the British struggle to end slavery
BMJ 2012 345 e8301
ACTION•Performance using stories & props is crucial (TV & social media)
•Clear Evidence ++
strong, substantial, self-evident, high quality, high impact,
multifaceted,
•Powerful first hand accounts are invaluable
•Cases that shock & capture the public’s attention crucial
(even if dismissed by authorities or vested interests)
•Iconic pictures can be stunningly effective
Learning from the slavery abolitionistsR Smith BMJ 2012 345 e8301 A Hochschild 2005. Bury the chains: the British struggle to end slavery
BMJ 2012 345 e8301
JMW Turner, 1840; Museum of Fine Arts, Boston Oil on canvas, 90.8 x
122.6 cm
"The Slave Ship“ Slavers throwing
overboard the Dead and Dying - Typhoon
coming on JMW Turner, 1840; Museum of Fine Arts, Boston Oil on canvas, 90.8 x
122.6 cm
VISION
STRATEGY
ACTION
"GOOD COPS" & “BAD COPS"
VISIONARIES & REALISTS
are all ESSENTIAL
Learning from the slavery abolitionistsR Smith BMJ 2012 345 e8301 A Hochschild 2005. Bury the chains: the British struggle to end slavery
BMJ 2012 345 e8301
SUPPORT: Implementation path for effective public health interventionseg. clean water, sanitation, pollution, slavery, immunisation, seatbelts, smokefree etc
• S• U• P• P• O• R• T
54
Professor Simon Capewell UK Faculty of Public Health & University of Liverpool
• SCIENTIFIC evidence emerges
• UNDERSTANDING spreads
• PROFESSIONALS accept paradigm
• PUBLIC & POLITICIANS become aware, then supportive
• OPPOSITION from vested interests is slowly Overcome
• REGULATION is introduced, often strengthened by
• TAXATION to reinforce regulations (eg Tobacco& alcohol control)
SUPPORT: Implementation path for effective public health interventionseg. clean water, sanitation, pollution, slavery, immunisation, seatbelts, smokefree etc
55
Professor Simon Capewell UK Faculty of Public Health & University of Liverpool
• Why focus on healthy food?•Individual approaches v. population policies?
- Equally effective?•From scientific evidence to public health policy decisions
- A rational, linear path ? •Opposition from powerful vested interests
- Inevitable? Surmountable? • Past history of public health triumphs
- Lessons for today?
• Ethical duties of PH scientists ?
- Apathy, Advocacy or Activism ??
and lastly…
WPHNA Building Healthy Global Food Systems
Day 1: Summary
Day 2: Policy Provocations
Ethical duties of PH scientists - Apathy, Advocacy or Activism ??
• Effectiveness hierarchy: ”upstream” policy interventions >> “downstream” individual
approaches
• Policy decisions reflect many factors apart from science
• Anticipate & Overcome Opposition from vested interests
• Impressive history of public health triumphs (water, sanitation, slavery abolition, smoke-free etc)
CONCLUSIONS
WPHNA Building Healthy Global Food Systems
Day 1: Summary
Day 2: Policy Provocations
• Effectiveness hierarchy: ”upstream” policy interventions >> “downstream” individual
approaches
• Policy decisions reflect many factors apart from science
• Anticipate & Overcome Opposition from vested interests
• Impressive history of public health triumphs (water, sanitation, slavery abolition, smoke-free etc)
• These triumphs exemplify SUPPORT pathway
from initial science to effective interventions: regulatory & financial
policies
• Current public health priorities resemble previous (tobacco, alcohol, junk food, sugary drinks, poverty, climate change etc)
•Every PH scientist has a choice: advocacy or activism
CONCLUSIONS
WPHNA Building Healthy Global Food Systems
Day 1: Summary
Day 2: Policy Provocations
Ethical duties of PH scientists?
Silence is NOT an option…..