WPHNA Building Healthy Global Food Systems Day 1: Summary ...€¦ · WPHNA Building Healthy Global Food Systems Day 1: Summary Day 2: Policy Provocations Simon Capewell Professor

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


Day 1: Summary


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


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: 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: Summary

Day 2: Food policy SOLUTIONS


(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


(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


Day 1: Summary

Day 2: Food Policy SOLUTIONS

Why focus on healthy food?

FIRSTLY


Day 1: Summary


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%



Diet bigger than

Tobacco+Alcohol+Inactivity

Effectiveness of individual approaches versus

population strategies?

- Equally effective ??

SECONDLY


Day 1: Summary


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)


• Eliminate Choice

• Restrict Choice

• Guide Choice

–

–

–

• Enable Choice

• Provide information

• Do nothing



• 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


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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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


Day 1: Summary


• 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


Day 1: Summary


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, &




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












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


Day 1: Summary


• 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


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)


BMJ 2012 345 e8301

STRATEGY


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


BMJ 2012 345 e8301

ACTION


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


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


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…


Day 1: Summary


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


Day 1: Summary


• 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


Day 1: Summary


Ethical duties of PH scientists?

Silence is NOT an option…..

Documents

WPHNA Building Healthy Global Food Systems Day 1: Summary ...€¦ · WPHNA Building Healthy Global Food Systems Day 1: Summary Day 2: Policy Provocations Simon Capewell Professor