Better Health For All

• by Dr Tom Scanlon
• Director of Public Health
• Brighton & Hove City Council

They say anticipation is the better part of pleasure and I have to confess that as a kid I quite enjoyed Lent. Like a good Catholic boy, I would defer some gratification for 40 days and 40 nights; for a few years it was sweets. This worked well because I was paid in sweets for delivering a neighbour’s milk after school, gifted sweets from mum’s old school friend who came to tea every Friday, and continued to make small pocket money purchases throughout my ‘fast’.

So as Easter Sunday approached my hidden stash accumulated and my excitement escalated. Not in the spirit of things perhaps, and indeed maybe there is a God as my annual sweet fast/fest came to a tragic end when my big brother – a bit of a Hyde and Hyde character back then, stumbled across my hoard and with his mates devoured the lot – on Good Friday too. Like a bad Catholic boy, I never quite forgave him.

Of course, if Joe had been at the launch of our Sugarsmartcity initiative in early October, he would have said he did me a favour (he tried that same line all those years ago).  Althoughhough when I think back; a whole Lenten’s worth of sherbet dib dabs and cola cubes in 1969 compares very lightly with the quantities of sweets and sugary drinks we experience today, often proffered in cut price supersize at a checkout – when all you came in for was a newspaper.

We now know that sugar consumption is indelibly linked with dental caries, obesity, and in drink form to Type 2 diabetes. National guidelines have been dramatically revised down by 50%, so that just one can of coke (9 teaspoons of sugar) contains more than the recommended total daily free sugar intake for an adult (7 teaspoons).  In Brighton & Hove each year, around 25% of children leave primary school obese or overweight, and just under 300 have teeth removed in hospital, while an estimated 9.2% of our adults is diabetic; so it felt like the right time to launch a city-wide Sugarsmartcity campaign.

Just as anecdote is a powerful evidence-based tool, so serendipity is an excellent means of planning.  A public health colleague knew a chef who knew Jamie Oliver’s Campaign Director, and as ‘make connections’ is a local public health mantra, she did.  Jamie Oliver had just released Sugar Rush and as campaign directors love to campaign – Jo Ralling was more than happy to join us and has proven herself quite a driving force.  We had recently appointed a new consultant for health improvement, a fast food/restaurant public health lead, and we have a very successful public health schools programme with 95% engagement. Our Healthy Weight Partnership Board has been running for five years, so the practical and governance infrastructure was already in place, coupled with a fresh ‘appetite’ to tackle sugar.

I knew there might be some concern from local elected members about being linked to a tax (just as it appears there is nationally) so I agreed that we would run it as a public health professional campaign linked to FPH objectives, but in partnership with Jamie Oliver team. That said; our Health and Wellbeing lead publicly endorsed the work at the Health and Wellbeing Board.

After the media launch, we kicked off with a children’s public debate – at Jamie’s Italian Restaurant, chaired by the youth mayor with a panel from industry, the voluntary sector, health and education. Another debate for young people will follow shortly. We have produced and already adopted new snack and lunch policies in several schools and Jamie Oliver’s team have helped to source them free cooking and growing equipment. I co-signed a letter with Jamie Oliver, sent to over 500 local restaurants by e-mail proposing a voluntary children’s charity levy of 10p on sugar-sweetened drinks.  Independent restaurants are signing up – we’ll take stock at the end of the month.

The blitzkrieg of media – they love talk of taxes, and bans – has helped us to target the local hospital, leisure centres and school meals service. The university hospital trust is now formally reviewing their vending machine policy. The school meals provider has already revised its pudding (sugar) policy and we are optimistic that we will hear more from local supermarkets on sugar free checkouts, and leisure centres on vending.

The national debate, accusations of big business pulling government strings and manipulation of Public Health England evidence has all helped. Serendipity is one thing; but having excellent public health and communications colleagues, and a professional campaign team like Jamie Oliver’s, doesn’t half help.

I thought at the start that even if we just get our population more sugarsmart – so that people understand better what they are eating, and how it affects them and their children, that would be something.  However, we have already achieved a lot more and I know there is more to come.  It’s working well – ‘sweet’ as young people say…

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• Daniel Flecknoe DFPH
• Bayad Nozad FFPH

Imagine there is an illicit drug, which is proven to cause lifelong physical and psychological damage.  Let’s call it “W”.  People under the influence of W routinely torture or kill one another, and neglect the essential societal responsibilities which keep the rest of us clothed and fed and protected from disease.

As a result, use of W frequently results in malnutrition, deprivation and disease for non-users living in the same area, not to mention the injuries, sexual abuse and violent death which are often inflicted upon them by addicts.  Those who can leave the area will usually do so, even when the journey is perilous, and many are known to have died making the attempt, while the elderly, sick and disabled are left behind, at the mercy of the intoxicated.

Children, already disproportionately at risk from the behaviour of adult “Double-Users”, are in many parts of the world forced to take the drug themselves, leading to unimaginable developmental trauma.  As is so often the case, there are stark socioeconomic inequalities in the global distribution of negative health outcomes associated with W, with the poor suffering the worst.

Communities fractured, economic & social development retarded, millions killed and billions scarred for life (mentally and physically).  In this scenario, would it be unjustifiably paternalistic and prohibitionist to suggest, as a public health community, that W should be the subject of an intense and comprehensive prevention strategy?

Of course W isn’t really a drug, and it isn’t strictly speaking addictive (although you might sometimes wonder).  W is an analogy for warfare and armed conflict, which despite being universally acknowledged root causes of preventable morbidity and mortality still remain issues which many public health professionals feel are not within their remit to address.  Given the horrendous human cost of this phenomenon, we would argue that an urgent re-examination of our profession’s self-imposed boundaries in this matter is long overdue.

In common with a significant number of other public health professionals, both authors have spent time working in armed conflict zones trying to ameliorate the malnutrition, lack of medical care and psychological distress they generate, as well as treating some of the injuries which they directly cause.

Front gate of the MSF medical facility at Shanguil Tobaya in North Darfur in 2008

Although neither of us thought of it in precisely these terms at the time, we might now classify these activities as types of secondary and tertiary prevention strategies for the negative health impacts of warfare.  It seems to us that the real challenge is to promote greater public health engagement with the primary prevention of armed conflict.

This may seem like an overly ambitious goal.  The diplomatic and political catalysts of armed conflict are somewhat remote from the field of public health, even when properly recognised as major causes of preventable illness, injury and death.  They have the same elusive character as poverty, in that they are well-understood determinants of health whose levers of change exist at least partly outside of the traditional domain of medicine.  However, public health as a profession does not shy away from naming poverty as a determinant, and calling for policies to reduce its prevalence.  If the most we can do is to do the same for armed conflict then that would be better than nothing.

However, there may be other avenues by which public health professionals can extend their sphere of influence into the realm of large-scale violence prevention.  Armed conflict is both a cause and an effect of social injustice, so work undertaken to reduce inequality, whether on a local, national or international level, may also be considered to be part of a primary prevention framework.  Conflict resolution, human rights activism, democracy promotion and community integration work aimed at reducing ethnic and cultural divisions could all be part of the same framework.

International humanitarian law is also a potential tool of armed conflict prevention.  However, these laws are the product of many self-interested compromises generally made in the wake of World Wars.  This is not to discount or undervalue them, but the political will necessary first to make, and then to enforce such agreements appears only to be generated by civilization-level traumas.

While the lack of global conflicts (which directly affected the civilian populations of Western countries) in the past seventy years is something that we should celebrate, one consequence is that international humanitarian law is becoming out-dated and harder to enforce.

Recent coverage of events in the Mediterranean, the largest influx of refugees into Europe since the Second World War, has brought this issue into heart-breaking focus.  Confronted with a human crisis of such devastating proportions we propose, perhaps idealistically, a synthesis of two philosophies of assistance and advocacy:

• Humanitarianism, which directly challenges the logic that orders, justifies or tolerates the premature death of any part of humanity in the name of some collective or national benefit, and
• Primary prevention, which identifies the root cause of a particular cluster of negative health outcomes, inequality and human suffering, and dedicates itself to eradicating or (more realistically) substantially reducing its prevalence.

“Health through Peace” is the title of a conference taking place in November, organised by a committee of humanitarian and human rights groups, which will explore the role that healthcare professionals can play in confronting and challenging the drivers of warfare and armed conflict. Anyone interested in attending the Health Through Peace conference can read more about it and sign up here.

In the meantime, we will investigate the possibilities of forming a Special Interest Group within FPH in order to further explore the positive contribution that public health can make to the primary prevention of armed conflict.  Please email daniel.flecknoe@nhs.net if you would like to be involved in this project.

References:
Mercy JA (2013)  “Assaultive Violence and War”. In Levy BS & Sidel VW (Eds) Social Injustice & Public health.  2nd Edition.  Oxford University Press, New York.

UNICEF (2009) Children and conflict in a changing world – Machel study 10-year strategic review.   Accessed on 15/08/2015.

Weissmann F (2004)  In the Shadow of “Just Wars”: Violence, Politics, and Humanitarian Action.  C. Hurst & Co., London.

Wiist W (2014)  Use of complex systems modelling to strengthen public health’s role in preventing war.  Medicine, Conflict and Survival.  30(3): pp. 152-164.

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