Saturday, 28 April 2018
Telling stories to public health...
Helped run a story-telling session for public health folk yesterday - my contribution included a direct challenge to their narrative - or rather to the narrative most people see through the media and from government. It's clear that there is still a debate within the public health business as to what we mean by "wider determinants of health" - on one side are those saying this is about economic circumstances, education and housing, while others see it as being factors in the social environment (advertising and marketing, fast food restaurants, capitalism).
Anyway, here's the challenge:
Public health has become an ideology of control rather than a set of policies intended to eliminate, mitigate or reduce environmental impacts on health.
I coined the term nannying fussbucketry to describe this ideology of control - its elements are:
Shooting the messenger - advertising, marketing creates an environment where people are lured into sin. This is despite there being very limited evidence supporting the idea that advertising and marketing act to increase overall consumption (aggregate demand) or consumption of a given product category.
Taxing the poor - taxes on alcohol, cigarettes, sugar and so forth fall most heavily on the least well-off. I can afford to carry on buying bottles of wine because nine or ten quid is not a hardship to me. Poor people - regardless of whether their lifestyle is 'harmful' - may no longer be able to afford
Inflating and conflating statistics - the entire case for minimum unit pricing is built on the idea that elasticity of demand is the same for heavy drinkers as it is for light drinkers (hint - if you think about this for a second, it's clearly nonsense). Every round in the obesity campaign begins with a picture of a very fat person - morbidly obese 40+ BMI - and then talks about how 2/3rds of people are 'obese or overweight'. Overweight - BMI 25-30 - is not a health risk and we shouldn't treat it the same as actual obesity (something that hasn't increased in ten years)
Targeting the whole population - even though most people are not unhealthy, not eating an bad diet, not overweight, not drinking excessively, not smoking. This means we're essentially ignoring the people who really do need help and support - smokers, alcoholics and the morbidly obese. And the whole population approach doesn't work - UK alcohol consumption has fallen by approaching a fifth but there has been no corresponding drop in alcohol-related hospital admissions.
It's for the children - campaigns like the latest 'cover your eyes' stuff from Jamie Oliver present children as agents of their own obesity when children are not, in the main, purchasers of the family's groceries. The attack on fast food restaurants - with its undercurrents of outright snobbery - is another example where there simply isn't any reliable evidence linking eating fast food to obesity. Worse 'it's for the children' is frequently used as cover for limits, price hikes and bans affecting only adults.
All of this is done within a narrative of 'we know better what is good for you'. Despite there being no such thing as an unhealthy food - just unhealthy diets - we demonise sugar, fat and salt as if they are the reason we are fat (consumption of all three sinful ingredients has fallen since the 1970s while average weight has risen and CHD has plummeted). While PHE has been positive about vaping, most public health functions at a local level remain hesitant to promote it as an aid to quitting - we still have vaping bans in public places that have zero health justification, just because it's easier. And public health continues - despite a mountain of evidence - to ignore the fact that moderate drinking, to levels well above current recommended levels, has a positive impact on mortality risk, up to 20% lower than in people who have never consumed alcohol.
You have become, for the people you most want to reach (the remaining smokers, the very fat and the very drunk), the little girl who shouts fire all the time. They've stopped listening to you because all you offer is a wagging finger - a wagging middle-class finger - of judgement about their lifestyle.
Let me give you a couple of little pen portraits - not real people but their circumstance reflect reality:
Mary - lives in a council flat, single mum, two young kids, smokes, drinks and is very overweight. She knows she should quit, should eat less and perhaps not get drunk but her life is shit and doing those things isn't going to make it better.
Stanley - old man, single, lives on state pension. Likes to watch the racing on a Saturday afternoon TV. Buys two or three cans of beer from the shelf with the cheap and damaged goods - all he can afford. That's all he drinks in a week. Minimum unit pricing means he won't be able to afford that any more. You've not made him healthier, you've just made him less happy.
I hope this left something for people to think about.