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.

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The Giant Malaysian Killer Chicken - story and the limits of skepticism

Readers may not be aware but Bolton Abbey – more specifically Strid Wood - is the last known habitat of the Giant Malaysian Killer Chicken (you may glimpse it in the picture above if you look carefully). It has been a few years since the last sighting of this elusive avian; indeed some suggest that the Killer Chicken is an invention, an artifice created merely to annoy a small child.

What is important though isn’t the provenance of the bird in question – after all you have to do something to occupy the minds of seven-year-olds who reject the concept of walking, even walking through a glorious English wood. Rather, it is the importance of stories – even stories that the intended target (the seven-year-old) wishes you’d shut up about.

I remember once being told – by a scientist no less – that fiction was a waste of time. Even more that it led to people getting the wrong idea. And, as is so often the case with such sceptical folk, this scientist cited creation stories – or “creationism” as he preferred to call it. Apparently, by teaching these stories to children, we are corrupting them and turning them into anti-science religious maniacs (I exaggerate but only slightly).

Such people struggle – for reasons that escape me – with the ideas that there is more to truth than scientific fact and that stories, even weird creation stories, have a valid truth in them. This one – from Assyrian mythology – is among my favourites since it involves the slaying of a dragon:

So were the enemies of the high gods overthrown by the Avenger. Ansar's commands were fulfilled and the desires of Ea fully accomplished. Merodach strengthened the bonds which he had laid upon the evil gods and then returned to Tiamat. He leapt upon the dragon's body; he clove her skull with his great club; he opened the channels of her blood which streamed forth, and caused the north to carry her blood to hidden places. The high gods, his fathers, clustered around; they raised shouts of triumph and made merry. Then they brought gifts and offerings to the great Avenger.

Merodach rested a while, gazing upon the dead body of the dragon. He divided the flesh of Ku-pu, and devised a cunning plan.

Then the lord of the high gods split the body of the dragon like that of a mashde fish into two halves. With one half he enveloped the firmament; he fixed it there and set a watchman to prevent the waters falling down.  With the other half he made the earth. Then he made the abode of Ea in the deep, and the abode of Anu in high heaven. The abode of Enlil was in the air.

The point of these stories is not merely to explain how the world came to be or even to describe mankind’s role in that world. Rather the story more often seeks to explain how “good” and “evil” interact and how we, as men, are corrupted. So the core of creation stories define a morality – whether this one in which Tiamet, the dragon slain to make the word, has aspects of good (the world’s creatrix) and evil (the serpent) or those we are more familiar with such as the Adam and Eve story.

Fiction - the making up of stories – is important if we are to allow our morals, what we see as ‘good’ or ‘evil’, to be understood. We know that the setting down of rules – the lawyers’ obsessiveness that gave us Leviticus and the accountants’ passion that brought Numbers – do not define our moral purpose or even, in that phrase of Mums everywhere, the difference between right and wrong.

The skeptic rejects story – This goes in part to explain the dry dullness of his chosen belief system – preferring instead the idea (a delightfully fictional idea) that truth and understanding derive from a thing called “empirical enquiry” and from that enquiry alone.

Skepticism ... is an approach to claims akin to the scientific method. It is a powerful and positive methodology (a collection of methods of inquiry) that is used to evaluate claims and make decisions. It is used to search for the (provisional) truth in matters and to make decisions that are based on sound reasoning, logic, and evidence. Skepticism is based on a simple method: doubt and inquiry. The idea is to neither initially accept claims nor dismiss them; it’s about questioning them and testing them for validity. Only after inquiry does a skeptic take a stance on an issue.

I see no place in this for story, for wonderment or for the learning that comes from telling an intelligent seven-year-old that Strid Wood is the habitat of a giant killer chicken. Some will observe the contradiction between arriving at a ‘stance on an issue’ through reasoning and through ‘doubt and inquiry’, via scientific method. But that would be to play games of logic with the core belief of a faith – in this case ‘skepticism’.

Story-making and story-telling must be central to our culture, to deny fiction is to deny an essential element of humanity. To characterise stories as ‘childish’ or ‘misleading’ is to misunderstand the power of those stories, the manner in which speculation, creation and change is driven by dreams and hopes rather than by the dry exploration of something “akin to the scientific method”.

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