Currently browsing posts about: Public-health

Sandro Galea.  Well: What We Need to Talk About When We Talk About Health.  Oxford University Press, 2019.

I blurbed this one:

A superb account of how money, power, politics, and the luck of the draw affect the health of individuals and populations. It should inspire us all to follow Galea in championing public health as an essential public good, and in treasuring and preserving the core values of public health—fairness, justice, and compassion for all.

Galea is the dean of the school of public health at Boston University and a prolific writer on public health topics, including food on occasion.  I am a big fan of his work.  I like his focus on social, economic, and environmental determinants of health and his consistent promotion of the core values of public health.  If you don’t really get what public health is about, this book is a great place to start.

Here is a brief sample from the chapter titled “Choice.”

We imagine our choices to be, for the most part, beyond the reach of outside influence and that, when we choose, we do so from an unlimited array of options; no one tells us what to eat, whether or not we are permitted to exercise, or who we must embrace as a life partner.  For this reason, much of our conversation about health has to do with “lifestyle”—making the correct choices for ourselves, choices which, we believe, will lead to better health.

…Yes, we can choose the food we eat, but our options are limited by what we can afford and by what kinds of food are available for purchase near our home.  These factors, in turn, depend on the quality of our neighborhood and the size of our income, which depends on larger socioeconomic forces over which we have little control.  Likewise, we can only choose to exercise if we live near parks, walkable streets, or athletic facilities, and we can only choose a person to marry from among the individuals we encounter within our community.  Place, power, money, politics, and people—all the forces we discuss in this book—shape the variables that ultimately influence our health.

When I give talks these days, I usually wear a pin—the O in the United Nation’s Sustainable Development GOals (SDGs).  These were authorized by the U.N. General Assembly in 2015 to be achieved by 2030.

Each goal has specific sub-goals.  These are listed here in interactive format.  Food comes up in several, but mainly in Goal 2 (End Hunger) and a bit in Goal 12 (Responsible Consumption and Production).  Here are the first three sub-goals for Goal 2:

The SDGs have sparked many organizations to take action.  The U.N. makes taking small actions easy for individuals by producing “The Lazy Person’s Guide to Saving the World“—things you can do from your couch, your home, or outside your home.

Here’s the U.N. report on how progress toward the goals looked in 2016.

I wish chronic disease prevention was more prominent in these goals, which would make food more prominent, but this is a start and well worth knowing about.

I’m in Europe this week so especially interested in its public health efforts. This report is an example.

Healthy and Sustainable Diets for European Countries. Report of a Working Group. EUPHA (European Public Health Association), 2017.

The purpose of this report is to encourage public health professionals to promote policies that will enable individuals to make healthier food choices.  It’s a long report, but summarizes its goals in one quick table:

Larry Cohen.  Prevention Diaries: The Practice and Pursuit of Health for All.  Oxford, 2016.

Larry Cohen is an old friend and I was happy to be asked to do a blurb for his terrific book:

Prevention Diaries is Larry Cohen’s intensely personal and introspective account of why stopping health problems before they start makes sense for individuals and for societies—and is possible.  His stories of how advocates have successfully intervened to prevent problems caused by unhealthy eating, cigarettes, automobiles, guns, violence, and system inequalities should inspire everyone interested in public health to get involved in prevention programs that will make a real difference in people’s lives.

Here’s a brief excerpt from his “food for thought” chapter:

The realities of our food system can feel overwhelming—too large and too entrenched to change all at once.  But, as with so many big problems, communities and businesses are taking valuable steps to create the system we want and need.  Indeed, it feels like the United States is at the beginning of a sea-change in its pproach to food—with a swell of interest in seemingly old approaches, like farmers’ markets, heirloom produce, and cooking from scratch, which benefit consumers and workers.  As the movement has been building, its momentum and innovation have increasingly started to reshape government policies and industry practices in ways that ensure all people can enjoy the fruits of a healthier food system (p. 93).

From his lips to God’s ear, as the saying goes.

I am a member of the New York Academy of Medicine and am happy to say that its Institute for Urban Health has just published a terrific new report in its City Voices: New Yorkers on Health series.

This one, published in June, is called “Food and Nutrition: Hard Truths about Eating Healthy.”

It is utterly remarkable and, in my experience, highly unusual.  The authors actually asked low-income community residents in Bronx, Brooklyn, Manhattan, and Queens what they think about their diets, risks for chronic disease, and challenges to eating healthfully.

If you care whether people of low income have financial and physical access to decent food, this report is essential reading.

Food advocates: If you are looking for something useful to do, read this report.  It makes the needs clear and also suggests where interventions might best be targeted.

I’m always complaining that public health advocates need to ask people in communities what they think.  These authors did that, and look how useful it is!

Tom Farley, MD.  Saving Gotham: A Billionaire Mayor, Activist Doctors, and the Fight for Eight Million Lives.  Norton, 2015.

Dr. Farley is the former New York City Health Commissioner under Mayor Michael Bloomberg, the second Tom in that position (the first was Tom Frieden, now head of the CDC).

He has produced a wonderfully written, personal, eye-witness, in-the-trenches account of how the New York City Department of Health and Mental Hygiene led the nation in creating public health interventions to reduce smoking, get rid of trans fats. put calorie labels on restaurant menus, and reduce soda consumption—with impressive improvements in the health of New Yorkers.

His book also covers the Department’s failures to convince the USDA to allow a pilot project to get sodas out of SNAP and the courts to support the city’s proposal to cap the sizes of sugary drinks at 16 ounces.

For me, a New York City resident  who lived through these events and wrote about some of them in Soda Politics, this book was fun, even gossipy, and disclosed things I hadn’t known.  It has much to teach anyone about how the politics of city public health agencies, how to get things done in complicated city institutions, and how to treasure even the smallest successes.

This particular health department had three things going for it: courageous health commissioners, huge city health problems that desperately needed to be addressed, and a mayor fearless (and rich) enough to take on the challenges.

Farley ends the book with a quote from Bloomberg:

While government action is not sufficient alone, it is nevertheless absolutely essential.  There are powers only governments can exercise, policies only governments can mandate and enforce, and results only governments can achieve.  To halt the worldwide epidemic of noncommunicable diseases, governments at all levels must make healthy solutions the default social option.

That is, ultimately, government’s highest duty.

Amen.

If I were teaching public health nutrition right now, here’s what I’d want students to read:

Geof Rayner and Tim Lang, Ecological Public Health: Reshaping the Conditions for Good Health, Routledge Earthscan, 2012.

Our case is that public health is an interdisciplinary project, and not merely the preserve of particular professionals or titles.  Indeed, one of the themes of the book is that public health is often improved by movements and by people prepared to challenge conventional assumptions and the status quo…In these cynical academic times, when thinking is too often set within narrow economistic terms—What can we afford? What is the cost-benefit of health action?—and when the notion of the ‘public’ is often replaced by the ‘individual’ or the ‘private,’ this book offers an analysis of public health which is unashamedly pro bono publico, for the public good.

David Stuckler and Karen Siegel, eds.  Sick Societies: Responding to the Global Challenge of Chronic Disease, Oxford University Press, 2011.

Sick Societies argues that we are building environments that are poorly designed for our boides: we create societies where tobacco, alcohol, and foods containing high levels of salt, sugar, and fats are the easiest, cheapest, and most desirable choices, while fruits, vegetables, and exercise are the most expensive, inaccessible, and inconvenient options.  The rise in chronic diseases is the result of a model of societal development that is out of control: a model that puts wealth before health.

Wilma Waterlander, Put the Money Where the Mouth Is: The Feasibility and Effectiveness of Food Pricing Strategies to Stimulate Healthy Eating, Vrije Universiteit, Amsterdam, 2012.

This one is for policy wonks and change agents.  This is Waterlander’s doctoral dissertation done as a published book but it is written clearly and forcefully.  Her conclusions:

The studies presented in this thesis show that the healthy choice is the relatively expensive choice; that price fundamentally affects food choice and may even form a barrier for low SES consumers in selecting healthier foods.  These findings make pricing strategies a justifiable tool to stimulate healthier choices…making healthier foods cheaper was found to be the most feasible pricing strategy to implement.

I received a couple of requests to define “public health” last week from readers Anthro and MA.  As MA puts it,

Maybe…we need a definition of “public health.”  I view my health as a private matter, my food choices as a private matter, and an expression of my freedom.  To me, public health is not an individual concern, it’s a corporate (group) concern – government, schools, companies, farms, etc.  Public health includes things like properly working sewer systems, sanitation, water quality, and air quality.   Marion – can we get a definition of ‘public health’ from you, as Anthro suggested?

My definition of public health isn’t much different from mainstream definitions.  But to me, public health is a critically important expression of democracy, and the antithesis of  a “corporate” concern.  Public health approaches promote good health for everyone, not just those who can afford it or are educated enough to make appropriate choices.

A standard definition such as the one given in Wikipedia, says that public health is about promoting health and preventing disease through societal choices and efforts.   Public health deals with health at the population level, rather than at the level of individual personal responsibility, and it emphasizes prevention rather than treatment.

In my experience teaching public health nutrition, the concept of public health is sometimes hard for people to grasp, especially since populations are made up of individuals. I like to explain it this way: public health makes it easier for individuals to make healthful food choices for themselves and their families. Or to put it another way, public health makes better food choices the default.

The classic example of a public health intervention is water chlorination.  As individuals, we could all boil our own drinking water to kill harmful organisms but this requires us to have stoves, pots, and fuel, and to know how to boil water.  For many people, having to do this would be an intolerable burden and responsibility.  Instead, some societies choose to take public health measures to ensure that drinking water is safe at the tap for everyone.

Other food examples: milk Pasteurization, banning of trans fats, food labeling.

The particular example that elicited the question has to do with food safety.   We, as a society, could insist that food producers take measures to ensure that their products are free of harmful microorganisms (public health), or we could teach individuals how to manage food safety in the home or restaurants and cook foods properly (personal responsibility).

Preventing obesity is another example: We could, as a society, take measures to make it easier for people to eat more healthfully and be more active (public health) or leave it up to individuals to do this for themselves (personal responsibility). Many of the arguments about suggested public health measures to prevent obesity are about how best to balance society’s needs with individual rights.  But as I see it, the proposals aim to tweak societal choices that have already been made: which crops receive farm subsidies, for example.

An exceptionally clear example is how to avoid toxic levels of methylmercury in fish.   We can teach pregnant women to recognize which fish are high in methylmercury and hope this works well enough so they will avoid buying such fish (personal responsibility) or we could–as a society–require coal-burning power plants to scrub their emissions so mercury doesn’t get into ocean or lake waters in the first place (public health).

Obviously, both public health and individual approaches are necessary, but the overall objective of public health is to make it much, much easier for individuals to make better health choices without having to think about them.

Because public health applies to everyone, it is essentially democratic.   And that’s one of the reasons why I think it matters so much.