Proponents of modern day public health measures (especially those measures that seek to tackle ‘non-communicable diseases’ through ‘lifestyle interventions’ or ‘behaviour change’) will invariably describe their proposed policies as fair, equitable, justified and any number of other feel-good words; but almost without fail the word progressive will feature somewhere within the missive.
In fairness, the deployment of this word comes about in an atmosphere in which every area of public life, and any form of public policy- not matter how trivial or banal- must be seen to comply with the overarching progressive narrative.
But nonetheless, if public health policies are to be described as progressive then it is fair to examine their claim to be so, in further detail.
What then is meant by ‘progress’ in public health? Should we take it that to be progressive means that people are able to live longer as a result of the proposed policy? Or given rampant trend toward egalitarianism within academic public health (Thanks in large to Marmot, Wilkinson and Pickett) does progress mean that policy will reduce health inequalities (perhaps through the use the marvelously paradoxical proportionate universalism as proposed by the Marmot Review?) Or should we consider fiscally regressive measures such as sugary drinks taxes to be progressive as they arguably reduce consumption of a product that has seemingly been ruled verboten?
That the concept of ‘progress’ must sit at the very core of public health policy stems from what I would argue is the skewed Weltanschauung of the public health community.
In this worldview, a policy is progressive if it extends lifespan, increases quality adjusted life years, diability-free life expectancy, reduces consumption of products/ingredients that are currently deemed unhealthy by the prevailing scientific consensus (Sugar? Fat?).
But what of those less tangible aspects of the human condition that don’t fit into the progressive worldview? Must public health policy only be considered progressive if it deifies diminishing time-preference (or declining concern for the present in comparison to the future)? After all countless philosophers, theologians, writers and sages throughout the ages have pointed out the folly and unhappiness that accompanies the wait for an imagined perfect future, rather than enjoying the present moment.
Perhaps the problem is best summed up by the phrase ‘immanentize the eschaton’. That is, public health policy often strives to make ‘heaven real on earth’ and fails to account for the inherent fragility of man (and all that actually being human entails). This clashes with those that would defend vices and ‘unhealthy’ behaviours and whose worldview is perhaps more inclined toward the human and romantic, rather than the scientific and rational (I would strongly emphasise that this is not necessarily a weakness!).
The inimitable observer of human life and foibles, G K Chesterton summed up this clash of worldviews perfectly; inveighing with his typical good humour against the obsessive progressivism of his ‘friendly enemy’ G B Shaw:
“After belabouring a great many people for a great many years for being unprogressive, Mr Shaw has discovered, with characteristic sense, that it is very doubtful whether any existing being with two legs can be progressive at all. Having come to doubt whether humanity can be combined with progress, most people, easily pleased, would have elected to abandon progress and remain with humanity. Mr Shaw, not being easily pleased, decides to throw over humanity with all its limitations and go in for progress for its own sake. If man, as we know him, is incapable of the philosophy of progress, Mr Shaw asks, not for a new kind of philosophy, but for a new kind of man. It is rather as if a nurse had tried a rather bitter food for some years on a baby, and on discovering that it was not suitable, should not throw away the food and ask for a new kind of food, but throw the baby out of the window and ask for a new baby.”
Chesterton’s words sum up this argument far better than I can. Whilst it remains important to try and improve public health, and to “look at the evidence”, I would argue that there is very strong case for public health to ‘remain with humanity’ and not let purely technocratic and progressive concerns override all others.
There are also cultural factors at play in this divergence of worldviews. When you are handsomely remunerated, intellectually stimulated by your work, cultured, intelligent and possess a social circle of equally well remunerated, educated and well-travelled peers- ‘lifestyle choices’ such as smoking, vaping, an unhealthy diet etc may seem derisory, unnecessary, inexplicable, disgusting even; but for those at the opposite end of the social scale they do not have the consolation of decent pay, stimulating and interesting work, and bourgeoisie leisure pursuits. Instead they turn to these ‘lifestyle choices’ despite (and sometimes because of) the detrimental impact on their long-term health outcomes. That these things are enjoyable and comforting is so often overlooked by those that do not indulge in them.
I’ll let a recently deceased Hobbesian philosopher bring this reflection to a suitably stark and blunt conclusion:
“Prior to the establishment of the state, life is nasty, brutish and short. Nothing changes once a state’s created. Only the longevity of the participant alters. And even that’s arbitrary.”
In plotting the ‘arc of history’ of public health policy and practice at a European level in recent decades one can see an accrual of power, resource and legislative influence for the cause of public health as policy makers accepted that “comparatively few of the major determinants of health can be controlled at the nation state level in the world”.(1)
Tracing the development of European public health we can see nascent efforts to plan and implement policy taking place on a voluntary basis owing to the paucity of the Treaty of Rome in providing a legal grounding for pan-European public health activity.
Such efforts on a voluntary basis did eventually bear fruit however. Article 129 within the Maastricht Treaty amended the Treaty of Rome to make allowances for European-level public health planning, policy and activity. Article 152 followed as part of the Amsterdam Treaty- providing further powers in two key areas: firstly a requirement to analyse the public health implications of all EU policies and programmes, secondly the harmonisation of public health protection in certain limited areas (e.g. collection of human tissue products and veterinary and phytosanitory health). (2)
Legislative progress may have shown relatively steady progress over the past three decades, however when we examine the policy and practice at a European-level, a more disparate, fractured picture emerges. Initially at least, ad-hoc programmes emerged at the expense of a comprehensive ‘European Public Health Strategy’. To compound this situation, no serious health impact assessments were carried out in respect of these early programmes and policies (the prospect of consolidation arose in a 1998 discussion paper). (3)
Institutional frailties aside, the growth and establishment of public health at a European-level has had a profound impact upon public health practice. More incisively, “these changes have to be viewed in the context of, and with consideration to, public health practice at a local level.” (4)
Why these changes are (and where) necessary becomes clear when one examines the macro-environment in which public health practitioners now operate. The rise of globalisation, free trade and the easing of cross-border capital controls (amongst a multiplicity of other factors) now means that “national, European and international actions govern local food systems etc” (5), taking control away from the nation state. As trans-national organisations and agreements have emerged- so too have opportunities to lobby and cajole decision makers. Hence the need for public health professionals to “develop the skill of integrating public health… influence at all levels of the economy”. (6)
A recognition of these supra-national factors (and the urgent need to mitigate their impact upon the health of the public) has arguably forced policy makers to consider ‘upstream’ factors; “The causes of the causes” (7) (e.g. non-communicable diseases, poor lifestyle factors such as excessive alcohol and tobacco consumption, poor diet and physical inactivity). The social gradient of health, progressive universalism, gender inequalities in health and inter and intra generational inequalities in health have now risen to the top of the European public health agenda. (8)
A tough task then; made tougher by the financial crisis of 2008 with its attendant social problems. (The economists Reinhart & Rogoff have found that financial crises typically produce rises in unemployment that persist for 4 to 6 years (9)). As governments across Europe have sought to rein-in their debts, reduce their deficits (and in the case of the UK, introduce significant liberalising supply-side reforms to welfare systems) debate has erupted within the public health community as the correct response to what has been dubbed ‘austerity’.
The Stuckler & Basu analysis (10) offers a cogent and compelling case that ring fencing not just healthcare, but also social welfare systems through government stimulus will protect health, “Adults in secure and safe employment, receiving wages above the level needed merely to survive, are less likely to adopt hazardous lifestyles… and can expect to live longer”. (11)
Looking ahead, it will be interesting to see how European public health responds to the immediate challenge of reduced public spending and rising health issues, but also the perennial challenge posed to all policy makers by what F A Hayek called the ‘Catallaxy’: the ever-expanding exchange and specialisation of the economy that can produce innovations and ideas that would not ordinarily be arrived at by a small group of policy makers.
Equally, the rapidly approaching (or recently arrived, depending on your perspective) era of big data (12) and quantified-self (13) may provide huge challenges and/or opportunities to European public health policy makers and practitioners. Sorting the signal from the noise may prove to be a primary challenge as European policy makers move from possessing a dearth of data to a glut. (14)
The rapidly changing ecology of public health policy making was summed up well (albeit in a niche context) by Viscount Ridley in a House of Lords debate on electronic cigarettes “The tobacco companies are worried… they are facing their Kodak moment, the moment when their whole technology is replaced by a rival technology…” (15) The tobacco industry has resorted to the blunt of hammer of litigation in response to European public health legislation (e.g. the European Tobacco Products Directive), or has focused on product innovation (e.g. moving into electronic cigarettes).
Although it is possible that the tobacco industry will avoid ‘creative destruction’ by such means- as well as using the brute force of its significant capital assets to diversify, purchase electronic cigarette manufacturers etc it seems less likely that public health policy at a European-level will face its own ‘Kodak moment’, given the secure nature of its funding and isolation from disruptive forces.
The key question for the future of public health policy at a European-level is whether or not it can keep up with ‘free market solutions for health’, resisting the temptation to suffocate very promising developments such as electronic cigarettes, whilst also dealing with changing attitudes to European collaboration and co-operation. As Clive Bates has pointed out- “culturally, the public health establishment is inclined to paternalism, and state-based or not-for-profit interventions. It instinctively distrusts the private sector and capitalism, and is ill at ease with the idea of consumers as empowered agents.”
Tackling this mindset may be key to nurturing European public health policies that are fit to meet the challenges of the 21st century.
1) Birt CA, “The Onward March of European Public Health”, editorial in the Journal of Epidemiology and Community Health, 52, 12, 770-771, December 1998
2)Birt CA, “A Widening Horizon for European Public Health Practice”, editorial in the Journal of Epidemiology and Community Health, 59, 0-1, 2001
3) Birt CA, “The Onward March of European Public Health”, editorial in the Journal of Epidemiology and Community Health, 52, 12, 770-771, December 1998
4) Birt CA, “A Widening Horizon for European Public Health Practice”, editorial in the Journal of Epidemiology and Community Health, 59, 0-1, 2001
5) Birt CA, “A Widening Horizon for European Public Health Practice”, editorial in the Journal of Epidemiology and Community Health, 59, 0-1, 2001
6) Birt CA, “A Widening Horizon for European Public Health Practice”, editorial in the Journal of Epidemiology and Community Health, 59, 0-1, 2001
7) Marmot M, Allen J, Bell R, Bloomer E, Goldblatt P, “WHO European review of social determinants of health and the health divide”
8)Marmot M, Allen J, Bell R, Bloomer E, Goldblatt P, “WHO European review of social determinants of health and the health divide”
9) Reinhart C, Rogoff K, “The Aftermath of the Financial Crisis” Working Paper 14656, NBER Working Paper Series, National Bureau of Economic Research, January 2009
10) Basu S, Stuckler D, “The Body Economic: Why Austerity Kills” Allen Lane 2013
11) BMJ 2010; 340 doi: http://dx.doi.org/10.1136/bmj.c3311
12) “Big data is the term for a collection of data sets so large and complex that it becomes difficult to process using… traditional data processing applications”. Wikipedia
13) “The Quantified Self is a movement to incorporate technology into data acquisition on aspects of a person’s daily life in terms of inputs (e.g. food consumed, quality of surrounding air) states (e.g. mood, arousal, blood oxygen levels), and performance (mental and physical)”. Wikipedia
14) The issue of sifting through large volumes of data and making predictions affecting public health is covered in Chapter 7 of Nate Silver’s “The Signal and the Noise: The Art and Science of Prediction”, Penguin 2012
15) HL Deb 17 Dec 2013, Grand Committee, Col GC264
Electronic cigarettes are dividing the public health community. Could a new caffeine product be about to do the same?
Caffeine makes the world go round, or at least that’s the impression one gets when watching commuters clutching their grande lattes and the proliferation of coffee shops throughout town centres and travel terminals.
Of course caffeine is not merely restricted to coffee but is increasingly found in an expanding number of energy drinks (as well as chocolate, tea, tablets etc).
Clearly our appetite for caffeination and stimulation is not being sufficiently satiated by these existing products; Reuters reports the launch this week of Reon, dubbed ‘on-the-go caffeine strips’ by its manufacturer. According to news reports Reon is still in market-testing stage, for now only being sold in select stores in Manchester and online.
Naturally, as one of those aforementioned commuters found most mornings clutching to a coffee for dear life I decided to procure a sample of Reon and see if it lives up to its billing as the “smart and innovative way to transform your day”.
Having plumped for the Blackcurrant and Fresh flavour I pulled the strip from its packaging and popped the strip on my tongue. It promptly dissolved leaving a strong menthol like taste in my mouth followed by a slightly acrid after-taste after 5-10 minutes (perhaps as a results of the delivery method- or more likely perhaps because of my own devastated pallet).
And yes, very quickly I was able to identify a distinct feeling of alertness- similar to a small instant coffee or a “can of coke” as described on the packet.
So “caffeinated mouth strips perform as advertised”. That’s not much of a review is it? Well no, but the real interest of Reon for me lies not necessary in the performance of the product- but rather it’s provenance.
Reon it transpires is a new product from Fontem Ventures, “a subsidiary of Imperial Tobacco that is dedicated to developing and growing a portfolio of innovative non-tobacco product opportunities in lifestyle and consumer good categories.”
As Martine Geller at Reuters points out “Big Tobacco firms are increasingly diversifying away from cigarettes, a market worth over $700 billion a year at retail but shrinking in many countries for health reasons.”
Indeed, increasing consumer-awareness of the negative health consequences of tobacco smoking, coupled with increasingly stringent public health measures, trading restrictions and fiscal penalties appear to be focusing the minds of tobacco executives on business opportunities in alternative (and less formidable) markets and goods categories.
Despite caffeine’s relatively benign nature Big Tobacco’s venture into this marketplace is bound to set alarm bells ringing amongst public health policy makers. Despite Reon being targeted at “young professionals” aged 25-45, there are no restrictions on sales to minors. And concerns are already being raised by the likes of the World Health Organisation concerning “potentially harmful adverse and developmental effects” amongst young people that consume ‘caffeine laden energy drinks’ (admittedly the warnings apply to energy drinks- but they are high in caffeine).
Conversely the European Food Safety Authority released its draft assessment on caffeine earlier this month, which made a number of provisional conclusions:
- Single doses of caffeine up to 200mg and daily intakes of up to 400mg do not raise safety concerns for adults in Europe.
- It is unlikely that caffeine interacts adversely with other constituents of ‘energy drinks’- such as taurine and D-glucurono-y-lactone or alcohol.
- For pregnant women, caffeine intakes of up to 200mg a day do not raise safety concerns for the foetus.
- For children (3-10 years) and adolescents (10-18) years, daily intakes of 3mg per kg of body weight are considered safe.
With these (provisional) conclusions in mind (and taking into account negative findings) how should public health policy makers react to Big Tobacco’s move into the caffeine market?
Certainly caffeine (or more particularly) coffee has long had an interesting and complicated relationship with lawmakers and other public officials. Ever since it was recognized that coffee contained a compound that acted as a stimulant it has variously faced bans and restrictions on its use with the likes of Charles II of England, Frederick II of Prussia and the Ottoman Empire turning their legislative ire on the substance.
History aside, from a purely economic perspective the tobacco industry’s diversification into this product category makes rational sense. Any business currently operating in a market that is being squeezed by regulation and restrictions (and with regulators and government officials regularly referring to an ‘endgame’ for said market) would seek to move into ‘freer’, more profitable markets that impose fewer barriers to trade and operation.
And caffeine most certainly looks like an appealing product category for a well-capitalised business- to quote Geoffrey Burchfield (1997) “Global consumption of caffeine has been estimated at 120,000 tonnes per year, making it the world’s most popular psychoactive substance. This amounts to one serving of a caffeinated beverage for every person every day.”
Should these diversification efforts prove successful and the tobacco industry gains a foothold in the caffeinated goods market it will be instructive to see the view the response of the public health milieu.
As the emergence of electronic cigarettes have caused significant divisions within the public health community, will Big Tobacco’s involvement in the provision of caffeine have a similar effect? Is there going to be the emergence of a ‘Big Caffeine’ (as a proxy for ‘Big Tobacco’) v public health dichotomy? Will we see harm-reduction advocates applauding the transition of the tobacco industry into non-tobacco product categories? Will we in turn see the abstention (prohibition?)-inclined wing of public health decrying any involvement of the tobacco industry in caffeine (pointing to the addictive nature of caffeine and reported negative health impacts of consumption amongst young people for example)?
Whatever your stance on the desired and undesired health impacts of caffeine intake- and the involvement of the tobacco industry in this product category, it is clear that this diversification- if successful- could well pose some major headaches for the public health movement in the years ahead.
This was a short piece that I was commissioned to write in 2013 to provide a critical analysis of the social investment marketplace; casting a light on the contradictions between the bold claims being made by social investors and the reality for frontline social enterprises. As social entrepreneur Robbie Davison has recently outlined, it seems little has changed in the intervening time since 2013…
Clearly 2012 has failed to be the ‘breakthrough year’ that the self-appointed coterie of social investment analysts in the south-east of England predicted. But, with traditional grant funding, soft loans and patient capital in short-supply, will 2013 herald the maturation of what has been dubbed the social investment marketplace and ergo, the flourishing of the social enterprise sector on Merseyside and beyond?
A recent report commissioned by Big Society Capital has outlined some frankly astonishing ambitions- from a meagre £165m worth of social investment deals completed in 2011, Big Society Capital aims to be completing £1bn worth of deals by 2016! Frankly, given the lacklustre demand from genuine social and community enterprises for this type finance the brakes should be applied to this wanton enthusiasm and unrealistic forecasting.
Looking closer, many of the claims made in the report are couched in caveats, and rightly so. We continue to see a major disparity between the reality of investment demand on the ground and the rhetoric emanating from this nascent social investment marketplace.
As has been widely observed in other discussions about the growth of a bullish social investment marketplace, there is a mismatch between the social finance products on offer and types and terms of finance requested by the social enterprises. Research commissioned by Big Society Capital reveals that social enterprises typically want unsecured risk capital on sub-commercial terms of between £10,000 and £100,000. This same research however indicates that what is on offer from social investors is larger, secured, asset-backed capital on near commercial terms.
This may sound unreasonable from a purely commercial perspective; as though social enterprises are ungratefully carping about investment opportunities that it can’t or is unable to handle. To view the situation from this perspective however is fundamentally wrong and demonstrates a misunderstanding of the role, governance, and business models of social enterprises (which are themselves dictated by the conditions in which they operate- tackling social need).
My work with social enterprises on Merseyside reveals a picture of a social enterprise sector that works in areas of acute market failure, using atypical business models, assisting some of the most hard-to-reach groups with what are often costly, but effective, interventions.
If the social investment marketplace is to reach the predicted £1bn mark and provide the injection of capital that social enterprises desperately need, social investors need to both take the financial products they currently offer back to the drawing board and garner a clearer understanding of social need.