Radical Public Health

A genuine man goes to the roots. To be a radical is no more than that: to go to the roots.
~ Jose Marti ~

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New York City “Soda” ban is a missed opportunity

Two weeks ago, in an effort to curb rising rates of obesity, the New York City’s board of health banned the sale of “sugary drinks”, i.e soft drinks, in servings larger than 16 ounces. Predictably the cries of undue government infringement, a nanny state, and anything else you can imagine have dominated the media coverage. I think the NYC health board and health advocates can expect to spend the foreseeable future embroiled in lawsuits and targeted campaigns attacking the new law. NYC has a history as a trendsetter for public health initiatives.  They were one of the first cities to ban indoor smoking and, in 2006, were the first to ban trans fats. Both are great initiatives but the soda ban misses the mark. So before anyone gets excited about the new pop ban, or thinks about following suit, a second look at the ban is due.

The pop ban is about winning the “war on obesity”, an issue that that we’re not doing very well on.  After a few decades of attempting to educate people about the perils of obesity, 30 percent of North American’s are now overweight or obese, a rate that has essentially doubled in 20 years. We are starting to conclude that continuing to teach people on the harmful impact of being overweight is more effective at creating a culture of blame than actually helping people be healthy.

Adds like these fail to address why people consume unhealthy food, but make it their fault if they continue to do so. Shame by education has been a massive historic misfire of public health, and we have our track record of a bulging waistline to prove it.

Advocates are looking for new ways to make North American’s slimmer, and topping the list is altering consumer choices by changing social and economic factors. The goal is to make consumers move towards healthier products because they have become more accessible or affordable.

However, with a closer look, it seems as though the designers of the soda ban were determined to ignore all research on the topic, along with experiences and evidence from previous attempts.

Forget that many skeptics believe the ban will not be effective: people will exploit the numerous loopholes to get their soda elsewhere, or switch to other non-banned sugary drinks and products. The real issue is that the ban works on a superficial of level in that the BEST-case scenario people will drink fewer large servings of pop, less often. This will bring about a less-than-impressive impact. The ban does not effect a change in the factors that lead people to consume sugary beverages it just infantilizes them by limiting their choices to certain arbitrary products.

Under the ban you may buy two medium sized drinks, or simply get whatever size you want at a corner store or grocery store that are puzzlingly exempt from the ban.

If I am right, the ban is not just bad for progressive politics but is, frankly, bad policy.

The economics of body weight are actually well understood. Studies in the US and Canada have shown that there is a consistent relation between the price of food, weight and health. The lower the cost of fruits and vegetables, the healthier people are. The lower the cost of fast food and high-energy dense foods, such as soft drinks and processed carbohydrates, the heavier and less healthy people are. Further, modest changes in the price of foods cause corresponding changes in their consumption. Other factors, such as accessibility to food are key but less amendable to federal regulation.

The situation is not overly complicated and is quite intuitive. But, our governments continue to financially support the production of the ingredients used to make unhealthy foods, such as corn and soy, with commodity subsidies, as well as research and development grants. At the same time, farmers of a diverse array of fruits and vegetables are not supported with subsidies and R&D grants. In short choosing to grow non-subsided healthy food is riskier, and less lucrative.

Looking at examples of the subsidies is almost comical. Each year the US government gives farmers the equivalent of 29 cents per taxpayer to subsidize all fruit and vegetable production. When I say fruits and vegetables, I mean apples. Just apples.  Compare that to the 8 dollars spent per taxpayer on just the production of high fructose corn syrup – a big component of sugary drinks. We are eating a lot of unhealthy food because partly because our government, with some generous pressure from interest groups, make that food more accessible and affordable. http://uspirg.org/issues/usp/stop-subsidizing-obesity

Working on changing agricultural subsidies is the best approach we have right now to combat obesity. This directly addresses the economic suprastructure in which people make decisions about the food they can and want to eat.  The NYC soda ban is a local issue; agricultural subsidies are a national issue, but the resources that have and will continue to go into advocating for the ban could have gone towards changing agricultural subsidies.

The costs associated with obesity are dire, and local action should be part of the solution. Then why is the soda ban so weak? Smoking indoors and trans fats were flatly banned in NYC. Is “big soda” more powerful than “big tobacco”, forcing the board of health tiptoe around with partial bans? More importantly why did NYC not opt for a soft drink tax, or an even more ambitious fast food tax? By throwing an almost unenforceable ban into the fray of food politics in NYC, another layer of bureaucracy has been added; it will distract from real issues like subsidies and have a limited impact.

It sounds like I am complaining that NYC is trying to ban the sale of pop rather than impose a tax. But it is not my point, what I am frustrated with is that designing health interventions to tell people what to do or actively limiting their choices is bad policy. It annoys consumers, galvanizes the right wing, and creates new problems. Changing the price of food through taxes or subsidies avoids the paternalism of directly denying people products but still achieves the end goal of decreased consumption, and hopefully healthier people.

I think the soda ban might have a modest impact on soft drink consumption but it will not be worth it, dollar for dollar. The ban passed unanimously with one absentee vote, a good indicator that more ambitious policy could have been pursued. I hope this is a stepping-stone in NYC to more aggressive policies. Instead of playing around with piecemeal local bans health advocates need to think more upstream and start changing consumption of all unhealthy foods by altering food subsidies.

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Systems and self-esteem: Being helpful and constructive on obesity.

By Ashley White

I am not sure it’s possible to better articulate exactly how far off the mark anti-obesity campaigns tend to be that in the way Jezebel’s Lindy West has done right here:  It’s Hard Enough to Be a Fat Kid Without the Government Telling You You’re an Epidemic

She writes, “But first of all, though weight loss can certainly improve some people’s health, “fat” does not universally equal “unhealthy.” Health itself is a much more effective and specific goal. And campaigns like this—which target fat people instead of the system that makes them fat—do nothing but hurt that supposed cause. An anti-fat-people campaign is still an ANTI-PEOPLE CAMPAIGN.”

But, after this piece was published, West herself commented first, “Question. So, okay, if I’m saying that these ads are NOT HELPFUL–and a lot of you are agreeing with me–can anyone come up with a pro-health ad that would be genuinely helpful and constructive? Thoughts? What would that look like?

And so, I’ve been thinking on it.  Aside from killing subsidies to corn, boosting subsidies to a diverse array of plant crops, creating better ways to get good and affordable food to the North – which definitely must happen – and addressing poverty, education deficits, and infrastructure problems, what would be a radical approach to helping people attain healthy weights?
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Anti-Trafficking Initiatives Hurt the Fight Against HIV/AIDS

By Kerry Porth

Recently, Washington DC hosted the 19th International AIDS Conference.  This was the first time the conference had been held in the United States since 1990 as the US had barred entry to any HIV-positive visitors for 22 years – this ban was lifted by President Obama in early 2010.  Sadly, the US chose not to lift two other immigration bans which precluded the involvement of two of the three “high-risk” groups, namely sex workers and drug users. Regardless, many sex work and drug policy activists managed to attend the 5-day conference and protested the US immigration ban and other ideologically-driven policies that are harming the fight against HIV/AIDS.

They found many opportunities to raise awareness of the harms that US policies, anti-trafficking initiatives, and stigma are having on sex workers (protest starts at 1:30).

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Take This and Shut Up

By Kerry Porth

Earlier this year, I attended a talk on the Global Drug War.  After the talk, audience members were given an opportunity to ask questions and I was struck by a comment made by a member of the Vancouver Area Network of Drug Users (VANDU).  After introducing himself as a heroin user of some 35 years, he declared that “abstinence should not be viewed as a victory but rather, a defeat. It represents the complete and utter failure of self-will.” I was surprised to find myself in enthusiastic agreement with him.

For 23 years, my regular attempts to “recover” from addiction were facilitated by the 12-steps. This model posits addiction as a chronically relapsing disease. The medical detoxification facilities I attended (12 times in as many years) required daily attendance of Alcoholics Anonymous or Narcotics Anonymous meetings and group therapy sessions where we were told that the only positive outcome was complete abstinence from all drugs and alcohol.  We were told that we must no longer associate with anyone who uses drugs or alcohol and that we should avoid “slippery” places such as bars or areas where we used to score drugs.  We were told that we could never control our use or have just one drink. Drug addicts who had never abused alcohol were told they couldn’t drink and alcoholics were told they couldn’t smoke pot. To do so would mean an immediate relapse into hard-core addiction. We were told we couldn’t make any decisions for at least a year.  We were told we couldn’t enter into a romantic relationship.  Basically, we were told that we were an extreme danger to ourselves, we were sick, incurable, and would never have self control.  Indeed, the first of the twelve steps is an admission of powerlessness.

Well, I call bullshit. Continue reading

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Narrowing Our Moral Community of Concern: A Critique of Canada’s New Refugee Policies

By Bengo

Here is an excerpt from an article I wrote for the blog AccessDenied, with the same title as the post.  The blog’s approach is from the social sciences, especially medical anthropology, and it attempts to seriously engage both theory and practice in its articles.  It is well worth perusing.  In the article, I attempt to deal with the fact that Canada’s debate over refugee care is not only, or even primarily, about legal, economic, or efficiency issues.  It is primarily about inclusion and exclusion, and drawing boundaries around who is “deserving” of our care.  Since the struggle is one over narrative, debating data and legal arguments needs to be complemented by the generation of a powerful discourse, a narrative into which we place ourselves that includes the provision of care regardless of arbitrary boundaries of status.

Willen recently wrote of unauthorized migrants that, “they are excluded not only from the political community, but also from the moral community of people whose lives, bodies, illnesses, and injuries are deemed worthy of attention, investment, or concern” (2012: 806). Only by portraying these extremely vulnerable people as “undeserving” (Willen 2012) can Canada deny them care while at the same time maintaining an air of generosity. And according to the new policy, these “undeserving” people should be detained, deported as quickly as possible, and denied access to health care.

This discursive manoeuvering imagines refugee claimants from DCOs, no matter what their personal situation, as bogus claimants trying to take advantage of Canada’s generosity. Regardless of the hardship of their lives and their journeys, those arriving in ways deemed “irregular” are imagined as immigration queue-jumpers – as people who freely choose a quick and easy route to Canadian protection and citizenship. Health care professionals, medical anthropologists, and others who care for asylum seekers and refugees and hear the intimate details of their stories are the most obvious candidates to combat these portrayals, which we know from our daily work to be both wrong and demeaning.

Only by telling – and listening to – stories like these will Canadians become attuned to the profound cognitive dissonance between how we want to see ourselves and current Canadian government policy. Pregnant women with high blood pressure, children with asthma, and men with diabetes have all lost access to care. We must repeatedly remind ourselves that they could be our siblings, parents, or children. Through this visceral, narrative approach, we can rehumanize the people most affected by these regressive policy changes and wake ourselves from our complacence. In short, we cannot convincingly declare ourselves generous while denying care to those who deserve it.

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Welcome to Land, Labour, & Liberation!

By Bengo

“The complexity of this whole world syndrome can be overwhelming, and yet to evade the complexity by taking the system apart to treat the problems one at a time can produce disasters. The great failings of scientific technology have come from posing problems in too small a way.  Problems have to be solved in their rich complexity” [i]

There is nothing that connects public health with ecology and social justice as much as the fact that we are but one hungry species among millions of others.  The basic need to fill our bellies is at the heart of human organization, especially the control of land and labour.

As societies have become more complex and globally intertwined, the production of food is more and more distanced from those who control the means of its production.  Changing ownership structures have long brought the consolidation of land and labour, seeds and breeds, fertilizer and pest control, into fewer and fewer hands.  This industrialization and commodification of food systems has had serious and far-reaching consequences, drastically affecting the determining conditions for people everywhere to lead healthy lives.

Land, Labour, and Liberation will examine stories from the struggle to bring control of the global food system back into the hands of the people.  The questions we must ask cut across divides of discipline, taking as their basis a shared project of liberation from systems of oppression and structural violence.  The rich complexity of these struggles include political, economic, historical, cultural, and epidemiological stories, and my focus will be on the way networks of power manifest themselves in the bodies of those most vulnerable and affected.

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What’s the evidence?

By Emily Groot

There has been a big push in public health to use the best available evidence to inform policy development.  When it comes to radical public health policy change, however, developing the evidence base for policy can be difficult.

In part, this is because randomized controlled trials (RCTs) are often considered the gold standard in health research.  When it comes to interventions that address the determinants of health, RCTs are often not feasible because the root causes of illness and well-being are interconnected and cannot be reduced to component parts (Norman, 2009).  Natural experiments are hard to come by.

Even when feasible, RCTs may not be preferred way to study systems change because the careful selection of the study population means that it is difficult to generalize the results to the broader population (Rockers et al., 2012).  As well, RCTs usually attempt to control the impact of historical, cultural, and political factors that are essential to understanding how an intervention will fare in a particular context (Best et al., 2009; Rockers et al., 2012).

Most RCTs only address single interventions, while in real life there are multiple policies already in effect.  These policies may interact in non-linear ways that are difficult to predict from the available evidence (e.g., a change to agricultural subsidies and a change to social assistance funding may both decrease the risk of obesity, but when both policies are implemented simultaneously, the total impact may be much greater than the sum of the impacts of both programs) (Peters & Bennett, 2012; Sanderson, 2009).

In essence, interventions addressing the determinants of health are often so context-dependent it is difficult to predict their effectiveness in a particular context.  That is not to say it is impossible.  What is necessary to change health systems to better address the determinants of health is a range of different types of evidence, including:

  • Information about overcoming local barriers to implementation;
  • Evidence from non-research environments;
  • Description of the unintended consequences or political ramifications of the intervention;
  • Evidence of the impact of the intervention on equity;
  • Assessments of the intervention’s technical feasibility; and
  • Assessment of the intervention’s acceptability to policymakers and stakeholders (Bosch-Capblanch et al., 2012; Peters & Bennett, 2012).

This can also include evidence of effectiveness from RCTs, when feasible.

References

Best, A., Terpstra, J. L., Moor, G., Riley, B., Norman, C. D., & Glasgow, R. E. (2009). Building

knowledge integration systems for evidence-informed decisions. Journal of Health Organisation and Management, 23(6), 627-641.

Bosch-Capblanch, X., Lavis, J. N., Lewin, S., Atun, R., Røttingen, J.-A., Dröschel, D., Beck, L., et al. (2012). Guidance for evidence-informed policies about health systems: Rationale for and challenges of guidance development. PLoS Medicine, 9(3), e1001185.

Norman, C. D. (2009). Health promotion as a systems science and practice. Journal of Evaluation in Clinical Practice, 15(5), 868-872.

Peters, D. H., & Bennett, S. (2012). Better guidance is welcome, but without blinders. PLoS Medicine, 9(3), e1001188.

Rockers, P. C., Feigl, A. B., Røttingen, J.-A., Fretheim, A., de Ferranti, D., Lavis, J. N., Melberg, H. O., et al. (2012). Study-design selection criteria in systematic reviews of effectiveness of health systems interventions and reforms: A meta-review. Health Policy, 104(3), 206-214.

Sanderson, I. (2009). Intelligent policy making for a complex world: Pragmatism, evidence and learningPolitical Studies, 57(4), 699-719.

 

Parts of this post were originally written for a paper submitted for CHL6020Y Y at the University of Toronto.

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Rediscovering Radicalism

By Emily Groot

Radical ideas are often perceived as novel, but the beliefs underlying radical public health are not new.  For example, in a report on the 1847 typhus outbreak of Upper Silesia, German pathologist Rudolf Virchow proposed reforms ranging from agricultural improvements to tax restructuring to avoid future outbreaks (Taylor and Rieger, 2008; Waitzkin, 2006).  Virchow called diseases to which susceptibility was determined by socio-economic conditions, such as dysentery, measles, tuberculosis, and typhoid, “artificial diseases”.  He recognized that although the etiology of these diseases was bacterial, the spread of the disease was determined by wider social circumstances (Taylor and Rieger, 2008).

Virchow was one of the key persons to popularize social medicine, the practice of preventing disease and promoting health by addressing systemic socioeconomic inequalities (Taylor and Rieger, 2008).  Although social medicine shares many features with traditional public health, social medicine focuses on collective variables that have no individual measure (e.g., culture, class) while traditional public health often focuses on aggregate individual measures (e.g., cultural practices, income) (Waitzkin et al., 2001).

I consider the concept of social medicine to be a subset of the wider concept of radical public health.  The Social Medicine blog will explore issues of relevance to social medicine and attempt to rediscover the historical roots of radical public health.


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