The recent debate between nutritionist Dr Rosmary Stanton and PepsiCo executive Dr Derek Yach generated much discussion at Croakey. Many public health experts were sceptical about the intentions of companies like PepsiCo.
However, Stephen Leeder, Professor of Public Health at the University of Sydney, argues that the public health community needs to move beyond moral indignation to effective engagement with industry.
“The recent Croakey conversation about obesity and the soft drink industry is imbued with strong moral concerns, as is the public health community more generally – many members march at the front of the platoon that seeks to secure equitable access to health care, even, indeed, equal health outcomes from care or equality of health status.
No great problem there: this moral concern has motivated deep inquiry into the social determinants of health and action to tackle maternal and child survival, extreme poverty, the humane care of people with AIDS and Indigenous health. It is in sympathy with international movements that promote human rights generally and those pertaining to health specifically.
While this moral concern has generated power in the grid of modern public health action – including the battles fought and partially won with tobacco companies – paradoxically it may inhibit progress in achieving better health for people who suffer because of the negative effects of global economic expansion, city building and food manufacture. Illnesses caused by these changes now dominate the lists of global mortality and morbidity.
Why may our moral indignation in public health be a problem? Before answering that question we need to hear a word from the philosopher John Rawls.
As Denver ethicist Jack Donnelly wrote recently in a monograph on concepts of human dignity, Rawls distinguishes notions of justice that derive from religious and philosophical doctrines such as Islam and Marxism from “political conceptions of justice”.
These, in Donnelly’s words, “address the political structure of society, defined (as far as possible) independent of any particular comprehensive doctrine. Adherents of different comprehensive doctrines may be able to reach an overlapping consensus on a political conception of justice.”
What Donnelly is getting is that while the foundational motivations and ideology of different people will vary, and sometimes radically so, it remains possible “to achieve an overlapping consensus [that is] partial rather than complete. It is political rather than moral or religious.”
Many of the solutions to our current health woes undoubtedly sit outside the health sector, and will involve stakeholders with sometimes very different values and objectives and different concepts of morality. Finding the points of ‘overlapping consensus’ is key for us to move forward towards health gain.
Recently in Sydney we listened to two points of view – from Derek Yach and Rosemary Stanton – about nutrition and how it might be altered in favour of a slimmer society. Derek works with PepsiCo and Rosemary definitely does not! Both are people of impeccable public health credentials and they deliberated about how we might enter an age where obesity and its dark consequences did not dominate our thinking.
It has generated lively debate but I do not see how we can make progress until such time as we accept that a solution to this problem will be based on a political conception of social justice, to use Donnelly’s term – at the school, local government, state and federal levels. It will be a political and pragmatic rather than ideological notion of justice that will motivate action.
Instead of allowing ourselves the indulgence of shouting from the moral high ground about the motivations of industry, perhaps we should seek a consensus around what a social conception of justice in regard to food means.
We need as public health people to get over our shock and horror at food companies being primarily motivated by profit. We need to move beyond saying, “Their good will is just PR!” A mutual understanding of each other’s values and goals is essential to merit a seat at the table, a table of policy and politics.
This applies to many public health policy problems. Recognising a problem, and even understanding it is different to choosing the most effective course of action, knowing how to speak in terms that industry will take seriously, being pragmatic and knowing how to go about getting things done when success more often than not requires people to negotiate the politics.
This viewpoint is reinforced by my previous experience. Two years ago I participated in a Canberra meeting hosted by Senator Guy Barnett about obesity. I chaired a small working group that included representatives from the food industry, academic nutrition, advertising, media and urban designers. Naturally we sparred about traffic light food labeling, advertising on children’s TV and other contentious topics, but we all stayed till the going home bell sounded. The conversation was prickly but OK.
Just before we went, one of the participants turned to me and said, “You know, professor, you have the wrong people at this forum. We’re middle managers. You need the CEOs. If they say something is going to change, it will.”
I was pondering the good sense of this suggestion – and others were nodding affirmatively, when my colleague added, “And you’re the wrong person to be chairing it. We should have the PM and a few of his ministers without their bureaucrats at the table. He could say to them all, ‘We have a problem and we are all going to contribute to its solution, so before you leave today I want to hear what you are going to do to help!’”
Besides revising our attachment to moral indignation, the other thing we need is a clear view of how long it has taken us to get into a situation where nearly half of all Australian adults and close to three in every 10 Australian children are overweight or obese, a mess that has disturbing similarities to global warming. Decades: so it will probably take decades to get out.
The history of public health progress is nearly always of incremental change with many people taking many different actions. Even the apocryphal wrenching removal of the Broad Street water pump handle has a richer context than we commonly recognize.
That is why public health is accurately perceived as a community movement and public health research workers as social scientists. There are times when aggressive advocacy and the force of the law are necessary. At other times they are not. Then, as Churchill put it, we need jaw-jaw and not war-war.
The rise and rise of obesity is complex. Recruiting the food industry – or a bit of it anyway – to our cause, while being true in our policy discussions with them to a “political conception of justice,” strikes me as a good move.
I am not at all convinced that confrontation and moral indignation do anything in this context other than make things worse. This does not mean that we should be silent if we find abuse and hypocrisy but rather in conversation we should define those interests that are common and where, if a consensus is struck – by the PM if not by us – we can inch forward.”