(More links have been added at the bottom of this post on June 13).
A recent Croakey article about New York City Mayor Michael Bloomberg’s latest public health foray – which has, predictably enough, pitched him into a battle with the beverage industry – asked for nominations for Australian cities or civic leaders who are public health trail blazers.
But Margo Saunders, an American-Australian public health policy researcher, argues in the article below that this was the wrong question to ask. Instead, we should be focusing on the structural and political barriers to public health leadership in Australia, she suggests.
(And at the bottom of the post are links to stacks more reading about the NYC initiative and related public health matters.)
It’s hard to be a public health hero in Australia
Margo Saunders writes:
As we read recently at Croakey, New York City Mayor Michael Bloomberg’s proposal to ban the sales of large sized soft drinks and other sugary drinks at restaurants, movie theatres, and food carts places him ‘high on the list of list of those to watch when it comes to public health progress.’
The city’s Health Commissioner, Dr Thomas Farley, has been up-front about blaming sweetened drinks for a significant proportion of the city’s increased obesity rates. Like his predecessor, Dr Thomas Frieden (chosen by President Obama to head the Centers for Disease Control and Prevention), Dr Farley believes in that governments have an important role helping to change the cultural landscape so that the ‘bad choices’ are harder and the good ones are easier.
With these cues, Croakey editor Melissa Sweet poses the question: ‘If New York City and Mayor Bloomberg are the trend-setters for public health in the US, where are their equivalents in Australia?’
This, I would suggest, is the wrong question.
The fact that American cities have a history of public health ideas and innovation is due in no small measure to the structure of local public health decision-making and implementation.
While a considerable array of public health responsibilities rest with Australian State and Territory Governments, public health decisions in the USA are taken at the city, county, state and federal levels; appointed officials such as Chief Public Health Officers and City Health Commissioners wield considerable power.
As a consequence, many of the pitfalls and delays that stymie public health advances in Australia are avoided. Australia has a striking pre-occupation with consultation, negotiation, and consensus-driven policy-making.
In our attempts to reduce the incidence of preventable diseases and conditions, we engage in long, drawn-out processes of developing ‘approaches’ and ‘strategies’ to alcohol reforms, tobacco control, obesity, road safety, and a host of other public health issues. Vested economic interests are often able to use their political clout to deter, delay, or water down what ‘evidence-based policy’ tells us we need to do.
A departmental officer involved in the preparation of a major national strategy document explained how it works: anyone who wants his or her contribution to be taken seriously should not waste time publishing articles in peer-reviewed journals, as these will have no effect since the Department would not know about them.
The way to influence the thinking around an issue is to directly lobby the Minister. The result of this system, of course, is that, unless Ministers are extremely well briefed by their departments, they tend to fall victim to ‘cushion syndrome’ in which they bear the impression of the last person to have sat on them.
Public health issues are not, and do not need to be, popularity contests and, to the extent that they are treated as such, the notion is perpetuated that public health is comprised of ‘soft’ issues. The lengthy and agonising process of developing and implementing reforms in relation to issues such as tobacco, alcohol, obesity – and even seemingly simpler issues such as food safety – involve vested economic interests being given the status of ‘key stakeholders’ rather than being viewed simply as vested economic interests whose financially contaminated views on public health have little, if any, legitimacy.
New York City, with a population of more than 8.3 million (about double that of Sydney’s), is governed by a Mayor and a 51-member City Council. The Health Commissioner and Board of Health are responsible for the Department of Health and Mental Hygiene. The Board is comprised of 11 public health and medical experts appointed by the City Council for 6-year terms. Each Board member is a recognised expert, and the group represents a broad range of health and medical disciplines. They serve without pay and, like judges, cannot be dismissed without cause. The fact that they cannot be dismissed without cause gives them considerable freedom.
Between 2002 and 2009, NYC Health Commissioner Dr Thomas Frieden banned added trans fats, required restaurants to display calorie counts, banned smoking in workplaces, brought in a suite of initiatives to reduce smoking, and introduced a major electronic health record project. Information about café and restaurant food hygiene has been publicly available in NYC for years, as it has been in other US cities. The Boston Public Health Commission, governed by a 7-member Board of Health, is another innovator.
The Commission and the Mayor have initiated a number of NYC-style programs to encourage ‘a shift toward healthier lifestyle choices,’ including phasing out sugary drinks in schools, health care facilities and other municipal buildings. The Commission also sponsors the HealthCREW (Community Resources for Empowerment and Wellness) program, a 15-month program for minority men aged 18 -25. The program empowers young men to take control of their health by engaging in preventative practices, accessing health care services, advocating for their own health needs, and providing health education to peers in their communities, while pursuing their own health career goals.
Commissions in Australia, which are seen as task-oriented and legitimate without being quite democratic, tend to serve a different role. Various jurisdictions have offices such as a Health Services Commissioner or a Health Care Complaints Commissioner. These are entirely different from the roles of the NYC Health Commissioner.
Before the establishment of its health department, and before ACT self-government, health services in the ACT were run by the Capital Territory Health Commission. Nowadays, however, appointed individuals and agencies such as Commissions and Commissioners tend to be trouble-shooters with responsibility for specific issues, with inspection and investigation powers, particularly with regard to complaints (human rights, equal opportunities, children and young people, environment).
Australian jurisdictions continue to appoint Commissions and Commissioners where accountability, coordination or implementation problems have occurred, eg: ‘The [Western Australia] State Government has reaffirmed its plans to establish Australia’s first Commission for Mental Health…. the Commission will be separated from the Health portfolio, headed by a Commissioner responsible for all aspects of mental health services.’
In Australia, politics plays havoc with public health to the point that it is a rare (or ‘courageous’, in Yes, Minister terms) Australian politician who reflects Frieden’s single-minded commitment without an eye to the next election.
One who did was former ACT Health Minister Wayne Berry who, in the early 1990s, decided that smoking should be prohibited in enclosed public places and workplaces.
A report by the National Health and Medical Research Council in 1987 had called for non-smokers to be protected from exposure to tobacco smoke, but there had been no legislative action at the State/Territory level — although by 1987, smoking was banned on domestic airlines and in Australian Government workplaces, both examples of major public health initiatives which relied on non-political processes, and both at the instigation of one of Australia’s public health heroes, the late Dr Peter Wilenski.
Berry called the local shopping centre owners together to lay down the bottom line. His approach was not, ‘We’re thinking about making shopping centres smoke-free — what do you think?’ but, ‘We’re going to phase out smoking in enclosed shopping centres. We want to know what your issues are so that we can work together to make this as smooth as possible.’
It is all too easy for public health decisions to be held hostage to political expediency, and it takes a very confident politician (or one contemplating retirement) to stand up to threats, either blatant or implied. It is one thing for Minister Berry to laugh off the tobacco industry (‘I think the tobacco industry has given up on me,’ he used to say).
But one of Berry’s Legislative Assembly colleagues told me, at the time of the smoke-free legislation, that it was made clear to her by the powerful interests in her local party Branch that if she openly supported the legislation, she could forget about ever again being supported for pre-selection.
That is not to say that there are not valiant stalwarts of public health in State and Territory governments throughout Australia. For such individuals, however (examples from NSW include Dr John Kaye MLC and former MLC, The Hon Dr Arthur Chesterfield-Evans) flying a lonely flag for public health may produce psychic rewards, but perhaps few others.
If we agree with Sir Michael Marmot that medicine and surgery are simply evidence of failed prevention, then it is not so difficult to understand Frieden’s view about prevention: if anyone in New York died from a preventable cause, it was his fault.
Frieden has made the point that, ‘Nobody ever had a rally on the City Hall steps to promote the general good. In some ways, public health is inherently unpopular’. According to Alfred Sommer, Dean of the Bloomberg School of Public Health, ‘Those who take up the field of public health are not always appreciated at the ground level. The people they’re helping may not know it and, in fact, may even be irate’.
The real question, then, is how easy it will be to find Australian public health heroes in our cities or in our civic leaders as long as decision-making on critical public health issues is seen as a matter for those pre-occupied with politics rather than with health.
For more reading on recent public health developments in New York City…
Timothy Noah, a senior editor at the New Republic, says most people benefit far more than they’d like to admit from paternalistic government or what its detractors call the nanny state. He writes that while public health paternalism can be carried too far, this is unlikely in the current anti-regulatory political environment, and that Bloomberg is simply going to “make it slightly more difficult to drink soda in preposterous quantities”.
“Indeed, the 16-ounce limit might actually enhance individual liberty by compelling restaurants and bottlers to sell soda in the smaller quantities that people often want but can’t get. It might become possible once again to order a Coke at a movie theater in something less than a Jacuzzi-sized tub. After all, the government isn’t the only actor imposing its will on Americans today; corporations boss them around quite a bit, and, unlike the government, they seldom have to answer to anyone but their shareholders for it. When their bullying gets rough, it sure can help to have a tough nanny in your corner.”
New York Times food columnist Mark Bittmantakes on the critics who’ve attacked “Nanny Bloomberg”. He suggests the public needs more nanny-style interventions, and writes:
“For sure, the government doesn’t always act in our best interest when it comes to nutrition — an understatement, really — but Big Food never does, nor should we expect it to. If somebody with some real political clout is willing to stick his neck out for the public health of his city, then good for him and lucky for us. It’s easy to forget sometimes, but that’s what government is supposed to do: identify the activities that are bad for us or for others and make it harder for us to do them; activities like smoking cigarettes, wearing seat belts or drinking 32 ounces of soda at a stretch.”
In The Telegraph, London’s mayor Boris Johnsonhas paid tribute to his NYC counterpart:
“For those of us who are instinctively libertarian, it is all a bit difficult – at least philosophically. But never mind the philosophy; what about the practical effects? This is the same Bloomberg, after all, whose smoking ban was also derided, and then imitated around the world. His action against smoking is now seen as a big step in reducing a particularly nasty addiction that had claimed the lives of millions. Across the West, we are seeing a falling away in the number of cancers contracted, a fall in the number of deaths. If we could reduce the consumption of sugary drinks, and release some children from the captivity of fatness, might that not be worth exploring? By next April, we will have a new and improved anti-obesity strategy in London, and yes, we will look at the practicality of Bloomberg’s ideas. In the meantime, I think we should pay tribute to the continuing boldness of the Mayor of New York. He has been a public official for longer than Obama. He has run a corporation far bigger than Romney’s. He is the 11th richest man in the US, with wealth of $22 billion, and yet he still cares about the size of paper cups and childhood obesity. There is still time for him to change his mind and go for the White House. Bloomberg for President!”
Todd Putman, who worked some years ago as a senior marketing executive at Coca-Cola, is regretful about his role in marketing to youth, Hispanics and African Americans. He also says that about 90 percent of all soft drink marketing is targeted at 12-to-24-year-olds. The Washington Post (which has been running full-page ads from the soft drinks industry) reported on Putman’s comments at a Soda Summit, sponsored by the Center for Science in the Public Interest. And see some more of the industry’s kickback at this website dispelling “myths” about soft drinks.
In an article for Time, Shannon Brownlee from the New America Foundation explains how “huge has become the new normal” when it comes to food and drink serving sizes in the US. She pursues similar themes in the clip below describing how corporate interests have manipulated the public’s sense of what is normal. [youtube]http://www.youtube.com/watch?v=gDONAHu6FeQ[/youtube]
Eric Jaffe, a contributing writer to The Atlantic Cities takes a methodical look at which places might follow NYC’s lead in banning the sale of over-sized softdrinks. As the diagram in the article indicates, he makes his assessment based upon the history of the uptake of other NYC public health interventions. His prediction: Seattle will be the next major city to try to ban sodas larger than 16 ounces.
Jeffrey Simpson, columnist at the Globe and Mail in Canada, suggests that traditional public health approaches will not solve obesity. Instead, he suggests addressing the underlying issue. He writes: “The core reason for poor health habits is overwhelmingly linked to income. The poorer you are, the poorer your health. Deal with income inequalities and the population will be healthier.” *** (Note to readers: the link to the Boris Johnson article was added after the initial posting).
Update, June 13
More on the industry kickback
This facebook site describes New Yorkers for Beverage Choices as a coalition of citizens, businesses, and community organizations who believe that consumers have the right to purchase beverages in whatever size they choose. New Yorkers for Beverage Choices!! Whatever next – I guzzle softdrinks and I vote, perhaps…
Check their website, and you learn who is behind the coalition: business interests. Surprise, surprise. But of course they give precedence to the “citizens” in the coalition.
Public health nutritionist Professor Marion Nestle has more on the industry kickback on her blog.
You can listen to a clip of Ontario-based Dr Yoni Freedhoff (@YoniFreedhoff) argue why other places should be following NYC’s general lead in seeking to create a healthier environment that makes it easier for people to make the healthy choices.
But as Margo Saunders points out in her article above, perhaps we need to be thinking of what makes a healthy environment in the broadest possible sense – what is the political and policy environment that makes it more likely the citizens can have a healthy environment?