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TRANSCRIPT OF A RECORDED
DOCUMENTARY
Presenter: David Walker
Producer: Dennis Sewell
Editor: Nicola Meyrick
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Broadcast Date:
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04.03.04
07.03.04
PLN408/04VT1009
2742

Taking part in order of appearance:

Anna Coote
Director of Public Health, the Kings Fund
Sian Griffiths
President of the Faculty of Public Health Medicine
Geoff Rayner
Chair of UK Public Health Association
Kate Fox
Director of Social Issues Research Centre, Oxford
Mike Kelly
Director of Evidence and Guidance for Health Development
Agency
Jonathan Wolff
Professor of Philosophy at University College, London

WALKER: If you smoke, drink, eat fewer than

five portions of fruit and veg a day and if your body mass index is outside
the green zone on the nurses chart, youre currently the focus of reports
galore and frantic policy making. Anna Coote, director of public health at
the think tank, the Kings Fund, is mighty busy.
COOTE: I would say that theres more interest
now in improving population health than there has been at any time since
Ive been engaged in public policy work, which is going on for fifteen
years now. And before that. I mean, as far as Im aware - I think probably
since they worked on the drains in London.
WALKER: In the 19th century?

Seriously?

COOTE: Mmn.
WALKER: Why?
COOTE: Well I think its to do with a moment
where the government, the Treasury in particular, have woken up to the
fact that they cannot go on pouring money into the bottomless pit of the
NHS to look after people when theyre ill and that there is a link between a
healthier population and the volume of demand on NHS services which
will, if the health of the population is improved, help to reduce spending on
the NHS in the future. Theyve woken up to that.
WALKER: Theres an avalanche of official
inquiries. Last week Derek Wanless told chancellor Gordon Brown how
changing behaviour now could slash NHS costs a generation hence. The
prime ministers strategy unit is due to report on the demon drink. Alcohol
is tricky. What goes on in pubs may damage health but also help regenerate
inner cities.
For some doctors the blue light is flashing. Four out of five deaths under
the age of 75 are down to diseases where diet, exercise and smoking play a
major part. Two thirds of English men are overweight; one in seven
children is obese. Those are epidemic proportions says Sian Griffiths,
president of the faculty of public health medicine.
GRIFFITHS:
If you look at an epidemic of
communicable disease, you see the numbers suddenly go shooting up. If
you just expand the timescale, the obesity picture looks almost the same;
the numbers are going shooting up. Its then whats the intervention that
controls the disease which will make it fall again. Now for obesity, we

think were still on the epidemic curve increasing we see no movement.

So if you look at it just as a sort of pattern of disease, what it does it says
there is an issue here, we need to act.
WALKER: While new strains of influenza or
SARS give rise to real epidemics, crisps arent infectious. So yes, it is
different now says Geoff Rayner, chair of the UK Public Health
Association.
RAYNER: Weve moved into the terrain of
whats called in the jargon non-communicable diseases for the rest of us
chronic disease. And if you look at a society like America where over two
thirds of the population is overweight, where despite their enormous wealth
theyre having to spend more and more and more of the public purse and
the private purse on healthcare and its projected that by 2011 some 17.4
percent of the American GNP this is a fabulous figure is going to be
spent on healthcare, now a lot of that is the consequence of chronic
diseases. Some of it is technology, some of it is ageing, but a lot of it is
this huge influx of the new type of disease since roughly the 1960s and 70s.
Obesity is the most visible form of it. Its certainly a consequence of the
new consumer society where people get rather detached from old patterns
of nutrition and lifestyle and enter into a new era of commercialised
entertainment, commercialised lifestyles, if you like, and commercialised
food. Its caused this thing that we refer to as the obesegenic society a
world all around us which makes it difficult for individuals to exercise real
choices over their diets. We have, on the one hand, a culture of
individualism; on the other hand more and more difficult for people to
exercise full individual choices. Thats the paradox.
WALKER: And if Geoff Rayners right, we need
to watch whats really at stake in this new public health debate. If it were
just the Treasury getting us to eat apples so we dont turn up in the diabetes
clinic 20 years hence, thats fiscal common sense. But theres more. At
issue are the nature of choice, the balance of public and private, individual
interest and collective consequence, adaptation to affluence. What Id like
to diagnose in this programme is public health as a symptom, maybe a
proxy for things that dare not speak their name, class and inequality for
instance.
Kate Fox is director of the Social Issues research centre in Oxford which,
its open about this, will research questions posed by the food industry.
Such as health scares. Shes an anthropologist and looks at behaviour over
the long, evolutionary haul.
FOX:
The problem is that we as human
beings are designed to in effect, programmed by our evolutionary heritage,
to take risks, and in effect to be comfortable in our lives with a certain level
of risk. Theres almost a sort of risk homeostasis. And the problem is that
we are living longer and healthier and safer lives than we ever have before
in human history and in a sense the fight flight muscle needs exercising.
Its why we take up dangerous sports in affluent societies take up
dangerous sports like bungee jumping and skiing and so on. Quite frankly,
if our ancestors back in the Stone Age had adopted the precautionary
principle, we wouldnt have had fire, the wheel. All of these things
required taking risks. I mean now, if we looked at the invention of the
wheel, we wouldnt do it if we adopted the precautionary principle. Wed
say ooh gosh, that could cause a lot of problems. Fire whoah, dangerous,
dont do it. But the fact is as a species we are programmed to be risk takers.

WALKER: Health scares pander to our need to

frighten ourselves, shes saying; could it even be that by diverting us from

risky behaviour, health promoters stop us learning from error? Ubiquitous
but not necessarily consistent diet and health messages, in the media, from
the government, ought to carry a health warning.
FOX:
I think we need to take a step back
from this kind of elitist moralising of the sort of making working classes
eat up their greens and so on, assume that everyone is just as intelligent as
you are in terms of their response to these kind of messages, take a step
back and actually start to look rather more seriously at the causes of obesity
because it just isnt as simple as banning this or warning people about that.
The rise of obesity has paralleled the rise in heavy-handed messages about
what we should and shouldnt eat, and to say that people are becoming
obese in spite of all of these health messages, it might be more sensible to
turn that on its head and look at perhaps people are becoming more obese
because of the kind of fear of food, obsession with food that is being
promoted.
WALKER: And do those who link obesity (as a
number of other conditions) with low income and social class and say that
many of these problems are actually problems of inequality, you would
say ?
FOX:
I would agree entirely with that. I
mean I think tackling child poverty is obviously a lot more expensive. I
mean the problem is that were talking about families on low incomes,
working mothers. These are the people who have less time and less money,
who cant go out and buy all these wonderful organic ingredients and so on
that are so much better for you because they cant afford them. And also
harassed, overworked dont have the time to prepare perfectly balanced
meals and so on every evening and simply telling them that packaged food
and fast food and so on is bad is supremely unhelpful and isnt going to do
the slightest bit of good. But the trouble is that tackling inequalities and
poverty is a lot more expensive and less dramatic than having yet another
health promotion campaign.
WALKER: Its striking how under the label of
health, we talk about things -- social division for example -- that
otherwise are considered taboo. Kate Foxs phrase about the working
classes eating their greens is anachronistic but also a reminder that some
social facts dont change, more sickness in lower income households for
instance. Mike Kelly is director of evidence for the Health Development
Agency, the government body charged with getting out messages about
good practice. What is this: a health or a class debate?
KELLY: While over the last fifty years weve
seen the health of the population of Great Britain improve as a whole,
generally speaking, on whatever measure you use quality of life, early
death or anything else at the same time, especially in the last thirty years,
weve seen the gradient in inequalities in other words the difference
between the most advantaged and the least advantaged in health terms
getting worse. And thats the key conundrum in public health: the overall
improvement things getting better and better but, at the same time, for a
significant proportion of the population things either not getting better at all
or actually getting worse.
WALKER: If a principal source of bad health is
associated with economic circumstance, shouldnt one attend to the socioeconomic condition of people how much money theyve got basically
rather than worry initially about their health?
KELLY: Oh certainly.

Theres no doubt that

the relationship between the economic circumstances is more or less a

direct one, but - as always - the pictures slightly more complex than that.
When you have a situation in which the causes of death are directly
attributable to the extremes of poverty and therefore to things like
infectious disease, then the broader social structural factors, which can be
led by direct government policy in housing and social circumstances, have
a very significant and big effect. When you move into an environment
where the causes of death are attributable to non-infectious diseases and
presently that, of course, means death rates from coronary heart disease and
cancer the social conditions still are very important but they seem to play
a less immediate and less direct role than they did in an earlier historical
period. So as we move into the 21st century, we have to take on board not
just the structural factors but also the factors relating to the way we deliver
healthcare, access to healthcare and of course individual behaviour.
WALKER: Here were not just into politics but
the texture of consumer society. Sociologists tell us some young people
derive their very identity from leisure and what they do on a Friday night:
that means they are what they drink. Should government stop them? Can
we, at one and the same time, extol peoples right to choose how they live,
what they buy, the proof of the alcopops they consume and say the State
should step in when choice harms health?
KELLY: Yes of course were all capable of
making choices and yes of course to suggest otherwise would be
patronising, but there is a sting in the tail of that which says you know
when we make those choices for some of us its a great deal easier and we
can draw upon a great many more resources both economic, intellectual
and otherwise in order to make those sorts of things effective.
WALKER: Are we in danger of being mealymouthed here? Is the link between income and ill health causal or are
cultural factors at play? Does anyone dare say that low income households,
formerly called working class, cant be trusted in the supermarket aisles or
the off licence cabinets? Anna Coote of the Kings Fund.
COOTE: Why do people so-called choose to
have McDonalds every day? What are all the things that you would need
to do if you wanted to give a family in a disadvantaged neighbourhood the
choice, a real choice to choose something other than cheap junk food?
Now if you think back along the pathway that would lead to that choice,
there are plenty of things that government and organisations in the
community could do to make that choice an open choice and not a closed
one. Its certainly not only about the price of the food. Its about what you
know, its about how much time youve got, its about how far away from
your home the food is, about the convenience of being able to buy it and
cook it. So all those things. Its about the way that childrens tastes are
developed in their early life. So all sorts of things can be done to affect
that - the most obvious being school meals. Most schools do not feed
children very nutritious meals. Most schools do not for, often for
understandable reasons, put a lot of energy into giving children the
education that they might need that would enable them to choose healthier
food to eat because its not a priority.
WALKER: Some people might say thats
idealistic. It certainly tells us that doing anything about health-related
behaviour is going to be hugely complicated. It will involve communities
(assuming they exist), school meals, buses to shops, womens time and so
on.
But have we answered the jibe about public health being essentially an
elitist business in which those who know whats right tell others how to

behave? The people who make it often also say choice is unbounded. And
of course it isnt: diet depends on income; in a market society resources
constrain choice all the time. Why not make a virtue of controlling choice,
asks the philosopher Jonathan Wolff, a professor at University College,
London
WOLFF: If government wants to change
peoples behaviour, what it needs to do is to make it easier for people to act
in the ways that they want those people to act. It takes incredible selfsacrifice for a young kid to buy salad rather than fish and chips at
lunchtime, but if salad was all that was on offer then it would be much
easier for them to do the right thing. So its a matter really of creating the
sort of structures in which people can make the right choices without
sacrifice rather than giving them a wide array of things and then expecting
them to choose in a sacrificial way.
WALKER: Government is increasingly trying to
set an example. Prison and NHS food is being scrutinised and healthy
choices flagged up. But for the public at large a precondition of a
government-ordered diet of lettuce is confidence that Whitehall, or local
authorities or primary care trusts do know better. In other words we accept
medical expertise, experts superior knowledge and the states veracity.
Better them, some might say, than the makers of that soup found the other
day to be saltier than the ocean. Geoff Rayner listens to a cacophony of
voices, advertisers among them, seducing us with biscuits and crisps.
RAYNER: I see that there are two types of health
promotion in the country. Theres the sort of the anti-health promotion
the negative health promotion, which is this mass, this wall of information
projected at children and everybody to consume this, consume that,
particularly crisps, sugary drinks, fatty foods, salty this, salty that. All of
these things have constituents in them we dont know about, were not
informed about. We dont know how much salt there is in a loaf of bread,
but its likely to be twice as much as we actually should have. So while
were told were making informed choices, its quite the opposite. These
choices are made in laboratories. You know , theyre made by marketing
people and theyre sold to us as all we have to is exercise our choice in the
marketplace and our problems are solved. Thats a fantasy world really. If
we really looked into it and looked into our souls, we know its very
difficult to actually take the healthy choice. And were all affected. I am
tempted by a packet of kettle fried whatever crisps as much as anybody
else and it is difficult to resist. So I dont think we should make the
separation of the middle classes, who are well informed, except the middle
classes have more control over their lives. They feel more secure. They
are less tempted because they feel weve actually achieved something.
We can control that, therefore we can control this. So often they cant.
WALKER: But what is he saying about those
tempting crisps. Should they just tell us how much salt and fat they contain
(and packets these days are pretty informative) or is he saying that
government should ban them from the shelves? That could sound not so
much like nanny as big brother. The proposal here is for a significant
extension of the States remit and a corresponding reduction in individual
autonomy and market discretion. Anna Coote thinks were at a tipping
point.
COOTE: I dont think we should underestimate
the value of getting really strong messages from central government, which
we are now beginning to hear. I dont know how long this is going to go
on for, but while its here lets be optimistic. I do think government could
be a lot more bold about it and what it does about some of the commercial
interests. For example, if you take food producers and retailers, the

government should put more pressure on them by saying, look, if you

havent got your house in order, if youre not going to reduce the content of
fat and sugar and salt in your products by lets say two years, well give
you that length of time to do it voluntarily; if you dont do it , were going
to legislate.
WALKER: Heres a muscular prescription for
state intervention. If leaks about a fat tax are at all accurate, its one
Dr.
Blair is at least considering. But I wonder if theres anything yet like a
consensus on the publics part to underpin such an extension of the welfare
state. Some medics are unabashed advocates of action. And they dont just
mean posters and television advertisements. Our crusader is the public
health doctors president, Sian Griffiths.
GRIFFITHS:
I dont think just relying on people to
change their behaviour will improve health because I think that we know it
doesnt work. I dont think just providing information will change
peoples behaviour in terms of health consequences upstream because,
again, well so far we havent seen it working. What we need is to have
environments that are health promoting, and to have an environment thats
self-promoting you have to address issues around social inequalities as well
as issues like advertising on television which is sort of generic and not
particularly class biased. But there are particular issues, if youre looking
at the publics health, where you have to look at the impact of disadvantage,
be it for an age group like older people or be it for an ethnic minority group
or be it for unemployed people or be it for people who are just less well off.
From a public health perspective, I would find it very hard to say to you
that inequalities dont matter, social factors dont matter. And I think that
it may be seen as inherently Left Wing. However, for me its just an
analysis of how you improve the populations health.
WALKER: State activism, so the doctor orders, is
of two kinds: direct intervention in markets and over consumer choices
plus measures to address inequalities. That, as Sian Griffiths admitted, is to
take a distinct political position, which many doctors of course dont.
Theres an argument about political hygiene here, too. Health should not be
used as an excuse. If its about the size of government, control of markets
and constraint of individualism, lets confront those old and big questions
directly.
But all that may be premature. There are distinct limits to what
governments can do even if they wanted to. If we dont trust them, why
pay attention to public health broadcasts? Sex, drugs and chips may even
acquire allure when they urge us to say no. Kate Fox of the Social Issues
Research Centre looks quizzically at what the record shows about our
willingness to heed safety advice.
FOX:
We found three quite separate and, to
some extent, contradictory side effects. The majority of people suffer from
what I call warning fatigue in other words they become desensitised,
habituated to these kinds of messages. And that is a dangerous effect in
itself because obviously its like crying wolf: when there is really a wolf,
sorry youve lost your audience. If you think about it, if the Doll Peto
research on smoking and lung cancer were to come out now, how would
anyone be able to distinguish that from the background noise of mobile
phones are going to fry your brains, GM foods are going to turn you into
Frankensteins monster, etcetera, etcetera, that are coming out everyday?
Its impossible for most people, myself included a lot of the time, to
distinguish between sensible messages and background noise of over
zealous and over productive health promotion. But theres a second effect,
which is almost the opposite of that a slightly smaller group of people,

largely middle class, who seem to suffer from something we call risk factor
phobia. In other words rather than being desensitised they, if anything,
become hyper sensitised to these kind of messages and start becoming
neurotic, hypochondriac, worrying about the risk factors inherent in
everything that they eat or drink or breathe or touch. And these are the kind
of people who would have responded when there was in 95 the pill scare. I
think there was a nine percent rise in the abortion rate and that was you
know your risk factor phobics seeing one scary headline about the pill,
going off the pill and getting pregnant. Also something that doctors call
muesli belt malnutrition you know mothers who are sort of feeding their
children low fat, high fibre diets that are quite inappropriate for young
children, so actually becoming malnourished in this land of plenty. The
third side effect is well known the forbidden fruit factor and this is one
of the main reasons why a lot of these kind of heavy-handed campaigns
simply dont work. Its because people myself included tend to
become defiant. Rise in teenage smoking is almost parallel with a rise in
heavy-handed anti-smoking campaigns. I would put myself firmly into that
category. I dont like being told what to do and I tend to do the opposite
almost out of a sense of perverseness.
WALKER: The prime ministers own strategy
unit has just published a report noting how even when offered information
and guidance a significant proportion of people dont choose the healthier
option. Their lives are just too complicated or they are downright perverse.
So while experts, the government, know more in general, they may lack a
prescription for individual circumstances. Philosopher, Jonathan Wolff.
WOLFF: The State or state scientists can know
things that the rest of us dont know. Knowledge about sexually
transmitted diseases, for example, is perhaps the modern equivalent that
there are sexually transmitted diseases that are initially symptomless and
without publicity campaigns the public simply wouldnt have known about
this, which would have led to and perhaps is leading to massive
increase in infertility among a generation. And so there is technical
knowledge that the government can have and that we still need public
health measures to protect us, so there are very large areas where the
government can claim some sort of superior knowledge still. I think that
we still dont know enough about nutrition and fitness to know what is
good for people in the long-term. I mean when I think about my own
medical problems, most of these are the result of trying to keep fit and if I
hadnt tried to keep fit I probably wouldnt have had half the physical
problems that I have had, so in my own case I might have been better just
smoking and drinking rather than trying to take exercise and that could
have been cheaper for the state as well.
WALKER: Gone are the days, it seems, when
generic messages hit the spot. People may talk about the visual impact of
those TV pictures of arteries oozing goo, but the moment your hand
reaches for the cigarette packet or opens the fridge another, intensely
personal calculus applies, way beyond the reach of propaganda. Public
health is, paradoxically, a private matter. But combinations of individual
advice, from GPs say, group support and billboards can change behaviour.
Mike Kelly has the evidence.
KELLY: What we do know in terms of the
sorts of things that work with respect to smoking or to exercise or to diet is
that interventions which are tailored to the particular needs of the groups in
question, to the people in question, which are targeted very specifically,
which are soundly based upon good psychological principles are much
more likely to be effective than broad brush approaches, talking to the
whole population. You can pick out a range of things which have been
specifically quite successful recent initiatives on nicotine replacement

therapy and smoking cessation, for example. Very good evidence that that
works. On exercise very, very good evidence that brief interventions by
general practitioners during routine medical consultations, talking about the
benefits of physical activity, that thats effective. And with respect to
obesity, theres very, very good evidence that family based approaches
work. So theres a knowledge base, actually a deep and strong knowledge
base, which can highlight specific things which we know, if theyre
implemented properly, will work.
WALKER: But I wonder if the public health
advocates mustnt confront the political point. Their agenda, conceived in
concern for public welfare, is interventionist. Thats no longer the old
welfare state sense of cod liver oil and nit nurses; these days its about
community involvement, product labelling and encouraging food
manufacturers to cut salt content. Health advocates are also strong
egalitarians. They want to turn society upside down, in terms of what they
see as unfair health outcomes. Are political conditions now right, that is to
say left, for this more active agenda? Ministers, John Reid the health
secretary, do talk more about social justice but has the public bought the
statism of the public health movement? Yes, says Mike Kelly of the Health
Development Agency
KELLY: We have a contract, if you like, with
the state and with government. The government provides certain services
and in return we give up certain of our freedoms to receive those services whether its education or the franchise, whatever it is. And the same is true
with respect to health. Now we could make choices, I suppose, as a society
in which we said well we want to maintain that private sphere and the role
of the state in helping to make it better should be limited. The
consequences of making that decision in an extreme form would be to
continue on the path in which were going. And the path on which were
going is not one in which just there is a kind of moral or social justice issue
about inequalities in health, which there undoubtedly is, but I think we
need to move beyond that because if we continue with the same pattern of
inequalities that we currently have and we do nothing about arresting the
early mortality and more specifically even than that the prolongation of
morbidity - the lengthy periods of ill health in old age that some people can
expect to experience as a consequence of the kind of current trends we
have - its unsustainable in terms of our National Health service to cope
with it. The costs of that into the long run are unsustainable. So its not
actually just a question of a nanny state interfering for our own good. In
the long run, if were to make sense of this financially and politically, we
have to do more and we have to do better than were doing now.
WALKER: But its not going to be easy. Its one
thing for the state to provide health care, including statins for
cardiovascular disease; its quite another for the state to intervene much
further along the food chain. Maybe peoples anxiety about their waistlines
will trump their distrust of government, and besides theres no great public
affection for food producers. Yet before this public health agenda really
gets going, dont we need some ideological readjustments, some new limits
to individualism, justifications for government to constrain choice? In other
words, the public has to assent to a definite shift in the political balance
before its long run health improves.

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