Thursday, 23 June 2016

‘First, do no harm’: How to think about austerity and public health

Posted by Ted Schrecker, Fuse Associate and Professor of Global Health Policy, Durham University

The current ‘neoliberal epidemic’ of (selective) austerity directs our attention to public health impacts of choices about public finance in several ways. Most fundamentally, anticipated post-2015 public expenditure cuts in the UK will reduce public expenditure as a proportion of Gross Domestic Product (GDP) to the levels of the 1930s, ‘taking the size of the state to its smallest in many generations’, in the words of a 2014 Institute for Fiscal Studies briefing. In fact, on recent projections by 2020 public spending in the UK as a proportion of GDP will be below the figure for the US, despite the latter country’s bloated defence budget. It is implausible that a National Health Service that is free at the point of use can be maintained with pre-World War II levels of public spending. Even a brief conversation with anyone familiar with US health care reminds us just how much that matters.

Meanwhile, the health consequences of social spending cuts that fall disproportionately on the poorest people and regions are beginning to be manifest in rising food insecurity and increased use of food banks – the latter trend probably related to the rising rates at which benefit recipients are sanctioned. Further health impacts, more difficult to isolate epidemiologically but probably at least as significant, are associated with the stresses of chronic insecurity, powerlessness, and lack of ‘control over destiny’.

There is a basic ethical and political point here about the politics of evidence. Sir Michael Marmot and colleagues wrote in 2010 that ‘It is hard to see how even ideologically driven commentators could think that having insufficient money to live on is irrelevant to health inequalities’. Good point.

In a previous blog with Clare Bambra, we demonstrated that politics can make us sick; Clare recently wrote a similar blog highlighting large health divides across Europe, showing that where you live (and the health policies implemented there) strongly affects how long you live. Against the background of austerity and the rising costs of healthy diets, it is indefensible to ask public health professionals and advocates to demonstrate, over and over again, that (for example) inadequate incomes lead to unhealthy diets and poor health. Rather, the burden of proof should be shifted: we must insist on clear and convincing evidence that national governments’ choices about the level and composition of public expenditure first, do no harm to health, except in extraordinary and clearly justified circumstances. This is an important part of the case for (independent, third party, adequately resourced) health impact assessments, especially of policies and programmes outside the health sector. Such a shift in the burden of proof is also congruent with the strong presumption in international law against retrogression (backsliding) with respect to human rights such as the right to health – a presumption that assumes special importance in an era of austerity.
Is corporate tax avoidance a public health issue?
Public finance, then, is a public health issue. This point applies to the revenue side, as well. The publication of the ‘Panama papers’ reminds us of the extent to which cross-border tax avoidance, whether legal or questionably legal, represents one of the ‘fiscal termites’ that can undermine states’ ability to provide everyone with the prerequisites for a healthy life. (Interestingly, the phrase ‘fiscal termites’ was coined by the former director of the International Monetary Fund’s Fiscal Affairs Department.) The question of how maintaining health services free at the point of use and investing effectively in prevention could be financed should be asked as a routine element of public health practice and advocacy – part of a broader strategy of interrogating scarcity. One answer could be using revenues from clamping down on UK corporate taxes avoided by major transnational corporations. In the real world, resources can almost always be found for the purposes of the powerful: think HS2, Trident renewal, and so on.

Choices about public finance are political choices with consequences for health and health inequalities; academics and practitioners must not be shy about pointing out those consequences.

A more extensive list of references is available from the author.  All views expressed are exclusively those of the author.

Photo: Servizi Mediali.  Reproduced under a Creative commons 2.0 licence

Thursday, 16 June 2016

Being critical of how bodies are ‘sinking’ the NHS: Lessons from the University of Wollongong (Part 2 of 3)

Guest post by Stephanie Morris, PhD Candidate at Durham University

My time at The University of Wollongong has been one of the biggest learning experiences so far on my Overseas Institutional Visit to Australia. My conversations with scholars there have led me to think more critically and question the status quo regarding physical activity, health and obesity. I had many conversations with Professor Jan Wright that made me realise the way in which physical activity is often promoted may have some unintended consequences for the health and wellbeing of those whose behaviours public health initiatives constantly seek to change.

The University of Wollongong
Many academics and practitioners stress the importance of understanding the political economy of health and health inequalities yet it appears that the media and other discourses in our neoliberal society remain focused on stigmatising individual bodies and their behaviours. I came across an article in The Spectator (a conservative magazine) recently entitled, Our NHS will sink under the weight of Britain’s fatties. The title alone got my blood curdling but one paragraph written by Dr Dawn Harper stood out in particular. It went as follows:

If you are a woman with a waist greater than 32in (80cm) or a man with a waist greater than 37in (94cm) you are at risk of type 2 diabetes. If you are a woman with a waist circumference greater than 35in (88cm) or a man with a waist greater than 40in (102cm) then your risk is very high… For your sake and for the sake of our beloved NHS, take this as a warning shot across your bow and get yourself on a healthy living plan.

Now, the first thing I thought about this extract was how fear mongering and morally loaded its tone was. The emphasis is put on the individual for being a bad citizen, immorally and self-indulgently sinking the NHS. Yet, causations and prevalence of obesity and diabetes is much more complex than a waist circumference category. The key question that I wish to raise here stems from the work of two critical scholars, Gard and Wright (2005), whose work is part of the literature critiquing the ‘obesity epidemic’, the link between body size and diseases like diabetes, and health education curriculums. They ask whether the prevalence of such obesity discourses are actually more connected with the morality included in cultural attitudes concerning fatness than about the clear communication of objective and conclusive scientific knowledge. I am not suggesting that there is no reason for some focus on body weight and size, nor am I attempting to condemn all quantitative research in this area. However, I am questioning what implications such a focus on the body might have for people, and future research and policy. First, many have argued that focusing on the individual body distracts us as researchers and citizens from looking at wider structural issues and health inequalities that need to be researched and addressed. Second, others show obesity discourses and 'Healthism' (a term coined by Crawford (1980) to describe a discourse where individuals are held morally responsible for their own health. Individuals then self-monitor and manage their health by objectifying the body.) fuel body dissatisfaction, feelings of guilt and eating disorders, thus negatively impacting on the wellbeing of children and young people.

Positive vibes from a hostel in Sydney
Due to these negative consequences on people's wellbeing I ask what we as scholars, practitioners and third sector workers in the field of public health really consider ‘health’ to be? Do we consider 'health' to be “a state of complete physical, mental and social wellbeing and not merely the absence of disease or infirmity” (The WHO definition)? Or do we view ‘healthy’ as appearing as an active and slim body? There are movements away from focusing on weight and body size, including Health at Every Size (HAES) – which Peter van der Graaf also writes about in this blog post – that focuses on promoting happiness in eating and an enjoyment of movement in life. Although HAES has been critiqued by many I wonder if some of its elements can be valuable. I do not think continually worrying about one’s body or fat composition is a ‘healthy’ way to grow up or live, as I don’t think it helps achieve “physical, mental and social wellbeing”. Moreover, perhaps if we stop fixating on the body and move away from changing individual behaviours we might consider societal inequalities more and help reduce inequalities that constrain people’s daily lives. What do you think?

Thursday, 9 June 2016

Aspiring to new lows in North West waistlines

Guest post by Naoimh McMahon, Postgraduate student, NIHR CLAHRC NWC

In theory weight management is a ‘simple’ balance between consuming enough energy to adequately fuel ourselves and moving enough to ensure that extra energy is used up. However, in reality there is a complex web of influences that determine our eating and activity habits. We are becoming increasingly more sedentary and are prone to consuming more energy-dense foods. This combination is making the energy balance harder to achieve. When it comes to weight management interventions, what works for one individual is rarely guaranteed to work for the next and so there are real challenges to understand what the right mix of actions are to enable people to achieve and maintain a healthy weight.

Last summer, when preparing a doctoral fellowship application I met with providers and service users from a range of local health improvement initiatives in the North West of England. I was really intrigued by one initiative in particular called Aspire. Aspire is a weight loss programme delivered by a local charity. The design of the programme was unlike any other weight loss programme I had encountered and there was a real sense of personal investment in the programme from both the providers and participants. The thinking behind Aspire is that for individuals who have a lot of weight to lose, intensive and ongoing support is needed to make a positive and sustainable change. The programme runs for 26 weeks and each group has 12 participants. Aspire includes all the traditional elements that you would expect to find in a weight loss programme such as advice and education on food and healthy eating. It also supports participants, many of whom have a body mass index (BMI) of over 35, to engage in graded physical activity.

I think what I found most intriguing about this programme was the emphasis it placed on the person, trying to build confidence and esteem to really convince people that they could achieve their weight loss goals. For example one of the activities that participants spoke about with most feeling was a step climb in a local park at the beginning of the programme. The Aspire providers discussed how this activity served two purposes: (i) to act as a ‘shock to the system’ by allowing the participants to really reflect on their current fitness levels and (ii) to provide a goal to work towards and make a commitment that it will never be that hard again. The group returned to this step climb at the end of the 26 weeks with smart phones in tow and there is some really fantastic footage that captures the excitement and pride at the progress they had made along with the disbelief at how it had once taken hours to complete.

There is never a ‘one size fits all’ and any programme will work for some but not for others. It certainly seems like now it is less about finding a single ‘effective’ or ‘perfect’ programme and more about trying to understand what it is about programmes that enable different people to make positive and sustainable changes. I think we will all know people personally who have taken control over their weight by stumbling upon park runs and ‘getting the bug’ or by using commercial weight loss programmes such as Weight Watchers or Slimming World - finding a system that really works for them. Like other weight loss programmes, there were Aspire participants who did not achieve their goal weight and there were participants who regained the weight that they had worked so hard to lose. What is important is not to write-off such efforts as ‘ineffective’ but to get a better understanding of how and why these outcomes came about. Aspire is only one example of a novel approach to enable people to lose weight but there are certainly elements that have been particularly effective for some participants.

Find out more about the programme and how participants felt about what worked for them.

Thursday, 2 June 2016

Boring to Baywatch

Guest post by Jane Johnson, PhD Researcher at Teesside University

The title of this post is perhaps not what you’d expect to hear at an academic conference but then again not all conferences broach the tricky subject of ‘sexy communication’.

The Hoff
This month I was invited - and funded thanks to help from Teesside University and the Royal College of Chiropractors (RCC) - to present an outline of my PhD at the Researchers’ Day of the European Chiropractors’ Union (ECU) Convention in Oslo. The theme for researchers was Down from the Ivory Towers: Breaking Down the Barriers Between Research and Clinical Practice.

As a clinician-turned-researcher and someone who has sat through countless presentations by researchers, this was a theme close to my heart. It felt like a win-win because not only was the RCC getting to see where its money was being spent but - as a fledgling researcher - I gained a valuable insight into the world of research and particularly into the opportunities and challenges presented to us in disseminating what we are doing and what we discover.

President of the ECU Executive Council, Øystein Ogre opened the conference by saying that research has always been a priority for the ECU, not least because chiropractors need a sound evidence base; a concept which, as a physiotherapist, drew me to apply for the PhD on which I am now engaged.

Two speakers from whom I took home important messages were Alice Kongsted and Jørgen’s Jevne. Firstly, Alice suggested that, when presenting our message to clinicians, we should “decide on a clear message” and “drop the details”. She gave examples of PowerPoint slides where the message was unclear and the details many, contrasted to the same information presented in a pared down format. The second take home message was from Jørgen, whose claim to fame could be that he managed to get the word ‘sexy’ into a British Medical Journal publication when they published his article The Sexy Scalpel: unnecessary shoulder surgery on the rise. He said that in getting our message across to clinicians we need to be ‘message brokers’, maximising the use of social media and including images, videos, catchy quotes in our delivery.

Having previously felt anxious about presenting my own work in a highly visual and often interactive way for fear of being criticised as lacking gravitas, I suddenly felt an immense sense of relief. These were experienced researchers and skilled presenters advocating not that we dumb down the content of what we say, but that we change the way we say it. For the first time I felt like I was being given permission to present in a manner that I was drawn to even if it didn’t match the majority of presentations I have sat through. Jørgen’s said that we need make the way we communicate sexy: we need to go “from boring to Baywatch”. I may not have the skill to incorporate images of David Hasselhoff or Pamela Anderson into my slides, but I’m inspired to think more creatively about communication to clinicians.

Photo attribution:, Geoffrey Chandler, "David Hasselhoff":

Tuesday, 24 May 2016

Why England could get knocked out in the quarter finals

Posted by Clare Bambra, Fuse Associate Director & Professor of Public Health Geography, Durham University

If Euro 2016 was based on how healthy each nation is, there would be some surprising results. England would get knocked out in the quarter finals of Euro 2016 if the tournament was based on how healthy each nation is. Based on health statistics, Switzerland would walk away as European Champions for the first time in the competition’s history, narrowly beating Iceland on penalties in the final. 

Our analysis of differences in life expectancy for men in the 24 countries taking part in the forthcoming football tournament shows huge health divides across Europe and highlights the links between where you live and how long you live.

The European Health Championship is an accessible way to shed light on these stark differences. It scores each nation’s football team based on the country’s male life expectancy at birth for 2013. From these scores, the winners and losers of each group are decided as well as the results of the games in the knock out stages.

England, with a male life expectancy of 79 years, would be winners of their group by beating Russia (63 years), Slovakia (72 years) and Wales (78 years). England would then beat Czech Republic (75 years) in the round of 16 knockout stage but would lose to Iceland (81 years) in the quarter-finals. Likewise, Wales and Northern Ireland, with a male life expectancy of 78 years each, would be beaten by Austria and France (79 years each) in the round of 16 knockout stages. Switzerland and Iceland both with male life expectancy of 81 years meet in the final, with Switzerland winning on penalties because female life expectancy there is 85 years compared to 84 years in Iceland.

The European Health Championship also reveals a clear east-west gap with worse health in the countries of Eastern Europe compared to those in the West. For example, in the host country France (the runners-up in group A), baby boys are expected to live up to 79 years old whilst in Ukraine, who finish bottom of group C, it is just 66 and in Russia (bottom of group B) it is a mere 63 years. Spain and Italy also fare well with men expected to live up to 80 in those countries.

But what explains these differences in health across European countries? Why do some countries perform so much better in health terms than others? Geographical research suggests that the answer is twofold: the health of places is determined by the population composition (who lives here) and the environmental context (where you live).

Who lives here? The demographic, health behaviours and socio-economic profile of the people within a place influences its health outcomes. Generally speaking, health deteriorates with age, women live longer than men, and health status also varies by ethnicity. Levels of smoking, alcohol, physical activity, diet, and drugs – all influence the health of populations significantly. Indeed, research has strongly linked Russia’s comparatively low life expectancy amongst men with the high levels of alcohol consumption in the country particularly since the collapse of communism. The socio-economic status – or social class in “old money” – of people living in a country also matters as those with higher occupational status (e.g. professionals such as teachers or lawyers) have better health outcomes than non-professional workers (e.g. manual workers). So differences in the characteristics of people in the countries of Europe will contribute to these country level differences in life expectancy.

However, research also shows that where you live matters. The economic environment of a country, such as poverty rates, unemployment rates, or wage levels can influence health. Countries with lower poverty rates, for example Switzerland or Iceland, do better than countries with higher poverty rates such as England. The social environment, including the services provided within a country to support people in their daily lives such as child care or health care and welfare, can also impact on population level health. The physical environment is also important determinant with research suggesting that proximity to waste facilities and brownfield or contaminated land, as well as levels of air pollution can negatively affect health. So countries with worse economic, social or physical environments will have worse health outcomes.

The underlying research to the European Health Championship and these links between health and place are explored further in Professor Bambra’s forthcoming book Health Divides: where you live can kill you. Reducing health inequalities between and within the countries of Europe is also the focus of HiNEWS, an international project led by the Department of Geography at Durham University. It is funded by the New Opportunities for Research Funding Agency Co-operation in Europe (NORFACE) which is a partnership of European research councils including the Economic and Social Research Council (ESRC).

Thursday, 19 May 2016

Dementia: not drowning but waving

Posted by Mark Parkinson, Post Graduate Student at Northumbria University

It's Dementia Awareness Week in England as part of Alzheimer’s Society’s ongoing campaign to raise public awareness of this disease. It also affords us the opportunity to take stock of just how far we have progressed since the dark days of the 1980s. Back then a mood of extreme pessimism surrounded dementia amid stark warnings that this ‘rising tide’ represented an unstoppable tsunami-like force that would engulf the UK. Attempts to avert the coming disaster were seen as futile and hopeless, akin to King Canute holding back the sea. The prevailing mood of despondency was ‘justified’ by nine fallacies of dementia emanating from a general lack of knowledge and understanding about dementia.

The Great Wave off Kanagawa
  • Fallacy No.1: Dementia was commonly perceived to be part of ‘normal ageing’. Dementia is now widely acknowledged as a clinical condition characterised by neurobiological abnormalities that distinguish it from so-called ‘normal’ ageing. The public perception of dementia as a disease that is separate from ‘normal’ ageing is increasing in the UK but campaigns such as Dementia Awareness Week are still necessary.
  • Fallacy No.2: Dementia is unavoidable. Protective factors that help guard against vascular dementia in particular include our lifestyle choices, including smoking cessation, regular exercise, adherence to a healthy diet and avoiding becoming obese. The identification of potential triggers for dementia paves the way for future interventions that might mitigate the onset of dementia entirely, including monitoring for catalysts for dementia such as cardio-vascular disease, obesity, diabetes and depression. Intervention programs targeting at-risk groups have demonstrated success in preventing dementia, e.g. FINGER (a two-year programme that focuses on diet, exercise, cognitive retraining and monitoring and treating vascular risk). Latest research also highlights further candidate triggers for dementia such as interleukin 33 (IL-33) protein deficiency which may be remedied via injections to prevent dementia.
  • Fallacy No.3: Dementia is irreversible. Although this remains the case for now, the development of treatments such as Galantamine have been shown to at least moderate the effects of dementia.
  • Fallacy No.4: Dementia is untreatable. The search for a cure for dementia remains ongoing and we have moved into an era where the potential discovery of better treatments and an eventual cure has never been so high. For now though prevention via identification of key triggers remains the main option in the absence of a cure.
  • Fallacy No.5: Dementia is a diagnosis to mortality within seven years. Dementia related diseases such as Alzheimer’s now have a typical duration of 10 or more years and evidence suggests that, in general, people with dementia are living longer. The challenge continues to be ensuring they live as well as possible.
  • Fallacy No.6: Dementia is too varied and unpredictable to treat. Greater understanding of the different sub-types of dementia, their different causes and symptoms, combined with improved ability to detect them makes treatment for dementia a more viable possibility.
  • Fallacy No.7: Dementia is only detected when it is already too late to act. This remains a key issue; however, improved diagnostic tests and screening have improved early detection of the disease.
  • Fallacy No.8: Dementia is too expensive to treat. Recent interventions such as Cognitive Stimulation Therapy (CST) can be delivered to people living with dementia via just 14 hourly sessions. CST has demonstrated equivalent but more sustained effects compared to relatively expensive drug treatments.
  • Fallacy No.9: The number of those with dementia will increase exponentially in the future. Recent comparisons between CFAS1 (Cognitive Function and Ageing Studies) (1991) and CFAS2 (2015) conducted by Cambridge University reveal that dementia prevalence in the UK has actually declined by 22 per cent over this 24 year period. Those born in the latter part of the 20th century exhibit a lower risk factor for dementia than those born earlier. The tsunami warnings of the 1980s have been proven wrong.
Importantly, all this does not signal a time to relax. The need to raise awareness of dementia and the challenges associated with it remains as urgent as ever. In the 1980s a sense of urgency towards tackling dementia provided a much needed catalyst for change. Today a key difference is that this urgency is no longer fuelled by impotent fear but by renewed hope and optimism that galvanises fresh impetus to all our endeavours to beat the disease.

With acknowledgement to the inspired presentation on 25 April, 2016 at the first Gateshead Dementia Conference by Dr.Daniel Collerton (Clinical Psychologist associated with dementia care at The Queen Elizabeth Hospital, Gateshead).

Thursday, 12 May 2016

The 'Wow' moments

Posted by Rosemary Rushmer, Professor of Knowledge Exchange in Public Health, and Dr Peter van der Graaf, AskFuse Research Manager, Fuse and Teesside University

From the 26-28 April, Fuse hosted the Third International Conference on Knowledge Exchange in Public Health in Newcastle-Gateshead. The conference explored “Evidence to Impact in Public Health" in partnership with Tranzo (Dutch Scientific Center for Care and Welfare) and the World Health Organization (WHO), Regional Office for Europe. More than 160 participants from five continents descended upon the Quayside to discuss the latest research and evidence on knowledge exchange practices through papers, posters, interactive workshops and soapbox sessions – and continued these deliberations during the conference reception and dinner, organised walks and yoga sessions.

How do you sum up a conference like this? We are used to filling in ‘happy sheets’ when we attend conferences, giving our scores on the speakers, the accommodation, and if the food was hot…but what about the ‘Wow!’ moments that participants share with each other in the informal spaces?

Below are a few of those hidden moments:

(Day 1: Keynote speaker Professor Bev Holmes, Vice-President, Research
& Impact at the Michael Smith Foundation for Health Research, Vancouver)

‘Wow, she has a lovely way of asking really difficult questions in such a nice, unthreatening way…’

(Day 2: Keynote speaker Professor Hans Van Oers,
Professor in Public Health, Tranzo, Tilburg University)

‘Wow, how did they manage to carry out that research against all that opposition and yet laugh about it now… you can have a good time, be funny, and serious as well…’

(Day 1: Keynote speaker Professor Kieran Walshe, Professor of
 Health Policy & Management, Manchester Business School)

‘Hmm, we can learn about innovation in public health from the car industry and Amazon…’

‘(Sigh) Is that how much we spend on pharmaceutical research and how little we spend on working together to get evidence used. That needs to change…’
(Day 2: Keynote speaker Claudia Stein, Director of the Division of Information,
 Evidence, Research & Innovation, World Health Organisation (WHO))

‘Wow’ it’s that last presentation of the conference and the room is still full.’
(Day 2: Professor Peter Kelly, Director of Public Health
& Adult Social Services, Stockton Borough Council)

‘Goodness! Your Directors of Public Health (DsPH) have taken time out to chair sessions and present…’ (When I fed this back to one DsPH, to show the planning committee’s appreciation of their participation, he was surprised at the delegates surprise… ‘What on earth happens elsewhere…?’ he said.

Maybe we, in Fuse, do have a ‘special relationship’ with our policy and practice partner that makes Knowledge Exchange in public health easier in the North East of England. We, the organising committee, were wowed by the enthusiasm and engagement of all participants during the conference. Discussions were lively with active and positive contributions from not only researchers but in particular public health practitioners and policy makers. Their engagement in the conference is the real evidence of how far we have come with knowledge exchange in the North East and the impact we are having together on public health and local wellbeing, and this is being noticed internationally.

Here's to the next conference!

Visit the Fuse website to find out more about the conference: