Three questions

Posted by Jean Adams

Editor's note: Earlier this year, Heather Yoeli suggested a little quiz of three questions. This post is another entry for the quiz. If you want to play, just get in touch.

1. In an entirely hypothetical scenario in which time, money and skill were no object and you could research absolutely anything at all, what would you choose?

I am pretty sure that I am very glad that my research interests are inequalities in health and health behaviours, and food policy and marketing. I really don’t think that I would rather be doing anything else. But maybe that’s some sort of avoidance/denial problem. Together the general topics of my research encompass ensuring that people can be as healthy as they want to be, that society is fair, and that multinational capitalism is not allowed to ride roughshod over the health of the population. Obviously I am biased, but these seem important to me.

What sometimes dissatisfies me is not the topic of my research, but the day-to-day work that I do and the impact it has. When I am embroiled in public health research with very clear policy implications, I am jealous of the people who get to do data analysis all day. When I spend my days immersed in Stata, I get frustrated that I am playing intellectual games with data rather than changing the world. Whenever I try and change the world, I get frustrated by how hard it is and think that perhaps being an academic is not the right way to go about it. Perhaps I should be a politician? Or a teacher? Or maybe an outdoor ed instructor?

Maybe I should be an outdoor ed instructor?

2. If you could poach a piece of research from one of your colleagues, which and whose would you pick and why?

On the days that I am jealous of the data-fiends, I want a birth cohort of my very own to play with – and probably one bigger that the one I do have access to. But mostly I love the simple studies that tell a good story well. George Davey-Smith’s analysis of historical social inequalities in life expectancy – demonstrated by correlating length of life recorded on gravestones with height of memorial obelisk in Glasgow graveyards. Steve Cummins’ exploration of social differences in exposure to obesogenic environments – a study of the density of McDonald’s restaurants. Mark Petticrew’s analysis of tobacco industry documents exposing the manipulation of scientific agendas by the tobacco industry to deflect attention away from the harms of smoking. There are flaws in all of these pieces of work, and in all cases the true situation is much more complicated than depicted in the study, but I enjoy the simple exemplar that makes a valuable point well.

There is also a special place in my heart for the prospective cohort study of teaspoon disappearance.

3. If you could study and/or work at any university in the world, where would you go?
The answer to this question seems to depend on a combination of where I would most like to live, who  I would most like to work with, and which universities have I heard the least horrendous rumours about on working conditions and treatment of staff .

So working backwards, let’s start by just not talking about the rumours of universities who seem to have markedly different criteria for promotion to professor for men and women, who never issue contracts beyond three years, and who are so focused on REF returns they ditch anyone without four 4* papers.

Let’s move quickly on to who I want to work with. I only ever want to work with people who are fun, bright and enthusiastic. People who wont let me cut corners when I'm bored of a piece of work and want to move on. People who challenge me to think in new ways. People who keep me grounded in what really matters. I have lots of these colleagues at Newcastle and across Fuse. I suspect that universities attract them.

And finally, where do I want to live. I have always wanted to live nearer to the mountains. But I can only speak English and don’t feel this is likely to change soon. So the Rockies, the Appalachians, maybe the White Mountains, New Zealand, that sort of thing. I miss Scotland in a non-specific, it’s just the place that feels most like home, sort of way. So Edinburgh or Glasgow would also be fine – and even they are nearer my mountains than Newcastle. I guess in an ideal world, Boston or Vancouver – good universities, good mountains, haven’t heard any bad rumours, but haven’t gone searching for them either.

Progressive conservatism or the return of blaming the victim?

Posted by Paul Crawshaw

On Tuesday 12th March 2013 the cross party think tank Demos published the provocatively entitled Control Shift, a report drawing heavily on 2012’s Rebalancing Risk andResponsibility. There is much food for discussion in what, overall, is a well argued report. But of particular interest to me, and I suspect my colleagues in Fuse and beyond, is Chapter 2: Public Health.

Consistent with the report overall, the key theme of this chapter is the promotion of greater individually responsibility for health behaviours and the adoption of so called ‘healthy lifestyles’: perennial themes for those with an interest in modern public health. Particularly striking is the proposal to offer ‘incentives’ for people to adopt more healthy lifestyles with the ultimate goal of reducing the ‘burden’ on the NHS, a ‘burden’ said to arise disproportionately from those who make ‘bad choices’. This is more broadly aligned with the theme, explicitly laid out in Rebalancing Risk and Responsibility, of encouraging greater civic responsibility outside the state. For too long, we are told, we have been accustomed to the state pooling risks. This has stripped us of our autonomy and the will to manage our own lives, and, most insidiously of all, has created dependency. We must learn to approach risks, we are told, in ways more akin to those adopted by, for example, the private health insurance companies, one of whom, interestingly, is the sponsor of this report.

Is it time to finally stop victim blaming?

One short paragraph struck me as epitomising the ideological standpoint (and despite claims to pragmatism over ideology, we must never be lulled into believing that such standpoints are not profoundly ideological) of Control Shift overall and is worth citing in full:

People receiving the new Universal Credit could, for example, be rewarded with cash top-ups if they attend the gym regularly. This would not only encourage people in low-economic groups (who are at most risk of leading sedentary lifestyles and developing obesity-related health problems) to become more active but would help to ensure that Government is seen to be encouraging high-risk groups to take responsibility to ensure that the risk they pose to NHS resources is less disproportionate (p. 32).

These few sentences encapsulate for me the most troubling assumptions of this form of (not so) progressive conservatism. Implicit is an assumption that it is a lack of volition that prevents ‘people in low-economic groups’ from being physically active. Ignored are the wider structural determinants that lie behind the individuals’ ability to choose and the actions they do (or do not) take. This has been convincingly argued recently by Marchman Andersen et al in the Journal of Public Health. Similarly, by stating that ‘high risk groups’ (a terminology more at home in largely discredited health education campaigns of the 1980s) should act in order to make their impact on NHS resources ‘less disproportionate’, the author clearly suggests that it is the actions of these ‘groups’ that lead to excessive ‘burdens’ and that these in turn can be redressed by the groups themselves. Little credence is given to the argument that it is wider structural inequalities that result in poorer health, a position supported by overwhelming evidence (see Marmot, 2010 and many more). It is hard to imagine a clearer case of blaming the victim.

Control Shift does not sit in isolation and must be read in the context of a series of other recent ideological projects that have in common an overt statephobia. The most obvious examples here are the relentless pursuit of austerity (despite the wealth of evidence contra to this as a method for economic growth) and the promotion of a ‘big society’ based on voluntarism, participation and, of course, responsibility. Like the continued push for austerity, in Control Shift we witness a clear disregard for the weight of evidence, established in over thirty years of public health research into inequalities in health, that the key determinants of morbidity and mortality are not individual behaviours, but rather, lie in structural factors such as employment, income, housing, education and so on.

As much recent research has shown, access to these resources is far from equal in the UK, where the End Child Poverty coalition has recently reported up to 40% of children living below the breadline. How we expect people with unequal access to what many of us take for granted as basic resources to behave as ‘responsibly’ as their more affluent counterparts remains, for me, a mystery. What is less mysterious is the clear propensity of such ‘progressive’ conservatism to continue to blame the victim (as classic work such as that of Crawford (1977) established decades ago) as part of a thinly veiled ideological strategy (and remember, to paraphrase the Marxist Louis Althusser, the positing of the end of ideology is the ideological idea par excellence) that aims, not to encourage responsibility, but to shift it from the state to the individual, to construct society as an image of consumer marketplaces in which we are all responsible for our own choices. Sadly for the victims of structural inequality, they can only make the choices they can afford.

Little legs

Posted by Linda Penn

I was pleased that the train arrived to take me to Middlesbrough on a freezing January morning, although not so pleased that it was the cold train (heating in this train hasn’t worked for months). By the time I got to Middlesbrough station I was frozen through. Claire picked me up and took me to an annex at the back of what used to be St Cuthbert’s church. In this very cold and rather dark annex was a ‘community gym’ and I was there to interview South Asian women about their physical activity, as part of the evaluation of our preventive intervention feasibility study. By then I was so cold I would have preferred to tramp the treadmill to warm up or maybe even indulge in beginners’ Zumba. However, when the women started talking I forgot to be cold. Qualitative research can be such joy.

St. Cuthbert's Church, Middlesbrough, 1965

St Cuthbert’s church used to be near my uncle’s butchers shop, until the planners bulldozed the community to drive a road through the heart of the town and move people out to a concrete desert. I didn’t know, until my cousin told me recently, but they had apparently sold halal chicken from this shop. So there must have been a Muslim community in Middlesbrough for some time.

My great aunt Minnie’s sweet shop was also somewhere nearby St Cuthbert’s. I think she ran the shop from the front room of one of the little terraced ‘slum’ houses. This house too has long since been reduced to rubble. I only remember going there once and I was very young. Minnie was too old then to keep shop and my sister and I had been warned that Minnie had ‘little legs’. We were not to ask or comment. In fact, we should just pretend we had not noticed. The legs were not at all obvious when we arrived as she was sat in her big chair by the fire, with a rug over her knees. However after a while she got up to fetch the coal from the back kitchen. When she got up she was walking on her knees – the little legs. It was a shock, which must be why I remember. Nevertheless Minnie managed to negotiate down the stone step into the back kitchen to fetch the coal and obviously back up the step with the bucket of coal. I remember watching her. I am sure someone would have offered to go and get the coal for her, but she must have refused with such determination that no-one dared interfere. 

St. Cuthbert's Church, Middlesbrough, 2008

Not until years later did I appreciate that Minnie’s little legs were as a result of diabetes related amputations. That was my first introduction to the nasty, progressive and debilitating disease that is diabetes. It was pure serendipity that this January I was back almost where I started and the prevention message is the same. Although I hope the prosthetics have improved.

Horse dung

Posted by Louis Goffe

The horse meat ‘scandal’ has been dressaged by the red tops as a tragedy but for most it’s been a great source of comedy and we’ve been left to ask ourselves whether to eat, or not eat a Findus lasagne, though that is equestrian.

I had a giggle last week when Tesco chose comedy actor Julian Barratt, to front a radio ad apologising on their behalf for the loss of trust caused over the minced mule dishes. An actor made famous by his show The Mighty Boosh, whom once played a character called “The Crack Fox”: a lying, manipulative, power obsessed canid that survived on a diet of cat blood, shampoo and even less desirable items, that tricked its way into peoples’ homes before poisoning them with a noxious substance.

Before one even had chance to whip up one of these night-mare-ish burgers the story had turned from outrage to “what do you expect in a patty that costs you pennies”. Writers and commentators jockeyed with each other to write the most amusing articles and turn the tables on the public. They slopped up the liability for ignorance of the disconnect between food production and what’s on the dinner table into the public’s own bowl. There is little to be concerned with from a health standpoint about consuming a filet of filly. But it’s my hope that the outrage will act more as our feathered friend, the canary in the coal mine, about the wider dangers associated with high consumption of processed food.

The champion stakes, by Paolo Camera 

In the champion stakes to sell the cheapest produce between the thoroughbred supermarkets, the producers are being pushed up against the rails and the odd fence is being missed. But the old nag of blame doing the rounds according to many in the press is currently grazing in the paddock of the consumer. Collectively we should cart some of the responsibility, but the ethical argument needs to be more nuanced. We should assess the nature of each decision along the production chain, are they passive or active, as well as our own choices to put certain food in our mouths, before we attribute culpability.

I’m currently investigating how certain characteristics and demographic variables influence food consumption. Some of my results confirm the obvious: the more we know about food the healthier the choices we make. But beyond this we are starting to see in greater detail the relationship between diet and educational attainment; where those with school qualifications only eat less healthy diets than university graduates. There is more than a healthy serving of snobbery, particularly from the food writers, directed at the consumer. But when education plays such a key role shouldn’t more anger be directed towards the policy makers that have the power to better inform, particularly young minds, about the nutritional qualities of the different food groups?

I have a particular passion and fascination for coffee, to the point that I even enjoy its preparation as a spectator sport! I buy from micro-roasters that specify roast date, bean varietal, farm name and elevation as well as the processing method. I happily pay more for this premium product. As a result of the reduced number of links in the chain from farm to cup, the farmer receives a higher price for his beans and is encouraged to produce a higher quality product and to take greater care of their land. Such obsession with food is taken to the ultimate level by octogenarian, three Michelin starred sushi chef, Jiro - as witnessed in the beautiful documentary ‘Jiro Dreams of Sushi’. Jiro has a personal relationship with every producer he buys from - from shrimp trader to rice farmer.

I place high value on food, but I’m certainly no Hugh Fearnley-Whittingstall. My love for coffee isn’t matched elsewhere in the kitchen, and you will see me on occasion scoffing down my old student favourite of chips, beans and cheese in the Baddiley-Clark café. We all place a varying degree of value, from functional to sensual, on our food and whisked together with career and family life creates strong pressures on purchasing behaviour. Many are now focused towards an ethical standpoint, such as air miles or organic (frequently conflicting) and others simply want to purchase the best tasting food possible. But the vast majority shop for a combination of cost and convenience. Parents shouldn’t be criticised based on the values of those within the industry and certainly don’t deserve to have potentially hazardous food served up when their main aim is to provide a nutritious meal for their hungry kids.

We need to provide better nutritional education for our kids, particularly the most disadvantaged in society, to encourage them to place a higher value in what they eat and to develop a better understanding of the impact that food has on their body. In tandem we need improved labelling so we can state categorically that each individual is expressing freedom of choice, as opposed to freedom of influence, and hopefully increase our collective odds of consuming healthier food.

Class of 2002

Editor's note: On Thursday 14th March 2013, Newcastle University are hosting a celebration in honour of the 25th anniversary of their MSc in Public Health & Health Services Research. This post was prompted by requests for reflections from past and present staff and students on their MSc experiences. 

Posted by Linda Penn

My class all started the MSc course in 2002 and graduated at different times, so for me it was the class of 2002. The first day I was terrified, these were all ‘Health’ people and I was not. Also it was more years than I care to admit since I had taken any exam. Professor Nigel took the first session and it couldn’t have been a better start. His kind professionalism included all the stock in trade responses for encouragement: “Good point” (staggeringly obvious to anyone who has spent more than 5 minutes in research, but not entirely stupid for a greenhorn), “That’s interesting” (you have probably missed the point, but I will explain it more clearly and it is better if you do ask because other people will have missed the point as well).

After the first day Cath organised the coffee club and it all became rather more comfortable. Then there was Health Economics. I quite enjoyed this subject, but it was allocated to the post lunch ‘graveyard’ slot and a few students were inclined to sigh. One student decided to liven it up, but that is their story. I was shocked.

My anecdote is around prescribing antibiotics (or rather not prescribing if unwarranted). Lecturer X developed a long and complicated story about a mother demanding of a GP that he would prescribe antibiotics for her child who had a cold and a sore throat. This went on and on and eventually (in the story) this poor inexperienced GP gave in and signed the perhaps not entirely appropriate, although probably not life-threatening, prescription for antibiotics. Lecturer X pressed us about what we would do at the end of surgery (if we were this poor, unfortunate, misguided, bedraggled GP). Several people suggested various options, “Yes and?” said Lecturer X, quite a few times. Now I had come from a practitioner land where beautiful theory and immaculate plans regularly crashed on the rocks of circumstance and reality and where a good practitioner would have a sleeve full of contingency rafts, but would not take on board too many ‘perhaps ifs’. In naivety I decided that the story Lecturer X was pressing must be a message about conflicts between ideal and real along the lines of “if you don’t look after your-self you can’t look after other people.” So I suggested that this poor GP should go home and have their tea.

Southwesterly Gale, St. Ives; Frederick Judd Waugh

I was wrong. Lecturer X put their hands over their head and curled up on the floor to emphasise how wrong. I kid you not. (The ‘right’ answer was look up the Cochrane review for guidance. The message was about learning from mistakes). If the floor had opened up just then my red face and I could have happily slotted through.

However, what was really nice was that afterwards quite a few of my student buddies took the trouble to come up to me and say, “You were right” or, “You had a point”. So I remember acceptance, not embarrassment. I don’t expect anyone else will remember at all. Usually I limit reminiscence, but a reunion is the perfect excuse for a reminiscence fest

Playing in the sand: the joys of peer pressure

Posted by Peter van der Graaf

Have you ever wondered what would happen if you put 28 stressed-out early career researchers in a country hotel and gave them the option to either enjoy the available swimming pool, spa, snooker room, and pub with sun soaked terraces, or to write a full research proposal of up to 5,000 words with five unknown people in less than four hours and submit their work for scrutiny to a hard-nosed review panel of senior academics and professionals? Remarkably, when Fuse tried this out last week in the Sandpit event at Linden Hall, the result was five serious proposals, steeped in blood, sweat and tears, that somehow managed to persuade the review board to part with £2,500 of prize money.

The distractions were plentiful: giant Jenga, Connect4, indoor cricket, extensive breakfast and lunch buffets, (attempts at) nouveau cuisine diners, tough pub quizzes presided over by quiz-wizard communications officer Mark, log fires with arm chairs, and more coffee, tea and cakes than was healthy to consume, while hero professors bared all (at least their life stories) under large glass chandeliers. In spite of all these temptations, the researchers locked themselves up in their rooms, questioned the wisdom of their mentors, cross-examined policy and practice experts on their chosen subjects, argued and quarrelled at length with each other, and somehow managed to produce something that could pass for a research proposal.

Nerd peer pressure

The secret, you might wonder, is a classic tale of peer pressure, which early careers researchers are especially prone to. What the event allowed them to do was to learn this lesson (and many others in the course of it) and, even better, to enjoy it: a relaxing swim or pint in the pub is much more enjoyable after a chaotic session with five strong minded colleagues who are trying to reach a decision on what topic to choose for their proposal (only to find out later that they were allocated their third choice). A quiz or game of Jenga seems all the more exciting after struggling for three hours to put anything on paper, only to realise you have an hour left to write the remaining 5,000 words.

Therefore, a big thank you is in order for the organisers of the event, particularly to Avril, who had to miss out on many of the temptations due to a sudden bout of flu, and to quizmaster Mark, who clearly has too much free time on his hand to come up with the questions he did.

Horizon scanning

Posted by Linda Penn

As I watched the midnight sun skim the lake horizon in Finland, I should have remembered there are ‘no free lunches’. Collating the European Diabetes Prevention Study (EDIPS) data required much effort and was mostly a spare time endeavour for Jaana, Annemieke, and me. Our first tangible reward, to which all co-authors have contributed much thought and substantial quantities of virtual red-ink, is our publication in PLoS ONE.

Midnight sun in Finland

There are three main messages in this paper:

1. Type 2 diabetes can be prevented by lifestyle intervention in European countries (including the UK, and not just in Finland - which was already known).

2. Weight loss has a diabetes preventive effect and maintaining weight loss for more than a year has a greater (quite dramatic) preventive effect.

3. Convenient identification of people at high-risk, so that interventions can be offered to the right people, remains unclear (and research is needed).

Drafting, redrafting and re-redrafting this paper was a learning experience and a privilege. As any first author may appreciate, coordinating input from my co-author list of illustrious professors might incur challenges. Since publication I have received several complimentary responses from colleagues - such is the power of social media - and I am satisfied that this paper represents good research. However it is just research. Translation to sustainable service provision remains the goal. Finland has made progress in this direction, but in the UK it is raining costs and cut-backs.

Recent NICE guidance for prevention of type 2 diabetes confirms the need for intensive lifestyle intervention services, and we are currently evaluating a translational feasibility study in Middlesbrough that is based on our EDIPS experience. We also plan further EDIPS publications. We agreed outlines for these during a November meeting in Helsinki. Finland was different in November - no sun, horizontal sleet and frozen snow - but still warm hospitality.

I have the additional bonus of including this paper in my portfolio towards my PhD by publication, which is of course the soft option for a PhD – or perhaps not. I wonder if I can include a Fuse Blog post as supporting documentation?

The Sandpit. Why Fuse is unlikely ever to overheat

Posted by Heather Yoeli 

At primary school in Melbourne, we learned about the Katherine School of the Air, which connects and educates children across the 500 000 square miles of the Northern Territory, which is the least developed and most sparsely-populated region of the Australia. For most of the year pupils and teachers communicate solely via satellite and internet technology, but when it’s not too hot they all meet together for swimming and teamwork-type activities. Fuse connects and educates across the North East of England which, though a mere 0.0016% of the size of the Northern Territory is the least developed and most sparsely-populated region of England and is, by overcrowded English standards, relatively remote – and in any case, Fuse members do much of their getting-together and collaborating and socialising online, too. However, Longhorsley is located at the same latitude as Novosibirsk in Siberia which means that, despite the Gulf Stream, this week’s Sandpit event was never going to be remembered for its warm evenings.

School of the air

I thoroughly enjoyed every aspect of the three days of the Sandpit. I enjoyed meeting people from across the region and I learned a huge amount from encountering research projects and perspectives and standpoints from across the vast expanses of public health theory and practice, being again reminded how incredibly broad a field public health can be. I loved the warmth of the conviviality of all those email addresses who suddenly transformed into faces and certainly. I loved the spark and sparkle of heated debates which energised and illuminated our groupwork. And I thought that the hot meals and heated spa were wonderful too. But it was nevertheless rather brisk, slightly chilly and somewhat requiring of more clothing than one might usually wear indoors.

And so I would propose that next year’s event ditches the name ‘Sandpit’ and rebrands itself as the ‘Snowdrift’ or ‘Ice sheet’, especially given that one of the projects undertaken was a research proposal into using the telephone to address the problems of cold-weather related winter deaths. Maybe it would attract funding from a refrigeration firm or the Alaskan state government. Maybe we could work on projects around the public health aspects of hypothermia and fuel poverty. Maybe we could have an ice-sculpting competition instead of the pub quiz.

So now that my fingers are warm enough to type, I’d like to thankall of the Sandpit organising committee as well as my fantastically knowledgeable, hard-working and thoughtful team members Emily, Karen, Sandra, Lynne, Leanne and Shelina. And thank you to the senior people in Fuse and the NHS who agreed to and funded the event. Please do please forgive me for taking the mick out of the temperature. Given that turning the thermostat up was the main suggestion offered for improving the event, you can be confident that you have really done something very, very right.