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.

Doing something about inequalities in health

Posted by Jean Adams

I was at a meeting in Edinburgh at the end of last year on inequalities in health. It was one of those events full of eminent (and emeritus) professors where I felt slightly out of my intellectual depth. I didn't trust myself to say much. But I tried to listen well.

We need to pro-actively engage with the media - like CJ Cregg did everyday

One of the things about health inequalities is that we all sort of know what the solution is. When I told my dad I was going to do a PhD on why poorer people tend to die younger than richer people, he said "well isn't it just because they don't have as much money?". This confused me. What I was interested in was the physiology - how does poverty "get under the skin?". I don't think the money thing had even crossed my mind.

Now, ten years later, I increasingly agree with my dad. Who cares about the physiology? Sure we could know more about the detailed biological processes going on, but what difference would it make to what we might do about inequalities? The solution remains that to change health inequalities to any substantial extent, we have to change the social structure. Reduce income inequalities, redistribute wealth.

You don't need to be a professor to work that out.

The problem seems to be that we (who? the academic community?) think any sort of drastic wealth redistribution is unattainable, or maybe just too difficult to attain. So we think of other little things we might be able to do to alleviate the problem, rather than tackle the cause. You know, target cancer screening programmes better, that sort of thing.

What would it take to get wealth redistribution? Political will. What would it take to get political will? Public pressure. What would it take to get public pressure? Media agitation. Just like everything else.

One of the things that I was slightly surprised we ended up talking about in Edinburgh was engaging with the media. Sure, I like a bit of science communication. But it's not something that has come up in any of my previous conversations about health inequalities. In fact in previous discussions about science communication, the conversation has rather stopped dead whenever I’ve mentioned inequalities.

The phenomenon of inequalities in health is not inherently media friendly. There are no breakthroughs to report on. No big shiny gadgets to take pictures of. Poorer people get sicker more and die younger. As one participant at the Edinburgh meeting pointed out, if there's a report documenting the extent of inequalities it might get a bit of coverage, but it will be presented as if this is some big, new finding. The coverage won’t go much beyond the data to explore what the cause or solution might be. Then there will likely be a few years of editorial 'fatigue' when it feels like that story has been done recently. Once everyone's forgotten, a new report might spark more interest, but again the coverage will be superficial. And the cycle will repeat.

Other participants described instances of reporters looking for a human angle on inequalities stories traipsing off to the most deprived parts of Glasgow and asking the people they met there why their health was so rubbish.

Mainstream media coverage doesn’t have to be like this. But it will be unless those of us within the public health academic and practice communities interested in inequalities in health get a bit more media-savvy. We need to pro-actively generate informed media debate ourselves. One fairly easy approach is to pitch articles to online outlets such as Comment is Free and newspaper blogs that are desperate for informed and timely content on policy issues.

We also need to be ready to publicly comment on anything to do with inequalities even before we are asked. One researcher, very experienced in media work, described how they prepare written commentary on new reports and statements on inequalities issues the day before they are released. It is fairly easy to guess in advance what the content of any new report will be and so respond appropriately – with final tweaks made on the day once they’ve had a chance to read the details. By staying a step ahead of events, it is possible to guide journalists and debate away from simple reporting to more in-depth consideration of what could be done to alleviate the problem.

Which is obviously all rather more easily said than done. We are, after all, full-time researchers, not part-time journalists. But maybe we could hold each others’ hands a bit and take it step by step and see how it goes? It seems we might have much more to gain, than to lose, from trying.

So who wants in with me on a Comment is Free post on what we need to do about health inequalities in the UK today? Ready to be pitched to coincide with the next big report.

A Christmas Blogpost

Posted by Heather Yoeli

And so, it’s That Season again. The time of year to do everything with alcohol and food which Public Health Guidelines say you shouldn’t, the time of year to tie-dye six multi-packs of Primark socks as Christmas and/or Hannukah presents for your ever-burgeoning brood of nephews and nieces, the time of year to argue with one’s partner about whose should come to fix your perennially inept combi-boiler. Happy times. Well, maybe; maybe not. This year, things do feel different.

The time of year to think about Those Less Fortunate Than Ourselves

This year does feel very different. It’s the first time – within my lifetime, at least – that such austerity and hardship and poverty in Britain have been so widespread. Certainly, this country has always had its marginalised and disadvantaged and poor... but the food banks, and the stories of people walking ten miles on foot to reach one because they cannot afford the bus fare, and the talk of “nutritional recession”: that’s new. It’s new, and it’s frightening. It reminds us that we live in one of the most unequal countries in the developed world and that, whereas that inequality is getting worse, we are most of us just one job loss, one relationship breakdown or one investment disaster away from destitution.

And so, it’s That Season again. The time of the year to think about Those Less Fortunate Than Ourselves, the time of year to try and decide whether to donate to That Charity or to get angry about the need for That Charity even to exist, the time of year to give an extra few quid to the Big Issue seller and to awkwardly wish him a merrier Christmas than he’ll probably be having. And so, I’m now going to propose that we in Public Health research do need to invest some more thought about what we’re doing to address this new sort of poverty and hunger we’re seeing across Britain. Do we organise collections and donations for our local homeless charity, or do we set up evaluations of cookery classes for vulnerable families, do we invite Osborne round to tea for a chat about the bankers and their bonuses, or do we set up a protest camp and get radical?

I don’t know what the answer is, I really don’t. But let’s talk about it, anyway...

From aged PhD to aged Intern

Posted by Lynne Forrest

I’ve previously blogged on why I’m doing a PhD in my forties and how I regard it as a career ‘second chance’, having not really quite got it together, career-wise, for the first 20 years of working life. As part of that spirit of positive thinking, when I started my PhD I decided I would embrace all the opportunities that came along. One of these was the chance to do a three month Internship, via my PhD funder the ESRC.

Now Internships don’t generally get a very good press, being pretty much regarded as a way for businesses to avoid paying someone a salary whilst offering ‘job experience’ that mostly consists of filing and making the tea.

However, I’d recently read that doing an internship was a good PhD career move. Also, as these were paid internships that were being offered by a range of high profile Government and charity organisations which required specific skills (of which tea-making wasn’t one), it seemed like a good idea. As a mature student, I didn’t need an internship to gain general work experience. I was looking for an opportunity to develop my skills base and gain experience in an area that wasn’t covered by my PhD.



The internship that I was interested in involved working in the Strategic Research Team at the Scottish Government conducting health research and translating the research into policy and practice. They were looking for someone with systematic reviewing experience, advanced quantitative skills and who had worked with large datasets, all of which applied to me. It seemed a perfect fit. And it was – they’ve offered it to me!

Although I’m very excited at this opportunity, the same age and status-related worries apply to doing an internship as to doing a PhD. However, for the most part, PhD students are treated similarly to staff in my department* and so I’m sure I will cope just as well as an aged Intern as I do being an aged PhD student. Unlike young interns I also have children, who are not best pleased that I will be away for 3 months. I’m hoping to negotiate flexible working hours and will be home every weekend, so I’m ignoring the emotional blackmail and guilt and am going anyway. It’s just too good an opportunity to turn down.

I think it’s going to be very interesting to be able to observe the reality of how the translation of evidence to policy actually works in a political environment and, indeed, to see how much policy is, in fact, evidence-based.

As well as the amazing career opportunity, the other positive for me is that I will be spending three months in Edinburgh, my home town. Having spent the past 15 years in Newcastle, I’ve latterly become terribly nostalgic for Scotland (getting all misty eyed over VisitScotland adverts and watching tartan and bagpipe-style programmes at New Year. I know. I need help). The reality of a few months in dreich Edinburgh over the winter may be just what I need to get over this.

Anyway, I’ll let you know how I get on….

*except that PhD students are required to ‘hot desk’. When I complained and got a proper desk it was on the understanding that I gave it up if someone ‘more important’ required it…

How to get the evidence message across

Guest post by Katie Cole

The mantra of “but there’s no evidence for it!” is one I’ve said or thought many times, both in my work, discussions with family and friends, or when shouting at the BBC Today programme.

But as an early-career academic, I’m increasingly aware there is a complex web of considerations when trying to translate evidence into policy, and that there are times when chanting our mantra may do more harm than good.

I recently attended a Royal College of Physicians/Alma Mata seminar on alcohol advocacy. At one point, a panel member suggested that social norms interventions to address excessive alcohol consumption on university campuses “sounded very promising” and policy-makers were considering it. I’ve looked into US research into these interventions: a national evaluation concluded that they are ineffective in reducing alcohol consumption. Whilst I could have made this point, I felt it was more complex than that. Don’t we need to test the policy in the UK drinking context to make a more robust contribution to the debate? Shouldn’t we seek to support policy-makers to integrate evaluations into pilots, or to finance full-scale trials?

Another challenge I’ve had was during a placement at a Primary Care Trust. I was involved in the Individual Funding Request process, where the PCT considers funding treatments and procedures not normally available on the NHS. I worked up a number of cases, looked at the evidence base and presented the case to a panel of clinicians and non-clinicians. In most cases, the evidence base was of poor quality: finding a case series for the exact condition and treatment in question represented a minor professional achievement. Usually, the case series found that, lo and behold, most cases improved, which often sparked disproportionate optimism that we had a justification for funding the treatment. In contrast, when I found a randomised controlled trial with only modest results, the panel were more inclined to propose not funding the treatment. Here I was challenged to explain the difference between the strength of the evidence base, and the strength of the effect size; whilst at the same time, acknowledging the difficulty of decision-making against a poor evidence base.

A final challenge has been in developing The Lancet UK Policy Matters website, which includes short summaries of the evidence underpinning a range of UK health-related policy changes. In developing the format of the summaries, we had to be very clear to authors that statements purporting the intended benefit of the policy should not be included in the ‘evidence’ sections of the summary – this was reserved for peer-reviewed research or evaluations. Our experience in guiding authors highlighted to us how meticulous we as professionals need to be in the choice of language we use when drawing on our scientific expertise.

Above all other lessons, these experiences have taught me that advocating for evidence in policy making is challenging, complicated and requires skill. It demands an understanding of the evidence itself – its strengths and limitations – but also of the policy making process. Whilst these issues can be difficult to reconcile, the above experiences have only strengthened my drive to communicate effectively with all actors in the policy making process.

Katie Cole co-founded The Lancet UK Policy Matters website with Rob Aldridge and Louise Hurst.

Just trying to make the world a better place

Posted by Jean Adams

People who work in public health research seem to have a universal desire to make the world a better place.

Mostly they also have that innate finding-out-new-stuff-is-cool streak that unites scientists of every flavour. But in public health research, getting out of bed seems more about working out how (health) things could be better. 

We just want to make the world a better place....

Which is what Fuse is all about: not just finding out how we could, under ideal circumstances, improve people’s health; but also working out how we can ‘translate’ public health research evidence into public health policy and practice to make it more ‘evidence-based’. To use the jargon.

I am grateful to Fuse. Not just because they have paid my salary for the last few years, but also for getting me to think more about the problem of evidence-based policy.

I was also really pleased to be invited to a workshop on Economic Evaluation of Population Health Interventions in Glasgow last week. Admittedly, I was pretty apprehensive before-hand: all I know about health economics, I learnt during an MSc module led by one of the guys who organised the workshop. What could I usefully contribute?

Perhaps I didn’t contribute anything useful. But I did enjoy the workshop – which was very trendily multidisciplinary (maybe I was just a token public health rep?). I particularly enjoyed chatting to an ex-academic, now working for the Scottish Government, who gave me a very candid window into how government works.

Way back when, before I had really thought about it much, I thought evidence-based public health policy was all about educating the policy makers – about what scientific evidence is, how us scientists generate it, and how the policy makers should use it. If we just shouted louder, maybe they would hear us.

This is not an unreasonable approach. So much so, that an eminent science writer has just written a, much-praised, book about it. But it only takes a minute reflecting on the minimal effectiveness of health education in changing behaviour, to work out why it might not work.

Of course policy makers, and politicians in particular, take more into account than just scientific evidence of what ‘works’ when they make decisions about what they should spend our money on. Which is where the health economists come in. If we can’t convince them with straight-up ‘what works’ arguments, perhaps we can appeal to their mercenary instincts and convince them with arguments about what might save money. But this is just more-better education.

So what can we do? My first suggestion is that instead of trying to get policy-makers to think more like scientists, us scientists need to start thinking a bit more like policy-makers. And what my loose tongued academic-turned-civil-servant-health-economist reminded me of last week, was that we don’t elect our politicians on the basis of whether or not they are the sort that might be ‘evidence-based’. We elect them on the basis of ideology.

Perhaps, the only way to change policy is to appeal to ideology. Blitz the broccoli-evidence, mix it up with some yummy-ideology, and slip it down the hatch airplane style.

Trial by select committee

Posted by Jean Adams

Well, trial by select committee has been and gone. It was certainly interesting. But I’m not sure it will achieve anything in particular.

I have never been inside the Palace of Westminster before. I was surprised how National Trust it was. A lot of unfinished stone staircases and grand halls that are clearly impossible to heat, followed by corridors that are far too narrow for modern life. Using my special academic congregating powers, I bumped into my fellow ‘experts’ long before finding the room I was looking for. When we finally arrived at our destination, we were greeted by a rather under-capacity committee. The Rt Hon Stephen Dorrell was in the chair. Other members came and went during the session.

Surprisingly National Trust

Disappointingly, the only refreshments were House of Commons branded bottled water. The coffee and pastries clearly flow a lot freer in the West Wing.

The session itself was pretty informal. After we ‘experts’ introduced ourselves, the members of the committee just seemed to think out loud and bounce ideas of us. What a remarkably priviledged position to be in – hmmm well when I was told that I would live longer if I gave up smoking, it really motivated me to quit...I wonder if that would work for alcohol...it would be good if I could just ask some– oh, look, three professors of alcohol studies, I’ll ask them!

Aside from Stephen Dorrell, who was John Major’s Secretary of State for Health, the committee includes a number of doctors, as well as a range of other members. The questions ranged from very sensible (do you think the alcohol industry should be ask to help set policy?), to a bit bizarre (does gin makes you more depressed than vodka?). Talk of ‘evidence’, and what counts as ‘evidence’, varied and there were a couple of occasions when one of my fellow ‘experts’ stated, perhaps a little too emphatically, that whatever the honourable member might think, the scientific evidence very strongly suggests the opposite. One member was rather obsessed with the idea of ‘anecdotal’ evidence and used this term as equivalent to any other sort of ‘evidence’. I hope he didn’t notice me snigger when he launched into another long and winding anecdote...

So what next? Well, the government has promised to publish its new alcohol strategy within the next few weeks. This may or may not be evidence-based or based on expert input. The committee will then begin a formal inquiry into alcohol and hear evidence from a variety of experts. They will make recommendations to the government on how their strategy could be improved. But the government will be under no obligation to act on these recommendations.

So that’s it. No more gallivanting around the corridors of power in my glad rags for me. Time to get back into my jeans and do some real work.

An expert in a day

Posted by Jean Adams

A few days ago, I got an email saying I'd missed a call from someone at the House of Commons. Oh. That could be a good or a bad thing. My first thought: what have I done wrong now?

The House of Commons Health Select Committee are going to have an inquiry into alcohol. No, no. I have not been called to give evidence. I have been invited to a preliminary seminar to acquaint members with the issues, and set terms of reference. Yeah, I know. That's not quite the real deal. But it is sort of important.

Palace of Westminster

The thing is, I'm not really an expert on alcohol. I don't mean that in the "it's not my area" way that academics say when they mean that they can't be bothered, or it's not exactly the sort of stuff that they're thinking about right now. I mean alcohol is really not my thing. Food advertising is my thing. Time perspective is my thing. Inequalities are my thing (I highly recommend chapter 5 at that link). Alcohol is not my thing.

I wrote a paper on alcohol marketing because food marketing is one of my things. I saw a gap for using a method I'd already worked out for food and applying it to alcohol. To be honest, it wasn't my finest piece of work. But the BBC got excited by the paper. Suddenly I'm an expert on alcohol.

So I agreed to do the House of Commons thing because what would my Mum say if she knew I'd been asked and had said no? But then I had to spend a day doing my best to become an expert on alcohol.

First port of call - BBC website for an update on Westminster (strong words, no movement yet) and Holyrood (making progress) policy. Next, recent NICE guidance on preventing excessive alcohol consumption. Plus three related systematic reviews and a massive mathematical simulation of what might happen with various different price restrictions. This leads me to a previous House of Commons Health Select Committee Inquiry into Alcohol.

Now hang on a minute. In 2009 there was an inquiry into alcohol. This drew on evidence that was being prepared for the NICE guidance. The NICE guidance was issued in 2010. Less than two years later we're doing this again? Has the evidence changed? Doesn't look like it to me. Has anyone acted on the guidance and recommendations from 2009 and 2010? Doesn't look like it to me.

Tell me this is not how government normally works.

My recommendation Mr chair? To read the last two sets of recommendations, which are largely the same, and act on them.

Dinner

Posted by Jean Adams

In my experience, there are two possible plans of action in that moment between drinks and dinner when everyone hovers around the table wondering if there is a seating plan.

Plan A is to actively manoeuvre to ensure that you sit next to the most interesting people.  Plan B is to hang back and grab the last seat.  Obviously Plan B is the introverts preferred method.  But there is a real risk that everyone else is following Plan A.  Meaning that Plan B’ers find themselves, by default, left sitting next to the very least interesting people. 

The other evening I found myself at a work related dinner where I hardly knew anyone.  I knew the people I probably didn’t want to sit next to.  So I manoeuvred away from them.  But I took my chances with the rest.

I was rather taken aback when, around 20 minutes into the dinner, the man on my right said in a rather loud voice: “Well, I used to be on the monetary policy committee, you know.  I disagreed with Mervyn King about almost everything.” 

Mervyn King

You what?  How did I, a university lecturer in public health, find myself sitting next to an economist who used to be on the MPC?  I am still not quite sure what the answer to this question is.  But it seemed unlikely that it would happen again.  So I decided to find out what I could.

I guess we are all victims of surrounding ourselves with opinions that agree with our own.  I feel quite privileged to work in a professional arena where my political opinions are mainstream, and are almost part and parcel of the job.  It’s nice to work somewhere where you feel your colleagues so strongly agree with your worldview.

So it was a bit of a shock to be at a work dinner with an economist who turned out to be just a little bit to the right of me.  It turned out he lives in New Hampshire – a beautiful part of the world, where the state motto is “Live free or die”.  They don’t have sales tax or state income tax in New Hampshire.  This means there are limited public services.  But it’s okay – because “there’s a market”.  You need your garbage collected – “there’s a market”, you need the snow swept from your drive – “there’s a market”, you need some health care – “there’s a market”.

“So what do the people in New Hampshire who can’t afford those things do?”  I asked.

“They live in Vermont.”

Apparently a new liberal era has washed in and the students are trying to get “Live free or die” replaced with the much more politically correct “Live free or move”.