This column includes a message, from Istanbul. Public health and other public goods have been trampled since the 1980s. The crisis of capitalism is telling us something that can and should inspire us. Crises are turning points. The message is that the great days of public health, of which public health nutrition is one part, will come again.

Food and the senses

Marcel Proust, and hot beans

First though, what coffee may mean. The title of Marcel Proust’s À la Recherche du Temps Perdu, rendered in English, is both ‘in search of lost time’ and ‘remembrance of things past’. Its theme is shown by his story of the evocation of the sensuous smell and taste of a madeleine biscuit, dipped in a tisane long ago, with all it came to mean.

Certain foods and drinks have such power. Recently I woke to the aroma of coffee filtering in the kitchen below. Eyes still closed, I saw the great wheel of the coffee roaster in the window of a café in Tunbridge Wells in Kent, long ago. When I was a little boy aged 3 to 5, walked along the Pantiles, I first scented the heating beans, and then looked in the window and saw them revolving and darkening, but was never allowed to enter that grown-up place. So – suddenly I realise – this is why I bought a great big old iron coffee grinder, with its screw to adjust from grains to powder, its wooden handle and drawer, in Les Puces de Saint-Ouen a quarter of a century later, during an intense romantic Parisian interlude. I had entered the space that had fascinated me so long before. In the spirit of research, I report that the smell of instant coffee has never had any such effect.

‘Health’ also means mental, emotional and spiritual well-being. There is more to food than nutrients. It’s time for this journal to broaden its horizons. Even so, if you met your own first true young love in McDonald’s, would your eyes brim with nostalgia as half a century later you sunk your gums into a cheeseburger? Somehow I doubt it.

Ecology. Recycling. Capitalism. Soil fertility

Karl Marx, and bird poo

Street cries are also evocative. Aged 7 to 11, moved to Finsbury Park in London, some days I could tell the time by the rag-and-bone man as he passed by, the iron-clad wheels of his horse-driven cart crunching on the road. ‘Ra-agboneanlumbeeeR! Raaa-agboneanlumbeerR!!’ His spirit lives on, for I can mimic him exactly, and I am telling this tale.

Bones? What bones? In those days of butchers’ shops, families prepared and devoured legs of lamb and joints of beef, first as ‘Sunday roasts’. Our neighbourhood recycler would gain a fair haul from any street usually later in the week, after the remaining meat had been cut away from the bone for daily successive cold cuts and then sandwiches with pickles, then stew, then shepherd’s pie, and the bones smashed and rendered for soups and stock. And why were the bones scavenged? To be boiled into glue.

They were also crushed into bone-meal, to be spread on allotments. As advocates of ‘deep’ recycling point out⁽¹⁾, bones – and bodies – help to keep soil fertile. This naturally brings me to Karl Marx, whose philosophy, in these dark days, is being reconsidered. Marx admired Justus von Liebig, the great German chemist who was also an inventor of modern nutrition science. In 1862 von Liebig denounced the ‘high farming’ that had become very profitable practice in Britain. This initial industrial agriculture was made possible by importation of bones, to a value that increased twenty-fold between 1823 and 1837. He wrote⁽Reference von Liebig²⁾: ‘Great Britain deprives all countries of the conditions of their fertility. It has raked up the battlefields of Leipzig, Waterloo, and the Crimea; it has consumed the bones of many generations accumulated in the catacombs of Sicily…. Like a vampire it hangs on the breast of Europe, and even the world, sucking its life-blood’.

Europe was relatively peaceful between 1815 and 1870. So, after supplies of skeletons on the battlefields and in the charnel-houses of Europe dwindled, the significance of the colossal mounds of bird droppings deposited on the islands off the shore of Peru for countless millennia was recognised. From 1841 to 1847 imports of this guano to Britain increased from an annual 1700 to 220 000 tons. When the poo mines were exhausted, the next resource was Chilean nitrates, whose exploitation to fertilise the soil of Britain and the USA is another remarkable story⁽Reference Foster^3, Reference Galeano⁴⁾.

Reflecting on this, and with reference to von Liebig’s work, Marx wrote⁽Reference Marx⁵⁾: ‘All progress in capitalist agriculture is a progress in the art, not only of robbing the worker, but of robbing the soil; all progress in increasing the fertility of the soil for a given time is a progress towards ruining the long-term sources of that fertility…. Capitalist production… simultaneously undermines the original sources of all wealth – the soil and the worker’. So there we have it: Karl Marx was one of the first great modern ecologists. The rag-and-bone man who so long ago trundled down Wilberforce Road N4, commemorated by his cry in my mind, was – no doubt unconsciously – a follower of Karl Marx.

Philosophy and practice of public health

States of revolution

Context! Always, context! At times of trial, in order to know where we are, why and what to do, we need to know about other such times and how they can guide us. We need to understand the nature, as well as the subject, of crisis. Here now are reflections on the five-day 12th Triennial World Public Health Congress. It ended on May Day. That day in Istanbul, armoured military police faced rioters protesting against lower wages and higher prices – in particular of food. We delegates got a whiff, as tear-gas wafted into the Hilton Hotel conference centre.

Trying times

Ideas! Always, ideas! One resonant time in history is late 1776. After the initial inspiration of the Declaration of Independence, the colonial rebels became divided, confused and demoralised, and faced defeat, humiliation and ruin at the hands of the tyrannical, rapacious and avaricious English and their German mercenaries.

Then came Thomas Paine, the man who envisioned and named ‘The United States of America’. One December day, after camping with George Washington’s shivering, underpaid, starving, ragged army, most of whom must have anticipated annihilation, he walked 35 miles to Philadelphia and wrote The American Crisis. This begins: ‘These are the times that try men’s souls’. On 23 December General Washington ordered his officers to read out the whole tract to all his army, squad by squad, who then at Christmas crossed over the Delaware river in a blizzard and won their first complete victory at Trenton. The tide had not turned, but it would. As Paine had already envisioned in Common Sense: ‘We have it in our power to begin the world over again’⁽Reference Nelson¹⁾.

The lessons? What we expect to happen tends to happen. In adversity, what’s essential is a shared sense of vision, mission and purpose, and ideas that flow into actions, together with solidarity and perseverance. Then comes good luck.

Positive waves

What most impressed me at the Istanbul congress was not the presence of transnational industries, resented elsewhere in this journal⁽Reference Bodini, Martino, McCoy, Kozorgmehr, Nascimento, Giugliani and Jassat²⁾, which was minor compared with what nutrition congress veterans experience. What was most palpable were positive waves: the common feeling of the 2000 or so delegates from over 100 countries, increasingly focused as the congress progressed, that we are now living in a new age. The congress became a parliament, a unique time to meet and to agree ideas meant as the basis for grand actions.

People who work in public health are often administrators, academics or physicians, and they are practically all activists. The reasons behind the tear-gas are one reason. Another immediate reason for the mood of the congress was the outbreak of swine flu, global headline news that week, which stopped WHO Director-General Margaret Chan personally delivering her keynote oration⁽Reference Chan³⁾.

A further reason was what Dr Chan said. Her text had a force and bite unimaginable before the collapse of confidence in the US banking system or the accession of Barack Obama to the US presidency, with all such momentous events signify. She was ready. She said: ‘Collectively, we have failed to give the systems that govern international relations a moral dimension…. In far too many cases, economic growth has been pursued… as the be-all, end-all, cure-for-all…. The rising tide of globalisation has not lifted all boats. Instead, wealth has come in waves that lift the big boats and swamp or sink many smaller ones’.

Then she perceived the opportunity. ‘The market does not solve social problems. Public health does…. We are hearing clear calls, from leaders all round the world, to give [international] systems a moral dimension and to invest them with social values – like equity, sustainability, community, and social justice’.

The Istanbul Declaration

The congress was masterminded by the World Federation of Public Health Associations (WHPHA), representing seventy national and regional associations with 200 000 members worldwide, and by its Turkish hosts. The Federation was prepared. Its executive board was already committed to an Istanbul Declaration, designed to state the nature, vision and purpose of public health.

As the congress progressed, the Declaration drafting group realised that a standard statement about the importance of public health as a discipline and profession would not do. Successive drafts became more radical. The preamble to the fourteenth and finally agreed draft⁽⁴⁾, declared and affirmed by and on behalf of all the delegates, begins as follows:

‘Now is the time to make a new commitment to the health of populations…. Protection of public health is a first responsibility of governments at all levels, especially including heads of state and prime ministers. This implies… a new understanding of public health as the first public good, needing adequate and therefore increased human, financial, and other material resources.

‘The years 2008 and 2009 so far, have been times of unprecedented and momentous social, economic, and political events. These have included linked food, fuel and financial crises. All this has occurred in the context of human-made global climate change, depletion of non-renewable sources of energy and of water, actual and potential extinction of innumerable habitats and species, and deterioration of soil, water and air quality.

‘These phenomena demonstrate massive structural failures in policies and systems…. Unemployment and poverty are increasing. Nearly one billion people are hungry, living in fear of starvation…. Senseless wars and conflicts are causing death, disaster and misery in many parts of the world…. This is a time of intense disturbance. We are now living in a new world, of unique challenge and also unique opportunity…. The challenges we now face are as great as those that faced public health pioneers of the 19th and early 20th centuries’.

So what to do? ‘Now is the time for all who affect the lives of others, working in government, industry, and in civil society, and as health care workers, academics, community and faith-based leaders, and citizens, to affirm the fundamental and elemental importance of public goods, including public health, and to assert and practice the basic human values of solidarity, sustainability, morality, justice, equity, fairness and tolerance’.

The Declaration was read out, acclaimed and adopted at the final session of the congress. Later in May, Federation President Paulo Buss presented it at the WHO World Health Assembly in Geneva. The preamble is followed by sixteen principles. Here are seven directly relevant to public health nutrition:

• • Good health and well-being are necessary conditions for personal, family, community, national and global social, economic, and cultural development.

• • The determinants of personal and population health are social, economic, political and environmental, as well as behavioural and biological.

• • Elemental needs for the world of which humans are a part, are for light and heat, and for clean air and water, fertile earth, and adequate nourishing food.

• • Fundamental human needs include safe shelter, nurturing parents, supportive communities, primary schooling, rewarding work, and peaceful societies.

• • The protection of public goods, including public health, is the prime duty and responsibility of all those responsible for governance at all levels.

• • Equal rights for all, and implementation of all components of the rule of law, are essential to encourage, protect and improve public health.

• • The globalisation of migration, transport, trade and communications implies that public health cannot be addressed in isolation or only at national level.

Concrete progress

Principles are inevitably general. The Istanbul Declaration then states how they will be made concrete bases for action. ‘Participants at the Congress now commit their associations, and themselves professionally and personally, to advocate this Declaration. They will act to ensure that its principles and its goals will now be appropriately quantified and steadily translated into rational public policies and effective actions, in their own regions and countries, and worldwide’.

How? National public health associations are invited to review, monitor, progress and achieve the Declaration’s principles and goals, in partnerships with other actors at all levels from global to local. The Federation itself will monitor and evaluate progress. The Declaration will be reviewed annually, and at the 13th WFPHA Congress being held in Addis Ababa in May 2012.

Courage! Always, courage! The global crisis caused by the collapse of international systems which, as Margaret Chan said in her keynote address, have so often been driven by greed, shows us a new road. As she stated: ‘According to many experts, the financial crisis is a watershed event. They foresee transformational changes as the world rethinks how it works’. Exactly. We now have the opportunity to succeed when we insist on collective action for the common good, as eventually did the great public health pioneers of the early 19th century. The task before us is indeed as colossal as that which, at first in Europe, gradually made water supplies safe, made cities generally healthier, and reduced rates of infectious diseases. It is time to begin over again.

Mythology

More uses for an apple

A couple of columns ago⁽Reference Cannon¹⁾ I deplored the tendency of organisations concerned with nutrition to use as their symbol either an ear of wheat or an apple. Neither naturally grows in lowland tropical regions, and both are over-promoted above other equally if not more nourishing grains and fruits.

At the Istanbul conference, browsing at the Oxford University Press stall, what do I find? The new book on food policy by Tim Lang and his colleagues from City University, London⁽Reference Lang, Barling and Caraher²⁾. Its cover illustration is… yes, a lovely illustration by Liz Castledine of… that classic English apple, a Worcester Permain.

Then I wandered upstairs and found that the Turkish Public Health Association has got in on the act. Its brochure includes a snap of its president, the estimable and hospitable Hikmet Pekcan, shaking hands with Kofi Annan. The cover is dominated by a global hemisphere more or less centred on Anatolia, shaped as a fluorescent green Golden Delicious, attractive to the trade because it stays firm and juicy after being transported halfway round the world. On the cover, its indented core, tucked under the Cape of Good Hope, subtly suggests the delights of the seraglio. This one may run and run! Let me know when you find more examples of health in general, and nutrition in particular, symbolised by an ear of wheat or by an apple.

The ecology of food

How many miles?

Colleagues in publishing tell me that the vogue for small books telling stories of one foodstuff such as sugar, salt, coffee, olive oil, chocolate, following Mark Kurlansky’s masterly history of cod⁽Reference Kurlansky¹⁾, is now ended. With Fresh ⁽Reference Freidberg²⁾, Susanne Freidberg may have started a new fashion, for chronicles on what’s done – or not done – to food.

Fresh is full of piquant stories. Thus in the 1930s the New York restaurant chain Schraffts boasted about the food miles travelled by its dishes on its menus. ‘The fresh oranges, grapefruit, and strawberries in its fruit cocktail had cumulatively covered 7,800 miles… while the makings of a vegetable salad altogether racked up 22,250 miles’. Let it be recorded that the cover picture is of a bathing beauty holding and gazing at – an orange.

One of the many virtues of the City University food policy book⁽Reference Lang, Barling and Caraher³⁾ is a series of clever tables showing how food systems, and experience of and attitudes to food and nutrition, continue to transmute – food miles being an example. Thus, ‘old’ food poverty is characterised by lack of food, water and thinness, ‘new’ food poverty by too much processed food, carbonated drinks and obesity. The core concept for what the authors call ‘life science nutrition’ is individuality; for ‘social nutrition’ sociability; and for ‘eco-nutrition’ biodiversity. In 1900, 39 % of people in the USA lived on farms; in 1930, 25 %; in 1970, 5 % cent, and in 2000–1, 1 %.

Tim Lang and his co-authors David Barling and Martin Caraher demonstrate that anybody who imagines that public education and information programmes will of themselves encourage healthy consumption, is deluded. They estimate that the total annual global food and drink advertising spend around 2005, virtually all for processed products, was about $US 400 billion. Let’s hope City University puts all such nuggets on to a continually updated website.