The biggest picture

High-flown ideas? Well, put up your hand if you feel the world is basically unchanged since the collapse of Lehman Bothers, the collapse and nationalisation of the American International Group, the US Congress resisting the pleas of President Bush II to increase the US national debt by close on a trillion dollars to prop up the masters of the universe, and the other events you know about that have taken place after this column is written and before it is published.

Or, do you think that the election of a new President of the USA, and later a new UK Prime Minister, will ensure that the world’s finances will became stable and secure, and will enable a natural process by which the many millions of communities who now live in poverty or misery will gradually prosper? Do you?

It has felt right to raise these issues at meetings in which I have participated in Brazil, the USA, the UK and Sweden, since the events of 15 September. Nobody has yet put up their hand. This surely means that we need to think much harder, and in unison. It is most unlikely that any current major public health policy or programme will – or should – remain unaffected.

We talk and write about ending poverty and hunger, and about education for all children, child and maternal good health, social equity and environmental sustainability, by the year 2015. But we might as well be discussing Kung Fu Panda. Do you still believe that programmes of distribution of goods and money administered by the masters of the global markets now presiding in the World Bank, the International Monetary Fund, the US Treasury and the overseas development agencies of what currently are the world’s most economically rich nations, working with Sir Bill, Sir Bob, Bono, American Express and the food and drink manufacturing industry, will fulfil the UN Millennium Development Goals⁽¹⁾, with their slogan ‘End poverty 2015. Make it happen’? No, you don’t, do you?

Awesome capacity in the South

So what can we do? A good time to think about this was the 18th World Congress of Epidemiology, held conjointly with the 7th Brazilian Congress of Epidemiology, in Porto Alegre between 20 and 24 September. Over 7000 people registered – more than twice the number expected by the admirable Álvaro Matida and his colleagues from ABRASCO (the Brazilian Public Health Association) in Rio de Janeiro and from the International Epidemiological Association and the University of Rio Grande do Sul. Part of the task of this column is to report on and appraise public occasions. The Porto Alegre congress gets ♥♥♥♥♥.

The final and fifth ♥, never awarded before, is because the congress was not supported financially or as far as I know in any other way by industry or any body whose interests conflict with those of public health. In my quarter of a century of attending and speaking at conferences, that’s a first. Revenue, apart from registration fees, came from the Brazilian government and its agencies at federal, state and municipal level, from national and local tourism agencies, from public and private universities, and from the UN Educational, Scientific and Cultural Organization (UNESCO) and the Pan American Health Organization (PAHO). In Brazil the state supports professional conferences as opportunities to develop the capacity especially of young people who are future leaders. In the USA and the UK this responsibility is usurped by Coca-Cola, Nestlé, Unilever, Danone, Kellogg’s and McDonald’s, who also offer employment opportunities to young graduates.

Social justice for all

A main theme of the Porto Alegre congress was the social, economic and environmental causes of disease, health and well-being. Riding the waves created by the Wall Street crashes, Michael Marmot, chair of the UN Commission on Social Determinants of Health, presented the commission’s remarkably outspoken findings^(2, Reference Davey-Smith and Krieger³⁾.

Nancy Krieger of the Harvard School of Public Health, George Kaplan of the University of Michigan, and Moyses Szklo of the Bloomberg School of Public Health, gave impressive and heartfelt major presentations on the deep causes of population health and the implications for public policy⁽Reference Krieger⁴⁾. Moyses Szklo ended his session with a quote from George Willis Comstock, a mentor at Johns Hopkins who died last year: ‘If not applied to prevention and public health, epidemiology tends to be fairly boring’.

Even more impressive was the evident vast strength and depth of the Brazilian public health profession, manifested by Paulo Buss, President of the Oswaldo Cruz Foundation (Fiocruz) for eight years. He is also this year’s President of the World Federation of Public Health Associations (WFPHA) whose 12th World Congress is being held in Istanbul between 27 April and 1 May 2009 (www.worldpublichealth2009.org). Fiocruz, founded in 1918 and based in a Moorish-style palace between the city of Rio de Janeiro and its international airport, formally an arm of the federal Ministry of Health, is responsible for advising ministers of successive national governments on public health policies and priorities. Its scale, scope, and combination of official status with remarkable autonomy, make it one of the most puissant public health institutions in the world. (‘One of’ is to be cautious – if knowledgeable readers know of a more potent institute, let’s hear.) True, there is a great deal of work for public health professionals to do in Brazil, especially those concerned with inequity.

Paulo Buss and his colleague Maria do Carmo Leal made sure that the Brazilian full-scale report on social inequities, commissioned by the President of the Republic as an extension of the global Commission’s work, was published and on sale at the congress⁽⁵⁾. He also masterminded a meeting at which José Temporão the federal health minister presided, joined by the health ministers and representatives of all the world’s Portuguese-speaking countries, including Portugal itself. This was not a mere show. The pledge from the platform is that the Lusophone world is an independent bloc, capable with shared capacities to look after itself in the world. Given the state of Angola and Mozambique and especially East Timor, after the comparatively recent burden of an oppressive colonialism, followed by civil war and other atrocities, this was a remarkable commitment, which will be monitored. A week later José Temporão was designated President of the governing council of the PAHO.

Order, progress, love and money

As you might expect, there was a lot of discussion in Porto Alegre – at lunch and dinner and other social occasions – about the news from the USA. My own presentation on public health was developed from the Hyderabad conference on which I reported last month, on the theme of ‘the South is taking the lead’, as it must. Take Brazil. Google the background economic facts that eventually drive politics and shape societies. Brazil is now a creditor nation – a staggering and cross-party achievement of the previous and current presidential period. The US national debt at the time of the Congress stood at $US 9 700 000 000 000 – 9·7 trillion dollars – of which over 1 trillion was owed to Japan and China and $US 149·5 billion to Brazil. Ten days later, on 1 October, the debt had risen to over $US 10 trillion. In February 2003 the exchange rate was $US 1 to 3·59 reais (the Brazilian currency). In September 2008 the value of the $US was more than halved, to 1·59 reais.

In my and your lifetime there will not be an attempt by any other nation to supplant the USA as the world’s dominant power – not, at least, in the way successive US governments have chosen to use their power. Instead, it is now time that nations with capacity in Asia, Africa and Latin America realise their independence, in support of one another.

A real new world order is taking shape, and we who work in public health must find our way within it. This might have seemed to be a fantasy even last year. After the events of this September and October, new realities are encouraging the strong nations of the South to stand tall. In Porto Alegre this was evident, in the intensive discussions in and out of sessions. Alas though, woe betide countries who have privatised their public health systems, or who have been forced to do so.

More praise for famous men

Now for something different, yet not. ‘Come and see me after I retire. I’ll be able to tell you more then’, Douglas Black said to me in early 1983. Having been the first Chief Scientist at the UK government’s Department of Health and Social Security (DHSS), he had become President of the Royal College of Physicians of London and prime mover of two reports that remain influential, one on dietary fibre⁽⁶⁾ and the other on obesity⁽⁷⁾.

These both took a more progressive line than anything produced by what wags called the Department of Stealth and Total Obscurity. Thanks to Francis Avery Jones, Ken Heaton, Richard Doll, Jerry Morris and David Southgate, the dietary fibre report emphasised the value of wholegrain bread and other foods high in fibre. Thanks above all to the indefatigable Phil James, who also served on the dietary fibre report, the obesity report among other things took a swipe at added sugar, saying that it ‘is an unnecessary source of energy in a community with such a widespread problem of overweight’ and recommended ‘a halving of the national average consumption of sugar’.

In Britain a quarter of a century ago this was incendiary stuff. Sir Douglas was in a position to know why the DHSS produced reports from its own Committee on Medical Aspects of Food Policy (COMA) that recommended a balanced diet and moderation in all things, and that a little of what you fancy does you good. I was at the time on the trail of a big news story, the topic of which was made into a book the next year⁽Reference Cannon^8, Reference Walker and Cannon⁹⁾, and I was becoming aware of what were known as ‘close ties’ between people in government, industry and science, who served on the aptly acronymed COMA committee.

Obviously Sir Douglas knew where the bodies were buried, and… He smiled and asked me to wait a while. He did say though: ‘My view has always been that if a food is advertised, there must be something wrong with it’. This sounds best in his Shetland accent. Foolishly I never took up his offer to shoot me the works. It would have been a good book.

Blindness and short sight

Twenty years later, in 2003, Sir Douglas’s words were echoed. This time I was in Chennai, for the annual meeting of the United Nations System Standing Committee on Nutrition (UN SCN). The then head of the Gates Foundation GAIN (Global Alliance for Improved Nutrition) public–private partnership had been invited to address us on the topic of vitamin A deficiency. He explained that food fortified with synthetic retinol such as ‘golden rice’, manufactured and distributed as a result of the largesse of Sir Bill, had the potential to cure xerophthalmia. This, he averred, with reference to current WHO and Asian Development Bank reports^(10, Reference Allen and Gillespie¹¹⁾, would prevent most cases of child blindness and also save the lives of up to a million children a year. Allelujah! The chairman of the session, a senior WHO executive, thanked the speaker for the address and indicated that there was no time for questions.

Pandemonium! One function of the UN SCN was – and is – to discuss unresolved and contentious public health issues, and not to be told what to think and do. Some of us in the room believed that estimates of vitamin A deficiency were – and are – exaggerated, perhaps grossly⁽Reference Cannon¹²⁾. The evidence that supplementation with synthetic retinol is an intervention whose value is comparable with the initiatives that eradicated smallpox is shaky, to say the least.

Indeed, the biggest intervention trial of all time in Uttar Pradesh, carried out between 1999 and 2004 and involving over a million children, shows there is no significant difference in death rates between children who receive massive doses of retinol and those who do not. Remarkably (or unsurprisingly, depending on your point of view) the results of this study have still not been published⁽Reference Mudur^{13, 14)}. Evidence that golden rice, in the amounts that children might plausibly consume, would make a real difference in vitamin A status were – and are – sketchy. Dr C. Gopalan, President of the Nutrition Foundation of India, believes that supplementation interventions are risky distractions, and that what is needed is investment in sustainable rural livelihoods and revival of horticulture⁽Reference Gopalan^15, Reference Gopalan¹⁶⁾. That is to say, all things considered, giving pre-eminence to retinol supplementation may do more harm than good.

In Chennai, what infuriated Arne Oshaug, then as now chair of the UN SCN bilaterals group, was what seemed to him the insolence and arrogance of being told there would be no questions. He contradicted the chair of the session, saying that there would indeed be discussion, in the presence or absence of the people on the platform. And so there was. He was followed by David Sanders of the University of the West Cape in South Africa, who doubted the value of externally imposed interventions running side by side with ‘structural adjustment’ programmes imposed by external creditors, that turn poverty into misery in many African and Asian countries.

Emboldened by this rhetoric, I asked for the microphone and roved the room, and ended my peroration by asking if we now lived in a world where the bread was fortified and the circuses were the mass deaths of Iraqi children as seen (or rather, not seen) on Fox TV. After the session had ended, and a fist-fight averted by a big strong nutritionist interposing himself between me and an eminent US scientist, I was approached by Tom Marchione. ‘That was very strong’, he said. Indeed. Sometimes extempore interventions in the arena of conferences lead to unexpected conclusions, as the brain leads thought, and I also was surprised by what I had said. ‘Am I wrong?’ I asked Tom. He reflected for a while, and then said ‘No’.

This astonished me, because Tom then worked for the US Agency for International Development (USAID), seen in recipient countries to be another way for the USA to dump its food surpluses and to do its neo-colonialist business⁽Reference George¹⁷⁾. And so, once again, the Douglas Black moment. After some intrigued enquiries Tom smiled, saying ‘I am retiring soon. Talk to me then’. But I did not; and now, to the sorrow of many colleagues who knew him altogether better than me to be a person of exceptional integrity and courage, Tom is dead, which is why I call tell this story now.

The way to immortality

After Tom died in September, the draft of his last paper⁽¹⁸⁾ was circulated to friends and colleagues. It indicates the fundamental reasons for the rapid rise in the prices of staple foods. In the South, indebted nations have been pushed to forget about family farming in the name of the law of comparative advantage, which decrees that subsidised imports from capitalised agriculture is a more rational choice than community-grown food and obliges farmers to concentrate on cash cropping for export. Tom says: ‘To treat food as if it were a commodity no different from gold or oil – with no inherent human value, subject to the whims of global traders and commodity fund speculators with only peripheral interest in humans’ needs – is a recipe for food price shock in poor households’.

Most people die and become forgotten except to their families. Some people, after they die, live on. Douglas Black and Tom Marchione are two such people. They retired from struggling with work that necessarily made them reticent, but they never retired from service to public health, and their work lives on.

Happy New Year.