There is festive spirit here, though only the first item relates to Yuletide. I mostly report on the fun and frolic of the 1st World Congress on Public Health Nutrition held in September in Barcelona and, as we bureaucrats say, points arising. But first, here are some reflections on booze.
Cigarettes and whisky
When I worked with Denise Coitinho at the Ministry of Health in Brasília in the early noughties, our food-and-watering hole was Carpe Diem in the Asa Sul, where the bolinhas de bacalhau are fragrant. At other tables a ritual was enacted. When three or more men were gathered to engage in conspiratsias (Brasília being stuffed with politicians, civil servants and lobbyists), the waiter served them with glasses and a bottle of whisky. Never cachaça, the national booze made from sugar-cane, and not any national or pirated hootch, but imported Scotch or occasionally US or Irish whisk(e)y. In Brazil, middle-class men choose their label of rot-gut as they do a brand of automobile. You want to impress a client, you frequent a bar or restaurant where they stock 12-year-old single malt and better, where the waiter serves your choice without asking you. That's class.
I had never seen this before. Beer and wine come to table by the can or bottle the world over. But booze by the bottle? Wow! Fascinated, I would glance over an hour or two later and as often as not a second bottle of whisky was on the table.
At the time I thought I was witnessing Brazilian machistic culture, evidenced in other Latin countries by practices described and followed by Ernest Hemingway, such as contests in which increasingly fiery peppers are eaten until the loser bursts into flame. Well, there is that aspect. But only now do I fully understand. I am looking at the pre-Christmas offers in the 32-page promotion of Carrefour, the French-owned retail chain enormous in Brazil. After spreads devoted to baby foods, biscuits, processed meats and ready-to-heat products, there is a spread for alcohol.
Imported and branded rum, vodka and whisky cost $US 6–8 a litre, around the price of a big packet of bon-bons or a couple of pre-prepared pizzas. The average consumption of alcoholic drinks in Brazil is roughly the same as in the UK, but this damnable statistic disguises the fact that most Brazilians drink little or no alcohol. The sizeable minority of regular drinkers tend to hit the bottle especially at weekends. Is this connected with the lack of tax on booze in Brazil? And is this in turn connected with the 40 000 road deaths and 40 000 homicides a year in Brazil? Do bears shit in the woods?
Will President Lula tax alcoholic drinks, or hike the tax on cigarettes? Judging by his record as a populist who claims that his soul belongs with the people, who believes in comforts for the poor, and who also flaunts his cast-iron guts, this seems not likely.
Congresses and parties
Barrie Margetts, Editor-in-Chief of this journal from its beginning until this issue, celebrates the 1st World Congress on Public Health Nutrition in Barcelona in September in his valedictory editorialReference Margetts1. So do I, although for somewhat different reasons; for Barrie valiantly sees the best side of things, people and institutions.
The term ‘congress’ is apt. At any big international conference, plenary sessions can expect to bag no more than half of the delegates. Why, is that the other half combine and permute elsewhere in the building or another agreeable nearby location, meeting, planning and plotting – a plot being any plan that may include mischief or even gaiety. Do people come to conferences to listen and learn from the presentations? Up to a point, though the material in most talks is accessed more coherently and conveniently by googling. But in general, congresses are for the craik. They are like vast parties which – if you are invited – are free, at which you meet your confederates, develop your assaults on grant-giving bodies, schmooze the chairs of programme committees of future congresses, bump into old friends, and avoid or become reconciled with old adversaries.
Barcelona, with some other big recent congresses, reminds me of the time I met my then Queen, in the mid-1970 s. She was angling for a pay rise, and had been advised to throw a party at Buckingham Palace at which hundreds of relevant movers and shakers were invited, in the hope that they would all depart full of wine and rosy thoughts, and write editorials saying that the Royal Family were broke and were a worthy cause. One memorable moment was seeing the then Prime Minister Harold Wilson elbow-pressing the television commentator Robin Day and the television disc-jockey Jimmy Savile, both later knighted. I was curious to know what they were discussing. Since my stepmother Elise had been Harold Wilson's appointments secretary when he was a rising star decades previously, I slid into the huddle and reminded him of me. With a happy smile he did his party piece, and told me and the others the results of the school examinations I had taken 20 years previously, and the provenance of my university scholarship. Awesome! Heady stuff! No, she did not then get a rise.
Suits and votes
At Barcelona the royal equivalent was Pekka Puska. In an early evening after presentations and before the congress dinner, a bunch of us were hugger-mugger in one of the lifts at the Princess Hotel where most of the heavy-hitting delegates were lodged, and there was Pekka, radiating charisma. Wow, I said, you look like the King of Spain, what a beautiful suit – which it was; he looked like an older male model for GQ. But it wasn't the suit. As the lift ascended it was as if we were with him in his apotheosis.
Then he explained. It helps if you know his deep grave tone of voice. ‘I am a candidate to be Director-General of WHO’, he said, and he told me he was in Brasília the next week to enquire after the Latin American vote, having (so the rumour went) secured the European bloc vote. Having helped engineer his meetings with the then president of the Brazilian republic and its health minister five years previously, I was chuffed.
My guess is that Julio Frenk of Mexico will get the job, one reason being that Latin America is currently under-represented at the top of UN agencies. Alternatively the appointment will be of a current insider. But Pekka is a terrific candidate. He is the hero of the North Karelia public health policyReference Puska, Tuomilehto, Nissinen and Vartiainen2; an academic who has worked in government and with civil society organisations, as Derek Yach's deputy at WHO until they both left after the late Dr Lee became Director-General, a UN system insider; and co-architect of the WHO global strategy on diet, physical activity and health. Plus, in the phrase often used by Rainer Gross, who sadly died in the bosom his family in Germany on the last day of the Barcelona congress, Pekka is a maestro of fancy footwork.
An argument against Pekka is that the D-G before Dr Lee, Gro Harlem Brundtland, is Scandinavian. Ha! But Finns are not Scandinavian, as Pekka is no doubt pointing out as I write, in Brasília and points NEWS. Nordic yes; Scandinavian no. We walked out to the bus taking us to the gala dinner, and I pressed his elbow. Gosh, I said, can I get to know you very much better in the next 24 hours? He smiled and pressed my elbow. ‘Geoffrey, you are already a good friend’, he said. What an operator! So, a message to all the heads of state and health ministers who read ‘Out of the Box’: Vote Puska.
Pipers and tunes
During the final ceremony at Barcelona, congress president Lluis Serra-Majem announced that the second congress will be held in three years' time in Mexico City. I congratulated Juan, potentially the president of the congress; but he was not pleased, because no deal has yet been struck. Juan told me he doesn't like the relationship congresses have with industry – or, to be exact, that section of the food manufacturing industry with most to lose from genuine food and nutrition policies.
This reminded me of an experience Juan and I shared at the 2003 SLAN congress held at Acapulco. Its closing ceremony included a film showing big-shot scientists with prominent cards planted in front of them, thus: Hector Bourges DANONE, Ricardo Uauy KELLOGG, Carlos Monteiro POWERAID – and Juan Rivera BIMBO. This was a prank; neither the congress organisers nor these sponsors had remembered to inform the scientists that they were going to be positioned like racing car drivers or football stars, seeming to endorse products, and Carlos for one was infuriatedReference Cannon3.
The issue of the food giants and nutrition congresses does not go away. At one Barcelona session Eileen Kennedy – who has succeeded Irv Rosenberg as Dean of the Friedman School of Nutrition Science and Policy at Tufts University at Boston, and who can now bask in his remarkable achievements – chaired a session on ‘advancing public–private partnerships for healthy nutrition and well-being’.
Two of the speakers were the affable and canny Ian Darnton-Hill currently of UNICEF, and Maria Neira of WHO, both of whom seemed glum, and if so no surprise, given the squeeze of the testicles of the UN system exerted by the US government and other rich member state paymasters. (Remember that old saying of US diplomats, ‘Grab them by the balls and their hearts and minds will follow’?) The other four speakers were Michael Knowles, Sven Thormalen, Paulus Vorschuren and Niels Christiansen, respectively of Coca-Cola, Danone, Unilever and Nestlé, transnational firms not un-adjacent to the industrial sponsors of the congress (Cola-Cola positioned as its Beverage Institute for Health and Wellness, no doubt generous in support of bore-holes in Africa).
After the presentations, a bunch of us queued behind the central microphone in the hall and made disobliging comments. I said that those of us who formulate food and nutrition policies, whether from academia, government or civil society, must make common cause with industry. The banking and insurance industries come to mind. Personally as a compromiser I would also consider the travel and oil industries, provided support came as part of a package that enjoined them to encourage consumers to grow, buy and eat locally, and to reduce food miles and other environmentally damaging practices.
Games and rules
As for the food industry, the first step is to agree rules of engagement, as the UN System Standing Committee on Nutrition carefully guided by Roger Shrimpton is now doing4. The second step is not to engage with those sectors of the food manufacturing industry whose commercial interests are in direct conflict with public health. Three that come to mind are the 1st, 5th and 6th largest food and drink companies globally, measured by sales: Nestlé, Unilever and Coca-ColaReference Lang and Heasman5. I pointed out that formula food kills babies, most of all in parts of the world where water is unsafe; that Unilever is in the business not of championing well-being but of flogging fat; and that Coca-Coca is contributing to what is now the pandemic of childhood obesity and thus of early-life diabetes.
Niels Christiansen, who after another session forgot to mention that he is the senior public relations officer for Nestlé while presumably also qualified to present scientific papers at nutrition congresses, won the Barcelona chutzpah award. Responding to an emphatic statement made by Mercedes de Onis of WHO that Nestlé continues to flout mutually agreed codes of practice on the marketing of artificial baby foods, he said she was out of date or mistaken, and offered to put her right. Niels, do please submit your reply to this journal.
Incidentally, in a presentation made at Acapulco, Maxime Buyckx – once an under-strapper of John Lupien in the nutrition division of FAO, then later of Coca-Cola, and now of the Beverage Institute for Heath and Wellness – explained that Coca-Cola's policy is not to promote its products to children under the age of 12. Very responsible, I thought – I didn't know that. On the way back to the airport I passed a fairground whose entrance was plastered with advertisements for Coca-Cola. Perhaps these flyers were posted by cowboys, against the will of the local bottlers. Perhaps Coca-Cola issues parents with guidance on keeping their products away from pre-teens, or tells them to blindfold their children when about to enjoy all the fun of the fair. But I mention this policy in the interests of even-handed commentary.
Coke and water
Maxime also presented at Barcelona; he led off a symposium on ‘the contribution of non-alcoholic beverages to hydration, nutrition and public health’. I did not attend, but I have a feeling he may have indicated that soft drinks save lives, which indeed they may do when the alternative is to drink contaminated water. Somebody told me that Coca-Cola is now the biggest bottled water company in the world. Or is it Nestlé? This should relieve the governments of sub-Saharan Africa from the tedious duty of supplying safe sewage systems to the citizenry. Let them drink Perrier!
After the session chaired by Eileen Kennedy, I then made the no-brainer point that of course bodies concerned with food and nutrition policy and practice should engage with the food and drink industries that have non-conflicting commercial interests, with provisos. First, the rules of engagement must be transparent, accountable and demonstrably in the interests of public health. Second, the engagement must be with industry as a whole, including representatives of producers, distributors, retailers and caterers as well as manufacturers, small and local as well as vast and transnational. Third, the industry representatives must be independently chosen and not self-selected whether or not as a result of a sponsorship deal. Then we would be in business.
Eileen seemed to like this proposal. But I have news: I no longer believe that big nutrition congresses need money from the food and drink industry. The solution proposed by Michael Latham and others of the hair-shirt tendency is to hold congresses at universities or churches, and have the delegates sleep in dormitories and tents. This worthy proposal will not fly: I can't see Pekka Puska's campaign to take over WHO taking in a session under canvas.
But! The most relevant recent information, as confirmed by Durban ICN president Esté Vorster, is that the surplus made by that congress last year was more than the income given by industry sponsors. The implication, bearing in mind the arduous task needed to hold the event in Africa, is that nutrition congresses do not need industry money.
Genes and obesity
Michael Gibney, the Irish inheritor of Justus Liebig's genius at turning unconsidered trifles into valuable commodities, was billed to speak at the first full plenary at Barcelona on ‘how can public health nutritionists arrest the diabesity epidemic’. He gave a bravura blarney with a tangential relevance to public health, on the vital and (he said) strangely neglected part genetics plays in obesity. From the floor, Ricardo Uauy pointed out the lack of evidence basis for the proposition that the human genome has suddenly transformed. Mike said he still thought genetics was neglected, so there. Neglected? Tell that to Craig Venter!
The contrarian view on obesity was well in evidence at Barcelona. Paul Campos, of the School of Law at the University of Colorado at Boulder, made a rhetorically excellent speech proposing that inasmuch as overweight and obesity were terms suggesting a tendency to disease, these conditions do not exist. In 50 years' time, he averred, people will look back at the days when obesity was thought to be pathogenic with the amused contempt we feel for phrenology.
Hello… this sounded familiar… A few weeks before Barcelona, the ineffable Gina Kolata – the staffer who now has an armlock on the health (that is, disease) coverage of The New York Times Reference Yvgve, Hambraeus, Lissner, Serra Majem, Vaz de Almeida and Berg6 – published a massive feature whose basic proposition was that being overweight and obese is good for healthReference Kolata7. That isn't quite how she put it: the word she used was ‘stocky’ – her epithet for Don Leroy Hotchkiss of Las Vegas, who at 6 foot and 280 pounds has a BMI of 38 and, as shown in a photograph used in the feature, a basketball gut. In a US Civil War re-enactment, he couldn't get into the tent. ‘In the last 145 years, we've ballooned up’, he said. Indeed.
In support of her case that the bigger the healthier, Gina Kolata cited the remarkable research of Robert Fogel, the Nobel economics prize-winner, who has carried out a meticulous comparison of US Civil War soldiers and US citizens todayReference Fogel8. This work shows that in the mid-19th century in the USA, soldiers – many sons and grandsons of impoverished European immigrants – were puny, often diseased and in general unlikely to live past 60.
Robert Fogel also proposes that, in the USA, being lean is not the best way to avoid premature disease and death, and suggests an optimum BMI of around 25, three points above the current consensus. But 38? No way. So, where are Gina Kolata and Paul Campos coming from? A clue is Gina Kolata's account of the good life enjoyed by Craig and Sandy Keller of Hamilton, Ohio, who ‘had all the advantages of middle-class Americans of their age: childhood vaccines, plenty of food, antibiotics when they fell ill’. Oh, and also ‘their strong faith’. So here we have it: shots, feasts and pills, fortified by prayer. Anticipate synergistic mergers within the food and drug industries.
Culture and cuisine
Change of subject. Towards the end of the 13th century CE at the time of the Mongol emperor Qubilai Qan (Kubla Khan), the city of Hangzhou in Zhejiang province, China, was characterised by Marco Polo as ‘the finest and noblest in the world’.
The Chinese natural philosophers in that time and in previous millennia did not distinguish between food and medicine, and their scholarship included celebrations of cuisine and compilation of cookbooks, many of which have survived. Their servants by day shopped in markets that sold fish, meat, poultry, vegetables, fruits, fungi and herbs in wonderful variety and abundance, and by night they dined out with their families in restaurants first established in HangzhouReference Erlich9. This was almost half a millennium before Francisco Procopio dei Coltelli founded what is now the Procope in the Rue de l'Ancienne-Comédie in Paris, at first as a salon de café, only later a restaurantReference Toussaint-Samat10.
The people of Zhejiang remain famous for their good health and long lives, and their diets now, which are still mostly traditional, meet the current WHO recommendations for dietary constituents and for vegetables and fruitsReference Li and Premier11, Reference MacLennan and Zheng12. In October, just after I write this column, I am invited by Duo Li and Mark Wahlqvist to present at the 5th Asia-Pacific International Symposium on Clinical Nutrition in Hangzhou.
Happy New Year
I trust this column is being enjoyed by a regular reader, the Sage of Hillgate Street; for John Waterlow has let it be known that what he wants is not relentlessly referenced disquisition but hot poop from congresses he does not attend. And indeed, the original brief for ‘Out of the Box’ is that it should mix news, reviews, interviews, satire and humour, with other more serious items. Fair enough.
Does this imply that the column will continue? I hear that a couple of readers, not un-adjacent to the food industry, have suggested that Enough is Enough of my rancid ravings and rantings, that it is Time for a Change, and that Other Voices Should be Heard. Indeed they should, and the editorial in this issue asks for more debate in the letters and other sections. As from the next issue, January 2007, when this journal becomes monthly in response to the burgeoning submissions of original papers, Agneta Yngve succeeds Barrie Margetts as Editor-in-Chief. What will she decide? What has she decided? Vale !
