IJE Advance Access originally published online on December 8, 2005
International Journal of Epidemiology 2006 35(1):74-76; doi:10.1093/ije/dyi257
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Commentary |
Commentary: Obesity—public health crisis, moral panic or a human rights issue?
1 Childhood Obesity Programme of the International Obesity TaskForce, London, UK
2 SPRU—Science and Technology Policy Research, University of Sussex, UK
E-mail: childhood{at}iotf.org
In responding to the paper from Paul Campos et al.1 I shall make the assumption that other respondents will review the accumulating statistical evidence that has justified the rising pressure for public health interventions, and instead look at the implications of their position when it comes to policy selection.
A ‘crisis’ is a point in time marking a decisive turning point, or a critical period when there is an urgent need for a change of policy. Campos et al. ask whether there is sufficient reason to treat the rising levels of overweight being noted in the populations of many countries as sufficiently alarming to trigger a change in public health policies. They propose that this is not the case and further propose that those who suggest that it is the case are acting from dubious motivations.
The usual suspects are indicted: the pharmaceutical industry with an interest in medicalizing the problem, and the weight-loss industry with products to sell. The authors could have added the food and beverage industry (including advertisers and the media) with a reputation and sales to defend, likewise the sedentary entertainment industry (TV, video games, etc.) and the transport industry (road, oil, automobile manufacture), which needs to resist moves to reduce car use and to make roads pedestrian-friendly and cycle-friendly.
Besides commercial interests, Campos et al. add the motivation of self-aggrandizement. Take, for example, their statement that the CDC (the US government-funded Centres for Disease Control and Prevention) has promoted the urgency of the crisis ‘while lobbying for greater program funding and policy setting authority’. The implication is that the CDC's concerns to contain the rise in obesity levels are motivated by self-promotion among the CDC's senior staff working in the relevant sections. Yet what is the CDC's job, if it perceives a health hazard on the horizon, if not to seek the resources and policy-setting authority needed to ensure they can properly avert a worsening of the situation?
The CDC's role, of horizon scanning and crisis prediction, raises the larger question of the nature of forecasting. In the case of obesity, the problem of accurate prediction is especially difficult because the past is not a good guide to the future. As with several other modern crises—including global warming and politically motivated violence—historical trends are not a very good guide to the rate of change, be it in obesity prevalence, sea levels, or terrorist activity. Obesity prevalence reflects the cumulative figures for individuals of varying ages in different population groups that have been exposed to many different environmental influences in their lifetimes. Children today have very different lifestyles to those of the 1930s or 1940s. Those earlier children, and the children of subsequent generations of the post-war years or the booming consumerism of the 1960s have experienced different exposure to risks and yet their life expectancies and morbidity patterns are being used to predict the health hazards being faced by today's and tomorrow's children and young adults.
Furthermore, the changing provision of health services has affected the survival rates of, for example, those with serious cardiovascular disease or chronic diabetes. Earlier diagnosis and improved treatment methods make the statistics hard to compare.
We, therefore, come to the problem of the appropriate counterfactual. It is not sufficient to compare life expectancies or disease rates among today's population with that of, say the 1970s, when obesity prevalence was lower and medical services less refined. The comparison should be between today's actual figures for morbidity or mortality and those that would pertain if obesity rates were lower. This can be a little tricky to calculate, but an estimate has been reported by the life insurers Swiss Re2 shown in Figure 1.
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The point of this digression into health assessment methodology is not to prove a statistical point but to show that the perspectives of the life insurance industry (and those that invest in the industry) can raise different and important questions, which might not otherwise get asked. And their interests, like those of the pharmaceutical, automobile, or advertising industries, are at least as legitimate in the development of public health policy as are those of the academic epidemiologist, political scientist, or lawyer. These variations in viewpoint need to be harnessed to progress policy development.
There are other, even more important constituencies. The critique that Campos et al. express—that the rising levels of obesity are being used as moral sticks with which to beat the poor, the black, or the working mother—needs to be expressed as an opportunity for change. In particular, if a belief in individual responsibility is being used to blame whole classes of victims for their own ill health, then how do these groups respond? What are the opinions of those whose voices are less often heard?
The Ottawa Charter for Health promotion states ‘Health promotion is the process of enabling people to exert control over the determinants of health and thereby improve their health’3 not only individually but through, for example, the social provision of education and economic advancement and the development of social capital to create health-supportive environments.
On this basis, obesity prevention would be seen as only one benefit from a larger social gain, including the gains made in the ability of a community or society to protect and promote its own health. Social and political empowerment becomes one of the indicators of health gain.
A follow-up meeting in Adelaide acknowledged that government plays an important role in health, but that health ‘is also influenced by corporate and business interests, nongovernmental bodies and community organizations. Their potential for preserving and promoting people's health should be encouraged. Trade unions, commerce and industry, academic associations and religious leaders have many opportunities to act in the health interests of the whole community. New alliances must be forged to provide the impetus for health action.’4
The need to involve stakeholders in the process of developing and implementing public health policies has been echoed by many organizations, including the aforementioned CDC, which noted the importance of involving stakeholders from a wide variety of interests in both the implementation and evaluation of any policy. It also noted certain caveats: ‘... Sharing power and resolving conflicts helps avoid overemphasis of values held by any specific stakeholder. Occasionally, stakeholders might be inclined to use their involvement in an evaluation to sabotage, distort, or discredit the program. Trust among stakeholders is essential; therefore, caution is required for preventing misuse of the evaluation process.’5
The challenge for policy development is to recognize the variety of stakeholder views, to acknowledge the fact that evidence and arguments will be put into the policy from various interested positions, and to find a way forward. At present, much of this process has been hidden (e.g. in the political lobbying process) and inequitable (being led by those with the deepest pockets). The principles of mature democracy and the principles for health development propounded by the Ottawa Charter demand that this process be opened up to all, in an inclusive and transparent manner.
Various forms of stakeholder opinion modelling have been developed, using interview and iterative questionnaire procedures, such as the Delphi technique for consensus building among a panel of stakeholders to reach mutually agreed judgement principles.6 Other versions have used selected juries as the stakeholder panel who first witness a debate conducted on adversarial lines and then work to reach an agreed ‘verdict’.7 A range of other consultative techniques (e.g. structured focus groups, group feedback analysis, convergent interviewing), which develop stakeholder views and form a body of qualitative methods, have been developed under the general umbrella of action-research techniques.
Other approaches have developed more quantitative approaches, which map opinions into a number of agreed dimensions, referred to as multi-criteria mapping techniques, originally developed to explore stakeholder views on genetic engineering.8 Multi-criteria mapping is a technique that provides: ‘...a systematic and transparent way of comparing policy options. It can tap into a wide range of perspectives and expertise, and produce an overview that ’maps' the debate. It has been applied, so far, to topics such as the choice of electricity supply technologies and alternative agricultural strategies, but a pan-European research team is currently applying the technique using data collected across nine member states in order to characterize the differing perceptions of key groups of stakeholders concerned with finding policy options to tackle ‘the growing challenge of obesity’.9
This methodology can form a valuable component of a broader stakeholder analysis, which also encompasses document review, questionnaire, and other assessment techniques and may fruitfully borrow from the experiences gained from Health Impact Assessment methods for evaluating non-health policies for their health effects.10
Stakeholder analysis has traditionally been a business management tool. Varvasovszky and Brugha11 have developed guidance on stakeholder analysis within the public health field, in part based on findings and experiences from a stakeholder analysis of alcohol policy in Hungary.12
The debate on obesity and the development of an appropriate policy response needs to move beyond the ‘There's a problem – No there isn't’ argument. We need to recognize that every contributor to the debate will have a position—some more vested than others, some claiming morality and some claiming science as their guide. A democratic, health-enhancing approach involves bringing this debate into the open and ensuring that those whose voices are less often heard, and least often influential in the policy debate, are properly given their rightful place. This is not a debate about moral panic: it is a debate about human rights.
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Notes |
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These organizations are not responsible for the views of the author expressed in this paper.
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References |
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 Top References |
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1 Campos P, Saguy A, Ernsberger P, Oliver E, Gaesser G. The epidemiology of overweight and obesity: public health crisis or moral panic? Int J Epidemiol 2006;35:55–60.
2 Figures from Swiss Re, cited in Hewitt R, Hebgen R, Maddock J, Vasudevan A. Insurance: Weighing up the consequences of obesity. London: Dresdner Kleinwort Wasserstein Securities Ltd, 2004.
3 World Health Organization. The Ottawa Charter for Health Promotion, Ottawa, November 21, 1986. Available at: http://www.who.int/healthpromotion/conferences/previous/ottawa/en/index.html (Accessed August 15, 2005).
4 World Health Organization. Adelaide Recommendations on Healthy Public Policy, Second International Conference on Health Promotion, Adelaide, April 5–9, 1988. Available at: http://www.who.int/healthpromotion/conferences/previous/adelaide/en/index.html (Accessed August 15, 2005).
5 Centers for Disease Control. Framework for Program Evaluation in Public Health. CDC Recommendations and Reports 1999; 48(RR11);1-40 Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr4811a1.htm (Accessed August 15, 2005).
6 Delphi Face to Face. Resource papers in Action Research (web-based documentation). Available at: http://www.scu.edu.au/schools/gcm/ar/arp/delphi.html (Accessed August 15, 2005).
7 Stevenson R. Evaluation of People's Panels and People's Juries in Social Inclusion Partnerships. Edinburgh: Scottish Executive, 2004.
8 Stirling A, Mayer S. Rethinking risk: a pilot multi-criteria mapping of a genetically modified crop in agricultural systems in the UK. SPRU Report No. 21. Brighton: University of Sussex, 1999.
9 PorGrow Research Programme. SPRU—Science and Technology Policy Research, University of Sussex, 2004–2006. Available at: http://www.sussex.ac.uk/spru/1-4-7-1-8.html (Accessed August 15, 2005).
10 National Institute for Health and Clinical Excellence. Health Impact Assessment Gateway. Available at: http://www.publichealth.nice.org.uk/page.aspx?o=HIAGateway. World Health Oragnization programme on HIA. Available at: http://www.who.int/hia/en/. (Both accessed August 15, 2005).
11 Varvasovszky Z, Brugha R. How to do (or not to do) a stakeholder analysis. Health Policy Plan 2000;15:338–45.
12 Varvasovszky Z, McKee M. An analysis of alcohol policy in Hungary. Who is in charge? Addiction 1998;93:1815–27.[CrossRef][Web of Science][Medline]
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