2011 April blog
Part of my purpose in placing a picture of one of my heroes at the beginning of my columns, is to infuse them with a particular savour, as dishes or drinks may be with a sprig of rosemary, a few juniper berries, or the juice from half a lime. This here is Henry James, the writer usually pictured looking almost baleful in older age. Above is a picture of him looking quizzical in middle life, soon after he went on his 'little tour in France', of which more at the end of the column.
The second item this month concludes my three-part account of the nature, scope and purpose of nutrition as a science and profession. In February I said that it is an error to imagine that we humans are separate from the rest of the living, natural and physical world. Also, quoting from the 2005 Giessen Declaration, I affirmed that nutrition is a social, economic, and environmental as well as a biological and behavioural discipline. Last month I told of how I saw more light in Amazonia. This month I go further, and see global nutrition from the point of view of the South, and indicate the implications of fundamental and elemental public health, including nutrition, by introducing and quoting from the 2008 Hyderabad Declaration and the 2009 Istanbul Declaration.
Nuclear power. Trans fats. Official policies
Things are never so bad...
First though, here is a reflection on the nuclear catastrophe in Japan, and why it should engage us professionally. This image is a play on 'The Great Wave', by the Japanese master Katsushika Hokusai. It represents an event and its outcome that the history of this decade or even this century may note as a turning point, towards what path as yet we do not know.
Barrie Margetts and I discuss the contents of our website and of WN every week or so. He said to me in mid-March, 'we must say something about Japan'. Isn't it ironic, Barrie said, that the Japanese culture is so much about humans being one part of the natural world, and now this. In response I agreed and said, isn't it ironic that the nation that suffered the destruction of Hiroshima and Nagasaki by atomic bombs should have built nuclear power plants in their own country, so vulnerable to earthquakes and tsunamis (a Japanese word), some close to their capital city.
The price and the cost of food
At first I felt, as you may do, that this is of course all very concerning, but nothing to do with us. But it is. Barrie is right. Here are two reasons.
One reason is comparatively obvious. Right now, it is difficult to believe that rich countries will persist in going 'full steam ahead' (sorry, not the right metaphor) with more and more nuclear power. Will some countries say 'we don't have earthquakes, this doesn't concern us''? Will the US persist in expanding nuclear power, given plants at Diablo Canyon and San Onofre already sited very close to the fault lines that striate western California, one of which was the source of the earthquake that as illustrated below, destroyed much of San Francisco in 1906? Maybe.
Some public policies are clearly insane, and some of these can be seen to be mad at the time. But right now it seems more likely that there will be a move back, or forward, towards.... coal and oil, or wind and water? There again though, environmentalists with a broad view are saying that nuclear power is of course extremely dangerous, but that the option of coal, which China might take, would almost certainly kill millions more people and leave a worse legacy for future generations. There is no safe choice. We have to accept and assess risk. We need to engage with this issue.
Specifically, public health nutritionists now need to get super-focused on the price, and also the real cost (with all the 'externalities' factored in) of food production, now, and also given various scenarios. This, of elemental importance to all of us concerned with food and nutrition policy, is systems work, in which we need to be team members.
Who can we believe?
Another reason why the Fukushima disaster is relevant to us professionally, is to do to do with a tricky issue. This is: 'What and who can you believe?' Here is an example. In this month's WN, Carlos Monteiro's commentary is on the hydrogenation process, and therefore also industrially generated saturated fats – and trans fats. My first exposure to trans fats (apart from having eaten the gunk all my life, as we all have), was in the mid-1980s, when a UK report on cardiovascular disease classed them with saturated fats as a cause of heart attacks (1).
Ever since then and even until now, the line being held by policy-makers in government, and their scientific advisors, and industry responsible for generating trans fats, pretty much goes like this. Yes, trans fats are a cause of heart disease, but they also occur naturally, they're sort of everywhere, and manufacturers are being asked to mention them on labels, and most people don't consume much of them anyway, not any more, for what problem there was mostly disappeared with the end of stick margarines, and everything is pretty much under control, so don't consume any more than you do now, and don't worry (2).
Beware of the official line
In any matter of public policy, official lines are what officials want you to believe. Such propaganda may or may not be well based on evidence. It may be the very best honest attempt to encapsulate the evidence. It may be guesses. It may be mistakes. It may be stated in bad faith. You never know at the time, unless you personally know most of the evidence yourself, and even then events may change a judgement based on previous evidence. That's life.
The connection with the latest nuclear disaster is this. We see and read 'the authorities' trying to give the impression that additional levels of radiation in Tokyo are trivial, whereas Tokyo citizens probably know there is no safe 'dose', are watching television, buying geiger counters, and coming to their own conclusions. The official word is that all these uncontrolled fires at the nuclear plants are of course worrisome, but as long as citizens in the vicinity brush dust off their clothes, teach their children arithmetic indoors, and eat canned food, no problem. And do they and do you believe this? Of course not! A surge of sustained candid concern would plunge the Nikkei – and in our interconnected world, this could lead to the value of your house falling. We can't have that.
In the UK, the government's chief scientific advisor Sir John Beddington advises that we get Japan in context. 'The point about the Chernobyl thing' he said, as quoted with what may be some typos in The Guardian on 15 March, was that 'it went up to 30,000 feet or so and it continued for months on end. The sort of thing that would happen with an explosion in Fukushima would actually be relative duration, hours at the absolute most... What happened with Chernobyl was that the graphite core caught fire and you got radioactive material being putting out to a very great height over a very long period and pretty much went round the world. That radioactive material then went in to the food chain, sheep ate it and concentrated it. That was the problem. It's totally different here in Japan'.
He is no doubt right. Let's trust so. But this statement is somewhat more forthright than any from an official source in 1986, as I recall. Check back and see what the government's advisors were saying about Chernobyl at the time. Remember the official estimate of deaths, at first limited to the 70 or so workers at the plant who died quickly from massive radiation? Many years later this became around 4,000-10,000 in what for most of us are the faraway countries of the Ukraine, Belarus and Russia. Despite the fact that the radioactive dust from Chernobyl, as Sir John reminds us, spread across continents? Hm. Do we believe this figure, or anything like it?
Even so though, and even admitting the real possibility of a future worse disaster than Chernobyl, and also the appalling problem of disposal of nuclear waste, the alternatives of oil or coal may be worse still. The data on the effects of the burning of coal on climate change are generally agreed to be incontrovertible. If China moves away from the option of nuclear power and increases its use of coal to fuel its economic boom and its increased global power, this alone might make global warming uncontrollable and irreversible. Either way, this is a troublesome issue, which we need to face as citizens and also professionally.
Trans fats. Killer or decoy?
Here is the analogy, with trans fats and saturated fats, another troublesome issue, which surely is our duty to face as professionals. Sustained statements and claims about the toxicity of trans fats, pressed by influential people (2), could lead to a new official line, and laws that might mean the end for ever of long shelf-life cheap packaged fatty snacks, and much fatty fast food. That is to say, it could mean bye-bye Big Snack and a rapidly redundant and retired Ronald McDonald. Good.
But would it? There are other ways to manufacture fatty snack products with long shelf lives, of the types that already crowd supermarket and convenience store shelves throughout the world, without generating trans fats. Trans fats could disappear, but industrially generated saturated fats would remain. What do labels proclaiming 'trans fat free' on junk product packages, giving an impression that the stuff is healthy, do to their sales? Is it really true that trans fats are the main issue here? Would elimination of trans fats, with emphasis lifted from saturated fats, improve public health? This is surely most unlikely.
References and note
- Department of Health and Social Security. Diet and Cardiovascular Disease. Committee on Medical Aspects of Food Policy. Report 28. London: DHSS, 1984.
- Having just now zoomed through some of the literature published in the last 50 years, up to the current FAO report on fats (3) and its relevant background papers, it seems to me that it would be nice to believe this soothing approach, but actually it is horse-feathers. Association members Ricardo Uauy and Walter Willett, who work independently of one another, are clear that industrially generated trans fats are toxic, much more so than saturated fats, and need to be eliminated from the world's food system. There again though, Association member Philip James, a member of the UK panel whose report is mentioned above (1), is clear, like the great majority of experts in this field, that the main single dietary cause of heart disease is indeed saturated fat from all sources, as confirmed again and again by evidence throughout 30 and more years. Furthermore, he believes that the dangers of trans fats are being exaggerated by interested parties. In such debates, bunches of peer-reviewed papers with opposing conclusions are like stick-bombs lit and hurled from opposing trenches. In the case of saturated fats and trans fats, this dispute among the experts is I feel largely unnecessary and unhelpful. To say that trans fats are toxic is not to say that saturated fats are harmless. To say that saturated fats – in the quantities produced and consumed typically in industrialised countries and settings – are a main cause of heart disease, is not to say that trans fats are incidental. Since the 1980s, when I worked with Caroline Walker (access www.cwt.org.uk) I have felt that the impact of food processing and specific types of processing on human health, has been largely overlooked. On the issue of saturated fats and trans fats, please access Carlos Monteiro's latest commentary, on hydrogenation.
- Food and Agriculture Organization of the United Nations. Fats and fatty acids in human nutrition. Report of an expert consultation. FAO food and nutrition paper 91. Rome: FAO, 2010.
Fundamental and elemental
This is the third of three columns in which I summarise my understanding of the nature of public health nutrition, as it needs to be taught and practiced for the times in which we live now, and in future. My column last month ended by saying that Amazonia in 2007 I realised that the natural resource and public good that most needs protection, to ensure security of food and nutrition, and also of society and the living world, is water. This led me back to the mediaeval concept of the four elements – air, earth, fire, as well as water (1).
The next year and the year after, 2008 and 2009, I had the opportunity to reason such issues out, with many distinguished colleagues in two big international meetings. One of the concepts we came up with, was that of fundamental and elemental public health – including public health nutrition - which, we agreed, now needs to be the main focus for all relevant professionals.
The Hyderabad Declaration
In August 2008 I was in Hyderabad, at the inaugural conference of the Public Health Foundation of India, masterminded and directed by my colleague and friend Srinath Reddy, the Foundation's director. This was the time when I realised that to be meaningful and effective, nutrition is rightly taught and practiced as a branch of public health. A number of us were invited to develop a Hyderabad Declaration, one of whose purposes was to see public health from the point of view of the South. It is consistent with The Giessen Declaration. .(2). But just as most of the people who worked on the Giessen Declaration were Europeans, most of the drafting group for The Hyderabad Declaration were Indians. We are all supposed to agree that science is science, wherever and whoever we are, but I dare say that none of us really believes this.
The preamble of The Hyderabad Declaration (3) begins firmly: 'The gross inequities that impoverish lower-income countries have historical and also current causes. These will continue to require redress. The major challenges faced by lower-income countries include continued rapid increases in national populations; rapid increase in chronic diseases with persistence of nutritional deficiencies and infections especially of childhood; deterioration and even collapse of public health services following economic structural readjustment interventions; widening economic, social and political inequalities between and within countries; the breakdown of political and social structures in a substantial number of countries; gross disparities of early-life mortality and life expectancy; and the adverse effects of overuse and abuse of natural resources and despoliation of the living and physical world'.
It continues with a passage that did not achieve consensus among the participants from Europe and North America. 'In this 21st century, leadership for maintaining and improving population health and well-being does and will increasingly originate from the South…. A global vision seen from countries with lower material resources is different from that from materially rich countries. In the 20th century, public health policies and actions have been largely based on the assumption that the welfare of lower income countries is dependent on support and intervention from higher income countries, and that in terms not just of money and material resources but also of skills, imagination and planning, the South needs and learns from the North… However, it is in lower-income countries that national, professional and community leaders and representatives, and the people themselves, have the most experience in understanding and influencing the most powerful threats to population health. … Now increasingly it is time for the North to learn'. It may have been this last sentence that made some of the US and European participants feel uneasy.
All the Declaration's principles and priorities for public health are directly relevant to nutrition. (The bulleted points below are all quotations). These include:
- Human population health and well-being depends on and needs to be seen as inseparable from that of the whole living and physical world.
- Good health and well-being are necessary conditions for personal, family, community, national and global economic, cultural and social development
- The determinants of personal and of population health are economic, social, political and environmental, as well as cultural, behavioural and biological.
Also, the vision of the children in the Amazonian forest for me influenced what is as far as I know, ancient principles of elemental and fundamental needs which have not been put forth in recent times:
- Elemental needs for the living world of which humans are one part, are for the light and heat of the sun, and for clear air, clean water, fertile earth, and nourishing food.
- Fundamental human needs also are for safe shelter, nurturing parents, supportive families, primary schooling, sustained activity, rewarding work, and peaceful societies.
- As these needs are increasingly met, the well-being of communities and populations will correspondingly improve, and rates, severity and duration of diseases will decrease.
Embedded in these statements, it seems to me, are the chief priorities for public health nutrition professionals from now and indefinitely. Our task now is to work out exactly what they imply for the teaching and practice of our profession.
The Istanbul Declaration
In April 2009 I was in Istanbul, as a member of the Brazilian team participating in the 12th triennial World Public Health Congress. The World Federation of Public Health Associations was already committed to preparing and agreeing what turned out to be The Istanbul Declaration, also on the nature, scope and purpose of public health (4). Álvaro Matida of the Brazilian national public health organisation Abrasco was asked to lend a hand, as was I, which we did. We were encouraged by our colleague Paulo Marchiori Buss, former president of the Brazilian Rio-based national official public health agency Fiocruz, who was then president of the World Federation.
The preamble begins with a call to governments to claim back one of their principal responsibilities: 'Now is the time to make a new commitment to the health of populations. The need for improvement and maintenance of public health must now be recognised, advocated and achieved by all policy-makers and decision-takers. Protection of public health is a first responsibility of governments at all levels, especially including heads of state and prime ministers. This implies renewed political will. It also implies a new understanding of public health as the first public good, needing adequate and therefore increased human, financial, and other material resources'.
The Declaration then touches on the context in which public health nutritionists now work, some of which was outlined in similar words by Margaret Chan, drector-general of WHO, in her address to the congress. Now are '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'.
All participants at the Istanbul congress, in affirming the Declaration, also stated: 'These phenomena demonstrate massive structural failures in policies and systems. Social determinants are causing increased disease and ill-health. Unemployment and poverty are increasing. Nearly one billion people are hungry, living in fear of starvation. Food security is threatened as never before in recent decades, most of all in Africa and Asia. Senseless wars and conflicts are causing death, disaster and misery in many parts of the world… We are now living in a new world, of unique challenge and also unique opportunity for those committed to public health and for everybody. The challenges we now face are as great as those that faced public health pioneers of the 19th and early 20th centuries'.
After going through 16 drafts, involving interrogation by the drafting group and other colleagues, some of the principles of The Istanbul Declaration are harmonious with those drafted in Hyderabad. (Again, the bulleted points below are quotations).
- Good health and well-being are necessary conditions for personal, family, community, national and global social, economic, and cultural development.
- Human health and well-being depend on, and are inseparable from, the health, welfare and maintenance of the living world and the biosphere.
- The determinants of personal and population health are social, economic, political and environmental, as well as behavioural and biological.
And on behalf of the world community of national public health associations, the Declaration also affirmed the vision I wrote about last month, which I saw in the forest clearing outside Belém:
- 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 public health profession has now entered the 21st century. It is time for the public health nutrition profession to do so. The first step is to learn from our colleagues in the general profession of public health, and to develop and refine their thinking in our own teaching and practice. We can then become altogether more relevant and effective.
- Cannon G. Visions from Amazonia, and other items. [Column] Website of the World Public Health Nutrition Association, March 2011. Obtainable at www.wphna.org
- The Giessen Declaration. Public Health Nutrition 2005; 8 (6A): 783-786.
- The Hyderabad Declaration. Prepared and presented at the inaugural conference of the Public Health Foundation of India, August 2008. Unpublished. Available from this author.
- The Istanbul Declaration. Agreed at the 12th conference of the World Federation of Public Health Associations, May 2009. Obtainable at: www.wfpha.org
Sense of place
The well-fed Bressois are surely a good-natured people… Their province has the most savoury aroma, and I found an opportunity to test its reputation. I walked back into the town… and as the hour of the midday breakfast had struck, directed my steps to the inn. The table d'hôte was going on, and a gracious, bustling, talkative landlady welcomed me. I had an excellent repast – the best repast possible – which consisted simply of boiled eggs and bread and butter. It was the quality of these simple ingredients that made the occasion memorable. The eggs were so good that I am ashamed to say how many of them I consumed… There was a bloom of punctuality about these eggs of Bourg, as if it had been the intention of the very hens themselves that they be promptly served… I came away through the town , where, on a little green promenade, facing the hotel, is a bronze statue of Bichat the physiologist, who was a Bressois. … I learned from it – my ignorance, doubtless, did me little honour – that Bichat had died at thirty years of age, and this revelation was almost agitating. To have done so much in so short a life was to be truly great
Henry James, 1843-1916
A Little Tour in France, 1884
This passage is about nourishment, and therefore about nutrition. (1). Elizabeth David quotes it (2), without the bit about Marie-François-Xavier Bichat (who may have been tubercular, and who died of a fever after falling down a flight of stairs). As I keep on saying, if nutrition scientists persist in assuming that their work is confined to the relevance of nutrition to physical disease, they are painting themselves into a corner. Here comes a new (to me) motto, which – with salutations to fellow columnist Fabio Gomes – I have offered to Michael Pollan as a candidate for the forthcoming new edition of his Food Rules.
Good food is celebrated in great poetry.
Making this more general and saying 'art' instead of 'poetry' may go too far, depending on whether you think of pop art such as that of Andy Warhol (as in Campbell's Soup) and Claes Oldenburg (as in 'soft sculptures' of burgers) as great art. Perhaps 'great writing', which includes Henry James, is safe. His paean to the people and town of Bourg-en-Bresse also includes a passage on the wonders of its fresh butter. No later traveller in France, or anywhere else for that matter, sitting down to breakfast and being offered margarine – that detestable invention of the French chemist Hippolyte Mége-Mouriés – would want to record or remember the experience, unless ironically.
So can bad food be good for you? The answer is either 'no, by definition', or 'yes, depending on what is meant by "bad".' If 'bad food' only means 'food which, if consumed regularly, increases the risk of disease', then the only issue is whether the judgement is reliable. But can such food increase the pleasure in life, and is enjoyment good for us? Obviously yes. In the days when nutrition scientists demonised butter, I continued to enjoy higher-quality unsalted varieties, to make an omelette, say, or soaked through crumpets, because it tastes wonderful. My guess is that people who can't tell the difference between margarine and butter must be on two packs of smokes a day: margarine smells and tastes foul. Yes, I know there are scores of varieties now. No thanks. Ironically, the nutrition science community is now coming round to the idea that butter should never have been on 'bad stuff' lists.
Returning to the theme of food and the experience of living, the times in journeys that I best remember are often and maybe usually to do with food, for like food, remembrance awakens and enlivens all the senses, and thus emotions. What I am remembering now are mornings a long time ago before dawn in Istria, my companion asleep in the beach house behind me. In my mind's eye now I am watching the sun rise above the sea and, as I write notes, gnawing chunks of hard rough fatty pork salami, drinking a tumbler of the local abrasive slivovitz, the Croatian fire-water distilled from the flesh and kernels of damsons, and sensing the warm breeze.
A trace of that time comes to me always these days, on occasions when I watch the sun rise over the ocean, at my computer, with a jug of water on the table. The combination of slivovitz and salami now would now permeate me with too intense a flavour of that long ago love that was bound to end. Besides, as Henry James indicates, the best experience of food is always of a particular time and place that cannot be repeated. If in those enlightening mornings in Istria I had served myself cornflakes, I would not remember them now.
- James H. A Little Tour in France. London: Sidgwick and Jackson, 1987. First published 1884.
- David E. Mediterranean Food. London: Penguin, 1955. First published 1950.
Acknowledgement and request
You are invited please to respond, comment, disagree, as you wish. Please use the response facility below. You are free to make use of the material in this column, provided you acknowledge the Association, and me please, and cite the Association’s website.
Please cite as: Cannon G. Things are never so bad… and other items. [Column] Website of the World Public Health Nutrition Association, April 2011. Obtainable at www.wphna.org
The opinions expressed in all contributions to the website of the World Public Health Nutrition Association (the Association) including its journal World Nutrition, are those of their authors. They should not be taken to be the view or policy of the Association, or of any of its affiliated or associated bodies, unless this is explicitly stated.
This column is reviewed by Barrie Margetts and Fabio Gomes. For the item on nuclear power and trans fats, I owe thanks to Philip James and Walter Willett, who sent papers and advised me. My thanks also and always to Google, Wikipedia, and Guardian On-Line.
The drafting group responsible for The Hyderabad Declaration, as well as Ilona Kickbusch and me, were Priyanka Dahiya, Snehendu Kar, Ravi Narayan and Kavita Sivaramakrishnan, together with Nandita Bhan. Written or oral comments taken into account were from Barry Bloom, NS Deodhar, N Devadasan, Dulita Fernando, Anita Kar, Neha Madiwala, Álvaro Matida, Thelma Narayan, LM Nath, Jayaprakash Muliyil, Srinath Reddy, and David Sanders.
Members of the World Federation of Public Health Association drafting group who guided The Istanbul Declaration and its supporting text were Margaret Hilson, James Chauvin, Federico Paredes, Mengistu Asnake, Theodor Abelin, Hikmet Pekcan, Deborah Walker, Peter Orris and Alena Petrakova, of the public health associations of Canada, Costa Rica, Ethiopia, Switzerland, Turkey, and the USA respectively, and of the World Health Organization. They were supported by the secretariat represented by Álvaro Matida of Abrasco, Brazil. and colleagues from WFPHA including Morgan Taylor. As rapporteur I drafted the document. Guidance and comments also came from the then WFPHA President Paulo Marchiori Buss and other WFPHA officers, staff, and members.
My thanks also to all the people in Brazil who have guided me and let me see the light, since I began to live and work in Brazil in 2000. As last month, some of the items here are introduced with images of spirals and curves, the 'brand image' of the New Nutrition Science. The ones earlier in the column are of the guaraná fruit, part of the sign of a street seller in the Brazilian city of Recife, and of palaeolithic Irish carvings. Above is a play on the Brazilian flag by the Santa Tereza street artist Getúlio, who in this enclave on a hill in the centre of Rio, has created his own world of Bonzolândia. The official words on the Brazilian flag are ordem e progresso (order and progress). Getúlio prefers lar doce lar (home sweet home).