Public health is never far from the news in any week – this week is no exception. Since this is a ‘round up’, let’s start with the ‘Roundup-ready’ soya bean.
The Chinese army is banning genetically modified foods including Roundup ready soybeans.
The Roundup ready soya bean is not more nutritious-it is a bean that can survive in a swamp of Roundup, glyphosate, the weed killer. The Chinese are concerned that pesticide residues are causing birth defects, depression, infertility and other afflictions. These health concerns may be circumstantial, but the Chinese are applying the precautionary principle. The harms of GMO crops may be disputed, but the harms of pesticides are known. The precautionary principle environmentalists encourage us to apply is akin to the Hippocratic duty ‘first do no harm’.
The harms from each new great thing take time to appear, the benefits are obvious, up-front and overstated. This was a major theme of the second Science and Technology Select Committee inquiry on NHS screening programmes. I was invited to give evidence.
Medical innovation outstrips the ability of communicators to support patients and the public with adequate information to make informed choices. Public health practitioners, myself included, have been guilty of not communicating the full facts, fearful that these might reduce screening coverage and not deliver the population benefit we expect. Availability of good clear information, created for informed choice and consent, is the new imperative. The recent breast screening information tries to do this, I think. The criteria for screening programmes haven’t changed much over the years. Decisions, which have been the province of the expert, need to be reclaimed by the public and the patient. Cut-off points for tests determine how many people will be falsely told they have a condition and how many will be missed who have the condition. How much anxiety over a result is acceptable? How many deaths on the operating table are acceptable, in aortic aneurysm screening, for a condition, which may not kill some men at all?
NHS health checks came under scrutiny of the Select committee, and in the media. The Danish randomised controlled Inter-99 trial, in the BMJ suggested there was no life saving from general health checks.
NHS checks don’t meet screening criteria and were railroaded into the NHS constitution without the usual assessment by the National Screening Committee. Margaret McCartney, GP and broadcaster told the Select committee screening inquiry that the tests represented hidden harms to people but also opportunity cost- money not spent on other preventive measures.
Cut off points of clinical tests, informed choice and population health benefit were also newsworthy in the debate over who should get a statin.
According to NICE Professor Mark Baker, the proposals are an offer of treatment not a requirement, and support informed choice. The NICE proposals suggest putting 5 million extra people on statins to prevent less than 500 deaths a year. For every death postponed, 10,000 people will have to take a statin to no purpose. Is that what one does to be a good citizen? I am with the dissenters on this – its over-medicalisation.
One of the national screening criteria says don’t go to screening until you’ve exhausted all preventive measures. Should we really screen for lung cancer? Are we really sure we have done everything we can to prevent smoking? Our health leaders, including John Ashton, President of the Faculty of Public Health don’t think so: they have written this week to the BMJ and the health secretary to speed up standardized cigarette packaging.
The pre-diabetes prevalence in UK adults has increased to a terrifying 35%, as Coca Cola launch their new lower sugar product alongside their financial support for three local authority ‘Park-life’ initiatives.
Is this responsible marketing of a healthier product.? Aseem Malhotra from Action on Sugar doesn’t think so: “Fundamentally, this is about a company launching a sugary product to encourage more people to consume a substance that contributes to a range of dietary and health-related problems, including diabetes. Coca-Cola appears to be using the cover of the government’s discredited responsibility deal to seek acclaim for bringing out a product that still contains over 4 teaspoons of sugar per 330ml can, which equates to one-quarter of a child’s daily recommended maximum intake of sugar.”
It’s still peddling more sugar than we need; if we need to have any- refined sugar has only been in our diets for a few hundred years. If WHO changes the cut off point for daily sugar consumption as we would like it to, a quarter of maximum intake will become half.
The national abortion statistics appeared without much fanfare showing a continued fall in the abortion rates but worrying trends in abortion for women who have had children. Here again public knowledge and choice comes into question – inadequate contraceptive services for older women? Men not taking the snip?
There is also a public health nutrition angle as the British Pregnancy Advisory Service pointed out. ‘Neural tube defects (NTDS) such as spina bifida and anencephaly are prevalent as conditions under which Ground E abortions are carried out. BPAS is saddened that the government continues to delay the mandatory fortification of flour with folic acid, which would markedly reduce the incidence of NTDs and the number of couples needing to make the difficult decision to end what is often a much wanted pregnancy.’ Amen to that.
So there it is, we are over-reliant on technologies- food, pharmaceutical, medical. They make somebody an extraordinary profit; they keep the masses dependent and largely ignorant of harm. There are no technological fixes that come without unintended harms.
Prevention is better than cure, especially as there is no cure. Prevention is also better than early detection of disease, especially where finding it early means living with a life of ineffective treatment or a lifetime of anxiety, or worse, a lifetime cut short. More public benefit comes about, for less cost, through national action, legislation, regulation, taxation. Reducing that pre-diabetic condition of the British public, alongside reducing obesity, will come about through the largely unsexy, largely unprofitable, basic public health advice to eat less and move more, stop smoking and cut out sugar. The advice on that is the same whether you have a health check or not.
These themes will be discussed at the Forthcoming Health and care conference at Excel Cetnre London, June 25th and 26th next week .
First published by the Guardian