When the original North Americans spoke of ‘medicine’ they were not referring to potions and pills. For them the term ‘medicine’ meant something like ‘what at all times affects the mind, body, heart and spirit of people, communities and nations’. Big picture stuff. Thus the election of Barack Obama as US President seems to be good medicine, though time will tell. This is also what public health is – or should be – all about. In itself technical skill is nothing. We need always to consider the implications of our work. Is it good medicine? This column ponders such ethical issues.

Cultural heritage

Coke™ in Venice

Here is a quick example. The city fathers of Venice have done a deal with Cola-Cola. In return for €500 000 a year for 5 years, sixty piazzas in Venice now feature Coke™ vending machines⁽Reference Kington¹⁾. That’s bad medicine.

The ‘free market’ ideology

What went wrong in the world, and why

Much of what has changed in the world since the beginning of the 1980s is bad medicine and continues to cause trouble and misery for most people, while having made a small number of people very rich. One example is a linked series of social, economic and other disorders. These include dependence on mechanised transport and spectator entertainment, leading to a drop in physical activity to levels below those to which the human species is adapted; chaotic growth of mega-cities and in particular of slums⁽Reference Davis^{1, 2)}; vast increases in production and consumption of processed energy-dense ultra-processed foods and soft drinks⁽Reference Monteiro³⁾; and the consequent pandemic of overweight and obesity and of those diseases that have causes in common with those of obesity. According to an impressive project undertaken by the UK organisation Sustain, these may include deterioration of intelligence and other mental and also emotional disorders⁽⁴⁾.

In the past I have gone along with scholars who call these disasters the ‘demographic, nutritional and epidemiological transitions’⁽Reference Popkin⁵⁾, but I now think this is a mistake. ‘Transition’ is one of those neutral terms that tend make us forget that most of what goes on in this world, bad or good, is the result of policies enacted by powerful people who should be identified and held to account.

The second calamity is an attitude. This is the increased tendency for health to be identified with absence of manifest disease and so seen mostly as a medical matter – in the narrowed sense of the word – and, correspondingly, for vast treasure to be spent on sub-molecular accounts of the biology of diseases. This reduction has for a while distracted attention from public health and one of its basic principles, which is that the immediate causes of disease are just one aspect of health and that epidemic diseases are manifestations of pathogenic societies and environments⁽⁶⁾.

What goes on? Obviously these disorders and this attitude are against our general interests, personally, or as citizens, or as members of the human race. They are in large part explained by belief in and enactment of twin doctrines: that of the sanctity of unregulated business and that of the supremacy of the individual. These have bred monstrous policies and practices, and have rationalised the neglect by elected governments or their responsibility to protect the interests even of their own people. Specifically, they have produced a horrible paradox: the privatisation of public health⁽Reference Garrett^7, Reference Castells⁸⁾.

Darkness before the dawn

Curiously, the collapse of casino capitalism, which is now looking like being the biggest burst bubble since 1929, may turn out to be public health’s salvation. As long as it was generally believed that red-in-tooth-and-claw laissez-faire politics and economics were generally beneficial, notwithstanding their trampling of the weak⁽Reference Klein⁹⁾ and their creation of outrageous inequities between and within countries⁽¹⁰⁾, public health and other public goods withered⁽Reference Garrett⁷⁾.

But now public squalor cannot be rationalised. Now that the ideology of ‘the free market’ is exposed as a mask for outrageous and stupid greed, and comfortable folks like us are feeling a hint of the pain suffered by the citizens of countries whose assets have already been stripped, first by the colonial powers and now by economic globalisation, we all may begin again to play our parts in the construction of reasonably equitable societies, without which the practice of public health nutrition is little more than band-aid⁽Reference Yngve¹¹⁾.

Ecology

The life and death of fish

Accounts of nutrition that are mostly about the metabolic and other biological pathways of energy and nutrients, that omit celebration of the pleasure of shared meals and their contribution to positive health and well-being, are as incomplete as would-be compendiums on love mostly confined to measurements of secretions. So here follows a recipe, within ecological, ethical and environmental contexts⁽¹⁾.

Fish from oceans and rivers are one basis of Brazilian cuisine. For moqueca, a dish that combines native Brazilian and African cuisines⁽Reference Da Câmera Cascudo²⁾, go to the market and choose a fish that was a strong swimmer and that weighs more or less a kilo. Chat with the fishmonger as he heads, guts, skins and fillets, and keep all the offals. At home take a suitably sized thick heavy earthenware pot with a lid. Heat your choice of plenty of oil (we favour a combination of babaçu and dendê), place the fillets drenched with lime juice in the sizzling oil and sear both sides, then add just enough water to cover the fish and simmer, while adding sliced onion, pepper and tomato, and the tastier offals, plus a big spoonful of urucum. Put the lid on, simmer, inspect, and when almost ready tip in all the contents of a 200 ml or so container of coconut cream, with a big handful of fresh coriander or other fresh herbs of your choice, chopped. Sample until ready. Serve in the pot, together with rice, and farofa (manioc or corn meal toasted together with herbs and what you will). This is plenty for four. For eight buy two fish and use a bigger pot. Moqueca can also be made with seafood. (For a fussy recipe using ingredients available outside Brazil, see⁽Reference Idone³⁾; or try http://www.brazilian-food.suite101.com/article.cfm/moqueca_fish_stew). Moqueca is best for a long lunch outdoors on a hot day, in which case ice-cold beer is essential. Serve the awful offals to the cat.

Post-modernist nutritionists scoff at worries about the impressive amount of saturated fats in the dendê oil and the coconut cream. For a start, moqueca is not a daily dish but a feast. Dendê and urucum are also stiff with carotenoids, fresh herbs are treasuries of bioactive wotsits, and fish that in life were physically fit are seething with the types of fatty acid that, according to Michael Crawford and his associates, feed the brain and account for the ascent of humans⁽Reference Crawford and Marsh⁴⁾. Besides, they say, forget any nutritional doctrine that condemns fresh food of any type, especially when it is prepared with loving care and made into delicious meals that create good fellowship⁽Reference Meyer-Abich^5, Reference Pollan⁶⁾.

Harbingers of doom?

A couple of columns ago I lamented the death of countless thousands of fish in the salt-water canals of Cabo Frio, a city on the Rio de Janeiro state littoral, where I am now as I write this. They were destroyed by lack of oxygen, or more relevantly by a combination of fresh water from incessant rain – the form climate change seems to be taking in Brazil – and from sketchily treated sewage from tourists that also stunk out the canal-side walkways and restaurants. As a result the local ecology went out of whack.

The state of fish tells us much about the state of the biosphere. Here in Brazil there may still be room for recovery. There has been no heavy rain for a month, and the peixe-voadors (flying fish) are leaping out of the canals again, the local fishers are back, using nets probably much like those cast by the original Tomoios people five or ten thousand years ago, and local fishing communities still survive in competition with industrial-scale trawlers. But if as people say the constant storms and flooding in Brazil is caused by weather bringing water from the melting Antarctic ice-cap, the inland salt-water fish of Cabo Frio will all die, and with them the life of the canals. Some people also say that the death of fish is a harbinger of the doom of Homo sapiens sapiens, though the species may survive in diminished numbers in a deteriorated form. Meanwhile I am hurrying on down to the fish market to boost my little grey cells.

Engagement with industry

Nesting with Nestlé, and other tales

As I mentioned in an earlier column, in an annual report of the Nestlé Foundation⁽¹⁾ John Waterlow regretted that he was not able to join its Council because, at the time, he was a member of an advisory council of the Nestlé company ‘in the hope of influencing their policy on infant foods’. Indeed, many if not most senior paediatric nutritionists regularly come together at invitation-only scientific meetings convened by Nestlé, whose proceedings, as for exampleReference Martorell and Haschke², complete with photographs of all present, are available in bookshops and from Nestlé stalls at international conferences.

What do we feel about this? Civil society organisations concerned with the health of children often see Nestlé as not just the biggest but the most troublesome food and drink manufacturer. Indeed, many of its products are confections of fat and sugar, and its nutrition guidelines contradict the consensus on what are healthy foods and diets. Nestlé is also seen by breastmilk advocates as having responsibility for unnecessary suffering and deaths of millions of children most of all in Africa and Asia.

But there it is. Suppose you are an authority on infant and young child health, and a Nestlé executive approaches you, and says something like: ‘We know that some of our leading products are problematic. We have a strategic plan to change. We want you to advise us on our foods for infants and young children. Please help us’. Suppose that you are then invited to Nestlé headquarters in Vevey, and the boss of bosses confirms this pledge as a personal and corporate commitment. What would you do? The International Baby Food Action Network believes you should say: ‘Get thee behind me, Satan’.

Personally I would say no to Nestlé – easy for me, since my standing in the paediatric nutrition science community is zip. But I am not so sure that John Waterlow made an ethical mistake. The more I think on, the more it seems to me that the current policy of the UN System Standing Committee on Nutrition is correct: engagement with industry should be according to clear rules, and contextualised and considered on a case-by-case basis⁽³⁾. Automatic brandishing of bible, cross and garlic won’t do.

Countering climate change

Sometimes analogies help. Take the environment and energy. Could climate change be controlled without government, scientists and civil society working with industry? This seems unlikely. Yes, energy industry giants do send up smoke-screens of self-serving publicity in which children romp through meadows under which pipelines have been laid, while in the real world, especially in countries with fragile governance, extraction of oil is often outrageously exploitative and destructive. But does this mean that all transnational industry is and will be like that, all the time? This seems most unlikely.

Indeed, surely the mould is most likely to be broken not by governments but by the energy giant that really does decide to think strategically in ways that governments do not and cannot. This is not done by CEOs announcing that ‘their’ firm is now abandoning non-renewables. No CEO would be able to make any such announcement. What can happen is that a transnational sets up a division headed by a main board member with the authority to do things differently. This is likely to be in response to pressure from leading environmental activists, who are therefore given scope to engage. It seems to me that they must, because if they don’t, the industry executives and their initiatives are liable to be badly guided, or go phut, or both.

You see the analogy. Yes, let’s support wind power, but don’t let’s spend our precious lives tilting at windmills.