Thinking and reading about food: Tales from lockdown

Like many people, I’ve thought about food during lockdown a lot more than usual.  Unfortunately, also like many people, the effects on my waistline have not been pretty.  But I’ve also done some reading, notably of three documents that are critically important for all of us concerned with health and health inequalities.

The first of these actually came out in 2016.  It’s the report of a London-based Global Panel on Agriculture and Food Systems for Nutrition, funded by the UK’s Department for International Development (DfID); co-chaired by a former president of Ghana and a former Chief Scientific Adviser to the UK government; and supported by what can fairly be called an all-start cast of expert group members, authors and reviewers.  It correctly identified the ‘nutrition crisis’ associated with the fact that ‘approximately three billion people from every one of the world’s 193 countries have low-quality diets,’ warning that ‘[t]he risk that poor diets pose to mortality and morbidity is now greater than the combined risks of unsafe sex, alcohol, drug and tobacco use,’ those awful things health promoters always complain that other people are doing. The risk factors being compared are actually a bit of a dog’s dinner, as you can see from the illustration, but that doesn’t alter the basic point.

Like the other two documents, it adopts a whole-system perspective on food and nutrition, which is itself a welcome conceptual advance.  Also like the other two, it explicitly identifies as a major problem the (un)affordability of healthy diets for many of the world’s people.  It points to some worrying trends and prospects in the sales of ultra-processed foods, which are levelling off in the high-income world but climbing elsewhere, especially in upper-middle-income countries, and are projected to continue doing so. 

And it warns that: ‘The power and concentration of large agribusinesses, manufacturers and retailers, has grown.  This in turn means that power structures in food systems have changed, which not only influences what is produced, but political decision-making’.  Perhaps not surprisingly, it’s a bit vague on how to deal with the problem – we have to remind ourselves that Coca-Cola’s annual marketing spend is about twice WHO’s entire annual budget – but as the saying goes, admitting that you have a problem is a first step.

The other two documents actually appeared during lockdown.  The first of these is a National Food Strategy for England, written by restauranteur Henry Dimbleby with a somewhat smaller but still impressive supporting cast of food system protagonists and public servants.  It offers an in-depth description of how the pandemic affected the UK food system, which is valuable in and of itself, and offers a number of recommendations for food trade policy after the UK leaves the single market at the end of 2020.  Guardian food writer Jay Rayner was harshly critical of the report, calling it ‘thin gruel and easy to set to one side’ and saying that the policy recommendations ‘will do little for the millions who go hungry’. 

Admittedly, the report is far too sanguine about the value of Parliamentary scrutiny of trade agreements under today’s conditions of elective monarchy, and it doesn’t even mention investor-state dispute settlement provisions or power dynamics that will favour agribusinesses based in our larger, richer trading partners in future negotiations.  However, among other strong points the report provides a powerful demolition of arguments against restricting advertising of foods high in fat, sugar and salt, and a similarly effective challenge to the claim that eating healthily is just as affordable as the unhealthy alternative (pernicious folk wisdom that is unsupported by serious research).  Perhaps most importantly of all for population health researchers, a valuable warning against the evidence-based policy fetish is worth quoting at length, and framing.

Over the past 30 years, there has been much emphasis on the importance of “evidence-based policymaking”. This sounds eminently sensible; indeed, you might think it the minimum one should strive for. But it has given birth to a new science of “policy evaluation”, which may actually lead to cowardice in policy making.

You can’t always find evidence to support a single policy. An evaluation of one intervention in a huge and complex food system might conclude that the intervention has no effect, because the effect is too small to measure. But the effect is still there, and if you press on with all the little things together, you might end up with a big effect.


The other problem with evidence-based policymaking is that it creates a Catch-22. You can’t bring in a policy until you have the evidence to show it works; but you can’t get the evidence without first introducing the policy. In the absence of data, it’s all too easy to end up doing nothing rather than risk unintended consequences.

Dimbleby points to the widely cited Finnish heart disease reduction initiative in North Karelia, quoting its architect Pekka Puska, as an example of what can be done when the Catch-22 is avoided.

Another strong point of the report is its focus on the food security implications of a coming wave of unemployment, given the context in which, ‘[b]efore the pandemic, four in ten working-age people in the UK (almost 17 million people) had less than £100 in savings available to them’.  Rayner was correct to say that the report’s recommendations would do little to address this basic problem of inequality, with origins entirely outside the food system and worsened by a decade of unnecessary and macroeconomically counterproductive austerity.  Yet here, again, recognising that you have a problem is a first step.  

The third document, and in some ways the most surprising, is the 2020 annual report on food security and nutrition from the Food and Agriculture Organization of the United Nations (FAO).  Previous annual reports have painted a cautiously optimistic if not Panglossian picture of progress in reducing hunger, even though the definition of malnourishment used – insufficient caloric intake over a period of at least a year – has been widely and rightly criticised as having little relevance to the real world.  This year’s report represents a remarkable turnaround, with FAO conceding that: ‘Two billion people, or 25.9 percent of the global population, experienced hunger or did not have regular access to nutritious and sufficient food in 2019’.   The continued prevalence of stunting alone is a powerful argument for more attention to diet in global health.

Further, it explicitly considered issues of the affordability of three reference diets (energy sufficient, nutrient-adequate, and healthy), concluding that: ‘Healthy diets are unaffordable to many people, especially the poor, in every region of the world.  The most conservative estimate shows they are unaffordable for more than 3 billion people in the world.  Healthy diets are estimated to be, on average, five times more expensive than diets that meet only dietary energy needs through a starchy staple. …. [A}round 57 percent or more of the population cannot afford a healthy diet throughout sub-Saharan Africa and southern Asia’.  Perhaps most disturbingly, it concluded that even on its earlier, inadequate and ultra-restrictive definition of undernourishment, under any scenario the number of undernourished people will increase between now and 2030.

There is more, much more, to be said, and no summary can do justice to these data-rich sources.  In another conceptual step forward, each explicitly addresses climate change, with reference not only to impacts on food production but also to food systems’ (substantial) contribution to greenhouse gas emissions.  I’ll be using them all in postgraduate teaching this academic year, hoping they herald a longer-term shift in how food systems are addressed in global health research and policy.  And I am not inclined to hopefulness on such matters.

Strange days, strange priorities

The news of the day sometimes throws up events that combine to highlight the absurdity, and the perversity, of today’s policies of selective market fundamentalism.

Tuesday, 14 January was one of those days.  The Guardian reported that councillors in the last county in England without a Burger King, Kentucky Fried Chicken or McDonald’s restaurant (if that is really the appropriate word) had approved a 24-hour McDonald’s drive-through in the town of Oakham.  This happened even though 55 of the 78 representations submitted to planning officers opposed the planning permission.

In a spirit of rough and ready critical discourse analysis, it is worth considering the language of the news report.  Damien Gayle and Kevin Rawlinson wrote that many people they interviewed were ‘hopeful that the new restaurant would give the town’s young people somewhere to go and create local jobs’ (my italics), and ‘[p]arents … said they would welcome not having to drive to neighbouring counties to “treat” their children to McDonald’s food’ (my italics again). 

So this is what market fundamentalism hath wrought, and obeisance before the deity of (private sector) job creation is only part of the picture.  Silly me; I would never have thought of McDonald’s on a list of places for young people to go.  Oakham’s library is still functioning, unlike the 343 libraries across the UK that closed between 2010 and 2015, although admittedly it is only open during the day Monday to Saturday.  Rutland County’s web site offers numerous links to parking information, but no mention of parks; I’m not certain what to make of that.  And these are strange days indeed when parents feel compelled to drive substantial to feed their children a McDonald’s meal.  The industry, of course, is not just a passive bystander.  It targets children in its advertising, as McDonald’s did in Chile; this was pointed out in the web summary of a September 2011 Euromonitor report that is no longer online, but I have it on file. 

‘McDonald’s arrived in Chile targeting the segment of children, but over time, the customer base has expanded from not just children to also their parents, as well as young people. This strategy has allowed this brand to claim an important part of the category, and it has established itself amongst consumers of fast food ’ (Euromonitor, 2011; photo from Santiago city centre: T. Schrecker)

It’s as if no one had heard of the epidemic of child and adolescent obesity, or the massive revenues, profits and marketing budgets of the ultra-processed food and fast food industries that contribute to it.  Encouragingly, the public health community is slowly coming to grips with the importance of commercial determinants of health, but it will be a long hard slog, with deep-pocketed adversaries.

On, then, to the second news item of the day.  Short-haul airline Flybe, which serves 56 locations in the UK and continental Europe, received a bailout from its major shareholders that may be accompanied by sweeteners from the magic public money tree including deferred tax payments and a reduction in air passenger duty on domestic flights.  Entirely understandable expressions of outrage, not least from its commercial competitors, seem likely to have no effect, yet as Nils Pratley pointed out in The Guardian: ‘Increased trading losses? Higher fuel costs after sterling’s decline last summer?  Brexit uncertainty?  None of those risks were unimaginable 12 months ago’.   This is a case of bad management, or more accurately bad accounting, pure and simple.  Management is surely what was lacking. 

It’s as if no one had heard of climate change, or the aviation industry’s contribution to greenhouse gas emissions.

Many forms of infrastructure are essential for modern life, and in the UK many have been dismembered by a decade of austerity. In a carbon-conscious age when, as economists never cease to remind us, resources are limited, a failing regional airline is not one of those essentials. The idea of letting markets work never seems to play very well in the commercial aviation industry, or with its political protectors. 

Now, please don’t take what I am about to write the wrong way.  All of us concerned with health inequalities recognise that governments must get in the way of markets, in all kinds of ways and for all kinds of reasons.  But here are two modest proposals, with apologies to Jonathan Swift, for how a creative, environment- and health-friendly government might use markets to move towards a healthier, less inequitable and greener world. 

First: let airlines, like your local drycleaner, price their services at a level that will ensure an adequate return on investment, whatever that may be, or go bust.  By all means subsidise transport, but concentrate on options that generate the fewest negative health impacts:  low-carbon rail and bus services, active transport, and reducing the need for travel.  Conversely, massively dis-incentivise polluting and carbon-intensive transport.  The British Heart Foundation have just launched an important campaign on air pollution, as has The Times; more power to them both, even though The Times’s proposals are modest, perhaps in deference to its Range Rover readership.

Second:  if planning permission for fast food franchises must be allowed, why can’t central government legislate a quota of such permissions for the entire country, or for each region (say, in the English case, each NHS footprint area); auction opportunities to apply for them to the highest bidders, with periodic renewal required; and gradually shrink the quota at each successive auction?  The tidy bit of revenue generated could be ring-fenced to reopen libraries and activity centres, restore parks, use traffic calming to improve the activity-friendliness of neighbourhoods, and perhaps subsidise the cost of healthy food.

Just asking …