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commandments for public health advocacy Marie McInerney Mike Daube Friday, April 21, 2017 Public health Mike Daube, Professor of Health Policy at Curtin University, has played a big role in critical public health campaigns in Australia and internationally over more than four decades. He has been instrumental in the fight to reduce the toll of tobacco with strategic, long-term advocacy that has seen Australia lead the world in tobacco control, particularly with the introduction of plain packaging. Earlier this month, Daube received the World Federation of Public Health Associations’ highest honour, the Hugh Leavell Award for Outstanding Global Health Leadership, presented at the 15th World Congress on Public Health in Melbourne. His responding Leavell Lecture trended nationally on Twitter, providing insights on the nature and role of advocacy, lessons he has learnt over time, what and where is the major opposition, and what should be the roles of public health organisations locally and internationally? Among many other tips and insights about dealing with government, media and vested interests, he offers 11 Commandments in public advocacy. The 11th is: Oppose and expose the opposition, because, he says: They are often the single biggest factor in resisting public health measures. They are always the best funded and most determined. While their opposition may seem to affect only, for example tobacco or alcohol or junk food, this extends to attacking and undermining public health much more broadly. Croakey thanks Professor Mike Daube for permission to publish his speech as a #LongRead. Readers might also be interested to listen to this ABC interview with Daube, recorded during the World Congress. And please see, at the bottom of the post, some Twitter reaction to his speech. Professor Mike Daube AO: Leavell Lecture First, I would like to acknowledge the traditional owners of the land, and pay my respects to Elders past and present. It is a great privilege to have been invited to deliver the Leavell Lecture. Hugh Leavell developed terms such as primary, secondary and tertiary prevention; but that was just one part of a lifetime in public health and supporting public health organisations nationally and internationally. I am grateful to the WFPHA for this honour. I also want to dedicate this talk to one of my greatest colleagues in public health, the late and much missed Dr. Nigel Gray, long-time Director of the Cancer Council Victoria, and President of the Union for International Cancer Control (UICC). It is a nice coincidence that VicHealth, the Victorian Health Promotion Foundation, for whose establishment he was responsible, today celebrates its 30th anniversary. Among many other achievements, Nigel did more than anyone to advocate for and generate action to reduce smoking nationally and globally, even if, as I said at his memorial event, I have never quite forgiven him for his 1970s comparison with a distinguished Canadian colleague, when he said, “Bob’s all presence and no performance. Mike’s all performance and no presence”. His unique status was summarised in a 1980s confidential tobacco industry memorandum. “It is the Australian, Dr Gray, who appears to have done more than any other individual to bring the anti-tobacco movement together in the international sense … his special contribution is to organise the integration of the disparate elements of the anti-tobacco movement into the most organic whole that it could be … ”. Public health: the grandest of grand challenges Martin McKee (Professor of European Public Health at the London School of Hygiene and Tropical Medicine, who spoke on ‘Enemies of the people’: public health in the era of populist politics and media) in his wonderfully eloquent opening address and other speakers have covered some of the big picture topics, so today I will focus on advocacy in public health, and some issues relating to the commercial opposition. The term “grand challenges” came into public focus in the 1980s, initially arising from US thinking about fundamental problems in science and engineering. Those of us who choose to work in public health do indeed face the grandest of grand challenges. The editor of The Lancet, Richard Horton recently wrote, “so what are the lessons for today? Nothing less than to grasp the necessity of re-evaluating the entire purpose of public health in the 21st century”. I will leave that as a longer-term task…..but to be seen in the context that public health has always been a Cinderella; and we need to keep getting on with the business of focusing our incredibly limited resources on the challenges of the day. We should also occasionally take a moment out to celebrate that we have been able to achieve some remarkable successes even against the most formidable odds. Much of the progress over the past two centuries, including the basic public health legislation that many of us now take for granted – giving us clean water, safe food and a healthy environment – occurred because small numbers of health professionals acted to promote evidence-based change. People like John Snow who first used meticulous epidemiology to make the case, and then advocated for action. Many measures we now see as pillars of public health came into being because of: sound scientific evidence support over time from health organisations small numbers of committed health professionals who were willing to speak out principled politicians persistence, and advocacy. So I will cover four themes. What is advocacy? Some lessons about advocacy that I have learned over time Where is the major opposition? And what should be the roles of public health organisations locally and internationally? What is advocacy? The term “advocacy” is derived from the Latin avocare – meaning to stand beside. Advocacy is simply defined as “the pursuit of influencing outcomes…..that directly affect people’s lives”. As the great American health and social advocate Michael Pertschuk points out, advocates are likely to succeed when someone, somewhere, has been made to feel uncomfortable. Or, as he put it, “Advocates are unabashed tellers of truth to power….They may often be irritating and difficult, but they churn up our collective conscience and annoy us into action”. But it is more than that, and important to emphasise that there is a role for everyone. Being involved in advocacy does not mean always being the general leading what our military predecessors used to call the “Forlorn Hope” – the front line of attack, where casualties are high. Many of the most important roles are played by those who work behind the scenes – from researchers who identify, then constantly find new and compelling ways of presenting the evidence, to working as committee members in organisations that help to promote action – such as public health associations, to people working within government agencies who can advocate internally or support advocacy through evidence-based advice. There are always obstacles – otherwise we wouldn’t be needed! The opposition can be commercial. Or philosophical, whether 19th Century or 21st Century style. Or, like many in governments and bureaucracies who are resistant to change. Or from friendly fire. Or from those who don’t understand or don’t care. And sadly, many of those who either don’t understand or don’t care are among our colleagues. This photo of the first four French heart transplant patients dates back a while, but shows all too clearly that some of our colleagues don’t even think about prevention, let alone prioritising it. And all too many still effectively ignore prevention. One example. We hear a lot these days about “research translation”. But for many of our colleagues, “translation” essentially means moving from one paper or project or funding application to another. Here, for example, we see Australia’s then Chief Scientist, Professor Ian Chubb, speaking about translation. “Two thirds of Australians are overweight or obese. In the last 20 years, there has been an explosion in the science underlying the genetics, basic biology and neuroscience regulating food intake and satiety. In the last ten years, we have spent almost $200 million on research. And yet such knowledge has not been translated to any new drugs that decrease weight safely and effectively.” That isn’t real translation. Real translation is making things happen on the basis of the best evidence, or setting in place at least some of the stimuli that will help to make things happen….. And that is what public health and public health advocacy are all about. We often hear comments from commercial interests and their allies about a “public health industry” – promoting the notion that vast armies of people are paid large sums to work full time on advocacy. That is of course particularly outrageous coming from massive global industries spending billions on advertising, public relations and lobbying. As just one example, in a recent European Union episode, the Philip Morris company – one company alone – employed 160 lobbyists to work on just one campaign issue. By contrast, the number of core campaigners even in areas such as tobacco and alcohol is tiny; very few are full-time; and for most of us this work is over and above the day job. But advocacy is indeed what we need both for real translation and to resist the powerful interests that promote unhealthy behaviours. 11 Commandments for health/social advocacy So to some key lessons I have learned from nearly five decades in health and social advocacy. I have tried to distil these into 11 commandments – 10 may have been enough for the Almighty, but some of us need a touch more space. 1. Act on sound evidence for action and the measures proposed – but when you have that, act. More than 150 years ago John Snow believed that he had sound evidence for action and knew what needed to be done to prevent cholera. He made the case, acted single-mindedly (and for a while indeed singly, in the face of fierce opposition and abuse) and we are all in his debt. (It is reassuring in retrospect that his solutions for cholera were a touch more evidence-based than some other approaches…..). 2. Be professional Gone are the days when lobbying meant barging in to a Minister’s office, thumping one’s fist on a table, and hoping for the best. We must be as professional in our advocacy as in any other aspects of our work. Many of the key themes here are set out in the West Australian Public Health Advocacy Institute’s Advocacy Toolkit. A sad reality is that these days being professional also means being prepared to withstand the vicious abuse that comes our way, all too often from industry-friendly sources. 3. Develop comprehensive approaches and consensus positions – and work in coalitions Nigel Gray identified early that there was overwhelming evidence for action on smoking, and we knew the basics for a comprehensive approach, but there was no broad agreement on the national or international consensus strategies for tobacco control. So he brought a group of us together, initially in 1976, to develop that consensus, evidence-based strategy, first for the UICC (Union Internationale Contre le Cancer), then for the World Health Organisation. After that, he worked to ensure that it would be adopted by other international and national health agencies, then governments. And while over time there have of course been assorted further developments, that is still the basis for our approaches to tobacco control, and serves as a model for many other issues. He also recognised early that we make progress when we work together. Coalitions are invariably more effective than lone wolves. All coalition members don’t have to contribute in equal measure – there will always be workhorses who carry much of the burden. But for decision-makers, media and the community it is much more impressive to know that action is not just sought by one person or group, but by a coalition of many influential organisations – often themselves with many influential members. Plain packaging is just one example of a measure that would never have been achieved but for its place in a comprehensive approach, supported by a united coalition. And coalitions can play important roles internationally as well as nationally. Working in coalitions isn’t always easy – but it is important always to recall that we all seek the same objectives, and should work collegially – the main opposition is external not internal! 4. Clear messages If we want to influence decision-makers who are being pressured from all sides on all manner of issues, we need to be clear about what is needed. Two examples, one of which reflects poorly on me! Shortly after Nicola Roxon, the champion of tobacco plain packaging, was appointed Federal Minister for Health, from my then role as President of PHAA, I arranged a forum on obesity which she agreed to open. My intention was to convince her of the need to act on an issue which I knew to be of concern to her. So I organised for several leading figures to speak briefly while she was there. It was a disaster. I had not done the necessary briefing and coordination, so they all appeared to be competing. Food and dietary issues were the highest priority. Physical activity was the highest priority. The built environment was the highest priority. Action across government was the highest priority. And so it went. Not their fault – entirely mine – but the Minister would have left thinking that if health groups couldn’t even get their act together on the action needed, her chances of convincing her colleagues to act would be minimal. My second example will be familiar to many of you. When the UK Foresight group, swimming in expertise and good intentions, was commissioned to develop a clear pathway of action for the British government, this was the crux of their response. Foresight: Obesity System Map 5.Understand government, policy, politics, politicians, bureaucracy – at all levels, and seek to work with all. This is less ‘know thine enemy’ than ‘know thy targets’. Professionalism in advocacy entails knowing exactly whom to influence, when, what their key influencers, and how their organisations work. As a former director-general of health I can tell you that there is little more frustrating than well-intentioned lobbyists who come in to see ministers lobbying about the wrong issue, even to the wrong level of government, and at the wrong time – such as ten minutes before a budget rather than many months ahead. It is also vital to understand the importance of working with all levels of government and the policy process. The decisions may be made by those at the top, but the briefings are written and advice given by people on different rungs of the ladder. And remember that politicians don’t think in the same ways as the rest of us. When the German Iron Chancellor Bismarck was given the news that the French statesman Talleyrand had died, he said, “I wonder what he meant by that”. 6. Be non-partisan We are all entitled to our political views – but in democratic systems it is important that health campaigners are not committed publicly to one party or another. That may work fine for a while – but elections can change our world overnight. We have also found on many issues, not least in relation to tobacco and plain packaging, that cross-party support is crucial to ensuring both success and continuity. By contrast, I recall from some years ago an occasion when the government of the day looked likely to lose the upcoming election. A health advocacy group decided to capitalise on this, and ran an event with the Opposition criticising the government for lack of funding. The Minister phoned me. I advised him that they were reasonably well funded, and would have known that they were about to get more money if they had bothered to return one of four phone calls the previous week. I was surprised that his comments on the evening’s television news were gentle, so called to ask him why. His response was, “had to kill the story before the election. This is what you do. Meet with them. Be nice to them. Don’t give them a cent. And after the election, we’ll slit their flipping throats”. Coda: the government won the election. 7. Understand and work with the media The media are crucial to much that we want to achieve. They can be invaluable, from publicising important information to exposing misleading industry. Just as it is vital to understand the way politicians and government agencies work, good advocates need to understand and be professional about their dealings with the media. Journalists are professionals – they have every right to expect the same professionalism from us. We want them to think we are important – they also have the right to expect that from us. And that includes being up to speed with the ever-changing media world, from traditional to new media. 8. Be innovative There are always new approaches to all aspects of advocacy, from media coverage onwards. In the early 1970s a leading British journalist solemnly assured me, “you know Mike, you’ll never find anything new to say about smoking”. But we have been finding new things to say and new way to saying them ever since – example after example after example…..yet another innovative approach outlined so well by Bronwyn King this morning. 9. Don’t be satisfied with soft options When advocacy is effective, soft options are often offered up, by those who oppose us or governments. Low-key programs. Inadequate funding. Short-term, one-off activity. Ineffective voluntary codes…… There may be times when we have to accept interim measures, but we should never ever be satisfied with soft options or accept and support as satisfactory those put up by vested interests clearly determined to delay or prevent effective action. 10. Be impatient – but patient. We are in advocacy because we are driven. We know what needs to be done and we want action now, rather than sometime in the next century. So of course we should be impatient and of course at times should show that impatience. But we also have to recognise that progress is never as fast as we would like. I have been involved in campaigning on tobacco for nearly 45 years. For most of that time, people would want to depress me by telling me that we were failing. But the world of tobacco has changed remarkably over that time……. and people now want to know the secret of our success! Overnight success takes time. 11. Finally and crucially: Oppose and expose the opposition I will focus here on the commercial opposition for three reasons: They are often the single biggest factor in resisting public health measures. They are always the best funded and most determined. While their opposition may seem to affect only, for example tobacco or alcohol or junk food, this extends to attacking and undermining public health much more broadly. A seminal 2011 Lancet paper by Rob Moodie and colleagues entitled “Profits and pandemics: prevention of harmful effects” summarised thus: “Transnational corporations are major drivers of non-communicable disease epidemics and profit from increased consumption of tobacco, alcohol, and ultra-processed food and drink (so-called unhealthy commodities)” (To which one might add the gambling industry whose increasingly predatory approaches match those of the others.) “They use similar strategies to the tobacco industry to undermine effective public health policies and programmes.” “There is no evidence to support the effectiveness or safety of measures they promote, such as self-regulation and partnerships”, and “Unhealthy commodity industries should have no role in the formation of national or international policy for non-communicable disease policy” They outlined some of the strategies used by these industries, for example: bias research findings co-opt policymakers and health professionals lobby politicians and public officials to oppose public regulation encourage voters to oppose public health regulation deflect criticism, promote actions (on topics) outside their areas of expertise offer alternative (invariably voluntary) approaches designed to have minimal impact, but that will cause delay or deter policymakers from introducing regulation that will curtail their own activity. In an important paper comparing tobacco and junk food, Brownell and Warner also summarised these realities. Their summary comment is equally applicable to the other areas: “At the center of this issue is whether industry can be trusted to make changes that benefit the public good and can be responsible with the accompanying marketing. The tobacco history is clear and is captured in a quotation from Cummings, Brown, and O’Connor (2007, p. 1070): “If the past 50 years have taught us anything, it is that the tobacco industry cannot be trusted to put the public’s interest above their profits no matter what they say.” More recently of course the Director General of the World Health Organization, Dr. Margaret Chan, has commented that: “Efforts to prevent non-communicable diseases go against the business interests of powerful economic operators. In my view, this is one of the biggest challenges facing health promotion………….it is not just Big Tobacco any more. Public health must also contend with Big Food, Big Soda, and Big Alcohol. All of these industries fear regulation, and protect themselves by using the same tactics. Research has documented these tactics well. ………This is formidable opposition. Market power readily translates into political power.” 5 strands to powerful industry opposition So we have here the biggest single active obstacle to action. After 44 years working in these areas, I see five complementary strands to their approaches: 1. Now as in earlier years, health is not a priority. This is nicely summarised in a speech we found in tobacco industry documents by the then Chair and CEO of Philip Morris, which at the time also owned major global alcohol and food companies. “Many of the threats to us, P.M. (Philip Morris), arise from concerns which have lost touch with common sense and reality. People (and politicians) do need causes, and in a world which is generally more peaceful and affluent that even before, there’s a shortage of big causes. That’s why we hear so much about really rather little causes: smoking, drinking, dietary hazards.” 2. Single minded focus. Sadly, nothing changes – they remain focused as single-mindedly as the most profit-oriented shareholder could wish on maximum possible sales and minimum possible constraint. 3. Even more ruthless and cynical than ever before. When I started working on tobacco, there might have been some excuse for those who had come into the industry in earlier decades. There had been warning signals before 1950, particularly from the work of Muller, but until then tobacco company Boards and their senior executives could have been forgiven for believing that theirs was a reputable and responsible business. Now there is no excuse. Anyone working for or supporting the tobacco industry lives in the absolute certainty that their product kills at least one in two regular users when consumed precisely as intended – and everything they do leads directly or indirectly to more death and suffering. Similar commentary applies to those now working in other harmful industries. These are not our friends. They know exactly what they do and should be held accountable. 4. Strong links between harmful industries and allied groups. They are both well-funded and well co-ordinated. Further, there are strong links between all these industries and their support groups. 5. Developing new approaches to resisting and undermining change. As the evidence on harm becomes more widely known, and the case for public health action strengthens, they become ever more adept at identifying and implementing new approaches to resisting change, undermining even the limited action that governments and health authorities put in place, and seeking out new markets. As (Deakin University’s) Peter Miller has outlined so well this morning (in his presentation:How do the vested interests of alcohol, tobacco and gambling steer our governments away from evidence–based public health policy?), these industries are immensely influential, and just as effective at using their influence. They have massive resources – on Monday we heard from President Vazquez that Philip Morris alone has an annual budget two or three times that of Uruguay. A quick glance over the weekend through the federal Parliament Lobbyist Register showed approximately 45 lobbyists with direct or indirect alcohol interests, over 30 for gambling and around 25 for tobacco – and that is only for declared third party lobbyists, let alone internal company board members, executives and lobbyists. In keeping with my comments about increased ruthlessness and new approaches, in recent years we have seen all the old tactics complemented by approaches such as: Apparently increasing use of former politicians and senior public servants in lobbying. Working through third parties (including organisations that may well have legitimate reasons to meet with governments). Soft and meaningless education programs. Seeking scientific credibility, funding research and researchers, publishing in sympathetic journals. Litigation against governments and health organisations. Attacking and intimidating public health organisations and individuals. Working through front groups and (to adapt President Trump) – fake organisations. Distraction approaches and charm offensives. Reassurance marketing and other action to undermine governments and health authorities. Using their campaigns on issues such as tobacco and alcohol to attack and undermine public health more broadly. And we can only expect their influence to increase – see here one summary of just some of the influences on the Trump administration. 5 ways to hold harmful industries to account So against that formidable backcloth, what can we in public health do? Marshal Foch famously said in the First World War, “My centre is giving way, my right is retreating, situation excellent, I will attack”. And that is what we should do. I want to propose five approaches to you, with a specific focus on holding harmful industries accountable. 1. Expose We need an increased focus from all sectors of public health in exposing the tactics and activities of the harmful industries. Just as there has been a constant stream of new approaches to demonstrating the harms of their products, so we should find new ways of exposing the ways in which the industries work, whether promoting to children and vulnerable communities or, as Bronwyn King has shown, in targeting their shareholders. We should expose their links with the front groups and abusers – the funders are just as culpable as their messengers. 2. Identify legal options. Industries such as tobacco are quick to use legal processes to oppose and delay public health measures. We should go down the same path – and encourage governments to do so. We have already in tobacco seen much successful litigation, on behalf of patients and their families, and through the US Master Settlement Agreement, on behalf of governments seeking to recover health care costs. Governments in Australia and elsewhere should plan for litigation to recover the costs of treatment from harmful industries. It takes time – but the results are worth waiting for. As Liberman and Clough have discussed in relation to tobacco, there may also be scope for litigation against major companies in terms of potential criminal liability. 3.Personalise the problem. As we have seen in tobacco, while the companies themselves are reviled, found guilty in courts, have to make massive payouts following litigation, and publicly pilloried – and some executives and PR people take any public heat, the individuals who are responsible for all their activities – Board members and Chief Executives – remain largely unscathed. They are treated as respectable figures in the business community. They participate in charitable and other boards and activities. And eventually they move into respectable retirement. So what will it take to change the nature of tobacco and other harmful industries? Perhaps it is time to personalise the problem much more – to focus attention not only on the companies themselves, but also on the individuals who are responsible for the companies and for the massive tolls of death and other harms caused by their products. It is time to hold them accountable personally and directly for all of those consequences. There are various ways in which this can be done, from quantifying and attributing harm to challenging these individuals personally and publicly. Is that tasteful? Perhaps not – but nor is the harm for which they are responsible; and we should recall that they and groups with which they are associated do not hesitate to personalise attacks on people who actually seek to promote and protect public health! In similar vein, I believe that we should also do more to expose the roles and activities of those who work with and lobby for harmful industries. 4. Make them pay for the consequences of their activities. Why should there not be levies on the profits of industries that knowingly promote harmful behaviours – even to children. It seems to me an entirely reasonable proposition that there should be legislation compelling these industries to transfer a percentage of their profits to action that will reduce their harms – with the caveat, of course, that this should be entirely independent of any involvement by or influence from the industries, which would only be interested in soft action or self-promotion. We have had hypothecated taxes – why not industry profit levies – applicable to both the major companies themselves and major sales outlets such as supermarkets. 5. Use of International Treaties. The WHO Framework Convention on Tobacco Control (FCTC) came into force in 2005, and is legally binding in 180 countries. Of course implementation is uneven and imperfect, but there is clear evidence that it has had a considerable impact in supporting, promoting and enabling evidence-based action to reduce smoking. I see no reason for tobacco to be unique. We should seek similar Treaties in relation to other pandemics where action is opposed by powerful vested interests, But beyond that, a key feature of the FCTC is Article 5.3 which mandates that: “In setting and implementing their public health policies with respect to tobacco control, Parties shall act to protect these policies from commercial and other vested interests of the tobacco industry in accordance with national law.” Implementation of course is again less than perfect, but Article 5.3, which applies across all arms of government, not only Health, is crucial in clarifying the tobacco industry’s pariah role, and reducing its capacity to influence governments and has been identified as the single highest priority for effective FCTC implementation. We should seek a equivalent of Article 5.3 for the major harmful industries. That may take time – so did the FCTC and Article 5.3 for tobacco – and would be fiercely opposed, but is a worthy target and challenge for us. What should be the roles of public health organisations in advocacy locally and internationally? Our resources may be modest, but we have evidence on our side, as well as many other organisations from the health and social arena, and more often than not public opinion as well. So I suggest that we should: Promote advocacy as a core role for all public health organisations. Ensure that advocacy becomes a core component of all public health training. Learn from what works – being professional and collegial; working in coalitions; ensuring consensus positions. Be creative – there is always scope for novel approaches. Stay with it. Expose and oppose the opposition. Work nationally – but also internationally, as our opposition does. Pursue the options for international treaties – further implementation of Article 5.3 of the FCTC, and equivalents of the FCTC for other areas. And fin ally, I want to show you my favourite tie. This tie was sent in the early 1990s to all members of the US Senate and Congress. On the front, as you can see, it reads “Democracy is not a spectator sport”. But when you look at the back, you see that it was “made exclusively for” – and of course distributed by – the Philip Morris tobacco company. So there is my final message for anyone who seeks to promote public health: Democracy is not a spectator sport. Some Twitter responses Please donate , subscribe or become a Croakey funder FacebookTwitterLinkedINWhatsappPinterestEmail Related Posts A former Health Minister asks, what can we learn from past public health reform successes (and failures)? 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