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When public health measures pass me by

In this morning’s Monocle Minute, there was a fascinating bit about a public health measure in Pakistan which had completely passed me by:

Pakistan’s Punjab province has taken an intriguing step to discourage its citizens from chugging too many cans, demanding that brands such as Red Bull and Monster remove the word “energy” from their packaging and replace it with “stimulant”. The move comes from the scientific advisory panel of the Punjab Food Authority (PFA), who ruled that the word was misleading. The PFA decided that the drinks do not provide people with nutritional energy per se, rather that the caffeine, taurine and guarana merely stimulate drinkers.

I think there is much to be done around the regulation of food packaging, as it often seems pretty misleading. But most of what I’d thought about previously was around claims about the “healthiness” of foods and claims about calorific content. In fact, I’ve had previous publications ranting about both the food industry and the public health response on the latter point, but don’t have any clear answers of my own to offer. I’d never really thought about the connotations of “energy” drinks as a name, so I think the story above is a really interesting development and I’ll be intrigued to see whether it spreads more widely.

Sometimes, even those of us in public health miss public health developments in our own country. I only recently because aware of the fact that liquid laundry detergent capsules are now packaged in opaque containers not because of changing consumer preferences but because of very sensible European legislation, designed to reduce their attractiveness to children.

That’s a public health legislative win by anyone’s yardstick… and while most had realised the packaging had changed, no-one in my office was even aware that the legislation existed. It’s amazing how much public health measures can pass by even those of us working in the field – we perhaps don’t do enough to celebrate public health achievements that aren’t badged like that.

A year or so ago, my friend James O’Malley wrote a great article revealing that Fuller’s pubs had gone sugar-free on soft drinks – years before the Soft Drink Levy came into force. This was a voluntary public health measure by a private business. Wouldn’t it have been great if, say, Public Health England or the Faculty of Public Health had seized on this as an example of responsible action and praised the chain – rather than simply ignoring it? Just a thought.

The photo at the top is a cropped version of this photo posted to Flickr by Mike Mozart. I’ve edited and re-used it above under its Creative Commons licence.

This 2,442nd post was filed under: Health, News and Comment, Posts delayed by 12 months, , , .

Acupuncture stings

In most of medicine, and in Health Protection in particular, one occasionally comes across people who have made questionable decisions which have had severe consequences. When people decline routine vaccinations or fail to use a condom for specious reasons, it can be both depressing and frustrating to be picking up the pieces.

It’s easy to rationalise that health is not at the top of everyone’s personal agenda and that sources of misinformation are common and commonly believed. At these times, it feels like the most productive outcome is to channel the frustration into improving the information on offer and trying to reach the people who have missed it.

A friend once told me to think of ‘health’, a topic which most of my life is dedicated to, in terms of ‘transport’, a topic with which I’m intimately engaged as a ‘user’ but in which I’m completely non-expert:

I might get frustrated that people don’t take obvious preventative health measures, but when was the last time I checked my tyre pressure, an obvious ‘preventative measure’ in the ‘transport’ world? (I’ve done it once in the nine years I’ve owned my car.)

I might get annoyed that people don’t have any idea of the true cost of their healthcare, but what’s the true cost of the public transport I take to work each day? (I’ve no idea.)

I might think that’s it’s patently obvious that homeopathic remedies contain no active ingredients and are a total waste of money, but what’s the evidence of benefit for the ‘premium’ grades of petrol? (I often buy them, even though there’s probably no benefit.)

And then, just occasionally, I come across something that seems so appalling unappealing that I’m baffled that anyone, medical knowledge or not, could possibly want to engage with it, let alone risk harm by doing so:

One type of apitherapy is live bee acupuncture, which involves applying the stinging bee directly to the relevant sites according to the specific disease.

Live bee acupuncture. Wowzers trousers. This paper by Vazquez-Revuelta and Madrigal-Burgaleta in the Journal of Investigational Allergology and Clinical Immunology, from which the above quote is taken, reports a terribly sad case of a 55-year-old woman who died from live bee acupuncture.

The paper reports that she’d been attending four-weekly for two years for the procedure, with the aim of treating

muscular contractures and stress.

As one might expect,

the risks of undergoing apitherapy may exceed the presumed benefits, leading us to conclude that this practice is both unsafe and unadvisable.

There is little about this paper which isn’t at least mildly astonishing. But then I wonder… I don’t know what the transport equivalent of intentional bee stings might be, but perhaps I engage in that too.

The alarmingly cute picture of a bee at the top of this post was posted on Flickr by Ozzy Delaney. I’m reusing it here under its Creative Commons licence.

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‘Broadcasting’ rules need to keep up with streaming services to protect health

A couple of news stories I’ve read lately have made me think about our approach to regulation of advertising.

First, there was this story by Travis M Andrews in The Washington Post about the portrayal of smoking in shows made for streaming services:

Among the vices often embraced by streaming services and avoided by broadcast television is tobacco in all in its forms … A study compared seven popular Netflix shows to seven popular broadcast shows. In this sample, it found Netflix’s shows featured characters smoking almost three times as often as those produced by broadcast networks like NBC, ABC and CBS.

Now, we could spend all day poking holes in this ‘study’, but the thought is still going to fester: it does seem like there might be more smoking in these shows than in those on broadcast TV.

Second, there was this BBC Trending story by Branwen Jeffreys and Edward Main about YouTube stars being paid to encourage kids to cheat on school assignments:

YouTube stars are being paid to sell academic cheating, a BBC investigation has found. The BBC Trending investigation uncovered more than 1,400 videos with a total of more than 700 million views containing EduBirdie adverts selling cheating to students and school pupils. In some of the videos YouTubers say if you cannot be bothered to do the work, EduBirdie has a “super smart nerd” who will do it for you.

This isn’t so obviously related to health but does highlight an issue with inappropriate advertising within online streams which are typically seen by children and young people.

Both of these stories made me reflect on the work that has gone into restricting advertising of harmful products such as cigarettes and energy dense foods, and how the fruit of that work might be lost if legislation doesn’t keep up with changing media consumption habits.

For example, there are no regulations around the portrayal of smokers on streaming shows, whereas broadcast shows must comply with Ofcom’s rules, including Rule 1.10:

Smoking must generally be avoided … unless there is editorial justification.

There seems to be non-stop debate in the media press about whether TV ads or online ads are more ‘impactful’, with the conclusion usually predictable according to who has funded or published the work. But it does seem increasingly clear that many people (including me) are now watching more streamed content than broadcast content, and that this is more common among younger people.

It’s hard not to worry that the slow pace of legislative change might cause us to unintentionally slide back to an era of lesser regulation of what is actually seen despite strong evidence of harm. We really mustn’t let that happen.

The photo at the top was posted on Unsplash by Tina Rataj-Berard and is used here under the Unsplash licence.

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The credulity of most Apple coverage

Over my cornflakes this morning, I read Ben Hoyle’s interview with Tim Cook, CEO of Apple, in The Times Magazine.

This was one of those interviews which is sort of interesting but doesn’t really say much. Though I was quite taken with this description of Apple’s canteen where the cutlery is hidden from view in an illuminating example of form over function:

You can’t tell what the chefs are cooking because there are no menus on display (the options are on your phone if you’re an employee). You don’t seem to be able to pay cash for anything and there are no sauce sachets or eating utensils to be seen unless you know where to look (they’re with the other unsightly essentials like bottled drinks and napkins, sunk out of sight in smooth, curved central islands reminiscent of giant iPods).

What really struck me about this interview was the weird cognitive dissonance in the tenth paragraph. In this paragraph, Hoyle points out that:

Apple’s App Store is “curated” to the extent that you (and your children) won’t find hate speech or pornography on there.

That is, Apple – for better or worse – prioritises its values over the freedom of its customers to easily use the platform for activities which meet with disapproval from Apple. I wish this (puritanical?) attitude had been used to challenge in this bit of the same paragraph:

Apple has regarded privacy as “a basic human right” for a long time and “built the company around” that belief. The sprawling, intimate personal data profiles that companies like Facebook and Google compile “shouldn’t exist”, Cook thinks.

Cook claims that Apple is built around privacy. Yet, while Apple is happy preventing access to hate speech on the App Store, it actively promotes the Facebook app despite it asking for user permission to build data profiles which Cook says are antithetical to everything Apple stands for.

This seems a really odd moral position to me: if your company is reputedly built around one “basic human right”, why allow apps which violate that fundamental belief and ban apps which contravene less dearly held standards? The answer seems fairly obvious to me: the Facebook and Google apps are among the most popular, and are core to the iPhone experience. But can you really claim something is a cornerstone value if you ignore it to sell more phones?

I was also a bit riled up by this ludicrous comparison:

On cybersecurity … the company also protects its FaceTime and Messages apps with end-to-end encryption unlike, say, Google’s standard Gmail.

Why compare a closed messaging system, where end-to-end encryption is easy, with an open standard like email? That reads like a line supplied by Apple. It should have been challenged by asking if Apple’s iCloud email service protects messages with end-to-end encryption, which of course it does not.

There are a lot of things that Apple does extraordinarily well. It is evidently one of the corporate success stories of our time and has inspired phenomenol brand loyalty among a huge population of users. But it isn’t perfect.

Much of the media, and Hoyle’s article is no exception, seems far too credulous when it comes to Apple. Coverage of Apple would be much more satisfying if it showed a degree of balance or at least an attempt at challenging some of the more outlandish media lines rather than simply repeating them verbatim.

The picture of Tim Cook at the top of this post was uploaded to Flickr by Fabio Bini, and is used here under its Creative Commons licence.

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How much would you pay to keep using Google?

The Economist’s data team has today published a blog post called “How much would you pay to keep using Google?” Unusually for The Economist, the headline isn’t really an accurate representation of the contents, which actually discuss research findings related to the amount people would have to be paid to give up using search engines in general.

But the original question got me thinking. A couple of years ago, I’d have responded with a fairly substantial sum. These days, I’m not so sure. I wonder what that says about the state of the company?

Google used to be the only decent search engine. That is no longer true. A couple of years ago, I decided to see if it was possible to go all-in on Bing. Ironically, this was somewhat inspired by Matt Cutts, formerly of Google, who gives himself 28-day challenges to test assumptions and better himself. Surely, I reasoned, it can’t be as bad as people make out, nor as bad in daily use as an occasional search to try it out makes it seem. I switched my default search engine to Bing in Chrome and on my mobile.

And do you know what? The vast majority of the time, it is perfectly competent. On very rare occasions when I’m struggling to find something I also try searching on Google: I’d say 75% of the time, I also fail to find what I’m looking for there. I’d also say, without any proper data to back up the assertion, that Bing’s results seem less replete with spammy useless links than Google’s. And Bing’s rewards scheme buys me an occasional coffee. I don’t think I’d pay for Google search.

But of course, Google provides more than just search. Would I pay for other components of their offer?

Would I pay for Gmail? There are perfectly decent alternatives to Gmail, and I rarely use my actual Gmail address but forward stuff to it from elsewhere, so redirecting future mail wouldn’t be a problem. Moving the archive would be a pain. I’d probably pay a small fee—a pound a month?—just to avoid the hassle.

One service I would definitely pay for is Google Maps. I use Google Maps every day and have not found anything that can even begin to compete. Back in December, Justin O’Beirne wrote a great essay on Google Maps’s moat—the content and time barrier which keeps it well ahead of competitors. On these terms, I guess Google Maps is probably the most “valuable” bit of Google to me.

Google Drive is great, but OneDrive is pretty great too. Chrome is my current default browser, but I’d happily switch to Firefox. Google Calendar is actually quite irritating (especially since ‘quick add’ was removed) and I use it only because it’s handy. I like my Android phone, but I’d get by on iOS. I’d be sad to lose my Chromebook, but Windows laptops aren’t quite the horror shows they used to be.

I enjoy watching occasional Youtube videos, but I wouldn’t really miss them if I couldn’t watch them any more. I use Google Photos, but I also upload all of my photos to other cloud services, at least in part because I don’t trust Google not to shut down Photos when it turns its attention elsewhere (à la Google Reader or Google Notebook, both of which closed while I was an active user).

More recent Google developments (Home, Assistant, Allo, Duo, Now) have totally passed me by.

Jeff Jarvis used to talk about “livin’ la vida Google” to describe his complete immersion in the Google universe. A couple of years ago, I’d have put myself in a similar category, but no longer. I am only one person, and I’ve no idea how ‘typical’ I am in this context, but I wonder if my change in behaviour represents a wider portentous shift for Google’s fortunes?

The photo at the top was posted on Flickr by Sigurd Magnusson, and is reproduced here under its Creative Commons licence.

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The next calling point for this service will be…

I usually try to avoid ‘grumpy’ columns in magazines. As a general rule, they are not very interesting and are not nearly as funny as the author intends. Turning a ‘moan’ into interesting writing is a tricky skill to pull off.

All of that aside: In 1843 magazine, Adrian Wooldridge recently wrote about irritating announcements on public transport:

Some companies seem to revel in redundancy. In the railway world Amtrak is the champion of verbosity. Recorded announce­ments on its trains proclaim the arrival of each station with a peroration ending in a request to “please take this time to look about you and collect your bags”, as though the majority of passengers were otherwise likely to canter off the train in a spiritual ecstasy, leaving their material possessions in their wake.

This complaint touched a nerve. When I was commuting to London on a weekly basis a few years ago, there was one particular train guard whose name became lodged in my memory, so annoying were his announcements. His tone tended to convey a weary sense of superiority: it was with some mild irritation that he reminded passengers to check that their tickets were valid for this particular service, as though only a moron could be confused. He spoke extremely slowly, as though he had been told in training not to speak too fast and had overcorrected. And, most irritatingly of all, he seeemed intent on lengthening every announcement to the greatest possible extent by including superfluous words.

Peterborough would never be the ‘next stop’; it would inevitably be ‘the next station stop at which our service will be calling this morning’. Passengers should not merely content themselves with ‘reading the displayed safety instructions’; rather they should ‘be sure to fully familiarise themselves with the safety information cards displayed on the walls of the vestibules at the end of every carriage on board this service’. Customers should not simply ‘have tickets ready for inspection’; they should ‘be aware that a full ticket check will now take place in all coaches, starting from Coach B at the front of the train, and ensure that they have all tickets, travel documents and railcards to hand both at their seat and when moving around the train.’

The verbosity was almost too much to bear. So while I disagree with Adrian’s preference for not knowing the names of service workers and wearing headphones through safety demonstrations on aircraft, I find it hard not to have a little sympathy with his complaints about excessively loquacious train guards.

As an aside, on a recent train journey, the guard issued the typical reminder that passengers should “take all of their personal belongings with them”. Somebody loudly responded that this wasn’t practical, as most of their personal belongings were at home rather than on a train. I’ll laughed quite loudly, despite myself.

The image at the top is of a Virgin train at Brighton station. The full version was posted on Flickr by Matt Davis, and I’ve reproduced a cropped version here under its Creative Commons Licence.

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Knowledge and understanding

I recently finished reading Don Bartlett’s translation of A Death in the Family, which is the first volume of Karl Ove Knausgård’s radically honest autobiography. It took me a long time to get through this book (around three months) because I found it so intense that I had to read sections at a time, interspersed with other books. Nonetheless, I thought it was a masterpiece.

Roughly halfway through, Knausgård writes:

There is no one who does not understand their own world. Someone who understands very little, a child, for example, simply moves in a more restricted world than someone who understands a lot. However, an insight into the limits of understanding has always been part of understanding a lot: the recognition that the world outside, all those things we don’t understand, not only exists but is also always greater than the world inside.

This caused me to reflect for quite a long time and stimulated a couple of thoughts to jot down here.

The description of people understanding their own world and being restricted to the world they understand is fascinating. I think there are lessons in that formulation for public health. People frequently make choices which are, by any objective measure, bad for them: smoking, refusing vaccinations, drinking a G&T while blogging. But taking action which is objectively harmful isn’t necessarily irrational, and we often forget that.

If someone’s understanding of their world is that vaccinations cause harm to children, then refusing vaccination is a rational choice in line with their understanding. Their understanding is wrong, but they are acting rationally within the limited world in which they move. If we are to effectively influence the behaviour, then we need to inhabit the world to understand the rationality of the choices people are making. Unpicking the reasons for the incorrect understanding and setting about correcting it is likely to lead to greater success than lecturing people.

At work, there is a sign in the lift which reads “Could you have taken the stairs?”. The answer for me is invariably “no”—I only take the lift when I’m unable to take the stairs—and every time I see the poster I get mildly annoyed at its accusatory tone. It also seems unlikely that it changes anybody’s behaviour, given that it is only seen after someone has decided not to take the stairs. It’s a poster that doesn’t have any effect on anyone’s understanding, nor does it expand anyone’s worldview.

I realise this is a fairly incoherent ramble (see also the reference to drinking and blogging), but I suppose my point is that public health interventions should try to be less preachy and more practical.

In professional life, it isn’t uncommon to hear people imploring other people to ask questions if they don’t understand something. “There are no stupid questions” and “If you’re thinking it, someone else is thinking it too” are commonly heard refrains. And yet, professionals often remain frightened to ask questions which they think might reveal a degree of ignorance.

A few years ago, after a particularly tense meeting which had featured the world “I really don’t understand what you’re talking about”, a former supervisor gave me a one-to-one aside of valuable advice which they said it had taken many years to learn: “If someone is coming to talk to me and is so poor at pitching what they say that I can’t follow it, it is my professional responsibility to politely challenge that by asking them to explain themselves. It solidifies my reputation as someone who is engaged, intelligent and listens to what people say.”

This made me pay much more attention to my own and others’ reactions to people asking questions. The first thing I noticed was the frequency with which, when challenged, people often weren’t able to explain their waffle. This is useful because it helps people to make a value judgement about the rest of what someone is trying to tell them. The second thing I noticed was that when people could explain, they were usually happy to do so, and altered the rest of their ‘pitch’ to a more appropriate level. The third thing I noticed was that my respect for the person who asked the question generally increased.

This completely changed my perspective, and I now regularly ask questions which I’d previously have thought might make me look stupid. This took an effort at first, of course, but now comes naturally. Sometimes the questions I ask are bloody stupid and I should know better—but rarely, and when it does happen, it at least gives people a laugh. I don’t know if it’s bolstered my reputation, but it has certainly meant that there are lots of things I now understand that would have otherwise passed me by.

“An insight into the limits of understanding has always been part of understanding a lot”.

I took the photo at the top of this post at Charles de Gaulle airport. It is a chandelier, which has absolutely no relevance to the content of the post. I just thought it was quite pretty.

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