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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 2,443rd post was filed under: Health, News and Comment, Posts delayed by 12 months, , , .

‘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.

This 2,440th post was filed under: Health, Media, Posts delayed by 12 months, , , , , , .

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.

This 2,435th post was filed under: Posts delayed by 12 months, , , , , , , .

Cruise ships and me

Last week, I read this remarkable story about a new cruise ship by Oli Franklin-Wallis in Wired, and have been thinking about it ever since:

Symphony of the Seas – which, on its maiden voyage from Barcelona in March 2018 became the largest passenger ship ever built – is about five times the size of the Titanic. At 362 metres long, you could balance it on its stern and its bow would tower over all but two of Europe’s tallest skyscrapers. Owned and operated by Miami-based cruise line Royal Caribbean, it can carry nearly 9,000 people and contains more than 40 restaurants and bars; 23 pools, jacuzzis and water slides; two West End-sized theatres; an ice rink; a surf simulator; two climbing walls; a zip line; a fairground carousel; a mini-golf course; a ten-storey fun slide; laser tag; a spa; a gym; a casino; plus dozens more shopping and entertainment opportunities.

Cruise ships mean two things to me.

Earlier this year, I went on a ‘mini-cruise’ from Newcastle to Amsterdam aboard a DFDS ship. The journey was an overnight 15 hour or so thing, so certainly not equivalent in any way to spending weeks at sea on the world’s biggest cruise ship. The rationale for this was that I fancied a last-minute break and couldn’t find a cheap flight from Newcastle, so went on a cheap boat instead, spent a day in Amsterdam, and took a cheap flight from there. This worked remarkably well, and I’d do it again.

This was the first time I’d been on an overnight boat since our annual family camping trips to France when I was a child. Prior to going, I’d sort of thought in the back of my mind that I might be the sort of person who might one day enjoy a proper cruise. This experience put me off.

The ship was lovely, and I was particularly impressed by the cabin. I had expected a pokey bunk-bedded hovel but was actually rewarded with a fairly large space which looked not unlike a Travelodge room, with an en-suite bathroom. The food on board was also much higher quality than I would have expected. But I am somebody who likes to wander—and even with only 15 hours on the ship, I was itching to get off and explore. Exploring the ship felt a bit constrained.

It was silly of me not to realise this in the first place. Wendy and I ruled out going to an idyllic holiday resort last summer for the sole reason that it was located on a main road along which walking was not advised, so we couldn’t ‘go for a wander’ without catching a bus or taxi somewhere first. I hadn’t really clocked that ‘going for a wander’ wasn’t really a go-er on a ship.

While the Symphony of the Seas is ridiculously bigger than the ship I was on (it’s more than twice as long and can take four times as many passengers across twice as many decks), I still think I’d feel ‘cooped up’ pretty quickly. So I don’t think I’ll be going cruising anytime soon.

My other relationship with ships is professional. One of the more esoteric parts of my role as a Consultant in Health Protection is that I am the designated Medical Officer for a number of ports. This gives me certain legal responsibilities relating to ships and the health of their crew—most of which are thankfully delegated to people much more expert than me. But just imagine how complex an outbreak of norovirus or Legionnaire’s disease could get on a ship as huge as Symphony of the Seas. I was fascinated to read in Oli’s article about some of the steps taken to mitigate the risks:

“The level of hygiene is extreme,” Yrjovuori announced, as we passed a hand-washing station. Though ship-wide outbreaks of sickness make the news at least once a year, the total number of passengers who fall ill is a fraction of one per cent. But close quarters enable outbreaks, so sanitation regulations at sea are stringent. Every part of the ship, from lift buttons to the casino’s chips, are sanitised daily; interior materials have to stand up to the high level of chlorination from the constant cleaning. Rubbish is frozen in vast storage containers to slow bacteria growth and is only removed in port.

Fascinating stuff… perhaps we could even try and replicate some of it on land!


The pictures in this post are my own from the above-described ‘mini-cruise’ adventure. The pictures in the Wired article are a great advert for the power of print, looking far more arresting as double-page spreads than as on-screen images.

This 2,431st post was filed under: Health, Posts delayed by 12 months, Travel, , , , , , , , .

2D: The economics of science & healthcare

The link between the two articles in this 2D is health and economics. It’s a reasonably weak link, granted… but it’s a link nonetheless!

The first article I’d like to recommend is this long and thoughtful interview with Bill Gates by Ezra Klein of the Washington Post, which carries the arresting title “death is something we really understand extremely well”. He talks through some of the financial decisions his Foundation makes, and the economics of disease eradication. I found it quite fascinating.

The second article is really rather different. For Priceonomics, Alex Mayyasi gives a history and economics lesson to explain why articles in scientific journals are, more often than not, behind a paywall. He argues, too, that the system needs to move on and develop in the 21st century. As someone who spends a disproportionate amount of time whining about medical journals and their paywalls, I found this detailed blog post very interesting and informative.

2D posts appear on alternate Wednesdays. For 2D, I pick two interesting articles that look at an issue from two different – though not necessarily opposing – perspectives. I hope you enjoy them! The picture at the top of this post was uploaded to Flickr by Howard Lake, and has been modified and used under Creative Commons licence.

This 2,039th post was filed under: 2D, Health, , , , , , .

Blood donation by numbers

Regular readers will know I’m a fan of infographics, and I thought this was was particularly powerful (though clearly more “graphic” than “info” – what’s with that 50% reduction “graph”?). Still, it’s a powerful message – 100,000 new donors needed in the next few weeks. Sign up to give blood today.

This 1,912th post was filed under: Health, , .

Photo-a-day 297: Success

20121024-170828.jpg

I’m celebrating tonight, as this letter arrived today to inform me that I’ve passed my Part B exam, and so earned membership of the Faculty of Public Health.

This is both scary and exciting on a couple of fronts: firstly, I’ve passed all the exams I need to pass to become a consultant in public health; secondly, for the first time since I was nine years old (the current age of my oldest nephew), I’ve no exams planned in the next twelve months. Or at all, for that matter.

It surely won’t be long until I end up like this:

[flashvideo filename=”http://sjhoward.co.uk/wp-content/uploads/2012/10/lisaclip.flv” ratio=”4:3″ /]

This 1,861st post was filed under: Photo-a-day 2012, Video, .

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