MENZIES CENTRE FOR HEALTH POLICY  -  2007 ORATION  -  17 September 2007

Roger S. Magnusson

Centre for Health Governance, Law & Ethics

Associate Professor, Faculty of Law, University of Sydney

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On a crisp autumn day in late November 2003, the well-known British expat journalist and political commentator Christopher Hitchens went on a crime spree in New York City.

During the course of the day, he sat on an upturned milk crate, he took his feet off the pedals while riding a bicycle, and he engaged in some loitering by sitting down on the subway steps.

In his article, Hitchens bemoans the over-reach of law, including laws that have deprived restaurant owners of the choice of allowing their customers to smoke.

Hitchens also repeats a story about Professor Sidney Morgenbesser, an American philosopher and pipe-smoker, who on one occasion put his pipe in his mouth as he ascended the New York subway steps. A policeman saw this and told him there was no smoking in the subway.

To which Morgenbesser replied “that he was leaving the subway, not entering it, and had not yet lit up”.

This didn’t satisfy the policeman, who then resorted to: “If I let you do it, I’d have to let everyone do it”.

To which Morgenbesser replied, “Who do you think you are – Kant?”

Michael Bloomberg comes in for ceaseless abuse throughout Hitchens’ article.

Hitchens end with this assessment of the man who may yet run for US President:

“Who knows what goes on in the tiny, constipated chambers of his mind?

When I read this story I decided to dig a bit deeper. It turns out that the editor of Vanity Fair, Graydon Carter [SLIDE – 6] had been reported to the Health

Department by his own staff – and fined - for having a cigarette in his office – with Hitchens.

Here’s a picture of the on-line complaint form that this unknown member of staff probably used.

Reflecting on the laws that eliminated smoking carriages on trains, Hitchens remembers thinking:

In liberal societies, public health regulation is least controversial when it targets contagious diseases, pollution and toxins, and other “external” threats that pose a risk to society collectively (such as bioterrorism).

Lifestyle diseases, on the other hand, are seen to be the consequences of private choices, and invite the response that people should be left to live their private lives as they choose. No one wants a nanny state.

It is an attitude that translates into strong support for economic freedom, voluntarism, and a latent mistrust towards the motives and merits of government interventions.

One might have thought that monitoring the cardiovascular health of train drivers by means of health checks, was a not unreasonable response to a fatal train disaster.

Before moving on, let me give you a British example. In July 2006, the actor Mel Smith vowed to defy a Scottish smoking ban by smoking a cigar during a play at the Edinburgh Fringe Festival in which he was playing no other than Winston Churchill.

The play calls for Churchill to offer a cigar to the visiting Irish revolutionary leader Michael Collins and to say:

“You have a long way to come if you have never enjoyed a Romeo & Juliet.

An enthusiastic cigar smoker off-stage, Smith said:

I will not have people protecting me from myself. That’s the whole problem with this country….[This ban] would have delighted Adolph Hitler.  Adolf Hitler, as you know, was anti-smoking. You couldn’t smoke at Adolph Hitler’s dining table, so he’d be pleased, wouldn’t he?

The Chief Executive of Ash Scotland took a slightly different view. She said:

The theatre is a workplace. This law was brought in to protect people in the workplace….When actors take drugs on stage they don’t really inject.

Smoking is perhaps an easy example, but the protestations of Hitchens and Smith illustrate an important truth.

Despite intense interest in the media and in the community about how we might live longer and healthier lives, the fact is that not everyone shares the goals of eliminating smoking, exercising more, and moving towards diets that are lower in sugar and saturated fats.

Public health advocates tend to think of themselves as “progressives” (whatever that means), and yet perhaps the most important challenge to a more expansive role for public health policies and law come from old-style liberals and others who regard economic and personal freedom, personal responsibility, and small government, as paramount virtues.

Suddenly thrust into the role of “nannies”, do-gooders, wowsers, and “picknose control freaks”, the public health movement is struggling to come to terms with the challenges that lifestyle diseases impose on policy-makers.

Responding to the “libertarian critique” of public health interventions in the area of chronic disease is therefore an important task, and that is what I want to talk to you about this afternoon.

Over the past few hundred years, the liberal impulse has become part of the bedrock of our society. It has two parts:

º Liberty, or freedom to make choices in one’s life;

º And personal responsibility for the choices thus made.

The liberal impulse translates into a populist view which disapproves of regulation and frames personal lifestyles in terms of the internal preferences of each individual. If individuals insist on smoking, eating a poor diet, and living a sedentary lifestyle, what can governments do?

Public health advocates, on the other hand, typically think of lifestyle risks as part of a broader system of determinants, many of which are beyond the control of individuals.

A public health approach asserts that responsibility for lifestyle diseases is shared more widely, and that in view of their responsibility for the public’s health, governments should act assertively to make healthy lifestyle choices easier.

This debate isn’t going away soon. How it is resolved will be central to the likely effectiveness of future efforts to reduce death and disability in Australia.

In my time this afternoon I would like to address this debate from several perspectives.

First of all, let’s briefly consider what’s at stake by looking at some of the determinants of the burden of disease in Australia.

Secondly, I want to outline a simple model for understanding different approaches to the regulation of lifestyle diseases.

And thirdly, I will -
consider the libertarian critique of chronic diseases regulation; and
defend a population health approach to policy in this area.

A quick tour of statistics provided by the Australian Institute of Health and Welfare confirms what many of us know already.

A significant proportion of the burden of disease in Australia can be attributable to a select number of proximate, lifestyle-related risk factors.

These include behavioural risk factors relating to diet, smoking and physical inactivity. As well as physiological risk factors that are at least partly modifiable through a healthy lifestyle, such as overweight and obesity, high blood pressure, and high blood cholesterol.

If health policy-makers could influence people’s lifestyles effectively, they could make a sizeable impact on mortality from preventable conditions, and the accompanying disability that typically leads up to death.

The diseases we could do most about include:

􀂁 cardiovascular disease, which is still the largest single cause of death in Australia, and a leading cause of disability.

SLIDE: Cardiovascular disease (CVD)

􀂁 CVD includes coronary heart disease and stroke

􀂁 Leading cause of disability: 6.9% of population have CVD-related disability

􀂁 Largest single cause of death in Australia: 47,637 deaths in 2004 (36% of total

􀂁 17% of overall disease burden in 2003

􀂁 $5.5 billion in direct health care expenditures

􀂁 Preventable risk factors:

􀂁 smoking,

􀂁 high blood pressure,

􀂁 high blood cholesterol,

􀂁 insufficient physical activity,

􀂁 overweight and obesity,

􀂁 poor nutrition,

􀂁 Diabetes

See further: AIHW, Australia’s Health 2006, pp 60-61

􀂁 Secondly, diabetes – up to 950,000 adults have diabetes in Australia, up to half of them aren’t aware of it. And again, healthy lifestyles can reduce the risk for Type 2 diabetes.

SLIDE: Diabetes

􀂁 An estimated 950,000 Australians adults (25+) had diabetes (1999-2000), 7.5% of population; up to half are unaware of it

􀂁 11,735 deaths in 2004 related to diabetes

􀂁 Diabetes also a major cause of disability

􀂁 5.8% of overall disease burden in 2003

􀂁 $812 million in health care expenditures

􀂁 Preventable risk factors for Type 2 diabetes:

􀂁 Obesity;

􀂁 Physical inactivity;

􀂁 Poor nutrition – inadequate fruit and vegetable consumption

See further: AIHW, Australia’s Health 2006, pp 68-74

􀂁 There are also several other conditions, including chronic obstructive

pulmonary disease and lung cancer, that are almost exclusively caused by

tobacco smoking, and almost completely preventable through smoking

cessation.

SLIDE: Tobacco-related diseases

􀂁 Chronic obstructive pulmonary disease affects at least ~3% of

population, potentially affects all smokers (and others exposed to ETS);

􀂁 leading cause of death: 5,200 deaths in 2004 (3.9%);

􀂁 54,000 hospital separations;

􀂁 $432 million in health system expenditure;

􀂁 3.6% of overall disease burden in 2004.

􀂁 Almost completely preventable through smoking cessation

􀂁 Lung cancer: 9,200 cases (projected) in 2006;

􀂁 leading cause of death: ~7,300 in 2004 (5.5%);

􀂁 17,700 hospital separations;

􀂁 mortality to incidence ration remains high (0.82)

􀂁 Almost completely preventable through smoking cessation

I’ve now reached my second theme.

To put the debate about personal responsibility and lifestyle diseases in better perspective we need a conceptual framework for understanding the implications of different approaches to regulation.

As you can see in this simplified but fairly conventional model, health outcomes within and between populations are typically described in terms of a hierarchy of influences. In this slide you can see that the determinants of health begin with:

º global influences, right at the top. These include factors such as the industrialization of food production and distribution, urbanization, global competitive pressures creating the stressful urban lifestyles we know and love, the activities of multinational food and tobacco companies, and other factors.

º At the national level, the model also takes into account the impact of the economy, the environment, and culture;

º It takes account of the local environment we live our daily lives within, and this includes the built environment, the workplace, housing and transport systems;

º At the bottom right-hand corner of the model are health care interventions.

Health care interacts with all the other determinants, and our genetic endowment and physiology, our bodies – to produce health outcomes at the individual and population level.

Within each of these coloured domains, or levels of the model, many more specific determinants exercise their influence upon health, either negatively as risk factors, or positively as protective factors.

Some determinants, of course, can’t be changed, like our genes, age, sex, and basic metabolic rate.

Whereas other determinants clearly are modifiable to a greater or lesser degree:

our diet, smoking status, physical activity, and even education.

In historical terms, the twentieth century reflects a gradual broadening of the determinants that are understood to contribute to states of health and illness in the population, and a growing realisation of their complexity and interrelationships.

If we recognize that health is a complex outcome that is the result of influences and interactions at a variety of different levels, then we can also see that each level creates opportunities for public health interventions.

This slide shows the same hierarchical model of the determinants of health on the left.

This model provides a kind of geography for understanding the intentions of various public health policies, and for locating where policy attention tends to be directed in places like Australia.

Let’s take cardiovascular disease as an example. You’ll remember that it is the largest single cause of death in Australia.

Clearly we need to do more than just treat disease when it manifests, because treating it does nothing to prevent new cases.

So our next strategy is to search out individuals who are likely candidates for developing chronic disease.

So, as the light blue panel on the right hand side of the model illustrates, our disease prevention strategy could target those who have already had a heart attack (secondary prevention); or it could target those with specific risk factors such as high blood pressure, cholesterol and smoking (primary prevention).

Many of you will know far more than I about the work that is being done – through the Australian General Practice Network, through the introduction of new Medicare item numbers, through Lifescripts and other initiatives – to improve the capacity of the primary care system to identify and manage patients with risk factors for chronic disease.

If you then look up to the light green panel, you’ll see that we can expand our strategy into the community: targeting specific high-risk groups in the community, or indeed seeking to educate the society at large about risk factors and how to reduce them.

In the interventions that seek to engage with context, and with place, you’ll notice something important.

Rather than engaging with people and their behaviour directly, policy is now engaging in specific settings and with places and processes and the economic and social forces that channel and create patterns of behaviour.

On the other hand, policies that engage with place and with context do have the capacity to influence the average health status of broad populations. Their reach is much wider.

Staying with the example of cardiovascular disease, policies at this level could potentially address many issues. These include the cost and accessibility of fresh fruit and vegetables, levels of salt, fat and sugar in the national diet, the built environment and opportunities for physical activity, and the influence of social and cultural factors including the promotion of high-fat foods, and of course tobacco control.

If you’ll let me take this model one step further, you can see that health policies that respond to lifestyle diseases can be grouped into three main categories.

First of all, policies that:

º support better treatment for individuals with chronic diseases and associated risk factors;

Secondly, policies that:

º focus on behaviour modification, through education and other means, whether directed at high risk groups or society generally; and

Thirdly, policies that:

º seek to engage with broader environmental or ecological determinants in order to reduce risk factors across the population.

A comprehensive approach to disease prevention might try to do all these things.

My aim in talking about the determinants of health is not to play epidemiologist, but to point out the pervasive influence of personal autonomy and personal responsibility as it affects health policy at each of these three levels.  Let me explain what I mean.

The theme of liberty and personal responsibility is anchored very firmly in medical law; that is, in law’s regulation of clinical care.

Personal autonomy is reflected in the American notion of “informed consent”.

This is the idea that, provided they act with reasonable care and tell you about the risks, health professionals can delegate the risk of a bad outcome to theindividual.

Patients exercise their personal autonomy in deciding whether to undergo the treatment, or surgery, or medication, but they bear full responsibility for the risks of misadventure.

How, then, does the ethic of personal autonomy affect policy at other levels?

In public health policy, liberty and personal autonomy have re-constituted epidemiological theories, and the result is that the causes of health problems within a population – think of diabetes, or obesity, or poor dental health – tend to be seen narrowly in terms of their proximate, behavioural causes.

Tobacco, obesity and “lifestyle diseases” tend to be framed in reductionist terms, as the price paid for bad habits that are somehow abstracted from their surrounding context: the price, easy availability and skilful marketing of tobacco, the relentless marketing of high-fat, high-sugar, high-salt foods, the price of a basket of foods making up a healthy diet, urban lifestyles and landscapes crowding out opportunities for physical exercise, and so on.

This slide shows you the “common sense” view of the causes of chronic disease.  You can see that the wider economic and social context of individual choices is ignored. These broader factors belong to other sectors, other Ministerial portfolios, other departments, and they are all too often ignored in public health policy.

The language of the Minister for Health and Ageing, Tony Abbott, provides an illustration of this commonly held view. Notice how the Minister frames the problem of obesity in this opinion piece in the Sydney Morning Herald:

I think Australia is lucky to have a Health Minister who practices what he preaches when it comes to healthy living.  I doubt many of us would be upright, let alone smiling, after a 100km run.  I agree with the Minister that the only way for an individual to lose weight is to eat less and to exercise more. We can’t assume, though, that populations will behave like motivated individuals.

A strategy of mass education and encouragement, without more, leaves government with the cost of funding treatment for chronic illness, but without the policies that could prevent new cases arising.

Finally, let’s turn from the behaviour of individuals to the socio-economic policy sectors and settings where laws and policies need to engage if they hope to influence patterns of behaviour across the population.

Personal autonomy has emerged as a pre-eminent value here as well. In the marketplace it is expressed as consumer choice, and freedom of contract. For profit enterprises defend their interests vigorously, and free market principles provide a powerful ideological barrier to too much legal interference.

So to sum up. In so far as law or policy seeks to regulate individual behaviours in ways that move beyond education and advice-giving, it runs the risk of offending civil libertarians.

In so far as it moves upstream, and seeks to interact with the social and economic determinants of chronic disease, in accordance with a determinants of health approach, it risks offending the free marketeers.

And in so far as law seeks to address that share of poor health that arises from health inequalities, it rapidly attracts the controversies that surround all attempts to re-shape the political economy.

Critics fume that public health should stick to what it does best: communicable diseases control, and keeping bugs out of the food supply. And they resent public health becoming a smokescreen for interference in market economies, or for launching some ambitious social justice project.

And that’s not all. From a practical and logistical perspective, many of the universal prevention policies that are required if you want to respond effectively to lifestyle diseases require policy-makers to engage with ministries and sectors outside of health.

And of course federalism complicates everything.

I’ve now reached my third theme. I want to consider what I call the “libertarian critique” of public health initiatives in the area of chronic diseases and lifestyle risk factors.

In a major speech in 2006, former British Prime Minister Tony Blair said that:

Epstein’s world view raises a number of issues, not all of which I can address here.

One response is to question whether, in fact, non-communicable diseases are non-communicable.

More generally, the possibility that obesity and other risk factors for chronic disease should be “socially transmissible” should come as no surprise.

But so what? There may be social pathways for the spread of risk factors for chronic disease, but I don’t think the case for responding to chronic disease should rely on harm to others or the analogy with infection.

At the empirical level it seems reasonable to argue that hitherto, with the exception of tobacco, private markets have not been burdened by a comprehensive suite of laws or policies focused on obesity or chronic disease. If private markets have an inherently health maximizing effect, then why are things getting worse?

Population health advocates would argue that market forces – past and present – have contributed to patterns of eating, drinking, smoking and physical inactivity that are reflected in current rates of chronic disease. Unless we do something about it, these problems will only get worse as the population ages.

Epstein’s assumptions about the circumstances in which state intervention is justified also warrant closer scrutiny.

(In the US context, my concern is that this would only increase the size of the health underclass who have no access to basic levels of health protection, whether because they cannot afford insurance, or are already poor insurance risks.

I find it significant that chronic disease risks like smoking and obesity are disproportionately in evidence at the lower end of the socio-economic continuum, where – if Epstein were correct – the incentives for healthy living should be highest, among those who cannot afford to self-insure.)

Whether we should use economic policies to tax consumers themselves, rather than the products they consume, brings us back to the issue of which level in the hierarchy of determinants public health policies should focus on.

One benefit of focusing on context and place, rather than behaviour per se, is that we can develop policies with broad reach that do not make victims of individuals who for whatever reason do not manage to live ideal, healthy lives.

Ultimately, I would suggest that what is driving Epstein’s views on the role of the state in public health is a deeper and far stronger commitment to an efficient and competitive marketplace, unburdened by regulation. The liberty he cares most about is not the liberty of individuals, but economic liberty.

Epstein believes that free markets do a far better job than governments of giving individuals the resources to protect their own health.

Ultimately, in order to justify a comprehensive policy approach to chronic diseases, I believe that public health advocates need to drill down and take a position on the role of the state in a liberal democracy. This is the underlying issue.

We can imagine a state, I would suggest to you, whose citizens not only expect their elected government to ensure minimum survival needs, and protection from infectious epidemics and contaminated food, but also to promote the health and vitality of its citizens.

Such a compact does not imply that citizens will be treated like children, nor “forced” to live puritanically wholesome lives.

Nor does it eliminate the need for collective goals, like public health, to be balanced with other public interests.

Nor does it imply the kind of socialist purgatory that critics delight in conjuring up: where private enterprise (forbidden from selling you choc tops, salted nuts and pizza) cower from the constant onslaught of those howling creatures of the far left. Such a compact is compatible with a liberal economy and it is ludicrous to suggest otherwise.

But it does recognize the importance of health both as a collective value and as a political goal, regardless of whether the diseases we get sick and die from spread quickly, or slowly – across a generation.

As my American colleague Larry Gostin has argued, a theory of public health law and regulation begins from the premise that adequate levels of health at the population level are a pre-requisite to a functioning society. These levels cannot be achieved through individual efforts or private markets: collective actions are required. In a democratic society, government has a special place in public health regulation to meet citizens’ expectations of meaningful health protection.

In a moment, I want to give you five reasons why I believe regulation has a place in our response to chronic disease.

But before I do, I think it is also important to ask who wins? and who loses? from the way we frame lifestyle diseases.

Since the tobacco industry did an about-face and began to publicly acknowledge the health consequences of smoking, the “informed smoker” has become a recurrent motif in industry language. As one industry executive said to me, “most people, unless they’ve just come from Mars, would know that smoking is risky to health”.

Lest you misunderstand me, I want to be clear that I am not saying that individuals are not responsible for their diet. To a large extent, individuals are responsible for what individuals eat.

But public health is a discipline that is concerned with how to keep populations healthy, not individuals. Populations don’t behave like individuals, and the individualization of public health is a brilliant framing technique for drawing policy attention away from the upper levels of our hierarchy of determinants towards the proximate, behavioural level.

This helps to shield industry from economic and social policies that might impact on their profits.

Just as importantly, it relieves pressure on government, which simply delegates responsibility for health onto individuals.

You’ve already seen one model of the determinants of health-

But there are many other ways of representing the hierarchy of influences upon our lifestyles.

The value of these models is that they explain how we live our lives in local places that influence us, in broader societies that shape and constrain and potentially empower our lives.

A population health approach seeks to harness this understanding in ways that could improve our collective health.

Individuals tend to be seen as beneficiaries in libertarian attacks on public health.

Freedom-loving individuals – like Christopher Hitchens and Mel Smith – standing up on behalf of the common man against the nanny state, “do-gooders”, “picknose control freaks” and sundry zealots.

Rarely, though, does one hear libertarians express satisfaction with the lifestyle that gave them diabetes.

Or gratitude for the diet that led to a heart attack.  Rarely do they give thanks for emphysema, because it was a fair price to pay for the delicious, intangible brand values of their favourite pack, and years of smoking pleasure.

But when illness appears, it tends to be lived out in the private domain: at this point, the health system gets on with the (expensive) business of treating patients.

Occasionally you do hear something. In February 2004, for example, Tasmanian Premier Jim Bacon quit politics after being diagnosed with lung cancer.   A

It is precisely when individuals show signs of illness, however, that the “personal responsibility” side of the libertarian coin rapidly warps into blame and discrimination.

At the level of clinical care, the “personal responsibility” frame has come into direct conflict with the “personal autonomy” that patients have hitherto enjoyed in their dealings with the medical profession.

For example, there is a growing literature that consists of calls by:

Outside of medical care, the focus on personal responsibility for lifestyle risks has led to disputes over whether employers can fire employees who refuse or fail to quit smoking.

The point at which these policies become legitimate ways of creating incentives for populations to adopt healthier lifestyles is an important and ongoing issue.

Happily, though, it is one that a population health approach can largely avoid, since its centre of gravity is not, specifically, the behaviour of individuals, but the

influencers of that behaviour.

Over the past couple of years, I’ve followed the public debate on obesity.

A week ago, a group called the Obesity Policy Coalition attempted to position obesity policy as an election issue by calling for government regulation in three areas. They want:

º And the removal of the GST exemption from cereals with more than 27% sugar (on the basis that these are confectionary).

The interesting thing to notice about these policies – which are advocated by Diabetes Australia, the Cancer Council of Victoria, and the World Health Organisation’s Collaborating Centre for Obesity Prevention at Deakin University – is that they engage with what I’ve called context: they seek to influence the economic and social context of food choices.

These policies apply across the population. Yet the liberty of anyone to eat whatever they like remains intact.

Bans on food marketing to children, and the traffic light labeling system are what I call laws or policies that alter the informational environment.

A ban on food marketing to children seeks to minimize pester power and to that extent makes it easier for harried parents to exercise their parental responsibility to ensure their children have a healthy diet.

A labeling system that can actually be seen without a magnifying glass might help consumers to make rapid and healthy choices in real time – in supermarket isles and in restaurants. This is an empowering policy that supports informed choice.

Removing the GST exemption from high-sugar cereals will make them more expensive. This is an economic policy that will dampen demand for high sugar cereals, relative to lower sugar cereals.

But unlike Epstein, here you’re taxing the product, not the person.

Taken together, these are examples of policies that could, over time, alter patterns of decisions around diet.

But make no mistake: reducing chronic disease will require reduced average intake, across the population as a whole, of high sugar, high fat, high salt foods.

It will require more fruit and veg, and more exercise.

Predictably, these policies will be framed by opponents as evidence of a nanny state.

But you’ll notice that individual liberty is left intact. Clearly corporate profits are an issue, but you’ll notice too how this issue has been cleverly re-framed in terms of personal responsibility.

So let me give you 5 reasons then, why I believe a population health approach should be the centerpiece of how governments respond to lifestyle diseases.

First, a reality check. One particularly vigorous critic of obesity regulation in the United States, Joseph Sullum, writes that:

The point is not to declare war on the market economy. I applaud the initiatives that are occurring in the private sector, and the important contribution of the not for profit sector.

Nor am I suggesting that policy is only the business of government. There are opportunities for private sector and NGOs to show leadership as “policy entrepreneurs”, and the Heart Foundation’s tick program comes to mind.

What I am saying is that we need some basic truthfulness when it comes to recognizing real-world influences upon consumer decisions.

The second point I would make is this. Despite the tendency to see the solution to obesity, or diabetes in terms of a personalized, individual commitment to healthy living, the evidence is not encouraging that populations benefit from this approach.

A small number of risk factors – you can see them on the screen - (smoking, physical inactivity, obesity, high blood pressure, high blood cholesterol, diabetes and inadequate fruit and vegetable intake) – are responsible for an alarming share of the burden of non-communicable disease.

Despite this, in a survey of over 150,000 Americans, 76% were non-smokers, 40.1% had a healthy weight, 23.3% had the appropriate fruit and vegetable intake, and 22.2% exercised regularly.

Few people provide a better example of healthy living than Minister Abbott.  But what do you do if the population finds it too difficult to follow the advice?

My role this afternoon is not to push or defend any of these policies, but to advocate a population health approach.

This brings us to the status quo in many societies today. On the one hand, we have food and tobacco companies pouring vast sums into promotions and advertising, suggesting a high degree of confidence that these efforts increase sales.

But individuals themselves are seen as isolated units who are expected to live wisely and eat healthily, drawing on personal resources wholly within themselves.

When they fail, it is their own fault, and any effort to criticize the status quo is framed as a dangerous attack on market freedom, and on the liberty of individuals.

The third point I would make is that the personal responsibility critique does not apply to other systemic issues that government is serious about tackling.

We do not fight corruption only by urging individuals to be honest. We take a whole of system approach: we don’t put all our eggs in the basket labeled “private morality of individuals”.

We do not reduce traffic accidents and road-related deaths only by telling individuals to drive safely.

Now I want to make one thing crystal clear.

None of you out there are going to start messing with my right to dessert.  Corruption and traffic accidents are different, of course in many ways from personal intemperance. But the common factor is that you regulate most effectively by looking at the wider environment, not only by seeking to directly change individual behaviour.

My fourth point is that if we want to alter the prevalence of lifestyle diseases, we need to reach the entire population. This requires policies that engage broadly across the nation, and make a difference in the daily lives of just about everyone.

This is a very different approach to trying to capture those who make it into the local GP, or trying to encourage people to eat five fruit and two veg (or is it five veg and two fruit)?

All of this evidence suggests that, if policies are to seek to redress health inequalities, they must be broadly based, and also engage with local environments.

In conclusion, I would say that a population health approach is a difficult sell because it offers what is really rather a sophisticated explanation [SLIDE – 48] that often finds it hard to compete with the over-simplification of the populist, “common sense” approach [SLIDE – 49] which matches the dominant narrative of individualism.

The irony, of course, is that by focusing on the influences upon behaviour, rather than the behaviour itself, a population health approach can minimize the need to micro-manage individual lifestyles.

It’s partly a war of ideas and language, and if you can look through the clouds of smoke in this slide [SLIDE – 50] you will see some of the verbal missiles hurled by Christopher Hitchens in the direction of Michael Bloomberg.

One can only imagine what Hitchens said when he learned in August last year that Bloomberg was donating US$125 million to global tobacco control efforts.  And with that, I will close. Thank you very much.