Their investigations raise concerns for the wellbeing of many vulnerable groups – especially in rural Australia – but also show there are many unanswered questions about the relationship between recession and health.

Dr Megan Keaney and Rebecca James from Research Australia, write:

“Amongst the millions of column inches written and hours broadcast about the global financial crisis, very little attention has been given to whether recession is bad for our health. It is not difficult to imagine that becoming unemployed is bad for our mental health but are there wider impacts? If so what will they be, who will bear the burden and is our health and welfare system prepared to meet the challenge?

Mental health professionals are already seeing a steady stream of recession casualties.  “BJ” is one such person. At age 57, he lost his business and savings late in 2008 and by November was severely depressed. He took an overdose of medication that left him with memory problems. When he left hospital, his ex-wife of 10 years took him home to a rural town, thinking that he would recover in a few weeks.  Twelve months later she remains his carer and his brain injury means that he has no prospects of returning to work or living independently.

A report released this week by Research Australia, Australia’s Financial Crisis: Implications for Health and Research reveals that becoming jobless is associated with higher rates of a variety of mental health disorders. Suicide rates in young men track the unemployment rate and even keeping a job in an environment where job insecurity is heightened is associated with higher rates of psychological disturbance.

Although the jury is still out, studies from previous recessions suggest that becoming unemployed is bad for physical health too.  For instance, a  UK study from the 1980s showed that job loss led to a 37% higher chance of dying in the next 10 years.

The good news is that for mental health at least, return to the workforce as the economy recovers, leads to improved mental health. If that was the whole story then health departments might be comfortable that although some extra mental health services might be needed to meet extra need during recession, with economic recovery, the status quo should return. However, as BJ’s case highlights, it may not be that simple. And the difference is that recessions don’t have the same impact for everyone.

It is well accepted that there is a strong correlation between socio economic status and health. In Australia people who live in disadvantaged communities with higher rates of joblessness, lower household incomes, lower levels of education and lower social status have much poorer health outcomes across the board than the well off. In Australia there is a strong link between poverty and unemployment.

The real risk of recession is that it adds to the pool of long term unemployed (those people who are out of a job for 12 months or more). The longer people are out of job, their return to the workforce is less likely. Unemployment impacts on those who can least afford it – people with lower education, fewer skills, and intercurrent health problems. Not surprisingly rising unemployment concentrates disadvantage in already struggling communities on the urban fringe and in rural Australia.

We know that long-term unemployment and poverty is bad for our health. So what will this recession bring and are we well prepared to meet that challenge?

During the early 1990s recession the number of long term unemployed receiving income support increased from 170,000 to a peak of 438,000. Although the percentage of unemployed who are long term unemployed in 2009 is low relative to the early 1990s (about 13%) it is feared that this group will rise by 150% over the next two years.

Treasury’s recently revised forecast that unemployment will peak at 6.7% might appear reassuring given that in the last two recessions unemployment rose to well over 10 percent. However the number of people looking for work is not the whole story.

Over the last 20 years there has been enormous uptake of the Disability Support Pension with the number of recipients increasing from 307,000 in 1989 to 750,000 this year. This recession too is a story of underemployment with the labour under-utilization rate increasing from 9.9% to 13.6 % in the 12 months to August 2009.

In other words, 1.5 million Australians are unemployed and looking for work or would like to work more hours. There is no doubt that for these people and their families, financial stress is real. So how will their health suffer?

Long-term unemployment might mean higher rates of illness and premature death from a wide range of illness including heart disease, cancer, mental illness and even accidental injury. Importantly the impacts are likely to be intergenerational.

Western Australian research shows that children from disadvantaged families start out life behind the eight ball with problems including lower birth weight which are carried through to higher rates of childhood illness such as respiratory and mental illness, and even into adult life with international research suggesting that chronic adult disease has its roots in early childhood and even prenatal factors.

Much of this health disadvantage is mediated through social factors such as lower educational levels, fractured families and communities and in turn higher rates of health risk behaviours including smoking, alcohol use, less physical activity and obesity. A good start counts for a lot when it comes to health.

At the other end of life, research shows that for older workers ill health and unemployment is a two way street. Close to half of Australians aged over 45 who retire early do so because of ill health. Older workers who develop heart disease or mental illness are especially unlikely to re-enter the workforce.

For the health care system, more illness means more demand. Australians enjoy relatively good access to the health care system and long-term data tells us that unemployed people and those who reside in urban disadvantaged communities see their GPs more often and have more hospital visits.

However recent polling by Research Australia and MBF reveal that for many Australians, this recession is already affecting choices we make about our health. For instance, over the last 6 months financial stress has caused close to 20% of people to put off seeing a doctor or dentist and a staggering two million people have gone to work ill, rather than take sick leave, because of concern about job security.

Many questions remain unanswered. Recessions might be bad for our health – particularly if we lose our job and never work again. However, as the economy recovers jobs will be regained and fears about joblessness and financial stress will fade. But are there lingering problems for our health? We really do not now whether cyclical economic downturns impact our health in the long term and well accepted research demonstrating that relative socio- economic status correlates with health outcomes provides only some of the answers.

Most importantly when reflecting on the possible consequences of this downturn for our health, we need to consider whether government policies and programmes designed to limit the economic fall out of this recession are working.

Do we need different strategies that better target social and health impacts? Are we making the right investments now to support vulnerable groups so that we have a healthy and productive workforce as we come out of recession?

What is clear is that we need to better integrate our health, economic and social research effort so that we learn the lessons of this recession. Only then will we be able to deal with the public policy challenges that are the legacy of this recession or accompany the next one.”

• (Declaration: Croakey’s moderator Melissa Sweet had a hand in editing the report)

Croakey’s North American correspondent, Dr Lesley Russell, writes:

“While an excellent discussion is underway on Croakey about the value of calorie labeling in tackling obesity, it has been shocking this week to confront front page news that the number of Americans who don’t have enough food is at an all-time high, largely as a consequence of the nation’s economic crisis.

Every year the Economic Research Service of the US Department of Agriculture compiles a report on Household Food Security.

The 2008 report released this week revealed that last year almost 50 million people in 17 million households (14.6% of all US households) were food insecure and families had difficulty putting enough food on the table at times during the year. This is an increase from 13 million households (11.1%) in 2007. The 2008 figures represent the highest level of food insecurity since national food security surveys were initiated in 1995.

Given that unemployment has risen from 7.2% at the end of 2008 to 10.2% today, this might now be an under-estimate of the number of people struggling to put enough food on the table.

The magnitude of the increase in food shortages, or in some cases outright hunger, has startled even anti-poverty advocates and those who have noticed the increasingly longer lines at food banks and soup kitchens.  It is especially concerning that so many children are going hungry.  In 2008 nearly 17 million children (4 million more than in 2007) lived in households where food was sometimes scarce, and children in more than half a million households faced “very low food security”.

The USDA did not actually use the word “hunger”, but President Obama did and in a statement yesterday, he called the report “unsettling.”  Others were even more forthright.  Mariana Chilton, a Drexel University public-health professor, said: “This is a catastrophe. This is not a blip. This recession will be in the bodies of our children.”

The fundamental cause of food insecurity and hunger in the US is poverty and a lack of resources to provide housing, food and health care.  The Obama Administration has taken action to help needy families through the American Recovery and Reinvestment Act of 2009, which provided a significant increase in nutrition assistance benefits for the 36.5 million people (half of whom are children) who participate in USDA’s Supplemental Nutrition Assistance Program (SNAP), formerly the Food Stamp Program.

The USDA also has a National School Lunch program which serves 31 million children a healthy meal each school day – for some children in need, this is their most important meal that day. Also, nearly half of all infants in the US participate in the Special Supplemental Nutrition Program for Women, Infants and Children, or WIC program, which ensures mothers and their children have access to nutritious food.”

• Dr Lesley Russell is the Menzies Foundation Fellow at the Menzies  Center for Health Policy, University of Sydney/ Australian National  University and a Research Associate at the US Studies Centre, University of Sydney.  She is currently a Visiting Fellow at the Center for American Progress in Washington DC.

But Ron Batagol, a pharmacy and drug information consultant, says this will require us to examine some of our somewhat hypocritical attitudes towards breasts.

He writes:

“A meeting of Health Ministers on 13th. November has endorsed the Australian National Breastfeeding Strategy 2010-2015.

The Strategy recognises the biological, health, social, cultural, environmental and economic importance of breastfeeding and provides a framework for priorities and action for Australian governments at all levels to protect, promote, support and monitor breastfeeding throughout Australia.

Australia’s dietary guidelines recommend exclusive breastfeeding of infants until six months of age, with the introduction of solid foods at around six months and continued breastfeeding until the age of 12 months – and beyond if both mother and infant wish.

It is concerning that a longitudinal study of Australian children conducted in 2004 found that while 92 per cent of new borns were initially breastfed, by one week, only 80 per cent were fully breastfed. The study also indicated a steady decline each month with only 56 per cent fully breastfed at three months and 14 per cent at six months.

The new federal strategy would include increasing community acceptance of breastfeeding as a cultural and social norm, establishing breastfeeding support networks for pregnant women and improved breastfeeding training for health professionals.

But, since it has been estimated that over a quarter of Australians still think that breastfeeding in public is unacceptable, obviously there is still a long way to go!

And  I have to say that it’s quite paradoxical. In the post-modern world of the 21st century, when the fairer sex “frocks up”, as they call it these days, no one gives a second thought about exposed cleavage.  In fact, the dress designers have lead the charge to make the breasts the focal point of society’s attention when women’s attire is “out there” being critically scrutinised by all and sundry.

On the other hand, as we’ve seen in recent times, with unfortunate regular monotony, the sight of women, anywhere outside the confines of their own homes, trying to nourish their infants with the most natural of all beverages, mother’s milk, provokes an outcry of pompous indignation.

Oh, yes, excuse me, I forgot!  On a plane, with all those complete strangers sitting in close proximity? In the sacrosanct and hallowed corridoors of Parliament of all places!  And for God’s sake, worst of all, in a 5-star restaurant – a place where other people pay good money to sit down, quaff a fine wine or three and gourmandise their way through their mouth-watering degustation.

Suddenly, the notion of these mammary glands doing what they were actually created to do in a “public place” is deemed to be titillating, and breastfeeding is transmogrified into something wicked and evil.

Yet, 28 years ago, a worldwide Marketing Code was established for synthetic milk formulas, because millions of infants died in developing countries where well meaning mothers tried to copy their emancipated, more affluent counterparts by preparing formulas despite lack of clean water, refrigeration or education about how to make up the feeds.

So now, breast-milk  is “in” again- transported in  unbreakable packages, and satisfying consumer demand- all in all, the perfect 21st century product, with breast-fed babies having better immunity, and better long-term medical benefits than their bottle-fed buddies.

One can only live in hope that, as a society we may become a little less hypocritical and to try to remember why these mammary appendages were given to women in the first place.

Surely that’s not too much to ask, is it?”

Would such a move be useful and welcomed in Australia? Read on…

Associate Professor Tim Gill, Institute of Obesity, Nutrition and Exercise, University of Sydney:

“Requiring calories counts to be placed on menu boards in restaurant chains is a good thing but as Jane Martin points out, it is unlikely to have a profound effect on food choice by itself.

It is akin to putting up speed advisory signs at dangerous bends in the road. They are useful if you understand and are accepting of the benefits of such advice; recognise your own limitations and the need to be cautious of road conditions; are not distracted by other issues and thus fail to acknowledge such advisory signs; or over-ride the advice because of your perceived lack of time to slow down.

Unfortunately with both calorie counts and speed advisory signs they are often ignored.

This is not a reason to avoid instituting such measures because they will be of benefit to those who are in a receptive state and can effectively process and act on the information.

Rather it is a reminder that such measures need to be instituted in combination with a variety of other strategies to encourage and support people to be more receptive to these signals.

Of course the preferred method of dealing with dangerous bends in the road is not to encourage people to slow down but rather to take that responsibility away from them by remaking the road at great expense to remove the bend.

Funny, no one ever suggests that this is a nanny-state approach to road safety.”

***

David Gillespie, author of Sweet Poison, Why Sugar Makes us Fat:

“Would you feed your kids a glass of milk or a glass of Coke for breakfast?  Yep, I’d go with the milk too.

How about if you know that the milk has 168 Calories but the Coke has only 108.  Would you switch to the Coke then?  No? You’ve just explained to yourself why Calorie labelling is a pointless waste of time.

You’ve also explained to yourself why Big Sugar is particularly keen on Calorie labelling.  They know a few things which most nutritionist have either forgotten or didn’t know in the first place.

Fat serves up 9 Calories per gram whereas everything else (including sugar) is only 4 Calories.  Calorie labelling is therefore really just fat labelling by another name.  The reason the milk has more Calories than the coke is because it contains fat and the Coke doesn’t.

The study referred to by Dr Russell tells us that it doesn’t really matter anyway.  Just over a quarter of the respondents noticed the Calorie information and it didn’t influence their choices anyway.

Big Sugar knows that no-one knows or cares what a Calorie label means and even if they did, sugary products would come out looking good by comparison.  Do we really want people being steered towards high sugar, low fat foods by Calorie labels?

Ignorance of the number of Calories in food has nothing to do with why we are all fat. We are fat because our food supply is laced with sugar.  Sugar has been proven to significantly interfere with our body’s internal Calorie counter (by making us resistant to the hormones which tell us when are full).

When our appetite control system is working, we eat exactly the number of Calories we need.  If they come from fat, we eat less of everything else.  If they come from protein or carbohydrate, we eat more.

We are fat because our fuel gauge is broken.  We are not fat because we don’t know how much fat is in what we are eating.  We don’t need Calorie counts on menus, we need our built in Calorie counters to start working again.  And the way to do that is eliminate sugar from the food supply.

But don’t fret too much about lobbying for Calorie counts, Big Sugar will implement them voluntarily soon enough.”

****

Stephen Leeder,  Professor of Public Health and Community Medicine at the University of Sydney and Director of the Menzies Centre for Health Policy:

“My personal view is that the more nutritional information that consumers can be given access to, the better.  The work that Tom Friedan, former chief health officer of New York City and now boss of CDC, in getting restaurants to label their menus is part of a larger enterprise to raise community and commercial awareness of nutritional responsibility. He did the same with tobacco control to good effect.

People DO take an interest in food labelling. Come with me one weekend to Coles in Katoomba – hardly the socioeconomic pinnacle of NSW society – and observe how often customers stop and read and compare food labels.

Many would argue, with evidence, that colour coding of foods with red, orange and green to indicate the safety levels of key components such as saturated fat, calorie density and whatever else.

The food industry presents elaborate objections to the ‘traffic light’ labelling. But in the meantime, until this is resolved, clear nutritional labelling makes sense. I think one of the craziest moves ever was the move away from the calorie, which many people understood, to kilojoules, which people don’t understand.

Food labelling is very political and much engagement with the food industry by action oriented politicians (and not all are) makes great sense.”

***

Boyd Swinburn, Professor of Population Health, and Director, WHO Collaborating Center for Obesity Prevention Deakin University:

“I am just travelling at the moment but have discussed this people here in the US.  It started in New York City where to got in regulations to include the calorie content next to the price on the menu boards of chain restaurants.  They also had an anchor that about 2000 kcal is what was needed for a typical day for a typical adult.

Several other cities/states started following suit and expending the provisions. The industry could foresee an escalating situation and called for federal regulations which require the calorie information but prevent local authorities for pushing it further.

I definitely think the Australia should follow suit and all the arguments that it is not possible have evaporated. Our use of kJ will add complexity however.”

All these years later, Canada is still mining, manufacturing and exporting asbestos.

At the American Public Health Association conference last week, a resolution (you can download it here) was passed calling for a global ban on asbestos mining, and manufacturing, and the export of asbestos containing products.

Canada received particular mention for continuing to export the stuff to developing countries while banning its local use, and also for blocking the inclusion of chrysotile asbestos in a list of hazardous substances requiring prior informed consent when exporting them under the Rotterdam convention.

But Dr Yossi Berger, an occupational health and safety expert with the Australian Workers’ Union, believes it’s time to shift the debate beyond bans, and to start looking at removing asbestos from buildings and anywhere else it may be putting lives at risk. He writes:

“It’s a good thing that the American Public health Association is calling for a total ban on asbestos containing materials (ACMs).  But it’s now time to shift the paradigm.  There are millions of acres and hundreds of thousands of tonnes of ACMs currently in use around the world.  These, I believe, are ‘faulty’ products that should never have been manufactured.  The Australian Workers’ Union recently called for a once and for all total removal.

Hundreds of thousands more people will be killed by ACMs.  Currently hundreds of thousands of people are the walking wounded as a direct result of exposure to ACMs.  They painfully understand the preciousness of every single unobstructed breath of air.  Their lives and that of their families’ have become nurseries for terror.

Drago told me that, “Each night I don’t know what the morning will bring for me”, and he adds in a rasping voice between laboured breaths and coughing, “I feel guilty when I look into my wife’s eyes and see the pain”.

I believe that ACMs are unsafe in any condition.  This is so despite painting over them, despite cladding over with safer products, and despite various poorly implemented laws and regulations.

No one can tell me which single asbestos fibre entering someone’s lung right now is the one that will not kill them, but if you don’t breathe any fibres you will not suffer an asbestos-related disease.  Doesn’t it follow that whilst extremely dangerous such products can be made safe by reducing exposure to fibres?  Yes, in theory.

But the time I inspect such presumed ‘safe’ ACMs in industry I see a great deal of damaged material, constantly vibrated and shaken material releasing fibres, I see it in broken bits on the ground, split and stuck back on with tape, I see the empty spaces where warning signs should be, I ask in vain for records of the presence and supervision of such materials, I try to find informed people, informed workers about the risks of such materials; in my dreams!  These ‘safe’ materials are temporarily safe only if these things happen, and they typically don’t.  What do I tell the worker who asks me, ‘Can the little bit extra fibres I’ve breathed kill me?’

It’s for these reasons that the AWU makes the case that such materials are ‘unsafe at any speed’.  They present permanent mortal risks that too frequently eventuate.  The AWU has called for what amounts to a total product recall, a total removal program over a 20 year period.

We have called on the federal government to implement a national removal program.  Such a program must be developed as a Prioritised Removal Program (PRP).  Once ACMs are discovered the program commences.  We argue that all buildings – once assessed and the PRP is triggered – (starting with industry, public spaces and schools) must have an asbestos designation and an ACMs identifier that’s colour coded as  red (immediate removal), amber (3-6 months) or green (6-18 months), an  Asbestos Presence Ticket.   This must be prominently displayed.

We need to move past banning and into total removal.  But a ban is good start.”

• A terrific piece bringing some much-needed perspective to discussions about mental illness, especially in the wake of recent murders. By Dr Tanya Ahmed, a registrar in psychiatry and a principal of the health and communications consultancy RaggAhmed.

• More than a million premature deaths across 30 OECD countries could be prevented each year if income inequality was reduced. That’s the best guess of a meta-analysis of studies involving around 60 million people, reported in the BMJ. The authors note that there are many caveats to their findings, including a lack of evidence from developing countries, but say their results have “potentially important policy implications for population health”. Meanwhile, I’m heartened to read that a fellow Crikey blogger is also putting inequality on the public agenda.

• When the law meets public health – Simon Chapman, professor of public health at the University of Sydney, considers the implications of a recent High Court judgment. It dismissed a duty of care negligence claim against a Tasmanian hotel owner who handed back motorcycle keys lodged for safe-keeping to an insistent, belligerent patron who on leaving the pub was killed in a crash while showing a blood alcohol level of 0.253.

• Investigating the ties between drug companies and doctors – A group of researchers from Australia, Canada and the US have done an indepth analysis of disclosures of pharmaceutical sponsorship of gifts and educational events, as has been required of Medicines Australia members since 2007. They conclude that the disclosure does not go far enough and also give some interesting examples of how companies are wooing doctors. Novartis, for example paid flights, accommodation, food, beverages, and conference registration fees for six ophthalmologists to attend a two-day conference in Spain, at a cost of AUD$10,993 per person. For those who follow this field, it will come as no surprise that the researchers include Ray Moynihan, Lisa Bero and David Henry. The other authors are Jane Robertson and Emily Walkom from the University of Newcastle.

Croakey’s North American correspondent, Dr Lesley Russell, has been investigating the history of calorie-counting menus, while a local obesity policy expert, Jane Martin, looks at whether such an option might be useful in Australia.

Lesley Russell writes:

“In 2006, in a controversial move in response to rising obesity rates, New York City’s Health Department amended the city health code to  require the posting of calorie counts by chain restaurants on menus,
menu boards, and item tags.

This move was based on the following key facts:

*nearly one-third of Americans report that they are trying to lose weight;

*people are unaware of the calorie content of food, and when asked to
estimate the number of calories in food, they greatly underestimate
them; and

*consumers who were provided calorie information were much less likely
to choose the higher-calorie items.

Many fast-food chains make nutrition information available, but not in places or at times when consumers can easily use it when they buy their food. Most often, the information is available for download on Web sites.

According to the company, McDonald’s Web site nutrition page receives approximately 2,000 visitors per day, but since McDonald’s serves more than fifty million people per day, this suggests that only about one in 25,000 customers obtain nutritional information from the Internet.

The law was finally implemented, after a series of tough legal battles with the restaurant industry, in July 2008.  The system has since  become a model for similar rules intended to combat obesity and  promote good nutrition being implemented in California, other parts of  New York state, the cities of Seattle and Portland, and elsewhere.

Now some of the early findings about the success or otherwise of the New York initiative are available, in a paper (sub or pay per view only) published recently in Health Affairs.

The study compared patrons of fast-food restaurants in low-income, minority New York City communities with those in nearby Newark, NJ, a city which had not introduced menu labeling. About half of the New York respondents reported noticing calorie information, but only a  quarter of these reported that the information influenced their food  choices. However the study found that even those who indicated that  the calorie information influenced their food choices did not actually purchase fewer calories.

Last week New York City health officials delivered a more upbeat  assessment of their own, saying that New Yorkers ordered fewer calories at four chains – Au Bon Pain, KFC, McDonald’s and Starbucks – after the law went into effect. There was a significant increase in calories ordered at Subway, which researchers attributed to a continuing $5 special on foot-long sandwiches which has tripled demand for them.

The results are good enough to cause policy-makers to think that calorie labeling might be one component of a multi-faceted plan to  tackle obesity.  Certainly that’s what US lawmakers think.

Tucked away in the 1990-page health care reform bill that passed the  House of Representatives last Saturday night is a provision that will require anyone who operates chain restaurants with more than 20 locations to provide a calorie count for each standard menu item.  In addition, anyone who owns or operates 20 or more vending machines would have to provide a sign in close proximity to each item of food or the selection button that includes a clear statement about the number of calories the item contains.

The National Restaurant Association supports the labeling  requirements; the National Automatic Merchandising Association is less enthusiastic.  We assume that the Republicans, still complaining about  the size of the bill, did not read it and therefore don’t know about  this provision, otherwise we would surely have heard.”

• Dr Lesley Russell is the Menzies Foundation Fellow at the Menzies  Center for Health Policy, University of Sydney/ Australian National  University and a Research Associate at the US Studies Centre, University of Sydney.  She is currently a Visiting Fellow at the Center for American Progress in Washington DC.

Should Australia require calorie-counting menus? Jane Martin, a Senior Policy Adviser to the Obesity Policy Coalition, writes:

“This is something the Obesity Policy Coalition supports. This is yet another study showing, like restrictions on junk food advertising, that an initiative with a modest effect can have a large impact on a population.

This study is an excellent assessment of the situation.  Currently in Australia, even if there is information given about meals in chain restaurants, it is on websites or on the packaging of the meal that you order (McDonald’s), therefore people are not making informed decisions at the point of purchase.  If there was a system such as in New York, together with an education campaign, the potential impacts could be large.

This is definitely something that should be on the table here, as part of a comprehensive approach.”

Firstly, the authors, investigative journalists Shannon Brownlee and Jeanne Lenzer are at the cutting edge of showing there is a place for philanthropic and not-for-profit funding of health journalism. The Huffington Post Investigative Fund has published some of their other pieces, including this investigation raising concerns about the conduct of clinical trials. Brownlee is a senior research fellow at the New America Foundation and the author of Overtreated (2007), and  Lenzer is a frequent contributor to the British medical journal, BMJ.

As you may have seen from recent reports, Croakey is taking a keen personal interest in this funding model just at the moment.  This article, from the Columbia Journalism Review, reviewing the state of the media in the US, gives a number of examples of universities and health organisations getting involved in funding journalism.

The other reason the Atlantic article is worth reading is that you’re unlikely to have heard of many of the issues it raises before, at least if you’ve been relying on Australian media’s coverage of the influenza pandemic. So far as I’m aware, we’ve seen nothing from the local media (for-profit or otherwise) to rival the depth and incisiveness of the Brownlee/Lenzer piece. Much coverage has simply amplified the statements of government spokespeople and public health officials without critically examining the evidence underpinning them.

Meanwhile, here are two reviews of the article by local flu-watchers.

Associate Professor Heath Kelly, University of Melbourne, writes:

“This article provides a succinct account of some of the issues that impinge on our understanding of the control of both seasonal and pandemic influenza. It concentrates on the pharmacological interventions aimed at controlling influenza, the influenza vaccine and ant-viral medications. We learn that the evidence for the use of both interventions is not as good as many in the influenza community would like it to be. The facts are reported faithfully and the insight into responses to reputable researchers who have rattled the cage of public health orthodoxy makes for interesting and recommended reading.

Part of the problem with our imperfect understanding on the effectiveness of the pharmacological interventions arises from our imperfect understanding of the laboratory confirmed burden of influenza. This issue is addressed briefly on a commentary on the pandemic to be published on-line in the Medical Journal of Australia on Monday 16 November.”

***

Professor Peter Collignon, Canberra Clinical School, Australian National University

“Swine flu continues to generate both fear and controversy.  It is very important that the community has adequate information available so that we can know what were the mortalities and complications associated with this virus in various age groups and in certain risk groups (e.g. pregnant women).

We now have data available to answer some of these questions, particularly from data made available by NSW Health. These show that when the H1N1 virus spread thru the NSW population last winter 1,214 people with pandemic H1N1 influenza infection were hospitalised (17.2 per 100,000 population), 225 were admitted to intensive care (3.2 per 100,000), and 48 died (0.7 per 100,000).

Figures for the whole of Australia were similar with an overall death rate of 0.8 per 100,000.  The death rate in those under the age of 40 was 0.4 per 100,000. About three quarters of deaths were in those with associated risk factors. Thus the death rate in those under the age of 40 years and who had no known risk factors was 0.1 per 100,000 (or 1 per one million people).

We need to remember that at the beginning of this epidemic many experts and even Heath Departments were postulating that 20% or more of the population would get infected and there would be an associated case fatality rate of 1% or more. That translates to a population mortality rate of 200 per 100,000 people (or 300 times higher than what occurred).

Thankfully we did not get anywhere near that figure but it shows how we need to reassess many of our assumptions as they have proved to be wrong.

Figure such as these are important as we need these to make sensible decisions re the likely benefits versus risks from vaccines or other interventions. The Atlantic magazine article looks at these issues with regards to the efficacy and safety of influenza vaccines and also the likely benefits and pitfalls of the widespread use of drugs such as Tamiflu. It shows there are still many unanswered but fundamental questions.

We need research studies done with appropriate control arms so that we can move forward after we gain essential information that is currently lacking. The article is essential reading if you want to see the broader picture about swine flu and what actions we can take to ameliorate the problem and the likely success of these actions.”

And a final pointer from Croakey:

• A new journal, World Medical & Health Policy, has just published an article arguing that there are sound reasons for NOT expecting the worst of the 1918 pandemic to recur. It says the debate about the threat posed by pandemic influenza should move beyond “facile analogies and worst-case scenarios”.

It states: “While there has been sustained attention to the myriad trends that increase our risk from emerging infectious diseases such as pandemic influenza, far less attention has been paid to countervailing forces… It is important to take the panic out of pandemic. The response to the pandemic influenza should be guided by sound science, realistic risk assessments, and good public policy.”

DEM – that’s what is left when you take the panic out of pandemic. Any thoughts on what that might stand for?

Post Script with some more links that may be of interest:

• The public health blog The Effect Measure, compares the paediatric toll of pandemic influenza and pneumonia

• The Wall Street Journal health blog analyses the swine flu toll in the US

• A bowel cancer screening program in Northern Ireland is reportedly a casualty of swine flu spending

But the real food war to watch is underway in the US, and you can read more about it in this investigation, “The Food Lobby’s War on a Soda Tax”, jointly undertaken by the Centre for Public Integrity and the Huffington Post Investigative Fund.

The investigation reports that:

Washington lobbyists have been enjoying a multi-million-dollar sugar rush from the food industry. Soft drink makers, supermarket companies, agriculture and the fast-food business have poured millions into campaigning against what they fear could be a burgeoning national movement to raise money for health care reform by taxing sweetened beverages.

During the first nine months of 2009, the industry groups stepped up their lobbying in Congress. They have spent more than $24 million on the issue of a national excise tax on sweetened beverages and on other legislative and regulatory issues, according to an examination of lobbying reports filed with the Senate Office of Public Records. The review shows that 21 companies and organizations reported that they lobbied specifically on the proposed tax on sugar-sweetened beverages — which among other things would include sodas, juice drinks and chocolate milk.

About $5 million of the money was spent on a national advertising campaign aimed at Capitol Hill lawmakers and promoting a newly formed coalition called Americans Against Food Taxes. The group bills itself on its website as a coalition of “responsible individuals, financially-strapped families, [and] small and large businesses” but its 400-plus membership list is dominated by industry heavyweights such as Burger King Corporation, Coca Cola, PepsiCo and Domino’s Pizza.

The heavyweight lobbying and spending is not so surprising, given what’s at stake for the industry.

In California yesterday, legislators were hearing arguments in favour of a soft drinks tax, including from Professor Kelly Brownell, who was the lead author on this landmark article in the New England Journal of Medicine arguing that there are “compelling” reasons for taxing sugar-sweetened beverages.

According to this LA Times report, one senator told the hearing that he wants “to end the Pepsi Generation,” and compared the marketing of soft drinks to cigarette marketing.

Brownell told the hearing that the landscape for the soda industry is not unlike what it was for the tobacco industry when governments began to increase taxes on cigarettes as a strategy to get people to stop smoking.

Meanwhile, Kellogg has announced that it will withdraw the IMMUNITY claim on Cocoa and other Rice Krispies cereals. The withdrawal follows this report in USA Today, citing concerns held by the San Francisco city attorney and prominent public health experts (including Kelly Brownell).

A collector's item...

On related matters, the SMH is  reporting on a project by the International Consortium of Investigative Journalists examining the climate lobby in eight countries including the US, Canada, Australia, India, Japan, China, Belgium and Brazil. The conclusion is that “big greenhouse polluting companies around the world, employing thousands of lobbyists, are exerting heavy pressure on governments to weaken climate change laws at home and slow progress on an international climate agreement in Copenhagen”.

It all starts to sound so familiar doesn’t it….

Boyd Swinburn, Professor of Population Health, and Director of the WHO Collaborating Center for Obesity Prevention at Deakin University, writes:

“Stephen Leeder makes a well argued plea for people to quit blasting the food industry with moral indignation and to work with them to find solutions to the food over-supply and over-promotion which are important drivers of our current obesity epidemic.

Indeed, there are many, many nutritionists, food technologists, dietitians and researchers working with the food industry helping them to re-formulate and market their products.   This is largely positive but that is not the role of everyone.

Public health is politics and effective public health gains have always had as a driving force the combination of passion and science being brought to the political debate. The passion, which I like to think comes from a strong ethical basis rather than a quasi-religious moralistic basis, is an essential ingredient to progress and I would be interested in the rationale or evidence that it is making things worse.

If the passionate advocates, like Rosemary Stanton, had not continually spoken out about the ways that the food industry has been contributing to the obesity problem and has been white-anting the solutions, we would have made very little progress.

It is an unfortunate fact of politics that Rosemary’s approach  will more likely catalyse the ‘banging heads’ meeting of the PM and the industry CEOs that Stephen talks about than will the cooperative approach of the embedded nutritionist or the industry-funded scientist.

But both are important for progress.”