Without a public health lens focused on commercial economic systems, we risk ‘staring down the barrel of history repeating itself’, says Dr Sandro Demaio.
Victorian Health Promotion Foundation (VicHealth) CEO Dr Sandro Demaio has traversed the globe in his efforts to understand the crux of public health improvement.
More often than not, the answer lies beyond the health sector.
Speaking at the Australia Medical Students Association Global Health Conference, Dr Demaio said a pervasive misconception continued to plague public health.
“It’s this dissonance between knowing what we need to do, but not enacting it,” he told delegates.
“Instead, we’re blaming individuals along the way.
“The idea that we live in a society where 60% of people struggle to achieve a healthy weight, and yet we somehow think that it can still be individual responsibility just blows my mind.
“And yet that’s still the prevailing mentality that creeps into our dialogues around nutrition and chronic disease.”
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Having worn many hats throughout his career – from medical officer with the World Health Organization to running the first national health census in Mongolia – Dr Demaio’s mindset on the most effective public health policies has iterated over the years.
“It was a Norwegian health minister who said to me, when I worked for the WHO, ‘Sandro, we know what to do, but we don’t know how to get reelected after we’ve done it’,” he said.
“How do you bridge that gap? A big part of that, I felt at the time, was raising awareness among the public and among policymakers.”
But education, for its many merits, doesn’t work in isolation, Dr Demaio found.
“It’s not just about telling the world that problems exist,” he said.
“You don’t change what people eat by telling them vegetables are good for you.
“There’s no way that education alone changes behaviors.
“[And] it isn’t just working through traditional institutions like WHO. I did that for a couple of years and found it quite frustrating.”
It was broader determinants like price, cultural appropriateness, access and other structural barriers that could really shape public behaviour.
“You can put a billboard on the side of the freeway that says, ‘eat your broccoli’, but if the structural barriers remain, eventually it becomes a bit insulting,” said Dr Demaio.
“We need to address the commercial determinants of health.”
During his time with the science-based global platform for food systems, the EAT Foundation, Dr Demaio was involved in the EAT-Lancet Commission publication on the Planetary Health Diet guidelines for the optimum diet for human health and environmental sustainability.
“The one thing that unifies all [people] is food,” said Dr Demaio.
“We all share the same food system, but the way that we’re using the food system at the moment, [means] half the planet is malnourished, it is the single biggest driver of land conversion, biodiversity loss, freshwater use, phosphorus and nitrogen use and CO2 emissions.
“Something is clearly very wrong.
“The theory of change with EAT was that by bringing together multi-sectoral leaders at the highest level, and then also having a unifying piece of science in the Lancet Commission [Planetary Health Diet], we could fast-track acceleration on our Paris climate agreements and the sustainable development goals.”
Despite attracting the ire of Big Ferrero and the Italian meat industry in particular, the work sparked a global conversation about how food system transformation could underpin efforts to reach climate and health targets.
Dr Demaio is now the CEO of health promotion foundation VicHealth, the world’s first health foundation funded by hypothecated tax on tobacco.
His years of learnings from traversing the globe have culminated in a 10-year, half a billion dollar strategy commissioned through VicHealth, which takes a wholly systems-based approach to health.
“It was quite risky putting commercial economic systems in a government strategy, but I knew that we needed to do it when vaping came along,” said Dr Demaio.
“[We saw] the same industry, same tactics, a different generation of politicians and a different product, but basically the same crap [Big Tobacco] were doing 50 years ago: lying, creating fake evidence, giving money to political parties, dividing the public health community.”
Dr Demaio said that without structural changes that prevented industries like Big Tobacco running amok, we risk “staring down the barrel of history repeating itself”.
“The product will change, but the practices will stay the same,” he said.
“The industry, the way they behave, the way they manipulate democracy, the way they manipulate science, the way they manipulate populations, that is all the same, whether it’s gambling, alcohol or tobacco.
“So we moved from the focus from individual risk factors to systems.”
Dr Demaio said it was understanding how industries interact with our democracies and tackling entrenched legal frameworks that could have a pervasive impact on public health.
Currently, VicHealth is in “active loggerheads” with the Victorian government over another prolific public health offender: Big Fast Food.
“For the last couple of years, we’ve had country town after country town coming to us, saying, ‘McDonald’s is about to open a new outlet in our country town, we don’t want it. We’re fighting them at the civil tribunals, but it’s costing a lot of money, and we’re worried we’re going to lose’,” said Dr Demaio.
“We’ve helped a few of these towns.
“But what we started to realise when we took a more systems-based approach, was that unless we look at the way the planning laws are structured, unless we change the protections in the Planning Act, we’re going to have to continue to fund town after town for the next 10 years.
“There are tighter laws in this country about how close you can build a pharmacy to another pharmacy, than a McDonald’s to another McDonald’s.”
Dr Demaio said he was confident that health would be integrated into the Victorian Planning Act, but conceded it was an uphill battle.
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Problems of public health weren’t “technical problems”, said Dr Demaio.
“I realised that in all of these environments [where I worked], people across all spectrums of income, from all different backgrounds, there was one thing that united them all,” he said.
“They were dying from diseases that we fundamentally know how to prevent. It wasn’t a technical problem, we have the solutions.
“But the average Australian lives with 11 years of pain and suffering from chronic disease, diseases like diabetes, heart disease, cancer, chronic lung conditions.
“And one in two Australians will live with a chronic disease.
“By the time you’re about 50, it’s two chronic diseases.”
Rather than repeatedly trying to “plug the dam”, it’s about looking upstream for a systems-based approach to solve these multisectoral challenges.
The Australian Medical Students Association Global Health Conference 2024 took place 20-23 September at the National Wine Centre in Adelaide.
