04.12.2015 «People make behavioural choices, we cannot deny that. But the creation of the environment is part of the State’s responsibility.»

Interview with Gauden Galea. Federal and Cantonal authorities joined Swiss Health Promotion on June 22nd at the NCD Stakeholders' Event to present and discuss a draft for a National Noncommunicable Diseases Prevention Strategy. Dr Gauden Galea, Director, Division of Noncommunicable Diseases and Promoting Health through the Lifecourse, WHO Regional Office for Europe, travelled from Copenhagen in order to show admiration for the Swiss model from the international perspective. Galea had special praise for the integrative aspects of the Swiss Strategy Draft, its solid basis on evidence, emphasis on prevention, and inclusion of economically disadvantaged and vulnerable population groups. He also commends the consultative and participatory process.

Pictures «People make behavioural choices, we cannot deny that. But the creation of the environment is part of the State’s responsibility.»


Pictures «People make behavioural choices, we cannot deny that. But the creation of the environment is part of the State’s responsibility.»


Pictures «People make behavioural choices, we cannot deny that. But the creation of the environment is part of the State’s responsibility.»


Pictures «People make behavioural choices, we cannot deny that. But the creation of the environment is part of the State’s responsibility.»


Pictures «People make behavioural choices, we cannot deny that. But the creation of the environment is part of the State’s responsibility.»


spectra: Dr. Galea, what do you think is worth exploring in the current draft of the Swiss noncommunicable disease (NCD) strategy?

Dr. Gauden Galea: As far as I can see, Switzerland is following extremely good practice; the country is very consultative, involving local governments, stakeholders, and civil society, and consulting the evidence and models from other nations. So your strategy is technically very sound. It is based on current evidence and practice on NCDs. The draft also has a strong equity focus with a lot of interest in identifying and targeting vulnerable groups. The scope of the document is very comprehensive, since it focuses on needs across the life cycle, and includes serious conditions that may not be traditionally defined as NCDs, not just relying on political or medical classifications. So the strategy doesn’t just look at NCDs, but also at other conditions like muscular-skeletal disorders or dementia. And there is also a preventive bias; it puts more importance on population-based public health approaches than just on treatment. But even within treatment, it recognises the importance of improving the balance between tertiary care and primary care. The draft has all of these merits. It also connects very well with the general principles of "Gesundheit2020" (Health 2020), which is the public health framework.

On the other hand, the strategy document could do with recognising Switzerland’s achievements a bit more. Switzerland is doing very well in many areas on risk factor control. The type of programmes you have put in place, such as the physical activity strategy, or the tobacco control fund, are aspects of your work that have had an impact on the rest of the European region. I recognise and thank Switzerland for supporting the European Physical Activity Strategy that we will present to the September Regional Committee. Most prominently, the Swiss population’s decreased mortality rate from circulatory diseases is significant. For the last thirty years there has been a steady reduction in deaths. The document would be improved by stating explicitly that Switzerland doesn’t just put public health programmes in place because it has an aging population and high treatment costs, but also because the country is confident of its record of ongoing public health service over three decades. That is important.

One point of improvement I focused on was to consider how explicit the strategy can afford to be in terms of the governance processes and the politics of NCD. In my presentation there was some debate that I was presenting an «us against them» model of NCD and health interests versus the food industry. On the contrary, I think the food industry must be part of the solution. We need to see how the industry can get involved in helping to solve the problem of NCD by first recognising that they are part of the cause of many of these problems. Marketing directed at children of products that are high in fat, sugar, and salt doesn’t happen just like that, someone in the company decides to do it in order to make money. There is a point where voluntary industry agreement and state intervention need to balance each other out.  

Could you give us an example of what this could look like?

In Denmark they have a properly working agreement. Companies in the food industry realised that if they didn’t manage to come to a voluntary consensus on regulation and adhere to it, they were likely to be facing state regulation. So companies banded together and produced a working model. They police themselves, they report, they follow up infringements.  

Are there more examples in other areas?

Oh yes, this applies in many areas. Another area is trans fat elimination. Switzerland is one of only five countries in Europe that has a legal limit on trans fat, and we would like to see many more countries go towards very low legal limits or even ban trans fatty acids. These are areas where the food industry can help. An important aspect of working with the industry is that it needs to be accountable, and its behaviour needs to be internationally consistent. It cannot be that a multinational company behaves one way in Switzerland and another in Eastern Europe for example. There has to be an open discussion of these matters.  

From your outside view on our NCD strategy: What are the main challenges that Switzerland is confronted with in the next few years?

Switzerland is a very advanced country in terms of public health. It is part of a region in which practically every country has ratified the Framework Convention on Tobacco Control, and it is doing some very good independent work on tobacco control. Considering this, it is very astonishing that Switzerland hasn’t ratified the Framework Convention. It greets visitors at the airport with obvious tobacco advertisements. With all respect for its many health achievements, and acknowledging that Switzerland is not the only country that goes back and forth with policies, I think this is a point Switzerland could improve by joining its neighbors and ratifying the Framework Convention.  

What other countries in the region haven’t ratified the Framework Convention either?

Only Monaco and Andorra. The vast majority of the population in the European Region is covered by the Framework Convention. The Swiss absence in that list is glaring. I think it would be worth it for Switzerland to revisit that omission, especially considering the tobacco control law and the good work that is being done.

But let me come back to future challenges. Due to the reduction of the mortality rate in the country, the challenge has now shifted towards providing ongoing care. As premature mortality declines and people live longer, treatment and care become more expensive, especially at the end of life. The solution to creating an appropriate incentive structure for organising and delivering good clinical prevention to me is almost a no-brainer. We have a population that is so elderly, and we are doing well with primary prevention for the healthy part of the population. Now the question is, how we can ensure that as much care as possible for chronic conditions happens in the community, with patients able to take care of themselves in partnership with well qualified and appropriately incentivised primary care providers? It’s not for me to tell a country what model of payment it should follow. But some indices could be created to compare how much funding is going versus tertiary and primary care. This data could drive national agreement on the direction essential primary care interventions should take.

What influence do you think the tobacco industry has on the ratification process in Switzerland?

Circumstantially the contribution of the tobacco industry to the Swiss economy is not too small. Tobacco is an economic influence, and there will always be people who say that this is income, this is revenue for the country. There are many countries in Europe that make more money from supporting tobacco and creating and controlling the manufacture and profiting from it than actually consume themselves. So there is also this issue of foreign trade and revenue. It cannot not be part of the political calculus. It is not for me to decide how big or small the influence is. It is just a realistic outside view of how things work. In your speech you said that health is a political decision and then you showed us that many governments do not take the measures that would have a real impact.

Do you have a strategy to encourage those governments?

Here is a really interesting lesson that I have learned over my thirty years’ career in public health. There was a time when being in the smoking or non-smoking area in a plane was extremely important. I used to check in and say that I would like an aisle seat as far away from the smoking area as possible. I said this sentence every time I checked in, since those times I had travelled close to the smoking area I almost choked. And suddenly smoking disappeared from planes all over the world. There was an interest of the airlines in terms of safety to ban smoking and suddenly it was banned. I had always thought that public health should work like this: you fight a battle, you make your point, the evidence becomes clear, the decision is made and then there is a worldwide adoption. But this model is very far from current reality.  

Why? Can you explain?

Take a measure like taxing tobacco or mandating smoke-free public places. There is a constant set of arguments that the tobacco industry uses in every market. Their tactic is to tell us that we are going to destroy agriculture, that we are going to promote crime by promoting smuggling, that we are going to hurt the poor addicted smokers because we take away more money from their income because of taxation; we are going to destroy our hospitality industry. These arguments all have strong evidence against them, repeatedly, in one country after the other. But somehow the industry manages to push them forward in every market. The process of promoting public health at the regional level is often to say: let’s <reinvent the wheel> by collecting all the evidence against these standard arguments. We in the global public health community need to help local public health workers to be aware that they are not being attacked for the first time, but that arguments like «if it is legal to sell it is legal to advertise» go back to the 1970s. Powerful industry will push again and again in every market. That delays the process and in a few cases even stops it. Improvement in this area doesn’t just happen by producing a regional guideline and assuming that all countries will simply adopt it.. More oversight is needed to counteract such a mighty industry. By the way, I’m picking on tobacco here in order to make my point clear. With tobacco it is very simple because we want to completely eliminate its use. It gets more complex with food or alcohol.  

More complex because there are more stakeholders involved?

Yes, intersectoral action is something we all want, but it is extremely complicated. If I want a public health worker to be an advocate for smoke-free public places, I am going to recommend a set of arguments levelled at the hospitality industry that will be extremely different from the arguments used with the agriculture industry when we talk about pricing or customs or finance. They will talk about cross border sales, substitution, elasticity, regressivity. There are all these arguments that belong to the area of fiscal policies that do not apply to the area of smoke free public places. Often, public health workers are too naive when they enter into these intersectoral discussions. It is not enough to say that we have a big problem and that we want to move that policy direction. They need to be able to understand the language of that sector or that industry in order to be able to both fight the battles and form real partnerships. I think this is the most exciting area of public health, but one should not enter it without preparation.  

Does it have to do with education?

Yes, with education at many levels. We haven’t talked about media so far but I think a more sophisticated use of the media is important for us in public health. We need to keep people aware of the importance of certain behaviours versus others in order for them to be able to make good choices. We mustn’t underestimate the importance of public awareness, which tends to be sometimes devalued by people in public health by saying that health education is not enough or that education doesn’t change behaviour, only environment does. But I think that being aware that something is good or bad for you is a prerequisite for making a decision. I also advocate for additions in curricula designed for training public health professionals. Students need to know the basics of sociology, management, governance, and policy processes. Case studies of how to deal with the EU, for example, or what the role of trade in public health policy is, or how to find the mutual advantage in it, or what it means to have a public-private partnership. None of these questions have a right or wrong answer. But public health workers that come out of schools today should have a more sophisticated knowledge of business, politics, economics and society.

The methods we use in public health are in many cases very old fashioned. We have models of data collection and analysis that are outdated. Taking a survey once in three years, or using these individual points to create a trendline and then setting targets based on these snapshots – these are all traditional public health skills. They need to be retained, but alongside them, we should also teach public health professionals things like how to enter a discussion on social media, how to analyse big data, how to use search engines as databases, and how to create a partnership with industries that would provide us with data, such as purchasing behaviour, that would give us both descriptive and predictive tools. I imagine a future where we can find out what impact an advert had on consumers’ choices in a supermarket. This is the type of thing we cannot answer but the industry can, all the time, and very well. We need to enter into that sort of partnership. I’ve strayed now quite far from NCD, but in terms of blue sky thinking about what comes next, I really think we should look into broadening the scope of public health education.

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