The most authoritative grouping of medical experts in the world released Policy and Action for Cancer Prevention, which identifies cancer as an environmental disease that can only be prevented by political and economic initiatives treating the “causes of causes” of a disease that kills 11 million people a year.
Sir Michael Marmot, professor of epidemiology at University College London and lead for the World Health Organization’s Commission on Social Determinants of Health, developed a consensus among hundreds of internationally respected researchers and practitioners. They give the report, published by the World Cancer Research Fund and American Institute for Cancer Research, the same stature as the Intergovernmental Panel on Climate Change, which settled the key scientific debates around global warming and moved the policy agenda toward corrective actions.
The report focuses on diet and fitness, and delivers a one-two punch to the food and auto industry. The first punch comes in the opening line: ‘Cancer is a largely preventable disease.’ Overwhelming evidence blames a third of cancers on cigarette smoking, the report says. Equally overwhelming evidence puts the combination of poor diet and insufficient exercise a close second. Without even counting the cancers caused by polluting carcinogens, these conclusive findings reframe cancer as an “environmental disease” – in medical terms, one that comes from the environment external to the patient’s body and genes.
Punch two comes from the doctors’ orders that cancer must be treated by the political equivalent of chemotherapy: what it calls ‘the classic public health approach’. The public health measures that are usually credited with the major gains in the quality and length of life in industrialized countries over the last hundred years rarely cured the immediate causes of the “big killer” – infectious and contagious diseases. Instead, they treated the first causes, such as overcrowded tenements and factory sweatshops, disease-festering water supplies and open sewers.
The standard “check-up and a check” recommended by mid-1900s cancer societies get short shrift, dismissed as “primary prevention” limited to early detection by primary physicians. The new science puts primary emphasis on what is called “primordial prevention,” directed at the deeper forces behind cancer.
Perhaps the very success of the classic public health movement and its first cousins in progressive social movements – women’s suffrage, abolition of child labor and workplace safety laws were standard accompaniments of public health campaigns of those days – led to the undoing of the classic heritage for a period of time.
During the era when “classic public health” was in its prime, substandard water suppliers were brought up to standard by public utilities that went to the enormous expense of cleaning and sterilizing water and delivering it virtually free to all residents. The analogy between what public authorities did and do for water treatment and what they should do for diet and exercise is repeated several times in the report. If people have a right to health, then government has a duty to provide the infrastructure, laws and regulations to protect health, the clear logic goes. The government doesn’t stop with information on the importance of drinking clean water; nor does it cut back because bottled water is available as an option. Neither factor absolves the state ‘from the obligation to ensure the provision of a safe supply of water.’ Nor does anyone accuse governments of acting like a nanny state when water regulators insist on high standards.
Perhaps the very success of the classic public health movement and its first cousins in progressive social movements – women’s suffrage, abolition of child labour and workplace safety laws were standard accompaniments of public health campaigns of those days – led to the undoing of the classic heritage for a period of time.
When safer and better food, water, air and work led to longer and healthier lives for the entire population, the old-time (in the industrialized world) infectious and contagious diseases were largely marginalized. The new source of threats came from chronic diseases, such as heart disease and cancer.
Many of these new big killers – they’re still common causes of death in the poor countries of the Global South, where the majority of the world’s people live – were classified as “diseases of affluence”. This framing of chronic disease implied that more willpower and moral strength was needed to counter the by-products of progress and affluence – too much salt, fat, sugar and starch and too little exercise. Governments had little role to play in this framing of chronic diseases, except to encourage individuals to opt for healthier lifestyles and nudge companies to voluntarily cut back on some harmful ingredients.
Only tobacco and alcohol addiction escaped this framing of health issues, probably because they cause problems for innocent others, through second-hand tobacco smoke, drunken driving and the like. They’ve been regulated with more or less classic methods, such as policies that reduce usage by raising prices and limiting availability and access. Aside from old-style safety measures, food and fitness matters have largely escaped such forceful government regulation and have almost totally escaped “classic” public health tools such as public infrastructure that ensures availability and access of high-quality options.
The report from the World Cancer Research Fund earns its place in public health history by arguing for forceful government actions that get to the causes of the causes – ending agricultural subsidies that make “junk foods” cheaper than unsubsidized healthier foods, for example, or undoing trade laws that prevent countries from restricting junk food imports, or limiting unfettered access to children by junk food advertisers or making healthful foods more available to people on low incomes. Getting to the causes of causes also requires infrastructure that overcome the carcinogenic infrastructure of suburbia with street designs that make walking or biking more pleasant, efficient and safer than driving a car.
The report also calls for treating farming practices from a classic public health perspective. ‘Air soil and water need to be regarded as public goods, and their preservation and protection as essential to the health, welfare and survival of the human species and the living and natural world,’ it says, meaning that agriculture departments beholden to interest groups no longer have the last say in regulating fundamental building blocks of life and health.
As might be expected by anyone following health advice over the last 50 years, the World Cancer Research Fund report comes out four-square in favor of breastfeeding and staying fit and trim, but against excess salt, fat, red meat, booze, sugar and processed meats.
‘The supply and demand mechanism has not got it right,’ Dr. Marmot says in his introduction to the report, a statement that may seem as obvious as recommendations to exercise more and eat less fat and sugar. But by identifying curative, restorative and preventative powers higher than individual lifestyles and self-regulated market choices, the report opens the door wide to entirely new ways of thinking about public choices that can prevent one of the most-feared diseases in modern history.
Read this report, and call me in the morning.