Whither (or wither?) public health?

The Nobel prize winning scientist Santiago Ramon y Cajal famously stated that ‘every disease has two causes. The first is pathophysiological; the second is political.’ In the UK, politics have taken centre stage in recent months, with the country reeling from political and economic crises, and the effects of these crises are likely to be felt in UK healthcare for some time to come.

What should be of further concern to health professionals is the fact that public health is no longer deemed a high priority in the UK National Health Service. This government's libertarian views on public health demands a reduction in the ‘nanny state’, suggesting that personal choice should trump all else in health decisions.^1,2

Obesity is estimated to cost the UK around £6–10 billion per year.³ As physicians dealing with complications related to diabetes, we find even more concerning the government's decision to review, and likely abandon, planned anti-obesity legislation.⁴ These interventions were to include a ban on calorie-dense products being displayed at checkouts, or being part of low cost ‘multi-buy’ deals (buy one get one free) and restrictions on advertising such products before the 9pm watershed. In addition, there is some suggestion that calorie counts should be ditched on restaurant menus and potentially even that the ‘sugar tax’ should be reversed. The soft drinks industry levy came into force in 2017, and has led to a 10% reduction in the amount of sugar household consumed through soft drinks.⁵ The money it has generated has paid for breakfast programmes, and sport facilities in poorer areas. There is plenty of evidence that the public are also on board with such messages, and people want it to be easier to make healthy choices.⁶

Furthermore, a government White Paper on tackling health disparities, aimed to ‘break the link between people's background and their prospect for a healthy life’, originally due for publication in spring 2022, has been delayed, and is also likely to be shelved.

A health system that ignores the need for governmental intervention on significant health threats such as smoking, air pollution, excessive alcohol and unhealthy food is likely to be faced with much greater health-related costs in the longer term. Tackling the cost-of-living crisis and dealing with poor economic growth are clearly major governmental priorities for the foreseeable future. However, public health intervention to ensure our population is healthier should also be a priority, and in the longer term are likely to be cost-saving. Such interventions are evidence-based, and improving the nation's health may be one of the best ways to increase productivity and workforce capacity and thereby drive economic growth. Using the cost-of-living crisis as an excuse for inaction seems to be a strategy that will increase poor health and exacerbate health inequality for years to come.

This special issue of Clinical Medicine aims to describe the state of the art in obesity care currently. Obesity is a disease with many potential treatments, and we have curated a selection of articles from a wide spectrum of the multi-disciplinary team required to manage and obesity.

Preventing disease, however, is much more cost effective than treating it. Public health interventions have a proven track record in reducing the burden of disease and supporting people in enjoying healthier lives. Prevention as well as treatment of obesity requires a thoughtful and coordinated response. Recognising the variations in phenotypes and outcomes will support personalised care and increase awareness of the wider determinants of health in obesity.

We are encouraged by the recently released WHO Health service delivery framework for prevention and management of obesity:⁷

Multisectoral efforts to influence behaviours around healthy diet and exercise, while essential, have been insufficient to halt the rising prevalence of obesity. While these efforts must continue and escalate, it is now imperative to also deliver a corresponding health system response which ensures that services to prevent, treat and manage the disease are universally available, accessible, affordable, and sustainable.

The framework outlines the need to scale up proven policies and strategies and harmonise service delivery with societal actions, and also the promotion of expanded access to obesity prevention and management services for all age groups across the life course. Undoubtedly, there will be challenges to implementation but we hope that this will be the time for the government to set aside ideology, challenge barriers and work towards helping people to achieve healthier and happier lives.

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