Shoot for the moon

Houston, we have Ozempic. That was the essence of the media response to the government’s ‘moonshot’ to end obesity, which formed part of the NHS 10 Year Plan released in July. The ‘moonshot’ was the centrepiece of the ‘sickness to prevention’ shift, one of three that make up the structure of the plan.

It includes a welcome focus on both increasing access to treatment services for obesity (for those that this is medically appropriate for) and preventing as many people as possible getting to the stage of needing treatment in the first place. The most significant announcement is the creation of a system so that supermarkets and other large food companies must honestly and accurately report what they sell – and using that data to mandate a shift to selling more healthy food and less junk. If implemented correctly, this would be a gamechanger for public health.

However, much of what journalists asked us after-wards boiled down to: “but why do we need any of this nanny state stuff, now that we have these shiny new weight loss drugs?” The answer is simple: when people come off the drugs, almost everyone will regain almost all of the weight they have lost within two years. We cannot medicate the two-thirds of UK adults that have a weight classified as overweight or obese indefinitely.

This would still be true if the significant costs – including of both the drugs themselves and the crucial wrap-around support (dietary, physical and psychological) necessary to make them safe and effective – were to fall dramatically. At current cost levels, it is optimistic even to hope that we will be able to expand services to all those living with the most severe obesity and associated conditions, for whom treatment is indisputably the most important intervention, even if it will be needed for life.

Mercifully, the government has not gone down the same rabbit holes as the press. But this media response reflect a wider attitude towards “traditional” public health in this country – that it is at best well-meaning but ineffective, and at worst an intrusive and politically unpalatable approach that breeds anti-government resentment. I say ‘wider’ not to suggest that such sentiments are popular: while I have heard such attitudes expressed by journalists and politicians alike, very rarely have I ever heard them from the public.

Likewise, I hear the term “nanny state” from politicos and the press on a daily basis. Ask yourself: how often have you heard a your non-Westminster friends use this phrase? Libertarianism is almost non-existent among the British public, whether on the left or right. From tiny focus groups to giant citizen engagement exercises like last year’s Food, Farming and Countryside Commission, the public is clear: they are deeply concerned about what the food they eat is doing to their health and they want the government to do something about it. And they certainly do not trust the large corporations that make almost everything we eat.

However, one roadblock comes up time and time again – cynicism. As with so many issues, from education and defence to policing, the public is deeply sceptical that the current political system or politicians of any stripe are capable of or even interested in making their lives better. They say they want the government to improve the UK’s food – but they often follow it up with “but they’d never do that” or “they’ll just mess it up”.

This lack of faith in the ability of the state to deliver tangible improvements to people’s lives is poisonous, not just when trying to deal with a specific issue like obesity, but to democracy itself. A belief that the current political system cannot, or will not, serve the needs of ordinary people leaves them to reach for alternatives, no matter how unpleasant they may be. It is no coincidence that these views were most strongly felt amongst voter groups that are turning away from the traditional parties to insurgent movements on both left and right.

The answer to countering this feeling involves looking at where government policy has actually, tangibly improved people’s lives and learning the lessons of success. And, contrary to the perceptions of those in the Westminster bubble, there is no clearer place to start than public health. We should start with smoking. From nearly half the country in the 1970s to less than 12 per cent today, we have successfully slashed rates of tobacco use and delivered immeasurable improvements in people’s health and the sustainability of the NHS. And we did this through decades of effective government policymaking, from tobacco taxes, smoking cessation services, regulation on advertising and finally the Blair government’s indoor smoking ban. Today, we stand on the brink of passing legislation that will one day end smoking once and for all.

But Britain’s public health successes don’t stop there. Teenage pregnancy rates fell almost 70 per cent between2007 and 2021, with the greatest benefits seen in the most deprived communities. To anyone that was a teenager in the late 2000s, this seems almost unimaginable. Most impressively of all, there is now a realistic possibility that we will be able to end the onward transmission of HIV in England by 2030. This would be the first time a transmissible disease has been halted without a vaccine. It would stand alongside the near eradication of polio and massive falls in infant and maternal mortality rates as among the greatest health achievements in human history.

The government’s ‘moonshot’ to end obesity can, and should, be the next groundbreaking public health success, following in the footsteps of these incredible achievements. To do that, it must learn the lessons of these successes. First – and most importantly – we did not expect education or “public awareness” alone to end smoking or teen pregnancy. Such interventions have an important role to play, but fundamentally, they place the responsibility on the shoulders of individuals and ignore structural issues like money, convenience and predatory marketing from companies with a financial interest in selling things that harm people’s health. It is welcome that, for the first time, we are starting to see government look beyond individual behaviour change alone as the focus of obesity policy. Second, we did not allow the foxes to be involved in designing the henhouse. Most notably, on tobacco, the incredible public health successes came only after the tobacco industry was cut out of designing policy.

Slowly but surely, big tobacco was denied the access it needed to subvert regulations, culminating in the World Health Organisation’s article 5.3 declaration, which placed obligations on countries to deny big tobacco access to government policymaking. Perhaps something similar is needed for ‘big food’.

Third, and finally, past policymakers understood both the benefits and limitations of technology. Vaping technology has been instrumental in helping people stop smoking, and PrEP medication has been a gamechanger for HIV. But these powerful technological tools are used to improve, not replace, efforts to prevent conditions from arising in the first place. And, as we have seen with the rise of vaping in children that have never smoked tobacco, if not carefully managed, some of these technologies can be subverted for harmful uses. We would do well to remember this when thinking about the future role of new weight loss medications.

Taking on board these three lessons will allow the government’s ‘moonshot’ to actually land. In doing so, it will deliver unprecedented improvements in people’s health, reduce massive pressure on the NHS, and help stem the huge flow of working-age people out of the workforce due to preventable health conditions. But these are not the only reasons that it must succeed. To rebuild people’s faith in democratic government and quell the rise of populism, we need to demonstrate that our current system of government is capable of delivering for ordinary people. Making the ‘moonshot ‘a success is a vital way of showing that our democracy is capable of putting people’s health above powerful commercial interests.

Image credit: machechyp via flickr