Why is it so difficult to ensure medicines for all?

Why is it so difficult to ensure medicines for all?

What is meant by “medicines for all” and how important is it?

In the United Nations Millennium Development Goals, the idea of “medicines for all” is an important and incorporated factor (UN, 2013). Goal 8E states “in cooperation with pharmaceutical companies, we aim to provide access to affordable essential drugs in developing countries”. The World Health Organization have also outlined “medicines for all” as something to be measured to quantify whether or not a developing nation is succeeding from the UN Millennium Development Goals. Indicator 8.13 is taken from “the proportion of the population with access to affordable essential drugs on a sustainable basis” (MDGS 2012). What this tells us is that medicines for all is a subject area of importance to the top organizations aiming to beat poverty and improve the lives of others. As well as this, the UN and WHO identify “essential drugs” as most noteworthy, and so it is apparent that essential drugs also needs to be addressed. The WHO have compiled a list of medicines which they believe are essential and should be not only available to all, but affordable and on a sustainable basis (World Health Organization 2014). The essential medicines list includes simple pain killing drugs such as paracetemol, ibuprofen, but also medicines such as morphine, codeine, insulin, diazepam, levothyroxine, vaccines, salbutamol, and even condoms. These are drugs which are easily accessible from over the counter or a general practitioner in the UK and other western countries. Thereby, to debate “why is it so difficult to ensure medicines for all?” is rather to debate “why is it so difficult to ensure essential medicines on an affordable, sustainable basis in developing countries?” To understand the importance of the question is to see the facts; “about one-third of the world’s population still has no regular access to essential medicines” (World Health Organization, 2004). The situation is never more apparent than in South Africa, with an extremely high HIV prevalence. The MSF South Africa (2009) explains how there are two lines of therapy for treating the HIV positive currently in South Africa, however, a substantial amount of people are failing both lines, and as Dr Eric Goemaere explains, MSF’s Medical Coordinator in South Africa, it is “unacceptable” considering there are a range of 24 different ARV therapies available in the UK. It is undeniable that medicines for all is not a topic to be ignored, however, the question should be re-addressed as “why is it so difficult to ensure essential medicines on an affordable, sustainable basis in developing countries?” as this is the underlying point “medicines for all” imposes.

Marxism

To question the difficulty of medicines for all invites subjectivity, as ‘difficulty’ in itself brings with it a form of measured adjective. The question offers theoretical opinions and therefore it is natural that the big schools of thought will have points to make on each theory. Notably, Marxism will have an interesting point of view. The ideas of Marxism include many criticisms of the Capitalist society and Capitalist markets. And so for a Marxist, they will criticise the way in which medicine acts as a commodity and the fact that there is a market for medicine when medicine is a necessary resource. The way in which a Marxist will approach each challenge to “medicines for all” tells us more about the challenges, and thus how each one can be tackled.

The first challenge: patents

Hoen (2013) analyses the difficulties of ensuring medicines for all by contextualising the matter at hand. Through explaining how the release of patented products in early aeronautical engineering accelerated the first successful airplane, she demonstrates how patent drugs are limiting the ability to provide accessible medication for the poorest countries in the world today. When India created a generic drug to tackle HIV, the rate of people with HIV sharply increased. Nonetheless, this is significantly positive as it meant instead of dying, people were now receiving treatment and living a HIV healthy lifestyle similar to those in the west. When the patent laws changed, new rules meant what India did is now illegal and this exemplifies the patent problem with drugs today. Patented drug laws state that “when a pharmaceutical company first markets a drug, it is usually only under a patent that allows only the pharmaceutical company that developed the drug to sell it” (News Medical, 2014). The expiration dates for these patents is now 20 years, outlined in the TRIPS agreement the World Trade Organisation established in 1994 (World Trade Organization, 2014).

Flint & Payne (2013) have also examined this major challenge in ensuring medicines for all. They extend the argument by suggesting that a HIV free generation is a realistic possibility and developing countries need to attack the World Trade Organization and developed countries after losing control of intellectual property rights. To achieve medicines for all, Flint and Payne argue for universal access. An opaque example of this is, as earlier mentioned, the basic two-line therapy the MSF South Africa (2009) identify for treating HIV in the country, compared to at least 24 different lines of therapy available in the UK. Patent laws means that South Africa cannot “copy” these drugs and they cannot afford to research or buy them for their own patients. Flint and Payne are suggesting that universal access is the only way to combat this as patent laws mean countries are heavily restricted in how much they are able to help their patients. With a disease as serious as HIV, it can be argued that patent laws allow for poverty and death.

The Marxist perspective credits Flint and Payne’s view, for a Marxist would argue that the instable drugs market means people from developing nations are forced into labour to prepare for when they will need healthcare. On a larger scale however, it also means that the instable and expensive drugs market stops developing nations from researching and developing their own drugs and therapies. In effect, if these countries were “allowed” to make their own, there would be no market and no profit for the rich west selling on their researched and developed drugs. A Marxist would say that the workers of developing nations have no choice but to submit to the exploitation as healthcare fees for when they fall ill or have a child are vital but unfairly too extortionate. Once again though, on the larger scale, developing nations have no choice but to submit to the exploitation of the rich west as they are the ones with the drugs and the knowledge, and so the ones with the power. For a Marxist, Flint and Payne are correct when they argue that the market needs to be eradicated and medicine should be universal.

The second challenge: lack of medication

One of the biggest problems with providing medicine for all is that there is a general lack of medication. Drugs are a finite resource, but the real problem is the lack of research, known in global health as the 10/90 gap (Lewis, 2002). The 10/90 gap is term used to describe how less than 10% of research and development in medicine accounts for the medicine needed by 90% of the world’s population.

Hogerzeil (2013) summarises the theory by explaining that medications for some conditions don’t exist, such as there is no heat-stable insulin for diabetics in tropic climates. Hogerzeil also explains that medicines that do exist are expensive, unavailable, of unassured quality, safety, efficacy, and may be formulated in unsuitable ways, for example, there are hardly any ARV medication for children with immunodeficiency syndrome. Hogerzeil argues that the difficulty in ensuring medicines for all is not monocausal, however the pharmaceutical industry plays a key, strategic role. He argues that if the pharmaceutical industry were to aim to ensure medicines for all rather than profits for themselves, then tackling the issue would be a great deal easier. Marxist point of view can strengthen this; the marketization of medicine means that profit is the motivation rather than provision and so to ensure medicines for all, it is extremely necessary to remove privatization and capitalist incentive. To extend the argument, there has been the neo-liberal counter to the question. Henry (2002) quotes the pharmaceutical companies who argue that “high drug costs are to compensate for the vast amount they invest in developing products”, but as Angell (2007) illustrates, $37bn was spent on research and development by 500 of the top US pharmaceutical companies in 2006, compared to $73bn they spent on marketing that year. This also amplifies the truth in the 10/90 gap, which altogether improves Hogerzeil’s and Marxist position that to ensure medicine for all we need to ensure that is the goal, and not ensure medicine for profit.

The Third Challenge: Lack of help and assistance

This challenge is best explained by the case study of Thailand. As argued by Songkhla (2009), the former health minister for Thailand, “medicines for all” is something unachievable in the current state of affairs because there is no support from those which can give the help. In the 00s, Thailand moved towards universalism and this included healthcare. They introduced compulsory licensing for universal coverage and essential medicines for all. However, this move faced global backlash. Developed nations retaliated with undue political pressure to end the introduction of safeguarding measures and cannot only be considered extremely “unhelpful”, but more destructive as they imposed trade sanctions and threats on Thailand’s lesser economy. Pharmaceutical companies are seen to have done a similar thing by applying pressure to Thailand to stop. It is considerably more shocking when the situation is compared to the Anthrax scare in USA and Canada. Governments of both countries distributed Ciprofloxacin universally to treat the infection, and the pharmaceutical companies allowed it to happen. There was no backlash to their universal approach to ensure medicines were available for all. Finally, the WTO and WHO lack of response and support to the situation left Thailand fighting on their own. Powerless themselves, the WHO’s minimal assistance highlights a problem in their own makeup in that a country trying to achieve one of their goals is burdened by rich nations and the organisation can’t do anything about it. The relationship can be argued as “under the thumb” in that the WHO serves the powerful nations, but what a Marxist may argue as Capitalist exploitation. Songkhla goes on to suggest that the debate has been left open purposely to discourage other middle-income and low-income countries from doing the same thing for public health purposes, regardless of the fact that Thailand have been successful in moving a step closer to ensure essential medicines for all. In 2008, there were 20,000 people receiving treatment for HIV/Aids compared to just 5,000 if the generic drug was not available. Songkhla concludes her argument by suggesting that global health governance needs to put human faces into their policy decisions when it comes down to health; “it is a moral imperative and global responsibility to ensure better access to essential medicines in other resource-poor countries”.

What this case study of Thailand can tell us is that if a low or middle income country is willing to put the effort in to reach “medicines for all”, there is no outside support for them to do so, especially if it’s done in a way that will not be advantageous for richer countries. In metaphoric terms, “the books are there but there isn’t a librarian around to help find the books needed”. The case study also signifies the powerless WHO and the free-market mind-set of the WTO, for which Marxist analysis would describe as the two organisations serving a Capitalist ideology; “medicines for all” implies universalism for which are not in the interests of pharmaceutical companies looking to make money off the ill-health.

The Fourth Challenge: Structural Adjustment Programmes

Structural Adjustment Programmes, or SAPs, are “economic policies for developing countries that have been promoted by the World Bank and International Monetary Fund (IMF) since the early 1980s by the provision of loans conditional on the adoption of such policies” (World Health Organization, 2014). Daly (2013) argues that the programs have made many developing nations roll back the state to a minimal model, and therefore many public sector services have been relinquished of government control. To expand on this, the argument is being made that one of the challenges to “medicines for all” is the inability of the developing nations to do as they choose because they are limited by the economic power of the World Bank and the IMF. Contrast to the powerless WHO, the IMF and World Bank can easily control the dynamics of developing nations and so have much more power than some may argue necessary. The structural adjustment programs, Daly argues, have undermined health policy and medicine which has been identified as crucial to the development of the workforce. Because the structural adjustment programs are established by the World Bank and the IMF, they have a free-market (or as a Marxist would argue, Capitalist) aim, and so are neo-liberal. The neo-liberal model within developing countries has made it particularly difficult to implement policy and health programmes. This is because the neo-liberal model requires debt to be the main priority – developing nations have to put debt repayment as the first objective before they can spend money on introducing policy programmes, including healthcare. Shah (1998) defines this as “the IMF and World Bank have demanded the poor nations lower the standard of living of their people”.

One good example of how Structural Adjustment Programs have worked to the detriment is explained by James (2002) and the trade of nuts from Senegal. Because Senegal was a poor nation with limited resources, they took out loans to grow and develop their nut industry. But because of their success, other countries began to follow suit and so the price of nuts worldwide plummeted, leaving Senegal with large amounts of debt and not enough trade to compensate for the money lost in the nut market. This left Senegal with little choice but to invest in structural adjustment programs, resulting in reducing the role of the government as well as cutting spending. Global Issues (2007) goes on to explain how “the pressure to embrace ‘free market’ economics, with its promise of a wealthy, abundant market place has actually driven many countries further into poverty”. With many developing nations being pushed further into poverty, the increased reliance of structural adjustment programs has never been more present and so it leads us to summarise that “medicines for all” is part of the bigger problem of resolving absolute poverty. Nevertheless, for this debate, it can be seen that medicines for all is so difficult to achieve because one challenge is the structural adjustment program limiting developing nations ability to tackle healthcare in the best way they can.

For a Marxist, this underlines more than ever the unfairness and exploitation Capitalism encourages. Richer, developed countries argue for free-market and less trade restrictions, yet they have the resources to do so, compared to the economically impaired developing world who are further limited by these structural adjustment programs. For a Marxist, medicines for all is not a plausible reality with the free market pressure.

Conclusion

In conclusion, there are 4 main challenges as to why it is so difficult to ensure medicines for all. As previously discussed, the debate should rather be why is it so difficult to ensure essential medicines on an affordable, sustainable basis in developing countries? The 4 challenges explain how the answer to this question explicitly lies in the gap between the rich and the poor: the rich have the economic power to be able to control the worldwide medicines market and so have been successful in establishing expensive and protected drug patents. As well as this, the rich pharmaceutical companies aim to make profit and so they will not try to reduce costs or create products which will not help them achieve their goal. Thailand provides an extensive case study of how the rich are in reality not trying to ensure essential medicines on an affordable, sustainable basis, additionally implying that the organization who is trying to achieve the goal, the World Health Organization, have no power to help. Finally, the structural adjustment programs put into context the limitations of developing nations of achieving medicines for all. One of the biggest schools of thought that promote medicines for all, Marxism, expose Capitalism as the reason for these challenges, arguing that they are the biggest evil of them all. However, in my opinion, the fact that medicines for all is a subject area of absolute poverty contributes to the reason why these challenges exist and the goal is so difficult to achieve. This is because to achieve essential medicines on an ‘affordable’ and ‘sustainable’ basis requires economic power and stability, and although this can be blamed for by Capitalism, it is more to do with the fact that those in need of the essential medicines are also in need of many things for which they are unable to afford and sustain, such as food and water. Therefore, I conclude that medicines for all is so difficult to achieve because it is part of the wider scope of absolute poverty, a problem which won’t be solved overnight.

References

Angell, M. (2012) ‘The Truth About the Drug Companies’ [online] Available at: http://www.youtube.com/watch?v=uDbQNBla6aU (Accessed: 26 Nov 2013)

Daly, T. (2013) ‘Why is it so difficult to ensure medicines for all?’ [Seminar to BSc Social Policy: Health Policy in a Global Context] (28 Nov 2013)

Emily, J. (2002) The Luckiest Nut in the World. Global Health Issues [online] Available at:  http://www.globalissues.org/video/778/luckiest-nut-in-the-world (Accessed: 12 Jan 2014)

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Tobacco control at a global level

How has tobacco control been approached at a global level, and what challenges does it face?

Following a major epidemic in 2003, tobacco control cemented itself at global level when the World Health Organization negotiated the Framework Convention on Tobacco Control (FCTC 2013), alongside the comments made by Gro Harlem Brundtland (former PM of Norway and Director General of the UN World Health Organization) “deeming malaria and tobacco as the two most serious global health problems” (Sugarman 2001). With a variety of case studies and examples of international policy and efforts, it is evident that tobacco control has been taken as a serious issue but has meant many new and old challenges.

The WHO FCTC was adopted by the World Health Assembly in 2003 and claims to be “one of the most rapidly and widely embraced treaties in the history of the United Nations” (FCTC 2013). It reaffirms the right of all people to the highest standard of health. Immediately, the goals sought by the WHO FCTC identify what tobacco control primarily is; the attempt at limiting tobacco users and the risks smokers cause to them and others around them. The key provisions of the WHO FCTC are, as outlined by Phillip Morris International (2013), Protection, Labelling, Illicit Trade, Regulation, and Taxation. However, with the attention focussed upon health, it raises questions as to whether tobacco control is the control of tobacco supply or the attempts to reduce tobacco demand. Because of the war between health risk concerned groups and the oligopoly of the international tobacco industry, (Tobacco Atlas, 2008) what can be learned from the WHO FCTC is that ‘tobacco control’ aims to reduce the demand of tobacco through attacking the supply side. There is sufficient evidence to support this claim, such as the previously commented FCTC provisions. In 2012, one provision the group introduced was a Protocol to Eliminate Illicit Trade in Tobacco Products (FCTC, 2013). Protocol activities included establishing cooperation between the UNODC and the WCO as well as introducing a study of tracing and tracking regimes. This demonstrates a clear effort to quash supply as it makes it easier to control tobacco if the trading of tobacco happens less ‘below the table’. With many UN agencies keeping a closer eye on illegal tobacco trade, it makes products harder to obtain and therefore naturally means reducing tobacco consumption is easier. As well as this, Joossens (2012) highlighted a study on Europe which indicated that the greatest response to the demand in tobacco is the price. Consumers prefer ‘cheaper’ products (as opposed to harsher flavour, or unappealing packaging) and illicit tobacco trade is the way in which the cheapest products can be found. Thus, in an attempt at thwarting the illegal trading of tobacco, not only is the supply of tobacco reduced, but it also suggests that demand for tobacco products will fall because of the rise in price. It is suggested that this will occur through the decrease in the availability of cheaper products, meaning that less are on the market and that tobacco companies do not need to depress their prices as they can no longer be matched by the absent black market. And so, it is evident that the 2003 WHO FCTC treaty is approaching tobacco control at a global level, and with their work including the protocol to remove illicit trade of tobacco products, they are making attempts at reducing both the demand and supply side of tobacco.

When looking at the history of tobacco control, the most prevalent smoking ban legislation of each country can undoubtedly be linked back to 2003, the year of the FCTC. For example, a case study of Ireland identifies a link between the FCTC and their smoking ban legislature; a link which cannot be put down to just coincidence. Ireland were one of the world leaders in banning smoking at the workplace in 2004 (BBC, 2004), and brought in recent legislation in 2013 for a “Tobacco Free Ireland” (FCTC, 2013). Research carried out by the Health Service Executive in Ireland (2012) discovered that the effects of Ireland’s strong fight against tobacco are rapidly apparent: prevalence fell 1.8% between June 2010 and December 2012. The case study of Ireland successfully argues the claim that global tobacco control, lead by the WHO, are undeniably making a difference. On a broader context, recent EU policies under the Tobacco Products Directive give extensive backing to the claim. Headlines were hit when the EU legislated on public health operatives regarding tobacco control, for example, banning 10 pack cigarettes was a key feature of the legislation (Waterfield, 2013). The increase in laws such as this, as well as Ireland being made a clear example of by the WHO, demonstrate how tobacco control is a global movement, and a problem which will be increasingly solved by a global effort.

Moving onwards, tobacco control has also been approached at a global level by many interest groups. As previously mentioned, the Smoke Free Partnership (n.d.) is one such group which is taking similar measures to the WHO FCTC as they attempt to reduce smoking, and advocate control of tobacco within the EU. They provide extensive coverage of smoking related legislature within the EU, watching each country closely. This is especially the case in regards to exposing those countries who have disregarded article 8 of the WHO FCTC which is legal statute to ban smoking in “indoor public places, work places, and public transport”, for example, the unenforced and weak laws in Austria for smoking inside the workplace. Additionally, the Smoke Free Partnership provide detail on the bare facts of smoking, raising awareness for the problems tobacco use causes. They expose simple statistics of the global burden of tobacco; “tobacco-related illness already kills 5.4 million people a year worldwide”. Another similar interest group is the Bill & Melinda Gates foundation. A respected and recognised philanthropic force in global health, the foundation supports “full implementation of FCTC provisions” (Gates Foundation, 2013). As a result of this, a core aim of the foundation is to reduce tobacco related deaths worldwide – with a specific focus on two of the poorest regions in the world, Africa and South-East Asia, and China, a country with approximately 350 million tobacco users (The BMJ, 2013). What these interest groups show is defiance against tobacco, but what they represent is having more implications for the global control of tobacco. They highlight the broader picture towards the global attitude on smoking; reducing and controlling it. What is automatically apparent from all these interest groups is that at their heart is FCTC policies. Not only has the WHO FCTC increased the amount of interest groups, but the groups are growing in popularity. The modern tobacco movement on a global scale can be tracked back to the 70s, but it hasn’t been taken seriously since the 90s, and especially not until the WHO FCTC in 2003. It can be argued a new phenomenon is visible: an unquestionable, intentional fight against tobacco on worldwide scale. It has not been seen before. This is meant in the terms of global efforts; there have been efforts to curve tobacco use for centuries (Borio, 2010). In modern history, individual nations have attempted to reduce the use of tobacco sometimes even on an international scale, as well as nationally. However, with all nations united in tobacco control, this global front can be seen as a new phenomenon. Concurring with rapid globalization, tobacco control, predominantly outlined by the FCTC, is being met with effective deliberation at a global level. Nevertheless, this has also meant fresh challenges in addition to the long-standing challenges brought forward by the tobacco industry.

The biggest challenge to tobacco control is the industry. As previously mentioned, there is a tension, a “war”, between the WHO FCTC and other health concerned groups, and the oligopolistic international industry. Following considerable merging in the 90s and 00s, Phillip Morris & Altria own 20.2% of the international market, British American Tobacco 12%, Japan Tobacco International 9.6%, Imperial Tobacco 4.9%, and the overwhelming China National Tobacco Co. have a staggering 37.1% of the international market (Tobacco Atlas, 2008). An oligopoly is an example of market failure (Economics Online, n.d.) and as explained by Sugarman (2001), “the increasing importance in the worldwide tobacco market of a few giant companies (all broadly transnational, apart from Chinese monopoly) is itself seen by many as a reason to view smoking and its control no longer merely as a series of separate national problems, but rather as global one”. Henceforth, the importance of global tobacco control cannot be underestimated as the industry has the power to penetrate deep within the politics and economics of every nation. The most prominent example of this is the failure of the US to ratify the FCTC treaty, with heavy, financial persuasion from the tobacco industry. Mulvey (2005) reported a $3.7million contribution from tobacco companies during the 2004 political cycle, and Tobacco-Free Kids reported direct payments to just federal candidates (through PACs) of $1.5million in the 2009-2010 political cycle, and $1.6million during the 2011-2012 cycle (Tobacco Free Kids, 2012). The industry counters many arguments raised by the tobacco control groups, as they naturally want to keep on increasing the demand for tobacco whilst maintaining the large fortunes earned by supplying it. As can be seen, this is achieved through their political and economic influence as a result of lack of competition from market failure. And so the greatest hurdle to global tobacco control is naturally the industry itself: not only is the industry logically going to oppose reduction, but their wide outstretched arms block the path to global health governance, providing a significant mountain to overcome if reduction of tobacco is to be successful.

Globalization can evidently be seen as a major driving point for the FCTC, but on the reverse of that, globalization has also been a challenge to tobacco control. As earlier cited, the large merging in the 90s and 00s resulted in bigger tobacco companies getting bigger and smaller tobacco companies getting smaller. This can be argued as a consequence of globalization, and what is predicted because of this implies how globalization is becoming an ever increasing problem as well as a good thing. As Sugarman (2001) notes, “the annual global death count is now projected to reach more than 8 million by 2020… Furthermore, the incidence of mortality is shifting from rich countries to poor countries… an estimated two-thirds of those deaths will occur in developing countries”. Another staggering point made by Sugarman is within regards to the market of potential female smokers, as developing nations reduce their gender inequalities. Mackay (1998) argues that by 2025, the estimated increase to 1.64 billion smokers worldwide will have three main causalities; one of which being an increase in the amount of women smoking. In developing nations, Mackay suggests there will be a 12% increase in female smokers. Gender Equality is a prevailing issue, but it is something many agencies are working towards; whether they are governments or local charities, there is an increase in feminism and a constant step towards equality for women. Tobacco use amongst women will grow as genders become more equal (Pampel, 2006) for example, an article published by Koutsoukis (2010) describes how women ignored a smoking ban on females in a public park in Gaza, leading to the smoking ban being lifted. It indicates that the government stronghold was weak and powerless, with women choosing to carry on their tobacco use regardless. The article exemplifies and exposes the stronger position women are taking in patriarchal communities around the globe – as well as exemplifying and exposing the stronger position global tobacco control will have to take in order to reduce the amount of tobacco users. Gender equality in patriarchal countries will only continue to become more apparent, creating a larger market for the wealthy international tobacco industry to uncover and exploit. Tackling an increase in female smokers in developing nations is just part of the picture; tackling the increase in all smokers in developing nations is a great challenge for tobacco control, regardless of socio-economic status, race, ethnicity, age and gender. Globalization is making advertising of tobacco products more accessible, and as McKarney (2010) explains, tobacco companies are targeting developing nations, illustrating Indonesia as having a “tobacco advertising overload”. The escalation of tobacco use in developing nations highlights the intensification of challenges global tobacco control is facing; the unstoppable forces of globalization providing both a stronghold for global tobacco control as well as a challenge.

In conclusion, tobacco control is met at global level through a series of partnerships and worldwide obligations. The World Health Organization on the Framework Convention on Tobacco Control has sufficiently set up a minimal level for every country to comply with, in regards to reducing tobacco consumption. It is one of the most important pieces of legislation in the 21^st century; it shapes and attempts to combat one of the biggest consumer industries in the world. Herein, the challenges that face global tobacco control are obvious. As it is one of the biggest industries in the world, trying to reduce the demand and supply of tobacco is not an easy fate for governmental and non-governmental organizations. Nonetheless, it can be summarised that tobacco control is an ever-increasing global phenomenon and it will grow as a force at the same rate the challenges will also grow.

References

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Mulvey, K. (2005) Break US Stronghold of ‘big tobacco’. Available at: http://www.csmonitor.com/layout/set/r14/2005/1109/p09s02-coop.html (Accessed: 12^th Nov 2013)

Pampel, C. (2006) ‘Global Patterns and Determinants of Sex Differences in Smoking’, International Journal of Comparative Sociology, 47(6) pp 466-487. Available at: http://cos.sagepub.com/content/47/6/466.full.pdf+html (Accessed: 6^th Nov 2013)

Phillip Morris International (2013) WHO and the FCTC. Available at: http://www.pmi.com/en_cz/tobacco_regulation/regulating_tobacco_products/who_and_fctc/pages/who_and_fctc.aspx (Accessed: 11^th Nov 2013)

Smoke Free Partnership (n.d.) About Us. Available at: http://www.smokefreepartnership.eu/about-us (Accessed: 8^th Nov 2013)

Smoke Free Partnership (n.d.) Austria. Available at: http://www.smokefreepartnership.eu/austria (Accessed: 8^th Nov 2013)

Smoke Free Partnership (n.d.) Global Burden of Tobacco use. Available at: http://www.smokefreepartnership.eu/news/global-burden-tobacco-use (Accessed: 8^th Nov 2013)

Sugarman, S. (2001) ‘International Aspects of Tobacco Control and the Proposed WHO Treaty.’ In: Rabin, R. and Sugarman, S. Regulating Tobacco (eds). Oxford: University Press pp245-284.

Tobacco Atlas (2008) Tobacco Companies Available at: http://www.tobaccoatlas.org/industry/tobacco_companies/market_share/ (Accessed: 3^rd Nov 2013)

Tobacco Atlas (2008) Global Cigarette: Market Share. Available at: http://www.tobaccoatlas.org/industry/tobacco_companies/global_market/ (Accessed: 11^th Nov 2013)

Tobacco Free Kids (2012) Tobacco Industry Contributions to Federal Campaigns. Available at: http://www.tobaccofreekids.org/what_we_do/federal_issues/campaign_contributions/ (Accessed: 16^th Nov 2013)

Waterfield, B. (2013) EU Bans Packs of 10 and Menthol Cigarettes. The Telegraph [online] 8^th Oct. Available at: http://www.telegraph.co.uk/news/worldnews/europe/eu/10364709/EU-bans-packets-of-10-and-menthol-cigarettes.html (Accessed: 27^th Oct 2013)

Coalition Health Policy - end of NHS?

Is Coalition health policy, as in the Health and Social Care Act 2012, the end of the NHS as we have known it?

Launching discussion about the end of the NHS as “we have known it” implies a political discourse; the NHS must “represent/mean” something for it to end. On its inception in 1948, the core founding principles and values of the NHS are that it has been, and should be, a health care system funded and provided by general taxation and should be free at the point of use (Hunter, 2008). Thus, we can succumb to the conclusion that the end of the NHS would mean the end of a predominantly tax based system incorporating user fees. However, those are the founding principles from 1948 – the NHS as “we have known it” also exposes the idea that our generation value the NHS in its own context. Furthermore, investigation appears to start in the 1990s.

A main feature of the Health and Social Care Act of 2012 is the move from Primary Care Trusts to Clinical Commissioning Groups. The Kings Fund (2012) argues that “the idea of commissioning as a discrete function within the NHS dates from 1991”. The NHS Community Care Act 1990 effectively introduced a level of competition in the market creating a split between ‘purchasers’ and ‘providers’ in local health authorities; an act which established itself well into the 90s, and one that New Labour chose to alter rather than abolish. New Labour launched Primary Care Trusts (PCTs) in April 2000 (NHS Confederation, 2011) with three initial objectives: i) to purchase care for local communities, ii) to directly provide services such as community care, and iii) to work with local agencies to tackle health inequalities and improve public health. PCTs later expanded and work involved much more than that, but their role was evident from the outset: competition to create marketization. And so what can be drawn from this then is how market forces have been playing a force in health care, notably general practitioning, since the early 90s, cementing under New Labour during the next decade.

As previously mentioned, the coalition government introduced Clinical Commissioning Groups (CCGs) under the Health and Social Care Act 2012. These replaced PCTs and in a simple form would be GP consortia, taking over all the commissioning functions of the NHS. As Naylor et al (2013) discusses, the new CCGs control approximately two-thirds of the NHS budget, with a GPs duty to commission the majority of NHS services to their patients. This means that GPs, in their CCGs, act as both purchaser and provider; they purchase and provide for patients. The belief is that CCGs will improve healthcare because GPs are in a better position than managers when it comes to making decisions over the services patients need. The implications of this are simple and easy in the sense that this creates competition and a marketization of health care, representing a move away from the traditional setting of Bevan’s 1948 NHS, through to Thatcher’s managerialism in the 1980s (Lart, 2012). A key feature of the 1948 NHS Act was central control of hospitals; the aim was to “nationalise” the capital stock of the health service, with local authorities still running community services. Quasi-market structures represent an “evolutionary” change, and the debate on this issue is centred on the end of Bevan’s “central control” of delivering a national service both as purchasers and providers. Fundamentally, this has consequences for the analytical discussion as to whether the Health and Social Care Act of 2012 means the end to the NHS as we have known it. It can be argued that in turn, a new phenomenon of marketization is occurring within health care in the UK, yet these ideas and policies have been around since the 1990s. And so the NHS as we have known it naturally must mean we have known it as a competitive system because our generation have not “known” the NHS from before the 90s. Therefore, the Health and Social Care Act of 2012, with a shift from PCTs to CCGs, cannot be seen as the end to the NHS, as the system has looked the way it does now for over two decades.

The Health and Social Care Act of 2012 reformations were laid out in the July 2010 White Paper “Liberating the NHS” (Lart, 2013). The term “liberating” immediately signals some form of reformation, and with the changes planned, it naturally raised debate regarding whether the value and ethos of the NHS were taken into account. First of all, the background to the act is important. During the 2010 election campaign, health policy was not taken as seriously as other issues; Cameron had his own personal reasons for defending the NHS (Watt, 2009), inferring a commitment to keep it free at the point of use, as well as stating intentions to increase health expenditure in line with inflation. Additionally, Andrew Lansley, the then shadow secretary of state for health, had already outlined his intention to move away from PCTs and put more responsibility on to the shoulders of GPs (Campbell, 2010). During the build up to the 2010 general election though, health and social care took more of a back foot compared to the bigger issues such as immigration, with the Telegraph (2010) reporting education, employment and the economy as more pressing matters. All parties displayed assurance to not forget the founding principles of the NHS, with the bigger evolutionary changes discreetly lined up. It can be argued that the coalition’s Health and Social Care Act 2012 unsettled many, but it can also be argued that debate has arisen out of the sheer fact that some were not expecting such a drastic change, resulting in the statement that it is the end of the NHS as we have known it. The debate appears to be much more to do with empirical discussion against rational thinking; the NHS in effect hasn’t changed that much in the last 20 years to justify the argument that the coalition is ending it. Rationality has been displaced for empirical arguments – what the NHS “represents” is slowly being eroded and the future ultimately looks “pessimistic”.

One clear example of this is in another of the major changes that the coalition government took in reforming the NHS operative. As part of the 2012 Act, Lansley aimed to make trusts more autonomous; all NHS trusts were to become Foundation Trusts (Nuffield Trust 2013). The state, instead of owning, would become more of a regulator. The coalition did this through allowing hospitals to generate more of their profit from private patients, as reported by the BMJ, “NHS hospitals in England will be able to increase the proportion of money they can earn from private patients to 49% from 1 October 2012” (Kmietowicz, 2012). The figure 49% is a vital statistic as it symbolizes much more than it lets on: it means that the NHS does not comply with EU Competition Law. On the one hand, this means that a citizen of a member state in the EU cannot “just come over and get their hip replaced in an NHS hospital”. In a more defined manner, the NHS will maintain its status as a healthcare provider for social functions, meaning it will not open itself up to the European market, where an uncertainty kicks in. It indirectly signals an attempt to lack convergence with other members. A rational argument from this is that the coalition is defending the universal aspect of the NHS, capping the income generated by hospitals from private patients at 49%. This is a rational argument as it takes the literal facts on board: the 49% falls below EU competition law of 50% (Pinsent Masons, n.d.). But on the other hand, there is the empirical argument as well. The empirical argument takes a broader picture in that the move towards a greater generated income for hospitals creates an internal market with quasi-market structures, with or without a cap. It puts those who argue that the coalition is destroying the NHS in a strong position as allowing any form of internal market in the NHS puts an end to the desired equitable NHS set up in 1948.

Such a debate is epitomized by Le Grand and Hunter (2013) discussing the bill representing an end to the NHS. Le Grand responds to the empirical argument on the fear of rising competition resulting in an unrecognizable NHS by introducing qualitative data: “colleagues at the London School of Economics found that during the period when patient choice was introduced in England, hospital quality improved fastest in more competitive areas. He later goes on to add that “colleagues at York found competitive reforms even improved equity of service delivery”. Le Grand’s comments are finalised in his response to the debate at hand by arguing the NHS will not end because “large chunks of the NHS are private and have been since 1948, for example, most GPs are in private, profit making partnerships”. The implications for this discussion are obvious in that they literally mean the marketization of the NHS from the 1990s does not mean anything as the private sector has prevailed since its inception in 1948. Nonetheless, my debate focusses upon the end of the NHS “as we know it”, implying that the 2012 Act must in some way be different to how it has been for the last twenty years or so. The immediate answer, as already discussed, is no. But Le Grand makes valid points to counter those that fear the coalition government has brought about the end to the NHS.

The points which Hunter makes in the debate are much more intriguing. Hunter does not argue that this is the end of the NHS, but that the end will begin to happen. More simply, the beginning of the end. He argues that the end will happen because the coalition “replacing publicly run and accountable services with a mixed economy of care largely delivered by for-profit corporation” and “embedding market competition as the driving force for the NHS” will come at detrimental effect. Hunter uses Sweden to make his point. Sweden, traditionally known for their universal principles and able to boast a GINI coefficient of just 0.24 (The Economist, 2012) is suffering from “profit driven health services, which are increasing the inequities in the supply of primary healthcare”. The set-up of the Swedish health care system is similar to that of the United Kingdom (Gallagher and Cruz, 2013). The Health & Medical Services Act 1982 gave county councils considerable freedom in health services, decentralization. It is also worth noting that the foundation of the system is in primary care. This is similar to what Lansley achieved through the 2012 Act by handing more responsibility over to GPs with locally run CCGs. Also, the Swedish health care system is primarily funded through taxes and the role of private health insurance is supplementary. The interpretation of Hunter’s argument goes far beyond fear of competition in that if Sweden, a country based on universalism and equality, is becoming steadily more inequitable in health care services, then it would be easy for a country such as the UK to fall into the same pattern. This is especially the case as the health care system of both countries is strikingly similar. And so, Hunter leads us to the conclusion that instead of the Health and Social Care Act 2012 representing an end to the NHS, it is the beginning of the end because it indicates further privatization in the future, “destroying the public service ethos”. In this instance, the new act introduces much more competition than previously known, inviting a greater presence for private companies, therefore meaning it is the end to the NHS as we have known it.

In conclusion, the question “Is Coalition health policy, as in the Health and Social Care Act 2012, the end of the NHS as we have known it?” should be grappled with in order to be resolved. To fragment the question, the Health and Social Care Act 2012 has been seen in the literature as much more than an alteration to the health care system in the UK. The 2010 White Paper “Liberating the NHS” offers debate in the title alone, with the proposals suggested further offering a political discourse as to how healthcare should be dealt with by the welfare state. The end of the question “end of the NHS as we have known it” corresponds more alternative meanings in that a pivotal to question is “who is we?”. If “we” is taken as the whole of society then the facts are incontrovertible; the Health and Social Care Act 2012 is a further move away from the universal, state-provided NHS introduced in 1948. But this essay has replied to the debate as “we” meaning my own generation, and so it is important to enquire how “we” can see the NHS. In my opinion, we cannot see the NHS as nothing more than it has been since the splitting of purchasers and providers under the NHS Community Care Act 1990. Consequently, the NHS has simply not changed sufficiently since the 90s to merit the end of the NHS by the coalition. In spite of this argument though, I do support Hunter’s argument that the coalition’s health policy is the beginning of the end of the NHS because they intend to spread competition throughout the health care system, demonstrated by the move to allow hospitals to generate 49% of their income from private patients. It cannot be denied that by trying to get more and more patients to pay for their service as well as paying for health care in general taxation will become more popular as it means patients can jump quickly up waiting lists and so forth. It is easier to predict we will move more towards a system of user fees following coalition health policy than a move back towards equity and universalism. Therefore, coalition health policy, as in the Health and Social Care Act 2012, is not the end of the NHS as we have known it; it is potentially the beginning of the end if coalition health policy is allowed to extend.

References

Campbell, D. (2010) ‘How would the NHS look under a Conservative government?’ The Guardian, 13^th April [online]. Available at: http://www.theguardian.com/society/2010/apr/13/interview-andrew-lansley-conservative-health-spokesman (Accessed: 22^nd Oct 2013)

The Economist (2012) Sweden: The new model [online]. Available at: http://www.economist.com/node/21564412 (Accessed: 27^th Oct 2013)

Gallagher, J., Cruz, M. (2013) Health Policy in other developed countries [Seminar to BSc Social Policy: Healthcare Policies] 30^th October.

Hunter, D. (2008) The Health Debate. University of Bristol: Policy Press.

Kiemtowicz, Z. (2012) ‘Hospitals will be able to earn 49% of their income from private patients from October’ The BMJ, 345(e4823), Highwire Press British Medical Journal Publishing Group [online]. Available at: http://www.bmj.com/content/345/bmj.e4823 (Accessed: 4^th Nov 2013)

Kings Fund (2012) Clinical Commissioning: What can we learn from previous commissioning models? Available at: http://www.kingsfund.org.uk/topics/nhs-reform/white-paper/gp-commissioning (Accessed: 11^th Nov 2013)

Lart, R. (2012) Health Policy in the Post-War Period [Lecture to BSc Social Policy: Historical Perspectives] November.

Lart, R. (2013) Coalition Health Policies [Lecture to BSc Social Policy: Healthcare Policies] 21^st October.

Le Grand, J., Hunter, D. (2013) Will 1 April mark the end of the NHS? The BMJ, 346(f1975), pp. 14-15. Healthcare Policies [online] 30^th March. Social Policy: Healthcare policies. Available at: http://www.ole.bris.ac.uk/ (Accessed: 26^th Oct 2013)

Naylor et al (2013) Clinical Commissioning Groups: Supporting improvements in general practice? Available at: http://www.kingsfund.org.uk/publications/clinical-commissioning-groups (Accessed: 14^th Nov 2013)

NHS Confederation (2011) The legacy of Primary Care Trusts. Available at: http://www.nhsconfed.org/Publications/Documents/The_legacy_of_PCTs.pdf (Accessed: 11^th Nov 2013)

Nuffield Trust (2013) The coalition government’s health and social care reforms. Available at: http://www.nuffieldtrust.org.uk/our-work/projects/coalition-governments-health-and-social-care-reforms (Accessed: 15^th Nov 2013)

Pinsent Masons (n.d.) Competition Law – the basics. Available at: http://www.out-law.com/page-5811 (Accessed: 15^th Nov 2013)

Telegraph (2010) General election 2010: education, employment and the economy key poll issues [online] Available at: http://www.telegraph.co.uk/news/election-2010/7449225/General-election-2010-education-employment-and-economy-key-poll-issues.html (Accessed: 15^th Nov 2013)

Watt, N. (2009) ‘David Cameron backs NHS with memory of his late son Ivan.’ The Guardian [online] 20^th August. Available at: http://www.theguardian.com/politics/2009/aug/20/david-cameron-defends-nhs-ivan (Accessed: 8^th Oct 2013)

Smoking, obesity and alcohol

How should government tackle public health issues such as smoking, obesity or alcohol misuse?

To begin with, it is essential to define public health. Discussed by Lart (2013), public health was rediscovered in the 1980s as a way of conceptualizing the health of the population. However, it has been apparent since the 19^th century. The Victorians associated civil engineering with the health outcomes of poor water quality and drains, later thinking about social housing and what this had to do with cholera epidemics of the time. Public health is usually thought about in regards to what the major problems with the health of society are at one given time, like in the 19^th century with cholera, and the HIV epidemics of the 1980s. Lart goes on to discuss how public health has “the ability to conceptualise, measure, record, and at some level manipulate the health of a population, and was central to the development of the modern nation state”. What is being explained here is that public health has been a measure by which the population can be seen as ‘healthy’ or ‘unhealthy’, and so naturally means that there is something which makes the population ‘unhealthy’. So the HIV epidemics of the 1980s were a public health issue because they illustrated the biggest cause of mortality and morbidity at the time. And so in order to answer ‘how should the government tackle public health issues such as smoking, obesity or alcohol misuse?’, it is necessary to remember that public health is what characteristically define the health of a nation and that public health issues are the things that need tackling in order to make the population “healthier”.

The main public health issues of today are issues such as smoking, obesity and alcohol misuse. They are public health issues because of the consequences they have on individuals and mortality/morbidity rates. The top cause of death in today’s society is heart disease, often heavily linked to smoking, obesity and alcohol misuse. In England and Wales in 2012, heart disease was the leading cause of death in men at 15.6%, and the second highest at 10.3% (ONS, 2013). There are many reasons which could lead to heart disease, however the NHS Choices (2012) does explain that smoking and diet related illnesses such as type-2 diabetes are influential in heart disease. To assess how the government should tackle these public health issues it is apparent that we need to look at how the government has tackled public health issues in the past in order to understand how to be successful.

As earlier mentioned, the HIV epidemic was a major public health issue in the 1980s. The government responded with committing millions of pounds in 1985 in order to tackle the problem, as well as launching campaigns such as “Don’t aid AIDS” in 1986, and “Don’t Die of Ignorance” in 1987 (HIV Aware, 2011). As Kelly (2011) explains, the “Don’t Die of Ignorance” campaign was used with a television advertisement labelled “shocking” but turned out to be hugely successful in avoiding the prediction of death on a mass scale. Immediately, what this can tell us is that the HIV/Aids public health issue in the 1980s was calmed through imminent government intervention and raising awareness for the issue, interestingly with advertisement playing a key role in solving the epidemic. To assess how the government should tackle the public health issues of today, credit must be given to their response in this particular incidence. Without a cure for the disease and treatment in the early ages of development, they took the issue straight to reducing the risk of spreading rather than attempt to cure. Consequently, the implications for this are bigger than it appears because it shows how the government sending out a message to the whole population rather than those it just affected was successful in preventing the predicted high death toll.

In 1992, the Conservative government issued the “Health of a Nation” White Paper. It was the first of its kind to identify outcomes of public health policy. Before the 1992 white paper, health policy was about inputs and allocating resources. Therefore to question ‘what the biggest factors affecting the health of the population are’, can almost be described as revolutionary, and today it can be seen as an important step in order to try to tackle the public health problems of the day. In 1992, mental health and suicide were big problems, and so the white paper attempted to reduce these targets. They implied a multi-sectorial approach: “health policy is bigger than the NHS”. What is meant by this is that to tackle these public health issues needs attention from more than just health policy, with areas such as education just as important. But being driven by mortality data and with the NHS still given the main responsibilities, suicide rates actually got worse as they were powerless to do much else than detain young men potentially or actually attempting suicide. This tells us a lot about how the government should tackle the problems of today. In 1992, their attempts at reducing suicide and mental health rates were falling because they were too specific, and more importantly, the government focussed too much on what the problems were, and not much on how to solve the problems they found. This already informs today’s government on how best to resolve public health issues as it means that knowing obesity, smoking and alcohol misuse is not enough; research needs to be taken in what leads to these issues, and what is the best way to resolve them.

In 1999, Labour reengaged the focus in public health issues with a new white paper “Our Healthier Nation”. They took a broader narrative in an attempt to improve the health of everyone, with special attention given to the worst off. Instead of shaping policy around specifically targeting one aspect of public health like the Conservatives had done earlier in the decade with mental health and suicide, the government took a more general approach. For example, with one public health issue being smoking, they attempted to reduce the harm of smoking by taking measures to outline where people can smoke, thus lowering the potential for non-smokers to inhale passive smoke. The success of this can be seen in statistics such as reported by Brimelow (2013) in the sharp fall of children admitted to hospital with severe asthma after smoke-free legislation was introduced in England. This adds to the argument that public health issues are better tackled when the government focusses on the population as a whole. By reducing the amount of smoking environments, the effects have been successful in healthcare.

Categorising the different ways in which the government can approach the public health issues of smoking, obesity and alcohol misuse is an important step in knowing how best to tackle the problems. McDaid and Suhrcke (2012) outline a key distinction between upstream and downstream interventions for which governmental intervention can take. First of all, upstream interventions are all about promoting good health. For example, promoting good health along with other goals; income support, housing improvements, better/longer education and so forth. They argue that it is critical that health systems liaise with other bodies to emphasise health impacts of their policies. This compares to downstream interventions which are specific to health. This includes interventions on diet and lifestyle advice programmes, tobacco and alcohol control policies, water and air quality monitoring, and legislative, regulatory safety measures against accidents and injuries. Downstream interventions are more common, such as the Change4Life programme operating currently, a programme attempting to improve the diet and lifestyle of the population. Nonetheless, the two interventions have an important relationship. Kelly et al (2005) describe the relationship as very interconnected; an upstream intervention to improve the general health of the population may be a “necessary precondition for other downstream interventions to be effective”. The implications of this distinction and categorisation of interventions appear to provide sufficient evidence that for governments to tackle public health issues they must tackle the situation with all the important means to do so. Basically, the government cannot tackle an issue such as obesity without educating the population on the reasons as to why diet and healthy lifestyle are of importance.

Returning to McDaid and Suhrcke (2012), they believe that public health experts forget the importance of market failure as a justification for government intervention by arguing that market failures highlight scenarios of individuals making mistakes and causing implications for society because of the free-market. A classic example of this is smoking; the cost of an individual smoking bares no comparison to the cost the smoker has on the NHS and so without government intervention with added tobacco taxes, the market would fail. Therefore, when arguing how the government should tackle public health issues, it seems vital to remember the significance of how important their intervention is.

One such measure the current government has taken in order to tackle today’s public health issues of smoking, obesity and alcohol misuse has been public health responsibility deals. Outlined by the Department of Health (2013), the public health responsibility deals are pledges committed by organisations to take responsibility in improving public health at either national or local level. Two of the biggest responsibility deals are the food pledges and alcohol pledges. The main food pledges consist of companies making healthier food products by reducing salt content and removing trans fats, whilst also providing better quality information about their products such as calorie information. With the biggest food and drink company in the UK, Unilever UK Ltd (Secomak Solutions, 2012), committing to the food pledges, some can argue that the government have taken a strategic effort in their attempt to tackle the obesity public health issue. But there are those which argue the public health responsibility deals are not and will not work. Panjawi and Caraher (2013) say that the responsibility deal approach is “fundamentally flawed in its expectation that the industry will take voluntary actions that prioritise public health interests above its own. Being government-led counts for little in the absence of sanctions to drive compliance”. The best way in which this argument can be tested is through a more explicit example of the food pledges in the responsibility deals.

Another way in which the government has attempted to tackle the obesity public health issue is through the Front of Pack Nutrition Labelling Scheme 2013. Whilst front of pack labelling has been popular for many years now, the new scheme is part of the voluntary food pledges outlined in the public health responsibility deals. The new scheme attempts to get all food and drink manufacturers to use the traffic light coding system to inform the consumer of things such as salt and energy content. The Department of Health (2013) explained how there is a need for consistency in the labelling amid the concern that “the majority of us should aim to limit our diets”. The British Heart Foundation (2013) carried out an investigation into portion sizes and labelling schemes, concluding that not only have portion sizes doubled, but most are unrealistic. However, the most important aspect to acknowledge is the fact that the research demonstrated difficulties in people’s knowledge of how much a portion actually is. Participants were “44-50% over when asked to measure out a 30g serving of Cornflakes”. What this can tell us is that despite best efforts to solve the obesity issue, it is pointless without the knowledge of how much one serving actually looks like. This lack of knowledge is where many argue the government should be focussing their attention on. This could lead to the argument that to tackle the public health issue of obesity, the government needs to remember how success in the past can be seen at directly informing or stopping the population with regards to the issue. For example, raising awareness of HIV in the 80s or creating smoke-free environments to reduce passive smoking. Linking back to Panjawi and Caraher’s argument (2013), the implications for this are that the government isn’t necessarily failing in their attempts to reduce obesity, they are just not sufficient enough to lead to real success. Even though the food pledges have successfully been voluntary actions to be taken by food manufacturers, the lack of hard-law legislation limits the ability for the public health responsibility deals to be of success also. Thereby, to tackle the public issue, the government should extend their efforts to reduce obesity by taking more verifiable action.

Alcohol misuse is another of today’s public health concerns. The Health and Social Care Information Centre (2013) report that “In 2011/12, there were an estimated 1,220,300 admissions related to alcohol consumption where an alcohol-related disease, injury or condition was the primary reason for hospital admission or a secondary diagnosis (broad measure)”. One way in which the government has responded to the issue is through the “Why Let The Good Times Go Bad?” Campaign. As part of the responsibility deals, the £100m campaign was established with three main recommendations; eating before drinking, alternating soft and alcoholic drinks, and looking after friends. Foottit (2011) argues that the campaign has been successful because she explains how “80% of young adults have adopted one of the recommendations for responsible drinking”. Instantly, the campaign can be seen as a success because of the strong level of response to the recommendations. Nevertheless, there has also been emerging evidence that the campaign posters have worked to their detriment. Morris (2013) found that exposure to Drinkaware posters actually appeared to increase alcohol consumption. What can be taken from this investigation is that it is too early to forecast any sound trending patterns as there is conflicting research over how successful the campaign has been. To contextualise this with earlier success of public health initiatives, it appears that raising awareness to the population as a whole could lead to greater success than specifically aiming the campaign at the target audience. And so even though at an early stage in approaching the drinking culture, it can be seen that the government is doing the right thing to tackle the alcohol misuse public health concern by addressing everyone with their campaign.

Finally, the smoking public health issue has to be assessed in a different manner to how obesity and alcohol misuse are. This is simply because the government does not work alone in attempting to reduce tobacco consumption. At current, global health governance sharply addresses smoking as a serious concern with Gro Harlem Brundtland (Director General of the UN World Health Organization) deeming smoking as one of the biggest global health problems we face (Sugarman, 2001). The World Health Organization has consequently set up the Framework Convention on Tobacco Control. Adopted in 2003, it the treaty is one of the most widely and rapidly embraced treaties in the entire history of the UN (FCTC, 2013) and introduces such provisions as the Protocol to Eliminate Illicit Trade in Tobacco Products. This included establishing better cooperation between the UNODC and WCO as well as implementing and researching tracking and tracing regimes. Other examples of where the FCTC have been succeeding is in persuading many countries to introduce smoking ban legislature, historically being linked to Ireland as the world leaders for the first country with a compulsory workplace smoking ban. And so subsequently, the smoking public health issue should continue being part of the global health efforts to thwart tobacco consumption as they have so far proved to be effective even if they have only been influential.

In conclusion, when looking at how the government should tackle public health issues such as alcohol misuse, obesity and smoking, it is pivotal to assess how they have been successful in the past to assess how successful they can be with current operatives. As analysed, the responsibility deals do not appear to be the best way to tackle the public health concerns over obesity and alcohol misuse because they do not impose any strenuous efforts to tackle the problems. It is easily argued that they are a positive step, but it can also easily be argued that they are not good enough to make a serious challenge at the issues faced, especially because they are voluntary commitments, which means all partners are not tied down to anything. In my opinion, because of the previous successes with smoking and HIV, the best way the government can tackle public health issues, with a good deal of interest in smoking, alcohol and obesity, is for them to put the dangers right at the heart of the entire population. This can be done through things such as television advertisements, but if the population believed that they could be affected by these issues, rather than the population just knowing about them, would be a great step in reducing the public health issues.

References

Brimelow, A. (2013) Childhood Asthma ‘admissions down’ after smoking ban Available at: http://www.bbc.co.uk/news/health-21067532 (Accessed: 12 Jan 2014)

British Heart Foundation (2013) Conclusion of our Portion Sizes Report Available at: http://www.bhf.org.uk/heart-matters-online/july-august-2013/news/portion-sizes/report-conclusions.aspx (Accessed: 13 Nov 2013)

Department of Health (2013) Front of Pack Nutrition Labelling Scheme’ Available at: https://responsibilitydeal.dh.gov.uk/front-of-pack/ (Accessed: 22 Jan 2014)

FCTC (2013) About the WHO Framework Convention on Tobacco Control. Available at: http://www.who.int/fctc/about/en/index.html (Accessed: 7^th Nov 2013)

Foottit, L. (2011) 80% of drinkers respond to the Drinkaware campaign Available at: http://www.morningadvertiser.co.uk/General-News/80-of-drinkers-respond-to-Drinkaware-campaign (Accessed: 13^th Nov 2013)

Health and Social Care Information Centre (2013) Statistics on Alcohol – England, 2013 Available at: http://www.hscic.gov.uk/catalogue/PUB10932 (Accessed: 22 Jan 2014)

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