What are the public health concerns for 2024?

What are some of some of the biggest health problems that policy-makers are likely to confront in 2024, and what can we do about them? I've been speaking to Linda Bauld who is the Bruce and John Usher Chair in Public Health at the University of Edinburgh and Chief Social Policy Adviser to the Scottish Government. I began by asking her what she made of what has been dubbed ‘the vaping pandemic’...

Linda - I am surprised to some degree in terms of the rise of the use of these products amongst young people and people who don't smoke. And the reason, or the biggest explanation for that from my perspective, is actually the market. It's product innovation. So in countries where these products are legal and there's many countries that have banned them around the world, the manufacturers came up with disposable vapes really over the last couple of years. They're very cheap, they're accessible, they're marketed to young people and that's what's driving the uptake.

Chris - Do we have any data yet though, on the potential health harms of vaping? Because many of the advocates for vaping have based their arguments around the fact that compared with smoking, it is much better for you, but compared with never smoking, I don't suppose we actually have that data. Or do we?

Linda - No. Well we have different kinds of data. So we know the relative risks from well conducted studies that have been done in terms of short-term exposures. We also have basic science research where we do have real concerns. So cell line and rodent studies that certainly show there are respiratory effects. There are cardiovascular effects and there may be carcinogenic cancer risks associated with it. But that's what we call preclinical research. So we don't know whether it will translate into humans and those kinds of early studies don't always translate to humans, but there's certainly markers there. We also know that for people, for example, who have asthma or other respiratory conditions that might make them more sensitive to vaping, we have had some really unfortunate cases. And then finally we know that the market is not regulated and there are illicit vapes. And if things get into the vapes that are really health harming as we saw with what we call the EVALI outbreak in the USA with vitamin E acetate, then actually these devices could be really harmful.

Chris - How are we going to get the genie back in the bottle?

Linda - Youth vaping rates vary around the world and, if you can regulate, you can reduce use, and we've got really good evidence of this from other things like smoking. I mean one of the biggest drivers is price. So if you make these devices, particularly disposables, much more expensive, young people are not going to be able to afford them. Young people are very price sensitive. Restricting marketing would certainly deter some youth use. And so I really am confident that you're going to see more action on this. However, we don't want to put the genie completely back into the bottle because of the trials that I and others have done that show that for people who are heavily dependent on smoking, actually these devices can help them quit. So it's a very, very tricky balance to strike.

Chris - Moving on to Covid pandemics, the Covid inquiry and so on. What sorts of things have governments, both the UK government, also the devolved administrations, you're in Scotland for example. What sorts of things have been changed and are now in place to make sure that if we do have disease X starting tomorrow, we will be more agile?

Linda - So the first one is to do with the workforce and readiness. So I think there's startup teams or, or mechanisms to pull people into a response very quickly, well above what we'd normally do in health protection. So in the government, in the Scottish government, in the UK government as I say, it's having the right people and also getting the right kind of scientific advice. Because you could argue that it was too narrow in the UK. So that's the first thing. The second thing is we've retained or we're trying to retain, although I'm concerned about this, some of the testing infrastructure. So that really needs to continue to be resourced. Things like PPE, I think. I don't know if how that was done is still in the news headlines, isn't it in the UK, but procurement roots and that kind of thing. Those are certainly things that are part of our preparedness. And then scientifically, in terms of vaccine development therapeutics, I think there are models and pathways that we would be able to follow.

Chris - So some good news there. That's a nice Christmas present. What about a less nice Christmas present, which is that obesity levels have continued to climb, not just in our countries, but across the world. What's the thinking in policy terms around this? Because obviously this is, some argue, going to knock COVID into next week in terms of its morbidity and mortality impact. The fact that maybe half the world population is now obese or about to be.

Linda - The problem with the pandemic, and it's not just because of the pandemic, but there are a lot of health issues which we basically ignored. And you can see the strain on the health service. And obesity is perhaps one of the best examples. I was looking at a chart in relation to the different health risks that we face for Scotland and where we are in comparison to some of the aspirations politicians set in Scotland. It was to reduce childhood obesity by half by 2030. I mean, we're so far off that target, it's actually difficult to describe how far off we are. We've had announcements about action, but governments have repeatedly delayed the kinds of action that we need to take on this. And the positive developments around weight loss drugs, for example, most people will have heard of some of those that have been developed, they're not going to tackle this problem. We can't treat our way out of the obesity epidemic. There needs to be population level measures.

Chris - And what should those look like?

Linda - The food environment needs to change, but it's really complex. If you go back to the second World War where we had to ask farmers and producers to produce much more from less space and, and fewer resources. And we're still overproducing the wrong kinds of food. So that's a complex thing. But the other things we need to do in terms of changing the food environment are trying to shift towards selling healthier products to people, making those more affordable and accessible. The UK government has delayed repeatedly restricting television advertising on junk foods, putting legislation around price promotions, those big packets of crisps. Three for the price of two. Interestingly, Latin America actually, because their obesity challenges are even greater than ours, some Latin American countries actually have been more ambitious and are starting to take that kind of action. But it's going to take decades.

Chris - It's almost that we've created an environment in which it's impossible not to get fat. Fast food is on every street corner. Supermarket aisles are crammed with impulse buys. One wonders if the only solution is to go back to a point where there just wasn't this abundance. But then you take away public choice.

Linda - People who have less money in their pocket in the UK are far more likely to be overweight and obese. So what causes those differences? It's because the really unhealthy products are often the cheapest people expect to consume those kinds of food. Their friends and family are. And there's some arguments that they're kind of addictive to some of these foods. So we've changed the way we're wired to want to consume them. It's different from smoking or vaping. We are going to have to work with manufacturers, with retailers, with producers so they can reformulate and change the food supply over the longer term.