In the first week of November, Sydney Health Law will be hosting the Food Governance Conference. The conference is a collaborative endeavor between Sydney Law School and the Charles Perkins Centre, the University of Sydney’s dedicated institute for easing the global burden of obesity, diabetes, and cardiovascular disease. The conference also has sponsorship from The George Institute for Global Health and the University’s Cancer Research Network.
The Food Governance Conference will explore the role of law, regulation and policy in addressing the key challenges associated with food and nutrition in the 21st century, including food security, food safety, and preventing diet-related disease such as diabetes and cardiovascular disease. It also engages with issues related to sustainability, equity, and justice in the food supply, with a strong focus on nutrition and diet-related health in Aboriginal and Torres Strait Islander communities.
In taking such a broad focus we hope that the Conference will highlight the interrelationships between the main challenges facing the global food system in the 21st century. The conference will also showcase the work of researchers in developing new, innovative solutions to these challenges, with the conference including presenters from across Australia, as well as from the UK, Canada, and New Zealand. Some of the issues considered at the conference include:
Taxes on sugar-sweetened beverages
Free range egg labeling
The role of business in improving nutrition and diet-related health, and
The influence of trade agreements on the global food system
We have an exciting program of events around the Food Governance Conference, including two free, public lectures to open the conference.
Professor Corinna Hawkes will be giving the opening address for the conference on Tuesday the 1st of November at 6pm at the Charles Perkins Centre Auditorium. This lecture is free and open to the public. Professor Hawkes is the Director of the Centre for Food Policy at City University London and a world-renowned expert on food and nutrition policy. She’ll be speaking on the three biggest challenges facing the food system, and how we fix them. If you’re interested in this talk, you can register at this link.
Dr Alessandro Demaio will also be giving a public lecture at 1-2pm on Tuesday the 1st of November at Sydney Law School. Dr Demaio (from the World Health Organisation) will be speaking on the links between food, nutrition and cancer, and what the nutrition community can learn from the cancer community from its fight against tobacco. Further details about his talk are available at this link.
Workshop on food advocacy
Along with the Charles Perkins Centre, the Australian Right to Food Coalition is hosting a masterclass on becoming an effective food policy advocate, featuring Professor Corinna Hawkes. The purpose of this master class is to encourage debate among academics and civil society about the role of advocacy in food and nutrition policy, what it is, and how it can be used more effectively. Registrations for the master class can be made here. Please note that the master class is now full.
We’re looking forward to the inaugural Food Governance Conference at the University of Sydney, and we hope to see you there. We welcome any questions about the conference, which can be directed to Dr Belinda Reeve: Belinda.email@example.com
Follow #foodgovernance2016 on Twitter for updates about the conference!
In Australia, doctors must notify public health authorities of new cases of HIV/AIDs. However, strict confidentiality requirements apply to the testing, treating and notification of HIV, protecting the identity of patients.
As part of its review of the New South Wales Public Health Act 2010, the Department of Health is considering whether to remove these confidentiality requirements from NSW public health legislation. Is this a move that should be welcomed by health care professionals and patients?
Infectious disease notification
All Australian jurisdictions have laws that require the notification of certain infectious diseases. In NSW, notification requirements can be found in the Public Health Act 2010, which creates five categories of diseases that must be reported by medical practitioners, pathology laboratories, and hospitals, including HIV/AIDs.
Section 56 of the Act places confidentiality requirements on information relating to a patient’s HIV status. There are three main components to section 56:
Notifications for HIV/AIDs must be made in a de-identified format;
A person’s identifying details must not be used when arranging a diagnostic test for HIV (except in hospital situations or with the person’s consent);
A person who, in the course of providing a service, obtains information that an individual has been tested for HIV or has HIV/AIDs, must take reasonable steps to prevent that information from being disclosed. However, the information may be disclosed to a person involved in the provision of care of the patient, so long as it is relevant to the provision of such care.
Section 56 allows for disclosure of identifying information in certain other circumstances, including if there are reasonable grounds to suspect that failure to disclose the information would likely be a risk to public health. This allows for the Secretary of the Department of Health to identify and manage HIV positive individuals who pose a risk to the health of others, including (as a last resort) through public health orders that allow for the mandatory treating and detention of patients living with HIV.
Review of the Public Health Act 2010 (NSW)
NSW Health recently published a discussion paper on the review of the Public Health Act 2010 (NSW). The Ministry’s preliminary view is that HIV-specific confidentiality protections should be wound back. The paper notes several difficulties that stem from the confidentiality requirements for HIV notification:
De-identified notification increases the likelihood of duplicate testing and errors in notification, and impacts negatively upon the collection of epidemiological data, surveillance, and monitoring, and follow-up care of HIV positive patients;
Confidentiality requirements create a barrier to testing for HIV in combination with testing for other conditions as there are different consent procedures for HIV tests and other tests; and
They prevent healthcare professionals from being informed of patients’ HIV status where they are not providing treatment directly related to the patient’s HIV condition, but it would assist in providing care to know about the patient’s status (given that HIV and ART treatment have a range of health implications).
The policy of de-identifying HIV/AIDs notifications was first developed in the 1980s, at a time when most HIV infections occurred in gay men and there was considerable stigma and discrimination against the gay community and those living with HIV/AIDs. At that time, no effective treatment options were available for HIV/AIDs, making it a terminal condition. Many activists, clinicians, and community organizations were strongly against notification, and confidential notification provisions were adopted to encourage at-risk individuals to access HIV testing and care without fear of recrimination or discrimination.
The situation has changed significantly since then. Anti-retroviral therapy (ART) has made HIV a manageable, chronic condition, and has demonstrable benefits in preventing onwards transmission. Community attitudes towards the gay community and people living with HIV have changed considerably over the past 30 years, assisted by the introduction of laws that address discrimination and privacy concerns.
The discussion paper lists a number of benefits that would flow from rolling back HIV-specific confidentiality requirements:
Named notification would enable more accurate epidemiological data on HIV to be collected, for example, by allowing for better linking of HIV notifications with notifications of other conditions, which would assist with tracking and managing HIV co-infections; and
It would potentially allow better service provision and care of people living with HIV: one outcome would be that it would enable public health officers to follow up with HIV positive patients directly; liaise with clinicians; and refer people living with HIV to the relevant health services.
However, there is significant disagreement between NSW Health and HIV activists over whether named reporting would improve epidemiological data and access to care. Advocates argue that while named reporting may provide some benefit, this would be outweighed by its impact on privacy, testing, surveillance, and treatment.
HIV remains heavily stigmatized, and many people living with HIV continue to experience discrimination. These concerns are particularly relevant given that NSW criminalizes individuals with HIV (and other STIs) who fail to disclose their condition to their sexual partners.
Named reporting may deter people from being tested for HIV, particularly people from culturally and linguistically diverse backgrounds, recent migrants, highly sexually active men with multiple STIs, sex workers, and non-gay identifying men who have sex with men. People diagnosed with HIV may also be less willing to report sensitive personal information (e.g., injecting drug use), particularly if it could be used for law enforcement purposes. This would undermine the effective care of people living with HIV, as well as the quality of population-level data.
Advocates recognize that making information about a person’s HIV status, co-morbidities, and treatment regimen more widely available in clinical settings could improve care outcomes. However, they say that there are not enough examples of non-disclosure causing adverse effects to warrant the proposed changed, and the amendment would undermine the right of people living with HIV to disclose their HIV status to medical and healthcare workers at a time of their choosing.
Winding back “HIV exceptionalism”?
Writing on the legal environment of sexual health care practice, Roger Magnusson describes HIV as an “exceptional STI,” with unique legislation regulating counselling, diagnosis, and reporting of HIV. The central concerns of this legislation are the provision of supportive treatment and maintaining patient confidentiality.
Professor Magnusson describes how some countries are now winding back HIV exceptionalism, for example, in the US, CDC guidelines now recommend opt-out screening for all patients, i.e., patients are notified that screening will take place unless they decline consent. Some states, such as California, have adopted these recommendations, and while anonymous testing is still offered in many states, named HIV reporting is now the norm.
Notification of HIV/AIDs is a contentious subject, engaging issues around rights to privacy and autonomy, as well as on the role notification plays in data collection, testing, and treating. Many jurisdictions are streamlining the legal treatment of HIV testing with that of other infectious diseases; the question is whether NSW will – or should – do the same.
Governing Food will bring together researchers and practitioners from a range of disciplines to explore the role of law, regulation and policy in promoting a healthy, safe and sustainable food supply. The conference will be opened by a public keynote address on Tuesday the 1st of November, to be delivered by Professor Corinna Hawkes from the Centre for Food Policy at City University London. The main days of the conference will be Wednesday the 2nd of November and Thursday the 3rd of November.
The call for abstracts and further details about the conference can be found at this address. You can also contact Dr Belinda Reeve in relation to any questions about the conference: firstname.lastname@example.org.
The UK tax on soft drink and Jamie Oliver’s call to action
TodayBritain announced that from 2017 it would levy a tax on soft drinks containing more than five grams of sugar per 100 millilitres, as part of efforts to contain rising levels of childhood obesity. The announcement prompted Jamie Oliver to post a video on Facebook encouraging other governments to follow suit, and telling Australia and other countries to “pull your finger out” on soft drink taxes.
Should Australia introduce a sugary drinks tax? Would a tax be an effective obesity prevention measure? Or would it just be a slow and costly way of raising the ire of the food industry?
Australians drink a lot of soft drink
Around one third of Australians drink about a can of soft drink a day, making Australia one of the top ten soft-drink consuming countries in the world. Soft drink consumption among young people is particularly concerning, with around 47% of children (aged between two and 16 years) consuming sugar-sweetened beverages (SSBs) every day.
Why is soft drink bad for our health?
A large number of studies show that soft drink consumption increases the risk of obesity, diabetes, heart disease and dental caries, and soft drink consumption has been linked to approximately 184,000 deaths per year globally.
Soft drink has a large of amount of added sugar (when it’s not artificially sweetened), making it a key source of added sugar in our diets. Drinking soft drink displaces the consumption of healthier beverages, and we tend not to compensate for the calories we drink by reducing our food intake. Drinks that are high in sugar have been shown to reduce appetite control, which also contributes to weight gain.
Around 60% of Australian adults and 25% of children are either obese or overweight and obesity has overtaken smoking as the leading cause of preventable death and illness. Reducing soft drink consumption could be one way of reducing the burden of obesity and chronic disease, and its impact on Australia’s health care system.
Soft drink taxes are gaining momentum
Public health experts recommend soft drink taxes as one component of a comprehensive obesity prevention strategy, and a number of countries have taken this recommendation on board.
In September 2013 the Mexican congress passed an excise tax on SSBs of one peso per litre – a price increase of approximately 10%. Mexico also introduced an ad valorem tax of 8% on a defined list of non-essential energy-dense foods.
The US city of Berkeley passed a one cent per ounce excise tax on SSBs in November 2014, becoming the first US city to levy a targeted health-related tax on soft drink.
Since January 2015 Chile has levied an 18% ad valorem tax on drinks with a sugar content of more than 6.25 g of sugar per 100 mL, including energy drinks and sweetened waters. Sugary drinks with less than 6.25 g of sugar per 100 mL are taxed at 10%.
These are just a few examples of jurisdictions with soft drink taxes; others include France, Mauritus, and Barbados. Countries are also experimenting with taxes on other unhealthy food products, or on specific nutrients such as fat or salt, often in tandem with taxes on sugary beverages.
Are soft drink taxes effective?
Soft drink taxes are a relatively new initiative, meaning that there’s not much ‘real world’ evidence of their impact. However, modelling studies suggest that tax increases are effective in reducing consumption of SSBs, and a recent evaluation of Mexico’s soft drink tax provides more concrete evidence of the effectiveness of taxes in shifting consumption patterns. The study found that the average volume of taxed beverages purchased monthly was 6% lower after the tax was implemented, with reductions accelerating over time, and reaching a 12% decline by December 2014.
The effects of soft drink taxes on diet-related health are less certain, but there is some evidence for this relationship too. One review of the evidence found a statistically significant association between “substantial” food taxes and weight outcomes, particularly in relation to children, adolescents, low socioeconomic status populations, and those at risk for overweight.
Other studies are more equivocal, but keep in mind that this a recurring problem in public health – the difficulty of showing that one initiative in isolation will lead to significant weight reductions. Experts agreed that a number of complementary measures will be required if we are to see meaningful reductions in obesity and overweight.
What are some of the criticisms of soft drink taxes?
One of the main concerns about soft drink taxes is that they are regressive. In theory, SSB taxes have a larger impact on lower socioeconomic groups, given that such groups pay a higher proportion of their income towards soft drink purchases. However, the evaluation of Mexico’s soft drink tax found that reductions in soft drink purchasing were greatest among low SES households (averaging 9.1%), suggesting that low SES groups were the most price elastic and thus benefited the most from the tax.
Governments can also take steps to offset the regressive nature of soft drink taxes, for example by targeting subsidies for healthy foods and beverages to low-income households, which could be paid for using the revenue generated by soft drink taxes. Alternatively, tax revenue could be used to address disparities in health or socioeconomic status more broadly.
The effectiveness of an excise tax in reducing SSB consumption hinges on the extent to which the tax is passed on to consumers in the form of higher retail prices. Distributors or retailers may “under shift” the tax by absorbing its cost, thus lowering their profit margins, but sustaining sales. Lower than expected price increases may undermine the tax’s public health benefit. However, evaluations of SSB taxes in Berkeley and Mexico find that manufacturers and distributors have mostly passed on the costs of the taxes to consumers, suggesting that these taxes will have the desired effect.
What’s the situation in Australia?
Australia’s GST exempts many foods that are a core component of a healthy diet, such as fresh fruits and vegetables. Sugary drinks are subject to the GST, meaning that there is a kind of differential tax on soft drinks. However, the GST is not intended for this purpose and operates differently to a specific, health-related soft drink tax.
In 2008 the National Preventative Health Taskforce recommended that the government commission a review of economic policies and taxation systems, and use economic incentives to decrease the production and consumption of unhealthy foods and beverages. It cautiously recommended a soft drink tax, given the uncertain impact of these taxes on consumer health.
In its response to the Taskforce, the then federal Labor Government stated that it had already commissioned an independent review of the Australian taxation system, i.e., the Henry Tax Review in 2010. This review did not recommend health-specific taxes on foods and beverages (despite recommending tax hikes for tobacco and alcohol) and the Government said that it would not consider another review. Instead, the Government pointed to voluntary food reformulation efforts taking place through the Food and Health Dialogue.
Should Australia introduce a soft drink tax?
Jamie Oliver’s right. The Australian government does take a “weak, pathetic” approach to obesity prevention, and we could do better.
The evidence shows that an SSB tax could have a real impact on Australian’s soft drink consumption habits, as does the effectiveness of tobacco taxes and other food taxes such as Denmark’s tax on saturated fat. Soft drink has no nutritional value, making it one of the more uncomplicated food products to tax.
As well as shifting consumption patterns, soft drink taxes could prompt companies to reformulate drinks to reduce their sugar content, or to introduce new, healthier products. Taxes could also generate significant revenue for health promotion activities, preferably targeted at the most vulnerable populations.
The health outcomes of SSB taxes need further research, but this should not stop the Government from “pulling its finger out” as suggested by Jamie Oliver, and introducing a tax on soft drink, as many other countries are doing. An SSB tax would send a clear message that the government is committed to protecting the health of Australians, even if it means taking on the powerful multinational companies that dominate the beverage industry.
This blog post incorporates a post previously published by Caterina Giorgi on DrinkTank. We’re grateful to Caterina for giving us permission to republish her post.
Sydney’s lockout laws have had a polarizing effect. One view is that they’ve killed off Sydney’s once-thriving nightlife, compromised the incomes of those in the hospitality industry, and simply redistributed alcohol-fuelled violence to other parts of Sydney.
Supporters of the laws – including NSW Premier Mike Baird, the families of assault victims, and St Vincent’s Hospital – cite statistics showing a significant drop in alcohol-related violence in affected areas and no increase in violence in other suburbs.
As a public health lawyer, to me these laws illustrate several themes that often arise in debates about the need for government intervention in public health matters.
Public health is only one “social good” among many. Sometimes we need to balance public health objectives against other social and economic goals, such as a vibrant nightlife – although that would be a hard argument to make to the parents of young men who’ve been killed by alcohol-related violence.
The introduction of public health legislation can have negative consequences, particularly on groups with a vested interest in the product or practice being regulated, including the hospitality industry.
However, these negative consequences can be mitigated, as when Australian government organisations replaced tobacco industry sponsorship of sports clubs with public funding, to ensure that clubs weren’t out of pocket when industry sponsorship was removed.
Finally, public health laws become normalized over time. Remember coming home from a club reeking of smoke? What seems like an invasion of individual freedom now often turns into a valuable health protection measure as social norms evolve over time.
Are the lock out laws an example of the Nanny State at its worst, or a proportionate measure designed to protect the public from the harmful, reckless actions of others? I’ll leave that for you to decide. Below we republish (with kind permission) a recent blogpost by Caterina Giorgi at the Foundation for Alcohol Research and Education (FARE) on the public health case for the lockout laws.
Sydney is not dead. Sydney is not closed
By Caterina Giorgi
Over the past few months, a small but vocal minority of people in Sydney have called for the Premier to wind back trading measures introduced to reduce alcohol-related violence. They present a narrow, exaggerated argument that Sydney is now ‘closed’ and that Sydney’s reputation as a global city is in shambles.
Two years ago the New South Wales Government introduced laws that meant people cannot purchase alcohol from bottle shops after 10pm, and from bars and clubs in Sydney CBD and Kings Cross after 3am. They also introduced a one-way door policy (more commonly referred to as a ‘lockout’), which meant that people cannot move between venues in this precinct after 1.30am. These measures were introduced to keep people safe and stop the violence and deaths that were occurring as a result of alcohol use. Today a vast majority of people in New South Wales (68 per cent) support these measures.
Two years on and these measures are working. Alcohol-related assaults in Sydney have declined by 20.3 per cent and Kings Cross has seen a significant 45.1 per cent decline, there has been no displacement to other areas and businesses continue to grow, with liquor licence numbers continuing to increase across Sydney.
Those opposed to these successful measures allege the measures were a response to “hysteria” and a “knee-jerk reaction following the deaths of some young men”.
Let’s put to one side the seeming disregard and disrespect for those who lost their lives.
And ignore for the time being the hysteria and hyperbole inherent in the ridiculous claims that Sydney is ‘closed’ or the even more insensitive suggestion that the city is ‘dead’, complete with flower adorned casket.
But the suggestion that the introduction of modest trading hour measures was a knee-jerk reaction is completely false and conveniently ignores the evidence.
These measures are as far from a knee-jerk reaction as a policy can be. Reducing the availability of alcohol as a measure to reduce harms was raised with the State Government in 2003 at the New South Wales Alcohol Summit, 11 years before the measures were introduced.
These measures were advocated for after their introduction in Newcastle in 2008, six years before the legislation was implemented in Sydney.
And finally, they were again advocated for when a young man, Thomas Kelly, was killed 18 months before the measures were finally introduced in February 2014.
These measures have been advocated for because international and national research shows that they reduce violence.
In fact, when Yvette D’Ath, Attorney-General of Queensland, spoke about the introduction of similar measures in Queensland in Parliament just last week she said she has never seen so much independent evidence on a bill.
On Sunday thousands of people marched against the earlier closing times and lockouts in Sydney. Part of me thinks that it’s great that people decided to take time out of their lives to march for something that they believe in. But I can’t help wonder: what it is that these people have lost in their lives that they felt driven to protest?
Were they comparing themselves to people who have marched and protested over the weekend for Medicare, refugees or gender equality?
Do they genuinely think that alcohol is needed around the clock for their lives to be whole and fulfilled? And more importantly, if yes, what does this mean more generally about Australia as a society?
Sydney is not dead.
Sydney is not closed.
Sydney responded to significant levels of violence and deaths by introducing evidence-based measures that had been advocated for by experts, doctors, police and community members for many years. Instead of protesting against these measures, we should be congratulating members of government for doing what policy makers should do, fixing a significant social problem by introducing evidence-based solutions.
Premier O’Farrell and Premier Baird should be congratulated for doing what many politicians are afraid to do, introducing and maintaining measures that benefit the community ahead of significant vested interests. For that I congratulate them and I sincerely hope that the New South Wales Government continues to prioritise evidence ahead of hysteria.
We’ve now had a few weeks to chew over the latest report linking food and cancer. Only this time it wasn’t a puff-piece in your Sunday newspaper, but an extremely comprehensive report from IARC, the World Health Organization’s International Agency for Research on Cancer. After a systematic review, IARC’s findings on the links between red and processed meat consumption, and cancer, were published in a press release and in The Lancet in late October (the full findings will be published later as a monograph).
In brief, red meat (“all mammalian muscle meat, including, beef, veal, pork, lamb, mutton, horse, and goat”) was classified as being probably carcinogenic to humans. Processed meat (“meat that has been transformed through salting, curing, fermentation, smoking, or other processes to enhance flavour or improve preservation”) was classified as carcinogenic to humans. This means that, based on epidemiological studies, IARC found “convincing evidence” that meat products like ham, sausages, corned beef and biltong cause colorectal cancer.
Is meat the “new tobacco”?
Despite widespread media reporting that red and processed meats were now “as big a threat as cigarettes”, IARC did not actually make this comparison. Rather, it rated the strength of the evidence for the link as “Group 1”, meaning that the evidence is strong. So, the evidence linking tobacco and lung cancer is equally persuasive (Group 1) but this does not mean that eating meat is as dangerous as smoking. (This classification system is widely used in systematic assessments of nutritional evidence, including in the Australian Dietary Guidelines.)
Among those who denounced the comparison between eating meat and smoking cigarettes was Australia’s Agriculture Minister, Barnaby Joyce. Clearly, Mr Joyce has an interest in dampening any concerns that might threaten Australia’s reputation as a nation of meat-eaters – but in this case his assessment of the evidence was correct.
Regulation of bacon: the next frontier for public health law?
All in all, you may want to consider throwing a few extra vegetable skewers on your next barbeque. But more interestingly for our purposes, what – if any – are the implications for law and regulation?
As countries such as India and China undergo rapid social and nutritional transitions, the demand for meat will only grow – worldwide, meat-eating is correlated with greater wealth. This has environmental as well as health implications. Together, these implications may eventually prompt countries to take regulatory action.
While there are currently no jurisdictions that regulate the consumption of meat, the following developments may be indicative of an early trend:
“Meatless Mondays” or “meat-free Mondays” campaigns have been springing up around the world since the early 2000s. These tend to be grassroots civil society initiatives aimed at making vegetarian food more acceptable and available.
In 2009, the Belgian city of Ghent became the first in the world to proclaim an official “Veggie Thursday”.
The most recent iteration of the US government’s dietary guidelines, “MyPlate”, refers to daily “protein” rather than “meat” consumption.
In the early 1990s, Ghana introduced food standards setting maximum fat limits for pork, beef, mutton and poultry, in response to concerns about diet-related NCDs. While not a curb on meat consumption per se, this regulatory response does speak to some of the concerns raised by IARC.
Perhaps most tellingly, the food industry has come to recognise the commercial potential of vegetarian foods, which are now said to have “gone mainstream” after decades on the hippie fringe.
This is where the comparison with tobacco control may be more salient. The evidence linking tobacco to cancer was recognised by some governments as early as the mid-1950s, but the WHO’s Framework Convention on Tobacco Control was not enacted until 2003. Biltong regulation will no doubt require a similar fermentation period. But the mix of voluntary, regulatory and commercial developments above suggests that the goal of curbing meat consumption is not far-fetched or conceptually unappealing. More controversial perhaps will be the methods of achieving that goal. Warning labels on a pack of sausages? A tax on bacon? A ban on quarter-pounders? We’ll get back to you in 30 years…
Public health lawyers like me are often challenged on their claim that the law can (and should) play a significant role in the prevention of noncommunicable diseases (NCDs). Future Leaders, an Australian philanthropic organisation, has recently published an open-access, clearly written book on NCD prevention called Dancing in the Rain: Living with NCDs, which includes a chapter by Professor Larry Gostin and I on the role of law in NCD prevention. Here we describe the growing global governance framework for NCD prevention, and the range of new initiatives that governments around the world are using to combat NCDs, including measures that draw upon law and regulation. We contrast this widespread global innovation with Australia’s failure to take decisive action in relation to the prevention of obesity and excessive alcohol consumption, asking why Australia has ended up as a ‘laggard’ in these areas when it remains the world leader in tobacco control. This is an easy-to-digest introduction to the interaction between law and NCD prevention, and it sits alongside a number of other insightful chapters from prominent Australian activists and academics, including Dr Alessandro Demaio, Professor Fiona Stanley, and Professor Rob Moodie.
Dancing in the Rain is accessible in full via the following link: http://bit.ly/1QoDyLS