Writing in the Sydney Morning Herald, Stephen Simpson (Director of the Charles Perkins Centre at the University of Sydney) and Rosemary Calder (health policy Director at the Mitchell Institute for Health and Education Policy at Victoria University), call for community-based action to prevent chronic disease. They point to communities like Broken Hill, which has high rates of obesity, but also a strong self-identity and good social cohesion, offering exciting opportunities for a community-led approach to prevention.
Steven Simpson and Rosemary Calder contrast community-led initiatives to government action, but maybe we could have both. Legislation and regulation could be much better used to support existing local initiatives, encourage community action, and improve local-level obesogenic environments. This is a relatively unexplored area in Australia, but there is growing interest in local level action in obesity prevention in some regions of the country. The City of Sydney encourages active transport, which it links to improving health in the city. The City of Marion, in Adelaide, implemented an obesity prevention program that included community meals and physical activity sessions, targeted to at-risk populations. And some states governments have moved to strengthen the role of local governments in health promotion through legislative measures. For example, South Australia’s Public Health Act 2011 makes local governments responsible (for the first time) for taking action to preserve, protect and promote public health within their area.
The US is much further ahead than Australia in local level prevention efforts, with states and municipal governments around the country trialling innovative obesity prevention policies. A US national prevention policy framework encourages local obesity prevention policies, as do federal grants for community-based initiatives. Local efforts in obesity prevention in the US could provide some lessons for Australian local governments that want to take action in obesity prevention, but they also illustrate some of the challenges that our local governments may face in taking legislative action.
High profile initiatives in the US have attracted significant media attention, as when the former Mayor of New York City, Michael Bloomberg, attempted to ban large sized sodas sold by food service establishments in the city. However these kinds of controversial initiatives are just the tip of iceberg. A range of state and local governments are experimenting with measures to improve the obesogenic environment and encourage physical activity, including Californian legislation that reduces taxes for landowners who make their land available for urban agriculture, and laws in Maine that require grocery stores to stock a minimum number of ‘staple foods.’ Some localities have introduced broad-ranging programs that combine infrastructure development, improved urban design, and health education. In this TED talk, Mayor Mike Cornett describes his obesity prevention strategy for Oklahoma City, and how it resulted in the loss of over one million pounds by city residents. Mayor Cornett also attributes his initiatives with encouraging economic revitalisation in the city.
There are many benefits to local level action. In both Australia and America, the division of powers between state, local, and federal governments enables local governments to act as ‘laboratories of innovation,’ i.e., to trial innovative policies without facing the political barriers that would impede federal-level initiatives (e.g., aggressive industry lobbying). Local governments use their legislative and administrative powers to develop policies that are tailored to the social, economic, and demographic features of their region, and which can diffuse ‘horizontally’ to other localities and ‘vertically’ – upwards to states and national government levels. Local leaders are closer to their constituents, allowing them to be more responsive to community needs, and facilitating ‘bottom-up’ initiatives that are built on a base of community consultation and ownership.
However, local policy making in the US illustrates some of the challenges that local governments in Australia may face in preventing obesity. As in Australia, local governments in the US are creatures of state government. Some US municipalities have expansive rule-making authority, but other states delegate only narrow powers, constraining local action and creating variation in the extent to which local governments can pursue obesity-prevention measures. Popular and media discourse frame obesity mainly as the result of individual’s poor consumption choices, meaning that government intervention to encourage healthy eating and drinking are often seen as paternalistic. Critics of the soda ban referred to Mayor Bloomberg as Nanny Bloomberg, and the soda portion rule was eventually declared invalid following a legal challenge.
Another concern is that some obesity-prevention strategies disproportionately impact vulnerable communities. Like tobacco taxes, soft drink taxes can be seen as regressive because they fall more heavily on lower-income groups who drink more soft drink and have fewer resources to absorb tax increases. Policies that actively target at-risk communities may also be discriminatory when they are based on ethnicity or race, as opposed to targeting neighbourhoods or communities with poor health indicators. Effective policies can also fail to reduce – or even exacerbate – health inequalities. Redesign of the urban landscape can increase gentrification, pushing low-income residents out of the inner city into areas with fewer amenities.
A final issue is that community-level prevention policies are a relatively new area of intervention and the results of evaluating studies are still emerging. Supporters of local-level innovation argue that policies such as the soda portion rule are supported by evidence linking soft drink consumption to diabetes and obesity, for example. However, many policies lack causal evidence to support their effectiveness in producing tangible obesity prevention outcomes. Yet some local initiatives have produced demonstrable changes in health-related behaviour and weight status, with particularly good evidence for school-based initiatives.
Despite these challenges, local government action could form the centrepiece of a revitalised approach to obesity and chronic disease prevention in Australia. Local government action is particularly important in Australia, where the current federal government appears entirely disinterested in chronic disease prevention (having recently cut funding for prevention efforts, including for local policies and programs), and some state governments are withdrawing from health promotion, and actively devolving preventive efforts to local governments.
Further, local government law making could be designed to address some the barriers outlined above. Health law academics in the US call for a participatory, inclusive approach to the design of public health law and regulation, where local communities are involved in identifying areas for action, as well as in processes of policy design and implementation. Their argument is that inclusive law-making processes are more likely to produce initiatives that reflect community interests, and have a strong base of community support, potentially ameliorating the concerns about nanny statism that attach to initiatives championed by public health’s ‘elites,’ such as Michael Bloomberg. Inclusive law making that is tailored to local concerns could also help to address health inequalities, while preventing initiatives from being perceived as discriminatory.
Local governments may provide a route for stronger action on prevention in Australia, particularly in light of the apathy of the current Liberal federal government. But if we are to frame obesity as a collective problem requiring community-based solutions, we need to reconceptualise public health law as a democratic, participatory and collaborative project that ensures recognition and supports self-determination for marginalized communities. Public health doesn’t need nannies; it needs local champions, facilitators, mediators, guides and leaders.