This handsome brute is Count Leo Tolstoy (1828-1910) around the time in his life between 1865 and 1869 when he wrote War and Peace, which I read in late December a couple of years ago. There’s more of him at the end of this New Year column, which is yet again a bumper number.

My first item below, on branding, touches on two of what my friend and co-author Carlos Monteiro calls ‘ultra-processed products’. Then I say why, once we perceive the fundamental and elemental causes of malnutrition, we need to act as citizens. Claudio Schuftan, my fellow columnist, has been saying this for decades. This leads me on to baroque worries, one of which is worms. Yes, the worms that crawl in thin and crawl out stout. A worm-free year to all my readers.

Brand image Vitaminwater™. Coke™

Buying and selling sizzle

J Darius Bikoff is a genius of our age. From New York City, he is still under 50. As a younger man he worked out regularly, drank lots of water, and downed vitamin pills. His Idea Number One was to combine the vitamins with the water, together with yummy sugar and ingredients that add colours and flavours. Here they are in their updated form, above. Idea Number Two was to protect the name ‘vitaminwater’ so that it became Vitaminwater™ and Vitaminwater®.(No doubt ‘vitamin water’ and ‘VitaminWater’ is also protected). In 2000 he rolled out the products. In 2007 he sold his company, in which he had a majority share, to the Coca-Cola company, for $US 4.1 billion.

There is more about Vitaminwater ™ elsewhere in this month’s World Nutrition. How much of the value of J Darius’s company is in the brand name and image? A fair guess would be $US 4.05 billion. That still leaves a cool $US 50 million for the value of the unprotected product itself – which, after all, is water, plus vitamins, plus sugar, plus colourful and flavoursome bits and pieces. You could whizz up more nourishing versions up yourself in your blender. Indeed, you could add slices of fruits.

J Darius might say that his products use particularly high quality ingredients. Maybe so, depending on what ‘quality’ means, but that’s not the point. The perceived value is the sizzle – the ‘active lifestyle’ image. Drink me and you’re one of the beautiful people! Vitaminwater™ is part of the kit that includes Sex and the City; plus it’s easy, anybody near one of its spiffy vending machines that look like mini-bars can handle and neck it. Plus it’s a better choice than booze, right?

The secret of Coke™

This point about sizzle is well made in the book that tells the history of the company whose name and leading product is, year after year, the best-known and therefore most valuable brand in the world – yes, Coca-Cola (1). Drink Coke™, and you consume the American Way of Life. That’s the promise on this vending machine above, on-site in a nutrition conference held in Acapulco, Mexico.

The annual revenue of the Coca-Cola company, at somewhat over $US 30 billion in 2009, roughly matches the national gross national products of Honduras, Jordan and Paraguay, which are placed around number 100 in the league table of 180 or so countries, and are more – often much more – than 30 sub-Saharan African countries. In this decade, Coca-Cola plans to double its current rate of investment in Africa, to $US 12 billion. Impressive, for what is still basically a soft drink firm. (Pepsi-Co is bigger, with a $US 43 billion revenue, much of it from snack products).

One of the legends of Coke™ is that its recipe is beyond the value of diamonds and is utterly pain-of-death secret. But during research at company headquarters in Atlanta, a Coke archivist handed author Mark Prendergrast a file containing ‘the sacred formula’ which – as he checked and proved to his own satisfaction – was indeed the real thing. But so what? As a company representative said to him, let’s suppose another company takes the real Coke™ formula, and calls it by another name. ‘Fine. Now what? What are they going to charge for it? How are they going to distribute it? How are they going to advertise? See what I’m driving at? We’ve spent over a hundred years and untold amounts of money building up the equity of that brand name. Without our economies of scale and our incredible marketing system, whoever tried to duplicate our product would get nowhere’. It’s all about the brand.

And Vitaminwater™? In effect, it’s Coke™ in colours. Plus it can hint at being healthy, notwithstanding being sugary water plus bits. Its ingredients may cost more than those of Coke™, sacred formula and all, but the difference will be trivial. Here’s the thing – per volume it sells at four or more times the price of large bottles of branded water and of Coke™, and roughly half the price of yoghurt, fruit smoothies and cheap wines (2). It’s promoted as fun, sexy – and good for mind, heart, and body too. As a new globalised brand it will rise above any decline and fall in perceived American glamour. $US 4.1 billion? A snip.

References

1. Pendergrast M. For God, Country, and Coca-Cola. The Definitive History of the Great American Soft Drink and the Company That Makes It. New York: Basic Books, 2000.
2. Cannon G. Food and drink as style. [In: Out of the Box]. Public Health Nutrition 2008; 11(9): 877-880.

Porto musings (6). Public health nutritionists

Arms and the nutritionist

‘Did you really say that nutritionists should campaign against the arms trade?’ Colleagues and readers have been asking me about an intervention I made at the Porto congress in September, in a session on the last day on ‘malnutrition in all its forms’. Yes I did and I’ll say it again here, with some context.

During the session, and others at Porto, and at conferences where I have presented or intervened since the mid-1980s, two underlying themes have impressed and depressed me – and other participants. The first is the assumption that we (privileged professionals) are OK, and that they (impoverished populations) are not OK, and we must do something for them – or, at them. As one zealous paediatric physician from the US whose field work is in Africa said, during the Porto congress, ‘We wanna fix the problem’. But do we know best? Have we thought about the consequences of our policies and actions? Are we ourselves in good shape? Do we have informed consent for our interventions? Do these work well? Not always.

Indeed, often not. In a wise presentation during this Porto session, Ben Caballero of the Johns Hopkins Bloomberg School of Public Health suggested that nutritional disorders that show as emaciation, and those that show as obesity, are not just different forms of malnutrition, but can be related. He pointed out that a consequence of (as he expressed it) ‘pushing calories into children’ identified as ‘stunted’ or ‘wasted’, in order to ‘catch up’ their growth to the velocity approved by UN expert committees, is to increase their body fat. In seeming to solve one public health problem, another can be created.

Of course it is true that many millions of communities and families in impoverished regions and countries are not OK, and are suffering the consequences of occasional or incessant hunger. Of course it’s true that children and adults who are starving need immediate help. Yes indeed, the public authorities in many of these countries do not have the resources to nourish and protect their own people. Virtually everybody will therefore agree that external aid remains essential. But!

But – are our minds so set, that we fail to see what goes down in the world from other points of view? It was in this mood that I began my intervention at Porto, by asking, of a room with about 80 people present, if all those who were brought up in impoverished areas of Africa or Asia would raise their hands. Four hands showed – more than I expected.

Fable. Imagine that India rules the world

The point can be made sharper by a fable. Imagine that the power politics of the world now are different from what they actually are. Suppose that the politically and economically dominant country, since the middle of the last century, has been and remains India (1), a country that in real history has earned a reputation as the world’s largest democracy. This is not a story about India, it is a fable. Stay with it, please.

In this entirely imaginary history, suppose that India’s global supremacy comes from being the victor in two world wars, now amplified by military and economic alliances say with China and Russia, and from its possession of a nuclear arsenal the use of 1 per cent of which would reduce the major cities of Western Europe and the USA to cinders. Suppose that its ‘soft imperialism’ has been hardened by military bases and other armed presences in over 150 countries (1), and wars against or invasions and occupations of say, Saudi Arabia (in the name of free trade), Mexico, California, and much of the rest of the originally Mexican area of what is now the USA (in the name of freedom), and northern Spain (in the name of national self-determination).

Suppose these conflicts have been amplified and enflamed by the supply of vast numbers of warplanes, tanks, and heavy artillery, including tens of millions of machine guns and automatic weapons. These have been shipped by India, its allies, and so also its enemies, to government, separatist, rebel, insurgent, criminal and wacko movements in all countries and territories in which India has an interest. To keep the peace, India has bombed to rubble much of say, San Diego, Barcelona and Manchester, with the constant threat of more. Also involved has been the seizing of Washington DC, the looting of the Smithsonian, and the occupation of the White House by Indian overlords, with their Russian and Chinese satraps in command in other strategic US centres. Also suppose that the headquarters of the United Nations is in Mumbai, and that the World Bank and the International Monetary Fund are based in New Delhi, the World Health Organization in Moscow, and the World Trade Organization in St Petersburg.

Suppose that most countries in Europe and North America are more or less bankrupt, mired in external debt, and constantly vulnerable to populist regimes whose leaders are supported and put in power by India and its allies. Suppose as a result of all this, in the UK there are areas, say in East Anglia, lowland Scotland and within most big cities, controlled by transnationally networked gangs whose businesses include the global hard drug system, training of terrorists, supply of sex slaves, and big business in child kidnap, and illegal immigrants, and human organs, whose leaders have purchased key politicians, judges, police, editors; and that for these and other reasons the UK has become identified by the UN as a failed state.

Crunching the numbers

Further, in this scenario most of the world’s leading scientific research centres are inevitably based in India, China and Russia, and their satellite states.

Now, suppose that as a result of expert panel meetings at WHO in Moscow, and then also at the UN in Mumbai, malnutrition in Europe and North America, taking the form of uncontrolled childhood obesity, adolescent diabetes, and rampant chronic diseases, is identified by UN expert committees as the world’s most urgent public health crises. In this context, teams of Indian academics, some based in the slums of US and UK cities for many years, recording and publishing data on their ballooning and diseased populations living in states of misery, squalor, or despair, organise pilot interventions in say, Glasgow, Barcelona, Washington DC, and San Diego.

Cohorts of schoolchildren in these centres are rounded up, with the help of native paramedics, and behind locked doors, are put on a regime of vegetables with fortified rice and dhal, plus supplements, and made to run on treadmills for a total ascending to two hours a day. Before, during and after six months, all relevant measurements are taken. Outliers, including kids who were too fat to trot, or who dropped dead on the treadmill, or who were considered to be too big or too small or just looked peaky, or who were caught picking the locks and going on burger binges, are excluded from the numbers that are crunched.

The results, reported in the New Delhi Journal of Medicine and the Indian Medical Journal, would be sensational. The subjects of the interventions who survived and who completed the regime would have become lighter, leaner and fitter, stronger and more alert, and in many if not most cases, all clinical signs of disease would have faded or disappeared. Scaled up – extrapolated from these results – this would seem to herald the end of obesity and chronic diseases as public health problems. Hooray!

But would these wonderful – while utterly predictable – findings be sustained in the populations subject to the interventions, let alone whole populations? No, they would not. Obviously they would not. Again, you get the point. Now, it seems to me that any sensible person, sensitive to such a scenario, would think and say that the intervention, although it worked, was not the solution, because it was not addressing the real problem. Which, once we break out of a mind-set that assumes that the way the world actually wags is irrelevant to our work, would include what, in the fable, some world power other than the one we live with, had done to destabilise much of the rest of the world.

Time to stand and testify

It was in this mood that I completed my intervention in Porto, and said the time has come for all conscious public health professionals, including those specialising in nutrition, to realise that they – we – are now in a situation similar to that of nuclear physicists after the dropping of the A bombs on Hiroshima and Nagasaki. So we should form, or join, a worldwide movement dedicated to stating, firmly and constantly, that we stand against the trade in arms and against pre-emptive invasions, and that we stand for the abolition of foreign debt. Plus other main points easy to identify and agree.

This does not mean that we stop our work. What such a campaign should mean, can include simple indications of support, such as wearing a discreet pin, as is now done with AIDS, and the badging of presentations. It should also include the basic principles of the campaign being stated at all conferences, all media interviews, all meetings of expert groups, and all relevant international and national government meetings. That would be a start.

Just a dream? Why? If we care, we can.

Footnotes

1. Or any big country other than the US – but not Russia or China, because this might give the impression that the issue is linked with capitalism versus communism, which it is not.
2. The actual number of countries in which the US has a military basis, as counted in 2002, was 153. Johnson C. The Sorrows of Empire. Militarism, Secrecy, and the End of the Republic. New York: Henry Holt, 2004.

Taxonomy

Baroque worries

A clique of which I was a member in London decades ago, had fun dreaming up what we termed ‘baroque problems’. These were usually expressed in the form of ‘what if?’ questions, and are more accurately termed ‘baroque worries’. An example is ‘What if adhesive tape stopped being sticky?’ To be baroque, the problem (or worry) had to be superficially trivial, not something you normally thought about, plausible when specified, and on reflection possibly important. Like, how much of our world is adhered with sticky tape?

Questions like ‘What if the Arctic and Antarctic ice-caps melted?’ (see picture above) or ‘Suppose there was a run on a UK bank?’ we would not have considered as baroque problems, for two reasons. First, they obviously were not trivial. Second, in those days they would not have occurred to us as possibilities (1). For the problem to be baroque there had to be general agreement that it was novel, could be real, but didn’t really matter... or there again, maybe it did... The best baroque problems – let’s now call them worries – stay remembered, like slight aches.

Lists and ideas

Now let’s apply this to our work. A possible example of a relevant baroque worry is: ‘Suppose lists control ideas?’ This occurred to me recently while I was dragging new files into my ‘Writing: Professional. Substrate’ folders. This is where I store stuff that I have originated or downloaded and maybe or maybe not used, and feel is worth keeping. Generally I feel that if I have written or downloaded something, it is worth filing. While this takes time, and leads to pile-ups of shame-generating folders labelled ‘DT [desk-top] ‘Heap of stuff to file’, it seems more purposeful than hoarding paper bags and cardboard boxes. You never know when a file will come in handy. (This is also true of bags and boxes, I admit).

Thus my substrate folder contains 21 folders in F for food, such as food governance, food and love, food miles, food taxes. After ‘food’ there is: foreign debt, fortification, ‘fresh’, GAIN (Gates), genes, Global Health Watch, globalisation, GMOs, grape cure, green economy, growth (energy requirements), growth and height, guidelines (food and nutrition), health (mental, emotional), hegemony, height and ‘stunting’, human rights, ice-cream, indigenous food, individualism, Industrial Revolution, infection, infestation, labelling (including chocolate), land, leaf concentrate. And so on, down to White House Conference, WHO, wine, wisdom and knowledge, World Bank, worms. (There is nothing on yoghurt because that’s a sub-set of ‘foods, dairy’, and I was interested in zoonoses – mad cow disease and antibiotic-resistant bugs, especially – only in my pre-PC days when I kept paper files).

Many of these folders themselves contain series of folders. The RU(T)F folder, for example, includes folders labelled Alive and Thrive, Codex, Jeffrey Sachs, Mark Manary, Michael Latham, MSF, New York Times, Plumpy’Nut and Nutriset, SCN CSNGOs – MFP, CSNGOs – ICN, Sprinkles etc, trials, UNICEF (incl data). What’s the rationale of identification variously with projects, organisations, people, or products? Sorry, I can’t say. They are what came to mind at the time, perhaps as mnemonics – clues to the tone of what’s inside (2).

In tidying up mode, I open up ‘worms’ to transfer what’s within to ‘infestation’ and discover, as well as some notes on the neglect of helminthic infestation, ‘Benjamin Caballero’. So that’s where Ben got to! I move him to a different filing system, ‘People: Friends, Colleagues, Other’ where he now nestles between Benito Juarez and Bernard Shaw.

Lists and brain-waves

The first thought that occurs when I browse these lists, is that a publisher should shell out a fat advance for me to compile a sarcastic encyclopaedia of food and nutrition. This would be a lot more fun than the scholarly jobs done by the late Sheila Bingham and John Yudkin.

But that’s not my worry. This is that the act of originating – and more so, developing – lists, is programming my mind to associate what actually is a more or less random alphabetical sequence. Do I associate GMOs with the grape cure, or human rights with ice-cream, because these files sit side by side within my computer? Are my electronic configurations driving my dendrites and synapses? Scary stuff. But we have to order information. That’s part of what humans are all about.

Rather nervously, I re-label ‘ice-cream’ as ‘food. desserts’ and put ‘grape cure’ within my DMYF (‘Dieting Makes You Fat’) substrate list, which, I note gloomily, is vast and overlaps mightily with the main list – well, it would. Now I also notice that I have a folder for ‘health (mental, emotional)’ and also for ‘mental health’. I merge these under ‘health’. But will my synapses and dendrites do the corresponding business? Or will my mind now always be split on mental health, despite this tidying?

My nasty feeling is that neurologically, what’s done is done, and that the organisation of my electronic files fixes my thinking. After all, plenty of folks see shrinks twice a week for ten years with evident effect only on their bank balances. And if so, my focusing on the issue now, and worse, writing about it, and worse still, writing about it for publication, can only consolidate the neurological architecture in my brain that determines the structure of my consciousness. Scary stuff indeed. Maybe not so baroque, after all.

What do you think? The way we organise information on our computers seems to be personal and private. If there is a Filing for Dummies handbook, I’ve never seen it. Do most of us not keep files? Or else, use completely different systems, like filing by date received with no attempt at classification – which after all is the default mode for emails and their attachments? And could it be true that unconsciously, whenever we ply our trade, we think of – read the next words with attention – pubic health nutrition?

Footnotes

1. These examples of impossibilities are given with feeling. My home is in southern Brazil, where a few weeks before I write, southerly winds brought historically low temperatures and, in some locations in the sub-tropical far south, snow for the first time recorded. Fun, you may think, but Brazilian houses are not insulated or heated, and electric fires are like gold-dust. Don’t think global warming, think climate change. Also, most of my life savings have been banked with Northern Rock (or Northern Crock, ha ha). A mattress would have been safer and, given the precipitous devaluation of the pound sterling and the US dollar against the Brazilian real, both of which are worth not much more than half of their exchange rate five years ago, a better investment. Times change.
2. Exposing these lists makes me feel slightly embarrassed. My own private filing ‘system’ is now feeling to me like the strange behaviour that we may refer to a shrink, but not mention in public.

Infestation

The worms crawl in

So it’s time to tell my worm story. Some time ago my admirable AVG programme identified a Trojan invader in one of my computers, and zapped it. By its nature and as its name suggests, this is not a computer virus but a worm. It occurs to me that we take more care to get rid of worms from our hard-drives than from our guts.

A schoolboy rhyme is: ‘The worms crawl in and the worms crawl out/ They crawl in thin, and they crawl out stout’. Paediatric nutritionists who work in the South know about worms. Stunting and wasting that really does impede human potential is often actually caused by parasitic infestation, together with constant infections. I well remember the mordant satisfaction of Michael Latham at the SLAN congress in Guatemala City in 1997, making his point about the impact of infestation on nutritional status by showing a slide of a bowl full of the evacuations of a de-wormed African tot, looking like spaghetti alla olio. Ugh!

Domestic dogs and cats are de-wormed regularly. So why do we assume that in rich societies, helminthic infestation is insignificant? It stands to reason that any worm that gets into your guts, from you handling animals, eating undercooked meat, weeding the garden, or whatever else, is going to have a go at evolving, thriving and multiplying in the cosy confines of your colon

Once upon a time London was a world centre for the study of infestation – hence the School of Hygiene and Tropical Medicine. No more. As the British Empire wound down, the demand for treatment of officers of the Raj vanished, and with this, knowledge of helminthic diseases. Funding bodies downgraded the study of worms. So, no funding, no departments, no professors, no teachers, no studies, no students, no evidence – but the worms continued to crawl in. This is why Michael Latham, after decades of field experience in Africa, continues to berate paediatric nutritionists trained in countries that have forgotten about worms, and who imagine that all that undernourished children need, is peanut butter or pills.

Worms do not only sit in your gut getting fat on your dinner. Macro- or microscopic, they can slither through your guts, invade your vital organs, be observed wiggling under the surface of your eyeballs, and invade your brain. How much does this matter? Some people believe that worms can derange cell replication and thus cause various cancers, either directly or from their waste products. As far as I know, there is no orthodox evidence supporting this idea (1). But no money, and no research, means no evidence.

If nice kind Sir Bill (as in ‘GAIN, Gates’) was prepared to invest as much in research on worms in people as he now must do on worms in computers, my guess is that we would all be in for a great big surprise.

Footnote

1. Anybody who proposes unorthodox approaches to the causes, prevention or treatment of cancer is liable to be condemned, outlawed, and in the US run out of the country. Quacks can be irresponsible and dangerous, but the ‘cancer establishment’ is remarkably heavy-handed. See Robert Proctor’s Cancer Wars, and Devra Davis’s The Secret History of the War on Cancer, for two relatively mainstream accounts, and Ralph W Moss’s The Cancer Industry for some vituperative denunciation. The ‘outlaw therapist’ best known as promoting the idea that worms cause cancer, is Hulda Regehr Clark, one of whose books is called The Cure for All Cancers. She recently died from cancer, aged 80. Most of what she claims seems nuts to me, and anybody who supposes that cancer has one ‘master’ cause or cure is surely deluded. That said, I think that anybody who supposes that helminthic infestation is irrelevant to cancer, is much mistaken.

Leo Tolstoy

Apparent and real causes

That looks interesting, I thought, of a displayed book title, as I passed the Wiley-Blackwell stand at the American Public Health Association conference in Denver, a few weeks ago. So I bought Syndemics. Author Merrill Singer is an anthropologist at the University of Connecticut and also Yale University, who uses systems methods in his work. The idea encapsulated by the term ‘syndemics’, is that different causal factors interact synergistically to produce states of health and of disease. The author defines the term more precisely, as ‘the concentration and deleterious interaction of two or more diseases or other health conditions in a population, especially as a consequence of social inequity and the unjust exercise of power’.

Adam Drewnowski is cited, stating that poor people in countries like the US are more likely to become obese, because their poverty pushes them to push energy-dense ultra-processed food into themselves and their families, to get plenty of calories at the cheapest cost (2). Or, as sung by British foot-soldiers: ‘It's the same the whole world over/ It's the poor wot gets the blame/ It's the rich wot gets the gravy/ Ain't it all a bleedin' shame?’

Like most great novels, War and Peace is also a work of philosophy, and in his book Merrill Singer quotes the boxed passage above (3). Tolstoy comes close to saying that there is a general human tendency to identify what is most embodied, concrete, tangible and immediate in any causal matrix, as ‘the cause’. He seeks to demolish the notion that the invasion of Russia in 1812 and the subsequent retreat from Moscow was just caused by Napoleon’s lust for power, and then again by Napoleon’s disastrous decision to leave the city. There was much more to it than that. Thus, with disease, Merrill Singer rightly says that microbes, or lack of nutrients – or worms – are only part of the story. We also need to consider what makes people vulnerable to infection, malnutrition, and infestation. Characteristically, deeper causes include inequity and injustice. It is indeed time for us to stand up and say so.

References

1. Singer M. Syndemics. A Critical Systems Approach to Public and Community Health. New York: Jossey-Bass, 2009.
2. Drewnowski A, Spector S. Poverty and obesity. The role of energy density and energy costs. American Journal of Clinical Nutrition 2004; 79, 1: 6-16.
3. Tolstoy L. War and Peace. London: Macmillan, 1942. First published in Russian, 1865-1869

Acknowledgement and request

You are invited please to respond, comment, disagree, as you wish. Please use the response facility below. You are free to make use of the material in this column, provided you acknowledge the Association, and me please, and cite the Association’s website.

Please cite as: Cannon G. Buying and selling sizzle, and other items. [Column] Website of the World Public Health Nutrition Association, January 2011. Obtainable at www.wphna.org

The opinions expressed in all contributions to the website of the World Public Health Nutrition Association (the Association) including its journal World Nutrition, are those of their authors. They should not be taken to be the view or policy of the Association, or of any of its affiliated or associated bodies, unless this is explicitly stated.

This column is reviewed by Barrie Margetts and Fabio Gomes. My thanks also and always to Google, Wikipedia, and Guardian On-Line.