Lugano. This is where I am now, in Italian Switzerland, overlooking the lake, at the end of a workshop conference starring Richard Peto, and editor-in-chief of The Lancet Richard Horton. So my reviewer Claudio Schuftan reminds me to mention The Lugano Report by Susan George, my hero in a previous column, on the theme of current dominant political and economic ideology and its consequences. In my room at the six-star Grand Hotel Villa Castagnola, it's a good time to be reminded of realities. Access a review of The Lugano Report here.

Everything has a context. More, everything has contexts. For those concerned with public health or with public affairs generally, the task is to determine which context is most relevant. Such judgements are not technical, but political. Technical approaches follow political decisions. These insights comes from my hero pictured above, Rudolf Virchow (1,2). He is a founding father of the public health movement, and has become especially influential in Latin America (3), so it's appropriate to celebrate him in the month of the SLAN conference being held in Havana, Cuba. Trained as a medical specialist, in pathology, he nonetheless saw epidemics as 'disturbances of culture' (1), warning signs against which the progress of states and civilisations can be judged. That is to say, mass diseases are symptoms of much deeper pathology. The concept of 'social medicine' comes from him.

He speaks to us now. He realised that descriptions of disease are not enough. In his day the big issues were starvation and infection, both of which he saw as being driven by immiseration – deep poverty, physical, mental, emotional and spiritual as well as material. His point about warning signs applies equally to obesity and diabetes. These, just as much as food price chaos and the collapse of confidence in money, tells us that the great powers are driving in pathological directions. 'Market' politics and economics are the modern equivalent of the 19th century laissez faire doctrine that caused famines in Ireland, India and Brazil in which tens of millions died, and also caused the immiseration of the urban and rural working classes as recorded in England by Charles Dickens, Elizabeth Gaskell and Friedrich Engels (4).

The recent dominant economic policies have failed. In which case, public health and public goods have the first priority. What's needed now on our side is determined organisation and also courageous champions, or 'public health superheroes' as now advocated in The Lancet (5). Where are our Rudolf Virchows now?

References

1. Ackerknecht E. Rudolf Virchow – Doctor, Statesman, Anthropologist. Madison, WI: University of Wisconsin Press, 1953.
2. Watson P. The dynamics of disease: Virchow, Koch, Mendel, Freud. [Chapter 20]. In: The German Genius. Europe's Third Renaissance. The Second Scientific Revolution, and the Twentieth Century. London: Simon and Schuster, 2010.
3. Waitzkin H. Salvador Allende and the birth of Latin American social medicine. International Journal of Epidemiology 2005; 34, 4, 739-741.
4. Davis M. Late Victorian Holocausts. El Nino Famines and the Making of the Third World. London: Verso, 2001.
5. Day M, Shickle D, Smith K, Zakariasen K, Oliver T, Maskol J. Time for heroes: public health leadership in the 21st century. Comment. The Lancet 380, 6 October 2012, 1205-1206.

The nutrition profession

We're only human

After 30 years of knocking around our topic, I remain struck by the fact that to the world outside, nutrition science remains on the whole a profession without public faces. Insiders know that it is full of remarkable, admirable and even spectacular characters, and coups, deals, ambition, scandals, jealousy, rivalry, 'revolving doors', double-dealing, charm, and achievement, not to mention personal quirks, just as with any other profession, from poets and playwrights to physicists and politicians. Some contributors to our journal World Nutrition and to our website are fascinating people.

But this knowledge remains private within the profession. What my friend the late John Rivers of the School of Hygiene and Tropical Medicine wrote in the official newsletter of the UK Nutrition Society in 1985, I think remains accurate: 'We nutritionists are on the whole a sibilant species… We are a profession dominated by consultants, advisors, and official committee members used always to acting in the acceptable shadows' (1).

In the past, leaders in public health nutrition were often charismatic. Justus von Liebig, John Boyd Orr and Ancel Keys, and in a quieter way Hugh Sinclair, John Waterlow, Cicely Williams and Derrick Jelliffe, are obvious examples. So are people outside the profession whose work influences us – like Susan George. So indeed was Rudolf Virchow. Once challenged by Otto von Bismarck, chancellor of Prussia, to a duel, and thus having the choice of weapons, he proposed pork sausages, one loaded with lethal germs. There's style!

So why now the low profile? This thought naturally brings me to the next item. This concerns somebody in the public health profession who has had great influence on international food and nutrition policy, and who for a long time now has been in the spotlight.

Reference

1. Rivers J. The hollow men. Editorial. Nutrition Notes and News, 9 August 1985.

Transnational executives

We have to talk about Derek

Derek Yach at the 2004 World Health Assembly: full (and witty) disclosure
of a stash of the transnational refreshments for the distinguished delegates

'Have you heard about Derek?' or 'You'll never guess what now about Derek!' Emails whizzed around cyberspace last month. The news was that after five years, Derek Yach is no longer Pepsi-Co senior vice-president, global health and agriculture policy (one of those 'masters of the universe' titles dreamed up by US-based corporations). Since early last month he is senior vice-president in New York of The Vitality Group, a branch of the South African-based Discovery Holdings (1). A company tweet of 10 October reads: 'Wow, just spent the last 2 d with newest TVG employee, Dr. Derek Yach. We are super psyched Dr. Yach has joined us'.

What does TVG do? To quote from its website: 'By capitalizing on our heritage of actuarial expertise, the Vitality wellness program is meeting the needs and cultures of a wide range of US companies in their pursuit of increased workforce health and productivity'. Which sounds like saying: 'We statisticians can prove to you industrialists in return for a truckload of cash, that if we teach you how to get your employees to do press-ups, you will get more performance and less absence from them'. But no doubt I misunderstand. TVG support services include (their bullets)

• Turn-key implementation
• Maintenance of the member wellness portal and employer portal
• Expansive rewards mall
• Support for The Vitality Champ Program

Whatever these may mean, a superficial outsider glance at the TVG website doesn't ring bells. But this can't be a retirement gig, because Derek is 57. So what gives?

From Geneva to Purchase

Any hermit who knows nothing about Derek Yach will wonder why I am running this item. The rest of us can see why. Derek once bestrode the world. Between 2000 and 2004 he was World Health Organization executive director responsible for the prevention of chronic diseases, including by food and nutrition, leaving WHO in 2005. He was our hero then. Two is that soon after, in early 2007, he was hired by PepsiCo. That also caused a flurry of emails. At that time Association founder member Ricardo Uauy went to Pepsi headquarters at Purchase, just north of New York City, and talked to him and Pepsi chief executive officer Indra Nooyi (pictured below) (2). Ricardo's question was, why?

Indra Nooyi, who has her own fascinating story starting in Chennai (Madras), gave a characteristically numinous reply. 'We have asked Derek to change this company. In five years we want to have most of our product line meet the international standards supporting life-long health. If he fails, we fail'. Aha! Now in 2012, it is five years after that interview, and nobody, not even Indra Nooyi or Derek, would claim that the dream of 2007 has come true. But who or what is it that has failed? I have been checking out the business press, and now see Box 1.

So after five years, did Derek realise, or did Indra Nooyi remember, that the time had come for the parting of the ways? Something like this seems rather likely.

A hero for our times

Say what you like about Derek, he is one of the most remarkable and influential people in our field. He was one of the champions of the Framework Convention on Tobacco Control early in his career at the World Health Organization. As such he has played a significant part in preventing mass premature death and disability, in those countries whose governments have done their duty to govern, and that have passed laws and enacted regulations that make it less easy and more expensive to smoke, and that reduce exposure to tobacco.

As mentioned, his final post at WHO was as one of the executive directors reporting to director-general Gro Harlem Brundtland, where he was responsible for the prevention and control of chronic diseases. When in this post he commissioned the expert panel responsible for what is still the current WHO '916' report on food, nutrition and the prevention of disease, chaired by Association founder member Ricardo Uauy.

Derek (practically everybody refers to him by his first name) is also charming and elusive, in the way that many resourceful senior executives and politicians are. I first met him in January 2001 when I was a member of the Brazilian delegation to the WHO Executive Board meeting. There he was, standing up in a plenary session and denouncing the Pan American Health Organization big-shots for having a person intimately connected with the tobacco industry (and also incidentally Coca-Cola) serving on one of their advisory committees. It turned out that he had not given prior warning to George Alleyne, then the director-general of PAHO, who sat stony-faced during the diatribe, and who may well then have decided to give Derek the Caribbean Black Spot. 'Interesting man' I thought of Derek. 'He will go further'. But in what direction?

Almost immediately afterwards, the later Association founder member Denise Coitinho, then responsible for Brazilian food and nutrition policy at federal level, and I, invited Derek and his then deputy Pekka Puska, later also an Association founder member, to Brasília. One outcome was the next World Health week, on the theme of physical activity, inaugurated by then Brazilian president Fernando Enrique Cardoso, in São Paulo.

Derek was informal and glamorous. He had the JFK touch – he often picked up the phone himself, or beckoned civil society champions into his nice office to shoot the breeze and to give and take advice. At the 2001 IUNS global nutrition conference in Vienna masterminded by Association founder member Ibrahim Elmadfa, Derek took me aside and told me who he proposed to chair the expert panel responsible for what became the '916' report, and asked me what I thought. So I told him that the appointment he mentioned would be idiocy, for what surely were super-obvious reasons. What about Ricardo Uauy? I said. Well, I am not suggesting that Derek in appointing Ricardo did so because of my advice, but all this was very charming.

Then came 2004

But by 2004 Derek had gone funny peculiar, in the eyes of people from civil society (7). Under financial and political pressure, it seems that his boss Gro Harlem Brundtland had decided that food was not like tobacco but was like pharmaceuticals, whose corporations worked with WHO to protect public health, and that he had to bring 'the private sector' into discussions on food and nutrition policy. In the interests of balance, transparency and so on, civil society organisations would also be consulted. Then after one turbulent term as WHO director-general, she was replaced by Lee Jong Wook, a gentle South Korean elected with the help of the bloc vote masterminded by the US on the understanding that he would focus on treatment, control and prevention of infectious tropical diseases.

In those days it was possible for anybody in the WHO building to take the elevator up to the floor of anybody's office and hang around outside, which I did. Quite soon Derek emerged and said oh, hello, and I said could we talk. Once in his office I said look, I know this arrangement to give 'the private sector' an inside track on the emerging WHO global strategy on diet, nutrition and health, meant to be based on the science of the '916' report published the previous year, is a done deal. But could he tell me, what and who was 'the private sector'? He said that WHO had a list of contacts.

Well of course, I guessed, but this will be a list of transnational food product manufacturers and their associated organisations whose heavy-hitters have managed to get into consultations with WHO. Moreover, I said, other than Unilever, McDonald's, Yum! Brands, and a few others, I bet you that the great majority are from Big Sugar – not so much the 'refiners', as the transnational manufacturers whose profits depend on sugars and syrups, like Coca-Cola, Nestlé, Kellogg's, Mars (I think already then known as Masterfoods), and Pepsi-Co. Come to think of it, also McDonald's and Yum!, whose 'meal' packages typically include a soda and a shake.

That will be your mailing list, I said. Moreover, WHO style is to accept anybody from those industries who respond to WHO invitations. This generally means public affairs directors well below main Board level whose task is to protect the bottom lines and investment potential of their corporations, plus even public affairs companies with this mission outsourced to them.

Further, most of the 'private sector' people who participate in crucial international meetings like those convened by WHO, operate globally, have their own trade organisations, hunt as a pack, and will come to your meetings with implacable pre-agreed positions. I suggested that invitations to 'the private sector' need to go to named people, usually main board directors, with no alternates accepted;

We were 10 minutes or even more in by now, and Derek was shifting from the 'let's slip over the border to Ferney-Voltaire and have a pow-wow' mode, to the 'I am a very senior executive' mode. I thanked him profusely and said 'Will you show me the WHO private sector list so I can advise you? Or else, can I send you a list of private sector bodies that collectively would represent the food industry as a whole?' Great idea, he said, and whoosh, I was gone.

Loose Cannon

By this time the writing was on the wall. Gro Harlem Brundtland had left. Pekka Puska had also left, a sufficient reason being that Derek's division had a derisory budget. Plus Derek had been instructed to work with 'the private sector' – which he did. In UN meetings you can tell where senior officials are coming from by the company they keep, and Derek was to be seen in affable conclave with industry representatives. At some point I made a disobliging remark in public, for Derek turned to me and hissed 'Loose Cannon! Loose Cannon!' But Derek, I said, why do you think it is the deck of your ship to which I am lashed?

The Assembly ended, and soon after Derek was removed from his post and given nebulous responsibilities, and in 2005 left, first to the Rockefeller Foundation, then to Yale University, and in 2007 to Pepsi. When questioned he said he had come to the conclusion that he could do more for public health working for a transnational food and drink corporation, than he could working within WHO. In the circumstances this made sense.

Soon after his move to PepsiCo, I was in the office where I worked in London when the telephone rang, and it was Derek. He said that after consultation with his boss, who in turn had consulted Indra Nooyi, he had an exciting proposal to put to me. He then explained… but that's another story from five years ago, which is now history.

References and notes

1. The Vitality Group. http://www.thevitalitygroup.com/content/our- company-background
2. Uauy R. Do we believe Derek's motives for taking his new job at Pepsi-Co? Public Health Nutrition 2007, 11, 2, 111-112. DOI: 10.1017/S1368980007001644
3. Colvin G Indra Nooyi's Pepsi challenge. Fortune, 11 June 2012 http://management.fortune.cnn.com/2012/05/29/pepsi-indra-nooyi-2/
4. Byrnes N. Pepsi brings in the health police. Bloomberg Businessweek. http://www.businessweek. com/ magazine/content/10_04/ b4164050511214. htm 14 January 2010.
5. Monteiro CA, Gomes FS, Cannon G. The snack attack. American Journal of Public Health 2010, 100, 975-981.
6. Monteiro CA., Cannon G. The impact of transnational "Big Food" companies on the South: a view from Brazil. PLoS Medicine 2012; 9 (7): e1001252.
7. 'Civil society' here means independent professional and public interest organisations and institutions. The term has now become tortured to include industry trade, front and representative organisations, so that a consultation with 'the private sector' and 'civil society' now is often with the same type of person. That's another story.
8. World Health Organization. Global Strategy on Diet, Physical Activity and Health. WHO World Health Assembly 2004. WHA A57. http://apps. who.int/gb/ebwha/pdf_files/WHA57/A57_R17-en.pdf
9. Cannon G. Why the Bush administration and the global sugar industry are determined to demolish the 2004 WHO global strategy on diet, physical activity and health. Public Health Nutrition 2004, 7, 3, 369-380.
10. Mooney C. The Republican War on Science. New York: Basic Books, 2005.
11. Revill J, Harris P. America stirs up a sugar war. The Guardian, 18 January 2004.

Being in the tropics (3)

Weighing it up

Access the September column here
Access last month's column here

Reasons to live in Brazil: freshly prepared good food in a typical per quilo restaurant (left) and (right) how these places encourage good fellowship

Here is my third in the series of reasons why to live in Brazil. The per quilo (also known as per kilo) restaurant is a Brazilian invention. It's one of those brilliant simple ideas. You serve yourself from a buffet as shown above (left), take exactly what and how much you want from what's on offer, and pay according to the weight of the food you have chosen. The restaurant displays the cost per kilogram, so customers with experience will gauge the cost and value. Once you have moved along the line your plateful is weighed, the weight of the standard plate automatically subtracted, and that, plus the cost of any drink, is that. In some places you don't pay straight away. Instead, your check gets marked or punched with the price of the food, and waiters circulate serving drinks, whose price also gets marked or punched, and you pay at the door. In places there is a separate buffet for desserts.

Most per kilo places in the city where I live are fairly standard, serving a selection of salads and then a variety of fresh meat or sausage dishes and sometimes fish, some pasta dishes, couve (a type of kale), rice, beans and other items. Filling and nourishing but not exciting. Hot dishes are kept gently heated, and items like beans and any type of stew with meat are often contained in big earthernware pots over a fire. Rustic per quilo (and also set price) places in the countryside on Saturdays serve rib-sticking feijoada (meat, offal, sausage and bean stew) with rice, couve and farofa (coarse cassava flour toasted golden with toothsome added bits like bacon, chopped olives, garlic).

Restaurants and canteens in the biggest cities, like São Paulo and Rio de Janeiro, both places where I work, may offer a great variety of salads, or specialise in say Arab, Japanese, German or Italian fare. Like anywhere, the price per kilo depends a lot on the quality of the food and the price of rent paid by the restaurant. But I can't recall ever paying more than 25 reais, which is roughly £8 or $US 12, for a delicious meal made up with freshly prepared foods of my own choice. In my last trip to São Paulo I went with my colleague Carlos Monteiro to a packed restaurant in the Rua da Consolação in the select Jardins district and had a healthy, satisfying and delicious lunch, including freshly steamed fish, for 10.80 reais.

Part of the art for per quilo customers is to know the best time to be there. The freshest and most delicious dishes naturally are the first to be finished, though in bigger places the kitchen staff renews the trays or dishes. Crafty customers also become aware that heavy items like slices of fruits and tomatoes tend to be first choices in the line, whereas green leaves, of which there is often a good choice, and lentils or chickpeas, whose weight is less watery, come later.

Another aspect of per quilos, is that seating arrangements are often informal. My favourite Rio place (right, above), opposite the state university in the Maracana district, has long tables with benches. This encourages good fellowship among colleagues who may all come in together at lunchtime to have a good meal and a good time, as you see.

So yes, per quilo restaurants are nourishing, in the broad sense of encouraging good fellowship as well as serving varied and enjoyable meals in amounts and at prices to suit almost everybody. In a more focused sense, what they provide is nutritious, especially in one vital respect. Household expenditure and whole-diet surveys undertaken throughout Brazil, consistently show that consumption of fruits is low, and of green leaves and non-starchy root vegetables like carrots and onions is very low. The sheer existence of per kilo restaurants in most main streets in any Brazilian city must by now be making a difference (2).

There are plenty of McDonald's outlets in Brazil – around 650 in total by the middle of this year – and there are other burger chains too. But there are many thousands of per kilo restaurants, almost all independently owned, often by a family working together, and usually serving freshly prepared and cooked food from which to make your own meals. Yes, they are a good reason to be in Brazil.

Notes

1. The other self-service system still occasionally found is the 'eat all you like for… (specified price). Churrascarias, the restaurants whose waiters walk around with cuts of meat and also offals on skewers, to supplement the salads you select yourself, operate like this.
2. Judgement that the Brazilian diet is very low in vegetables, depends on what is defined as a 'vegetable'. The usual definition excludes starchy roots and tubers, and also legumes (pulses). If however cassava and inhame (a type of yam), not eaten in temperate countries but commonly consumed in Brazil, together with beans, an insignificant item in North America and Europe but often consumed every day in Brazil, are counted as vegetables, overall average consumption in Brazil is not low. The implication of this definition is that potatoes as tubers would also be defined as a vegetable.

Rudolf Virchow

Meanings of food and nutrition

At the age of 27, Rudolf Virchow was asked by the Prussian government to investigate an epidemic of typhus in Upper Silesia (1,2), which his masters in Berlin knew could spread to important people like themselves. He found that the communities he investigated subsisted on a diet of potatoes, sauerkraut, and vodka. He concluded that a year of hard rain and bitter cold had tipped these wretched, insecure and impoverished communities into starvation who, huddled together in their huts, had incubated the contagion that, as an epidemiological nemesis, had already started to spread to the wealthier classes. The appropriate intervention he proposed was radical social reform. He was fired. He then founded the weekly journal Medical Reform, proclaiming poverty as the breeder of disease, and throughout his long life proclaimed politics as medicine writ large (2).

References

1. Waitzkin H (ed). Social Medicine 2006; 1, 1, 5-98
2. Mackenbach J. Politics is nothing but medicine at a larger scale: reflections on public health's biggest idea. Journal of Epidemiology and Community Health 2009, 63: 181-184.
3. Ackerknecht E. Rudolf Virchow – doctor, statesman, anthropologist. Madison, WI: University of Wisconsin Press, 1953.