It’s timely, in light of current debate about how best to tackle obesity, to take a trip back in time, to California in the early 1990s when new tax laws created a huge windfall for efforts to reduce the tobacco toll.

An unholy convergence of interests arose between the medical profession and the tobacco industry — both wanted the bonanza spent on improving treatment for patients with tobacco-related diseases, although presumably for different reasons.

This history is outlined in an illuminating book called Tobacco War, Inside the California Battles, which states “…the financial and political interests of organized medicine often had more in common with the tobacco industry than the public health groups”.

The book also records that public health advocates had some significant wins in this war, with California introducing a raft of measures to drop smoking rates, and these were subsequently estimated to have prevented 58,900 deaths between 1989 and 1997.

If all of the money had been devoted to treatment services, nowhere near the health gains would have been made.

It’s something to think about in a week where we’ve had yet another report on obesity, generating plenty of discussion about the need to improve treatment and ensure surgery is more widely available.

Of course effective treatments should be available to those who can benefit from them (and isn’t the finding that most obesity surgery is being done in private hospitals a telling comment on the two-tier health system we’ve been busy developing).

But it’s notable that the House of Reps committee wimped out on making a strong call to action for some bold prevention policies — like tougher regulation of food formulation and a ban on junk food advertising to kids.

Another lesson from California is that lack of evidence — so often cited by those opposing calls for such policies — is no excuse for lack of action. Policy makers have an opportunity in obesity to help create evidence to inform responses to a global health problem.

A few years ago I interviewed Dileep Bal, who was one of the key tobacco warriors within the California Department of Health Services for fifteen years; he laughed when asked about the role of scientific evidence in guiding California’s tobacco control efforts.

“Most scientists will say you need a randomized controlled trial level of proof to do a community intervention,” he said. “That’s horse feathers. We tried twenty-five things — twelve worked and we renewed those. Empirical trial and error is the oldest scientific device and we used it to distinction.”

A further lesson from California and other battlefields of public health is that major gains come only when legislators find the determination and the thick hides to take on powerful lobbies.

We’re not there yet in Australia, when it comes to obesity anyway. The tidal wave of chronic diseases approaching our shores just doesn’t whip up the same level of political and public alarm as a boatload of swine flu, which is unlikely to extract anywhere near the toll of our weight-promoting environments.

*Declaration: Melissa Sweet is the author of The Big Fat Conspiracy (ABC Books 2007).

Peter Fray

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