Gauden Galea: "Four industries cause 7,400 deaths daily in Europe"

When Gauden Galea (Malta, 1960) was studying medicine at the University of Malta, he was drawn to the idea of implementing measures to improve the health of an entire population instead of focusing on a single patient. And he has dedicated the last thirty years of his career to defending and working for this idea. Today he is one of the most authoritative voices in prevention and public health at the World Health Organization (WHO), from where he has led the fight against chronic non-communicable diseases on a global scale. Furthermore, he has been a key figure in responding to international health crises, such as during the covid pandemic.

If anyone is clear about how politics and the sociocultural environment in which we live determine how long and how well we live, it is him. This is why they recently launched an initiative, the quick buys, a list of 25 effective actions to prevent diseases such as cancer, diabetes, or cardiovascular diseases and see results in a short period of time. To be precise, within a legislature. “We had to convince politicians that if they implemented some of these actions, they would see the results before the end of their term,” Galea argued a few days ago at the Palau Macaya in Barcelona, where he participated in a session framed within the cycle Prevention and promotion of health: from evidence to action.

— When he was studying medicine in Malta, even though there was clear and compelling evidence of the harmful effects of tobacco, its presence was omnipresent: there was advertising in newspapers, tobacco brands sponsored events, smoking enjoyed absolute social normalization. We don't remember it now, but it was allowed on planes, in restaurants, in classrooms! That situation seemed inadmissible to me. We adopted measures to ban advertising, to explain to people the harmful impact it had on their health, and we succeeded! It was a great victory. Another key experience was with measles.

What happened?

— I worked for the Ministry of Health and, while reviewing data, I realized that Malta suffered an epidemic of this infectious disease every four years. There was a recurrent, repetitive pattern. At that time, we were in the third year after the last epidemic, so we had little time left to try to prevent the next one. I implemented a social awareness campaign aimed at the public, and when the first cases began to appear, many families reacted and vaccinated their children. That year, no outbreak occurred, nor in the following years. It was a turning point and showed that taking measures at a population level has a much greater impact than the thousands of children I could have treated throughout my career as a doctor. Even so, we made a mistake.

What?

— We did not warn the importers of the measles vaccine that we would run that campaign and that summer they ran out of stock twice!

Prevention in health largely depends on political decisions, as in the examples you have just mentioned, but it is often linked to individual responsibility.

— It is true that prevention remains very focused on the individual and it is crucial that it is so because it is an essential part of primary care. But over the years the concept has been changing. First, individual behaviors were discussed; then, we moved on to considering risk factors; later, multifactorial models. The big change came with the recent concept of social determinants of health: access to resources, opportunities, and power directly conditions health. A person suffers a heart attack due to an individual genetic predisposition, but also because they smoked, because they were overweight, or for any other factor they have accumulated throughout their life.

The postal code determines health.

— This is how, because it determines the opportunities you have: it defines the quality of housing you access, the type of job you have, surely the education you can opt for, the food you can buy and that is in the shops in your neighborhood. Everything has a lower price so you can access it, but it also has less quality and leaves you in a situation where you end up having to face more dangers.

Can it be reversed?

— Social aid and support are needed because only by addressing poverty, lack of education, and access to health services can the foundations be laid for a more holistically healthy population, not with the objective of, for example, preventing cancer. The next challenge in prevention is to reach the most vulnerable segments of the population. Let's think, for example, about the screening for early detection of cervical cancer.

In Catalonia, free cytologies are offered to women every three years.

— But women from more vulnerable groups do not usually get them, but only people with a certain educational and socioeconomic level. Those who have a more precarious job surely cannot afford to stop working to get a check-up. In the end, personal circumstances push people to make choices that are detrimental to their health, and this makes public services inequitable. Health services must be rethought to address these vulnerabilities. But not only that, but it would also be necessary to address certain aspects of certain activities, let's say commercial ones.

The industry.

— In the last two years, my team at the WHO has generated a report on industry determinants related to non-communicable diseases in Europe. We have shown that four industries, tobacco, alcohol, food, and fossil fuels, cause approximately 7,400 deaths per day across the entire European region. This data raises many questions, from why products are manufactured the way they are to why we pay so little attention to alcohol in our region; or why Europe, despite having led global tobacco control measures, will become the region with the highest per capita smoking rate in the world by 2030.

Do you have any answer?

— The industry! It's enor-mous. When we started to fight tobacco, it was a giant industry, but shortly after, alcohol's was of a larger magnitude, and now the ultra-processed industry is even of a larger magnitude. All three are related and the only way to fight against them is to go little by little, gather evidence of the harm they cause with their products, how they produce them, how they set prices and what influence these industries have on public policies.

Why don't we legislate? Why don't governments take action?

— Because it is not possible to face everything at once. Political opportunities must be seized when they arise. It is better to move forward with concrete measures than to wait for a perfect reform that encompasses everything. In this sense, there are quick and effective interventions, such as increasing the price of tobacco, expanding smoke-free spaces, or increasing the price of alcohol. Companies, of course, do not like this. The Tobacco Products Directive (2014/40/EU) caused many problems during its gestation, counter-attacks from the industry and allied industries, hoteliers, demonstrations in Brussels, and even accusations of corruption within the Commission, public investigations, and more. But, even so, the directive was adopted and was an important guide for subsequent legislation at the state level. Great triumphs can be achieved.

What about alcohol?

— Last year, Diageo, the world's largest multinational headquartered in London, published a job offer titled "Global Alcohol Policy Manager." I still have the advertisement, which directly asked for a person to work with the WHO and allied NGOs. It's no longer that companies reject scientific evidence or try to provide alternative evidence they themselves have generated by paying for research, but rather that they now attack organizations, the WHO, or anyone else who is against a product. They label them as radical leftists or as going against the sovereignty of the people, or as being biased by ideology and not based on science. They generate an empire of doubt, moving the game away from the product towards politics and ideology. And in today's geopolitics, this is enough to scare a politician and prevent them from legislating on a product.

You, however, have shown that behaviors can be changed and health changes can be brought about in just five years.

— The effective interventions proposed by the WHO, the best buy interventions, we saw that they were not being carried out because to obtain results it took time.

In addition to the courage of politicians...

— Agreed. We wanted to do something that would have a quick impact, so we could tell politicians: if you do this, before the end of the term you will be able to say that you have produced a beneficial impact on the population's health. This is where the quick buys come from. We started with a list of 49 interventions and established a five-year framework, prioritizing based on scientific evidence. And we ended up with a list of 25 that have a detectable impact in between 1 and 5 years.

Which ones apply to Spain?

— Tobacco continues to have a significant impact in Spain. Measures such as increasing its price, providing aid for people to quit smoking, expanding smoke-free areas...

It is a hot topic with the smoking ban on terraces...

— But passive smoking is a very potent argument, because being exposed to other people's tobacco smoke is also dangerous. And it is not fair that a non-smoker has to stay inside the restaurant because the terrace is an area for smokers. Furthermore, when smokers are asked in surveys, the vast majority want to quit, and the more exposed they are to tobacco in their environment, the more temptation there is to relapse. Therefore, many will agree to ban smoking on terraces. Another very relevant area in Spain is alcohol.

Catalonia is a land of wines, and we consider them part of our culture.

— It is important to include on the labeling of alcoholic beverages that they cause cancer; also wine, no matter how much it is considered culture. The producing companies know this, and that is why they refuse to do so and often try to twist the message in favor of individual responsibility. They don't say don't drink anymore, but rather do it responsibly. It's marketing, like with ultra-processed foods: they tell you "consume" and add an adverb, "responsibly". It's up to you. It's even starting to be seen as playing responsibly. Effective interventions are increasing the price, reducing availability, and banning advertising.

He states that salt, sugar, and saturated fats are the main toxic ingredients we consume.

— They are the main causes of health damage. We use them every day because they are extremely cheap. But if you put them together in a product, add an attractive wrapper, make the product give you a pleasant jolt when you put it in your mouth; even if afterwards it doesn't even taste good, you have everything for it to be addictive. Governments can pressure industries to reformulate the products they manufacture. In Chile, legislation was passed so that all products, on the label, inform with a kind of traffic light...

The Nutriscore index.

— ...of the impact on health that it has. And it's working! No brand wants a label with a red 'E' because consumers stop buying it. The industry is changing product compositions to make them healthier. In the case of Spain, we could first start by making it difficult to acquire ultra-processed foods, keeping them out of educational centers, public buildings, and hospitals. The compositions of foods can be examined and it can be established which ingredients are candidates for a tax or a label. This is an incentive for the industry to reduce or eliminate them, which improves the quality of available foods. In public health, the strategy is essential. We must prioritize, act with evidence, and especially protect the most vulnerable groups with the ultimate goal of building healthier, more resilient, and equitable societies.