The foremost public health emergency in our mind at the moment is, of course, Covid-19. But we must be careful, not to forget more familiar enemies, such as hypertension, cancer and heart disease, which are all closely associated with Covid-19 severity and mortality.
As we saw in the 2013-14 Ebola outbreak in West Africa, when the health system is preoccupied with one disease, others can run rampant. The latest Office for National Statistics (ONS) death statistics show an extraordinary rise in deaths from causes other than Covid-19, leaving doctors around the world nervous and bemused.
To offset the potentially devastating indirect impacts of Covid-19 and future pandemics, we need healthier populations. In this pursuit, we can either target those at highest-risk, or introduce measures that affect the masses. It is easy to imagine that highly targeted public health interventions are most effective, but this is not always the case. Note that with Covid-19, the global position quickly escalated from tracing and testing high-risk individuals, to enforcing lockdown measures affecting everyone.
A population centered approach
Covid-19 aside, as long ago as 1985 in an article “Sick Individuals and Sick Populations”, epidemiologist Geoffrey Rose questioned the traditional presumption that interventions should only target high-risk groups.Rose observed a “painful truth” that even for those deemed to be low risk, the commonest cause of death was by far coronary heart disease. Everyone, he concluded, “is a high-risk individual for this uniquely mass disease.” Rose opined that even a small reduction in risk at a population level would therefore provide a greater benefit than merely targeting those at highest risk.
This is the winning essay of this year's Bennett-Prospect Prize for Public Policy. To find out more about the prize, click here Since Rose’s article, extensive evidence has accrued in his support. From obesity to smoking, interventions affecting whole populations are known to be more effective than those targeting high-risk groups alone. Such measures typically involve legislation to inculcate healthy behaviours at a societal level. By changing society from above, they do not depend on a sustained individual response. These measures therefore have the potential to be the most effective, equitable, and affordable, of all interventions.
Health Taxes
The vast majority of spending on health is delivered through government: the NHS system and the wider public sector. Investing in any individual public health intervention diminishes the government’s ability to invest in another, as both are derived from a common budget. Moreover, no complex public health issue can be confronted with one single intervention, no matter how effective. The only single intervention that has the ability to deliver long-term health benefits at almost no financial cost to the state, instead generating revenue, is a health tax. Its effectiveness is a corollary of not just its own impact, but also the other interventions it runs alongside, and for which it preserves funds.
Adam Smith, considered the father of free market economics, affirmed “Sugar, rum, and tobacco are commodities which are nowhere necessaries of life… which are therefore extremely proper subjects of taxation.” Excise duties on these goods have indeed delivered huge improvements in health worldwide by facilitating long-term behavioural change. According to the World Health Organization, a significant increase in tobacco tax is the most cost-effective measure to reduce tobacco use. Public health policy must now turn to the leading risk factor for disease in the UK: diet.
The Soft Drinks Industry Levy (SDIL) was introduced in the UK in 2018 as part of the national strategy to combat childhood obesity. One year after its introduction, sugar content within the soft drinks sold decreased by 21.6 per cent, removing 30,100 tonnes of sugar from soft drinks in a year. The overwhelming success of the SDIL led to calls from the former UK Chief Medical Officer to extend the levy to other harmful goods.
The Proposal: A Food & Beverage Industry Levy
One of the major criticisms of the SDIL is that sugar is not just found in beverages. We cannot expect far-reaching health benefits without a reduction in the consumption of all sources of processed or added sugar.
My idea for a Food & Beverage Industry Levy (FBIL) would bring together a combination of excise taxes on a range of goods known to be deleterious to health, to be paid by producers and importers. It was cooked up with a variety ingredients from around the world: the fat tax in the Indian state of Kerala, the junk food tax in Mexico, the salt tax in Fiji and the SSB tax in the UK. The proposed list of taxable items, shown below, takes into account goods known to contain high concentrations of harmful products, existing UK industry targets, and also goods that are most frequently overconsumed in the UK, as outlined in the latest Public Health England National Diet and Nutrition Survey.
The inclusion of essential food items in the 2011 Danish fat tax led to its unpopularity and repeal. The FBIL accordingly excludes goods usually considered essential, or staple parts of diet, such as bread, rice, and milk. It also excludes some harmful products such as industrial produced trans fatty acids, from the perspective that they should be banned altogether, as they are in Denmark and Austria.
| Domain | Item |
| Salt | Salty snacks Condiments and sauces Processed meats (excluding those under saturated fat) Fresh and frozen ready meals and soups Tinned produce (e.g. baked beans) |
| Sugar (food) | Chocolate confectionery Sweet confectionery Breakfast cereals Sweet spreads and sauces Yogurts and fromage frais Desserts (e.g. ice cream, lollies) |
| Sugar (drinks) | SSBs (as currently defined in UK SDIL) Fruit juices Milk-based drinks (excluding plain milk) Energy drinks Alcopops |
| Saturated Fat | Fast food (e.g. burgers, chips, pizza) Morning goods (e.g. pastries, buns, waffles) Cakes and biscuits Fatty meats (excluding those under salt) Butter, lard, ghee, high-fat oils and cheeses Creams (e.g. crème fraîche, sour cream) |
In the UK, cardiovascular disease (CVD) continues to be the leading cause of death in those aged under 75. These deaths are not inevitable. Indeed, many Covid-19 patients die from cardiovascular complications, triggered by the infection but facilitated by pre-existing disease. A staggering 80 per cent of (non-Covid-19) premature cardiovascular deaths are thought to be preventable, related to lifestyle. By targeting dietary risk factors, the FBIL can treat the problem at source—breaking the long chain that goes from poor diet to obesity, hypertension and high cholesterol, through to heart disease, stroke, and sometimes death. Since many diseases share these common risk factors, the benefits extend beyond CVD, to dementia, cancer and mental illness prevention too.
The principal components of diet responsible for obesity are sugar and saturated fat. As sugar consumption has increased in the UK, the rate of diabetes has soared and is predicited to hit 4 million cases by 2025. Reducing sugar consumption provides a powerful counterweight to the crisis: a 2019 modelling study estimated that a 20% reduction in the sugar content of high-sugar products would result in 154,550 fewer cases of diabetes over ten years. Saturated fat is excessively consumed by 80% of the UK population. It is not surprising therefore, that NICE estimates 30,000 CVD deaths in the UK are preventable every year, if average consumption of saturated fat is halved from current levels, to 6–7% of total energy intake.
But it isn’t just about fat—a special word is due on salt, the leading dietary risk factor for high blood pressure. Hypertension is the largest single known risk factor for CVD. It affects one in four UK adults, and is associated with at least half of all heart attacks and strokes. Until now, government policy on hypertension has centred on early detection followed by clinical management, which usually means medication. But the 2019 NHS Long Term Plan has stated that a reduction in salt intake of 1 gram/day could prevent 1,500 premature deaths, and save the NHS over £140 million a year. The current strategy on salt reduction though, founded upon voluntary initiatives with industry, is woefully out of step with this ambition. If the government wants to make good on this—or the plan’s other goal to prevent 150,000 strokes, heart attacks and dementia cases over the next ten years—it is going to have to do more.
The FBIL represents the low-hanging fruit that must be picked ahead of more costly ‘downstream interventions’ to later deal with the fatal consequences of obesity, hypertension and high cholesterol.
Design & Implementation
In designing the levy, the primary objective must be to improve health rather than to generate government revenue. With this in mind, industry must be given sufficient time to react to the levy, as seen with the SDIL where the announcement was made two years in advance of implementation. An expert, interdisciplinary team will set and revisit objectives, liaise with stakeholders, and establish a process for monitoring and evaluation as it is phased in.
It is imperative that the tax substantially increase costs from baseline, specific to the dietary component. For instance, salt is inexpensive, requiring a much higher rate of tax than sugar or saturated fat to adequately influence price and thereby induce product reformulation. Thirdly, other taxes on goods must be altered to operate in harmony with the FBIL. For example, some biscuits are subject to a 20% VAT rate whilst others have no VAT at all. The FBIL provides a long-overdue opportunity to revisit not just other taxes but also existing subsidies. Finally, the tax must be adjusted to keep up with changes in inflation and levels of disposable income, similar to the (now repealed) UK alcohol duty escalator.
Securing political, public and industry support will be vital. The food and beverage industry typically shudders at the prospect of regulation, but the wiser heads within it will recognise the advantage of getting ahead of fast-changing public priorities. Consumers are—already—showing they are willing to pay for healthier products. There is an opportunity to be had: health and profit are not mutually exclusive. Note that overall sales of soft drinks increased by 10.2 per cent in 2018, after the introduction of the tax.
Another, more serious, anxiety for some is that consumption taxes are considered regressive, penalising the poor. But many risk factors are concentrated in poorer groups, meaning the health benefits delivered through the FBIL would also accrue in these groups. Social justice will not be advanced by our continuing to turn the poor into the sick. Besides, any revenues generated from the tax can be used progressively—as they were in the Philippines, where revenues from alcohol and tobacco taxes are earmarked for health insurance coverage for the poor.
A tax whose time has come
Back in 1985, Geoffrey Rose transformed the way we think about improving health. Yet despite their proven effectiveness, the population level interventions he supported remain relatively unexploited, due to their political, multi-stakeholder nature. Health taxes provide an inimitable opportunity to invest in health whilst generating public sector revenue. Harnessing the power of fiscal policy will prove instrumental in preventing thousands of preventable heart attacks and strokes. The majority of those dying with Covid-19 have underlying chronic conditions: now is the time for such policy change. Following the success of the UK Soft Drinks Industry Levy, a comprehensive extension in the form of a Food & Beverage Industry Levy is not just reasonable, but essential.
