Bruce Neal

Executive Director, George Institute Australia
Professor of Medicine, UNSW Sydney
Honorary Professor, Sydney Medical School, University of Sydney
Professor of Clinical Epidemiology, Imperial College London

What inspired you to work in health research?

Probably not the right way to start, but I ended up in health research by chance. I thought I wanted to be a vet and I left school with a place to do veterinary medicine in the UK. Fortunately, I decided to take a year out beforehand and after 6 months on sheep farms in New Zealand it was pretty clear to me that veterinary medicine was the wrong choice. Travelling through Asia on the way home, I decided I needed to save the world(!), and that medicine was what I wanted to do.

I turned up to vet science on the first day and let them know that I’d changed my mind. And then went to the medical school and told them I’d just relinquished that spot and asked if I could be a medical student. Probably because I had been rash enough to quit the vet course before asking to do medicine, they agreed to interview me the next day. The day after I became the shortest application to admission in the history of the Bristol medical school. You don’t need to plan everything months ahead!

After qualifying I worked hospital jobs in the UK National Health Service for about four years completing initial postgraduate training in general medicine. While trying to pick a speciality to further train in, Anthony Rodgers who I went through medical school with, called me from the other side of the world and said, “What about research?” Long story short, I got on a plane to New Zealand for a three month trial and ending up there for five years. I found the work really interesting, got a PhD with Stephen MacMahon as my supervisor ,and decamped to Sydney for the establishment of the George, then called the ‘Institute for International Health’.

How long have you been at The George Institute for Global Health? What’s your role?

I joined The George at the beginning, so it’s been 19 years. I'm now the Executive Director for Australia. I split my time about equally between clinical and food policy research. My focus at the moment is the latter, as we try to build the program in scale and scope. But the clinical work, where I've done most of my research over the last 20 years, remains extremely rewarding.

How did you come to focus on Food Policy?

The work in food policy grew directly from my clinical research interests. Even as a first year junior doctor, it was clear to me that poor diet, alcohol and smoking underpinned the great majority of clinical presentations. After a decade in clinical research assessing new interventions for the consequences of these issues, I decided we should also work on some of the upstream determinants. Food seemed like the area most aligned to my prior work, as well as being an area in which few people were doing global research and an area where there was an enormous amount to be gained from new discoveries.

I had done a fair bit of research on blood pressure lowering drugs so my interest in sodium (salt) followed from there. The vision was for a new program that spanned the globe – there were some amazing people doing food research, but most of them were working in just one area, or just one institution, and few were taking a global perspective. I also wanted to bring the sorts of methods that we use to such good effect in the clinical space to public health nutrition: research that is highly quantitative, massively collaborative, drives policy change, involves lots of countries and employs standardized methods and protocols. This seemed like something novel that we could bring to the space.

How many countries are you doing that sort of work in now?

We’re working in about 15 countries now. Most recently we launched the FoodSwitch program in the US. We use a franchise-type model with FoodSwitch identifying partners to work with in each country. We have developed technology, tools, and expertise but are not in a position to do it ourselves in all the places we want to operate. Therefore, we find an interested collaborator, typically an academic institution, and then support them to implement the project. We help them raise money, collect the data and use the outputs with government, industry, and their academic colleagues.

What are some of the most pressing goals in food policy?

We’re interested in the issues that cause the most disease burden. Ultimately that comes back to sodium and high blood pressure, fats and high cholesterol as well as sugars and obesity. We're mostly focused on the over consumption part of the malnutrition problem but in many low-income countries there is now a dual burden of malnutrition. With under consumption, mostly during pregnancy and early childhood, accompanying overweight and obesity throughout older life. These problems can now co-exist in communities, families and even an individual.

A big part of the next few years will be figuring out how to link up the research and response agenda to these joint nutrition problems. Bridging that gap between under consumption and over consumption offers a real opportunity, because there is great infrastructure in many low-middle income countries for the under consumption piece. But almost nothing able to address the other over-consumption side of the problem. This is a huge issue, because in many poor countries economic development and greater access to food means that the disease burden caused by over consumption has now overtaken that caused by deficiency disorders.

In terms of the prevention and low cost solutions we're working on at the moment, which ones are you most excited about?

Our philosophy is to focus on the environment, not the individual. Trying to get individuals to do the right thing has been the priority of most initiatives for the last few decades but has been almost entirely ineffective. This is because diet related ill health is caused first and foremost by changes to our food environment – not because everyone has decided to become a sloth or a glutton. They're essentially the same people as they were 30 years ago, they just now live in a food swamp - high calorie, high salt, high fat food in big portion sizes provided at low cost is available everywhere, all the time. In that situation, it is difficult to do anything but get fat and get diet related diseases.

Instead of trying to persuade individuals to do the right thing, we have to change the underlying food system, and that is our focus - generating data that can be used to push governments and industry towards a model that is sustainable from not just the economic perspective, but also for health and the environment.

The potential impact of our food policy work is enormous because everyone eats and almost everyone eats a diet that is sub-optimal for health. The way forward is to change the food environment so that individuals don’t have to make any active change themselves. For example, if industry reduced the salt in every food by 10 per cent almost no one would notice and we would prevent thousands of strokes and heart attacks every year in Australia. And millions more worldwide. If we can figure out how to get the system to make this sort of intervention, it's potentially really low cost and highly cost effective and that's where we’re heading with our research.

We have a long-term plan but it’s happening too slowly. Fifteen countries are contributing toward our program and the transparency and accountability agenda we are pursuing is getting real traction. We believe we can change the food supply in 50 countries, affect what a billion people eat and avert a million deaths each year by 2025. We need a few million dollars investment each year to make that happen and achieve this impact – and getting that is mostly what occupies me right now.