Letter (#2) to the DAA Board: DAA as an advocacy organistaion

This post is an adjunct to the Trust in Professional Integrity series.  This is a letter I sent to DAA while I was still a DAA member and acknowledged APD in response to DAA's [in]action on a juice product that hit our Australian supermarket shelves uncontested....now an "open" letter because it will be available publicly when it is published.   


The product: a 250ml organic juice product marketed to mothers as suitable for infants from 6 months old as "a safe and convenient way to feed infants on the go" because of its "ready-to-go" teat attached.  The product was engineered and manufactured in Australia by a local Melbourne group; juice source is from New Zealand.

The product, specifically, the organic juice product with teat, is no longer available for purchase on Australian supermarket shelves.  There remains a Bebi bottled water with teat available in supermarkets. 

To me, this product represents our lax approach to public health.  It is easier for us to "help" and "educate" once the problem is there, rather than saying NO to food industry.....just in case opposition to a product might accidentally affect our economy for a moment.  If a product like Bebi can enter the market uncontested, then what hope have we got as dietitians, the experts in "what to eat to achieve health", in making any difference at the other end?  

It is so difficult to compete with the hard-core marketing of these products.....how can we truly convince people not to buy these "fun", "healthy", "convenient" products.  There is not much fun or cute about buying an apple.  

.....................................................

23-11-12

via email to Claire Hewat, Julie Dundon, DAA National Office, DIPSIG

23 November 2013

  

Dear DAA,

I will write here as my individual opinion because I have not canvassed the membership on this issue, but in the interests of healthy debate, strengthening our profession, and fairness and transparency I must write this now.

The reason I made sure DAA was included in all correspondence on the list-serves about the Bebi product is because it was an opportunity for DAA to demonstrate they are serious about their vision, and achieving two of our four strategic directives 1) influence government policy and 2) influence the food supply. I have copied and pasted the mission and the two strategic plan points at the end of this email.

In a way, Bebi was an 'easy target' because of the 'teat' and the clear marketing strategy to infants.  In the correspondence on the list serves, I did point out my struggle to find much wrong with the product in terms of 'food law' and even 'misleading and deceptive'.  Even my complaint to MAIF took some time to find a specific contravening issue.  The response via [Name removed for privacy: "a DAA staff member"] sent to DIPSIG yesterday, outlining the process by DAA-FRAC to 'redress breaches of The Code'...is 'due process' not advocacy.  

In fact, DAA already has its own evidence-based reference point, a set of guidelines against which to advocate to achieve our mission, vision, and a great deal of the items in the 'strategic plan'.  This reference is the Australian Dietary Guidelines.

Based on my work in 'achieving effectiveness in dietetic practice for obesity, a main barrier for dietitians to achieve effectiveness, is their client being able to navigate through a supermarket, past the two-for-one tim tams and over to the F&V area (and then the weighing-up of the relative risk with perishables vs packaged foods).  'Influencing the food supply and influencing policy' sets up the supportive infrastructure for dietitians to make a serious dent in Australia's obesity statistics.  Bebi characterises everything we are up against in the food supply - accessible, cute, start them early, convenience, making parents think there is a need etc. 

From my work so far, to create a supportive framework for dietetic effectiveness, my position statement is this:

The aim of this position is to influence the food supply toward a 'healthy normal'.

Melanie Voevodin will publicly oppose any product that enters the market that does not meet the Australian Dietary Guidelines.  Products targeting and/or marketed to children (i.e <15 years of age) will be particularly scrutinised.  

Melanie says NO to products entering the market that are not on the healthy eating pyramid.  Melanie supports innovation and marketing to close the gap on making the healthy choices easy choices and this means fruit and vegetables relative to packaged and processed foods.  

Melanie recognises the economic fragility, the global market, and Australia's position in this.  However, where one market fails, another takes it's place; Melanie's position seeks to move the free market away from a reliance on packaging and processing, to a reliance on local and sustainable.  

As a health professional, Melanie has a responsibility to speak up and oppose the importing, distribution, development and sale of any product that contradicts the Australian Dietary Guidelines. 

Imagine if we replaced the 'Melanie's' with 'DAA'.  A statement like this really would, i believe, make it clear that DAA is serious about achieving its vision, mission, and strategic plan. But then DAA does have a position on 'position statements'....

Excerpt from the DAA March e- newsletter 

 ..........................................

Position statements: Everyone wants them but . . .  

“From time to time members question 

why DAA no longer produces 

position statements, or members 

ask for a statement to be written on 

a particular topic. DAA used to have 

position statements on a number of 

subjects but the Board took a clear 

decision some years ago that this 

was not a route the organisation 

would continue to take.”

 .................................................

As an active and concerned member of DAA, I commit to supporting DAA to:

a) Decide on our position about positions

b) Be clear about what advocacy means 

c) Fill the 'Strategic plan' with clear operational objectives

d) Add to the strategic plan how we will know the objectives are achieved

e) Be clear in the annual report on income from industry vs membership vs other funds

Whatever the decisions are for this, for us (DAA) to clearly communicate decisions to all members. And the vision and mission adjusted accordingly. Remembering, everything DAA does in the public arena reflects on all dietitians.  I am sure all members will do what they can for DAA to truly achieve our current mission - and are looking to DAA to look beyond 'due process', and toward the global concepts of GOOD governance, and the attributes of a civil society organisation.  

DAAs Vision and the two strategic directives referred to earlier in this email are copied and pasted below my signature block

Kind regards

Melanie Voevodin

.............................................................

DAAs Vision and the two points in the strategic plan

Vision

DAA is the leader in nutrition for better food, better health and wellbeing for all.

And in the strategic plan 2011-2014

1.  Influence Government Policy

- Contribute to build the recognition of DAA as the peak nutrition body

- Identify key policy agendas for advocacy efforts

- Develop and implement DAA advocacy action plan

- Increase member capacity to influence government policy

- Communicate DAA's positions to members

- Appoint and resource high profile advocates

- Develop tools for members to resource and encourage "grass roots" advocacy 

- Develop and leverage alliances with other organisations

- Proactively engage media in relation to action plan objectives

2. Influence the food supply

- Build member expertise in the area of food regulation

- Provide regular and informed input on food regulation decisions

- Advocate to ensure nutrition holds an appropriate level of importance in the overall food security debate

- Advocate to ensure nutrition holds an appropriate level of importance in the overall food supply and sustainability debate

- Action the food and nutrition policy statement developed in collaboration with the PHAA

- Advocate for, and support the development of, improved nutrition and nutrition standards in all settings

- Work with partners and other stakeholders to achieve a safe, secure healthy and sustainable food supply

- Increase opportunities for members to work within the food supply system

Other blogs by me

[Series] Posts in response (prn)
Pete Evans
Dietitians

[Series] Trust in professional integrity (March 2014)
March is [unofficially] professional integrity month 
The story of dietitians for professional integrity
What is professional integrity?

[Series] Are dietitians effective? (July 2013)
Heads up GPs, we can save $billions together

Evidence-based confessions of a dietitian

Dietitians: as effective as the evidence from clinical trials

Evidence small health changes are good

[Other stuff]

Time for a health bottom line
The power of consumers
NO juice for Australian babies
Contributing to understanding dietetic practice
Maximising online survey participation
An evidence-based food future?

Letter (#4) to the DAA Board: Corporate Sponsorship

This post is an adjunct to the Trust in Professional Integrity series.  This is a letter I sent to DAA while I was still a DAA member and acknowledged APD in response to DAA's call for member feedback on their sponsorship policy. Of course this is now an "open" letter because it will be available publicly when it is published.

February 11, 2013

To the DAA Board,

RE: CORPORATE SPONSORSHIP AND DAA

I am against corporate sponsorship of any kind for any organisation who represents themselves externally (or internally) as an ‘advocate’.  This is because the mission and vision for corporations is, for the most part, in conflict with the mission and vision of an advocacy organisation.  Whether intended or not, whether perceived or real, an advocacy organisation with corporate sponsorship can never truly advocate [because of the conflict of interests].

I submit with this statement the Guidelines for ethical relationships between physicians and industry, Third Edition 2006, by the Royal Australian College of Physicians.  This publication is currently under review and due for release later this year. 

I recommend DAA adopt the RACP guidelines as a benchmark for ‘next steps’ on addressing their corporate relations.  As well as make consideration for an ‘ethics committee’ to monitor all process and procedure across the organisation, this includes executive proceedings, member-executive interactions, member-member interactions, and any external relations.  In particular (Pg 5):

Some health care professionals may be unaware they are being influenced or argue that it could happen to others but never to them. The guidelines recognise that everyone can be influenced and that health care professionals need constantly to evaluate their relationships with industry.

Which appears consistent with DAAs current position that there is ‘no problem with having sponsorship’, and specifically, ‘the DAA sponsorship policy is clear’ and members are referred to the policy should they have concerns about these relationships. 

I suggest DAA consider in particular (Pg 7):  Implementation of the guidelines and Conflict of Interests committees

- In every organisational or practice setting a group of individuals should be identified with responsibility for ensuring that processes exist for identifying issues and developing policies relevant to relations with industry in that particular setting. This function may be taken on by a pre-existing body such as an Ethics Committee or a Conflict of Interests Committee may need to be established.

- Details of membership of this group and the outcomes of its deliberations should be publicly available

- The group, or those delegated by it, should have responsibility for deciding how to respond to complaints, inquiries and changing circumstances.

At minimum, DAA needs to offer an ‘opt out’ clause at the time of membership renewal for members to request their address is not given to a third party.  This should specify the ‘giving of addresses’ as an incentive for sponsorship, where members would need to again opt out. That the ‘opt out’ process is clear, is implemented, and there is an avenue for alerting DAA to ‘opt out’ not working (i.e member continues to receive unwanted material).  The ‘opt out’ is to recognise ‘informed consent’ in business-member relations, privacy, and the ‘right to choose’.    

Yours sincerely

Melanie Voevodin

Dietitian, Health Economist

Letter to the DAA Board: a suggestion for member centred communication

Date: 04 Feb 2013
To: Dietitian interest group lists, DAA CEO, and the DAA president
By: email 
Subject: A suggestion for member-centred communication

To the DAA Board

Re: Member-centred communication: suggestions for consideration by the Board

Members of DAA are concerned about the future of the association and the profession of dietetics. It is my understanding, and my personal experience, of years of 'issues' being presented to DAA following the 'correct channels', has not in fact achieved its objective. 

In bringing the discussion to the interest groups (IG), members are attempting to engage each other to table these issues, and discuss options.  And in fact, what this has done is demonstrated to members that there are very important issues we should discuss with each other and then take a 'summary' to the Board.  

The problem is there is currently no forum for members to raise concerns freely, and have these open to comment across the membership.

As a profession we subscribe to patient-centred care as the cornerstone to effective treatment.  One of the philosophies of patient-centred care is to recognise the imbalance of power between the health professional and the patient: to encourage the professional to have empathy for and listen to the patient.  Here I propose we transfer that concept to the relationship between the DAA Board and the DAA Members.  

Therefore, I present here two 'first steps' for the DAA Board to consider in moving toward member-centred communication to identify issues, explore options, and for members to make recommendations to the Board.  

a) Setting up an open discussion group named 'the future' or 'critical dietetics' or 'professional insight' for members to have a forum for discussions on any topic at any time - this is where 'issues for the Board' may be raised, discussed by all members, and then presented to the board as a 'brief'

b) Dedicate part of the members section to a 'call for submissions' where all green papers are posted, and every response is also posted, and the final report posted - similar to that of the set-up for the National Food Plan  http://www.daff.gov.au/nationalfoodplan/national-food-plan  (notices of submissions being 'up for comment' could go via the suggested IG - as well as the usual lines of communication).

I am available to 'work-up' these options suggested here when required.  

Claire, I was unable to find on the DAA Website how to contact directors (there email addresses are not with their profiles), and I was also unable to find the DAA Policy/Instruction on 'how to table issues with the Board'.  In the past I have sent 'issues for the Board to consider' directly to you, but I am unaware of what happens once issues are 'posted'.  Please advise.

For my colleagues: I give permission for anyone to use all or part of this 'Letter for the DAA Board' in their own letter or submission as you wish, and/or to propose a 'letter of support' on the options I have suggested.

Kind regards

Melanie Voevodin

What is Professional Integrity?

If I had to sit an exam with a two-point short-answer question “what is professional integrity?” I would probably write:

“Professional integrity is professional ethics in action”

Here is my explanation. 

“Integrity” is a person’s public front: the decisions, actions and behaviours of an individual that others can see.  The chosen behaviour and action allows those around them to make an informed decision about how much they might “trust” that person.  What shapes, or drives, the person’s behaviour is the ethical principles to which they subscribe.

Now, a “profession” is a socially recognised label, for example, lawyer, doctor, dentist, teacher, dietitian.  This means any “profession”, any one of these socially recognised labels, comes with it an assumed level of “integrity”.

“The socially recognised label for a “profession” comes with an already attached public trust in professional integrity.”

This assumed “professional integrity” is the privilege of choosing to be a professional as a purposely-selected vocation to serve the public and act in the interests of the individual in front of you.  A “professional” therefore has a higher expectation of self, and, in a way, the “expectation of self” is to recognise the public’s assumed trust associated with the label. People who choose a “profession”, and maybe this is particularly true of health professionals, are driven by a desire to help others, believe in social equity, and recognise the trust they are afforded by the public. 

So, “professional integrity” is still about others’ perception of you, and how much they “trust” what your intentions are, what drives you to give the instruction and information you do.  Therefore, an individual practitioner relies on [perception of] “trust” to be effective in their chosen profession.  Once that “trust” is lost, it follows the service is no longer effective. 

“Professional integrity” is central to the credibility of a profession, and the effectiveness of the service provided by an individual practitioner.”

Any professional association, such as the Academy of Nutrition & Dietetics (AND), or, our Australian equivalent, the Dietitians Association of Australia (DAA), act for and on behalf of the profession.  A professional association is the “public voice of the profession”, reflecting the collective professional integrity of the individual practitioners.  What the association does and says, and the way in which they conduct their business reflects what [the majority of] the profession wants and stands for. 

“The association’s “professional integrity” IS the profession’s integrity, and, at the level of service delivery, IS the individual practitioner’s integrity.”

Here it is: if the individual practitioner has chosen a particular vocation knowing they enter the profession with the expected higher level of self-professional integrity, it seems reasonable the public assumption, and the professional’s assumption, extends to the professional association.  What the American group, Dietitians for Professional Integrity (DFPI) is asking of the AND is to protect the dietetic profession’s integrity by recognising the conflict of interest that exists with the AND’s financial ties with the food industry. 

Having corporate funding is not against the law, and the AND, like the DAA, rationalise their corporate relations by referencing their “corporate sponsorship policy”. DFPI, as members and non-members of their association, have worked many years trying to support their association to change from the inside.  Now they take this request public to encourage their association to remember the principle of “integrity” on which the profession is based.  The reason for taking the issue public is twofold 1) to be clear to the public the AND’s reliance on corporate funding is not what dietitians want or support and 2) to use public pressure to hold the AND to account – there is no other avenue available to hold the association to account for a slip in professional ethics. 

It is reasonable to suggest it hypocritical the association who can hold an individual to account for a slip in their professional ethics cannot themselves be as easily held to account for their own slip in professional ethics.  In playground speak: they get to tell us what to do, but they really can do whatever they want.  There is an imbalance of power here too: the association has the power to hold an individual to account but there is no real accountability for the association – accountability of the association relies on the association having a “higher expectation of self” which includes acknowledging this higher position of power.     

Even if we put “professional integrity” as a reason to limit corporate involvement in the association to the side for a moment, there is a more obvious reason for a professional association to NOT have corporate sponsorship.  This reason is evidence.  There is more than enough evidence for a professional association, especially one who is an advocate for health, to recognise the damage these ties have to professional integrity.  It is not against the law to have corporate funds, but it is certainly within “professional ethics”.  Again, is it hypocritical an association who promotes their profession as “evidence-based” is not in fact operating to the evidence?

What I am saying here is “professional integrity” is more than just “following the law”, it is more than just following policy and procedure.  Professional integrity is making an active commitment to the “profession” and the profession’s ethics to put the patient first. If an individual has a high expectation of self, then the association who represents them should have an even higher expectation of its collective self. 

There is simply a fundamental philosophical difference between [health] professions, and any company/corporation: a company has financial gain as the driver for behaviour; a profession has the patient and the patient’s interest as the driver for behaviour. Commercial interest and professional interest cannot exist together because of the difference in the dominant driver of behaviour.  Even with the best of intentions, once money is the driver, it is difficult to be absolute in defence the acquisition of funds from commercial enterprise does not affect the “patient first” expectation of professions.  

Professions have been around long enough to recognise “what is ethical” is, to some extent, subjective.  This is why “professions” have “standards of professional practice”, supported by professional registration and accreditation programs.  And an individual practitioner can be held to account to these professional standards by “the law”.

Here is the bit I would say to students is “examinable”.  For the non-students – this is the “list of professional ethics principles” I would want to see in action to make the decision an individual (and their association) has unquestionable professional integrity…..

Professional integrity is professional ethics in action.  Professional ethics is a set of principles outlined by professional practice guidelines, accreditation and credentialing programs, and then the law is the recognised scaffolding to hold practitioners to account [if they move outside these expectations]. 

Professional ethics means a practitioner:
The links here are specific to Australian dietitians

1.     Recognises the public trust in their title and credential and reward this public trust by expecting a higher level of self in professional conduct

2.     Follow their profession-specific standards of professional practice including ethical conduct and the requirements for continued learning and development

3.     Know the law and by-laws of the association, and recognise this legislative arm is there to protect the public

4.     Conduct business within the law, but to subscribe to the higher elements of good governance (transparent, fair and just, accountable, democratic, participatory and responsive)

5.     Respect the complexity of conflicts of interest and recognise the role of adequate disclosure of interest

Extending this to professional associations to demonstrate their professional integrity by complying with 1 to 5 plus three more:

 The links here are specific to Australia

6.     To operate within the law, meaning the associations own laws are in line with the greater law

7.     When implementing the association process and procedure, particular attention is given to conflict of interest, as well as procedural fairness and natural justice

8.     The terms of good governance are adhered to, and in a collegial and solution-focussed approach to problem-solving

Ok, I made that last one (#8) up – but for those of you who have followed my posts on “dietitian-only discussion groups” would know #8 trumps all others, and means the association is operating to the law and has a [publicly] demonstrated high level of professional ethics that extends to all arms and operations of the association. 

PS #7 is a close 2^nd in the “weighting of importance” in the integrity of an association.

@MDPStudy

Want more on professional ethics and professional integrity? 

S Tyreman.  Integrity: is it still relevant to modern healthcare?  Nursing Philosophy 2011; 12:107-118

What is ethics? 
Definitions by second-year Monash Medical students.

Medical Ethics Under the Knife

The Global Mail, October 2013

The Royal Australasian College of Physicians produces an internationally respected set of ethics guidelines for health professionals. But the college executive has taken a new edition down from its website and quietly disbanded the committee who authored it. Why? In the meantime, The Global Mail has posted a copy of the draft guidelines here.

Independent Therapeutic Advice: how achievable is it?

Australian Prescriber 2013 36: Supplement 2

This supplement is likely to be of interest to anyone involved in the development of clinical guidelines and clinical research, including:

- Health professionals, trainees and students who use guidelines as a basis for their decision making

- Policy makers and others working to improve the quality of health care

- People involved in university, college and hospital education

Excerpt: Around the world it is commonly assumed that clinical practice guidelines, systematic reviews and the scientific literature are dependable and credible sources of information about the efficacy and effectiveness of therapeutic products. Health practitioners and consumers expect that these are reliable sources of up-to-date information about treatment options, and policy makers rely on them to guide important healthcare decisions.




Other blogs by me

[Series] Posts in response (prn)
Pete Evans
Dietitians

[Series] Trust in professional integrity (March 2014)
March is [unofficially] professional integrity month 
The story of dietitians for professional integrity
What is professional integrity?

[Series] Are dietitians effective? (July 2013)
Heads up GPs, we can save $billions together

Evidence-based confessions of a dietitian

Dietitians: as effective as the evidence from clinical trials

Evidence small health changes are good

[Other stuff]

Time for a health bottom line
The power of consumers
NO juice for Australian babies
Contributing to understanding dietetic practice
Maximising online survey participation
An evidence-based food future?