There has been recent coverage in local media on the need to tax unhealthy food in a bid to reduce avoidable mortality from heart disease. The suggestion was made in the context that Malta has among the highest rates of obesity in the EU. The proposal was coupled with the suggestion to subsidise healthy food to nudge people to adopt healthier diets.

In direct response to this well-intentioned proposal, I contend that a food tax comes with limitations. Rather, what we should be primarily focusing on is enabling environments for active mobility. This is a more empowering solution to improve rates of physical activity (and reduce heart disease) that was largely overlooked in the news coverage.

In this article, I attempt to compare the merits of enabling environments (for active mobility) with the introduction of a food tax. The intention is to broaden the discussion to encompass other aspects of a healthy lifestyle, as well as to prioritise measures and avoid apparent quick-fix solutions which can have serious repercussions and not necessarily achieve their objectives.

There are certainly other measures that can empower people to adopt healthy lifestyles, such as education, social engineering and regulation on advertising. This is beyond the scope of this article. For the sake of brevity, I focus exclusively on the comparison between enabling environments and a food tax.

Firstly, I believe that creating enabling environments for Maltese residents to move around actively should take priority. Walking and cycling, and the use of collective mobility (such as public transport), are the cornerstone of mobility of advanced nations. In places such as the Netherlands, Norway, Sweden and Austria, people enjoy peace of mind and the safety to commute and shop around in appealing environments and in a fun way, as anybody who visited Utrecht, Trondheim or Vienna knows. These countries also have lower rates of obesity.

In contrast to a tax on unhealthy food (which might have its own merits), promoting active mobility and creating environments for people to move actively increases people’s choices to lead lives they have reason to value. In contrast, a tax on ‘unhealthy’ food reduces people’s choices unless this is coupled with heavy subsidisation of relatively expensive healthy food, which is unlikely. A food tax might also tip people on modest means into material poverty, leading to social problems.

Road safety is key if Malta wants to see a modal shift from car mobility to active mobility

Secondly, road safety is key for people to commute actively. Many people do not use a bicycle in Malta for no other reason than because it is unsafe. It is equally unsafe to take children to the playground or to the local school on foot or on a scooter.

It is of no surprise that Malta boasts the highest rate of obesity in children in the EU. This is because Malta’s urban environment is hostile and incompatible with most forms of outdoor exercise. It makes people opt for using a car over walking, even if they are only running errands within walking distance.

Countries such as Wales and cities such as Bilbao and Brussels have taken the bold decision to pledge or reduce urban speed limits in roads where traffic and people mix to 30km/h. This is called for in the Stockholm Declaration on Road Safety of 2020. These measures do not cost money. They save people’s lives and give back the roads to the people, so to say.

In Malta, around 20 people die every year from road traffic accidents, many of whom are pedestrians or vulnerable road users. Road safety is key if Malta wants to see a modal shift from car mobility to active mobility, and to see higher rates of physical activity and lower rates of obesity and chronic diseases such as heart disease.

Thirdly, the co-benefits of shifting from motorised transport to walking, cycling and the use of micro-mobility are tremendous. In addition to creating the enabling environments for

people to be physically active, people would enjoy cleaner air and less noise, both of which adversely and significantly worsen heart disease.

The principal source of both indigenous air pollution and noise pollution in Malta is road transport. Air pollution is a serious cause of premature death from cardiorespiratory disease. Just last month, the World Health Organisation published a revised version of the Air Quality Guidelines (2021), calling on countries to be more ambitious in their efforts to curb air pollution in light of recent evidence exposing serious concerns to health.

Similarly, people exposed to higher background levels of noise pollution above certain thresholds have been observed to suffer from significantly higher rates of heart disease, as shown in the World Health Organisation’s Environmental Noise Guidelines (2018). A modal shift in mobility has the double-effect of increasing rates of physical activity and reducing levels of air and noise pollution.

Finally, the monetary benefits of creating enabling environments for people to move around are tremendous and would include and vastly exceed the figure of €56 million per year in savings from obesity reduction as reported in recent media coverage.

Taking estimates published in the National Transport Strategy of 2050, car congestion alone costs the Maltese taxpayer around €500 million per year in wasted hours, contribution to air pollution, value of accidents and value of additional operating costs (such as fuel and car maintenance) as a result of congestion.

This figure is projected to increase to €1.2 billion per year by 2050 and does not include all healthcare costs nor does it account for the hundreds of millions of euros spent to maintain the car fleet in Malta each year. In terms of monetary benefits, the lowest hanging fruit is definitely mobility – as a minimum, this means providing safe infrastructure and spaces for people to mobilise themselves actively.

In conclusion, if, as a public health specialist I was asked to prioritise between introducing a food tax on unhealthy foods coupled with a health food subsidy or creating enabling environments for people to commute actively and safely, I would without doubt choose the latter. A food tax needs to be studied in detail before it is considered due to its political and social implications.

Both healthy diets and physical activity have positive effects on the human body. However, creating enabling environments for active mobility gives people more choice, secures people’s basic rights to clean air and low noise, and produces the biggest financial returns both for the country and for individuals. Creating enabling environments for people and children to move around actively and safely should, therefore, take priority over a consideration to introduce a tax on unhealthy food.

Roberto Debono is a specialist in public health medicine with a special interest in environmental health.

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