Big public health reform can happen quickly when the conditions are right, but most often effective and long term change is incremental and slow.

We saw in the aftermath of the terrible loss of life in the Port Arthur Massacre that gun control could happen rapidly. The community across Australia united with Parliament to loudly reject gun violence in Australia, with a law swiftly passed to reduce the future risk of any such incidents happening again.

The circumstances that lead to rapid change such as this are gratefully very rare. Instead, in the usual course of events, change in public health occurs in small steps over many years. When advocating for change in this environment, it is important to think about the perspective of decision makers, particularly Ministers of government. Our aim is to ensure a clear, stepwise path to best practice and so we need to think about this strategically. Changes need to generally be small and palatable to the electorate, which means we need to be very careful about picking what interventions should come first.

We know that for many of the challenges we face that we need a suite of interventions working together to affect a significant change in outcome. An intervention that requires a large political cost and for which we think the outcome when implemented on its own is likely to be minimal may reduce the willingness to make any further changes. Changes where there is minimal political cost, and even better, with widespread praise from the electorate and other stakeholders alongside small improvements in outcome is a more effective strategy. These small wins can increase confidence by all those concerned that the changes being proposed will not lead to crisis, loss of jobs, and economic collapse, as we often hear from naysayers to change.

Taking this strategic lens, if we took the example of population nutrition, we could think about where the lowest hanging fruit for change is. Marketing of junk food on government property is a step that can be undertaken as a policy of government, rather than requiring legislation. It is not complete as an environmental change, but it does signal government is taking serious steps which may have an impact on the market, both consumers and customers. The cost of implementation is relatively low, and the political cost is even lower, as we know that parents are asking for help with the issue of junk food exposure. A focus on children as the beneficiaries is also important because we mostly agree they should be offered more protection from predatory marketing than adults because of their lower competence level.

Alternatively, a soft drink tax potentially has a high political cost, because it is a new tax. There are ample studies demonstrating that soft drink taxes work both to deter consumption but also to raise revenue which can be used to further population health gains. Further, soft drink taxes are highly cost-effective. As with many population-based interventions, soft drink taxes work best when part of a suite of interventions. A focus on introduction of soft drink tax as the main strategy has a high political cost and may not be as effective as more politically palatable options. It can also mean that no changes are made which is the worse outcome.

It is the job of the research sector to establish the evidence base for what works in prevention, how it works and the health economics of the intervention. It is the role of policy people to make these come to life which requires translation into real world policy making.