Picking our battles: public health in public

I bloody love being a generalist, me. I was in academia before I came into public health and didn’t enjoy how that career path tends to funnel you into one small, esoteric area.  But being a generalist brings with it the temptation to try and be an expert in – and get involved with – everything, which can be exhausting.

Public health is so broad, there are so many unnecessary obstacles to improving population health and wellbeing, that we often end up trying to influence everything.  As a profession as whole, it’s right that we do so.  As individuals – and I’m absolutely including myself – I think we need to get better at prioritising, and not just for the sake of our own sanity. The public perception of our profession can be damaged if we are perceived to be focussing on trivial or unimportant things, or when we fail to grasp the balance between advocacy and annoying people.  I’ll try and illustrate with a few examples.

Picking the right battles

First, banning the Coke truck.  I know all about the commercial determinants of health; the power, dubious ethics and vested interests of many big corporations who think that improving health will harm their profits; that these companies, their practices and their products are undoubtedly contributing to obesity and other health issues; and I also happen to agree that celebrating a diesel-powered sugary drinks advert as an essential part of Christmas is daft and sends out completely the wrong message. I’m for the ban – but not the way we as a community played our hand in public.

I felt uncomfortable with the condescending tone of some – and only some – public health folk calling for and then celebrating the local bans: the gloating, the we-know-best tone, insulting people who like the truck, or who thought that perhaps there were more important things to focus on.  To me, it came across like we were trying to dictate what we think people should care about, rather than appealing to what they do care about.

It was a small but genuine victory, so campaigners had every right be pleased.  But, given the publicity and backlash, did the benefits outweigh the damage to the ‘brand’ of public health? I don’t know. Maybe. We get to pat ourselves on the back and re-Tweet each other, but nothing much changes and we potentially lose a few more of the crowd. 

This isn’t just a ‘public health’ thing of course, there are many examples where of course intentions are good and the cause worthwhile, but the advocacy approach backfires or alienates people. I’m reminded of the time Extinction Rebellion (XR) protested climate change by pissing off a load of commuters attempting to use the most climate-friendly transport option available to them.  I also attended an environmental summit that was hijacked by a 40 minute XR protest, thus pissing off a room full of people trying their best to save the planet.  Read the room, chaps…

We need to weigh up when private influencing is more appropriate than public pontificating, to tailor our approaches and pick our battles wisely.

Preaching vs. pragmatism

I thought the former Chief Medical Officer Sally Davies’ final report Time to Solve Childhood Obesity was brilliant. It made the case for change really well and provided some fantastic recommendations.

And one rubbish one.

2.3 Prohibit eating and drinking on urban public transport, except fresh water, breastfeeding and for medical conditions

Of course, this was the one that made the headlines and left an open goal to boot the ‘nanny state!’ ball into.  If someone tried to tell me I wasn’t allowed to neck a pack of the Greatest Crisps in the World (Roysters T-Bone Steak, obviously) on the bus home from work, or even  to give my daughter a bloody banana, I’d want to be booting balls too. All those lovely, sensible, evidence-based recommendations largely ignored because of one ill-thought-out one.

The causes above are really important, but when we are perceived to preach or patronise the reputational damage to the cause can be greater than the benefits of raising awareness.  I consider public health not just a profession but a way of thinking about the world – looking upstream, influencing the ‘causes of the causes’. A lot of people don’t think like that, for a number of reasons – it’s far easier to find the time and headspace to worry about the big picture when you’re not also worrying about paying bills or feeding your kids, for instance – and we won’t get them on our side by being annoying.

Less preaching, more pragmatism. As public health professionals we shouldn’t lecture; we should engage with people who hold different opinions to our own, meet halfway, try to find common ground and move the dial a bit. If there is no common ground, let’s just disagree without being a git.

Accepting uncertainty and complexity

Humans are still basically just angry apes, even though we have sitcoms and fondue sets and those things we put on our bike spokes in the 80s.   It has never taken a lot for us to form tribes and hate others by default; for their nationality, race, religion, even what football team they support or the music they like.  Even though it’s always been there, social media seems to have amplified that tendency and led to tribes being formed based only on thoughts or feelings, often on one specific thing.  If someone agrees 100% with you – and it needs to be 100%, mind – then they’re in your squad.  If not, then they’re a Nazi or a fascist or a snowflake or a Remoaner, or whatever.  The world is messy and complex, full of uncertainty and trade-offs, but collectively we seem to be losing the ability to accept that. 

It should be possible to not have to pick a team, to understand both sides, to recognise shades of grey. I’m quite comfortable with my state of general confusion about absolutely everything. I’m very happy to say “I dunno” or “it’s probably a bit of both”. For example, a few of my own contradictions:

• I accept that alcohol causes a lot of health and social problems, but it also brings economic and social benefits
• I accept we all need to eat much less meat, but I wouldn’t want to ruin the livelihoods of farmers
• I accept that Transgender people are discriminated against and their rights need to be protected and respected, but I also think that women who wouldn’t feel comfortable sharing a space with somebody born male should be listened to as well
• I accept that the Black Lives Matter movement is enormously important, but I was uncomfortable about mass protests being held during a pandemic
• I accept that the involvement of young people in the climate protests is necessary and pretty amazing, but I also worry about the mental health impact of ‘climate anxiety’
• I accept that the public sector and the State are best placed to perform many functions, but that the private sector and free market work well in others
• I accept that e-cigarettes probably cause some harm, but they’re a lot better than smoking

In a world where people seem compelled to pick a side, to stick to opinions with religious certainty, I hope that we in public health are able to embrace nuance, complexity, and uncertainty; to accept the fact that there often isn’t a single right answer; and to be patient in forming our opinions.  If we only listen to the those who shout loudest we may rush into things – with the very best intentions – without thinking of the wider consequences (which is what I believe happened with the Adverse Childhood Experiences movement).

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I know I often write about what I think we do less well as a profession, but I promise it comes from a good place!  I love working in public health, I believe in the principles completely and get frustrated at what often seems such a slow pace of progress.  I want to help and – as the ADPH put it – I try to be “as constructive as possible and as challenging as necessary”…

It’s clear from recent events that as a profession we haven’t done well enough in selling what we do to the public or to politicians. Sometimes we ourselves can fuel the misconceptions about who we are, and we should take some responsibility for the fact that so many people think public health is about only stopping outbreaks and telling people off.

If you want to read more on communicating public health (from people who actually know what they’re on about) see the brilliant work of the Frameworks Institute and Health Foundation, or this briefing for the UK Public Health Network.  In the meantime I’ll sum up my rambling with this:

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As ever, agree or disagree, you can let me know on Twitter.