Picking our battles: public health in public

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I started thinking about this blog last year, when it was still basically socially acceptable to cough on strangers.  Simpler times.  It was to be about my worries that we were losing the battle for ‘hearts and minds’ on what public health is, and should be, and how we are occasionally our own worst enemies.    

Then Covid-19 hit and I thought it wasn’t the right time to write about something I thought we don’t do so well as a profession, at a time when we were all working our arses off on what we do really well.  But, right from the outset of the pandemic I’ve seen the usual, predictable bollocks from the usual, predictable places, like tobacco lobbyists, intransigent free-marketeers and shouty, semi-anonymous libertarian bloggers.  They’ve moaned about public health using Covid-19 to make the same arguments we always do, while simultaneously using Covid-19 to make the same arguments about public health they always do.  Abolish PHE! Defund the WHO! Overpaid nanny state fat cats! What do they actually do anyway?!

I saw their arguments making ground and noticed that they often used ammunition that we had unintentionally given them.  So, I started writing again, before the announcement that Public Health England (PHE) will be subsumed into a ‘new’ National Institute for Health Protection.  I’ve included my original introduction below as I think it was prescient.

From June 2020…

The profession of public health is under a glaring spotlight and is probably going to take a bit of a battering over the coming months.   Critical analysis is completely necessary and there will be a time for an independent enquiry into the preparation and response to Covid-19 including, amongst other things: the UK’s readiness for a pandemic; the assumptions behind – and weight given to – predictive modelling; the transparency of how, and by whom, decisions were made; the diversity of experience within SAGE; the clarity and dissemination of guidance; the relationship and balance of responsibility between local and national government; and the use of private contractors over existing public sector bodies.

Where mistakes were made they should be accounted for and learned from.  I’m certain PHE and others will have made mistakes but the issues above are ultimately down to Government decisions, not only during the pandemic but for many years before. It is important not to confuse political decisions with ‘on-the-ground’ public health practice.  I’ve witnessed lots of people conflating dubious national policy with the local responses of councils and PHE.  That isn’t fair. I have plenty of colleagues in both who have been working themselves into the ground, swimming against the tide of constantly changing and often contradictory Government guidance; all with far fewer resources and staff than they had during the 2009 swine flu pandemic, thanks to the government’s austerity drive.  The NHS has it’s fair share of problems, but NHS staff would never be criticised in the same way their public health colleagues have been for decisions taken far above their heads.

I worry that the blurred lines of accountability and responsibility between the Government, the NHS and PHE is going to lead to scapegoating.  PHE is less revered and less well understood than the NHS, and seems a likely target for blame.

To now…

Well, that escalated quickly.

Just those few weeks ago I was actually almost hopeful that the huge and unequal impacts of Covid-19 might convince the Government of the importance of prevention, reducing inequalities, and resilience in the system; maybe even lead to them realising that yanking hundreds of millions of pounds out of the public health system was a stupid idea in the first place.  Instead it’s time for yet another massive, expensive reorganisation. Just imagine what good could have been done if the £10 billion lobbed at the not-really-NHS Test and Trace service had been given to PHE and local authority public health teams instead.  Instead, there has been:

  • A complete lack of consultation, transparency,  or even advance notice to staff of the dismantling of a national public health body during a pandemic.
  • A similarly secretive process of appointing a partisan interim leader of the new body, who has a shaky track record and no public health or scientific experience. 
  • No inquiry into mistakes made, lessons learned and so no explanation of which problems this reorganisation is actually supposed to address.
  • No justification about why PHE is to be subsumed into Test and Trace and the Joint Biosecurity Centre, two – what are they? services? departments? – which, like Keyser Söze, I’m not even sure exist as anything but an idea.  Why not just give extra money and resources to PHE – an established, world-renowned public health agency – to do their job better, rather than spontaneously create a couple of mysterious Schrödinger’s health organisations and hand them the keys to PHE?
  • No reassurance about what will happen to the other functions or employees of PHE, many of whom may very reasonably decide to look elsewhere for jobs at the exact time they are most needed and should be feeling most valued.  I don’t doubt their expertise would be snapped up.

The only thing that is clear to me from this decision is that the public health profession is not valued, listened to, respected, or even properly understood by the current UK Government.

So who is? Who has been consulted?  Well, I doubt it’s a coincidence that Matt Hancock’s announcement was similar in title and theme to a an April webinar from the Institute of Economic Affairs (IEA), who have financial links to Hancock.  My colleague Matt Atkinson highlights the “pervasive view amongst ‘free-market’ think tanks and right-wing commentators that public health should just be about infectious disease control. The prevention of ill health from other social and environmental causes is just the nanny state”.  They’re lapping this up.

The IEA, Taxpayers Alliance and their ilk are always in the media, putting forward their very particular brand of libertarianism as simple common sense.  And they’re really bloody good at it and clearly influential. Unfortunately, I think that too often we provide them with unnecessary ammunition to use against us. 

I have written previously about how we should (and shouldn’t) make the case for investing in public health, and how the language we use often prevents us from communicating effectively.  I hope you read them too and find them useful companions to the rest of this piece. 

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:

Public health in private

It’s a tough time for the public health profession at the minute and we’re in for a bit of a scrap to make sure we get the public health system we need and deserve. I wanted to share some reflections on what stops me getting too fed up.  

First, I’ve realised that public health is one of those careers in which you probably need to look back every 10 years or so to appreciate the progress that has been made.  When things are tough – as now – it can often seem we’re standing still or going backwards. But we’re not – we are making steady progress if you look for it.

For instance, we are all smarting about this Government’s decision to scrap PHE and likely disagree with many of their policies. But the devolved administrations in the UK are much more appreciative of our profession, as are opposition parties and plenty of back bench Conservative MPs.  England will catch up. 

It’s also pretty amazing that this Government, who can seem so beholden to the advocates of personal responsibility over all else, has come so far in its approach to tackling obesity.  We are making progress.

It’s been welcome to see so much written in defence of the public health and of PHE this week, including from those who were no champions of the organisation.  Most recognise that much of PHE’s perceived faults were due to political decisions.  As civil servants, PHE staff were not permitted to publicly criticise these, even as those above them appear not to adhere quite as closely to the same principles of public life.

It’s been great to see Directors of Public Health being much more visible and doing a fantastic job of calmly explaining what’s going on (as well as what isn’t, but should be). I hope the public continue to value their expertise; hopefully they can be more influential on poverty and inequality, funding, policy, and other long-standing public health issues. The visibility and recognition of local public health in the media has been great – keep it up!

Lastly, I have been so uplifted this week by my fellow public health registrars. Within about a nanosecond of the PHE announcement, registrars from across the UK had organised themselves, published a letter and accompanying story in the Telegraph. The constant bleeping of my WhatsApp while I’m writing this is a signal of all the other work they’re doing right now to protect and promote the public health profession, just as we protect and promote the public health of our communities. There’s no credit to me, I’ve just been swept along by the work of others – but it’s been brilliant to see what a bunch of intelligent, committed, moral and tenacious people we have coming through to lead and improve public health over the decades to come.

We’ll be alright.

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


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