On the ideology of public health

Building London's sewers - real public health work

I know I rant and rave about them, complaining about their outlook, attitudes and policies. I've called them health fascists, nannying fussbuckets and the Church of Public Health. And I don't regret a word if it.

However, being a kindly sort, I thought I'd have a bash at understanding what we mean by 'public health'. Not just for the entertainment but rather to set out why the approach and strategy - how millions in public funding is spent - might be improved.

We recognise that public health begins with us recognising that there are environmental factors that affect the health of populations. The classic example is John Snow and the Broad Street Pump but there are many other examples where interventions in the environment improved health - clean water, sewage systems, the clean air acts and the whole system of driver training and road safety. We should also note that, while the medical profession was involved in identifying the problem, its solution was largely in the hands of different professions, not least the often criticised environmental health officer.

Within public health budgets these interventions are still important - responding to epidemics and disease outbreaks, vaccination and inoculation and pollution control. But the profession made a significant shift away from public health being about environmental intervention to improve people's lives. Instead of clean air, clean water and inoculation against disease, we got this as a definition:

The science and art of promoting and protecting health and well-being, preventing ill-health and prolonging life through the organised efforts of society.

This comes from the Faculty of Public Health and represents a significant change from the idea of public health being about interventions where either an all-population or environmental justification exists.  We've gone from using science and statistics to understand how cholera can be prevented to using price intervention to try and alter the behaviour of alcoholic. And the starting point for this shift was smoking - or rather the long campaign against smoking.

I won't revisit the history of anti-smoking - if you want to know more read Chris Snowdon's 'A History of Anti-smoking' - but the decision to target smoking allowed public health people to link environment and personal choice. And, at the beginning of the campaign, smoking was more-or-less an all population problem - most people smoked. In this campaign (and it was, up to five or six years ago, very successful) the crucial moment wasn't Professor Doll linking smoking to lung cancer but the acceptance that passive smoking was a health problem. There may be some question over this belief but there can be no doubt that eliminating passive smoking provided the substantiation for other public health interventions in lifestyle choices.

Running in parallel with this idea of societal harm from the cumulative impact of lifestyle choices (typically drinking, smoking and overeating) was another idea - the passive consumer. Popular books such as Naomi Klein's 'No Logo' presented us as victims of marketing, led by the nose into excessive consumption, at the mercy of manipulative corporations. This idea's inception goes back to what TV viewers should see as the 'Golden Age' of advertising when discredited theories such as 'subliminal advertising' were proposed. However, it was another age of excess - from the mid-1980s for about ten years - that spawned the idea of consumption as sinful and the consumer as victim.

By portraying the individual as a hapless addict, some public health thinkers were able to justify extending public health interventions into those individuals' personal choices. Both because those choices affected wider society (such as by costing publicly-funded health services more) and because the individuals weren't making real choices but were merely responding to an 'intoxogenic' or 'obesogenic' environment.

To complete the picture (again Chris Snowdon has the definitive review here) we need to add an older tradition - moral disapproval. We know that the temperance movement has considerable influence within public health and this more considered moralising is compounded by the more hypocritical sensationalism in popular media.

These three factors - environment as a factor in personal choice, the passive consumer and a sense of moral offence - combine to create the platform on which today's public health policies are constructed and support for them from politicians and media is obtained. And it presupposes the significance of government in health:

...recognises the key role of the state, linked to a concern for the underlying socio-economic and wider determinants of health, as well as disease

So, when Bradford Council considers its new role as a public health authority, it brings its broader ideology into the discussion.  Onto the prevailing ideology of state-directed opposition to certain choice behaviours is latched the idea of 'health inequality'. At present nothing has changed, public health remains unchanged in Bradford. But, at some point, the imperative of inequality will mean that the idea of public health addressing environmental (and all-population) issues is further blurred as resource is targeted to those places suffering 'health inequality'.

My concern with all this mission creep is that the ideal of public health becomes lost. It seems evident that anti-smoking campaigns have stalled as campaigners focus their efforts on denormalisation rather than on the reduction of harm. And, with the apparent success (in political not health terms, I might add) of these approaches, other areas adopt the denormalisation palette rather than approaches aimed at reducing harm or preventing harm from occurring in the first place.

Also this focus on choice and lifestyle overlooks some important public health issues - reducing excess winter death in the elderly population, improving air quality in cities, extending vaccination programmes - in favour of media-friendly campaigns around smoking, drinking or fast food. We enlist other parts of the local authority into these campaigns - trading standards, planning, licensing - pulling them away from their own public safety and regulatory responsibilities.

My polemic - the stuff about nannying fussbucketry and health fascism - is a reaction to all this. And it reflects a real desire to get public health back to its roots - concerned with the real environment in which people live, with preventing the spread of disease and ill-health and with promoting well-being. None of these require the condemnation of lifestyle choices let alone their denormalisation.

....