On Monday 23 April, the ‘Do No Harm’ amendment, tabled by Lord Warner to protect the public’s health as we leave the EU, reached Report stage of the EU (Withdrawal) Bill.

Responding on behalf of the Government, Lord Duncan of Springbank accepted that Ministers had “not thus far provided sufficient assurance…on the issue of public health”. At the despatch box, he presented fresh legal analysis of Clauses 4 and 6 in an effort to reassure Members that the Bill, as currently framed, already provides adequate legal safeguards to ensure that as we leave the EU there will be no erosion of our vital public health legislation, policy and practice.

In offering this new analysis, Lord Duncan acknowledged that Peers and the coalition of 54 medical Royal Colleges and health organisations supporting the amendment would need time to reflect on the detail, and so, in a rare Parliamentary move, agreed to revisit the issues at Third Reading. We welcome the Government’s reassurances and will now carefully scrutinise its legal advice. Should we feel that it does not offer sufficient certainty, we will encourage Ministers to table an amendment that will do, or, if necessary, will work with Peers to table a further amendment to the Bill.

Together, as a coalition, we’re changing the course of the debate and putting the public’s health at centre stage of the Brexit negotiations. We thank Lord Warner and the Labour and Liberal Democrat frontbench health spokespeople, Lord Hunt and Baroness Jolly, and Crossbench Peer Baroness Finlay, for tabling so important an amendment and working so tirelessly to make the case in Parliament. And, in turn, we thank our partner organisations and our members.

Former health minister and Crossbench Peer, Lord Warner said: “I welcome legal clarification that Government accepts EU protections of public health will be carried over after Brexit as part of retained EU law. We will return to the issue again at Third Reading to ensure these guarantees are adequate.”

Prof John Middleton, President, UK Faculty of Public Health, said: “I’m proud that the health and medical sector has made such a strong case for protecting the public’s health as we leave the EU, and am encouraged that the Government has recognised that the sector needs further reassurance.

While we take the time to understand whether these assurances do what we want them to, we look forward to continuing to work with the government towards our shared goal of safeguarding the public’s health as we leave the EU.”


Fifteen years ago, in March 2003, the US invaded Iraq. The legality of this war continues to be debated and whether the world is a safer place as a result is also controversial. Meanwhile, the country continues to struggle with fighting terrorism, the economy is devastated and the lives of millions severely impacted.

Saif* was only 5 years old when the first American troops entered Baghdad on 9th April 2003. Whilst many children in the developed world would be learning to read and write, Saif was experiencing the “shock and awe” strikes by the coalition forces. Unable to attend school, with his family lived in a dark, cold and damp house. Growing sectarian violence in the power vacuum left behind following the deposition of the Ba’athist regime led Saif’s family to leave their home in Baghdad, living in a tent to avoid violence.

Saif is now 6 and used to death. His father was killed in a suicide bombing attack and he is forced to work in order to provide for his family. Saddam Hussein has been captured but this has no bearing on the trials Saif must endure. Clean water, electricity and food are a luxury. Saif sleeps in his tent not knowing if he may wake up the next morning.

A few years later and the new Iraqi government has reopened the schools near Saif’s new home. Scarred by bombing, riddled with bullet holes and lacking teachers and equipment, Saif attends school in the hope of educating himself to improve his life. Despite being a bright student, Saif is often seen distracted in class as he gazes at the walls remembering how a recent bombing left 155 dead. Saif has flashbacks of the bodies in the street, the blood smeared against the walls and the screaming that left his eardrums ringing.

In 2008, aged only 10, Saif fell ill with severe gastroenteritis and ended up in isolation in hospital for 2 weeks. He was diagnosed with cholera similar to 4696 other cases. The outbreak struck again in 2015 affecting over 2000 individuals. There are only 0.8 doctors per 1000 people in Iraq compared with 2.8 in the United Kingdom so the untrained nursing staff did their best to care for Saif.

After decades of conflict the region is littered with unexploded landmines and Explosive Remnants of War (ERW). Saif lost an arm fiddling with ERW, the only toy he could find in the neighbouring field, and had retrain himself in writing with his left hand. It is estimated ERW caused over 30 thousands casualties by end of 2015.

At the age of 16, ISIS took over large swathes of Iraq. A few of Saif’s friends, frustrated and disillusioned with their lives join their ranks. None are heard from again. Saif is working on a market stall and counts himself lucky to do so, with unemployment officially at 15%. All the money he earns is spent on caring for his now bed-bound mother and siblings. She coughs badly and lost weight, she was diagnosed with tuberculosis. There are an estimated 20,000 tuberculosis patients in Iraq with increasing levels of multi-drug resistant tuberculosis. Saif’s mother is one of the 4,000 Iraqi people that dies from this preventable disease this year.

In 2018, Saif is the oldest surviving member of his family, raising his two siblings. According to the WHO the probability of Saif dying between 15 and 60 years old is 224 per 1,000 population. If lucky Saif is expected to live up to 66 years.

The UN estimates that 4 million children in Iraq are in need of at least one form of humanitarian assistance in 2018. Despite this, the Iraqi government has deprioritised healthcare, slashing the healthcare budget by 25% in 2016. Iraq remains a public health disaster with clear scope for improvement should healthcare be prioritised. As per the Transparency Index, Iraq is consistently within the worst 10% of countries.

Saif is 20 years old now, with a traumatic history, interrupted education, mentally and physically damaged and the sole breadwinner in a young family. All he wants is a normal life, but has no job or marital prospects on the horizon. His only hope is that if he does have children, that they can live a full and healthy life like the one taken away from him.

* Saif is not a real person, but this is an example of what life has been like for many children growing up in Iraq in this period.

Written by Dr Bayad Nozad, FFPH co-chair of Global Violence Prevention SIG, and Dr Ahmed Razavi, Academic Clinical Fellow in Public Health

By Mark Weiss, Senior Policy Officer, Faculty of Public Health, markweiss@fph.org.uk

Last week, cross-Party Peers debated the ‘Do No Harm’ amendment to the EU (Withdrawal) Bill in the House of Lords, and FPH’s Senior Policy Officer was there to watch. A ministerial assurance that there will be no rollback of public health standards is welcome. We now call on the Government to put that assurance on the face of the Bill.

Responding at the despatch box on behalf of the Government, Lord Duncan made a ministerial commitment to the spirit of the amendment, assuring the House that “there will be no rollback of [public health] standards”. The Government’s “intention to secure the highest possible engagement on matters of wider public health” will, he set out, be a “cornerstone” of the Brexit negotiations, and the UK’s leadership role in public health will continue to be a “beacon” to the EU.

Yet this ministerial reassurance stops one step short of a simple, necessary, and, as Baroness Jolly asserted, “Brexit-neutral”, commitment to put on the face of the Bill the “high level of human health protection” that would guarantee its practical effect – to protect against a gradual erosion of our vital public health legislation, policy and practice. As former Coalition health minister Baroness Northover observed, if it is the Government’s intention to not roll back on public health standards, then it should “enshrine that in the Bill”.

In calling on Lord Warner to withdraw the ‘do no harm’ amendment, the Minister reasoned that such a commitment is unnecessary, since it is already Government policy, simply replicating the Secretary of State’s existing duty to protect the public’s health. In fact, the amendment is broader than this duty in a number of important ways supportive of the Government’s intention. And, at committee stage, a large number of cross-party peers united to outline how.

Lead Peer Lord Warner outlined that the duty to ‘do no harm’ is placed on the whole of government, including a wide range of public authorities – a very important distinction that is far broader than the Secretary of State’s existing duty. It further covers, as Baroness Jolly set out, the whole of the UK, “irrespective of whether legislation is made or adopted in Westminster, Belfast, Cardiff or Edinburgh”. It reminds a wide range of interests that they must continue to protect and ‘do no harm’ to public health.

The public need, peers stressed, an “effective legislative provision to challenge in court the Government, devolved administrations and public bodies when they fall down on the job of protecting public health”. Landmark cases, such as the failed challenge by the tobacco industry to the Standardised Packaging of Tobacco Products Regulations 2015 show that the amendment, which is based on the high level of protection under Article 168 the Treaty of Lisbon, is such an effective legislative provision.

In that example, Article 168 was used to interpret EU tobacco products law as well as the powers to implement it. Article 168, the High Court emphasised in its judgment, places the protection of public health “at the epicentre of policy making”. In this way UK courts would be under no misapprehension about what Parliament expects them to continue doing after Brexit.

While the Minister offered assurance that the Government will be addressing existing protections for public health as part of the negotiations, Conservative Peer and Chair of the Committee on Climate Change, Lord Deben, cautioned that whether or not the UK upholds the highest standards of public health “will not be part of the negotiation at all”. We cannot, he made clear, have a system whereby law is “affected by the whims—or sensible policies—of Ministers”.

The EU (Withdrawal) Bill, Baroness Jolly made clear, “is where our constitutional stability and certainty will be secured within the UK legal system”, and is where the amendment should sit. It would not be sufficient, as Lord Hunt asserted, for the duty to be placed within a “theoretical health and social care Bill which may be introduced” at some future point. Peers further agreed that health, alongside the security of the nation and our economy, are surely the most important duties of any Government.

The duty would also be supportive of the Department of Health and Social Care in ensuring that the public’s health is a key part of the Brexit negotiations. Baroness Jolly noted regret among Peers that the Secretary of State for Health and Social Care “is not a member of the Cabinet committee for EU exit and trade”.

An issue of particular concern, the negotiation of future free trade agreements, was raised by Peers. While the Minister offered reassurance that our “values and principles [will not be] traded away”, Lord Brooke focused attention on the 760 treaties with 168 countries that the Government will need to negotiate – many of which will affect the public’s health and our national health service. Baroness Northover warned that public health standards “could be out of the window” should the UK decide to lower them “in an effort to increase competitiveness”.

Baroness Finlay noted the unprecedented and co-ordinated effort by transatlantic think tanks to secure the “ideal” trade arrangements “which would involve the UK diluting, for example, its existing standards on food safety”. The precautionary principle, she said, may be under serious risk. In turn, Lord Warner asserted that the duty to ‘do no harm’ has already been used in the High Court to determine the standard according to which freedom to trade versus public health is balanced.

Ultimately, while a ministerial reassurance is welcome, the Minister cannot offer reassurances that we have nothing to worry about while at the same time making clear that future Governments might decide on a different path, one perhaps that didn’t put the health of the people of this nation at its heart.

This amendment does not seek to preserve EU law and regulation. It simply ensures we have some legal precedent and interpretative guidance on which to draw when protecting the public’s health in the future. British courts, on the basis of our doctrines of parliamentary sovereignty, will decide the future interpretation of the law. This, as Baroness Jolly put it, “should give remainers a rosy glow [while] Brexiteers will be grateful that the amendment puts a marker down: British law for British people.”

In closing her speech, Baroness Neuberger – former CEO of the King’s Fund and Fellow of FPH – said that she could not “remember the public health community coming so strongly together on anything since tobacco packaging”. As we approach the report stage of the Bill in mid-April (when peers get a chance to vote on amendments), we need your support more than ever and ask again for your help. There are a number of ways in which you can get involved:

1. Tweeting your support for the amendment using #DoNoHarm and following @FPH
2. Talking to your professional networks about the amendment and encouraging their support
3. Speaking about the amendment at any conferences or events you’re attending
4. Talking to Parliamentarians you are in contact with and, if possible, introducing them to FPH
5. Sharing intelligence on grant funding opportunities enabling us to do bigger and better things.

Natalie Lovell, one of the authors of What makes us healthy? An introduction to the social determinants of health, writes about distilling such a big topic into a quick guide

SOME people might think it’s a bit ambitious to attempt to produce a ‘quick guide’ to the social determinants of health – the social cultural, political, economic, commercial and environmental factors that shape the conditions in which people are born, grow, live, work and age. But, despite the vastness of the topic, we decided to give it a go.

The social determinants of health: what are the key messages?
Firstly, we should care about good health because it’s essential if individuals, society and the economy are to thrive. I recently read that “all members of a community are affected by the poor health status of its least healthy members”. Whether your cause is social justice or economic development, or you’re interested in social cohesion, good health is a relevant piece of the puzzle.

Secondly, health is about more than healthcare. When people are asked about health, their thought process often leads them straight to illness, medicine, and treatment of disease. But many of the drivers of health sit outside health and social care. As Michael Marmot puts it, “Why treat people and then send them back to the conditions that made them sick?”

Thirdly, as individuals, we have less control than we think. The factors that make us healthy sit largely outside individual control, and it is the conditions in which we find ourselves living that make us healthy or unhealthy – consider the greater density of fast food outlets in deprived areas in England. This is echoed in a recent report by Guy’s & St Thomas’ Charity about inner city childhood obesity, which found “it is in these areas in particular where people are bombarded with opportunities to eat high energy food and have less defence against ‘obesogenic’ city environments that promote unhealthy choices”.

Finally, collectively, we need to create the surroundings that give people the opportunity to be healthy. As set out in our quick guide, the evidence shows that many people and sectors have the levers to improve people’s health and reduce health inequalities (the differences in health outcomes that exist between groups in society). These include people sitting across government, the voluntary sector, the private sector, media, advertising and local communities. But if we don’t understand and act on this knowledge, we will never overcome our biggest health challenges.

What is already happening?
Many people can make a difference. It could be a charity that helps a group of people feel less lonely, an employer who decides to become a Living Wage employer, or a councillor who puts cyclists and pedestrians first when coming up with an action plan to tackle congestion. The list of those with the power to influence our daily lives for the better (often through structural changes), and therefore our health, is long.

We uncovered some great examples, particularly at local and regional level, of where, despite the odds stacked against them (such as severe budget cuts in local government), action is being taken that will improve people’s opportunities for healthy lives.

Read our quick guide, What makes us healthy? An introduction to the social determinants of health, to find out more about:

  • how local councils are using innovative inclusive economic growth techniques
  • how local councils are making the most of planning and transport policies to design and create healthy places
  • how charities and businesses can influence health
  • what approaches national governments are taking.

What’s the aspiration for this quick guide?
My hope is that this quick guide will make its way to those people across society who have the potential to influence people’s health, and that they might pick it up and think, “This is about me and the work I do.” Perhaps a public health expert will pass it on to a Director of Economic Development and Planning, who will pass it on to a business leader or employer they are working with, who might then be able to ask themselves important questions such as, “Did the last decision I make have an impact on people’s health?”

The quick guide sits within a broader programme of work at the Health Foundation. It offers a broad overview of the interconnectedness of virtually every aspect of people’s daily lives and their health – and therefore, the dizzying potential that exists for people across society to take action.

Order a free copy of the quick guide now. It will fit right into your pocket.

Oh, and the answer as to how you eat an elephant? Piece by piece.

Natalie Lovell is a Policy Analyst for the Health Foundation




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Tobacco control letter PM Abbasi 3+

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By Neil Squires, the elected International Registrar on FPH’s Board and member of FPH’s Brexit Advisory Board

Neil Squires web cropI am very pleased to have been re-elected for a second term as International Registrar. The past 3 years have helped to demonstrate the real potential of FPH members to contribute to public health development in other countries and opportunities for members to engage globally are now beginning to increase. Over the last couple of years we have delivered training in Odisha, India, which has provided public health leadership skill training to 300 senior personal in the Government of Odisha. That work sparked requests for similar support in other States and an invitation for FPH and PHE to support the development of India’s MPH curriculum – an important in-road in to developing the next generation of public health leaders in India.

Similarly, the Pakistan Special Interest Group (SIG) has been increasingly active, working alongside PHE, developing a mentorship programme for health leaders in Pakistan. Stronger links have been made with both the National Institute of Health and with Academic Schools of Public Health, laying the foundation for future capacity building work. This programmes of work were commissioned using Overseas Development Aid (ODA) funding, and respond to needs identified by host countries. In addition, the Africa SIG has made strong connections with the Public Health Foundation of Africa, meeting public health leaders from across Africa in Nigeria, and has developed a network of health professionals who will be the cornerstone of future efforts to build on African Public Health Assets to strengthen Regional capability.

In addition to work with resource poor countries, there are an increasing number of requests to FPH from wealthier countries wishing to build stronger public health systems and adopt competency based training. A recent funded mission to Kuwait has created opportunities for potential future collaboration, where we hope to draw on a number of FPH members who have expressed interest in supporting training and public health capacity development. These funded opportunities both allow FPH to support our partners to develop their public health capacity and also generated the necessary income to enable FPH members to work internationally, helping to cross-subsidise work in the poorest countries.

At a time when it seems even more important that the UK remains actively committed and engaged internationally, the work of the Global Health Committee provides a real opportunity to productively engage in support of our colleagues in other countries as we collectively strive to achieve the Sustainable Development Goals (SDGs). In June FPH will organise a global session for the Association of Schools of Public Health in the European Region (ASPHER), where we hope to promote a coming together of a number of international networks committed to strengthening public health training and capacity globally, linking this to support of stronger national public health agency development. There is a significant opportunity and appetite for the international public health community to come together to tackle common concerns linked to poverty reduction, inequality, to global threats such as climate change, and to tackle global challenges such as violence.

Collaboration with other Royal Colleges remains an important objective, and strengthening relationships across the UK health system in support of global public health a priority. We are actively seeking committed members to join one of a number of causes that have global dimension, where there is a real opportunity to shape the future work and growing global profile of the Faculty of Public Health. These are opportunities we encourage all interested members to engage in, with a growing international membership to serve and an expansion in our practitioner members, who can help us champion multi-disciplinary public health globally.

To find out more about FPH Special Interest Groups specialising in global public health, click here.

By Stevie Benton, Communications Manager at ASH (Action on Smoking and Health)

As smoking prevalence continues to fall, NHS and public health organisations are taking things to the next level with the NHS Smokefree Pledge. 

Co-ordinated by the Smokefree Action Coalition, the NHS Smokefree Pledge is a commitment to help smokers in their care to quit for good and to create smoke-free environments that support them to do so. By signing the Pledge, organisations agree that they will take a number of actions to reduce smoking prevalence and help smokers quit. The commitments in the pledge include:

  • Treat tobacco dependency among patients and staff who smoke, as set out in the Tobacco Control Plan for England
  • Ensure that smokers within the NHS have access to the medication they need to quit in line with NICE guidance in secondary care
  • Create environments that support quitting through implementing smoke-free policies as recommended by NICE

Smoking remains the single greatest cause of premature death and disease in our communities. Around 79,000 people die because of smoking in England every year and for every death, another 20 smokers suffer from smoking-related diseases. Smoking imposes a huge burden on the NHS. Stopping smoking is the single most effective action a smoker can take to improve their health.

Signing the pledge is simple and a visible commitment to a smoke-free NHS. This No Smoking Day, if you’re a director of public health, why not take that crucial first step and encourage your Trust to sign up?