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By Prof John Middleton, FPH President

John Middleton 2 web

August was a stock-take month for me. I held several meetings which all pointed to the need for public health and the woeful neglect of public health expertise by local, national and international policy makers.

Early in August we held a productive session of the Global Violence Prevention Special Interest Group which resolved to look at training tools for work in conflict and post-conflict areas – how to make rapid needs assessments, how we build alliances with public health resources in conflict areas and how we make sense of prevention and resolution of conflict through working with political scientists, theologians, international lawyers and aid non-governmental organisations. The work is being led by Daniel Flecknoe and Bayad Nozad. We plan to join up this work with that of Brian McCloskey and David Heymann for Chatham House (Royal Institute of International Affairs) looking at emergency responses in conflict zones. Mark Bellis’s work for the Commonwealth will also play a key part. The FPH statement says our unique role is in preventing violence and building and implementing the evidence base – locally, nationally and internationally. Economic inequality and unequal power-sharing are major causes of violence at local, regional and international level, and major challenges for the public health community, whether in relation to violence, childhood obesity or premature mortality. It is clear to me that FPH can play a greater role in violence prevention by harnessing the disparate skills of our members, from the frontline to high-level international policy – in emergency preparedness, health protection and health services organisation and in public mental health and community development.

In August I also met with David Ross from the armed forces public health services. They clearly have much expertise to contribute – in relation to international conflicts and closer to home. We have resolved to have a meeting with forces colleagues in the new year. The root causes of violent behaviour are also often the root causes of accidental violent injury. This was never more demonstrated than with the Grenfell Tower disaster. I am pleased that we could respond to the terms of reference consultation for the inquiry. Sadly our representations were not heeded and a limited range has been set for the inquiry with a junior minister leading consultation on the implications for social housing and some superficial examination of the causes of the causes. Nevertheless, I am extremely grateful to the FPH members who responded rapidly to our request for help on the Grenfell submission and particularly to Ruth Gelletlie who put together our response on the terms of reference. We received a wealth of material on every aspect from health protection and response, public mental health responses, health inequalities and the London housing market, building design, regulation and controls and social issues regarding migration and homelessness. Ruth and colleagues in the revitalised Housing and Health Special Interest Group will be drawing on this material for our formal submission to the inquiry (and for a listening minister…?)

A sustainability and transformation partnership has announced a £2.7million contract with the private sector for a year’s support for an accountable care organisation. It’s a mind-numbing figure and would buy an awful lot of public health health-care expertise and analysis. We will follow this programme carefully and see what it teaches… and in the meantime, continue our work to rebuild training and capacity in healthcare public health.

As we return from the summer holidays, FPH will once again get into full swing with major policy-planning days. Our workforce strategy is nearing completion and will be formally signed off in November. We are much exercised by the need to build our membership and would urge you to invite all your colleagues to join us – we have a category for virtually everyone working in public health or associated with our work. I will also be involved in the Academy of Medical Royal Colleges planning days. Our policy team priorities on Brexit and public health funding are taking shape. I will be at the Public Health England conference in Warwick at which we will launch the Public Health Prevention Concordat for good mental health. I will also be speaking at MEDACT’s conference in York with the International Physicians for the Prevention of Nuclear War on the theme of the progressive-health movement. I will also be speaking at the Oxford public health registrars symposium on the theme of partnership in public health. I believe there are still places available at all of these meetings.

As the US President flexes his nuclear options, and our government stumbles over complex imponderables of Brexit, it is clear to me we absolutely need a progressive health movement which addresses inequalities in income, in opportunity, in education and environment, which understands and builds new programmes for public mental health and conflict resolution, which stands strongly for non-violent resolution of problems, which looks at the health impacts of all policies and across future generations, and which believes in partnership, in shared benefits and better outcomes for all.

Can I draw your attention to an exciting event coming up which provides a unique opportunity to share learnings about advocacy. Mike Daube, Professor of Health Policy at Curtin University, Perth, Australia, will be delivering the DARE Lecture entitled ‘Not a Spectator Sport: public health advocacy and the commercial determinants of health’ on 27 September in London.

By Dr Jennifer Mindell, Reader in Public Health, Research Department of Epidemiology and Public Health, University College London

Today nearly a third of children aged two to 15 are overweight or obese (1, 2), and younger generations are becoming obese at earlier ages and staying obese for longer. Given the evidence that children and adults’ diet is influenced by advertising, summarised by Adams and colleagues (3), the World Health Organization (WHO) made 12 recommendations in 2010 about marketing food and non-alcoholic drinks to children (4).

However, industry spends 500 times as much on promoting high fat, salt or sugar (HFSS) foods as the WHO spends on promoting healthy diets. For example, food companies in the UK spend one billion pounds on marketing. Not surprisingly to a public health audience, there are marked differences in proportions between constituents of a healthy diet and food advertising (Figure). The ways that marketing can influence behaviour, as well as some examples, were available in the presentation given at the FPH 2017 annual conference session organised by the FPH Health Improvement Committee.

Disproportionate food advertising
Adapted from: www.foodcomm.org.uk/pdfs/Broadcasting_bad_health.pdf

In the UK, legal restrictions on television advertising of HFSS foods to children under 16 focused on preventing screening of such advertisements on children’s channels, and around or during programmes on general channels of particular appeal to children aged 4-15 years. As the Health Improvement Committee had predicted, this had no effect on children’s exposure overall (despite adherence to the restrictions) because of increased HFSS advertising around programmes aimed at a general audience, not covered by these regulations, screened before 9pm (4): larger numbers of children watch these general programmes than watch ‘children’s TV’. Similar restrictions were introduced on 1 July 2017 on advertising HFSS foods to children under 16 via non-broadcast media, including on children’s media and on media where children form more than 25% of the audience. However, the exclusions are many (see examples).

Discussions by about 25 people at the FPH conference session produced the following policy suggestions:
A. Gold standard: Ban advertising of all HFSS products (regardless of to whom, when, where).
B. Banning marketing aimed at or influencing children is a good place to start, if (A) isn’t (yet) politically acceptable. This should be a part safeguarding children.
C. We need to keep reiterating our point that the proportion of the audience who are children is irrelevant:

  • Far more children may watch a generally popular show (eg. X Factor) than children’s TV or TV programmes where children are 25%+ of the audience, so restrictions need to apply based on the number of children exposed as well as the percentage.
  • Advertising aimed overtly at adults also influences children through what adults buy for them, what adults do, and what adults see as the norm.

D. Online material is now more important than TV; even TV is mostly watched on-demand, so the timing of programmes is now largely irrelevant: Should we ignore the watershed?
E. Ban anything aimed at children or young people, eg. toys, cartoon characters, celebrities, that can increase desirability of the associated HFSS products or influence behaviour adversely. The Olympics should not be associated with MacDonalds, Coca Cola, etc.
F. Ban HFSS product displays and marketing at point of sale (PoS) eg. supermarket checkouts, newsagents.
G. Ban displays of HFSS products at children’s height (put on top shelves only?)
H. Ban HFSS displays or marketing posters in shop windows (seen by children as they pass).
I. Ban marketing that displays people eating except when sitting at a table for a meal The benefit of the Mediterranean diet may be partly because of eating slowly at a family meal while talking, etc, instead of eating ‘on the go’, as well as the actual diet itself.
J. Harness the opportunity of controlled environments to change the accepted norms (eg. rules for schools, workplaces, hospitals, prisons).
K. Recognise the time it takes to change social norms and to make regulation socially acceptable; balance this with the size of impact of HFSS products on health and health inequalities.
L. Need for a clear iteration of the harms of HFSS with agreement amongst influential public health bodies, to start influencing the debate.

Other ideas suggested were to ban price-based promotions of HFSS, given that fruit is often more expensive to buy than crisps or chocolate bars. Chile introduced health warnings and standardised packages for HFSS last year; we need to monitor what effects these have. Brexit may yield an opportunity to influence front-of-packaging labelling, for example by portion size rather than per 100g, if EU rules no longer apply. Given most children’s incessant exposure to marketing, schools should be encouraged to teach advertising literacy.

The main conclusions by those attending as that this is a societal responsibility, rather than individuals or their parents being to blame. Population-level initiatives are needed to control commercial activities that are costly to the country both in terms of poor health and regarding healthcare, social care, and economic costs of ill health.

References:

1. Fuller E, Mindell J, Prior G (Eds). Health Survey for England trend tables 2015. Leeds: NHS Digital, 2016.
2. Childhood obesity: a plan for action. London, 2017. https://www.gov.uk/government/publications/childhood-obesity-a-plan-for-action/childhood-obesity-a-plan-for-action
3. Adams J, Tyrrell R, Adamson AJ, White M. Effects of restrictions on television food advertising to children on exposure to advertisements for ‘less healthy’ foods: repeat cross-sectional study. Plos One. 2012;7(2):e31578.
4. World Health Organization. Set of recommendations on the foods and non-alcoholic beverages to children. Geneva: WHO, 2010.

By Claire Beynon MFPH

BACP Travelling Fellowship
Every two years the Faculty of Public Health (FPH) awards a BACP travelling fellowship to assist members of FPH in training to undertake educational travel. This fund was established in 1994, using funds donated by the British Association of Community Physicians (BACP) on its dissolution.

At the FPH Conference in Telford in June I was delighted to receive the travelling fellowship funding based on my application to travel to Japan to experience its culture and make observations about why its levels of childhood obesity were so much lower than those in the UK, and to present my public health work at a conference in Japan.

Observations on Childhood Obesity in Japan
Before I left for Japan I read many articles that explored the differences between childhood obesity rates in the USA and Japan. Their focus was on lifestyle factors including diet and physical activity.

Whilst in Japan I met with several academics who specialised in obesity, physical activity and diet. They were all most welcoming and shared their research and experiences readily.

The key points they raised were:

  • Younger children spend less time in school. As age increases so does the length of the school day. This gives more free time for outdoor play.
  • 90% of children walk to school daily.
  • Children do three hours of physical activity each week in school time.
  • There are no cleaners in Japanese schools; part of a child’s everyday activities includes cleaning their own school – children are active when cleaning.
  • Schools often have before-school sports clubs as well as after-school sports clubs.
  • Between each lesson there is a five-minute break to allow children to run around in the play area. This is in addition to morning break, lunch and afternoon break.
  • There are multiple opportunities in school for competitive sports, with regular competitions and celebrations. Children spend time practising for these with friends.
  • Children have three hot meals a day at breakfast, lunch time and in the evening.
  • Children serve each other a cooked meal at lunch time and sit and eat this hot meal together.

Further Observations
Whilst travelling in Japan I observed a number of additional environmental factors that tip the balance in favour of walking and cycling:

  • Priority is given to the pedestrian, then cyclist, then the motor vehicle. Encouraging walking and cycling. By giving priority to more vulnerable road users speed of motor vehicles is also decreased.
  • Cyclists and pedestrians share the pavement area, which is often separated from the road with a barrier and/or low-level bushes. This makes for a safer cycling experience than the UK where cycle lanes are often shared with buses.
  • There were a number of covered shopping areas, which were accessible only to cyclists and pedestrians and proved very popular thoroughfares.

    Shopping area in Japan

    Covered shopping area where pedestrians and cyclists share space

  • There was consistent and regular signage for cyclists and pedestrians, including details of directions and distances to the nearest public transport options.
Example of road, cycling and walking space in Tokyo

Example of road, cycling and walking space in Tokyo

• The number of employed people working on any urban street was much higher than the UK, with police highly visible, construction staff, cleaners, car park attendants and others all adding to the sense that the street was a safe place.

 

Policeman on the street in Japan

Presence on streets of local police make a space feel safe

• Public art installations make walking and cycling spaces more interesting and appealing.

Street art in Japan

Example of simple art installation

We know from the 2007 Foresight Report that obesity is a complex issue with multiple factors influencing obesity levels in adults and children. My own research looking at the risk factors for obesity in children in Wales using Welsh Health Survey data showed a reduced risk of obesity for children who met the one-hour physical activity guideline.

 

The new experiences and culture that I have experienced from this educational trip make me more determined than ever to tackle childhood obesity in Wales. I am looking forward to being involved in the drafting of an obesity strategy for Wales as part of my placement with the Welsh Government and will share my experiences with other registrars and colleagues at every opportunity.

By Dr Frank Atherton, Chief Medical Officer, Wales

(This article is based on a presentation to the Faculty of Public Health Conference in Telford on 20 June 2017 – view slides from the presentation)

Public health should be proud of the fact that we are an evidence-based profession. We have brought both the ethos and the tools of evidence-based clinical practice to the NHS and the wider public sector. However, we should not lose sight of the fact that public health is both a science and an art; this requires us to bring judgment to bear alongside evidence.

There are plenty of reasons that can be deployed in order not to use evidence. Sometimes issues can be seen as “blindingly obvious”; I recently saw a video of Brian Cox using the fact that we can actually see cosmic background radiation to energetically (and using colourful language) rebut a claim that the Big Bang is just a theory and may not have happened: “YOU CAN JUST ****** SEE IT.” As a newly qualified doctor on my first surgical firm, I worked with the team that had led the development of highly selective vagotomy as a curative treatment for peptic ulcer. In addition to the small operative mortality, many of the patients were left with long-term side effects such as malabsorption or diarrhoea. If I had dared to suggest that peptic ulcer might be a consequence of infection and amenable to curative treatment with antibiotics I would have been ridiculed, or worse. And yet this was subsequently found to be true and most patients are now successfully treated by H.pylori eradication rather than surgical intervention. The lessons I draw for my public health practice is that we should beware of our hidden prejudices and the influence of received wisdom; we should always be willing to challenge our assumptions. Other, less noble reasons for ignoring evidence include laziness, incompetence, pressure of work, and vested interests in outcomes; all issues that we should recognise and guard against as part of the ethical management of our own work.

Sometimes the evidence is rock solid but it is still not used to drive population health. The classic example must be smoking; we have known about the link between smoking and lung cancer since the work of Doll and Hill in the 1950s. But it took until 2007 for smoke-free public places to be enshrined in legislation across the UK. The 10-year anniversary of this achievement is an opportunity to recognise and celebrate its impact but also to raise the important question about where accountability lies for the thousands of avoidable deaths that have resulted from the decades-long delay in effective action. The answer seems to be “nowhere”. It seems to me that there is a failure in public sector governance if there is no accountability for inaction in the face of convincing evidence. The horrific events at Grenfell Tower perhaps serve as a more recent example.

And, of course, the evidence base is never complete, and we are often faced with contradictory evidence that steers us towards different courses of action. The recent debate about regulation of electronic cigarettes is a useful example. Evidence of the benefits as a smoking cessation aid have to be balanced by currently unquantifiable risks including the direct and indirect effects of vaping, and the potential for a new generation of young people to become addicted to nicotine. When faced with these sorts of uncertainty we have several options. We can commission further research, but that takes time. We can use a trial and error approach, but that brings risk (think of the death and illness last year of fit young volunteers in pharmaceutical trials in France). We can use a risk management and mitigation approach – something we all do unthinkingly in our daily lives when we buckle our seatbelts. And we can use a precautionary approach but, if used inappropriately, this might stifle innovation and change that could have a positive impact on population health.

Our approach in Wales has been to follow the thread of evidence-based public health action, from our research and development commitments (£43m per year), through the programme of action for our government, the legislative framework of the Wellbeing of Future Generations Act which requires public bodies to plan and report on population health outcomes, then through to our recently passed Public Health Act which has incorporated health impact assessment into our policy and planning. In Wales, we believe that evidence matters, but judgment and compassion also need to factor into our decision-making.

By Dr Jennifer Mindell, Reader in Public Health, Research Department of Epidemiology and Public Health, University College London

The government is proposing to ban the sale of diesel and petrol vehicles from 2040, to address air pollution in the UK that regularly breaches health-based EU regulations.

There are three main ways to improve UK air quality: reducing emissions from vehicles; driving less; and dealing with other sources of air pollution. The government’s preferred approach seems to be ‘business as usual, but less pollution from existing travel patterns’. Yet, even with this route, they are not committing to a scrappage scheme for diesel. This would produce air-quality benefits in the short-term, instead of in the 2040s – or even the 2050s and 2060s, as some individuals and businesses keep their vehicles for a long time. A scrappage scheme needs to be available to all individuals and businesses, regardless of size, and needs to encompass vehicles of all ages. Although older vehicles are known to be very polluting, no-one really knows about new vehicles! This could be complemented by financial help for retrofitting, particularly for older buses and lorries, if replacement isn’t an option.

Drivers of diesel cars are understandably aggrieved. They were urged to buy diesel engines by previous governments and given financial incentives to do so, because of the lower CO2 emissions per km. The higher emissions of other pollutants were ignored. Those with newer vehicles have no idea what their car really emits, due to the scandalous behaviour of manufacturers. This is yet another parallel with the tobacco industry (1) which designed cigarettes to produce low tar and nicotine in the laboratory but not when used by actual smokers.

Chargeable clean-air zones (low or ultra-low emission zones) are, according to a technical report issued by the government earlier this year, the most effective mechanism, but we understand that the government’s strategy will restrict charging to the last, not the first, resort. This is one of the areas, along with improved infrastructure for transport options other than private car use, that local authorities can contribute to greatly, but they need adequate powers and adequate resources. As air pollution costs the country £20 billion annually (2), the proposed figure of £255million to local authorities is a drop in the ocean.

The government is apparently also going to urge local authorities to speed traffic flows, by amending traffic-light settings and removing speed humps. What is actually needed is more calming, not less, to support smoother driving. It is not speed humps but the marked acceleration and braking that many drivers do that increases pollution. Greater use and enforcement of, and adherence to, area-wide 20mph limits without traffic calming would be better still.

Lower speeds, which would also support more and more pleasant walking and cycling, bring me to the better approach. Instead of persuading (in the next two decades) or requiring (from 2040) people to replace their existing car with an electric car, the health gains would be far greater if people travelled by public transport, walked or cycled whenever possible. As well as reducing pollution and carbon emissions, this generally increases physical activity and can improve wellbeing and reduce obesity and its consequences.

Reductions in pollutant emissions can also be achieved by reducing the need to travel. If people who could do so worked at home once a week, that would reduce their commuting by 20%. Land-use planning that encourages mixed use can shorten journeys sufficiently to make non-car options more feasible, although this will take longer. But as the government proposal for banning sales of diesel and petrol cars is to start in 2040, they are talking longer term anyway.

The government also needs to acknowledge that, although mobile sources are the largest category of pollutants, they are not the only ones. Two major contributors are buildings, including both homes and businesses, and transboundary industrial pollution from mainland Europe. Ministerial engagement with European countries will be necessary to deal with the latter. Local authorities need to be given the powers to address the former.
Air pollution is a major contributor to health inequalities. Poorer people are more likely to be exposed to higher pollutant levels. They are also more susceptible to the harmful effects of pollutants as they are more likely to have circulatory diseases (particularly heart disease and strokes) and respiratory diseases, such as chronic bronchitis or emphysema (now called chronic obstructive pulmonary disease) or asthma. Improving air quality is an important factor in reducing health inequalities.

The other option that we trust the government won’t take is to move the goal posts when (or if?) the UK is no longer bound by EU legislation. That would really be a cynical approach to the population’s health.

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1. Mindell J. Lessons from tobacco control for advocates of healthy transport. J Public Health Med. 2001; 23:91-7.

2. Royal College of Physicians, Royal College of Paediatrics and Child Health. Every breath we take: the lifelong impact of air pollution. London: RCP, 2016.

By Andy Beckingham FFPH, Fernandez Hospital, Hyderabad

Giggling Girls!

The scope of our profession gives opportunities to branch out. These may not always look at first glance like ‘public health’.

In 2010, working in India on maternal mortality, someone asked over dinner if I thought UK-style midwifery might be useful in India where doctors provided all the care. “Perhaps if you try the bits that work for women,” I said. “And avoid the bits that the NHS got so wrong.” My dinner companion turned out to be the MD of India’s most famous maternity hospital, and I found myself designing her midwifery pilot programme.

The midwife who had run the UK’s most woman-friendly midwifery service (the Albany Practice, which achieved great outcomes for disadvantaged women) was inveigled into joining us as a mentor. Eight anxious trainees found themselves becoming India’s first evidence-based woman-centred midwives (pictured). They began to develop their own profession, promoting choice about labour and supporting and empowering women to have more natural births. They had to challenge established obstetric practice. Our hospital’s maternity care began to change. Babies had been routinely separated from the mother at birth, although this impedes attachment and breastfeeding. The midwives worked with paediatricians to change that. Now most mothers have immediate contact and breastfeed their babies in the first hour.

Now leaders in their own right, those first eight have since mentored other trainees to become strong professional midwives, supporting thousands of Indian women to have better births.

Like most countries, India has unnecessarily high rates of intervention in childbirth. A local public hospital’s c-section rate is 52%. A local private hospital’s is 90%. But thanks to the midwives, ours has come right down. Instead of epidurals being routine, midwives ask women what pain relief they want. They offer choice. Women get continuity of care. The outcomes are better. Satisfaction rates are high.

In 2017, the state government invited us to train midwives to work in their hospitals too. They want c-section rates to come down. But they also want compassionate, respectful maternity care for the large numbers of women who are mostly ‘below poverty line’. So maybe, just maybe, this could become a model for wider public maternal-health improvement in lower-income countries. I have to assess its impact.

Designing a midwifery programme and curriculum doesn’t at first look like a public health role. But it is starting to address unmet needs, inequalities and disadvantage, improve care quality and effectiveness, show that Indian women and their choices matter. Of course, it will need to be part of wider action on social and economic determinants of maternal health.

And now, this alternative to the medical model is available, and the state government is actively promoting compassionate, effective midwifery care and supporting us to roll out professional midwifery more widely, among very disadvantaged women.

Public health, in disguise.

By Dr Justin Varney, National Lead for Adult Health and Wellbeing, Public Health England

Public Health England estimates that between 2-5% of the population identify as lesbian, gay, bisexual or other – comparable to many ethnic minority and faith populations. Despite legislative reform many LGBT people continue to experience discrimination, marginalisation and harassment.

  • 38 per cent of trans people have experienced physical intimidation and threats and 81 per cent have experienced silent harassment (e.g. being stared at/whispered about)
  • One in five (19 per cent) lesbian, gay and bi employees have experienced verbal bullying from colleagues, customers or service users because of their sexual orientation in the last five years
  • Almost 1 in 4 trans people are made to use an inappropriate toilet in the workplace, or none at all, in the early stages of transition. At work over 10% of trans people experienced being verbally abused and 6% were physically assaulted.

The impact of this discrimination on mental health is easy to understand, however the stark data on suicide and self-harm demonstrates the depth of the impact that this discrimination can have:

  • 52% of young LGBT people reported self-harm either recently or in the past compared to 25% of heterosexual non-trans young people and 44% of young LGBT people have considered suicide compared to 26% of heterosexual non-trans young people
  • Prescription for Change (2008) found that in the last year, 5% of lesbians and bisexual women say they have attempted to take their own life. This increases to 7% of bisexual women, 7% of black and minority ethnic women and 10% of lesbians and bisexual women with a disability
  • The Gay Men’s Health Survey (2013) found that in the last year, 3% of gay men have attempted to take their own life. This increases to 5% of black and minority ethnic men, 5% of bisexual men and 7% of gay and bisexual men with a disability. In the same period, 0.4% of all men attempted to take their own life
  • The Trans Mental Health Study (2012) found that 11% of trans people had thought about ending their lives at some point in the last year and 33% had attempted to take their life more than once in their lifetime, 3% attempting suicide more than 10 times.

The impacts aren’t limited to mental health, and the level of inequalities in lifestyle behaviours such as smoking and substance misuse will almost certainly play out in a great burden of chronic disease and premature mortality over the life course.

The evidence base of inequalities affecting LGBT populations continues to grow as we get better at incorporating sexual orientation and gender identity into the demographics of research and population surveys. Positively, as the NHS rolls out the sexual orientation monitoring information standard this year, this understanding will no doubt continue to grow.

As public health professionals we have a responsibility to advocate for the populations in our care, and this should include advocating for LGBT populations. Lesbian, gay, bisexual and trans communities are diverse, vibrant and varied and have many assets, although the LGBT community sector has faced fiscal challenges due to the economy there remain many small local LGBT organisations that are keen to work with public health teams to address these inequalities.  This is population who clearly need our professional expertise, advocacy and support to co-produce solutions for change and one where we could have a real impact.

So during this lesbian, gay, bisexual and trans Pride season please take up the opportunity to engage, empower and partner with your local LGBT community.

FPH is committed to improving the health and well-being of the LGBT population. If you would like to join us in our work please consider joining our Equality & Diversity Special Interest Group or our LGBT Health Special Interest Group. To express an interest in joining please email policy@fph.org.uk and we can help you get started!