By Dr Nadeem Hasan
The importance of effective advocacy to achieving public health goals cannot be overstated.
Every day policies and regulations that affect health outcomes for better or worse are put on the agenda and kept off the agenda; discussed and debated; approved and rejected.
Many, if not most of these relate primarily to non-health sectors, such as food and beverages, energy and infrastructure, and alcohol and tobacco. But their impact on health outcomes is very real: all the stop-smoking programmes in the world can’t match the impact of the ban on advertising and smoking in public places on smoking prevalence; and there’s no amount of spending on childhood obesity programmes that can make up for the regulatory vacuum in this area.
Looking more broadly, policy decisions that affect income inequality, carbon emissions, and military action all have serious consequences for health across the world.
If we’re serious about prevention, we need to be serious about advocacy.
Where profits can be affected (almost everywhere), industry lobbyists seek to influence the regulatory environment in their favour. And they are very good at it. In principle, this is quite right – those affected by policy and regulatory shifts should indeed be able to make representations and provide additional evidence to support the decision-making process – and this includes relevant industry actors.
Representing the interests of everybody else is where advocacy organisations come in – acting as sort of ‘civil society lobbyists’ to balance out the discussion – advocating on behalf of the health, wellbeing, and broader concerns of the general population. Notably, this isn’t always an ‘us vs. them’ relationship: health insurance companies are routinely allies on advocating for lower drug prices; and renewable energy companies are more than happy to work with advocacy organisations on climate change regulation.
Put this way, it might sound like a fair playing field, with decision-makers receiving submissions from a range of groups and making balanced decisions to maximise the benefits to all parties. The reality of course is quite different, and much, much messier.
In 2014, there were an estimated 30,000 industry lobbyists in Brussels alone, falling just short of the 31,000 employees for the whole European Commission.
Civil society pockets are not deep enough to come close to matching this (or the salaries of lobbyists), and civil society advocacy and pressure groups are few and far between. Transparency falls short of the ideal, and the revolving door between policy-making and industry remains alive and well. Most recently the former President of the European Commission José Manuel Barroso was appointed Chairman of Goldman Sachs International, a move that has been widely criticised.
Advocacy organisations, then, have a difficult task – but one where even small successes can have far-reaching benefits for public health.
The European Public Health Alliance (EPHA), based in Brussels, is one such advocacy organisation. They bring together a range of health-related NGOs to advocate for better public health in Europe, working across five campaign areas: antimicrobial resistance; food, drink and agriculture; healthy economic policy; universal access and affordable medicines; and trade for health (and specifically the EU-US free trade agreement – TTIP – and the EU-Canada free trade agreement – CETA). Earlier this year, they hosted myself and another registrar in a pilot placement to understand health advocacy at the European level and to develop skills in this area.
So how to sum up the placement?
Invaluable. EPHA track the policy process for each one of their campaign areas and engage at every possible point. They attend every meeting at the European Parliament and the European Commission on these areas and make oral contributions at every opportunity; they submit comprehensive written responses to every relevant consultation; they engage on a daily basis with journalists to publicise their positions and build public support; they engage like-minded actors in the public, private, and not-for-profit sectors on a case-by-case basis to coordinate action; and they do all of this with just a handful of relatively young staff and interns.
They were very welcoming in bringing us into the whole process, allowing me to engage in every one of these steps – from writing position papers and consultation responses to making oral contributions at the European Commission and Parliament on their behalf.
Notably, EPHA also position themselves as an advocacy agency that actors from across the spectrum can engage with – in contrast to, for example, much more vocal organisations such as Greenpeace.
By way of example, the area that I was working on was TTIP. Whilst there are a raft of advocacy organisations across Europe (and the USA) that reject TTIP outright, EPHA’s
approach is to work through the whole agreement and advocate for the protection of public health on a section-by-section basis without rejecting the whole deal. With the European Commission politically committed to getting a deal, this makes EPHA one of the few organisations they can meaningfully engage with on this issue (though recent developments have called into question the likelihood of getting a deal in the near future).
This isn’t to say that their approach is ‘superior’ – every actor plays a particular role, with the more intransigent organisations key in shifting public opinion and providing the space for actors such as EPHA to engage in more balanced discussions. This means that they are invited to closed-door sessions with only a handful of actors, and have much more influence on the process than they otherwise would.
One of the challenges from a ‘public health professional’ perspective was that effective advocacy sometimes involves taking – shall we say – a less balanced view than we would normally as technical experts. From an ethical perspective, this raises a number of questions around whether the ends justify the means. I witnessed first-hand industry lobbyists making quite outrageous claims, including a rather undignified moment where I coughed up half my glass of water in a large auditorium at the European Commission when it was submitted that ‘alcohol is in no way an unhealthy commodity’ .
In a world where climate change denial is alive and well despite the most overwhelming evidence to the contrary, the ‘best’ approach to making our points is perhaps not so easy to discern.
And what of the relevance to the UK, particularly as we now start closing our doors to the EU in a bid to be a more open, global-facing country?
Whether or not the UK is a member, the EU remains a powerful actor that can influence policies related to public health both for its own citizens (which will still number ~450m after the UK leaves), and globally. As a close neighbour, EU regulations will have a strong bearing on public health in the UK too, and so engaging in advocacy at this level will continue to be an effective approach to improving UK public health.
This is true for everything from environmental regulations and air pollution, to pharmaceutical regulations and drug pricing and safety.
Within the UK, whilst it’s true that our policy-making process is not as amenable to advocacy as at the EU level (or remotely as civilised), effective advocacy still has huge potential to improve public health. We have not done well recently, with a watered-down childhood obesity strategy, no resistance to an unfunded ‘7-day’ NHS (that differs from the 7-day NHS that has existed since 1948 in some undefined way), and year-on-year increases in the use of food banks without any policy response (to name just three areas).
At the local level, there are a cornucopia of opportunities for advocacy to improve health, from influencing urban planning (fast food outlets close to schools, street design, cycling lanes) to advocacy around shifting public perceptions e.g. from opposing to welcoming refugees into local communities.
In this context, strengthening the advocacy skills of the UK public health workforce through engaging with and learning from experienced actors such as EPHA should be pursued with vigour – we can ill afford the alternative.
Dr Nadeem Hasan is a Specialty Registrar in Public Health