Better Health For All

The Faculty of Public Health (FPH) prioritises tackling health inequalities and promoting anti-racism to address racial and ethnic health disparities. Anti-racism has been a focus for the FPH since 2020, following the murder of George Floyd and the renewed sense of injustice, combined with the racial disparities exposed by the COVID-19 pandemic.

As FPH President, I am committed to addressing the persistent racial and ethnic health disparities that plague our society. These disparities manifest in higher rates of chronic diseases, maternal mortality, and lower life expectancy among minority ethnic groups.

The roots of these disparities lie in systemic racism, a pervasive societal ill that has shaped our institutions, policies, and practices for centuries. Racism has created inequities in access to education, employment, housing, healthcare, and other essential resources, ultimately resulting in poorer health outcomes for minority ethnic populations.

FPH as an Anti-Racist Organisation

Anti-racism is the practice that recognises pervasive racism in society and actively combats racial prejudice and discrimination to promote racial justice and equality. It requires systemic change to dismantle the structures that perpetuate racial inequities and create an environment where everyone has an equal opportunity for good health.

FPH is committed to being a leader in anti-racism in public health. In line with our new Framework on Anti-Racism we will continue to raise awareness, develop new resources, promote anti-racism in our profession, and advocate for policies and practices that promote health equity.

We believe that together, we can create a world where everyone can live a healthy life, regardless of their race or ethnicity. In this blog, I highlight some of the recent work of the Faculty on anti-racism and what is next for the organisation and our members.

Visible Leadership

FPH has taken a leading role in championing anti-racism and addressing racial and ethnic health disparities, and have prioritised this as one of our eleven Board Led Focus Areas for action between 2022-2025. We have also declared racism a public health crisis, emphasising the need for a comprehensive public health approach. We will provide this leadership and advocacy wherever we can – internally, in our work supporting our members, in how we work with other organisations, and in our external communications.

Providing visible leadership within the public health family and across the Medical Royal Colleges is critical. FPH has raised awareness through publications, events, and advocacy efforts. We hosted the first FPH Distinguished Lecture with Professor Camara Jones, a leading expert on racial and ethnic health disparities. Professor Jones’s lecture provided a critical analysis of the issue and highlighted the importance of anti-racism in achieving health equity.

Policy and Programmes

This year, we have developed our new Framework on Anti-Racism to shape FPH policy and action on anti-racism. This ground-breaking document outlines a comprehensive framework for embedding anti-racism into public health practice, research, and education. It calls for a multifaceted approach that includes addressing unconscious bias, promoting diversity and inclusion, and advocating for structural change.

This work is critical to public health practice today and in the future. As public health professionals, we have a moral and ethical obligation to address the root causes of health inequities and promote health equity for all. By embracing anti-racism, we can transform our public health systems and create a healthier, more just world for all.

With the publication of the Framework, FPH is ensuring a comprehensive approach to our anti-racism work, ensuring robust governance and oversight for progress, defining appropriate metrics for monitoring and evaluation, and being transparent about our priorities for action.

Partnerships

Deepening and developing strategic partnerships at home and abroad on this important agenda is critical. As well as delivering our role as a convener, the Faculty brings a unique voice and perspective to an important and challenging area of public health practice.

Our participation in the O’Neill-Lancet Commission on Racism, Structural Discrimination and Global Health will identify and promote the implementation of anti-racist actions and strategies by states, civil society actors, and global health institutions, in order to reduce structural discrimination through targeted research and collaborations that will foster policy dialogue within and across sectors that impact health and wellbeing.

We will recognise and support the important work being done by public health partners across the UK on anti-racism. We are exploring opportunities to strengthen our collaborative work with the NHS Race and Health Observatory to amplify the emerging evidence, promote promising practice, and facilitate continuing professional development and education. The Faculty supports work from ADPH on racism as a public health issue, and the London Health and Care System’s work on anti-racism as part of the Mayor of London’s Health Inequalities Strategy.

These collaborations have strengthened our resolve to address racial and ethnic health disparities and have amplified our impact on a national and international scale.

Training and Capacity Building

FPH is committed to ensuring that the training and examination process for public health registrars is fair and equitable for all. We are working to identify and address any instances of structural discrimination that may be preventing minority ethnic candidates from achieving their full potential.

In our report with the UK Recruitment Executive Group of Health Education England and Imperial College London, we have made a number of recommendations to address structural discrimination in public health training. These recommendations include:

• Collecting and analysing data on the ethnicity of public health registrars at all stages of the training and examination process.
• Developing and implementing targeted interventions to support minority ethnic public health registrars.
• Reviewing the recruitment and selection process for public health training schemes to ensure that it is fair and equitable.
• Working with public health training providers to create a more inclusive and welcoming environment for all public health registrars.

We updated our progress with our actions in a recent FPH President’s blog and this remains a key area of our work to tackle wider structural discrimination.

Summary

Anti-racism is not just a moral imperative; it is also a critical component of effective public health practice.

We cannot achieve health equity without addressing the root causes of health disparities, and those root causes are deeply intertwined with racism. FPH’s work on anti-racism is centred around creating a more just and equitable future for all. By dismantling the structures of racism, we can create a society where everyone has the opportunity to achieve their full potential and live a healthy life.

Professor Kevin Fenton CBE FFPH
FPH President

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The crisis of overcrowding in our prisons has led to some drastic and potentially unsafe changes to sentencing practices. So far there has been less attention to preventing people being in prison when they shouldn’t be there. There is extreme unfairness, injustice, and indeed cruelty in our system of punishment, with prisons full of inadequate, vulnerable, mentally ill and addicted people, largely from poorer social backgrounds. These incarcerations need to be prevented, and alternative methods of support, and fair punishment, needs to be found.  The gross inequalities in sentencing suggest it really is a crime to be poor.  

In the health field, we have become acutely aware of inequalities in health outcomes, and in access to health care. Our efforts to overcome these inequalities have been hampered by 13 years of austerity policies which have seen inequalities in life expectancy worsen. In the environment field, the concept of environmental justice has become an important policy goal in seeking to secure for people in poor environments, equal treatment under the law.  In the world of law enforcement, enlightened police forces are pursuing trauma-informed processes when dealing with some of the most vulnerable and disadvantaged people in our society, recognising the complex life experiences which disable people physically, mentally and socially , leaving them simply, unable to cope. Court diversion, crisis intervention teams and mental health training for police forces, harm reduction approaches to drugs and other problems, give hope that alternative models of policing are possible. It seems only in the world of criminal justice, that there is little appreciation or allowance for the problems individuals acquire through a lifetime of poverty and disadvantage. In the eyes of the law, when a crime is committed, a due process and judgement must be reached, a sentence must be passed.  But these processes of justice are not dispensed even-handedly. Unconscious biases are applied. The most defenceless individuals are victimised the most severely, and unable to recover from the consequences; the costs fall not only on the individual, the societal costs of incarceration and the health and care consequences are amplified.

Disparities in sentencing operated by the courts, apply adversely to the poor, the ill and the addicted. Epstein and Hunter reported on breaches of Anti-Social Behaviour Injunctions (ASBIs) and other injunctions found on the official site of judgments. There were 307 cases in all, with 33 in which the judgment of the court mentions mental health issues and/or addiction. The judgements came from 52 different county courts out of the 170 in England and Wales. Two thirds of cases were men, one third women. 46% resulted in immediate sentences; 32% suspended sentences. The convicted people were frequently unaware of their rights, and many were unrepresented.

One example, the case of Floyd Carruthers, illustrates the problem, in the most extreme way, as sadly, it resulted in Mr Carruthers’ collapse in prison, neglect by prison staff (the coroner’s conclusion) and then death shortly afterwards in hospital.

Floyd Carruthers was diagnosed with schizophrenia in 2003. In April 2021, the Court found he had breached his ASBI by banging twice on his neighbour’s door; he was remanded in custody. When the case was again before the Birmingham County Court on 6 May 2021, he was committed to prison for 66 days. He had an infected heart valve and did not eat in the prison for four days. No medical personnel were called. When prison officers entered his cell, they found he had collapsed. He died in hospital on 14.6.2021. The sentencing remarks show that Mr Carruthers did not understand the court proceedings, including his right to appeal. Mr Carruthers should not have been in prison custody when he died as he had completed the custodial part of his sentence on 7 June. He was in hospital by this time, but his family would have been able to visit him without the presence of prison officers if he had been released when he should have been. 

Imprisonment is not the solution to the problems posed by anti-social behaviour. Imprisonment contravenes the basic legal principle of proportionality. The Civil Justice Council reported on this subject in July 2020, pointing out the disproportionate punishments imposed and their finding that half the defendants had no legal representation, and that many were extremely vulnerable. They made 15 recommendations to improve the system; none have been implemented.

Contempt of Court imprisonment raises basic questions of social justice. The rich get sent to rehab: the poor go to prison. It is an anomaly that people are given a criminal sanction of imprisonment for behaviour that is not criminal. This is in contradiction to the law as set out in S.230 (2) of the Sentencing Act 2020: imprisonment is a last resort to be used only when ‘an offence was so serious that neither a fine alone nor a community sentence can be justified for the offence’. In the criminal law there are protections for the defendant: pre-sentence reports, referral to probation service for support, for example. Furthermore, in criminal cases there are out-of-court disposals, diversion, and pre-court measures available to the police to deal with less serious low-level crime. There is evidence that these measures have been largely successful and have kept people subject to them out of the criminal justice system, for example, in the West Midlands New Chance scheme. Help with drug and alcohol problems, housing and employment issues, and mental health problems have proven effective in curbing criminal activity and lessening the harm to communities. These approaches which have been found to be effective in the criminal system should be applied to anti-social behaviour, which although not criminal, may lead to custody.

We require a more just approach to the problems posed when mental illness and addiction leads to anti-social behaviour, one that respects human rights, with a welfare, not a punitive approach to social problems. Prison sentences for ASBIs are not appropriate treatments and they are not effective in preventing the behaviours they are applied to. Consequently, they are not cost-effective in delivering improvement for money spent on the penal system, and they only perpetuate misery, ill health and injustice for the victims, and the misery for victims of their antisocial behaviour. In the present overcrowding crisis, there is no room for them in prison.  Alternative approaches are long overdue.

Rona Epstein, Honorary Research Fellow, Coventry Law School, Coventry University

John Middleton, Honorary Professor of Public Health, Wolverhampton University

Postscript: There are many other examples of the unfair system of criminal justice we have in the UK and the criminalisation of poverty. Many of these are covered on the website: https://crimetobepoor.org. There is also a group of researchers who come together to look at these issues. The UK Faculty of Public Health Special Interest Groups, especially those for mental health, drugs, alcohol and poverty should find this work of relevance to their agendas. Surprisingly, perhaps we do not yet have a UKFPH special interest group for prisons? Criminal justice? Or Policing? 

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