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By Dr Uy Hoang, Chair of the FPH Film Special Interest Group

Following the announcement of a General Election, FPH called for the next Government to think more about our long term health, embed health in all policies, and work with people and communities to focus on preventing ill health and easing pressure on our overburdened NHS.

At FPH’s Annual Conference in Telford (20-21 June), FPH’s Film Special Interest Group (SIG) will bring together public health specialists, academics, and film makers to discuss the role that film can play in helping policy makers locally and nationally perform the type of joined-up thinking that health in all policies demands. We’d love for you to join us in Telford as we screen critically acclaimed films, hear from expert panels of film makers and public health professionals, and open to the floor for wider discussion and debate.

Headlining the FPH Annual Conference will be a screening of I, Daniel Blake, the winner of the 2016 Palme d’Or Cannes award and the latest film from legendary director Ken Loach. The film highlights many issues that are in the fore of this election campaign, including how to best support people with complex health and social needs.

With Brexit and the impact of economic migration likely to dominate this election cycle, we will use film to shine a light on a less discussed aspect of the movement of people- human trafficking- to ensure that that story is not missing from the dominant narrative surrounding immigration. We will screen the award winning film Slaved, followed by a debate with representatives from the police force, public health, and NGOs working within the field. The film brings to life the personal stories behind the public health statistics, shows what our public health workforce is contributing now to tackle these issues, and demonstrates how relevant a public health perspective will be to the next Government as it grapples with these complex problems.

Those of you interested in prevention will find the screening of Up for Air particularly engaging. This award winning documentary follows Jerry Cahill, a 60-year old pole-vaulting coach battling cystic fibrosis. Due to his vigorous exercise regime, Jerry is now 20 years past his expected life expectancy and is one of the oldest living patients with the genetic disease. This film is a powerful and stark example of the benefits of exercise, especially for those living with a chronic disease.

The Global Violence Prevention SIG will highlight the work of public health practitioners, especially women on the front lines of care delivery, with a screening of the film Grace Under Fire. The film follows the story of Dr Grace Kodindo, a leading reproductive health advocate and champion of women’s rights, as she works to expose the horrific toll of the conflict in the Democratic Republic of Congo and rebuild health services for women and children.

As you can see we have a full and compelling programme. We hope you will join us for our ‘film festival’ and contribute to the debate.

For details of the conference and to register please visit http://www.fph.org.uk/fph_annual_conference_and_public_health_expo_2017

For FPH’s election briefing please click here

If you are interested in joining the FPH PH SIG or have any suggestions for films that we could screen, please contact Policy@fph.org.uk

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By Daniel Flecknoe, Co-Chair of the FPH Global Violence Prevention Special Interest Group

The preliminary report of the Lancet/American University of Beirut Commission Health workers and the weaponisation of health care in Syria [Fouad et al, 2017] was published on 14 March, calling attention to the principles of medical neutrality and unhindered patient access that have been so badly neglected in the ongoing Syrian conflict. Systematic targeting of health workers by ISIS, Syrian and Russian military forces is a war crime committed against civil society, and epitomises a disturbing trend of indifference and impunity to international humanitarian law by warring governments and armed groups over recent years. Established norms in the conduct of war, built up over the past century and a half since the founding of the International Committee of the Red Cross, may be irrevocably degrading, and the public health consequences for civilian populations exposed to such deliberate brutality will be correspondingly more severe.

The Faculty of Public Health’s (FPH’s) Global Violence Prevention Special Interest Group (SIG) is committed to engaging with this neglected and worsening cause of preventable morbidity and early mortality. Its members contribute to research into the health impacts of armed conflict (including the Lancet paper referenced), engage and collaborate with other conflict-prevention organisations and conduct advocacy for arms control, economic/democratic reforms, and respect for human rights and the rules of war. We encourage all public health professionals to give parity to armed conflict along with other major global causes of illness, injury and death, and to lobby (both as citizens and medical professionals) for foreign policies that will protect and preserve health.

The SIG will be represented at the FPH conference in June, and members will be happy to discuss our current workstreams with anyone who might be interested in getting involved.

References:
Fouad FM, Sparrow A, Tarakji A, Alameddine M, El-Jardali F, Coutts AP, El Arnaout N, Bou Karroum L, Jawad M, Roborgh S, Abbara A, Alhalabi F, AlMasri I,  Jabbour S. 2017. Health workers and the weaponisation of health care in Syria: a preliminary inquiry for The Lancet–American University of Beirut Commission on Syria. The Lancet. Published online 14/07/17 http://dx.doi.org/10.1016/S0140-6736(17)30741-9

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By Ben Barr, Senior Lecturer in Applied Public Health Research, University of Liverpool, and Lee Bentley, Research Associate, University of Liverpool

The Chancellor of the Exchequer is due to deliver this year’s Budget on Wednesday. It is imperative that he provides additional financial support for disabled people affected by the planned cuts to Employment Support Allowance (ESA) – or risk further widening the disability–poverty gap.

One in three working age disabled people are living in poverty. Their risk of poverty is one and a half times greater than for people without a disability. The government’s strategy, however, for improving the lives of disabled people, focuses almost exclusively on the disability-employment gap rather than this disability-poverty gap (1). It is true that the high risk of poverty amongst disabled people is largely because they are less likely to be in work and supporting people into employment is an important strategy for reducing poverty. Welfare benefits, however, also play a crucial role in preventing poverty by limiting the loss of income people experience when they can’t work due to disability.

People who have lost their jobs because of a disability are likely to be out of work for longer than people who become unemployed. For this reason, disability benefits have generally been set at a higher level than unemployment benefits. From April, this will no longer be the case. The government is reducing the level of ESA for disabled people who are assessed as being currently unable to work but potentially capable of work at some time in the future. The benefit will be reduced by 30% to £73 a week – the same level as unemployment benefits. But whilst 60% of new claimants of unemployment benefits will move off the benefit within six months, 60% of people on ESA will still be claiming this benefit two years later (2). This means that many people out of work because of a disability will have to survive for long periods of time without an adequate income.

Levels of poverty are already very high amongst people out of work with a disability and have been increasing since 2010, particularly amongst people who have a low level of education – the group most reliant on disability benefits (see Figure 1). Cutting these benefits will exacerbate this adverse trend.

Percentage of people with disability in poverty

FIGURE 1: % of people with a disability in poverty, aged 16-64, between 2007 and 2014, by employment status and educational level 

The government argues that reducing these benefit levels will incentivise disabled people to stay in or return to work (3), but there is little evidence to support this assumption (4), and some that suggests it may reduce their employment chances (2). Strategies to reduce the disability-employment gap over recent decades have increasingly focused on more stringent assessment criteria for disability benefits, reduced payment levels and requiring claimants to do more to prepare for work or risk losing their benefits (5, 6, 7). These strategies have had little impact on the employment of people with disabilities (8). It remains to be seen whether the government’s new strategy to halve the disability employment gap will be any more successful (1).

Even if the government’s strategy does improve the employment of disabled people, it is likely this will disproportionally benefit disabled people with greater skills and education (9, 10). The planned cuts in ESA will increase the risk of poverty for the most disadvantaged disabled people who remain out of work, and this may increase the disability-poverty gap.

Increasing poverty amongst people out of work with disabilities will adversely affect their health and increase health inequalities. We know that poverty damages peoples’ health, and adequate welfare benefits for people who can’t work can reduce these effects (11). We have seen that in recent years inequalities in health are increasing (12) in part due to disability benefit reforms (13). The severe cut planned by the government will further exacerbate these inequalities, potentially increasing levels of disability.

1    Great Britain, Department for Work and Pensions, Great Britain, Department of Health. Improving Lives: The Work, Health and Disability Green Paper. 2016 (accessed March 2, 2017).
2    Work and Pensions Committee. Disability employment gap. London: House of Commons, 2017 (accessed March 2, 2017).
3    Kenedy S, Murphy C, Keen K, Bate A. Abolition of the ESA Work- Related Activity Component. House Commons Libr Brief Pap 2017.
4    Barr B, Clayton S, Whitehead M, et al. To what extent have relaxed eligibility requirements and increased generosity of disability benefits acted as disincentives for employment? A systematic review of evidence from countries with well-developed welfare systems. J Epidemiol Community Health 2010; 64: 1106–14.
5    Watts B, Fitzpatrick S, Bramley G, Watkins D. WELFARE SANCTIONS AND CONDITIONALITY IN THE UK. York: Joseph Rowntree Foundation, 2015.
6    Banks J, Emmerson C, Tetlow GC. Effect of Pensions and Disability Benefits on Retirement in the UK. National Bureau of Economic Research, 2014 (accessed Sept 26, 2015).
7    Baumberg B, Warren J, Garthwaite K, Bambra C. Rethinking the Work Capability Assessment. London: Demos, 2015.
8    Mirza-Davies J, Brown J. Key statistics on people with disabilities in employment. House Commons Libr Brief Pap 2016; 7540.
9    Burstrom B, Nylen L, Clayton S, Whitehead M. How equitable is vocational rehabilitation in Sweden? A review of evidence on the implementation of a national policy framework. Disabil Rehabil 2011; 33: 453–66.
10    Clayton S, Bambra C, Gosling R, Povall S, Misso K, Whitehead M. Assembling the evidence jigsaw: insights from a systematic review of UK studies of individual-focused return to work initiatives for disabled and long-term ill people. BMC Public Health 2011; 11: 170.
11    Cooper K, Stewart K. Does money in adulthood affect adult outcomes? York: Joseph Rowntree Foundation, 2015 (accessed July 30, 2015).
12    Barr B, Kinderman P, Whitehead M. Trends in mental health inequalities in England during a period of recession, austerity and welfare reform 2004 to 2013. Soc Sci Med 2015; 147: 324–31.
13    Barr B, Taylor-Robinson D, Stuckler D, Loopstra R, Reeves A, Whitehead M. ‘First, do no harm’: are disability assessments associated with adverse trends in mental health? A longitudinal ecological study. J Epidemiol Community Health 2015; : jech-2015-206209.

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claire-beynon-at-fph-conference-2016My name’s Claire Beynon and I’m a registrar in my third year of training.

I went to the Faculty of Public Health (FPH) conference in Brighton last year (above) and I’m going to this year’s event in Telford in June.  So I thought I’d offer some thoughts on the benefits to other registrars of coming along as well.

As a registrar working in Wales I know most of the people in my area really well, but I don’t have much of a chance to find out about what’s happening across other parts of the UK or meet other registrars.

The FPH conference brings registrars from across the UK together.  Last year I met several other registrars from opposite ends of the country and we shared stories and experiences about the different health systems we now work in.

I also bumped into a few people who I hadn’t seen in a long time, and we caught up in the relaxed breaks and mealtimes over the course of the two days.

I was lucky enough to have my abstract accepted last year and I spoke in one of the parallel sessions on childhood obesity.  I shared my work with people who, like me, are really dedicated to tackling childhood obesity.  I found it was a great platform to share work you have finished recently and get some vital feedback and new ideas from other experts in the field.

The thing I liked most about last year’s conference was the atmosphere.  As we all know, people working in public health are fabulous, so perhaps it isn’t a surprise that the conference was fun.

The FPH Specialty Registrars Committee (who represent registrars) also has a dedicated conference session at which registrars will be sharing their experiences of the National Treasure placements.

And there will be time to socialise too.  This year committee members will all be at the conference party at the end of day one.  It’s going to be a fantastic opportunity to get to know people informally who you will very likely end up working with over the rest of your career.  So come along and say hello!

You can register to come to this year’s conference here http://www.fph.org.uk/fph_annual_conference_and_public_health_expo_2017

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By Nadeem Hasan

I’m five months into a year-long stint in Sierra Leone as one of the global health fellows for 2016/17. I hope to blog about the positives of the experience, hence the format ‘in praise of’.

After all, there’s enough negativity around as it is.

I’ll be working in the Ministry of Health and Sanitation (MoHS) in Freetown, supporting their mission to strengthen the health system following Ebola, and learning as much as I can along the way.

Predictably, I’ve already learned a lot more than I’ve contributed.

I’m engaging with the financial and capacity challenges in the MoHS; the political challenges; and the complexity of operating alongside the World Health Organisation, the World Bank, UN agencies, and hundreds of NGOs and private sector implementing partners. And all of that before even getting to the content of the day-to-day work of the ministry.

Accordingly, I don’t feel too bad about the learning overshadowing my own contributions.

Not being sure what to expect when I got to my office, what first struck me was the sheer number of international staff embedded in the MoHS. I found technical experts from the Clinton Health Access Initiative (CHAI), Oxford Policy Management (OPM), Overseas Development Institute (ODI), USAID and others – all with desks inside the ministry, working hand-in-hand with national staff.

Foreigners everywhere. And now here I was adding to their number.

The ability of the ministry to pursue its goals should be improved by international experts working together with their national counterparts: on the face of it, it’s a win-win situation. However, the sheer number of international staff also leads to challenges for sustainability and country ownership of health policies and programmes – and if not managed carefully could have a negative impact in the long-term.

So what’s the appropriate balance?

Three months in, it’s clear that these long-term embedded experts have had the time to build strong relationships with their national counterparts. Through these relationships, they’ve been able to develop a deep understanding of the local context – including the enablers and barriers to successful design and implementation of policies and programmes.

Crucially, a lot of this information isn’t written down anywhere (for very good reasons), and can only be gathered through living in the country.

As a result, these individuals end up being highly skilled in their ability to compare and contrast what the evidence and data says should be done to improve health outcomes, with what can actually be achieved on the ground at any given time. Importantly, this requires taking into account the personal relationships that exist between key individuals.

Compared with short-term consultants that ‘parachute in and helicopter out’, they’re highly valued by senior national staff in the MoHS for their expertise and sensitivity to the local context. And, I think, rightly so.

All of this is fine of course, but what about the questions of country ownership (what happens after external ‘experts’ have done their bit) and sustainability (what happens when they leave)?

Well, I’ve watched how some of the more seasoned experts resist the temptation to look at the evidence and data and write the ‘ideal’ policy or strategy, presented with a shiny bow, only for it to sit gathering dust on a shelf.

Instead, they work on the sidelines; gathering the relevant data on a topic and developing the questions for discussion by national actors. They support the process of convening national actors to discuss the best way forwards without taking too active a role in those discussions themselves. They therefore support leadership by national staff, which in turn generates the momentum and wider ownership required for success.

The ‘capacity building’ aspect is harder to see at the central level than in a health facility, where the traditional ‘teaching and mentoring’ approach is more appropriate.

At the MoHS, knowledge and skills are shared (both ways) through building trusting relationships with national staff and working together on routine aspects of the job. The mutual respect that this generates in turn increases the rate of knowledge and skills transfer.

Accordingly, the longer the expert is embedded in the team, the more effective the process. In this way, the sustainability of the work done and approaches taken by international staff is to some extent ensured.

A major challenge comes in the form of convincing donors focused on results that this long-term, ‘softly, softly’ approach with no concrete ‘measurable’ outputs is worth the investment – but that’s a whole other issue.

This is of course a rose-tinted view, but the blog is, after all, entitled ‘in praise of’.

Thinking back to practice in the UK, I wonder whether there is a broader relevance of this approach for ‘health in all policies’. Embedding public health specialists in non-health teams on a long-term basis can have two major benefits. First, the use of a robust evidence and data-led approach to policy making that considers the health impacts of non-health policies. Second, the contextual understanding of how to do achieve this effectively under the leadership of the host team (thereby ensuring sustainability).

Comparing Sierra Leone to, for example, the Department for Education in Whitehall might seem odd at first glance. However, for a public health specialist they’re both new contexts that have to be learned and understood before being able to operate and influence effectively, and both places where our skillset and approach could lead to significant improvements in health outcomes.

I know this is already happening in some places such as Transport for London. If it is anywhere near as effective as it is in Sierra Leone, then we could do with a lot more of it.

Nadeem Hasan is a public health registrar

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By Professor John Ashton

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The statue near the site of the Christmas truce football match.

Granny Ashton’s half brother, my great uncle Arthur Anderton, died on the Somme in 1918.

According to the Commonwealth War Graves Commission, ‘Private Arthur John Anderton 283444, serving with the 2nd/ 4th Battalion, London Regiment (Royal Fusiliers), died on 25 April. Sadly he has no known grave and therefore he is commemorated by name … on Panel 86 on the Pozieres Memorial, France. Pozieres is a village about 6 kilometres north-east of Albert.’

Great uncle Arthur was from Liverpool but unlike many of his fellow Liverpudlian victims of the First World War his name does not appear with the thousands of others on the walls of the memorial room in Liverpool Town Hall. Rather, at the time of his death resisting the last German attempted push to Paris in the dying months of the war, he found himself in a London regiment.

Reading the daily log of his commanding officer, as we retraced his final weeks’ footsteps some years ago, the reason becomes clear. A typical morning entry would record that two or three hundred men had joined the regiment and an evening entry would record that at least a similar number were missing presumed dead, with no body to be found.

The result was a constant forming and reforming of battalions.

Spending several days immersed in the tragedy of such inhumanity, I was struck by the relatively small size of the battle area of the river Somme; space which saw so much death and maiming.

I was also reminded that this tragedy affected so many nations and people. Arriving at the cemetery at Poitiers we were surprised by the arrival of two young Germans on a motorbike whose relative was remembered in a British cemetery. Tears were never far from my eyes.

That trip made a lasting impression on me and the fragility of the peace of 1918 and that of 1945 has become ever more apparent as our 21st century world fragments, instability and ancient hatreds return and battle lines are drawn up. On average, in recent years around 200,000 people have been killed in conflict each year.

In the First World War 90% of those killed were soldiers and 10% civilians. Today that ratio is nearer 25%:75%. Never has it been more important to learn the lessons of history.

So this year when political biographer Sir Anthony Seldon decided to do something about establishing the Western Front as a cultural reference point for peacemaking, I was up for the challenge.

While writing a book about the First World War, Sir Anthony came across the story of Douglas Gillespie who was killed in the Battle of Loos in September 1915. Shortly before his death, Douglas had suggested in a letter home the creation of a ‘Via Sacra’ when the war was over. He wanted it to run from Switzerland to the English Channel, a secular pilgrim route to help future generations understand the need for peace.

And so, on 22 June this year, a varied group of us met on the steps of the Mairie in Pfetterhouse, close by the Swiss-German-French border, and set off to walk north to the Channel. It was a remarkable experience. It was bitter-sweet; poignant and sad; a significant challenge; great fun; and a unique opportunity to share in an adventure with some remarkable people.

In some ways it felt like a contemporary re-run of Chaucer’s Pilgrims Tales; everyone had stories to tell, including Gillespie’s descendants and others who had lost family or had family members taken prisoner of war.

But it was also a three dimensional education.

On the second day we got lost in the Vosges mountains in temperatures well into the 30s and discovered the price the French paid to hold the Germans in the south, dug in for the freezing winter of 1914 at 3000 feet.

On the last day of June we reached the Somme itself, ready for the centenary ceremonies near Albert the next day and I felt the spirit of Great Uncle Arthur once again. We moved on to Vimy, Armentieres, Ypres and Passchendale; past the spot where a British soldier spared Adolf Hitler’s life and where Winston Churchill served his country.

We passed by the ever so poignant field of the Christmas truce and the football match, now part of folklore (the statue commemorating the truce is in the photograph above). We walked on past the Menin Gate with English schoolchildren laying wreaths at the sound of the Last Post; and finally to the coast at Diksmuide, where a local farmer had the presence of mind to open the sluice gates, flood the marshes and cut off the German troops.

Sir Anthony’s vision is of a long distance path which will be trodden for hundreds of years to come; perhaps long after the Commonwealth War Graves Commission has ceased to exist.

It is a necklace-like path punctuated by educational oases – like the remarkable little museum created out of a German medical field station in Cernay, where we were shown such hospitality by the local mayor. A path which will engage with future generations and steer them away from the path of intolerance, hatred, war and death. A path which will mean no more great uncle Arthurs cut down in the prime of life.

It is Sir Anthony’s intention to repeat this year’s walk in 2017 and 2018. You can find details on the Via Sacra website (http://www.viasacrawalk2016.org.uk/).

John Ashton 7 November 2016

 

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By Philip Daniels, Health Education England Global Health Fellow

Over the next year I will be working within the Public Health England Global Health Team. Based in London and Freetown, I’ll be supporting the development of the Sierra Leone National Public Health Agency, working with colleagues from Sierra Leone, USA and China.

Being awarded a Health Education England Global Health Fellowship is an enormous privilege. It gives me the chance to work with colleagues from a diverse range of backgrounds, disciplines and nationalities. I’ll be blogging regularly to help me record what I see and learn.

It is an incredibly exciting time to be involved in Global Public Health. Issues such as pandemic disease, outbreaks such as Ebola and Zika, as well as the growing threat of antimicrobial resistance (AMR) and climate change are increasingly informing the UK’s approach to Public Health.

The UK is a signatory of both the International Health Regulations (2005) and the Sustainable Development Goals (2015) – the latter of which include an explicit commitment to ensure healthy lives and promote wellbeing for all at all ages.

The UK Aid strategy (2015) restructured Overseas Development Aid (ODA), on which the UK spends 0.7% of its GDP, to ensure that it is spent on tackling the great global challenges. As part of this, the UK government has established:

  • The Ross Fund, a £1 billion initiative to tackle the most dangerous infectious diseases such as Ebola, malaria, neglected tropical diseases and drug resistant infections
  • A £500 million ODA crisis reserve to enable effective cross-government responses to crises as they happen
  • A Global Challenges research fund of £1.5 billion over the next five years to ensure UK science takes a leading role in addressing the problems faced by developing countries – such as building resilience during emergencies and tackling AMR.

In addition, the government has committed to increasing UK climate finance for developing countries by at least 50%, to reduce emissions, increase access to energy, build resilience of the poorest and most vulnerable people, and to reduce deforestation.

All of this reflects an awareness that what happens internationally and globally affects health security in the UK. It’s also apparent that the expertise based in the UK has much to offer the rest of the world, as illustrated by PHE’s successful efforts to give public health and science a bigger role within the Sendai Framework for Disaster Risk reduction (2015-2030).

Reflecting this, Public Health England and the Faculty of Public Health have published Global Health Strategy. It highlights not only the complexity of the problems faced, but also the enormous contribution that will be made in the coming years by UK Public Health. It is within this context that I begin my Global Health Fellowship.

It is set to be a challenging and rewarding year; I look forward to sharing it with you.

 

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