Better Health For All

In public health we often work in partnership with statutory and non-statutory organisations developing relationships that are necessary to implement public health projects to benefit local communities.  How often have we teamed up with colleagues where the relationship is informal, not prescribed and not expected?

April 2020 the national spotlight was on acute physical health care and there was a frantic attempt to scale up provision of acute beds and ventilators. Those of us working in community Trusts saw our services take a back seat and many were stopped altogether; but there was unease over impending problems over the horizon. What would be the impact on community rehabilitation services? What would the mental health ramifications of the pandemic be?  Would our community palliative care services cope?  

It was reassuring to network with other public health colleagues who had similar concerns. Connected by the national network for public health professionals working in providers (facilitated by PHE) we joined forces and worked as one team on this topic of mutual concern. One of the challenges for public health specialists in provider trusts is that we often work single-handedly and don’t have colleagues in a team, as in local authorities for example. Becoming a virtual team (consultants, StRs) doubled the number of people working on the project and meant we could split up article reading and writing up. It also gave us more brains to think about the implications and critique what we were reading and thinking. We barely knew each other, but had our training in common and shared public health language meant that we were able to work effectively together – and enjoyably!

So even before the term Long Covid had been coined and mental health concerns had been profiled nationally, we had teamed up and started needs assessments and were doing papers for our local integrated care systems. We even managed to submit articles for publication. 

Furthermore, we have continued regular problem solving meetings and act as a virtual department separated by a dotted line of a few hundred miles. Freed up from formal, standard ways of working – under the radar – our organisations get a greater range of public health expertise than they pay for!

Jane Beenstock
Consultant in Public Health

Dr Zafar Iqbal
Associate Medical Director Public Health
Chair, FPH Pakistan SIG

Given the widespread recognition of COVID-19 as a public mental health emergency that has deepened existing mental health inequalities, the theme set by the World Federation for Mental Health for World Mental Health Day on Sunday 10^th October – Mental Health in an Unequal World – was especially fitting.

It seemed to have come around even more quickly again this time, which probably says a lot about what the past year has been like. Those of us working in public health will be well versed in efforts to promote wellbeing in our own organisations and others, particularly at a time when workload and stress have been high and morale has been low.

What comes through less clearly is where the focus is not just on reducing stress in individuals, but on tackling wider underlying issues contributing to that stress – particularly where there are marked disparities.

I don’t just mean equal access to support, services and activities that help to improve wellbeing, although that is extremely important – both in our own workforces and the populations we serve. I’m talking about workplace policies, working practices and cultures that seek to actively counteract prejudice, discrimination and structural disadvantage, all of which are detrimental to mental health and wellbeing.

In other words: what are we doing to advance equality in our own workforce?

Last year the FPH highlighted the importance of embedding anti-racism into public health practice. This means challenging our own unconscious biases and refusing to be silent bystanders to racism in our own organisations. The same principles can be applied for other forms of discrimination, including but not limited to sexism, ableism and homophobia – however, this is as much about questioning the status quo in the ways we work as it is about challenging overtly discriminatory behaviour.

The public health workforce is diverse in itself (people, roles, organisations) and has wide-reaching links across partner organisations and communities. If we want to be effective advocates for mental health equality in the population, we need to start with equality overall and we need to start from within.

What stress means and what it looks like is different for everyone, but can be summarised as ‘a lack of fit between individuals and their world’ (Cassidy, 2001).[1] We’ve started to recognise the limitations of traditional workplace wellbeing approaches, which focus on supporting individuals to fit into existing structures rather than improving their ‘world’ to fit them – but we also need to be looking at who built that world in the first place. Many workplace policies and interventions for inclusion and wellbeing still operate within norms and cultures that have been established by white, middle class men without disabilities – even where workforces are considerably more diverse, and even where there is representation at senior levels.

For example, offering flexible working arrangements such as flexible start/finish times and remote working can improve work-life balance and wellbeing for people with children or care responsibilities (who are disproportionately women), or those with disabilities or long-term health conditions. Yet limiting the offer to these groups where there is no real business need to do so just reinforces the current culture as the norm and those who don’t fit in as ‘others’, instead of including everyone as equal partners in re-shaping that culture.

It also ignores the wellbeing benefits that these changes can have for everyone. A workplace that promotes equality and diversity is a workplace where everyone can flourish and feel that their contribution is valued. More flexible working as standard can help to improve work-life balance for all. Making workplaces more autism friendly can make those workplaces happier, calmer and more productive spaces for everyone. When we default to the status quo and consult rather than co-produce, we all miss out.

The brilliant Dr Nisreen Alwan explains this far better than I ever could in the context of language and anti-racism:

“Diversity” and “inclusion” imply charity from a position of power and superiority.

They give the impression that the group who is opening the door to diversify and include others still holds the key. The point of antiracism is that there should not be a key in the first place. The door should be widely open to all. Clubs with locked doors should not exist in an equitable society. Once that is achieved, the natural result of equity is diversity. It is the end not the means.”

So what does this mean for promoting mental health equality?

We cannot improve mental health and wellbeing in the public health workforce without actively tackling inequities in our workplaces – and we cannot address those inequities without confronting the structures underpinning them. Whether it’s improving opportunities and experiences of people with mental health problems, or reducing disparities in mental health and wellbeing, we have to actively change working practices that allow systemic discrimination to persist.

It isn’t enough to work to improve mental health in an unequal world; we also have to work to make the world more equitable to improve mental health.

Lina Martino

Chair, FPH Public Mental Health SIG

[1] Cassidy T (2001). Stress, Cognition and Health. Psychology Press: Hove & NY.

A public health approach in policing allows opportunities to address the clear yet complex links between health, wellbeing, offending and behaviours which lead to contact with police. Social determinants of health, such as housing, education, employment and income, often mirror or overlap with social determinants of crime. Inequalities which result in poorer health and reduced life expectancy also result in increased likelihood of entering the criminal justice system or being policed for problem behaviours. Those at risk of offending are more likely to suffer from multiple and complex health issues, including mental and physical health problems, learning difficulties, and substance misuse.

In 2018 the national Policing, Health and Social Care consensus statement was published to set out how the police service and health and social care services would work together to improve people’s health and wellbeing, reduce crime and protect the most vulnerable people in England and Wales. In the run up to the publication of this document and in the years following public health and policing organisations have been working together, alongside other partners, to focus on prevention and early intervention, recognising that the majority of police work is rooted in complex social need. The Public Health and Policing Consensus Task Force was established to bring together these partner organisations.

The Landscape Review 2021 was published on 22 September which outlines the progress in leadership, practice, culture and evidence within policing since the publication of the consensus statement in 2018. This review describes progress and opportunities for development in four key areas:

• policy and systems
• evidence for primary prevention
• public health practice
• research in public health and policing

Policy and Systems

Since the formation of the Public Health and Policing Consensus Task Force there have been several policy documents related to public health approaches within policing. In 2019 a discussion paper was published considering what a public health approach in policing looked like. This described five key pillars for public health in policing: working at a population level, using data and evidence, considering the causes of the causes, prioritising prevention and partnership working. This paper has stimulated discussion within the policing community, ultimately resulting in the College of Policing and National Police Chiefs Council outlining the 5 key pillars as shared principles in a policy document. This and other documents explored in the Landscape Review have fostered partnerships across England and there are opportunities to build on this moving forward.

Evidence for primary prevention

It will always be difficult to prove you prevented something from happening which makes gathering evidence for primary prevention challenging. Primary prevention may also lie outside of traditional remits of an organisation (e.g. response to crime). However, for primary prevention to truly be effective all sectors must make it a priority. A mapping exercise was carried out as part of the Landscape Review which considered the evidence on the effectiveness of primary prevention in a public health and policing context. This found a lack of specific detail on “how” and “why” interventions impacted on outcomes.

Public health practice

A survey carried out by the College of Policing for the Landscape Review explored what progress has been made in embedding public health approaches in policing.  While there is evidence of effective partnership working and public health approaches more generally across a breadth of business areas within policing there is still more to do.

Research in public health and policing

Developments in policy, evidence and practice are promising, however, these must be realised in line with the evidence base. Therefore, a modified Delphi study was carried out across the four nations of the UK to identify priority topics for research as part of the Landscape Review. The results revealed a desire to prioritise wider social determinants of health and wellbeing, mental health and wellbeing, children and young people, vulnerable groups, and domestic and sexual violence and abuse in future policing and public health research.

The Public Health and Policing Consensus Task Force continue to forge and foster strong links between Public Health, Policing, Health and Voluntary Sector organisations with the ultimate aim of improving health and wellbeing of vulnerable people. If you would like to hear more about this area of work or to get involved with the work of the Public Health and Policing Consensus Task Force you can:

• read the Landscape Review 2021 here Public health landscape review published | College of Policing
• hear more from the Public Health and Policing consensus Task Force via Twitter (@police_health)
• Join our next webinar “A Public Health Approach to Modern Slavery” on 14^th October 2022 at 2pm https://event.on24.com/wcc/r/3420189/0F5F3C39E4C4F68B606B9DAB0333BCBF
• Future webinars will shine a spotlight on prevention and sports, trauma informed policing and law enforcement working with health colleagues around drug death prevention

Dr Jaimee Wylam
Public Health Registrar

In April 2010, one of us wrote a short retrospective of the  H1N1/09 (“Swine Flu”) Pandemic, for  the newly relaunched “Public Health Today”, under the guest editorship of another of us,  entitled, “Modellers not public health doctors had lead in flu planning”.  Its sentiments were echoed in the report on the Swine Flu Pandemic for the UK Cabinet Office by Dame Deirdre Hine, former CMO Wales, that judged that the UK government placed too much reliance on “modelling evidence”.  That Cabinet Office Report went on to recommend that, “The Government Office for Science, working with lead government departments, should enable key ministers and senior officials to understand the strengths and limitations of likely available scientific advice as part of their general induction. This training should then be reinforced at the outbreak of any emergency”.  In doing so the report acknowledges that the mathematical and academic nature of mathematical modelling can be attractive to hard pressed politicians and officials who aspire to “follow the science” but warns against regarding mathematical modellers as, “court astrologers”. Public Health Today, a few short years later, was no more and with it, was forgotten, in the management of the COVID-19 pandemic, this particular lesson.

Indeed “court astrologers” have been ubiquitous in the COVID 19 pandemic from the moment in March 2020 when Imperial College London’s implausible predictions, the most recent example of a long history of the same, led directly to almost simultaneous lockdowns in the UK, France and the USA.

Meanwhile on 24th March 2020, in a letter to the Western Mail, “the national newspaper of Wales”, entitled, “Will social distancing actually work”, one of us wrote,

“This new virus will keep circulating until either we’ve all had it or vaccines or effective treatments become available, both solutions possibly years away. Distancing just makes the virus get round slower, and the pandemic last longer. Distancing also means less wealth and resilience to fight it.”

Previously, on 28th February, another of us had written in a BMJ editorial,

“Given the lessons from 2009—which taught us that containment for a globally disseminated disease was futile….once the disease is recognised as a global pandemic nations, commerce, and healthcare can move into a much more rational phase with resources targeted at those most at need. We should plan on the assumption that most of the population may contract the virus….”

Why have risk based approaches, or “focussed protection” as some have styled them, not been followed; neither in Wales nor elsewhere?  A part of the explanation has been the dominance of mathematical modelling in the scientific advisory machinery.  Welsh ministers, like many politicians and journalists, internalised the widely popularised idea of the effective reproductive rate (R_t)  as a sort of epidemic volume control responding in small increments/declines to their “cautious” changes, a framework that entirely ignores the determinant role of social networks in epidemic patterns. Welsh Government’s Technical Advisory Committee (TAC) is chaired by the Chief Scientific Advisor, not the Chief Medical Officer and despite a number of members, experienced in all aspects of infection, it has been suggested, privately, that it is the mathematical modellers that have dominated the agenda. Certainly the TAC’s outputs, available online, are consistent with this explanation, for example, a paper showing that the Welsh Government’s two week October firebreak was “successful”. In this paper, arcane mathematics is used to claim success, whilst, from a simple eyeballing of the observed COVID incidence, it would be difficult to conclude other than that any effect was marginal at best.

Whilst such global approaches to pandemic management were used, loss of a focus on risk meant that preventable infections remained unprevented, evidenced by the high proportions of deaths in which the infection was acquired in hospital or care settings and the proportion of care home cases, linked to hospital discharges.  Field data to orientate such approaches was available, early on in the pandemic from the “OpenSAFELY”, “ISARIC” and RCGP Research and Surveillance Centre projects, not to mention timely papers from China.  Public Health Wales, subsequently, made important contributions to this work with their studies of hospital discharges and of the community screening project in Merthyr Tydfil. Empirical data from field investigations might similarly be used to establish what works in protecting the vulnerable as well as to evaluate whether some of the Welsh Government’s more singular decisions (closing selected supermarket aisles, pubs prohibited from selling alcohol, vaccine passports for night clubs) were/are of any benefit.

Finally, the Wellbeing of Future Generations Act, some of Wales most forward thinking legislation singularly failed to translate into any sort of systematic evaluation of the downsides of global “lockdown” approaches; downsides most likely to impact on just those future generations whose interests the Act seeks to protect.

What scope was there for an independent stance in Wales, given the high level of economic and social interaction with England?  It has been done. Wales refused to endorse claims from DH in England that BSE could not transmit to humans, chose to wait before embarking on smallpox vaccination of health care workers, due to the high levels of side effects documented in the US, before the Iraq war and during the 2009 Swine Flu pandemic, Wales chose to use usual healthcare providers, bypassed in England by the costly, centralised and often ineffective “Flu Line” (National Pandemic Flu Service).  The scope for leadership is, nevertheless, limited but should that mean that letters to Welsh ministers, from us, suggesting how more focussed approches might look, in practice, simply remained unanswered?

So this is distinctly not the view from Wales but it is a view and a view from four of us who spent much of our senior careers in the epidemiology and control of communicable diseases.  So whatever form Wales’ Public Inquiry takes, we’d like to see our views, particularly in regard to the need to use real world surveillance and investigation, including of the downsides of interventions, taken into account and this time, practical lessons learned and remembered.

Roland Salmon
formerly, Director, Communicable Disease Surveillance Centre, Public Health Wales

Meirion Evans
formerly, Consultant Epidemiologist, Public Health Wales

Stephen Palmer
Emeritus Professor of Public Health, Cardiff University

John Watkins
Professor and Consultant Epidemiologist, Cardiff University

The COVID-19 vaccine programme has been the largest vaccine campaign in NHS history. The approach in London has and continues to be a true partnership endeavour, bringing together and harnessing the assets of all system partners and our communities in order to achieve high and equitable vaccine uptake across the city. Delivery has been multifaceted, bringing together activities at the hyperlocal, borough, Integrated Care Systems (ICS) and regional levels.

The regional Public Health function has worked to support, enable and contribute to system delivery of the vaccine programme in London by adopting a four-pillar approach focusing on:

• data and evidence
• tackling hesitancy and increasing confidence
• addressing practical barriers to vaccination
• evaluation, monitoring and system leadership

The data and evidence

Timely, high quality data and intelligence on vaccine uptake has been fundamental to London’s effort. Working closely with key London partners, we have developed a range of analysis and reports examining uptake by various groups and demographic factors. This has helped us to track progress in London and guide ongoing system efforts to increase uptake and tackle inequalities. Using presentations and analysis in creative ways has helped to demonstrate progress with delivery and highlight gaps and inequalities creating a shared understanding across partners.

Tackling hesitancy and increasing confidence

Lower self-reported vaccine confidence or likelihood of accepting the vaccine amongst London’s Black, Asian and minority ethnic communities has been mirrored by COVID-19 vaccine programme data showing lower uptake in many minority ethnic communities, and in areas of greater deprivation. Given the stark and persistent inequalities experienced by these communities in terms of risk of COVID infection and poorer outcomes, equitable vaccine uptake across the city has been a critical priority of the programme.

Engaging and working with Londoners has been central to understanding the questions, concerns and barriers experienced by London’s diverse communities. At a regional level, this has included a series of round tables with community groups including a pan-London Community Champion Coordinator programme and resources developed to reach specific communities and populations. A regional ‘bureau of speakers’ was developed to include medical and Public Health experts from a range of communities and backgrounds to support local events. From this grew the Public Health Ambassadors programme where colleagues from across PHE London used their lived experience and networks within their communities to co-design resources  and activities.

Many communities have concerns and fears that reach well beyond vaccine safety and efficacy. Historic and recent medical malpractice was a big feature as well as long standing issues of mistrust, discrimination and fear of state-run services and systemic racism. Listening to and acknowledging these fears and concerns linked to deep-seated and structural issues has been a vital first step towards rebuilding relationships and trust.

Addressing the barriers to vaccine uptake

Vaccine hesitancy is not the only factor behind inequalities in vaccine uptake, practical access issues are also key, The NHS, working with London borough colleagues and wider partners, have sought to adapt programme delivery over time in order to overcome these barriers and maximise convenience.

The use of local community venues, vaccination buses and other hyperlocal locations in non-traditional and more familiar settings are examples of this approach. Outreach models were developedto take vaccination to people who may otherwise not access them through other sites if they were housebound, homeless or asylum seekers for example. Hyperlocal vaccination options, alongside targeted outreach, such as door knocking or street engagement teams, has been effective at reaching people with barriers to access. Local booking systems were developed to overcome some of the challenges associated with the national booking system, and many sites offered walk-in clinics. Local call centres were also established to proactively follow up unvaccinated Londoners and provide support with booking.

Evaluating what we did

A pan-London evaluation of the COVID-19 vaccine programme was undertaken to learn lessons and share innovative practice in real time to inform programme delivery.

The evaluation report was recently published and is itself an example of strong collaboration and partnership across many partners. The report is divided into four distinct areas of focus – barriers, demand, access and legacy–and makes a number of recommendations in order to build on the learnings gathered throughout the programme and to drive continued improvement,  not only for the COVID-19 vaccine programme, for wider vaccines and for broader health systems more generally.

What we learnt

A vital thread across the system has been the importance of partnership working. Whilst the NHS led on the vaccine programme the strength of different partners was brought together through various elements whether it was the deep understanding of localities from Directors of Public Health and local authority partners to best practice engagement from the mayoral team. Much of this was facilitated by meeting to highlight issues and share good practice but also embedded through the agile learning of evaluating our work regularly. This enabled system partners to all constantly learn and grow together towards increasingly innovative methods and approaches.  

Another essential element has been the importance of working alongside communities to understand their aspirations, needs and concerns. This takes time, energy and resource but is vital to understand and address inequalities and is crucial to build confidence in vaccines and health systems. As we start to reflect on the last 18 months, it is essential that we take this as a legacy of learning from this pandemic – aiming to embed and sustain this approach going forwards. This is key not just for a focus on COVID-19 and vaccination but should be used for all health and prevention services more widely.

Written by

Dr Cyril Eshareturi
Senior Project Manager: PHE London COVID-19 response

Dr Leonora Weil
Public Health Consultant: PHE London COVID-19 response

Julie Billet
Director of Operations: PHE London Operations

In London, we have been talking with different communities about vaccines. We wanted to learn from their experiences so we can better serve their needs. One consistent theme we have heard loud and clear is the role of racism.  Questions of “Why isn’t the systemic racism that results in health inequalities for Black people…not being given the same attention as the push for this vaccine?” We are no longer only talking about vaccines.

Throughout the pandemic, we have seen the devastating and inequitable impact COVID-19 has had on populations in UK and worldwide. Last year, Public Health England (PHE) published a review of health disparities from COVID19, and Beyond the Data report, based on stakeholder feedback. [i] It comes as no surprise that people from ethnic minority backgrounds continue to face poorer outcomes and access to health and care. [ii] What we are seeing is an exacerbation and amplification of existing health inequalities. These inequalities, which are unjust and avoidable, are not new. What is new is the attention these injustices have garnered and the opportunity to make a true and lasting difference in how we work with our diverse communities.

The reasons underlying these ethnic health inequalities are complex. Consider multigenerational households, now a known risk factor for transmission of COVID19, particularly for Asian households. In non-pandemic times, an older family member living with their children and grandchildren are protected from social isolation, leading to better physical and psychological health. They also provide childcare and support for working parents and transfer of skills from one generation to the next. This myriad of interconnecting socioeconomic factors are well-defined in the socio-ecological model, encapsulated in the Dahlgren and Whitehead diagram which is emblematic of the public health approach.

In our conversations with Londoners, the pernicious effect of discrimination, stigma, and most of all, structural racism resonated in all the voices we heard. Racism, in different forms, shapes the conditions we live in, and has been called one of the causes of the causes of the causes.[iii] As well as colouring the canvas of people’s lives, it cuts and obstructs their progress throughout the lifecourse, interweaving a path of cumulative disadvantage through multiple mechanisms. Not everyone from ethnic minority groups are born to disadvantage, nor do they stay in disadvantage, but it is the intersectional nature of race, gender and socioeconomic position that makes it harder for people from ethnic minority backgrounds to thrive. The impact of racism, and identifying racism as a public health issue[iv], has led us to integrate racism into the Whitehead and Dahlgren model. It is time to reform the public health agenda and recognise the connection between structural racism and racialised disparities in health.

Reducing health inequalities is core public health work.  If we accept that racism plays a causative role in health equalities, then developing a deeper understanding of possible links between racism and health is a prerequisite for interventions that target health inequalities at a community and individual level. Addressing racism is central to eliminating racialised health disparities, and therefore, should be central to public health research and practice,

As we reflect on the past year, and work to build back lives and livelihoods, now is the time to listen, the time to collectively work and amplify unheard voices, the time to take action and dismantle the White hegemony that has reverberated in the policies and organisations around us. Within PHE London public health colleagues who have insights as community members have collaborated co-design solutions with communities according to their needs, and not to fulfill our needs to deliver vaccinations or tests. We aim to help the system work more proportionately, ensuring that we build trust and strengthen relationships so we’re in a better position to support all our communities to thrive and be resilient should the next pandemic or health threat occur. We will listen and ask what would have worked better, how we could have worked better and what we can do from now to be better.

Dr. Jennifer Yip

Leah de Souza-Thomas

[i] Public Health England. Disparities in Risks and Outcomes from COVID19. June 2020 https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/908434/Disparities_in_the_risk_and_outcomes_of_COVID_August_2020_update.pdf

Public Health England: Beyond the Data: Understanding the impact of COVID-19 on Black, Asian and Minority Ethnic groups. https://www.gov.uk/government/publications/covid-19-understanding-the-impact-on-bame-communities

[ii] Mathur R et al. The Lancet  Apr 2021. Ethnic differences in SARS-CoV-2 infection and COVID-19-related hospitalisation, intensive care unit admission, and death in 17 million adults in England: an observational cohort study using the OpenSAFELY platform

https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(21)00634-6/fulltext

[iii] From Sir Michael Marmot reported by The Guardian wed 7^th April. UK public health expert criticises No 10 race report ‘shortcomings’ | Race | The Guardian

[iv] ADPH Policy position: Supporting Black, Asian and minority ethnic communities during and beyond the COVID-19 pandemic

Disease outbreaks, climate change and conflict are affecting millions of people each year and that number is growing.  We’re facing a global-health crises and tragically it’s the poorest people who suffer most. 

UK-Med is an international emergency health charity who believes everyone should have the health care they need when crises or disasters hit.  We save lives in emergencies.  So, when health systems are over-whelmed, we send expert health teams to where they’re needed fast.  We help communities prepare for future emergencies, and we share what we learn so people across the world can get the best care. 

Our global response to the COVID-19 pandemic:

Since February 2020 UK-Med has responded to 13 requests for help to support the global COVID-19 pandemic in countries including Ghana, Cambodia, Zambia, Lebanon, Bangladesh, Armenia and Eswatini in Southern Africa.  Our work involves providing direct clinical care, delivering specialist training and on the job mentoring and support to better prepare health care teams for future emergencies and developing research projects to share best practice and inform policy improvements across the humanitarian health sector. 

We’re a lead partner in the UK Emergency Medical Team (UK EMT), the Government’s frontline response to a medical emergency and we played a key role in the set-up of the Nightingale, Manchester.

Helping fight COVID-19 in Djibouti, East Africa:

UK-Med’s most recent response in June, follows an urgent request for help via the WHO Emergency Medical Team’s (EMT) Secretariat to support Djibouti’s response to the COVID-19 pandemic. 

Djibouti is a small country on the East coast of Africa which has become a temporary shelter to around 33,000 asylum seekers and refugees fleeing war and drought.  Prior to the COVID-19 pandemic, it was estimated thousands of people passed through the country each year from its neighbours:  Somalia, Ethiopia, Eritrea and from across the Bay of Aden, Yemen. 

With a population of less than a million, Djibouti itself is facing a number of crises, particularly extreme poverty, limited access to healthcare and continual health problems, including HIV/Aids[1].   Nearly half the country’s population live in slums on the outskirts of the capital city, making it a hotspot for a future COVID-19 surge. 

The UK-Med team:

Although current case numbers of COVID-19 are low with (as of June 22^nd) 11,591 confirmed cases and 155 reported deaths, Djibouti needs urgent support to prepare for a future wave.  

UK-Med has sent a team of four medics to assess and deliver urgent training in four of the larger hospitals in the capital – Djibouti City.   

The team is made up of a critical care doctor and nurse from the Democratic Republic of Congo and Rwanda, a specialist nurse in infection, prevention and control (IPC) from Benin – West Africa and a British biomedical engineer from Bedfordshire. 

They are providing specialist training to healthcare staff to treat serious and critically ill patients with COVID-19, setting up a triage system in each of the four hospitals, encouraging the uptake of the COVID-19 vaccine amongst healthcare workers and developing infection, prevention and control guidelines to prevent the further spread of the virus.  The biomedical engineer is also delivering training in the distribution and supply of oxygen and maintenance of medical equipment. 

A Manchester charity, born of the NHS:

Born of the NHS, UK-Med is a Manchester charity that has been responding to emergencies around the world for more than 30 years.  Our founder Professor Tony Redmond OBE led the first response – a team of eight Manchester clinicians to Armenia in aid of those who had been hit by a devastating earthquake in 1988. 

When Ebola hit West Africa in 2014, killing over 11,000 people, we recruited, trained and sent 150 NHS clinicians to work in treatment centres alongside local health workers to help bring the outbreak under control.

A unique mix of expertise:

Today, UK-Med draws our teams from a unique mix of top NHS and international clinicians, experienced aid workers and local expertise.  Our register of nearly 1000 doctors, nurses and allied health professionals of all specialities is rigorously trained for emergencies.  The patients we reach receive the best possible care because our teams are verified to international standards by the World Health Organisation. 

Support us to help everyone get the health care they need when crises or disasters hit. 

For the pandemic to end it needs to end everywhere. And right now, there are too many forgotten places. A donation today will help us continue our work in Djibouti or on another emergency health response.  UK-Med only responds to local requests for support and when we know we can add value.   Read more about our COVID-19 responses around the world.  

Alison Mee

Media and Communications Manager

UK-Med

[1] https://borgenproject.org/tag/healthcare-in-djibouti/

The 2010 Marmot Review was a landmark, evidence-based, review into public health and inequalities. Ten years on, Sir Michael Marmot has demonstrated that overall life expectancy has stalled and even decreased in some groups. Levels of deprivation have not improved, and people are spending more of their shortened lives in poor health.

Poor health and inequalities are expensive to the public purse, creating a clear logic to tackling this issue, beyond the moral imperative. The timing of reform to public health organisations in England may have been surprising but does present an opportunity for change. The recent consultation on public health systems sets out proposals to split health security and health improvement into two bodies – the UK Health Security Agency and the Office for Health Promotion. The covid pandemic has devastatingly shown the value of each.

The reforms present an opportunity to approach commissioning differently. Too often decisions are made on the immediate need of the health system to cope, such as with winter pressures. This defers public health decisions, yet every tomorrow the problem is bigger. We need significant public health programmes, with wide remits, over a multi-year cycles. Rather than expecting immediate returns, we need to recognise that quality and benefits can take time.

By way of comparison, energy supplies and sustainable energy plans are designed over decades. Targets set in 2007 were designed to be achieved by 2050. The commissioning, building, and eventual decommissioning of a nuclear power plant is not designed to meet the energy needs of the upcoming Christmas holidays. The benefits of building a power plant will be delivered over decades. Public health should be no different.

The evidence for tackling modifiable risk factors has been known for years. Yet prevention is routinely not adequately funded. Whether this is smoking cessation services being decommissioned, EHC services being restricted, or great ideas to tackle weight or blood pressure never getting past the first hurdles – opportunities are being missed. Changing the public’s health is not a quick fix, nor is it solely the responsibility of healthcare professionals. Public health stretches from education to housing to diet to social activities. There is often talk of the benefits of a “system”, but the absence of an inclusive, truly integrated system means we miss the full potential of public health to reduce poor health and tackle inequalities. Clear lines of communication, shared objectives, and co-designed plans are essential.

Community pharmacy is an obvious partner in any national strategy. Community pharmacy’s role within public health, health security and prevention has never been more visible. Covid vaccinations and testing kits have reinforced the importance of accessible healthcare teams within communities. There is a network of over 14,000 pharmacies across the UK who can work with local leaders, their communities, and patients to change the health of local populations. Changing behaviours and culture is not a quick fix, and objectives can be no less rigorous even while recognising this.

Balancing the needs of local and national is never easy. Although all populations are unique, they often have similar requirements. The public need to know what support they can expect and how to access it. Individual services may not be prolific if there is little need in one area, but there is no need to ‘redesign the wheel’ in every area. Universal demands such as emergency contraception should be nationally commissioned from every pharmacy, eliminating any element of ‘post-code lottery’. But even services that may be more tailored to local need, reflecting specific priorities, should embrace an overall framework. There are gold standards for much of healthcare, but commissioning remains firmly patchwork and inconsistent.

During the height of the pandemic, when pharmacies were under immense pressure, local interpretation of guidance added confusion and inefficiency. There is a need to balance universal principles and key actions, whilst accounting for local implementation. Various national bodies have been criticised over the last year for the clarity (and timeliness) of their communication. Local leaders need to have both the confidence to implement locally and the discipline not to create local variation unnecessarily.

Whether seen through the lens of “levelling up” or reducing health inequalities, local and national leaders need to build on the amazing ‘can do’ spirit of the healthcare sector during pandemic and seize the opportunity that public health presents to achieve lasting change. Community pharmacies are placed within communities, trusted, and accessible. The ”inverse care law” does not apply to community pharmacy, and commissioning just a few well designed intervention programmes would make a material difference to our nation’s health. Moving the prevention aspect of public health into the remit of the Chief Medical Officer presents an opportunity to supercharge our collective efforts. Pharmacy has the expertise, the national network and local reach. All we need is the opportunity to use them.

Nick Thayer
Professional Research and Policy Manager
Company Chemists’ Association

None of us can envisage how the complex adaptive system of planet Earth and its ecosystems will develop over time, but one thing is certain – that our planet, and the human societies, animals and plants which inhabit it – will change in ways which are unknown and unknowable. The dominant cultural paradigms of modernism and postmodernism which have defined public health practice are being replaced by a new paradigm which is increasingly referred to as ‘metamodernism’. Public health leaders are ideally placed to shape this slowly evolving cultural revolution, and will also need to attend to their own development to thrive.

Human beings have lived in societies and created culture for at least 40,000 years. Cultural  ‘memes’ (non-biological units of cultural transmission) are spread between human beings by communication: similar to a virus becoming endemic, some memes take off within a society and become dominant. Memes which become dominant may go on to define a broader paradigm (‘meta-memes’) and thus define a society, we regard such meta-memes as being the symbols and signs of a society’s ‘culture’ (as represented by their forms of art, literature, music, philosophy, religion and science etc).

The spread of cultural paradigms is not even within a society, nor can a paradigm be readily contained within specific time periods as discussed by the authors under the pseudonym of Hanzi Freinacht. The cultural paradigm which has increasingly dominated Western society for the last few hundred years (‘modernism/scientific rationality’) has its roots in the 17^th and 18^th Century Renaissance, Scientific Revolution, and Enlightenment periods. While one cultural paradigm may dominate a society, nation, or group of nations, as in the example of modernism, there are actually multiple paradigms co-existing globally – and also within a nation or even within a local society – at any one time. For example, the range of cultural beliefs within societies and individuals across the planet currently spans from ‘animistic’ (tribal society with magical and ritualistic thinking) through multiple paradigms to ‘post-modern’ (criticism of the rational, scientific thinking of modernism). This presents a challenge to public health leaders, whose endeavours to improve the health and wellbeing of local communities and national populations cannot, as we know, ever be a one-size fits all. This is before we even consider the additional issue of stage of adult development of individuals within a society.

Each new cultural paradigm has brought some degree of improvement to the health and wellbeing of people and the planet. However even the most well-intentioned moral projects resulting in new and seemingly ‘better’ paradigms have brought unintended negative consequences of their own: every paradigm contains ‘the seeds of its own destruction’. Freinacht reminds us that modernism has led to further inequality, alienation and ecological collapse, and that while postmodernism has provided a narrative in response to oppression and inequality, it has largely failed to have impact.

There is evidence, especially in Nordic countries, of an emerging new cultural paradigm which public health leaders may wish to consciously pay attention to, in order to shape its direction, to enhance the benefits and to mitigate the unintended, inevitable, negative consequences. It is a paradigm evolving under the names including post-postmodern, TEAL, integral, and increasingly referred to as ‘metamodernism’.

Metamodernism is a perspective which transcends and includes many aspects of previous paradigms, and is based on complexity, emergence, and dialectical thinking. Individuals are seen in the context of transpersonal networks integrated with the planetary ecosystem, ie both autonomous and indivisible from others and the whole.  Descriptions of a possible metamodern society are based on ideas of cultivating new forms of social welfare – building societies where people feel heard and valued, with a focus on adult development and psychological wellbeing. Metamodern politics focuses primarily on process, in order to ensure that all people can flourish and thrive – and all of this in a way which is open, democratic and without ‘being controlled’. As public health leaders, we know that this must be underpinned by the essential needs of food, security, income, and other key determinants of health: and yet there is also increasing evidence that people with, for example, poor mental health can also experience high levels of wellbeing, and vice versa.

Public health professionals have always worked at the forefront of new ideas and new paradigms, working across systems, organisations and communities in service of their populations. In order to lead in the context of new, post-postmodern cultural paradigms, public health leaders will need to grow their own forms of mind to embrace the metanarratives of metamodernism.

Dr Fiona Day is a former Consultant in Public Health Medicine, now working as an Executive Coach offering world-class coaching for senior doctors, medical and public health leaders in the UK and internationally. She specialises in using adult development theory in the context of complexity to enable leadership development.

What is COP 26?

We are hearing a lot about COP 26 these days, so what is it? It is the next annual UN Climate Change conference. COP stands for Conference of the Parties and the meeting will be attended by the countries that signed the United Nations Framework Convention on Climate Change (UNFCCC) a treaty that came into force in 1994. 194 countries ratified the treaty.

COP 26 is happening in Glasgow in November 2021. It should have been in 2020 but was postponed due to the COVID-19 pandemic. It will be hosted by UK and Italy. There is still some debate as to whether the meeting will be partly ‘virtual’ due to the continuing issues of the pandemic.

COP 26 is significant as it is 5 years since the landmark Paris agreement and is the first time countries will come together to renew commitments to strengthen the ambition to meet the 1.5 degree target agreed at the Paris COP in 2015.

Each country has to produce a NDC (Nationally Determined Contribution) outlining what they will contribute to the global reduction in emissions towards net zero by 2050. Most NDCs need to be more ambitious than they are at present and the delay to COP 26 has given an opportunity for countries to revise them. UK has recently produced a revised NDC. During the Leaders’ Climate Summit, hosted by President Biden on 22 April, USA published an ambitious NDC, including the commitment to achieve an economy-wide target of reducing its net greenhouse gas emissions, and other countries also made further commitments. However taken together they still do not get us to the target.

Why is it important for Public Health?

Climate change is a public health emergency, as FPH recognised in 2019. The response to the COVID-19 pandemic has shown how countries can respond to a health emergency and the science shows the next 10 years are critical if we are to respond effectively to the climate crisis. Climate change has serious health impacts but there are also important co-benefits of addressing the environment and climate issues and addressing health, for example in the area of clean air, active travel, diet and nutrition.

The issues of climate change, biodiversity loss, environment degradation, and sustainable development are inextricably linked and underline the need to take a One Health approach to population health. 

The international health community has been trying to ensure that health issues are more centre stage in the NDCs and also centre stage at COP 26.

Climate Change is the biggest threat to health.

There are major health impacts of climate change, not just across the globe but also here in UK. Floods and severe weather conditions cause both physical and mental health impacts. Only last week we saw the landmark ruling, with air pollution recorded as a cause of death for the 9 year old Ella Adoo-Kissi-Debrah, who died of an asthma attack in 2013.  This is due to emissions, mainly from cars and lorries. Air pollution accounts for 4.2 million deaths per year globally and 40,000 across the UK.

This pollution is happening now in our cities. Many areas in the UK do not meet the WHO standards for air quality.

We all as PH professionals have a responsibility to make the connections between everyday health issues and climate change, and address both, tackling them together. 

Why now?

Whilst the COVID-19 pandemic has hit the globe in the face, climate change is the other big emergency that is hitting as we speak. Besides air pollution, we are already seeing the out-of-control wildfires in Australia and USA, and islands literally disappearing with rising sea level.  We are seeing extreme weather conditions across the globe and in UK. Wildfires happened last week in UK due to the lack of rain and floods regularly cause major problems across the UK with some families not back in their homes 18 months later. 

The Biden summit last week was seen as the first marker for COP 26 and has been welcomed as it signals the USA being back in the Paris agreement and working with other countries on climate issues.  

We have to act NOW if we are going to stop these health impacts and we have to act locally, nationally and globally.

The run up to COP 26 gives us an opportunity to think differently about this both as individuals and in our professional public health lives. Many recognise that sustainability and climate change issues need to be a day-to-day part of our public health practice and we need to act now.

As Greta Thunberg said earlier this week on the BBC “Hope doesn’t come from words, it comes from action”.

Sue Atkinson
Chair, FPH Climate and Health Committee