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A generation of children who grow up in poverty, and have worse health as a result, risk being airbrushed from official records, according to an inquiry by the All Party Parliamentary Group (APPG) on Health in All Policies into the impact of the Welfare Reform and Work Bill.

FPH provides the secretariat for the APPG, which is chaired by Debbie Abrahams MP, Shadow Minister for Disabled People. The APPG’s inquiry into the impact of the Welfare Reform and Work Bill 2015-2016 on child poverty, child health and inequalities wa launched in December 2015.


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  • by Peter Sheridan, Registrar, FPH

The Faculty of Public Health (FPH) provides advice to employers and others on appointments procedures for senior public health posts at consultant level in the UK. Public health consultants work to promote healthy lifestyles, prevent disease, protect and improve general health and improve healthcare services.

They work across the spectrum from a rural community to the global population. Some consultants become experts in a specific area of public health, while others find that their job incorporates a cross-section of public health activities and research. It is this broad spectrum of background that can make it difficult to assess which consultant is the best fit for any particular role.

Consultants are required to have a broad understanding of all the factors that contribute to health, including the structure of healthcare systems and services, current government policy and how to interpret available data effectively. They need to be skilled at evaluating evidence to devise and implement strategies for improving and protecting health, and health services. They must be able to work on multiple projects at the same time, and be able to respond to emergencies.

Tough negotiation skills and good powers of persuasion are critical attributes. The consultant in public health has to be qualified as a public health specialist and on the GMC, GDC or UKPHR specialist register. They are also required to undertake CPD and revalidation to ensure they remain on the relevant specialist register and licenced to practice (where appropriate). This means that the consultant is qualified to FPH standards and formally regulated, including procedures to identify fitness to practise and apply sanctions if necessary.

FPH provides external professional assessment and advice, through its network of regional Faculty Advisers and FPH assessors who sit on appointment panels. The panels deliver the assurance that public health consultants have the necessary technical and professional skills required to promote, improve and protect health and provide high level, credible, peer-to-peer advice to the NHS about public health in relation to health services. This is based on the Faculty’s knowledge of training, professional development and standards and its ability to provide independent assessment and advice to local authorities on these issues.

FPH has worked with the Local Government Association, Public Health England (PHE) and Association of Directors of Public Health to provide local authorities with guidance on appointments of Directors of Public Health (links to pdf) and Consultants in Public Health (links to pdf).  This builds on the NHS process and ensures that there is senior professional input into selection with a senior PHE consultant and an assessor appointed by FPH.  We now have around 160 assessors trained in the last three years in Birmingham, London and Manchester and we now give them feedback on their contribution to the selection process.  We also do individual matching of assessors to particular types of post.

Many local authorities are maintaining the links to NHS terms and conditions (T&C) with posts advertised on medical consultant T&C or Agenda for Change (AfC) band 8d. This provides some equity with PHE and NHS posts.  Some authorities are moving to their own salary scales for new staff and some even restructuring existing staff.  These salaries can be significantly lower than what NHS was paying for a consultant in public health.

Those councils who have tried to recruit at lower rates of pay have not been particularly successful and have re-advertised at higher rates offering “market supplements”. We know that PHE are able to appoint to nearly all advertised posts but significantly fewer local authority appointments are successful. There is a demand for interim consultants across the country and I am turning down offers of up to £700 per day.  So I can see consultants moving on if they see their salaries cut either to a more enlightened authority or to NHS posts at Band8d or higher.

This has been the local authority response to equal pay challenges which have proved very expensive.  So James Gore, Head of Professional Standards at FPH, and I have been working again with our partners in LGA, PHE and ADPH to describe multidisciplinary teams in local authorities.  This has offered national guidance on how to address issues around equal pay, some encouragement to accept continuity of service and explains that a public health team will contain a range of specialists including those from a medical background. 

Medicine is the background of most of our members and half of our registrars.  It is important that medical public health consultants are not pressed into posts in PHE or NHS.  Their experience in local authorities will equip them to join the next cadre of Directors of Public Health (DsPH) and provide leadership of the public health system.  I work for PHE in Wellington House, where nearly all the consultants are former DsPH.  I believe it is important that they continue to be drawn from the field.

We need to start the conversation about retaining equity for AfC remunerated consultants who reach the top of scale.  If they take a DPH route they are rewarded with Band 9 or Very Senior Manager (VSM) pay or local authority equivalent scale.  This new guidance restates the FPH position that the AfC equivalent of medical consultant is band 8d/9.  I think we will need some additional items in the job description such as educational supervisor, Faculty assessor, and formal deputy director role.

James and I are continuing to meet with this group to take forward some of this thinking and monitor its implementation over coming months.

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  • by Miranda Eeles
  • Researcher at London School of Hygiene & Tropical Medicine

“Why are we not more angry?”

That was the question being raised by the participants of Sandwell Health’s Other Economic Summit (SHOES) which brought together academia, doctors, architects, journalists, local government and civil society to discuss issues ranging from sustainable food policy and climate change to the privatization of the NHS.

The Summit, which was held at the Balaji Temple in Tividale on Friday 28th March, is Sandwell Health’s annual event that aims to explore current themes and challenges in public health both at global and local level.

Neo-liberalism, corporate power and an assumption that development equals economic growth were identified as some of the mains reasons behind the problems facing the world today, and the increasing gap in inequalities.

“We need to change the narrative”, said Dr David McCoy, senior clinical lecturer at Queen Mary University, London and Chair of MEDACT.  “We need to demonstrate an alternative system and put forward intellectual and scientific arguments to eradicate poverty and address climate change.”

Corporations, government and the insurance industry were all put under the spotlight as speakers lamented a lack of leadership across the party spectrum.

But as in previous SHOES events, the audience also heard about the achievements at local level which illustrate how change can happen, provided the political will is there.

Urban food growing, investing in community assets and young people, creating a culture of activity and a return to a strong synergy between rural and urban environments were listed as some of the ways in which to address local needs.

This year’s Summit also was a celebration of the exemplary work done by John Middleton, Sandwell’s Director of Public Health, who retired at the end of March after 27 years in the job.

‘Dials’ and ‘levers’ were terms used to describe priorities and actions that have been employed under his leadership to bring different agencies together to improve the health and well being of the local population, including the Police, NHS Trusts, Clinical Commissioning Groups, a Youth Council and different departments of Sandwell Council.

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– by Dr John Middleton

–  Vice President, Faculty of Public Health; formerly  director of  Public Health for Sandwell, 1988-2004

When I first came to Sandwell in 1987 it was in the depths of recession. In health services there was no local mental health service, no palliative care and much general practice was single-handed out of shop fronts. Waiting lists for basic elective procedures could be up to four years. Over half the population was living in poverty. There were 120 high-rise blocks and nearly fifty thousand council houses. Less than half of all children were immunized against measles and other childhood immunisations were less than satisfactory.

There have been great advances in health and health services provision. Progress began in the early 1990s and became exponential in the early 2000s.  Even nine-month waits for operations were no longer to be accepted. They had to come down to 18 weeks. And no more than 4 hours in A&E.  Services for people with serious and enduring mental health problems were improved substantially in the early 1990s. Over many years there have been improvements in community based palliative care, with fewer people dying in hospital.

In my final annual public health report for Sandwell, ‘ Public health: a life course’, I have reflected on some improvements in outcome.  Heart disease deaths have gone down by an astonishing 2/3rds. Some of this is reflected in the long-term trends. But those trends have been influenced by the new and evidence based services, which have been implemented across the country over the years. We can point to improvements made in Sandwell, which have reduced deaths faster than the national rate and have reduced our gap in life expectancy with the national rate. Most recently, our GP based risk management system has saved more than 70 lives a year and closed the gap with the national life expectancy. Not a bad result considering heart disease deaths went up in the mid 2000s.  I believe this was a cohort effect. The group of men thrown out of work in the 80s were dying prematurely from heart disease, brought about by a lifetime without work, hope, and probably smoking, drinking and being inactive.

Teenage pregnancy has come down by 44% since 1998. This I attribute principally to rising expectations in education. From 2007, exam results went up and teenage pregnancy came down. Over a number of years, it ceased to be acceptable to attribute poor results and low expectations for our children to  ‘the deprivation’. If one teacher, or one school could make a go of educating children under difficult circumstances, they would all be expected to.  In health, there were also some excellent services built up painstakingly over a number of years, in personal social education, young people’s contraceptive services and morning after pill availability from pharmacists.

The fact that teenage pregnancy has not gone up again in the latest recession is, I think, due to the insulating effect of the Surestart programmes, which began in 1998. Surestarts gave support to parents from deprived backgrounds, Surestart plus gave additional support to teenage mothers and Surestart maternity grant gave some financial support to pregnant mums.  Most recently the Family nurse partnership has provided additional support to young mums. The policy advisory team from cabinet office that came to Sandwell in 1998 expressly set out the idea to support teenage mothers at that time, to break the cycle of babies born to teenage mothers then, becoming themselves teenage mothers 16 years on, I think we are seeing the benefits of that.

There has been an outstanding achievement in improving  Sandwell homes to Decent homes standard. In our local research which we plan to publish,  we have found much larger health effects in reducing cold related deaths and hospital admissions than have previously been reported.

There has also been the excellent achievement of Sandwell probation service in having the lowest reoffender rate in the country.  The health component of crime reduction this has been considerable- in tackling drug and alcohol related crime, responding to domestic violence, providing appropriate care for mentally disordered offenders and supporting community development programmes to combat violent extremism.  The recovery agenda for drugs and alcohol related offences has been a substantial contributor to reducing reoffending.

On a downside, there is much for my successor Jyoti Atri, to pick up on and deal with. Tuberculosis rates remain stubbornly and unacceptably high.  It is normal to be overweight in Sandwell.  Infant death rates have not reduced in the last 15 years. The West Midlands has the highest perinatal and infant deaths in the country and they have not come down as fast as they have elsewhere. The West Midlands has the highest rates of child poverty and the highest rates of obesity in the country both known risks in terms of infant health outcomes. We  also need to review our antenatal policies, particularly with regard to growth monitoring in utero. I have recommended that Sandwell should commission an expert review of infant deaths, preferably with other councils in the West Midlands conurbation. The review would look at how we should prevent deaths, and what might be needed in improving care in pregnancy and childbirth.

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  • by Martin Caraher
  • Professor of Food and Health Policy/Thinker in Residence Deakin University, Melbourne (February 2013)
  • Centre for Food Policy, Department of Sociology, School of Arts and Social Sciences, City University London

There has been recent concern in public heath circles with the media reporting that the UK has opted out of the new EU Social Welfare Fund scheme, which began in January 2014. This replaced the ‘Food Aid Programme to the Most Deprived Persons in the Community’, commonly known as the MDP programme ran from 1987 to December 2013. The reporting has focussed on the issue that by opting out of the new scheme that food banks in the UK cannot access food or funds from the new scheme for those in need. While this is true and a consequence of the opting out (Hansard 2012), there are deeper – and maybe hidden – issues to be addressed.

These relate to the role of food banks in our society and the right to food for citizens as well as questioning why such a need exists? While food banks have captured the public imagination and grown from one in 2000 to over 400 today their emergence raises questions over the roll back of the state around food welfare and the role of charity as a replacement. Focusing on the supply of food to food banks while it may be important does not address the fundamental question of the place and role of food banks in a welfare society.

In the UK the methods of operation and funding of food banks varies. However, they generally rely on donations from retailers and to a lesser extent the general public. In the UK Food bank provision is broadly provided by two schemes currently in operation. The key provider of food banks in the UK is the Trussell Trust, a Christian charity which franchises its model to local groups allowing them access to food supply sources and the use of publicity materials. In the three months to the end of September 2013, 356,000 people received three days of free food from one of the 400 + food banks in the Trussell Trust network.

The second major operator is FareShare which collects surplus food from supermarkets and shops and distributes it through 720 charities and organisations to needy families and individuals feeding one million people every month. It itself does not operate outlets but distributes to those who do, some of which might be food banks but others could be homeless charities, shelters or soup kitchens. Aside from this there two schemes there are many other food banks operating on their own either as independent charities or part of existing community groups, see Milestone London for an example of a group setting up a food bank for the Muslim community.

So we are seeing increases in the number of food banks and also a divergence in delivery to specific groups. Such initiatives might be welcomed under the Big Society banner; the PM has praised the work of food bank volunteers, although the Work and Pensions Secretary of State Iain Duncan Smith is on record as accusing the Trussell Trust of expanding by nefarious means when he said:

I understand that a feature of your business model must require you to continuously achieve publicity, but I’m concerned that you are now seeking to do this by making your political opposition to welfare reform overtly clear.

Many contend that the rise in the numbers using food banks is indicative of household food poverty, while the official government line is that there is no evidence that the welfare reforms are contributing to the rise in numbers using food banks. There remain unanswered questions as to the abilities and appropriateness of food banks to tackle food poverty in the long-term and as to their ability to provide healthy food, even in the short term. Underfed people are also likely to be badly fed, leading to long-term health problems. This problem of supply is because of the reliance on donations and surplus/waste food stocks.

There is a body of work examining the mechanics and efficiency of operation of food banks and their contribution to nutrient health outcomes but few, UK focussed, questioning their social relevance. Dowler and colleagues (2001) argued that such schemes perpetuate food poverty by enabling the problems in rich societies to remain marginalised.

Looking to the situation in Canada which has a long history of food banks, Riches, (2002) asserts that those seeking assistance do so repeatedly and become dependent on food aid; as what starts as an emergency response risks becoming entrenched in civic society, a la Big Society model.

Such depoliticisation of food poverty and normalisation of food bank usage can have profound consequences not just for the users of food banks but for society as a whole -‘[T]his is precisely what government wishes to hear and it helps them promote their argument that it is only in partnership with the community that the hunger problem can be solved.’ (Riches 1997)

So while decrying the opting put of the new European Social Welfare Fund it needs to be understood that the UK decision was based on issues of subsidiarity and the right of the UK to determine its own solutions. The principle has much wider implications for the UK in terms of the part it plays in European policy formation.

The debate reported in Hansard (2012) concerning the social fund is nothing more than political mud slinging with MPs, across the political divide, accusing each other of being responsible for the increase in the number of food banks but no discussion on the determinants of food poverty.

In fact, the new The Social Welfare Fund is a cohesion policy justified by Article 174 of the Amsterdam Treaty which allows the Union to promote overall harmonious development by pursuing economic, social and territorial cohesion. It is not exclusively focused on food aid. It might be important to note that the Labour government never partook in the MDP programme or other EU initiatives such as the fruit and vegetable to schools scheme.

Additional supplies of food to food banks in the short-term may help but the long-term issues of ensuring a right to appropriate and nutritious food and needs to be addressed. Key to this is how people access food and without having to resort to emergency food provision through food banks. Food banks were set up to meet failings in the welfare state and to provide emergency assistance not to be the long-term providers of food to those in need.

The elephant in the room is not the food banks but the reasons why people are turning to food banks for help.

This is a combination of welfare reforms, increasing pressure on household budgets as income remains static while food and other prices such as fuel increase. The food banks themselves are beginning to be overwhelmed by the needs and the numbers being referred. The UN Special Rapporteur on the Right to Food, commenting on the UK said the solution was for the government to define social benefits in terms of rights  (Justfair 2013).

Thus we need to see food banks as the failure of government to deliver on the right to food. Winne (2009) in his book on the US food system says: “we must seriously examine the role of food banking, which requires that we no longer praise its growth as a sign of our generosity and charity, but instead recognize it as a symbol of our society’s failure to hold government accountable for hunger, food insecurity and poverty” (p.184).

In exercising the principle of subsidiarity and non participation in the new EU Social Welfare Fund the UK government may have limited access to additional food and resources for food banks in the UK; however this should not stop the public health movement from questioning and debating the role and place of food banks in society and looking to government for solutions to food poverty. Food banks are ‘band aid’ and needed to help people in emergency situations. As to what part they play in the longer term remains to be debated.

References
Dowler, E., Turner, S., with Dobson, B., (2001) Poverty Bites, Food, Health and poor families, London, CPAG.

Hansard. (2012), Fund for European Aid to the Most Deprived [Relevant document: Twenty-second Report from the European Scrutiny Committee, HC 86-xxii.] 18 Dec 2012: Column 806, (Accessed 28th October, 2103).

Justfair (2013) Freedom from Hunger: Realising the right to Food in the UK. Doughty Street Chambers, London

Riches, G., (2002) Food Banks and Food Security: Welfare Reform, Human Rights and Social Policy. Lessons from Canada? Social Policy and Administration. Vol. 36, No. 6, pp.648-663.

Riches, G., (1997c) Hunger, food security and welfare policies: issues and debates in First World societies, Proceedings of the Nutrition Society, 56: 63-74.

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by Professor Frank Kelly and Dr Julia Kelly
King’s College London

When the UK passed the Clean Air Act in 1956 to reduce smoke and sulphur dioxide, it led the world in cleaning up air. In recent years air quality improvements have miserably stalled. We have been breaching European Union (EU) limit values every year since 2005 for the modern day pollutants nitrogen dioxide (NO2) and particulate matter (PM). Currently there is no prospect of achieving compliance for NO2 in some areas until 2025.

More worryingly, evidence to support the detrimental short and long-term effects on health has increased substantially over the same period of time. Data for 2008 estimate that air pollution contributes to at least 29,000 premature deaths in the UK each year.

In 2012, the International Agency for Research on Cancer classified particulates in diesel fumes as a known carcinogen. In 2013, a WHO report concluded that the health effects of PM and NO2 can occur at concentrations lower than the their health-based Guideline values which of note, are lower than the EU limits we fail to adhere to.

In addition, other than the well-documented risks to cardiopulmonary heath, increasing evidence exists that air pollution exerts a wider threat, negatively influencing reproductive outcomes and neurological health.

The lack of progress in improving air quality isn’t due to lack of attention by professionals in the field or lack awareness by Government. I and other expert witnesses have given evidence to the Commons Environmental Audit Committee in 2010 and again in 2011 – the ensuing reports were blatant in their conclusions, calling in 2010 for ‘political will’ and ‘committed resources to meet air quality targets.

The 2011 report concluded that ‘the Government has failed to get to grips with the issue’ and ‘must not continue to put the health of the nation at risk’. In February 2014 the European Commission launched legal proceedings against the UK for excessive emissions of NO2. This is the first case by the EU against a member state for breaching limits. One can only hope that this may have the clout to shake political indifference to air quality in this country.

Unlike the powers that be, up until the beginning of last week, it is probably fair to say that the majority of the public was relatively unaware of day-to-day air pollution, the sources and the dangers associated with current concentrations. This is partly because PM can’t be seen by the naked eye and NO2 is invisible and probably owing to a poor understanding of what is undisputedly a complex science.

However on Sunday 30 March 2014 light southeasterly winds began to blow Saharan dust plus polluted air from Europe over the UK. This mingled with our domestic emissions from cars and industry resulting in high levels of rather unusual mix of pollution. Owing to the persistence of easterly winds and dry weather, poor air quality remained with us until the end of the week.

Light easterly winds taking pollutants from continental Europe to the UK where are own fresh emissions are added is not unusual – even dust flows from the Sahara are not uncommon. Instead, what really grabbed the attention of the nation – other than the visible hazy smog – was the prolific reporting of the events in every conceivable form of media.

This was because on the 1 April 2014 the Met Office, our national weather service provider, took over responsibility for forecasting air pollution on behalf of Defra. With that came greater publicity. In comparison, previous episodes have attracted insignificant coverage. Other than registered users of proactive air pollution alert services, you would have been hard pressed to hear about the even worse poor air quality affecting parts of England three weeks ago. This particular event culminated in London recording the greatest concentration of PM10 in 2 years.

The highly charged media coverage did not stop even when air quality improved. This was the result of a change in wind direction to southwesterly, coming in from the cleaner Atlantic, combined with wet weather washing the pollutants out of the air. Sunday’s press covered emerging evidence that traffic-related air pollution may target neurodevelopment and cognitive function as well as holding diesel fumes to account.

British drivers respond to the marketing of diesel cars as the “green” option – on the basis of reduced CO2 emissions and lower fuel costs – such that approximately one half of all new private car registrations in 2012 were diesel. Added to this, in most cities diesel engines power the majority of our buses and taxis. The image however is now tarnished.

Diesel engines emit especially harmful particulate pollution and owing to lenient European testing regimens, NO2 emissions have risen steadily of the past 10-15 years. It was reassuring that this information reached the front pages of the Sunday broadsheets.

This pollution episode has certainly raised the profile of what, to many, has previously been an invisible problem. However the chronic effects of air pollution, owing to year-round exposure, are much more worrisome than the short-term, often transient outcomes. We cannot afford to just focus on distinct episodes. As succinctly put in one online blog earlier this week: ‘We need to reduce air pollution when it isn’t making the headlines as well as when it is.’ Traffic must be reduced and we must ensure a cleaner and greener element to what remains on the road.

This can be achieved through a number of strategies: an expansion of low emission zones, investment in clean and affordable public transport, a move back from diesel to petrol or at least a ban on all diesel vehicles not fitted with a particulate filter and a lowering of speed limits. Focused education and continued evolution of sophisticated information systems can also achieve a durable change in public attitude and in turn behaviour.

But engagement must be blatant and put in the context of other public health risks such as passive smoking and utilise compelling messages such as premature death. There will be costs – but these should be balanced against the economic cost from the impacts of air pollution in the UK that are estimated at £9-£19 billion every year.

Cracking our air pollution problem is a huge challenge. It is highly unlikely that our major cities will ever be able to boast ‘pure air’ especially if strategies focus on small areas of an overall road network – as I have been quoted before: ‘air pollution does not respect any boundaries’. With bold, realistic and moral leadership however, enormous potential exists to reduce air pollution so that it no longer poses a damaging and costly toll on public health.

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  • Andy Graham – specialty registrar in Public Health, County Durham

A couple of years ago I found myself in need of a dissertation topic for an MSc in Public Health – ‘make sure it’s something you are interested in’ was the advice. Simple I thought, I just need to weave football and beer into a research project! All joking aside though, I have become interested in the relationship between the two over the years.

As a public health professional and former A&E nurse, I am well aware of the potential harms of excessive alcohol consumption. Also, as a fan who both attends matches and watches on TV, I have become increasingly aware at how visible this relationship has become. Of course, football and beer have long been associated, ever since Victorian landlords would set up teams, use the land out back for a pitch and, in the amateur days, employ the team as barmen in lieu of pay.

But at the risk of sounding like my dad, when I ‘was a lad’, you either went to the match, where as a young working class man it was normal to have a pint with the lads, or you waited for Saturday night’s Match of the Day for your football fix. The pubs were open sporadically, had no TVs, and the football was rarely broadcast anyway.

Fast forward a few years and we have football on satellite TV almost every night of the week and all day at weekends, most top flight football clubs sponsored at some level by an alcohol brand, marketing of alcohol, beer in particular, is rife and the norm appears to be drink beer and watch football with the lads in the pub. Opportunities to do both are far more common than when ‘I was a lad’, and not just within pubs, but within living rooms, where the cheaper alcohol deals of the supermarkets are very popular. As a dad myself I was disturbed by these developments, but hadn’t been able to quantify them.

I decided my dissertation would try to measure the amount of alcohol marketing that football TV viewers were exposed to. With the help of Jean Adams at Newcastle University, I planned the research. I chose six live broadcasts representing over 18 hours of footage, developed coding frameworks and watched 40 hours plus of coding footage to consider all the verbal and visual references.

The results shocked me:

• Over 2,000 visual images, 111 per hour on average, or around 2 per minute.

• 32 verbal references.

• 17 traditional advertisements, accounting for 1% broadcast time.

• Over 1,100 visual images in one alcohol sponsored Cup competition alone

The issue of traditional advertising commercials is interesting because the ‘voluntary’ codes of practice in place to regulate how alcohol is portrayed (should not appeal to youth, should not suggest social success, etc.) are most relevant to this type of advertising. Given that we know that quantity of alcohol marketing is more important than content, then the apparently unchecked stream of visual references in this research may be even more important, and we could argue that the current controls are completely inadequate because they are focused on content, rather than quantity.

I can’t help but feel that we have taken our eye off the ball – the globalisation of sports such as premier league football as a product, the satellite age, the endless thirst for profit and market share within corporations, the ‘self’ regulation that fails to control the exposure reported above, the relaxed licensing laws in this country, and the increase in type, availability, and affordability of alcohol. All of these things create a perfect storm in which alcohol and sporting idols become normalised as one and the same, and the brand becomes a member of the team. It feels as though the relationship between sport and alcohol has evolved towards its perfect and logical form.

I am disturbed to be one of a generation of football fans that has been manipulated in this way and that my children are also targets. And meanwhile, the alcohol industry has a seat at the policy making table through the Public Health Responsibility Deal. So we must ask the question: are we sleepwalking into a situation where drinking alcohol is so closely associated with the sporting heroes that children see on TV, that they are being actively normalised to become drinkers? No one seems to question this, but it is time someone did, and through public health advocacy it may just be up to us.

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