We Need a Public Health Revolution
The coronavirus crisis has demonstrated a need to rethink healthcare, breaking from outdated technocratic models and seeing the full social and political context behind public health.
In a matter of weeks, Covid-19 has irrevocably changed society’s expectations about the role of government in protecting health. The nature of the threat — which is likely to endure in one form or another until an effective vaccine can be developed, mass-produced, and then efficiently administered on a large scale — has left the global population highly dependent on state intervention to guarantee its physical safety and in many cases its economic livelihood. In the UK, as in other countries, the legitimacy of our system of government now rests on its ability to institute proportionate and effective measures to avoid excessive numbers of deaths while allowing some forms of essential economic activity to continue.
In one short shock, this crisis has overturned the neoliberal notion that individuals are best placed to manage and navigate risk in the modern world, while government is there to simply nudge us, and to steer and shape the market environment to meet our preferences. This shift is profound and destroys the excessively narrow conception of ‘health policy’ which has come to dominate thinking about the role of government in relation to the health of the population.
This conception of health policy, which is propagated by the nexus of well-funded think tanks and management consultancies which surround the Department of Health, sees the role of government and the health of the population in almost entirely technocratic and managerial terms, producing an often arcane debate about ‘health systems’. It has an almost exclusive focus on the cost and distribution of healthcare facilities while failing to engage in any meaningful way with the wider social determinants of health. Discussion about how best to allocate healthcare facilities — such as which hospitals to close or open — takes place largely outside the public realm and scant attention is paid to involving the public in any of these decisions.
This limited way of thinking about what constitutes health policy has meant that anything which falls outside the medical model of treatment — such as the wider social care needs of the most vulnerable — are neglected. As a result, for over twenty years policy makers have failed to come up with a way of providing adequate funds to social care, instead passing responsibility back to families and individuals while relying on the market to provide services at what is supposed to be the lowest possible cost. Lip service is paid to any studies which show that societal changes are required to improve the health of individuals — for example, through the redistribution of wealth to reduce health inequalities — but no action is ever taken.
A Social Doctrine
Of course, the provision of comprehensive health and social care services to the population is a key part of any government’s health policy. If government is to treat access to healthcare as a human right — as it should — the provision and distribution of health care services will always form a large part of its annual expenditure. But there is another conception of health policy which sees the government’s role in protecting health in much broader terms. It is this second conception of health policy which will need to be at the forefront of our thinking when the crisis caused by Covid-19 subsides.
The doctrine of public health emerged in the nineteenth century as a response to the diseases and ill-health caused by industrial capitalism. Before many life-prolonging drugs and other medical technology were available, public health doctors, epidemiologists, and public servants sought to improve the health of local populations through a range of interventions that were developed on the basis of the latest advances in scientific knowledge — by improving the supply of clean water and sanitation, getting rid of squalid housing, regulating food quality, and working hours and conditions, and so on. The great German health researcher Rudolf Virchow memorably summed up the conclusion to be drawn: ‘politics is nothing else but medicine on a large scale’. The demonstrable impact of these policies in dramatically increasing life expectancy provided a justification, both morally and economically, for state intervention.
It was also through the discipline of public health that government learned the techniques needed to control infectious diseases and the importance of developing health protection systems capable of responding to public health emergencies, including those caused by war and natural disasters. The NHS itself was in significant part the realisation of a concerted government public health initiative to create a national emergency hospital system to protect the civilian population from the effects of aerial bombing, as well as to look after injured troops.
However, even though there is clear evidence that a public health approach has a greater impact on the health of the population than the provision of health care services or medical technologies, both the resources dedicated to public health and the voice of public health professionals have been deliberately diminished by government over the last decade.
The downgrading of public health as a discipline has been painfully revealed by the UK’s slow and problematic response to Covid-19. The idea that this was an unforeseeable and unprecedented event in terms of both its magnitude and its likelihood is belied by the fact that it has been the main risk on the civilian risk register since 2008.
Yet not only did the Conservative and Liberal Democrat coalition government abolish the main public health body specifically set up to assist in preparing for such an eventuality — the Health Protection Agency — it also stripped the NHS of its public health capacity, and cut the local authority budget for public health by £700 million. The consequences of this in terms of infectious disease are revealed in the growing numbers of Sexually Transmitted Diseases, Tuberculosis, and measles outbreaks, particularly in London. The lack of any state capacity to roll out mass testing of NHS staff for Covid-19, with the government having instead to rely on a private company Boots to do so, is further evidence of how our public health infrastructure has been run down.
And the status of public health profession itself has also been undermined. Whereas directors of public health — and before them the powerful medical officers of health in local government — used to play a significant role in both monitoring the health of the population at local and regional level, and recommending interventions, their resources and capacity to act have been significantly downgraded. And at the national level, rather than use proven public health interventions, such as minimum alcohol pricing, to reduce poor health, policy makers have instead preferred to rely on behavioural economics — ‘nudge theory’ — to encourage ‘lifestyle changes’.
But more seriously still, as the recent Marmot report reveals, the government has prioritised austerity over all other areas of public policy leading to the improvement in life expectancy stalling, and for the poorest 10 per cent of women, actually declining.
The Public Health State
However, as a result of Covid-19, a public health approach has suddenly once again become official orthodoxy. It could be said that we are, at least temporarily, living in a ‘public health state’. Although it is not clear how much of the government’s response is being informed by public health specialists, as opposed to those who are experts in statistical modelling and behavioural economics, it is still the case that all of the actions now being taken by government are being assessed primarily through the lens of population health.
This seems likely to be the case for the foreseeable future. Decisions on when and where to release the current restrictions on population movement will be informed by the likely public health impact of such a move, and for as long as the virus remains actively contagious other large areas of government policy will likewise have to increasingly take into account the advice of public health specialists if the strategy is to succeed.
This experience of living within a ‘public health state’ seems bound to change longer term attitudes to government health policy. However, to reinstate public health as the dominant discipline in our thinking about health policy will require three major changes, none of which is certain to be made, and all of which will need to be achieved through collective action.
The first is structural. The NHS must in future be planned and organised in such a way as to be able to anticipate and respond effectively to public health emergencies of the kind represented by Covid-19, because this pandemic as a public health emergency is unlikely to be a one-off event. Major infectious disease outbreaks which threaten the UK population are now happening more than once every decade — SARS in 2003, the Swine Flu pandemic in 2009, and MERS in 2013.
In addition, our ability to control infectious disease is being undermined by the diminishing efficacy of antibiotics. According to the World Health Organisation:
‘Antibiotic resistance is rising to dangerously high levels in all parts of the world. New resistance mechanisms are emerging and spreading globally, threatening our ability to treat common infectious diseases. A growing list of infections — such as pneumonia, tuberculosis, blood poisoning, gonorrhoea, and food-borne diseases — are becoming harder, and sometimes impossible, to treat as antibiotics become less effective.’
The health threats to the population as a result of climate heating are no less significant, but remain unmentioned in any NHS planning document produced over the last decade. Addressing these threats requires building the precautionary principle into health service planning and wider government policy, so that there is a presumption in favour of taking concerted action to mitigate risks, even when the likelihood and magnitude of these risks is not easy to predict.
All this means having a health system which has the resilience to produce the necessary surge-capacity to meet population needs, and which is able to adapt quickly. It means having a surplus of resources in terms of both facilities and staff to provide the system with the required resilience. Efficiency will need to be redefined to include effectively protecting the public from health threats, as opposed to merely keeping down the capital and running costs of hospitals. It also means having sufficient public control over the necessary supply chains to guarantee the availability of drugs and equipment.
Public health teams with significant authority, along with strengthened professional and administrative capacity across local government, will need to be put in place, within rationally defined geographical areas, and enabled to deploy the huge amounts of data which the NHS generates to plan and co-ordinate all forms of care services across local populations. This data belongs to the public and must be used by NHS epidemiologists rather than being handed over to big tech companies to exploit for commercial benefit.
Moreover, a health system capable of meeting these challenges cannot rely on leaving social care to be provided by thousands of charities and businesses, as is currently the case. Social care needs to be fully integrated within the health service. And to achieve all this, the NHS will need to have an organisational structure which is simple, coherent, and provides a new kind of democratic accountability; not mere formal accountability to a minister but a genuine direct accountability to the public and to NHS staff through new forms of reporting, and new modes of public response, at both local and national levels.
Achieving such a shift in the health service will require major additional resources and a collective recommitment to the importance of the NHS as a state-owned, state-funded institution.
Medicine as Politics
The second change is political. The extent to which public health considerations become more dominant in other areas of government policy will depend on whether the current radical reinvolvement of the state in the economy is seen as the only possible solution to a crisis which is just one of a growing range of threats, and so becomes the new orthodoxy, in the same way that the post-war consensus emerged out of the crisis of the Second World War. For this to happen the legitimacy of the government must be seen to depend on its capacity to protect the population from the real risks of harm that we now face.
The final change is that public health by its nature requires a much more collective approach to government than the liberal individualistic philosophy which has predominated for the last fifty years. The significant gains to health, well-being, life expectancy, and security which a public health approach delivers depend on a degree of trust in the authority of the government which the last forty years have undermined, and a renewed willingness to place common goals above individual preferences. The experience of living for many months in the shadow of an existential threat could lead to this shift in attitudes.
But less benign outcomes are also possible. Instead of the failure of the existing model being recognised and admitted, there will be a strong push to frame the current crisis as a ‘black swan’ event, having no relevance to thinking about our economic model or system of government.
It is entirely possible that lessons learned from this crisis will be confined to a narrow technocratic perspective — a focus on the stockpiling and supply of PPE, emergency preparedness plans, and the procurement of ventilators rather than on the failings inherent in our current system of government and the hitherto dominant conception of its role. Opposition parties, the media, civil society, and above all healthcare professionals — especially including the public health community — will need to ensure that the terms on which the crisis post-mortem is carried out are sufficiently broad to prevent any attempt to return to business as usual.