The award-winning blog of the Faculty of Public Health. The aim to promote and protect the health of the population, and improve health services by maintaining professional and educational standards, advocating on key public health issues, and providing practical information and guidance for public health professionals.
Community cardiopulmonary resuscitation (CPR) teaches people living in the local community the basic skills of delivering chest compressions and artificial breaths until lifesaving defibrillation can take place for people that have suffered a cardiac arrest (their heart has stopped beating). Many causes of cardiac arrest are reversible with the right treatment, but without CPR and early defibrillation people do not survive long enough to receive these treatments. On average only 10% of people who suffer a cardiac arrest outside a hospital setting will survive. This figure more than doubles when the victim receives community CPR(1).
History of CPR
We haven’t always had this valuable skill at our disposal. People have been trying to resuscitate victims of cardiac arrest since the 1500s, with varying levels of success. By the 1800s the accepted method of treating cardiac arrest became surgically opening the chest and massaging the heart by hand(2). The first publicised mention of CPR as we know it today appeared in Journal of American Medical Association in 1961, entitled ‘Closed Chest Cardiac Massage’. The revolutionary new technique was an alternative to the currently accepted technique of open heart massage(3).
Community CPR in the East Riding of Yorkshire
The East Riding of Yorkshire is a predominantly rural locality. Precious minutes can be lost before victims of cardiac arrest receive CPR, making community CPR even more important. The local council is offering free 1 hour drop-in sessions on CPR and defibrillation to their employees and the public, giving people the opportunity to feel more confident about what to do if someone close to them suffers a cardiac arrest be it family, a friend or someone on the street. The events are advertised using the council intranet and Facebook page and have been received very well. 100% of the feedback collected has been positive and all attendees reported improved confidence performing CPR and using a defibrillator. The council also took part in the British Heart Foundation’s ‘Restart a Heart’ day, raising awareness and training around 50 employees in CPR. There is a common misconception that you have to have a qualification to perform CPR on somebody. The truth is that is you have the knowledge, you can use it to try and save someone’s life.
Automated external defibrillators (AEDs) talk you through how to deliver an electric current to restore a person’s own heartbeat. There are over 100 publicly available AEDs in the East Riding of Yorkshire and Hull, a number the council and partners have worked hard to increase(4). When you call 999 the operator will direct you to the nearest AED if needed, and give you the code to open the safety box. AEDs are much less useful when CPR does not take place – something the council has recognised in its efforts.
The Yorkshire Ambulance Service are also working to address this issue with a successful community responder scheme. Community responders are normal people who are trained to provide initial lifesaving treatment and help to bridge the gap until paramedics arrive.
Community responders carry portable AEDs and are often able to reach the people who need them much faster.
Does it work?
The resus council recognises a Chain of Survival for Cardiac Arrest, which includes: early recognition of cardiac arrest and calling for help, early CPR to buy time and early defibrillation to restart the heart. When each link in this chain is strong, chances of survival can rise to over 50%(5), but if one part of the chain is delayed this percentage drops dramatically.
‘Is it difficult to do?’
Research has shown that life-saving skills such as CPR can be taught successfully to children as young as 10 years old, whereas younger children aged 4 and above have been shown to be capable of calling for help and operating an AED correctly(1). In fact the Department of Education has plans to add CPR and first aid to the curriculum by 2020(6).
‘What if I hurt them, can I get sued?’
When a person has a cardiac arrest they are effectively dead. You cannot make the situation worse, but you may save their life. Sometimes you can crack a rib when giving CPR, but broken bones will heal and are a small price to pay for your life. No one in the UK has ever had legal action brought against them for trying to help someone by giving them CPR(5).
‘How can I get involved?’
The worldwide annual Restart a Heart Day courtesy of the British Heart Foundation takes place on the 16th of October. Why not raise awareness and join the millions of people all over the world learning CPR to keep each other safe. You can also look out for local BHF Heartstart schemes which run free 2 hour courses across the country. The easiest way to learn about CPR is via the British Heart Foundation website where you can browse their free information and videos.
Plant. N, Taylor. K. (2013). How best to teach CPR to schoolchildren: A systematic review. Resuscitation. 84, 415-421
June was a busy month for the Policy team at FPH. We released our project’s second discussion paper, furthering our investigation into how NHS organisations are responding to or shaping the broader prevention agenda. Thank you to all FPH members and other partners who contributed!
We also released the results of our opinion polling of 310 NHS leaders about prevention – which we think provide a fascinating starting off point for understanding the journey that NHS organisations are on towards (hopefully) a more prevention-led service.
We also travelled to Edinburgh to meet with our Committee of the Faculty of Public Health in Scotland (CFPHS) members and others working in NHS Scotland organisations, NHS Health Scotland, and NHS National Services Scotland to discuss our findings from a Scottish perspective. We received a very warm welcome from the CFPHS Chair Julie Cavanagh and all of the attendees, ensuring the workshop was not only incredibly informative but also very enjoyable.
We covered a huge amount in a relatively short period of time, but here are our initial 5 takeaways from the event:
The planned public health reforms are a huge opportunity to make a significant step-change towards a culture of health – Scotland’s public health reforms are striving to address three key issues: Scotland’s poor relative health, significant and persistent health inequalities, and the unsustainable pressure on health and social care services. The ambitious reform programme has already seen the development of public health priorities for Scotland and the development of a new public health body, Public Health Scotland (PHS), is currently underway. There is a commitment that PHS will be an NHS organisation, at least initially and the current NHS public health workforce will continue to be employed by the NHS, but with increased reach/relationships with local authorities and other community partners. CFPHS is broadly supportive of this approach, but recognises the need to maximise NHS contribution to public health while broadening the reach of the public health function. This is the space of the debate at the moment.
Our opinion polling findings of NHS leaders about prevention only partially reflect the Scottish experience and mind-set – only 6% of NHS leaders who we polled were living and working in Scotland. We were curious to see if our overall results around prevention priorities, barriers to prevention delivery, prevention budgets, and the most pressing issues facing the health and wellbeing of local communities reflected the situation in Scotland. Workshop attendees told us the following main points:
NHS leaders overall who we polled were most likely to say that the NHS should be prioritising the following five approaches to prevention delivery: the systems approach, embedding prevention into routine practice, embedding prevention into clinical and/or patient pathways, reducing health inequalities, and addressing common risk factors. Attendees at our workshop similarly emphasised the need to prioritise the first four of those, but then prioritised ensuring the NHS is a good employer, e.g. by improving NHS staff health and wellbeing over addressing common risk factors.
We also asked NHS leaders to tell us (based on a long-list of potential tax and regulatory measures spanning alcohol, drugs, obesity and food, and tobacco) the policy or regulatory changes that they thought would most benefit the health of their local communities. NHS leaders overall were most likely to choose measures that impacted on the local food environment, with four out of their top five shirt-listed measures relating to that. Participants at our Edinburgh workshop, however, also chose some of the same measures relating to the local food environment, but they also short-listed a measure relating to drug and alcohol treatment. This, they told us, reflected the fact that in Scotland drugs, alcohol, and suicide are the three largest contributors to years of life lost to premature mortality.
They were most surprised (in a good way) that around half of all NHS leaders polled say that prevention is a core or large part of the work in their department. They were heartened by that result, but some wondered whether understandings of what ‘prevention’ approaches or activity actually constitutes is so variable as to render this finding misleading.
FPH may need to revisit our definition and understanding of healthcare public health – Interestingly for FPH colleagues working across health services and in education and training, we heard the strong message that the FPH definition of health care public health (as one of the three domains of public health) was not necessarily applicable to the Scottish health system. Unlike in England, in Scotland there is no existing national framework for the delivery or governance of HCPH and the domain is experienced and described differently. Due to the structure of the public health and health system in Scotland, the majority of those working in specialist public health capability and capacity for HCPH are located within territorial NHS Board Public Health Directorates and are often working across all of the domains at once. This workforce is unlikely to find the FPH definition of HCPH useful for their work. They told us that we need to establish better the scope and vision for HCPH in Scotland and strengthen the HCPH role beyond clinical healthcare services. The Improving Services Commission in Scotland is exploring whether or not to describe the function as ‘Population Integrated Care’ instead.
Colleagues in Scotland agree that better governance of prevention is absolutely critical to supporting a prevention led NHS – In our first workshop back in October 2018, stakeholders identified better governance of prevention as a key area that needed to be prioritised if the NHS was to sustainably pivot towards prevention. Scottish colleagues were very interested to learn from the Deputy Director of Healthcare Public Health at PHE East Midlands, Ben Anderson, about his team’s work addressing the prevention challenge and the governance gaps that they’re striving to fill at trust and CCG levels. Colleagues in Scotland spoke of similar challenges around ensuring strategic leadership for healthcare public health across the system (including the NHS, LA, HSCP, education, public sector, voluntary sector, SG policy makers), the need for better coordination and optimisation of data and intelligence, issues incentivising outcomes, and the need for better performance management of essential prevention activity.
FPH needs to do more support learning across the nations and help our workforce tell a better story – Despite some clear differences and unique challenges, many of the barriers standing in the way of prevention within the NHS are shared, for example: a lack of funding, a lack of understanding of what prevention and more broadly health care public health actually constitutes and their impact, and a lack of data, and service fragmentation. But different places are overcoming these barriers successfully or identifying some of the missing pieces to help other places overcome them. Attendees at our Scotland workshop want to learn more from what colleagues elsewhere are doing. They would like FPH to host more events like our workshop, to bring colleagues working across the UK on similar issues together to learn from one another. There was also a really strong message for FPH ‘to support us to think differently as a workforce’ and ‘develop a more compelling narrative for what the public health workforce does.’ This will help them communicate the value of the public health approach more effectively.
These are just a few of our initial thoughts. But we’d love to know what you think of our papers, findings, and initial conclusions.
Please let us know by emailing firstname.lastname@example.org Thank you so much and we look forward to hearing from you soon
Written by Ahmed Razavi, Specialty Registrar in Public Health and member of FPH’s Public Health Funding Project Group.
On April 29th the Faculty of Public Health Special Interest Group on alcohol held its annual learning event. With support from Public Health England and from the Faculty, the event was able to attract national speakers who came to share their work around reducing alcohol related harm.
Chaired by Professor Woody Caan, the event began with a keynote presentation from Dr Amy O’Donnell from Newcastle University, who shared her work on implementation of alcohol Identification and Brief Advice. Although there is good evidence for the effectiveness of alcohol IBA, particularly in the primary care and Emergency Department settings, embedding this into routine practice has proved difficult. Barriers identified included lack of financial incentives to act as levers, GPs being unconvinced that the advice actually changed behaviour and clinicians seeing alcohol as a ‘sensitive subject’.
Amy went on to share her recent implementation science work in the primary care setting. Emerging findings suggest that both patients and GPs are supportive of the delivery of IBA in primary care, but that more work is needed around promoting the benefits of delivering IBA in this setting as well as around improving understanding of the long term health implications of heavy drinking.
We were also joined at the event by colleagues from Scotland. Debbie Sigerson from NHS Health Scotland shared research that has been done to understand the key strategies needed to embed alcohol brief advice, and also shared the count14 campaign that has been put in place to increase understanding of units and alcohol consumption. Debbie also shared progress of a review that is currently underway to determine variation in delivery of IBA across Scotland and to agree what suite of resources are required for public and professional use, ensuring these are fit for the future (e.g. digital first).
Barriers and enablers to delivery of alcohol IBA were also the theme of Dr Ben Rush’s work, with a specific focus on delivery in the ED setting. Ben, a Specialty Registrar in Public Health working with Nottingham City Council, described a project that had been completed with ED staff at a large acute trust. This had identified high levels of staff support for the delivery of IBA in this setting but that achieving this required ongoing staff training. Similarly to what was presented by Amy in relation to primary care, delivery of clear messages to staff about the benefits of delivering IBA in this setting was also raised as an important issue.
The meeting then received an update on the Lancet Liver commission from Professor Steve Ryder, Consultant Physician in Hepatology and Gastroenterology. The commission has been successful in giving liver disease a high profile and in bringing agencies together in a unified approach to reducing morbidity and mortality associated with liver disease. Steve shared recent research on the impact that use of ‘care-bundles’ has on patients admitted with decompensated cirrhosis and also shared progress made by Hepatology Networks around treatment for Hepatitis C.
The final two presentations of the day had a more local authority public health focus. The first was work presented by Dr Emily Walmsley, a Specialty Registrar in Public Health working with Portsmouth City Council. This focused on tackling issues associated with ‘pre-drinking’ through the use of breathalysers by door staff in the night time economy. The evaluation of this innovative
intervention was associated with small reductions in violent crime and ambulance call-outs and also raised the complexity and challenges that are associated with implementing and evaluating interventions of this kind. Professor Paul Roderick then shared another local authority based intervention that has been led by Rob Anderson-Weaver from Portsmouth City Council. This reported on the introduction of a voluntary initiative called ‘Reducing the Strength’ that put in place requirements of retailers that would limit sales of high strength beers and ciders. More than half of off-licences supported the initiative and it was concluded that it had reduced availability of high strength beer and cider. Issues were raised around evaluating wider health and social impacts and also the long term sustainability of this and similar voluntary schemes.
This learning event built on our 2018 event that was around alcohol licensing and we will be running a further event in 2020 on another key issue relating to reducing alcohol related harm. Anybody interested in joining the SIG can contact either Jane Bethea (email@example.com) or Catherine Chiang (firstname.lastname@example.org). Copies of slides from the event are also available through either Jane or Catherine.
Written by Dr. Jane Bethea FHEA FFPH, Associate Professor of Public Health, Leicester Medical School, co-Chair FPH Alcohol Special Interest Group
The blood which has disappeared without leaving a trace isn’t part of written history:
who will guide me to it?
It wasn’t spilled in service of emperors - it earned no honour, had no wish granted.
It wasn’t offered in rituals of sacrifice - no cup of absolution holds it in a temple.
It wasn’t shed in any battle - no one calligraphed it on banners of victory.
But, unheard, it still kept crying out to be heard.
(Faiz Ahmed Faiz writing after the 1965 Indo-Pak war)
In the aftermath of the Pulwama attack in February 2019 that martyred over 50 Indian soldiers, one of the authors happened to have been caught up in the ensuing conflict between India and Pakistan and could not return to the UK. This was because the airspace was closed and all flights grounded due to security concerns on both sides of the border. The incident gave us an opportunity to observe and reflect on the situation, the nature and ideology of war, the history, the current political landscape, the state of politics globally, the role of the media and the cost of conflict.
This recent episode was like the trailer of a blockbuster war movie. The author witnessed blackouts, the feeling of fear, the emotions of hunger for victory and blood, the sounds of fighter planes patrolling the skies, all being drummed up and whipped into a sense of frenzy by the incessant reporting of the media that was often biased, provocative and irresponsible. Amidst the turmoil, voices of sanity by those who could foresee the implications of destabilising the region, were being drowned on either side of the border and the reverberations echoed globally. There was also the realisation of how much power the media holds over the public and how easy it is for human beings to defy logic, and so easily become ensnared and enticed to adopt ‘copycat’ violence within a short span of time, much as occurred during the 2011 English riots.
The Changing Nature of Warfare
Nelson Mandela likened violent conflict to a bonfire, the ingredients of which are needed only to light a spark, that then has the potential to spread from nothing to something that could become uncontrollable. However, conflict and violence involve choice, but a bonfire does not choose whether to burn. The reason people engage in conflict and war is rooted in a common system of beliefs and values, the defence of which is seen as of foremost importance and legitimacy.
The shifting nature of ‘warfare’ has meant that wars are no longer being fought on the battle-field with guns and horses, but in the minds of civilians. Here, media is sovereign, both the judge and the jury. In this new era of social media, fake news and increasing xenophobia, combatting divisiveness has taken a backseat. The media is not always neutral and, in some instances, can be an active participant in crises since they can profit from sensationalising disaster. This, in turn, has meant that they are often responsible for shaping public belief and attitudes.
When we come to the case of India and Pakistan, we see states that exist on the basis of religion and political ideology. Even though there is more that unites than divides, harmony does not overrule the fervent nationalism that often teeters just on the edge of extremism. The question of whether this was a ‘Partition’ of the soul of one nation, or an ‘Independence’ from the colonial forces of the British Raj is not debated in the current discourse: rather, the struggle is always to establish points of contention to gain political control, after which an escalation of conflict and the loss of life becomes inevitable. The ideology of war here was born when communities were grouped on the basis of religious identity and political representation; when people “stopped accepting the diversity of their own thoughts and began to ask themselves in which of the boxes they belonged”.
The Ideology of Kashmir
In 1947, Cyril Radcliffe submitted the Partition map with a boundary line drawn between what is now India and Pakistan, just 5 days before the date of the two countries’ independence in August. Little did he know, that for the next 70 years, that line would be the centre of contention, conflict, and the largest mass migration in human history. Lord Mountbatten’s desire to prove himself worthy of his new position as Viceroy of the ‘Jewel in the Crown’, combined with his commitment to the new Labour government in Britain regarding Partition, meant that the process was rushed. Astoundingly, many states had not even decided on whether they were to join India or Pakistan until after that fateful midnight in August. Kashmir was one of those states.
The princely states could either remain independent or accede to one of the new countries. At the time, Hari Singh, the Hindu ruler of the Muslim-majority kingdom of Jammu and Kashmir, initially chose to remain independent. However, in October 1947, afraid of losing his crown to invading Pashtun forces, he signed the Instrument of Accession to India. The two countries promptly went to war, which ended with a defacto border, the Line of Control, that has been witness to much violence since. In the following years, two more wars were fought, each with larger consequences than the last – in 1965, over 3000 Indian soldiers and 3800 Pakistani soldiers died, and in 1999, during the time of the Kargil War, over 2000 people died on both sides of the border.
The Cost of War
Many lives have been lost in this conflict over the years. Homes, families and entire communities have been destroyed and devastated in the wake of the erupting violence, much like a volcano that becomes dormant but never ceases to rumble.
The Partition of India and Pakistan in itself was a humanitarian disaster. Over 2 million people died, and 14 million were displaced. Entire communities were destroyed, villages were razed to the ground, and all that remains of the memories of an entire generation is ash and smoke. To this day, despite the ongoing refugee crises all over the world and the War on Terror that has wreaked havoc on the Middle East, the Indo-Pak Partition is still the largest mass migration in human history. This communal violence ripped a hole in the fabric of colonial society, and the hole has only grown bigger and more divisive since 1947.
Internal violence has been unprecedented, and external forces are constantly forced to intervene to establish peace, or whatever form of peace they can maintain. The divide runs much deeper than the physical border which divides the two states as families and communities have been split. Enforced or involuntary disappearances of people occur, and human rights are violated and abused. Unlawful killings, sexual violence, kidnappings and injuries abound with no recourse to justice for civilian populations. Although highly underreported, official figures report that 9,042 people were injured during protests through injuries sustained from the use of bullets, metal pellets and chemical shells in Kashmir between July 2016 and February 2017 and this is just a snapshot over a short period of time. The first ever UN Human Rights report on Kashmir called for international inquiry into multiple violations and stresses “an urgent need to address past and ongoing human rights violations and abuses and deliver justice for all people in Kashmir, who for seven decades have suffered a conflict that has claimed or ruined numerous lives.”
According to the World Bank and Nation Master, there are only 0.9 and 0.7 hospital beds and 0.6 and 0.7 physicians available per 1,000 people in India and Pakistan respectively. In nations where health indicators are so poor e.g. the life expectancy at birth is 68 and 66 years and the infant mortality rate is 38 and 67 deaths per 1000 live births in India and Pakistan respectively, one questions how the two nuclear states can even envision to go to war when their citizens face such poor health outcomes and mortality rates in peace times!
The damage does not just stop at physical health. A 2015 Medecins Sans Frontieres (MSF) study covering all the districts of Kashmir between 1989-2005 show the burden of conflict on mental health. During this period approximately every 1 in 10 Kashmiris reported suicidal thoughts or suffered from severe depression and a fifth of the Kashmiri adult population was estimated to live with post-traumatic stress disorder (PTSD) symptoms. On average, an adult living in the Kashmir Valley had witnessed or experienced 7.7 traumatic events during his/her lifetime of which 93% followed conflict-related trauma. The high reporting of physical symptoms reflected the more common somatic manifestation of mental distress in the Kashmiri population.
In addition, the various costs are not just limited to the inhabitants of those two states. The recent conflict of spring 2019 gave us a simple teaser of the direct and indirect astronomical costs that ripples of conflict can generate, even without full-fledged war. It also demonstrated how the consequences are not limited to geographical borders. For example, over 800 international flights use the India Pakistan airspace daily. Hence, the two countries were not the only ones affected when India and Pakistan shut down the airspace for inbound, outbound or any international flights flying over their airspace and thousands of people were either re-routed or stranded. In an increasingly global world, the consequences of this has huge knock-on effects on the international, regional and local resources, economy and trade. Thus, what happens in one part of the world has an impact on another part of the world, be it disease, conflict or politics.
In the post-Partition world of South Asia, Kashmir represents the unattainable, the ‘ultimate prize’. Both sides are willing to use the ideology of this land, its people and their resilience in the face of hardship as a call to arms whenever tensions between India and Pakistan escalate. Nowhere, however, are Kashmiris and the victims of the ensuing violence asked for their opinion, just as they were denied a right to decide their fate in 1947.
In conclusion and looking to the future, various groups can enact changes that will contribute to easing IndoPak relationships. There is no greater contention in the history of these two countries than the Kashmir issue – two wars have been fought, each undecided and each a loss for both sides. This has not been simply because territories were lost, or lives were ruined; instead, the Kashmir issue has been a failure for both bordering countries because, on the levels of humanitarian principles, both countries have failed to put the people of Kashmir above their own political agendas.
The dangers of an irresponsible media should not be underestimated – without a reliable and neutral distributor of information, alongside thoughtful analysis, it is difficult to predict the common man’s reaction to violence. The focus and aim of reportage should not be to produce sensational headlines to clickbait readers and viewers, since this will only incite anger and turn Indian and Pakistani audiences against each other. Those readers aware of the dangers of poor reportage should campaign for responsible media coverage. If enough people put pressure on social media and mainstream media providers for fair and unbiased evidence-based reporting, there may yet be a shift in reporting tactics.
Instead of focusing on differences, media outlets should be tasked with drawing attention to commonalities to remind Indians and Pakistanis of a singular heritage, and the many reasons to repair relationships. It is important to remind both sides that, should war be waged, it will be waged against men and women just like them. In fact, only two generations ago, they were neighbours and citizens of the same country. This shared sense of belonging and history should mean something, and it is this aspect of identity that the media should draw attention to, to encourage efforts of peace and neutrality rather than fan the flames of war and dissent.
Furthermore, both countries should fund research that tries to better understand the role of ideology in conflict and how it might be used to inform conflict management and resolution. If it was possible to understand the impact of societal inclusion, norms, morals and religion on violent tendencies, perhaps it would be easier to see what could be done to target these. For example, studies suggest that modifying perceived transformative experiences of groups of people that feel oppressed or threatened and reducing that common perception of oneness or shared self-defining experiences can help in resolving conflict. Other studies on the cognitive drivers of conflict show that immediate cognitive pathways (hot cognition) can stimulate strong feelings linked to identity (ethnic, geographical) and associated political attitudes. The question, therefore, is that is there a role then for cognitive ergonomics to support the human mental processes of perception, attention, reasoning and decision-making to rationalise war and violence?
The final group that can help install long-lasting and positive change is the international community. Multilateral forums can provide legal and diplomatic pressure as well as a balanced and neutral opinion. It should be stressed, however, that international interest groups have in the past used tumultuous Indo-Pak interactions to further their own interests, and this issue is too dire to allow this mistake to be made again. International bodies ought to act as fair advocates and be reminded of their own responsibilities to prevent global violence through mediation and de-escalation.
The naked passion of the self-love of Nations, in its drunken delirium of greed, is dancing to the clash of steel and howling verses of vengeance.
The hungry self of the Nation shall burst in a violence of fury from its shameless feeding.
For it has made the world its food.
(Tagore, Nationalism (1917:157))
Dr Samia Latif, Consultant in Communicable Disease Control, Public Health England. Assistant Academic Registrar and member of the UK Faculty of Public Health’s Global Violence Prevention and Pakistan Special Interest Groups
Ms Fatima Naveed, MSc student of International Development & Humanitarian Emergencies, London School of Economics
Dr Jharna Kumbang, Consultant in Communicable Disease Control, Public Health England
We, as a nation, will strive together to build a Culture of Health enabling in all our diverse society to lead healthier lives, now and for generations to come.
You could be forgiven for thinking this bold vision came direct from the mouth of a secretary of state for health, a prime minister, or better still the queens Christmas speech. In fact, it comes from a US thinktank the Robert Wood Johnson Foundation . But it got us thinking at FPH about whether we could build as a compelling a vision to advocate with policy makers, and if so, how we could work with our wider civic society to make this happen.
A big question!
We started by exploring the following (slightly smaller) questions: What do we mean by a culture of health in the UK? Is it helpful terminology? What assumptions are we making? How close are we to a culture of health and how is it different to the status quo? And finally – what is the role for the Faculty of Public Health?
What do we mean by a culture of health in the UK?
In the UK, recent reflections on a Fifth Wave of Public Health perhaps come the closest to describing a culture of health. It is emerging as we develop new approaches to complex public health challenges e.g. obesity, social inequalities, loss of wellbeing; all in the context of stresses on population, environment, climate and the economy.
It requires commitments from a range of social actors and structures: government, law, education, business, communities, arts… However, we know that each of these have the potential to both promote and inhibit a culture of health.
Is it helpful terminology?
We are a long way off from being able to articulate a vision for a UK culture of health with the same clarity and conviction as the RWJF; but the sentiments are present in policy emphasis on systems approaches, integration and reach into the community and voluntary sector. Additionally, the Welsh Government’s focus on ‘wellness’, NHS Scotland’s focus on fairness and social change and discussion of a ‘social movement’ for health in the recent Prevention paper in England all contribute to a vision of health as a key value in society. The challenge is 2-fold – how these polices are enacted and interpreted within health and local government structures, and then, how these values are nurtured and developed in wider civic society.
Reflexivity is fundamental as a starting point – being aware of our own paradigms and how they differ from others. The recent Health Foundation and Frameworks Institute Seeing Upstream report highlighted for me the real differences in expert and public understandings of health and the implications for practice. At the first meeting I chaired as a public health practitioner, after previously attending in a voluntary sector provider capacity, a colleague told me that I ‘already spoke all the NHS language’. 9 years later, there is no doubt I am completely immersed in public health thinking, writing and speaking.
A culture of health in action
The changing place of smoking in our society provides a good case study and some experience to draw on:
This thought-provoking paper explores the changing culture towards smoking over the last 60 years concluding that change was facilitated by a number of factors interacting over time: the publication of evidence showing the link between smoking and non-communicable disease, a growing non-smokers advocacy lobby, ever-tightening legislation and policy, and the changing image of a smoker from someone who deliberately undertook a harmful activity to someone who is addicted to a harmful substance and needs support (individually and within their environment) to break the addiction.
The caveat, which is recognisable to us, is that cultural perceptions of smoking did not change uniformly across the population, there remains socio-economic and ethnicity related inequalities in smoking. The authors propose that culture is a product of interactions at a ‘micro-social level’ – in this case smoking is ‘a social behaviour that responds to the convenience or inconvenience of smoking, and this is influenced by legislation, social attitudes and social prevalence in one’s own reference groups’.
Alcohol consumption is another example of an interplay between evidence, values, public opinion and policy, following a similar story arc to tobacco.
What is the role for FPH?
Recent consultation to inform the new FPH Strategy described the role for public health professionals to lead across systems, reframe public health issues to be of relevance to the public and value to policy makers, and to work at community and macro-policy level in the ‘Art’ and ‘Science’ of public health. This makes us key facilitators in developing and promoting a culture of health.
So, we might be a way off realising a vision like the RWJF quote above, but we know that in public health we work in long story arcs. For now, the achievable part of this vision is to collectively work through our networks, with awareness of how and when to best influence at micro and macro- level and that is a good start.
Join us in developing these ideas further, through the SIGs and committees at FPH and at the forthcoming workshop on Means, ends, and ethics in the ‘culture of health’ agenda as part of the pre-conference programme at the PHE Conference 2019.
Siobhan Horsley, Specialty Registrar in Public Health on behalf of the FPH Health Improvement Committee. You can follow Siobhan on Twitter @siobhanmari
My name is Claire Beynon and I am a Specialty Registrar in Public Health in Wales. I am passionate about reducing childhood obesity in the UK and wanted to explore how the wider determinants of health impact childhood obesity in children after accounting for deprivation.
One of my placements gave me the opportunity to work with the Nuffield Trust and University College London (UCL) as well as my home institution of Public Health Wales. I used the Childhood Measurement Programme data for Wales collected over the last five years and matched this to the wider determinants of health by local authority area.
Following a presentation of the results to the Welsh Government and Welsh Local Government Association I produced a simple one page summary of the research to share with local authority staff.
The idea of this simple summary was to turn research language into plan English and to communicate the findings of the research clearly. This work was also timed to influence the Wales Obesity Strategy (Healthy Weight: Healthy Wales). For more information on the study please contact Claire.email@example.com
Work undertaken by Public Health Wales, University College London and the Nuffield Trust.
Written by Claire Beynon, Specialty Registrar in Public Health, Public Health Wales
“I would like you to close your eyes. Imagine that you have lived on the Moon for 15 years, and now you are returning to Earth. You land in Yemen. It is a very peaceful country. Begin to imagine a peaceful Yemen.”
I was sitting in a grand but tired Council room in Birmingham’s Town Hall. I was aware of a slight nervousness, my own, mingled perhaps with that of the others who were present; Yemeni diaspora from across the West Midlands, humanitarian aid groups, Members of Parliament and people like me who are connected to Yemen in some way. I grew up in a city called Taiz which has been hit pretty hard by the “Invisible War”.
The idea for the event came just four months before. I had been invited to an All Party Parliamentary Group for Yemen event and I met Taher Qassim for the first time, the founder of Friends of Yemen. As we enthused about Yemen, we shared our pain, even despair, at the apparent impossibility of Yemenis from different sides of conflict being able to work together.
While we shared, something new was sparked; hope. Now hope is an intoxicating thing where there has been none; we were both undeniably excited. We speculated. As the world awakened to the tragedies in Yemen, perhaps Yemenis, not only in Yemen but also right here in the UK, would be feeling as we did. We would host an event, we would have it in Birmingham, and it would be about peace. It might not work, but hope had thrown us into an open space of risk and believing in others, shouting a peace cry convinced that others would join. Taher then started to contact different organisations and individuals to make the workshop happen.
And now here we were. It was a Saturday afternoon, yet 50 people had gathered from far and wide to be part of a new conversation and movement. Perhaps I was nervous because it was new, but I sensed the undercurrents of suspicion. Some more overt; a whispered “which side do you support, you must know there is only one side that should win?” I pointed silently at my little wooden badge that said “I’m with Yemen”. Would it be possible to put these differences aside?
We were being led by peace-advocacy worker Kate Nevens from Saferworld; it was her fun but authoritative voice that rang out now. I did as she said, and closed my eyes.
I was landing in Yemen after 15 years on the Moon. Despite the benefits of imaginary travel through time and space, to begin with I only imagined complete desolation. The silent cry of mothers. The abandoned shells of homes, hospitals, markets. Tiny bodies struck with cholera, life literally running out into the ground. I was so used to these thoughts that they filled my mind.
But Kate went on: “Think about what it would look like on the streets in a peaceful Yemen, what would the children be doing? What would you see?”
Slowly, I imagined the view from my bedroom window where I grew up, the light wind in the fruit tree where the little yellow weaver bird was making her nest.
The hundreds of tiny lines of smoke rising from the mountain slopes as villages baked their bread. The peaceful streets were far from quiet, clattering with the sounds of laughter, bustling with greetings and street venders, goat herders and honking horns. Along the little rough stone alleys between the houses washing lines full of colour billowed out. The school playgrounds were full. Even as dusk fell, no one feared to go outside. Children wandered through the balmy evening eating toasted watermelon seeds as the old men watched on street corners and drank their tea.
I realised that tears were pouring down my face. I had not thought of Yemen in this way for so long. In all my grief about the War, I had stopped remembering her beauty. But the spell was breaking. I listened in absolute wonder as others across the room called out what it was that they had seen; everyone was describing the same thing. In almost no time, we had covered a board with our vision, scribbled on paper shapes of hearts and doves.
The scene was set: we were gathered together for peace. The rest of the afternoon sped by. We watched a short film about the infrastructural impacts of war, providing context for why action for peace is so crucial. Guest MPs held a panel and spoke of their love of Yemen, support for the diaspora and commitment to speak up for peace. Their presence and contributions felt deeply honouring, giving power and purpose to our fledgling peace movement.
Bursting with ideas, snatches of conversations and new-found friendships (and also very good sandwiches), we split into four workshops to design small projects that we as the diaspora could initiate to support peace in Yemen.
Group themes included children and young people, women, mental health, and local humanitarian organisations. Such was the enthusiasm after our learning, an extra group was formed on sustainable peace. Everyone seemed to get louder and louder as we considered current challenges, shared connections and drew our ‘headlines’ as if they were newspaper stories.
At the end we gathered back as a whole room, and discussed our next steps. We wanted to do this again. We wanted more MPs to be involved. We wanted other regions to join the movement and form a national platform for the Yemeni diaspora and friends to act together for peace.
We also took some pictures, swapped numbers, and laughed a lot. Trying to get out of the room in time for closing was joyful chaos, like a peaceful Yemeni street.
If you have been wondering, as I was, whether it is possible after so much violence and conflict to find a way to come together, I think we would like to say: there is hope for peace in Yemen. We are ready for a new movement, and it has already started. I hope you can be part of it.
To be part of this new ‘Together for Peace in Yemen’ movement contact Taher Qassim via email: firstname.lastname@example.org. You can get involved in many ways that include; helping your region join the movement, asking your MP to join ‘Friends of Yemen’, being part of one of our project subgroups, or requesting a free “I’m with Yemen” badge.
Written by Dr Ann Hoskins, Chair of the Faculty of Public Health’s (FPH) Yemen Special Interest Group (SIG). To join the Yemen SIG, contact Ann via email email@example.com or to find out more about the SIG, click here.
Air pollution impacts us all – from our first breath to our last.
What is Clean Air Day?
Clean Air Day is a campaign coordinated by Global Action Plan, a charity who aims to help the UK discover what is good for us, and what is good for the planet. The purpose of Clean Air Day is to raise awareness about the issue of air pollution, and to learn how we can each make small changes to drastically improve the quality of the air that we breathe.
As you might already know, we have reached a crisis point with current pollution levels in the UK, which have now surpassed legal EU limits (1). Only a few weeks ago residents in West London had been warned to avoid jogging due to the dangerous levels of pollution at that time (2). Exposure to air pollution has many potentially negative consequences for our health, which can result in an increased risk of lung cancer, high blood pressure and cardiovascular disease. Furthermore, air pollution could trigger asthma in children, or make symptoms worse for sufferers. Shockingly, is thought that up to 36,000 deaths per year in the UK can be accounted for by air pollution.
Whilst the hard facts and stats may seem overwhelming, they are necessary to illustrate just how damaging the effects of pollution can be. However, you’ll be glad to know – it is not all doom and gloom! By making small but necessary changes to some of our daily activities, together, we can significantly reduce air pollution.
It can be challenging to get involved with an “invisible issue” such as air pollution. A lot of the time, we can’t physically see air pollution, so it can be difficult to understand just how bad the problem is. Furthermore, air pollution levels vary from area to area, and will even fluctuate throughout the day. (You can check the pollution levels in your area at https://uk-air.defra.gov.uk).
I like to imagine that there are two “spheres” of pollution – one within our homes, and the other within our neighbourhood. There are small changes you can make to positively impact both of these spheres.
There are several steps to limit the negative effects of pollution at home. They may sound simple – and that’s because they are!
When cooking, open the window and/or turn on the extractor fan if you have one.
Vacuum regularly to reduce the amount of dust.
Limit the use of a fire/wood-burning stove.
Burn dry, well-seasoned wood or smokeless fuels if you have an open fire or barbecue.
If redecorating, choose paints with a low volatile organic compound (VOC) composition.
In your neighbourhood
It is well known that reducing both the amount you travel by plane or car can result in a significant reduction in the wider levels of air pollution. However, depending on where you live, it may be unrealistic to not use or own a car. If this is the case, have you considered:
Switching to walking, cycling or public transport? Walking and cycling are not only good for the planet, but they are also great for your health! Make an experience of the walk or cycle, particularly when the weather’s nice. Or, use Google Maps to see if there is a feasible public transport route to your destination.
Ensuring your car is regularly serviced, particularly keeping the tyres inflated to increase efficiency?
Make a pledge
Finally, as part of the Clean Air Day campaign on the 20th June, we are encouraging you and your family to make a small pledge of one (or more!) activity that you can alter in order to reduce pollution levels. This might be in your sphere at home, or in your neighbourhood, or even one for each sphere!
It is important to remember that small changes to the choices we make every day can make a big difference when widely adopted. So, what will you change this Clean Air Day?
Find out more at the Clean Air Hub, which contains lots of easily accessible information, material to raise awareness in your area, and other ways that you can get involved www.cleanairhub.org.
With this poll we wanted to explore with an NHS audience several of the key issues that have emerged from our project’s extended consultation so far with predominantly a specialist public health audience. We were interested to see if the opinions, perceptions, and priorities of these two (sometimes overlapping, but often distinct) groups diverged or were in general alignment.
We explored the following six main issues:
Do NHS leaders consider prevention to be part of their job, e.g. is it a core, large, or small part of their departmental work?
Prevention priorities now and for the future – which approaches to prevention delivery (e.g. addressing common risk factors or targeting specific populations) is their local NHS currently prioritising and which approaches do they think their local NHS should be prioritising?
The effectiveness of NHS prevention activity – how effective or ineffective do they think their local NHS is at delivering its current prevention priorities?
Prevention budgets – on average, what percentage of their budget do they currently spend on prevention and what percentage do they think they should be spending? Do they think the NHS should reallocate its budget away from treatment and towards prevention?
The top barriers to NHS prevention activity – what is getting in the way of their department doing more or more effective prevention?
NHS advocacy for prevention – which taxes and regulatory measures do NHS leaders think would most benefit the health of their local population?
You can learn all of the answers to these questions and with some very brief analysis in our short summary paper here.
We think these results provide a useful (and much needed) benchmark for the current state of what the NHS does, spends, values, prioritises, and would like to do more of (or better of) when it comes to prevention. We also think they can help our members and others working on the frontline of healthcare delivery ‘do’ more prevention. Additionally, we also think they can inform the ongoing debate around the implementation of the prevention aspirations laid out in the NHS Long Term Plan.
I had watched and read news reports about the plight of displaced Rohingya people, and as I travelled towards the camp I imagined that I would encounter a scene of squalor and desolation, reminiscent of the most extreme among informal urban settlements.
What I found was completely different to my mental image. We drove into the camp along a pristine brick road. Dwellings were mostly made of bamboo, and were nicely laid out as in a French campsite. There were regular bore-hole outlets providing safe water at source, numerous advanced pit latrines, and no unpleasant smells. Many of the adult inhabitants were hard at work making a concrete drainage system in preparation for the coming monsoon. Children were in school. They looked healthy and were well-groomed. There were football pitches and plants growing in the many parts of the camp.
Four things seem to have come together:
The government in Bangladesh, after some hesitation, decided to accommodate the refugees – a country of 170 million can absorb another 1 million, said the Prime Minister.
UN agencies, such as the High Commission on Refugees, were available to supply logistics and know-how.
Money was provided on the back of the many NGOs that gravitated to the area. At the peak, over 150 NGOs had a presence in the camp.
The effort was co-ordinated by the Office of Co-Ordination of Humanitarian Affairs. There was no ‘free-for-all’.
Too good to be true? Yes, I am afraid so. If you look at “Open Street Map” (OSM) you will see that we visited a well laid out, orderly part of Ukhia. There is another section where the dwellings are much more closely packed among narrow lanes laid out in a disorderly way – much like a slum. Apparently, this was where the Rohingya settled following the initial, unanticipated influx that we all watched on our television screens. What lessons can I draw, tentatively, from my visit?
First, what I observed is a good news story on balance – a tiny proportion of the worlds resources were harnessed and focussed on a real and present need, and the majority of the camps in Ukhia appeared to be in good order.
Second, it is amazing what moderate resources can achieve, given an organising hand. I think there may be an important lesson in the contrast between the orderly, planned part of the Ukhia, and the disorderly sector where I understand WASH is less developed and intrinsic violence is prevalent. I hypothesise that planning for an influx of people lends itself to a favourable environment, whereas, once an urban area has developed in a disorderly way, it is much harder to remedy.
Third, service provision in slums could learn a lot from refugee camps. Bamboo could be provided free of charge by NGOs to provide better insulated, more attractive accommodation. I fancy this would be a big improvement over corrugated iron shanties that are hot by day and freezing by night. Advanced pit latrines I observed in the camp would be a big advantage over the facilities usually provided in slums and their marginal cost is modest. Above all, a centrally co-ordinated approach is essential. I think cities that harbour slums should appoint officials with responsibility for informal settlements and a responsibility to co-ordinate investments and community engagement.
Fourth, the problem for the Rohingya people is averted not solved – a long-term, sustainable solution is required and a return to Myanmar does not seem to be that solution.
Written by Richard Lilford, Professor of Public Health at the University of Warwick. You can follow Richard on Twitter @rjlilford.