That is me up there. Trying to look vaguely interesting and intelligent. Another page hosts a copy of CV which describes a meandering route through the fields of medicine and public health; here in the UK and abroad.
I haven’t treated a sick patient, delivered a baby or mended a broken bone for well over a decade now. But I did that for about five years before becoming a public health doctor.
What is ‘public health’? In my book, it’s everything to do with health that doesn’t involve seeing a patient. This is lucky, because it means I get to read, write, teach and talk about politics, economics, sociology, philosophy, climate change and even the law … all issues that relate to the health of people. It also covers more traditional subjects such as epidemiology; health economics; environmental health; and infectious disease control.
I’m going to blog on three broad themes here: 1) Health Systems Policy in the UK; 2) The Social Determinants of Health; and 3) Global Health Governance. Read further if you want to see where I’m coming from in terms of these three topics …
Health systems policy in the UK
The NHS is one of the great iconic symbols of post-war Britain – a fact encapsulated in Danny Boyle’s brilliantly constructed opening ceremony for the Olympics. Although many icons fail to live up to their reputation or mythology, in the case of the NHS, there are good reasons for why it is treasured and held in such high esteem. Put simply, the NHS is not just an effective and efficient system for the provision of clinical care, but is also a social institution that encapsulates certain social values and principles.
The NHS shaped the practice of clinical care as a public service – not a business or sphere for speculation. It placed trust at the heart of the doctor-patient relationship – and removed pecuniary interests from getting in between the doctor and patient. The NHS allowed money and resources to be allocated rationally, fairly and cost effectively – and was designed to prevent money and resources from flowing through inefficient and dysfunctional markets. It maximised spending on patients – not on accountants, lawyers, administrators and shareholders. It encouraged and motivated clinicians through pride and professional excellence – whilst keeping in check the temptation for greed and profiteering to grow. It universalised care, rather than segment the health system into different tiers according to the thickness of one’s wallet.
But over the last thirty years, corporate and financial agendas, encouraged by an uncritical adoption of neoliberal economic and management theory, have led to the steady dismantling of the NHS. And in 2012, we saw the actual abolition of the NHS through legislation. While the NHS logo and name remain, we now have a system that is designed to deliver health care as a commercial activity, and which will disintegrate the universalism that was established in 1948.
The end result will be a more inefficient, unequal and expensive health system; and an erosion of professional and ethical standards. Patients and families will inevitably become more insecure, frustrated and anxious as a result of the ensuing fragmentation and commercialization. I wrote about this when the Health and Social Care Bill was still being debated in parliament (see here). But it will be important to continue writing about the NHS.
The social determinants of health
Health systems are important. And the NHS is worth fighting for.
But the determinants of health and well-being extend far beyond the health system. What we eat; where we live; whether we work; what we do in our non-work time; and how we feel …. all have powerful influences on our health. But little of this is shaped by doctors and nurses; nor by pills and x-rays.
But we mostly know all this. The UK is home to many of the world’s leading experts on the underlying causes of ill health; and on what has become known as the social determinants of health. The World Health Organisation has a whole programme of work dedicated to this (though it’s poorly funded).
But why is the UK so bad at applying what it knows so well? Why, in spite of so much academic and policy emphasis on health inequalities, have differences in health status widened between the rich / advantaged and poor / disadvantaged? And why do we fail to stem the frightening incidence of childhood overweight and obesity? (the same questions can be applied to the global level).
Clearly, the answer is not ‘a lack of knowledge or data’; nor a lack of ‘political rhetoric’ or ‘public concern’ about health. While these are complex questions requiring complex answers, I would point my finger in the direction of two very broad and general issues (what might be considered as two of the causes of the causes of illness and health inequalities. The first is the large and growing degree of social and economic inequality. The second is the general promotion of economic policies that have accentuated inequality and which frequently contradict our stated desire to promote fair (and just) health outcomes.
Politics is too important to be left in the hands of politicians. Economics is too important to be left in the hands of economists. Publc health professionals need to get stuck into both politics and economics.
Global health governance
We live in a globalised world. We know this instantly when we walk down any aisle of any major supermarket; or when we take a look at the staff composition of a typical London hospital.
Not surprisingly ‘health’ has become ‘global’. Globalisation has profound impacts, for example, on the prospects for economic development in all countries. The health systems of all countries are being pulled into a new globalised terrain of market and financial integration, and where many multinational corporations dwarf the capabilities and budgets of entire governments. Many threats to health are increasingly supra-national and cross-border in their nature. Climate change is the ultimate global determinant of health.
Over the last twenty years, there has been a mini-explosion of interest in global health issues, accompanied by a five-fold $$$ increase in development assistance for health (DAH) and a proliferation of new global health agencies, programmes and institutions. The Gates Foundation. The Global Fund for AIDS, TB and Malaria. The GAVI Alliance. These are only three of well over a hundred new actors operating in global health; joining older and more established organisations such as the World Health Organisation; World Bank; and UNICEF.
But what do these organisations do? How effective are they? Who do they represent? What policies and approaches to health improvement do they promote? How do they engage with both the problems and benefits of globalisation? Whose interests are served? How are the boundaries between politics, commerce and science safeguarded?
Lots to consider and discuss ….