Health Protection and Public Health

Given that PHE’s remit included tackling non-communicable diseases, many of which are caused by things like tobacco, alcohol, and unhealthy foods, it’s not that surprising that assorted lobbyists for those industries are pleased to see the back of the agency.

One such lobbyist, Christopher Snowdon, wrote an article for the Spectator celebrating the end of PHE. In it, Snowdon argues that health protection (protecting people from infectious diseases and other hazards) and health improvement (tackling non-communicable diseases and the things that cause them) are different things.

“For too long, these two different agenda have been bundled together under the umbrella of ‘public health’.”

— Christopher Snowdon.

Here, I’m going to try to explain why this is a load of bollocks and why health protection and health improvement are intimately connected.

But to start, it’s probably worth saying that Snowdon and I agree about a few things. We both worry about governments intruding into people’s lives without reason. I’ve blogged elsewhere about how I think ideas like patient activation and risk stratification risk becoming forms of coercion. Where we disagree is that I also worry about non-government agencies like companies intruding into people’s lives, both through advertising and by being able to shape economic and social policies (such as by funding ‘think tanks’ to lobby on their behalf). I also worry that poverty and insecurity can be pretty coercive too, and can steal the freedom to live well and enjoy good health. Neither of us is particularly keen on lecturing people about what they eat or drink. The difference is I’d rather make it as easy as possible for people to do things that will keep them healthy.

So why does Snowdon think health protection and health improvement are different? His argument is that ‘public health’ really only encompasses those health issues for which collective action is justified.

Covid-19 has forced us to relearn the distinction between risks that threaten us all and justify a certain degree of coercive action and those which are the result of individual choices and pose a threat only to the individual concerned.

— Christopher Snowdon

I think there are a couple of arguments tangled together here. First, the risk we face from non-communicable disease is the result of ‘individual choices’ but infectious diseases isn’t. The second is that only things like communicable diseases (and I think Snowdon would also include environmental threats like air pollution here) need a collective response.

The first is obviously nonsense. A moment’s thought is needed to see that your risk of catching an infectious disease has as much to do with behaviour as non-communicable disease. Sexually transmitted diseases are an easy example. But COVID-19 has shown how important behavioural changes are in controlling disease, whether we’re talking about hand washing, wearing face coverings, or staying away from people we don’t live with (‘hands, face, space’ to use the current three-word slogan).

The second argument is also cobblers. There is plenty of evidence that our behaviours are influenced by all sorts of things that are outside of our control. Advertising is probably one specific example — I can’t imagine why the industry exists if it doesn’t work. And by work, I mean cause people to buy something they wouldn’t otherwise have. We also have no control over the conditions that we’re born into, but we know that they have a big effect on our lives. Our food choices are influenced by what foods are available where we are and what we can afford (no shit, Sherlock). And there is a big and growing research literature on the way that not having enough money changes people’s incentives so that they, sometimes completely rationally, prioritise something nice now over their health in years to come. All of these things are outside of our individual control. The only way we can do anything about them is by acting together. Collective action.

Snowdon also claims that public health should stay out of things that it doesn’t have expertise in:

“We can all agree that environmental degradation, poor housing and gender inequality are undesirable, but there is no reason to expect the World Health Organisation to have any special insights into how to solve these complex problems. There is no reason to expect the Chief Medical Officer to understand how marketing works and yet Chris Whitty’s predecessor, Dame Sally Davies, had forceful views about advertising. No one expects Public Health England to be experts on food manufacturing and yet the agency spent years dictating the precise quantity of ingredients that can be used in processed food.”

— Christopher Snowdon

This is wrong for two reasons. The first and simplest is you don’t need to be an expert on an important social problem to be entitled to a view on it. Snowdon demonstrates this amply. Many of these big problems are hard because they involve trading off different entirely legitimate goals against each other. Like the ability of people to enjoy good health and the ability of private firms to make profits for their shareholders. A public health voice can simply be about saying that as we try to solve these problems, we should try to maximise benefits to health. This isn’t to say other goals don’t matter, but those other priorities clearly have plenty of able champions. The second reason is that health agencies can easily work with experts in nutrition, planning, and so on. Just because Snowdon doesn’t expect PHE to have experts in nutrition and planning and a whole range of other causes of health doesn’t mean they don’t. To pick just one example, Michael Chang has done some brilliant work bringing planning expertise into PHE.

You only have to spend five minutes actually doing health protection (as I and others have and Snowdon has not) to see that it is intimately connected to other parts of public health. So many cases of infectious disease happen in people who are suffering in other ways — from homelessness, drug or alcohol addiction, or from frailty and multimorbidity that comes from a lifetime spent focussed on keeping the lights on rather than going to the gym or eating salads. The ‘external threats’ that Matt Hancock talked about happen in part because of lack of regulation, poverty, poor sanitation, destruction of natural habitats, and instability in other parts of the world. And although COVID-19 was brought to the UK largely by people coming back from holidays in Italy and Spain, it has brutalised poorer communities more than richer ones. This is partly because those communities suffer more of the chronic illnesses that make COVID-19 worse, and partly because people living in those communities tend to do jobs that come with a higher risk of catching COVID-19. Addressing chronic diseases and wider causes of illness is part of health improvement but success there matters for health protection. So while carving out health protection from the rest of public health might make some superficial sense, a moment’s thought about how to go about preventing infectious diseases leads straight back to health improvement and the wider causes of health.

The sanitary movement showed that to tackle outbreaks of infectious diseases we need to act on the conditions under which these infections thrive. In the 19th century, these conditions included poor sanitation, crowding, and the poverty that caused them. These things still matter but have been joined by things like poorly regulated food industries, low paid insecure work and lack of sick pay that mean people working when they should be at home in bed, homelessness, and deprivation and insecurity more broadly. If we ignore this, then the new National Institute for Health Protection will fail in its mission to protect the public’s health.