'Matters': is that a noun or a verb in the title? Well, both. As a noun, the word has at least 20 different meanings, but as a verb, only one important one. Public health obviously matters to all of us – the public – and the matter of sudden decisions to change the entire system of public health in England in the throes of a pandemic also clearly matters, even to us in Scotland.
As a medical student, I was required to attend lectures on public health. Some of my fellow students were cynical about them, finding them removed from the more exciting business of diagnosing and treating patients, but I quite enjoyed them. What I found interesting were the stories of the detective work that had led to the important discoveries of causes of diseases and of how to prevent them. Not for nothing had public health originally been called medical police.
Interestingly, 40 years after we had qualified, I found at a reunion that many of my fellow students' careers had involved work in public health; in practice, they had found prevention to be as satisfying as cure. Some of us had the good fortune to be able to combine them in our careers but in general a doctor will choose between the two, and clinical medicine obviously requires more practitioners to deal with individual patients than public health does to deal with populations.
Origins
The origins of public health can be traced back to ancient times, persisting in the hygiene rules and rituals of the older religions. On holiday you may have had the Roman lavatories pointed out in Ephesus, where the water for washing was separated from the waste. But it was the influence of epidemics and pandemics (plague) that saw the first laws on prevention of disease in Europe, with the introduction of measures to isolate sick people such as those unfortunates suffering from leprosy, prevention of gatherings, and what became known as quarantine (isolation for 40 days) on ships into Dubrovnick and later many other Mediterranean ports from the late 14th century. In Britain, this was exemplified by the famous self-isolation of the Derbyshire village of Eyam during the Great Plague of 1665. This was based, partly correctly as it turned out, on an ancient belief in miasma or the transmission of disease by something invisible in the air and empirical observations that such measures were partly effective.
The urbanisation and overcrowding accompanying the Industrial Revolution in the late 18th century brought with them increasing epidemics of transmissible disease and the early demonstration of water as the medium of transmission of cholera and typhoid fever by John Snow and William Budd in the 1850s. Tuberculosis or Consumption became the dominant cause of death, spreading in households and factories, leading to the building of sanatoria to accommodate patients and give them access to fresh air. The fact that no-one was immune was demonstrated dramatically by the death of Prince Albert from typhoid fever in 1861, but the predominance of these diseases among the poor in overcrowded accommodation became an issue taken up by reformers and some in the medical profession, which hitherto had concerned itself predominantly with the wealthier classes.
Governmental interest started in France in the early 19th century and in 1836 registration of births, marriages and deaths became compulsory in the UK, allowing the collection of accurate statistics on life expectancy and mortality at different ages and among different social groupings. There followed detailed reports on the conditions of the working classes and the establishment of local Boards of Health and Medical Officers of Health, the first being William Duncan in Liverpool in 1846. He is celebrated, ironically, in the name of a pub close to the very university public health department that my fellow students shunned (the department, not the pub!). In 1858, John Simon was appointed as the first Chief Medical Officer in the new medical department of the Privy Council in London, a post that was to become the government's Chief Medical Officer, now occupied by Professor Chris Whitty.
Thus, from the beginning, public health in Britain has been locally based to deal with local infectious and other environmental diseases and their causes but with oversight from central government to collate statistics and direct overall policy.
Changes through the 20th century
Five extraordinary matters enhanced the role of public health in Britain: the discoveries of bacteria and viruses, the application of vaccination, the discoveries of anti-microbial medicines, the introduction of the Welfare State and National Health Service, and the increase in both the size and longevity of the population. The last of these is in large part a consequence of the others but has brought with it a shift of emphasis in public health from infectious disease to diseases associated with national affluence but maldistribution of wealth, such as diabetes, high blood pressure and the disabilities of old age including mental deterioration. But the success of medicine to control infectious diseases induced complacency among both doctors and the population generally, leading to the two important consequences that we are now witnessing: the rise of acquired resistance of bacteria to antibiotics and neglect of preparations for epidemics. A third, less commented upon, has been loss of concern about health and hygiene in the poor world when transglobal travel has come within the reach of so many.
In the UK, there has been a shift in focus from infections, largely controlled by vaccination or curable by antibotics, to means of preventing the other diseases of maldistributed affluence, and this seems to have taken the emphasis from local control to central organisation. The roles of the local Health Boards and Directors of Public Health, answerable to local authorities, have been downgraded.
Consequences in the 21st century
To me, the most significant changes stemmed from the actions of our governments from 1979 onwards, first with the emphasis on the individual rather than society and the move towards reduction of the role of central government and privatisation of many aspects of health and social care and, secondly, the severe austerity following the bank-induced economic crash of 2008. The Public Health Laboratory Service, set up in 1948 to provide diagnostic services throughout the UK, was put into a new Health Protection Agency (HPA) in 2003. Paradoxically, the move towards 'small government' led to serious underfunding of local authorities and decimation of staffing in many government agencies, including the HPA and Health and Safety Executive, with consequential centralisation of control and loss of local diagnostic capability. HPA and essential equipment and staff from local public health laboratories were next centralised in Public Health England in 2013. The dangers of this were brought to a head by the election in 2019 of a populist government on a single issue – the implementation of Brexit – which severely limited the number of politicians suitable for ministerial posts in government by restricting them to those who had espoused this self-destructive cause. This included the vacillating Prime Minister who had earlier announced that he was not a suitable person to hold that post and was shortly to demonstrate that, in this at least, he was right.
In Scotland the pandemic response was initially and rightly coordinated with the rest of the UK, but included the disaster of transfer of elderly people from hospital to care homes. We shared with England the unpreparedness and lack of vital equipment but had a week or two more to make up for this and the Scottish NHS coped, although becoming a centre of infection itself. At this point, the Scottish Government woke up and remembered the importance of regional response, test for infections and trace contacts, and reverted to tried and tested methods while England stumbled. These methods are still working well here, though the tension between the centre and the local regions still shows up occasionally. In England, serious difficulties in supply of and access to testing persist.
The UK Government has proved itself unable to shed the role of campaigning, at which it excelled with the aid of dubious money and skilful use of lies and the electronic media. It continues with a belief in power by proclamation and use of world-beating or magical remedies for problems. And now we are seeing enacted in real life the old civil service joke about ministers: the story of the three envelopes. This tells of the new minister being briefed by his predecessor: 'Things will inevitably go wrong, but don't worry. I've left advice in three envelopes in your desk to read when you are summoned to give account to the Prime Minister'. So, when the first crisis struck, the minister opened envelope 1; it said 'Blame your predecessor. Say the department was in chaos but you are now getting control'. That worked and he continued to the next crisis when he was again summoned. Envelope 2 said 'Say you are completely reorganising your department in order to cope with the new circumstances'. Again, he retained his post and stumbled on to the third crisis, when he opened envelope 3 with some confidence. 'Write out three envelopes for your successor,' it said.
I think we know where Mr Hancock is now. In the midst of a pandemic, the wholesale reorganisation and splitting of Public Health England is likely to sow confusion, cost money, and cause anxiety among staff and be of no help to achieving any objectives that the different parts may be asked to address. Even worse, to put the control of a major public health institute in the hands of a fellow-PPE graduate with David Cameron, horsey friend of Matt Hancock, who happens to be a Conservative peeress and wife of a Conservative MP stinks of cronyism. The only positive to this apparent reinvention of HPA is that with such influence at the top, it is likely to recover some of the funding that it has been deprived of in the lead-up to the pandemic.
Where are we heading?
I think that we are now in a no man's land when flare-ups will continue and be controlled by prompt local public health management, schools and universities will have a hard time but will cope, and most people will settle down to a new pattern of work and a rather chastened lifestyle. Over-indulgence, foreign holidays and extravagant use of fossil fuels will be reduced substantially. The over-70s will continue to be very restricted in our activities and wary of any gatherings, especially indoors, until a vaccine becomes available. Even then, there will be a long period of wariness until it becomes clear that it is safe and effective. It is now quite likely that one or more vaccines may be available, at least for the most vulnerable, by early next year. Among the young and middle-aged, unemployment will again become a real problem.
All governments have a strong desire to hang on to power at all costs, but sometimes their majorities mean that this is fairly easy and they can take some risks with their popularity in order to do what is best for their country. There is an overriding need in the whole of the UK to tackle inequality and climate change, as well as to deal with the pandemic. The pandemic will, in due course, settle down to be more of a nuisance requiring nationwide hygiene measures and vaccination, responsible for relatively few deaths among the elderly and chronically ill. It will be controlled by good local public health organisation with overall direction (but not interference) from the centre, and this must ensure preparation for the next one.
The other two threats to our future, inequality and climate change, require firm governmental action with legislation, enlightened taxation and regulation that will be painful to many, especially those with Conservative inclinations. They are literally existential threats to our civilisation and are also lurking behind the current and future outbreaks of infectious disease. If you doubt this, look at what is happening in the USA and consider what happened in the 1930s and the rise of fascism. It is particularly distressing for those of us with long memories to see that in both England and Scotland the obsession with nationalism and exceptionalism is leading both our countries into an economic black hole, just at the time when a clear vision of the perils ahead and how to deal with them on an international scale is needed.
I believe the young are ready to accept what this implies. However, many of our politicians from the me-first generation have lost sight of longer-term issues in both countries, and in England are primarily concerning themselves with writing out envelopes. As Cicero said, the welfare of the people should be the supreme law.
Salus publica may also be translated as the public health.
Anthony Seaton is Emeritus Professor of Environmental and Occupational Medicine at Aberdeen University and Senior Consultant to the Edinburgh Institute of Occupational Medicine. The views expressed are his own
