Why Do We Know So Much and Do So Little in Public Health?
Rt. Hon. Professor Baroness Tessa Jowell & Mary T. Gorski Findling
The purpose of public health—to promote and safeguard the health and well-being of people and their communities—is well-informed about how to improve health in the face of some of our greatest challenges, including obesity, tobacco-related deaths, communicable diseases, and developmental delays in early childhood.1 So it is frustrating that while the means to improve health are available to us, so often, publication of the latest health statistics produce only hand-wringing and a sense of helplessness. So often the evidence is a call to action to implement what we know. However, before we can act on the evidence, we have to understand the nature of the obstacles.
Policy decisions about public health action are often seen as striking at the heart of the relationship between individuals and government, government and business, government and communities. It is the reaction to proposed government policy that so often delays, diverts, or nullifies the government’s will to act. The representations against action for the public’s health are varied, but individually and in combination are considered destructive to the application or the implementation of policies for health improvement. So intervention by government—e.g. to introduce a smoking ban, regulate sugar in food and drinks, extend vaccination, etc.—may be lambasted as an attack on individuals’ autonomy and freedom to choose. For many, the long arm of government should not intrude in private lives. Conflict with commercial interests, in relation to food labeling or a sugar tax, will set the food industry against public health advocates.2
Of course we must pace change in line with the public’s willingness to embrace and support that change, but we must also be bolder in showing leadership about the lives saved and health gained if, together, we act. For example, decisions to ban smoking in public spaces in the UK and the USA were highly contentious, but huge improvements in air quality and health have been overwhelmingly appreciated by the public.
The “post-truth” world poses a great new challenge. Post-truth is commonly defined to mean that judgments are increasingly based not on fact, but on what people feel to be true. This phenomenon gives way to increasing skepticism about science and challenges the evidence of experts.
Engagement over time and investment to improve the health of communities give great returns, yielding the benefits of healthy and active extra years of life. The gains are not just numerical, but personally fulfilling increased life expectancy, which demonstrates that prevention is invariably cheaper than the greater costs of treatment and cure. And that investment in public health builds solidarity and cohesion in communities by tackling the injustice of health inequality, which so often results from poverty and disadvantage.
There is clear evidence of new momentum in support of improved public health. Particularly, we see city mayors taking the lead, like Michael Bloomberg improving New York City’s food supply and extending tobacco-free spaces, and Mick Cornett tackling obesity in Oklahoma City. Cities like Stockholm and Bogotá have committed to improving infrastructure to support cycling,3 while the 2012 London Olympics were carefully designed to improve sustainability and reduce social inequality.4
With more people moving to cities, mayors are increasingly able to take on major public health challenges, including climate change and poverty. There are many ways health can be planned into neighborhoods, communities, and cities. But like the most effective and sustainable change through public policy, this takes time. And to imbed sustainable change takes very clear and defined mission-led leadership.
What is mission-led leadership in public health? It pre-supposes the ability to build a team who reflect a shared culture and commitment to change. It relies on judgments, which underpin decisions, which draw on the best available evidence, careful consultation with stakeholders more widely, and personal engagement over time with the individuals and the communities who will be the beneficiaries of change.
The big vision is public health leadership where politicians, executives, or clinicians will invariably begin with a major visionary speech, setting out the case for change and the benefits of change. Rarely does the visionary’s speech chart the detailed path from value-driven ambition to lives changed in practice. To do that relies on the rigorous and applied discipline of delivery. We are grateful to Sir Michael Barber for his eight rules of delivering change: (1) prioritize; (2) define success clearly; (3) set strategy and policy; (4) ensure operational planning; (5) use routines to drive progress; (6) solve problems as they arise; (7) persist in the face of adversity and challenge; and (8) “If you are going to negotiate with someone tomorrow, don’t insult him today” (--Clement Atlee).
The need for improved public health is evident. And as the means of addressing those needs are available to us, there is no excuse for knowing so much and doing so little.
Thank you to Sir Michael Barber for sharing his eight rules of delivery.
About the Authors
Baroness Jowell served as a Member of British Parliament from 1992-2015 and was the first Minister of State for Public Health. She also initiated and managed the London 2012 Olympics and Paralympics. She currently serves on the Advisory Board of the Ministerial Leadership in Health Program, an initiative of the Harvard Chan School and the Harvard Kennedy School.
Mary is a PhD candidate in Health Policy at Harvard, where she conducts research on policy opportunities to improve the public’s health. Mary holds a ScM from the Department of Social and Behavioral Sciences at the Harvard Chan School and a BA in Public Health from Johns Hopkins University.
- World Health Organization. Global health risks: mortality and burden of disease attributable to selected major risks. 2009. [cited December 1, 2016] Available online: http://www.who.int/healthinfo/global_burden_disease/GlobalHealthRisks_report_full.pdf.
- Mello MM, Studdert DM, Brennan TA. Obesity—The New Frontier of Public Health Law. New England Journal of Medicine 2006. 354: 2601-2610.
- Sallis JF et al. Use of science to guide city planning policy and practice: how to achieve healthy and sustainable future cities. Lancet. 2016; 388(10062): 2936-2947.
- Burdett R. “The London Olympics—making a ‘piece of city.’” British Politics and Policy Blog, London School of Economics. August 1, 2012.[cited December 1, 2016] Available online: http://blogs.lse.ac.uk/politicsandpolicy/london-olympics-making-piece-of-city-burdett/.