Tuesday, 22 October 2013

Public Health and bedtime stories

Although I ended up rambling about municipal pubs, my last post was prompted by my enthusiasm after going to a public health conference hosted by the LGA.  As I’ve said before, I see real opportunity for public health to make a difference to a wide range of policies in local government, not necessarily through spending, but by being a voice around the table – or, given the discussions in London the other day, embedding that voice into the decision-making process by winning over other stakeholders, whether they’re within the council – say in the transport department – or outside, like pharmacists and dentists.

On the other hand, though, I’ve sometimes been wary of a public health approach.  Because the approach increasingly focuses on ‘lifestyle’ illnesses there’s a tendency to understand public health in individualistic terms where people are felt to be making bad ‘choices’.

There are two key problems with this approach.  First, there’s the liberal JS Mill argument that someone’s own way of living their life is the best almost by definition.  Second, there’s a question as to whether this model of individual free choices actually reflects reality, where certain choices are easier than others and people’s options and the relative attractiveness of them will be affected by structural factors, such as wealth, environment and so on.  (This point was made by several speakers at the LGA conference.)

On this front, say on smoking policy, the first point would question whether the state should have any role in trying to reduce smoking prevalence, as that’s just the expression of individuals’ decisions, balancing up the costs and benefits of smoking and deciding that the pleasures are worth the risks.  The second point (which would only be relevant if you didn’t accept the first) would note that people’s propensity to smoke seems to be affected by their background and other factors, so you’d need to do more than address individuals; you’d need to change those background factors.

Certainly I’ve made both of these criticisms in the past.  Why shouldn’t someone drink if they want to?  Who defines too much?  And let’s not, from ivory towers, guilt trip people about the joys of an abstemious life.  Sometimes, reading something like the Marmot Review, given what we know about how wealth and income inequality determine health, it can seem like the only way to achieve its objectives is a shift in political culture – instituting communism.*

However, this wasn’t the way I felt on Tuesday.  As I say, I felt enthused.

But I was reminded of these questions about the scope of public health when I heard about a public health initiative to ensure that children are told bedtime stories.**

This is in some ways exactly the sort of thing I was enthused about – public health looking at the broader determinants of health.   But it also raises the question as to whether this is really a public health intervention when its influence on health is so indirect.

In fact, because of the interlinks, such an intervention is best understood not as a health intervention, but as part of a broader project to foster fulfilment, and possibly the development of ‘good citizens’.

The principle of the bedtime story reading in its relevance to health is the same as the Good Behaviour Game, for example: strengthening what is sometimes called resilience.  To some extent, this idea of resilience could be seen as an attempt to combine the individual and the structural perspectives on public health.  One of its key defining features is the ability to make choices.

The vision of a resilient individual is one who makes wise, considered choices.  To some extent, this sort of intervention could be seen as neoliberal: an attempt to make people self-governing, rather than reshaping the structures around them.  I don’t want to discuss here whether I agree with this mode of governance or not; simply to acknowledge that there are other ways to ensure public health – more direct interventions, that focus less on individual choice, might be at least as effective.

Also – and this is what distinguishes neoliberalism from classical liberalism – the government has clear ideas of what ‘good’ choices are; it doesn’t really sign up to the Millian point that everyone’s own way of living their lives is by definition the best (within certain limits).

To some extent, the elements that constitute this new public health approach are not controversial, or specific to left or right wing agendas.  Equally, they are not aims that are specific to public health.  I was enthused by the discussion of initiatives within Wigan and Hertfordshire at the conference not because they would enhance people’s health, but because they are more than this – in the case of Wigan the campaign was explicitly about community and aspiration in general: “Believe in Wigan”.

As I said previously, when writing about Brighton’s public health report, I’m more engaged when education or community are invoked as, if not goods in their own right, then contributing to something like eudaimonia or fulfilment – rather than being ways of protecting one’s health.

And here’s the rub.  I was enthused by the projects described on Tuesday because they were about fostering wider fulfilment, happiness, eudaimonia – whatever term you prefer.  You might choose the term wellbeing – and indeed health and wellbeing boards are part of the governance for public health teams.  But this is not public health in itself.

I would like to think that the idea that local government should put in place conditions that allow people to flourish is uncontroversial.  However, what we mean by flourishing is certainly up for debate.  In Mill’s view, you wouldn’t want too many restrictions as people become fulfilled humans actually by the process of reasoning and choosing.  (You aren’t a moral person if the choice to behave in a certain way is made for you.)

This could bring us onto a discussion of liberalism and nudging – appropriate, as nudging was a theme of the conference – but the point I want to make here focuses on public health specifically.  I was uncomfortable with the idea of happiness in the Brighton report, where it seemed to be either a meaningless proxy for health or a means to achieve health.  Similarly, community, or education, or bedtime stories shouldn’t be justified as good things on the basis of public health.  This is not why we want these things.  Scientific evidence continually emerges, and we might find that there is some drug that ensures health and longevity better and more efficiently than any amount of green space, or bedtime stories, or cycle paths.  Would this mean that we should abandon encouraging these things?

Public health is at the moment a good strapline under which to group all sorts of concerns that are not directly financial.  Given that the overriding dynamic in local government policymaking at the moment is saving money, having such an emphasis can be helpful, and that’s why I found the discussions positive.  However, it’s attractive to embed these ideas across local government departments precisely because they are not specific to public health; they simply amount to good government.

Maybe, for the moment, public health teams are a useful tool to remind local authorities that there’s more to life than short-term balance sheets.  However, it’s helpful sometimes not to take too instrumental a view.  The language of price and value is embedded in social mobility discussions, with Alan Milburn stating a few days ago:

“When 2.3 million children are officially classified as poor it exacts a high social price. There is an economic price too in wasted potential and lower growth.”

Just as equality shouldn’t be justified on the basis of economic growth, there’s a danger in suggesting parents should tell bedtime stories to boost their children’s health and resilience.

*The way PHE’s aims are stated, it’s actually as if the core task is reducing inequality of any kind: ”Our mission is to protect and improve the nation’s health and to address inequalities”

**I should confess at this point that I know next to nothing about this specific intervention and how it’s delivered.  The points I’m making here, though, should still be valid as I’m talking about the general principles.

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