5th June 2009
Carbon calories, rising winter deaths, social marketing and public health in the NHS are some of the themes that EHP has covered this year. These touch on the professional turf of others and demonstrate how diverse environmental health has become. They also show its potential to cross boundaries and take public health from the boardroom to the kitchen, shape policy and deliver qualitative changes to people’s lives.
But how comfortable are we with what environmental health has become compared with its origins in Victorian Britain?
In 1842 Edwin Chadwick presented his Report on the sanitary condition of the labouring population of Great Britain and on the means of its improvement. He outlined a vision of public health protection where “the removal of noxious physical circumstances, and the promotion of civic, household and personal cleanliness” were seen as “necessary to the improvement of the moral condition of the population; for that sound morality and refinement in manners and health are not long found coexistent with filthy habits amongst any class of the community”.
Wise words
During our 24 years of public service, including the delivery of global diversity projects on public health, we have seen the wisdom of Chadwick’s words in communities from Bognor to Baghdad. However, in the last few years we’ve heard concerns about environmental health drifting away from these founding principles.
Judging by feedback from our diversity work and conversations with EHPs around the country, we are not alone. In the January EHP Alistair Witt’s “Is writing on the wall for generalist EHPs?” was letter of the month. He made some thought provoking points about the march towards professional specialisation including the fear that “we have put the final nail in the coffin for the generalist EHP”. To deliver public health the profession must evolve, yet it must also keep a firm foothold on its public health foundations.
One view expressed in our forums is that the primary function of EHPs is to enforce the law. Some think that only through enforcement can we create a level playing field. There are problems with this view. The most serious is that it doesn’t work. You only have to look at the statistics on prosecution rates, environmental protection notices and statutory notices and at anecdotal evidence to see “nick them” is flawed.
These debates reveal that without a clear, unified vision of what environmental health is and what it seeks we risk serious pitfalls. We have no intention of forming an EHP protectionist movement. Our aim is to invite debate about how people see themselves not just as public health professionals but as service users. The goal is to develop a meaningful “public health ethic” that guides professionals, protects public health and presents to the wider world a clear vision of environmental health.
Chadwick’s report identified some vital points that should be seen in a contemporary light. Whether we are talking about disease control, antisocial behaviour, clean air, unfit housing or even climate change, none of this exists in a vacuum. Every day delivery of environmental health requires EHPs to maintain a professional focus in the same way that a specialist doctor or a police officer might. But the profession also needs to work within a broader environmental health framework that reflects the connections through all areas of public health.
Effective interventions
Take hard-to-reach communities, where we need to recognise the reality of people's lives to intervene effectively.
One way of looking at this is to think in terms of investment and calculate the most productive public health return from our interventions. This is where the generalist EHP comes into their own, being able to achieve positive public health returns through joined-up thinking. Hard-to reach communities show us how complex and interconnected public health can be. We must think hard about protecting the skills needed to reach these sectors because if we can crack the challenges of delivering initiatives here, our labours will bear fruit elsewhere.
Many EHPs will be familiar with equality impact assessments on how service delivery affects communities, ranging from those with diverse physical needs to those with diverse faith aspirations. To audit services in this way we need some sort of public health impact assessment that considers the contribution an intervention makes to the overall quality of public health. It would need to be underpinned by a public health ethic that makes a simple point: if it doesn’t make a positive contribution to public health, then don’t do it and if certain actions and strategies are counterproductive, then stop them.
With an ethical assessment framework we can start to think about interventions such as enforcement policy, inspection regimes and how services are audited. Take, for example, the use of contractors paid on a per-inspection basis. Clearly this is linked to issues such as annual returns, so they can be considered alongside each other. In the context of food hygiene inspections it can be argued that playing a numbers game, particularly in hard-to-reach communities, is damaging our ability to improve public health.
Some contractors will carry out 10 inspections in a day and “full” inspections in as little as 15 minutes. Some people will claim they can do this without compromising their inspection but what about time spent educating, time with staff and the food business operator? In many cultures time-driven inspections are counter-intuitive, leaving people feeling unvalued, confused and at times offended. Notwithstanding questions about the real ability of an inspector to be professional and thorough, the public health impact of these strategies risks being negative.
Ethical framework
With an ethical framework professionals will be able to make decisions that result in tangible public health improvements. We need to be able to measure outcomes and efficiencies. If performances have to be measured, let them be measured against their impact on public health.
The creation of a public health ethic does not mean the profession is becoming fluffy and trying to discourage the use of all of the tools at our disposal. On the contrary, an ethical framework ensures that all interventions are considered and if public health is best served by vigorously applying the law, then so be it.
Three groups require formal action. There are those who run a business in a criminal manner to make money and avoid legal responsibilities. They calculate the risks against the benefits of contravening statutory obligations. The second group are those who are lazy and see legal requirements as an inconvenience. Then there are those who don’t understand what is required of them – they are not bad, they just don’t get it.
An ethical framework would acknowledge that the first two groups require robust legal interventions that protect public health. The third group challenge us to come up with more creative and flexible interventions.
Chadwick gave us a public health legacy that presented a cohesive response to the difficulties of managing public health. His vision showed how the complex strands of human life throw up obstacles that are best managed through joined-up public health management.
Protecting public health now is no less tough than it was in 1842 but EHPs stand out as professionals capable of weaving complex threads together and are embedded in communities where they protect public health.
Our goal is to show how a cohesive national public health ethic could raise the profession's profile and help EHPs become the public health champions that Chadwick would recognise.
Sara and Anthony Sharpe will be presenting a paper on this subject at Best of the Best. Contact through: www.internationalfaithsolutions.com