The future of ‘public health’

I was an interested observer of an IEA webinar yesterday.

Hosted by director-general Mark Littlewood wearing a fetching pair of headphones that subsequently stopped working and had to be replaced, the hour-long event featured a 30-minute talk by Chris Snowdon (above) followed by some Q&As.

The subject was ‘What’s the future of public health post COVID-19?’

It was a private event so I won’t go into detail because I believe Chris’s contribution will be posted online when you can see and hear it for yourself.

I was going to ask the question ‘How do you define ‘public health’?’ but Chris sort of answered that during his talk.

If I can repeat one thing he said, he took the view that ‘public health’ should be responsible for just two things - environmental pollution and contagious diseases.

I agree with that, I think. The problem is, that’s not how the public health industry sees its current role.

Ever since the scourge of tuberculosis, measles, chicken pox, diphtheria and so on were addressed and either eradicated or substantially controlled in the West, the meaning of ‘public health’ has evolved dramatically.

Today, if you Google ‘What is the meaning of public health?’, you are directed to this definition, courtesy of the World Health Organisation:

Public Health is defined as “the art and science of preventing disease, prolonging life and promoting health through the organized efforts of society” (Acheson, 1988; WHO) ... Public health focuses on the entire spectrum of health and wellbeing, not only the eradication of particular diseases.

As you can see that covers just about everything and gives carte blanche to organisations like WHO and Public Health England to interfere in just about every aspect of our behaviour if it helps prolong our lives for a few more years.

Therefore, in a post COVID-19 world, we must have a serious debate about what is meant by ‘public health’. In particular we need to try and redefine it in terms that do not allow ‘public health’ bodies like WHO and PHE to dictate our lifestyles to the extent they would like.

A big worry is that, on the pretext of ‘protecting’ the public against future pandemics, governments will give public health organisations even greater powers to restrict and change our behaviours.

We’ve all seen what happens when you give the police extra powers or ‘guidelines’. A handful go too far. Drones in the Peak District, officers patrolling parks and beaches, moving on solitary couples ...

This morning Cambridgeshire Police tweeted:

Officers visited Tesco Barhill this morning as part of their patrols around supermarkets and green spaces this weekend. Good to see everyone was abiding by social distancing measures and the non essential aisles were empty.

The tweet was subsequently deleted but it interested me because Tesco Bar Hill is between my home and the Forest office in Cambridge.

I rarely go there (Tesco Bar Hill not the Forest office!) but I’m not sure how I would react if a police officer started rooting through my shopping for ‘unessential’ items.

Wine, beer and hot cross buns may not be essential but that’s subjective, surely? Ditto ice (for my evening G&T), Ben & Jerry’s Phish Food chocolate ice-cream, and a case of Diet Coke, all of which I purchased from Waitrose on my weekly shopping trip yesterday.

If such things are on sale in a supermarket or convenience store, why in hell’s name shouldn’t we be allowed to buy them?

As long as it doesn’t involve numerous trips to multiple shops (which it didn’t), what’s the problem?

Imagine, though, if Public Health England was to propose, post COVID-19, new shopping guidelines for the ‘benefit’ of our health.

We already know that from May 20 menthol cigarettes - which account for 25 per cent of the UK cigarette market - are going to be prohibited.

It’s not a huge leap to envisage a day when more products will be banned or severely restricted as ‘not essential to a healthy lifestyle’.

The threat to tobacco and alcohol is obvious. The South African government has already prohibited the sale of both as ‘non-essential’ during the current public health crisis.

Namibia (or Malawi, I can’t remember which) has followed suit. There are suggestions Kenya may do likewise, although a report I read yesterday said tobacco and alcohol are on the Kenyan government’s list of essential items.

A week ago there were even reports that the Mayor of New York intended to ban the sale of tobacco but that was quickly rebutted by his spokesman.

I suspect that over the next few months the tobacco control industry will fly a lot more kites like that to gauge public support for similar prohibitionist policies.

There is a very real danger that if we don’t nip this in the bud, calls to further restrict or ban the sale of tobacco will get louder and more frequent.

Meanwhile, when they’re not spreading alarming and sometimes misleading messages about the increased threat of coronavirus to those who smoke or vape, public health campaigners are mostly content to urge governments to use COVID-19 as an opportunity to press home the quit smoking message.

But that’s another story to which I’ll return.

I'm with Clive – former director of ASH questions Public Health England 'story' about smoking and coronavirus

Public Health England may come to rue their 'story' that 'smokers with COVID-19 are 14 times more likely to develop severe respiratory disease.’

On Sunday, in response to a statement issued by PHE on Friday, I noted:

PHE's claim was based on a single study with a sample size of just 78 patients including a tiny number of smokers.

Nor did they mention that other, larger, studies have reached very different conclusions. For example, according to a preliminary meta-analysis published in the European Journal of Internal Medicine (sample size: 1,399), 'Researchers found no link between cigarette smoking and the severity of COVID-19 among cases in China.'

In another, ongoing, meta-analysis, cardiologist Dr Konstantinos Farsalinos has reported that of '2,352 hospitalized cases examined, the observed prevalence of current smoking is <1/3rd the expected.'

Naturally Public Health England failed to mention these studies, probably because they're not 'on message'.

I added that:

As a publicly-funded body, Public Health England has a duty to act responsibly and not cherry pick studies that suit its agenda.

Yesterday, referring to the same 'story' (that has now echoed around the world), Clive Bates, the former director of ASH, tweeted:

I had hoped @PHE_uk would look at the evidence on smoking, vaping and COVID-19 in the round, take expert advice, and update advice on a rolling basis. But what they have done is terrible. It looks like crass PR rather than sound science.

He then linked to the PHE statement, and didn’t stop there. In a series of hard-hitting tweets he wrote:

It draws on a single study from China of 78 subjects who were already very sick with COVID-19-induced pneumonia. Of the 78, 11 deteriorated. Of the 78, 5 were smokers, 3 deteriorated and 2 improved. This is the basis for the 14x headline risk claim.

But this overlooks a very important detail. Of the 78 included in the study, there were only 5 smokers (6.4%). Yet smoking prevalence in China is about 27% (52% men, 3% women). So smokers are dramatically underrepresented in those already very sick with pneumonia. Why?

It gets worse. Of the 11 who deteriorated, 7 (67%) were men. But it is clear men generally are more likely to develop severe symptoms once they have the disease (maybe due to immune system differences). So the smoking effect could be a 'male' effect.

PHE is giving advice on the basis of a single study, which is bad enough. But it ignores the striking underrepresentation of smokers in the sample and misrepresents the findings of the study as general advice to smokers. Where's @SwitchFinder? We need sound science from PHE.

When someone with Clive Bates' background in tobacco control points the finger it really is time for others to take note and start asking questions – about PHE and the anti-smoking industry in general.

Incidentally, the person Clive refers to as @Switchfinder is Martin Dockrell, formerly Deborah Arnott’s right hand man at ASH.

Dockrell joined Public Health England in 2014 (I wrote about it here). Since then his advocacy of e-cigarettes as a quit smoking tool has turned him into a bit of a hero for vaping activists who seem to hang on to his every word or tweet.

I see him in a somewhat different light but it’s worth noting that, as I write, Dockrell has not yet tweeted a link to his employer's claim that 'Smokers [are] at greater risk of severe respiratory disease from COVID-19' which is odd, given his job title – Tobacco Control Programme Lead for Public Health England.

PHE’s credibility is already in danger of being damaged as a result of the coronavirus crisis. Although smokers have relatively few friends in high office, statements that are little more than propaganda won't help PHE's reputation.

Credit, then, to Clive Bates. I have my differences with him, which I’ve written about several times (see 'The canonisation of Clive Bates', 'The canonisation of Clive Bates, part two' and 'I'm with Clive (up to a point)'), but I've never doubted his ability as a shrewd and tireless campaigner and an excellent communicator.

What has frustrated me is his failure to acknowledge that many of the people and bodies responsible for scaremongering about vaping are the very same people who previously published or promoted some very questionable studies about smoking, passive smoking in particular.

The fact that he is now openly speaking out against unsound science when used against smoking is a welcome, if long overdue, development.

It takes courage for a leading vaping advocate to highlight the anti-smoking bias of the one body that, if it known for anything globally, is its relatively liberal attitude to e-cigarettes.

I hope other vaping advocates will do the same. The battle is not between smoking and vaping. It's between sound science and unsound science.

One question they should ask themselves is this. If PHE’s reputation is eventually trashed by stunts like this, why should anyone take anything they say seriously, even on the rare occasions they get it right?

Public Health England will have a positive influence on vaping only as long as it maintains some degree of credibility. Once that is lost - and it is currently hanging by a thread - PHE’s qualified endorsement of e-cigarettes could become a liability.

Talking liberties

Video calling is all the rage right now.

Zoom and House Party are two apps that appear to be popular for webinars and other online events but until a few weeks ago I’d never heard of either of them.

I thought it might be interesting to host an online meeting for friends of Forest during which guests will be invited to discuss a range of issues including ‘Quit for COVID’ and the forthcoming ban on menthol cigarettes. The discussion may be recorded and posted online.

I’ll post details in due course and if anyone wants to take part they will be very welcome to join in. Watch this space!

At home: smokers in isolation

Over on the Friends of Forest Facebook page we are considering one or two initiatives to while away the time during the coronavirus lockdown.

Inspired by the photograph of Dan Donovan below, which was taken yesterday, the first idea is to invite smokers to send an image of themselves smoking - in splendid isolation - in their house or garden. You may be smoking a cigarette, cigar or pipe, or you may be vaping.

Photos can be taken with a mobile phone but, ideally, they should be high resolution because we want the option of publishing them as part of a printed document. (Note: we will not use your photo without your permission.)

If you are interested, email your photo to me at contact@forestonline.org.

I'll post details of our second idea tomorrow.

A proper public health emergency puts 'Public Health' into perspective

Government and 'public health' activists take note.

When the current crisis is over it is clear there will have to be a serious re-evaluation of our bloated 'public health' industry and the role it plays in tackling genuine public health scares.

Rae Maile, an investment analyst at the investment bank Panmure Gordon, hit the nail on the head when he wrote, 'A proper public health emergency puts 'Public Health' into perspective':

The 'public health' industry has spent years lecturing people about lifestyle choices more than anything else, and questions have been raised by the response to COVID. Some elements have been seen to be the wrong side of the debate when arguing that PMI's Greek affiliate, Papastratos, should not have donated 50 ventilators to the local health service. It is too much to hope that lifestyle nannying goes away, but it might perhaps moderate.

I have written many times about Public Health England and its obsession with smoking in particular, but the problem goes much deeper than PHE and its well-remunerated army of mandarins.

The 'public health' industry has ignored what should be its real role for years if not decades. Instead of focussing on infectious diseases or illnesses caused by deficient hygiene, sanitation and water supply, campaigners – most of them living comfortable middle-class lives – have fought an increasingly nasty war on habits and behaviours that have little to do with public health.

Part of the reason for this is that, in the West at least, most of the major diseases of the past, like tuberculosis, have been consigned largely to history.

Many other common illnesses that were once potentially fatal have also been eradicated or reduced to a minor inconvenience in large parts of the world because of vaccines or antibiotics such as penicillin.

As a result of this, perhaps, the 'public health' industry appears to have taken its eye off the ball. Not even viruses such as ebola and SARS (which had relatively little impact in the West) could shake their belief that the great public health battles of the 19th and 20th centuries had been won.

Today that confidence looks a bit misplaced and while it's too early for an inquest it's worth noting that since the introduction of the Clean Air Act 1956 – which was in response to London's Great Smog of 1952 – 'public health' has increasingly focussed on private rather than public health.

Two factors could be jobs and money. Governments, by and large, aren't going to employ thousands of people or throw millions of pounds at problems that appear to have been solved.

New issues had to be found and smoking was an obvious target. The concept of passive smoking was enormous because now it could be argued that smoking was not just about individual choice, it was a public health issue – in particular, the health of non-smokers 'forced' to breathe other people's tobacco smoke.

It didn't stop there, though. 'Public health' now covers obesity and drinking even though the idea of secondhand eating and drinking have yet to catch on. (That said, it’s only a matter of time.)

Which brings us back to COVID-19.

It's no coincidence that neither the World Health Organisation (on a global scale) nor Public Health England (at domestic level) have provided much leadership on tackling the current crisis.

The WHO stands accused of turning a blind eye to what was happening in China while PHE, as I explained yesterday, responded to an attack on its competence by neatly deflecting the media's attention back in the direction of smoking.

I'm speculating, but the reason bodies such as the World Health Organisation and Public Health England have been unable to react in a convincing fashion to the coronavirus crisis is because neither organisation is fit for purpose – that is, capable of responding to a genuine public health emergency.

I could go on but I won't, for now. All I'll add is that the day of reckoning is fast approaching for a 'public health' industry that lost sight of its primary function a long, long time ago.

PS. I've just remembered that in September 2011 the World Health Organisation launched a 'Decade of Action for Road Safety’ campaign "to raise awareness of dangers on the road".

I wrote about it here – Now WHO turns on drivers.

People die in road accidents, it's true, but is road safety a public health issue in the accepted meaning of the term?

Either way it's another example of the WHO losing focus on what should arguably be its primary purpose - fighting illness and disease over which the general public has little or no control.

From Longleat to Hollywood

Sorry to hear that Lord Bath has died aged 87.

I never met the seventh Marquess of Bath, the ‘eccentric’ owner of Longleat, but I know someone who did.

In 1995 I was editing a small in-house magazine when I received an unsolicited article from a 19-year-old girl who, I found out later, was working on the checkout at a superstore in west London.

I can’t remember the exact details - it’s a long time ago - but I was sufficiently impressed by her irreverent and lively style of writing that I gave her a regular column and commissioned her to write a number of feature articles including several interviews.

Goodness knows why but one person I suggested she interview was the Marquess of Bath whose ‘colourful’ lifestyle included over 50 ‘wifelets’. (The number later rose to 74.)

He agreed and off she went to Longleat in Wiltshire where she got the full tour of the house, including the infamous Kama Sutra room.

What happened next still amazes me.

After I published the interview I got a call from the Daily Mail asking if they could reproduce it.

“It’s the best interview with the Marquess of Bath I’ve ever read,” the features editor told me.

The paper then offered her further work and within a few months she was given a full-time job. I could not have been more pleased, or proud.

A few years later, with numerous celebrity interviews to her name, she moved to Los Angeles to start a freelance career and to the best of my knowledge she has worked there ever since.

I still see her byline in the Mail, Mail on Sunday (including today's edition) and the Telegraph.

And all thanks to the 'flamboyant' and aristocratic Marquess of Bath!

Nanny-in-chief loses her seat in parliament

There was a notable loser during Ireland’s Seanad election count yesterday.

Catherine Noone, who was elected to Ireland’s upper parliament in 2011, lost her seat after a series of incidents including the well-meaning but calamitous suggestion that Taoiseach Leo Varadkar is “autistic” and “on the spectrum”.

To put this in perspective, in the 2016 general election Noone was Varadkar’s Fine Gael running mate. He got elected, she didn’t. Instead, after she was re-elected to the upper house, and in a clear vote of confidence, he appointed her deputy leader of the Seanad.

By then Senator Noone had already made a name for herself with interventions on subjects as diverse as regulating ice cream vans and mixed martial arts, which she once wanted to ban before doing a sharp U-turn.

She also called for ‘no fry zones’ near schools and supported minimum pricing of alcohol and plain packaging of tobacco.

She took a more liberal attitude to vaping, one of only a handful of Irish politicians to do so (publicly at least), but only as a smoking cessation tool.

To her credit she showed enormous courage, chairing a parliamentary committee on abortion, a hugely controversial issue in Ireland. As a result she attracted a shocking amount of personal abuse and online trolling but proved remarkably resilient.

What I really liked about her was her sense of humour and her willingness to engage with her critics, especially on the issue of the nanny state.

When, in November 2017, Forest Ireland awarded her the title ‘Nanny-in-Chief’ she not only accepted her trophy in person, she gave a witty speech that began, “Libertarians, contrarians, barbarians, thank you.”

She later tweeted, ‘Proud recipient of the Golden Nanny Award 2017 – proud moment.’

The following year she returned to present the same award to her friend and colleague Marcella Corcoran Kennedy (who lost her seat, in the Dáil, in January).

We have our differences on policy but I wish there were more politicians like Catherine Noone. Dare I say it, but I hope she’ll be back, older and a little wiser.

But first, I would recommend a good media training course and a personal mute button!

PS. The Irish Independent reports (Fine Gael Senator loses Seanad seat after career marked by political blunders):

Ms Noone has had a colourful career after first being elected to the Seanad in 2011 ... She admitted at one point that she’s seen as “queen nanny” in some quarters and once turned up to accept a ‘nanny-in-chief’ award from a smokers’ rights group.

See also: Senator wins award as head of Ireland’s ‘nanny state’ (The Times)

Below: Catherine Noone accepts her Golden Nanny award

Reading the news

An old friend I haven’t seen for some time emailed me this week.

A former award-winning journalist, he asked, ‘Are you all surviving the lockdown?’ followed by, ‘How do you read what’s happening?’

I fear my reply may have disappointed him:

I’m reading/watching as little of the news as I can. I don’t think the media is helping matters at the moment. Decision-makers will make mistakes but I’m sure everyone is doing their best in difficult circumstances and I’m not keen on the ‘Gotcha’ attitude of many journalists and broadcasters - or the army of armchair experts!

Of course, I’m largely aware of what’s going on - it’s impossible to avoid all the news - but I have stopped listening to Five Live’s incessant chatter on the subject and yesterday I even stopped buying the Daily Mail, a paper I have read for almost 50 years.

My wife insists on listening to the Today programme (it acts as an alarm clock at 6.00am) but I insist on the sound being turned down so low (“Alexa, volume down!”) it’s difficult to hear, especially with a pillow over one ear (mine not hers).

The World at One passes me by and I only listen to PM if I’m in the car, which I rarely am these days.

Credit to PM’s Evan Davis, though. Calm and thoughtful, he’s one of the few presenters who doesn’t repeatedly interrupt his guests. God forbid, he may actually be listening to them.

If there is a five o’clock news conference at Number 10 I may watch that but I switch off as soon as journalists start asking their inane and often deliberately provocative questions.

Most of them are clearly more interested in a sensational headline than informing the public of the latest developments in a sane and rational manner.

So I rarely watch the news and I NEVER watch Newsnight.

Am I missing out? I don’t think so. It’s like muting or blocking someone on Twitter. They’re still there but you no longer have to listen to them.

It’s quite liberating actually and life is far more tolerable.