The first great wave of gains in public health arguably owed as much to plumbers as to any other profession. From the mid-19th century onwards, improvements in sanitation and access to clean water had a huge impact in reducing infectious diseases and improving both life expectancy and quality of life.

1. “The NHS should pay more attention to
prevention”
The first great wave of gains in public health arguably owed as much to plumbers as to
any other profession. From the mid-19th
century onwards, improvements in sanitation
and access to clean water had a huge impact in reducing infectious diseases and
improving both life expectancy and quality of life.
In the 20th
century, a wide range of initiatives then contributed to improving health. The
Center for Disease Control in the USA proposed the following as the ten most important
public health achievements of the last century:
· Immunisations
· Motor vehicle safety
· Workplace safety
· Control of infectious diseases
· Declines in deaths from heart disease and stroke
· Safer and healthier foods
· Healthier mothers and babies
· Family planning
· Fluoridation of drinking water to prevent dental caries
· Reduction of tobacco use

2. Translated to a UK context, we would note the involvement of the NHS in the majority of
these, but as leading in fewer – with substantial roles for employers, industry, legal
regulation, local authorities, and a wide range of lobby groups.
And much of this now looks like an historic agenda – not as battles which have been
completely won, of course, but as ones where the gains of the next century are not
likely to match those of the past. Managing climate change, reduction of use of the
internal combustion engine, and sustainable energy could be the main public health
challenges facing us over the next 100 years.
Alongside these big-picture environmental issues, there remains a big untackled
agenda – sadly,still - the consequences of poverty and material inequality. The healthy
life expectancy gap between the most and least deprived parts of the UK is 19 years,[1]
with poverty lying at the root of both behaviours and life experiences. Secure,
meaningful and adequately-paid work; access to healthy food; reasons to make
personal investments in health; decent and affordable housing; access to green spaces
– these and many other factors of a healthy lifestyle are constrained by poverty.
I recall hearing a psychiatrist once describing, with both sadness and anger, how he’s
too often asked to assess and treat the “depression” of people living in precarious
housing, with insufficient money to meet daily needs. “These aren’t patients, they’re just
poor” – and what they need isn’t either medication or talking therapies, but help with the
many practical problems of their lives.
So I’m not arguing that prevention of ill-health doesn’t matter, quite the reverse. But this
isn’t an agenda on which the NHS should presume to be leading in coming years. The
main responsibility lies elsewhere, and the NHS is not well-placed to act on most of it.
The NHS will – sadly, still – be required to pick up the pieces of the consequences of
environmental problems, of poverty and material inequality. But society as a whole –
central and local government, employers, industry, voluntary organisation, and
ultimately all of us – need to pay substantially more attention to addressing this
century’s agenda, if this century’s next wave of major public health benefits are to be
realised.
[1] https://www.health.org.uk/infographic/poverty-and-health