The history and political context of health improvement: presentations for the Masters inPublic Health course at Liverpool university including global and local approaches to health improvement and a history form Persia to the Present

1. The historical and political context
of health improvement
Prof John Middleton,
University of Wolverhampton
President, UK Faculty of Public Health
Masters in Public Health, Liverpool University,
October 6th 2016

2. John Middleton, Historical and political context of health improvement; MPH Liverpool University, October 6th 2016

3. Where there is no vision the
people suffer
Andrija Stampar, Yugoslavian Public health pioneer and WHO founding
father
After Proverbs/29-18.

4. The science and art of promoting health,
preventing disease and prolonging life through
the organised efforts of society
Acheson 1988, after Winslow 1927 , WHO 1948

5. Public health:
‘promoting health, preventing disease, prolonging life through the
organised efforts of society’
Sustainable development:
‘protecting resources from one generation to the next’
Environmental justice:
‘the pursuit of equal justice and equal protection under the law for all
environmental statutes and regulations without discrimination based
on race, ethnicity, and /or socioeconomic status.’

6. John Middleton, Historical and political context of health improvement; MPH Liverpool University, October 6th 2016
The strategic definition of health promotion is the process of
enabling people to increase control over and to improve
their health. This is underpinned by a further statement of
the WHO “This perspective is derived from a conception of
‘health’ as the extent to which an individual or group is
able, on the one hand, to realise aspirations and satisfy
needs; and, on the other hand, to change or cope with the
environment. Health is, therefore, seen as a resource for
everyday life, not the objective of living; it is a positive
concept emphasising social and personal resources, as well
as physical capacities”
RSPH Public health and commissioning 2014 , from the
Ottawa Charter 1986
RSPH Public health and commissioning
2014 Health promotion is …

7. Health, hygiene
and councils …

8. John Middleton, Historical and political context of health improvement; MPH Liverpool University, October 6th 2016
Salus populi
suprema lex
esto
Cicero

9. John Middleton, Historical and political context of health improvement; MPH Liverpool University, October 6th 2016
• Hygiea, daughter of Aescalapius, God of
Medicine
Goddess of health,
cleanliness and sanitation,
Described in Greek literature
700 BC, deity, 200 BC

10. John Middleton, Historical and political context of health improvement; MPH Liverpool University, October 6th 2016
Sons and daughters of Asclepius, God of
Medicine
Panacea,
Aceso, healing processes
Aglaea, - good health, ‘the glow of health’
Hygieia,
Iaso, - recuperation
Meditrina,
Machaon,
Podaleirios,
Telesphoros

11. John Middleton, Historical and political context of health improvement; MPH Liverpool University, October 6th 2016
• Salus - ‘safety’, ‘salvation’ ‘welfare’

12. John Middleton, Historical and political context of health improvement; MPH Liverpool University, October 6th 2016
Sirona- goddess of health of
Eastern Gaul to Danubia
(representations found
map below)
(left) statue from the temple
discovered at Hochscheid,
Moselle, Germany

13. John Middleton, Historical and political context of health improvement; MPH Liverpool University, October 6th 2016

14. John Middleton, Historical and political context of health improvement; MPH Liverpool University, October 6th 2016
http://www.dimensionsofculture.com/2010/10/traditional-asian-
health-beliefs-healing-practices/

15. John Middleton, Historical and political context of health improvement; MPH Liverpool University, October 6th 2016
Vitalism is based on a core belief that disease is the result of some imbalance
in the vital energies which distinguish living from non-living matter. In the
formative days of the Western medical tradition founded by Hippocrates,
these vital forces were associated with the four temperaments and
humours. In Eastern traditions, related terms are qi and prana. Today,
vitalistic approaches to health are widespread in Asia. The ancient art of
acupuncture in China is an example of this system which focuses on the
flow of vital forces or energy within the body. If energy within a person’s
body is flowing harmoniously, their health is deemed good. Illness results
when this smooth flow of energy is disrupted and therapeutic measures
are aimed at restoring a normal flow of energy in the body. In India, yoga
(particularly hatha yoga, the physical form of yoga) is used therapeutically
to restore a balanced energy flow through body and mind.
Chinese traditions

16. John Middleton, Historical and political context of health improvement; MPH Liverpool University, October 6th 2016
• East Meets West In the 17th century,
traditional Vietnamese and Chinese
practitioners began identifying their medicine
as Dong Y to distinguish their medicine from
the Western colonial medicine. Similarly,
people in the West began to use the term
“Oriental medicine” to differentiate Eastern
medical practices from Western ones.

17. John Middleton, Historical and political context of health improvement; MPH Liverpool University, October 6th 2016
• Health is seen as a state of balance between the
physical, social, and super-natural environment.
Western medicine tends to approach disease by
assuming that it is due to an external force, such
as a virus or bacteria, or a slow degeneration of
the functional ability of the body. Disease is
either physical or mental. The Eastern approach
assumes that the body is whole, and each part of
it is intimately connected. Each organ has a
mental as well as a physical function.

18. John Middleton, Historical and political context of health improvement; MPH Liverpool University, October 6th 2016
‘Health’=‘Shalom’= ‘Peace’

19. John Middleton, Historical and political context of health improvement; MPH Liverpool University, October 6th 2016
Salamati
• In Persian, one word for health - Salamati
encompasses mental, physical and spiritual
health, as well as a balanced diet and social
life
• illness is perceived as a lack of balance
• Illness as atonement
• Illness and death accepted by meditation and
prayer

20. Bimaristans of old Aleppo
places of light calm, peace, reflection, mindfulness , scents and sensibility

21. KUSAMALA
INSTITUTE OF AGRICULTURE & ECOLOGY, Malawi
3 Ethics
 Earth Care
 Provision for all life systems to continue and multiply
 Working with nature, rather than against it
 People Care
 Provision for people to access the resources necessary for
their existence
 Ensuring the wellbeing of people and communities
 Fair Share
 The earth's resources are limited, use/consume only what
you need
 Don't forget about future generations

22. A (very) short history of English public
health

23. John Middleton, Historical and political context of health improvement; MPH Liverpool University, October 6th 2016

24. John Middleton, Historical and political context of health improvement; MPH Liverpool University, October 6th 2016

25. John Middleton, Historical and political context of health improvement; MPH Liverpool University, October 6th 2016

26. John Middleton, Historical and political context of health improvement; MPH Liverpool University, October 6th 2016
The English Civil War

27. John Middleton, Historical and political context of health improvement; MPH Liverpool University, October 6th 2016

28. John Middleton, Historical and political context of health improvement; MPH Liverpool University, October 6th 2016

29. John Middleton, Historical and political context of health improvement; MPH Liverpool University, October 6th 2016

30. John Middleton, Historical and political context of health improvement; MPH Liverpool University, October 6th 2016

31. A (very) short history of public health
• Sanitory revolution

32. John Middleton, Historical and political context of health improvement; MPH Liverpool University, October 6th 2016

34. John Middleton, Historical and political context of health improvement; MPH Liverpool University, October 6th 2016
William Duncan of
Liverpool
The first English Medical
Officer of Health….

36. John Middleton, Historical and political context of health improvement; MPH Liverpool University, October 6th 2016
The Butcher Row,
Coventry
‘an area where
contagious fevers
prevailed to a fearfull
extent’
Coventry Board of
Health 1849

39. John Middleton, Historical and political context of health improvement; MPH Liverpool University, October 6th 2016

40. John Middleton, Historical and political context of health improvement; MPH Liverpool University, October 6th 2016
• Health for all by the year 2000: the Alma Ata
declaration 1978
• Global health strategy for achieving health for
all by the year 2000 WHO 1980
• European Targets for Health for all by the Year
2000 WHO 1985

41. John Middleton, Historical and political context of health improvement; MPH Liverpool University, October 6th 2016

42. John Middleton, Historical and political context of health improvement; MPH Liverpool University, October 6th 2016

43. John Middleton, Historical and political context of health improvement; MPH Liverpool University, October 6th 2016

44. The inverse care law:
‘People who need the most health care
get the worst, and the poorest quality’
‘Poor people get poor services’
West Midlands Regional Public Health Excellence Conference, JMiddleton March 6th 2015

45. John Middleton, Historical and political context of health improvement; MPH Liverpool University, October 6th 2016
• The new public health
• Local authorities
health network
• European targets for
Health for All by 2000

46. John Middleton, Historical and political context of health improvement; MPH Liverpool University, October 6th 2016
• The Healthy cities movement 1986-
• The healthy regions initiative 1990 –
• Health 21 WHO 1999
• Health 2020 WHO 2012

47. John Middleton, Historical and political context of health improvement; MPH Liverpool University, October 6th 2016
• Local authorities health network 1987
• UK Public Health Association 1991
• First UK Health improvement plan ‘ The Health
of the Nation’ 1992 UK government
• ‘Variations in health’ report 1996 UK government

48. John Middleton, Historical and political context of health improvement; MPH Liverpool University, October 6th 2016

49. John Middleton, Historical and political context of health improvement; MPH Liverpool University, October 6th 2016
Reducing health inequalities in health UK
English health policy since the Black report
• 1979 The Black report on health inequalities
• 1986 The Health Divide Margaret Whitehead and David
Player
• !996 Variations in Health
• 1998 The Acheson report
• 1999 Health Action zones
• 2004 Spearhead PCTs
• 2008 Marmot 1,
• 2010 Marmot 2
• 2012 Health and Social Care Act duty to reduce inequalities
on Clinical commissioning groups and NHS England

50. John Middleton, Historical and political context of health improvement; MPH Liverpool University, October 6th 2016
• Health and Social care act 2012
• Public health ‘returns’ to local authorities
• Public Health England set up
• Duty to reduce health inequalities on new NHS clinical
commissioning groups and NHS England
• NHS England responsible for public health
interventions such as immunisation and screening
• Local authorities responsible for NHS services such as
health checks and mandated advice to CCGs
• ‘Responsibility deals’

51. A (very) short history of public health
• Inequalities in health
• The economics of health :some examples

52. Shaw et al.
Critical public health
2001,11:289-304

53. Shaw et al
Critical public health,
2001;11:289-303

56. Source: The poverty site http://www.poverty.org.uk/09/index.shtml

58. CHD Mortality 2000-2005
MALES, Less than 65 years
0.00
10.00
20.00
30.00
40.00
50.00
60.00
70.00
80.00
90.00
2000 2001 2002 2003 2004 2005
Rateper100,000
West Midlands England Sandwell
FEMALES, Less than 65 years
0.00
5.00
10.00
15.00
20.00
25.00
2000 2001 2002 2003 2004 2005
Rateper100,000
West Midlands England Sandwell
PERSONS, Less than 65 years
0.00
10.00
20.00
30.00
40.00
50.00
60.00
2000 2001 2002 2003 2004 2005
Rateper100,000
West Midlands England Sandwell

59. 59

60. 60
The Marmot Review
• Early years interventions
• Young people
opportunities
• Workplace health
• Fairer more equal incomes
• Healthy town planning and
housing
• More equal access and
outcomes in healthcare
John Middleton, Historical and political context of health improvement

61. 61

62. 62

63. Food poverty, food banks
63

65.  Social care
 Leisure
 Education
 Environmental
protection
Housing
Town planning
Transport
Environment and
sustainability
Economic
development
Culture and heritage
Council services should all be
involved in the health agenda

66.  Social care
 Leisure
 Education
 Environmental
protection
Housing
Town planning
Transport
Environment and
sustainability
Economic
development
Culture and heritage
Council services should all be
involved in the health agenda
Office of
Public
Health
West Midlands Regional Public Health Excellence Conference, JMiddleton March 6th 2015

67. West Midlands Regional Public Health Excellence Conference, JMiddleton March 6th 2015
Population health needs assessment
Joint strategic needs analysis
Health impact assessment
Health advocacy
Reducing health inequalities
Specialist public health commissioning and
provision in health protection, health
improvement and health care related action
Office of Public Health

68. John Middleton, Historical and political context of health improvement; MPH Liverpool University, October 6th 2016

69. These 10 Corporations Control Almost Everything We Buy
Industrial Corporations prioritise PROFIT, not public health

70. Burden of disease attributable to 20 leading risk factors in 2010
expressed as a percentage of global disability-adjusted life-years
Global Burden of Disease Group. www.thelancet.com 2012 380 2245
Diet ≈ 40%

71. Effectiveness Hierarchy
Effects of different policy options
(evident for tobacco control, alcohol control, dietary salt & transfat
71
Downstream Upstream
Sizeofpopulationhealthbenefit
INTERVENTIONS

72. Downstream Upstream
0
5
10
15
20
25
30
35
Tobacco Control Scale (Joossens & Raw)
TCS points
Joosens & Raw 2008
Tobacco Control Score (TCS)
Estimated effects of different policy options

73. CVD can change fast
CVD death rates are DYNAMIC
Evidence for rapid effects
• DIET: Poland, Czech, E Germany, Cuba
• BP & CHOLESTEROL: tablet trials (6 months)
• cholesterol effect (1- 5 years) Law BMJ 1994
• MONICA analyses Lancet 2000
• 1940s Hunger Winters (1- 2 years)
• PrediMed RCT (Mediterranean diet RCT (3 months)
Capewell & O’Flaherty Lancet 2011

74. Fairer and
more sustainable
global health…

77. • All based on an
unsustainable economic
model
• consumerism
• status
• trust
• social cohesion
• Unequal societies are less
sustainable

81. The world map reflecting production related to climate change. “Climate
Change presents the biggest threat to health in the 21st Century” The Lancet (373;9697 pp 1659-1734, May 16-22
2009).
Who produces the greenhouse gases?

82. Who bears the burden?
The world map reflecting mortality related to climate change. “Climate
Change presents the biggest threat to health in the 21st Century” The Lancet (373;9697 pp 1659-1734, May 16-22
2009).

83. A (very) short history of public health
• Climate change and health

85. Unfair resource use causes illness and death
directly...

86. …there are MUCH greater health risks for the
least empowered though:

87. • Food and obesity
• Physical activity
• Travel related
trauma and death
• Access to green
space and health

89. The Birmingham
Tornado, 2005

93. The 1995
Chicago heat
wave led to
approximately
700 heat-
related deaths
in Chicago over
a period of five
days

94. AUGUST 2003
Temperature distribution
across Europe on 10
August 2003 at 1500hrs
British Summer Time

95. France, August 2003
~14800 deaths (30,000+ in Europe)

96. MORTALITY IN PARIS, 1999-2002 v 2003
peak: 13 Aug

97. COP21 Paris Agreement

99. COP21 Paris Agreement

100. COP21 Paris Agreement
‘Climate complacency’

101. COP21 Paris Agreement

105. Te change, en

106. Food and Agriculture Sector
• Source of 10-12% of global greenhouse-gas emissions
• Change in land-use (eg. deforestation) significant contributor
to global emissions (adds further 6-17%)
• Total emissions from sector set to rise by up to 50% by 2030
• Four-fifths (80%) of total emissions in sector arise from
processes involved in livestock production

107. SUMMARY
[1] There is strong evidence that greenhouse gas emissions
from the burning of fossil fuels are changing the global
climate
[2] The projected rate and magnitude of change will have
adverse impacts on ecological systems and populations
in many regions, especially in low income countries
where the capacity to adapt is limited
[3] The challenge is to ensure more equitable but
sustainable development that enables human societies
to live within the Earth’s regenerative capacity

108. Conclusions
Policies that address both public health and climate change
are more attractive than focusing on either in isolation.
The health gains associated with climate change mitigation
policies should feature in Climate Change negotiations
A ‘low carbon’ world would be a healthier world

109. Health co-benefits
1. Traditional person focussed benefit
– Physical activity, diet, mental health, trauma, air
pollution…
2. Benefits for health care system
– Congruent with policy direction for many health care
systems: care closer to home, empowered, self care,
better use of drugs, better use of ICT, prevention
3. Benefits for international (health) inequity
– Cost effective leap frogging from pre-industrial, pre-
carbon to post carbon, missing out high carbon step in the
middle
– Justice: Contraction and convergence
– Energy: Concentrated solar power (CSP), much from
warmer and poorer countries

112. Carbon footprint of the National Health Service

113. Procuring for Carbon Reduction
• NHS carbon footprint 18.6 MtCO2
• 59% related to upstream goods and services procured, (11 MtCO2)
• P4CR – Roadmap, guidance and pilots
• Carbon Disclosure Project
• Sustainable Food guide for hospitals
• Energy efficiency guide for
medical devices

114. Action now…
1. SDC Good Corporate Citizenship
toolkit
– www.corporatecitizen.nhs.uk/
2. NHS Carbon Trust Management
Programme
– http://www.carbontrust.co.uk/
carbon/publicsector/nhs/
3. Sustaining a Healthy Future
– www.fph.org.uk
4. NHS Confederation briefings
– http://www.nhsconfed.org/Publications/
briefings/Pages/Briefings.aspx
5. NHS Carbon Reduction Strategy
and 2030 health care scenarios
– www.sdu.nhs.uk
See notes of this slides for some of the most important specific actions

115. Rockefeller Lancet
Planetary Health
commission

120. • Security: ‘Freedom from danger’
• Economic
• Environmental
• Social
• External military

124. Ten tips for better health: Dave Gordon
– don’t be poor, if you can stop, if you cant, try not to be poor for long
– don’t have poor parents
– own a car
– don’t work in a stressful low paid manual job
– don’t live in a damp house
– be able to afford a foreign holiday and sunbathe
– practice not losing your job and not becoming unemployed
– take up all the benefits you are entitled to
– don’t live next to a busy road or a polluting factory
– learn how to fill in complex housing benefit asylum applications
before you are homeless and destitute

129. The green recovery ?

130. John Middleton, Historical and political context of health improvement; MPH Liverpool University, October 6th 2016

131. John Middleton, Historical and political context of health improvement; MPH Liverpool University, October 6th 2016

132. John Middleton, Historical and political context of health improvement; MPH Liverpool University, October 6th 2016

133. John Middleton, Historical and political context of health improvement; MPH Liverpool University, October 6th 2016

134. John Middleton, Historical and political context of health improvement; MPH Liverpool University, October 6th 2016

135. John Middleton, Historical and political context of health improvement; MPH Liverpool University, October 6th 2016

136. John Middleton, Historical and political context of health improvement; MPH Liverpool University, October 6th 2016

137. And to conclude ……

138. I sit on a man's back, choking him and making
him carry me, and yet assure myself and others
that I am very sorry for him and wish to ease his
lot by all possible means - except by getting off
his back.
Leo Tolstoy

139. And the peculiar evil is, the less money you have , the less
inclined you feel to spend it on wholesome food. A
millionnaire may enjoy breakfasting on orange juice and
Ryvita biscuits; an unemployed man doesn’t
When you are unemployed, which is to say when you are
underfed, harassed,bored, and miserable you don’t want
to eat dull wholesome food……
George Orwell, The Road To Wigan pier.

142. Public
‘ealth

143. it's not who
your doctor
is, it's who
you vote for,
that most
affects your
health

144. The Sandwell section

155. Sandwell Valley,
King George
Playing fields
2014

157. New leisure
centres Tipton

159. Working together, March 2015: John Middleton Vice president Faculty of Public Health
A life course
Improving ou
Improving
outcomes ?

160. A life course – 24th annual report for
Sandwell

161. Figure 1, Teenage Conception 1998 - 2012
Sandwell's reduction since baseline (44%) is higher than England &
Wales's reduction of 40.8%. The West Mildands reduction has also
been lower than Sandwell at 42%. Figure 1, above, show that the
gap between Sandwell and England is reducing further.

162. Long term conditions

163. Working together, March 2015: John Middleton Vice president Faculty of Public Health

164. Working together, March 2015: John Middleton Vice president Faculty of Public Health

165. Marsch Addiction 1997

166. Domestic burglary Sandwell 2001-2005Full implementation
drug intervention
project doubling
numbers of drug users
in treatment
1300 fewer
domestic
burglaries
33% fall

169. • I recommend Sandwell reviews its clinical policies for management
of failure of growth in the womb.
•
• I recommend this review be undertaken for the conurbation as well
if this can be agreed and organised rapidly.
•
• I recommend that the review should involve externally
commissioned experts with a national or international reputation.
•
• We need a new strategy for improving outcomes for pregnant
mothers, newborn babies and their families.
•

170. West Midlands Regional Public Health Excellence Conference, JMiddleton March 6th 2015
Wolverhampton
University’s Health
Futures University
Technical college , being built
in West Bromwich, opening
Autumn 2015
Providing education
and prospects for
careers in health,
public health and
care for 14-19 year
olds

176. Options for
life ife self
built
community
centre

184. The food desert becomes the
fat swamp

187. The three domains of public health
West Midlands Regional Public Health Excellence Conference, JMiddleton March 6th 2015
Health protection
Health improvement
Health care public health

188. Local authorities must grasp their responsibilities and
opportunities in health care related public health
• Respond to NHS five year plan for prevention
• Respond to National Audit Office concern about the
failure to honour the ‘Core public health offer’
• Rise to the challenge of the Manchester initiative, and
be the intelligent, strategic leaders of whole system
health, social and preventive health – ‘needs-led and
evidence-based’
West Midlands Regional Public Health Excellence Conference, JMiddleton March 6th 2015

190. Long term conditions
Kidney
disease
Standardised
prevalence ratio
for
haemodialysis

191. Long term conditions
Kidney disease
Access to pre-
emptive
transplantation

192. Table 2 a Preventable causes of hospital admission, Sandwell and Western
Birmingham Clinical commissioning group, 2012-13

194. West Midlands Regional Public Health Excellence Conference, JMiddleton March 6th 2015

196. Good corporate citizen award
38 apprentices
Rationalisation of offcies : 6
leases surrendered
890 tonnes of CO2 reduction
£200k saved

197. Birmingham
Sandwell /
Urban Living
Smart
housing
manifesto
2004

198. i- House, demonstration
house West Bromwich
2008

199. • Thank you
• John Middleton
• Johnmiddleton@phonecoop.coop

200. References
• Climate and Health Council (www.climateandhealth.org)
• Collapse, Jared Diamond.
• Global health, global warming, personal and professional responsibility,
Cambridge Medicine, Pencheon D, Vol 2, No 22, 2008
• Stott R, Healthy response to climate change, BMJ 2006;332;1385-1387
• Gill M, Why should doctors be interested in climate change?
BMJ Jun 2008; 336: 1506
• Griffiths J, Alison Hill, Jackie Spiby and Mike Gill, Robin Stott Ten practical actions
for doctors to combat climate change, BMJ 2008;336;1507
• Sustaining a healthy future: www.fph.org.uk
• Griffiths J et al, The Health Practitioner's Guide to Climate Change, Earthscan
2009
• Pencheon D, Health services and climate change: what can be done? J Health
Serv Res Policy. Editorial Jan 2009
• UCL Health Commission/Lancet: Managing the Health effects of Climate Change.
May 2009
• The health benefits of tackling climate change, Wellcome/LSHTM, Nov 2009
• Sustainable Development Commission: http://www.sd-
commission.org.uk/pages/health.html

201. Appendix: public health futures
A public health manifesto

203. 1001 critical days
Personal health and social
relationships education, PHSE in all
schools
2 hours physical activity per week
reinstated

204. Stop marketing of foods high in sugar, salt and fat,
before the 9pm watershed and tighten marketing
restrictions
Introduce 20% duty on sugar sweetened beverages
Tackle alcohol related harm by introducing a minimum
unit price for alcohol of at least 50p
Rapidly implement standardised tobacco packaging
20 Mph speed limits

205. A living wage
Reaffirm commitment to universal
health care system free at the point of
need funded through general taxation

207. Invest in active transport to promote good
health and reduce our impact on climate change
Implement a cross national approach to meet
climate change targets, including a rapid move to
a 100% renewables and a zero carbon energy
system