Practicing public health, past present and future. annual lecture to the Maastricht Global Public Health Leadership students course. with an extended additional section on the year 2020 in pandemic and lessons 201211 middletonj maaastricht

1. John Middleton
Maastricht Public Health Leadership course
December 11th 2020
The best job in the world: practicing
public health, past, present, future

2. Public health is :
The science and art of promoting health and
wellbeing, preventing disease and prolonging life
through the organised efforts of society
Acheson 1988, after Winslow 1920, WHO 1948

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

4. William Beveridge designed a welfare
state for the UK in the deepest point
of the Second World War.
‘We should regard want,
idleness , ignorance,
squalor and disease as
enemies of us all. That is
the meaning of a social
conscience; that we refuse
to make our separate
peace with evil.’

5. Human rights are everyone’s
business
“Where, after all, do universal
human rights begin? In small
places, close to home … they
are the world of the individual
person; the neighborhood he
lives in; the school or college he
attends; the factory, farm, or
office where he works”
Eleanor Rooseveldt

7. A life in local public health
The best job in the world: practicing
public health, past, present, future

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

16. Improving
outcomes

18. Sandwell Valley,
King George
Playing fields
2014

21. New leisure
centres
Tipton

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

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

25. Marsch Addiction 1997

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

30. Middleton J. The hospital of the future comes to the West Midlands. BMJ blogs October 1st 2014.
http://blogs.bmj.com/bmj/2014/10/01/john-middleton-the-hospital-of-the-future-comes-to-the-west-
midlands/

32. 02/03/2021 31
• Asset based public health
• Community assets

33. 32
Community health network

34. 33
Sandwell Youth Cabinet

35. Agewell-Sandwell
Agewell -Sandwell

36. • Reducing social inequalities: UK Marmot review
• Create fair employment and good quality work for all and improve
quality of work across social gradients

38. By 2003 the mixed use site was in production…

40. 39

42. 02/03/2021 41
• Asset based public health
• ‘The health dividend’

43. 42
Birmingham
Sandwell /
Urban Living
Smart
housing
manifesto
2004

44. 43
i- House, demonstration
house West Bromwich
2008

46. Health Futures
University
Technical
College
West
Bromwich,UK
www.healthfutures.co.
uk

47. The best job in the world: practicing
public health, past, present, future
Ways to manage

48. 02/03/2021 47
• Troops,
• money,
• or influence?
I’ve had them all
The greatest of these is influence
‘Sapiential authority’
What other ways have you got to improve the
public’s health ? Apart from chasing the money?

49. 02/03/2021 48
If the policy is wrong, money will not
make it right; and if the policy is right,
money may not in fact, present an unduly
difficult problem.
EF Schumacher, Small is Beautiful, p 162

50. 02/03/2021 49
What other ways have you got to improve the public’s
health ? Apart from chasing the money?

51. 02/03/2021 50
Control the information
Control the knowledge
Control the agenda
Hold a wide network of partners
Applying the law?
Human rights ?

52. Wider global concerns for the public’s health
The best job in the world: practicing
public health, past, present, future

53. The public’s health
There’s never been a
better, or more
necessary, time to be
in public health

54. 53
02/03/2021
The public’s health: global burden
of disease, corporate anti-health
interest,

56. Globally, mortality rates have decreased across all age groups over
the past five decades, with the largest improvements occurring
among children younger than 5 years. However, at the national
level, considerable heterogeneity remains in terms of both level
and rate of changes in age-specific mortality; increases in mortality
for certain age groups occurred in some locations.
Countries have saved more lives over the past decade, especially
among children under age 5, but persistent health problems, such
as obesity, conflict, and mental illness, comprise a “triad of
troubles,” and prevent people from living long, healthy lives.
Total deaths in children younger than 5 years decreased from 1970
to 2016, and slower decreases occurred at ages 5–24 years. By
contrast, numbers of adult deaths increased in each 5-year age
bracket above the age of 25 years.
Global burden of disease study, 2017

58. 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%

59. These 10 Corporations Control Almost Everything We Eat

60. http://www.bmj.com/content/358/bmj.j4443?sso=

61. 02/03/2021 60

62. 02/03/2021 61

63. 62
02/03/2021
Violence, conflict and public
health at home and abroad

64. The epidemiology of violence
Evidence-based violence prevention: a life course
approach
Asset based community development
Primary, secondary &tertiary prevention role of the
public health community as primary preventers of violent conflict,
through healthy public policies and tackling major social inequalities in
health; and as early reactors, mitigaters and responders to violence.
New public mental health approaches
A role for public health in conflict resolution with
aid agencies, political scientists, theologians and international lawyers
A role for public health educational bodies
A leadership and partnership role for public
health
www.fph.org.uk/uploads/Violence%20report.pdf
Areas of action for the public health
community in preventing violence

65. 64
02/03/2021

66. Interconnectedness:
conflict over natural
resources: oil, water

67. Interconnectness: Loss of agricultural land through global
warming, crop failure, food riots, Arab Spring, Syrian war

68. 67
02/03/2021
Planetary health: environment, loss of
biodiversity, food and ecosystems balance,
climate change.

69. A role for our climate
change special
interest group

71. •
70
02/03/2021

72. 71
02/03/2021

77. Coccolithophore (diatom): Produces 50% of the
world’s oxygen
Algal blooms photosynthesising off
south west coast of Wales

78. Climate
change
policing:
protests
and
disasters

79. Climate
breakdown
is here
now!- 1 fire

80. • Climate
breakdown is
here now!- 2
floods

81. Climate
breakdown
is here
now!- 3
marine life
extinction

82. 02/03/2021 81

83. ‘Protecting
resources from one
generation to the
next’
The Welsh Wellbeing of
Future Generations Act,
2015

84. A future without antibiotics?
A future with only public health ?

85. The best job in the world: practicing
public health, past, present, future
After 2016…

86. This is a looming disaster and
priority is to limit damage

87. BREXIT and the public’s health
Loss of health and care workers
Loss of research grants and networks
Loss of leadership role in areas such as tobacco control and
antimicrobial resistance
Loss of international agencies which protect health –European
Communicable Disease Centre; The European illegal drugs
monitoring centre; European Medicines Agency; Pulling out of
Euratom Access to Medical isotopes for cancer treatment and shared
safety procedures for nuclear power stations;
Loss of protections for health - in the workplace, the Social chapter;
environmental protections; soil, beaches and air quality; equality
provisions;
Shared Security?

89. 02/03/2021 88

90. ‘Valuing public health’: Three areas of
focus short-listed
1. Making the case for prevention (return on
investment; affordability; value for money; a call
for the ‘radical upgrade to be made real)
2. Investing more in prevention through the NHS (
including secondary prevention; rebuilding health
care public health)
3. Investing for outcomes (Developing the public
health outcomes dashboard, assuring the future
of public health investment)

92. Effectiveness Hierarchy
Effects of different policy options
(evident for tobacco control, alcohol control, dietary salt & transfats etc)
91
Downstream Upstream
Size
of
population
health
benefit
INTERVENTIONS

93. Mason R,
Capewell,S,
et al

94. Commissioning Public Health
Services Conference - June 2017

95. Austerity kills
Climate breakdown
Service cuts
Brexiting health
A manifesto for health, J Middleton November 28th 2019

96. You can change
her environment
through public
health advocacy!
120 high rise
blocks in
Sandwell 1988-
less than 30 in
2014

97. The best job in the world: practicing
public health, past, present, future
this year …

98. 2020 begins
Floods, fires
and
pestilence

99. We find the public health community ill-equipped and poorly
connected for the new challenges of ‘ISIS, crop failure and no
antibiotics’; we need to grow our partnerships with international
lawyers, political scientists, climate scientists and ecologists. To
those new challenges we now operate in the era of surveillance
capitalism, fake news and disinformation. We live increasingly in
political systems with little respect for expertise, willing to destroy
scientific capacity, ignore expert advice and promote disinformation.
The ‘merchants of doubt’ have infiltrated all political systems and all
aspects of policy making. The white horse, Conquest has taken on a
new guise – a cadre of elite, super-rich, world leaders who see
ignorance and partial information as virtues, suiting their control of
power and misuse of wealth. And, as in the Australian fires, the UK
floods, and in China in the early stages of coronavirus, these leaders
show themselves to be rabbits in the headlights, incompetent and
ASPHER president Winter 2020 message

100. Public health systems are
being depleted; prominent
public health figures
removed silenced, or ignored.
Dr Li Wenliang, is only the
most prominent of Chinese
whistle blowers who first
expressed concern about the
new COVID19 to have been
killed by the virus or to have
disappeared. It is timely that
our
intrepid Talkpublichealth team
chose the theme
of whistleblowing for the public
good for their recent podcast.

101. JOHN
HOPKINS
GLOBAL
COVID
TRACKER,
7TH
MARCH
2020

102. WUHAN EPICURVE AND NARRATIVE,
PAN A ET AL , JAMA APRIL 2020

103. John Middleton [lecture title]
[date]

104. John Middleton [lecture title]
[date]

105. The danse macabre
We are not in a war, we are in a civil
disaster, the biggest act of
governmental failure ever in the UK. We
are victims of serial acts of negligence
and wilful mismanagement. It is the
biggest single act of corporate
manslaughter our country has known.
People have said it before about war
propaganda; in the era of coronavirus,
blind acceptance of our rulers’ orders
will get you killed.
Middleton J. Personal blog. The danse-macabre
moves offline, out of sight, out of mind. June 27th
2020. Https://www.aspher.org/articles,4,80.html

106. 02/03/2021 105

107. 02/03/2021 106

108. John Middleton [lecture title]
[date]

109. Global governance for health

110. John Middleton [lecture title]
[date]
https://www.aspher.org/d
ownload/413/aspher_stat
ement_on_the_strategic_
use_of_masks.pdf

111. John Middleton [lecture title]
[date]
https://www.asphe
r.org/download/421
/aspher_statement_
on_the_covid-
19_testing.pdf

112. John Middleton [lecture title]
[date]

113. https://blogs.bmj.com/bmj/2020/05/05/now-is-not-the-time-to-undermine-the-world-health-organization/
Global governance for health

114. Race and ethnicity risks Black men 4X
as likely to die from COVID_19
Risks-
• Pre-existing Health risks- long term
conditions, diabetes, obesity
• More likely to be in high risk
occupations-health, food
processing, transport, security,
front-line health and social care
• Institutional racism- not being
listened to when concerned on
risks (Kevin Fenton PHE report,
West Midlands Labour Party
report)
▲Journal
American Medical
Association, May
2020
◀︎ UK
Office of
National
Statistics,
April 2020

115. 02/03/2021 114

117. There are seven rules, for managers,
leaders and governments.
1. Communicate Clearly
‘We will announce lockdown extensions at
lunch-time every Thursday, based on data
you can see and track here…’
Management by mumbling doesn’t work.
02/03/2021 116

118. 2. Avoid mixing up the
messages.
Be clear and bold; ‘What the
rules will be this time next
week, I don’t know but if you
go on holiday you are taking a
risk. Don’t come home
crying. It was your call to go’.
Manage by being clear about
who is responsible for what.
02/03/2021 117
There are seven rules, for managers, leaders and governments.

119. 3. Don’t fudge to be popular.
Don’t fudge rules, people won’t
follow them. Spell out simple
guidance.
Manage in black and white.
do the simplest of things.
118
There are seven rules, for managers, leaders and governments.

120. 4. Get aligned.
Covid variations among home
nations are partly political. Labour
Wales and SNP Scotland are very
good at making BoJo look flat-
foot. Remember, management…
electors or workforce, it’s about
people.
Manage with one clear tune. Get
people marching in step.
119
There are seven rules, for managers, leaders and governments.

122. 5. Be clear…
… about how the decisions are made and
transparent about where the data is coming
from.
Management by rumour creates title tattle
and mistrust.
02/03/2021 121
There are seven rules, for managers, leaders and governments.

124. 6. Be honest.
We know, this is about
keeping the holiday
businesses, airlines and
coffee shops going. Covid
safety is up to decisions made
by individuals. Say it.
Honest management is ethical
management.
02/03/2021 123
There are seven rules, for managers, leaders and governments.

125. 7. Make the messages simple.
The Transport bloke Grant Shapps,
on Friday, trying to explain the
mess was pure Monty Python. He
couldn’t do it because no one
could.
Good managers, manage the
message.
124
There are seven rules, for managers, leaders and governments.

126. 3. Don’t fudge to be popular.
Don’t fudge rules, people won’t follow
them. Spell out simple guidance.
Manage in black and white.
Don’t fudge rules, people won’t follow
them. Spell out simple guidance.
02/03/2021 125
They say, history repeats itself. It’s
true. Want of foresight, unwillingness
to act, indecision, accept advice, be
truthful… time and again,
governments fail to do the simplest of
things.
There are seven rules, for managers, leaders and governments.

127. Don’t be incompetent
02/03/2021 126

128. 02/03/2021 127

131. John Middleton [lecture title]
[date]

132. Don’t be negligent
02/03/2021 131

134. Don’t be corrupt
02/03/2021 133

137. Institute of Health
Metrics and
Evaluation
Washington (Gates

138. 02/03/2021 137

139. 02/03/2021 138

140. 02/03/2021 139

141. 02/03/2021 140

142. 02/03/2021 141

143. John Middleton [lecture title]
[date]

144. John Middleton [lecture title]
[date]
Upsides
of
lockdown
1 :
Decline in
air
pollution

145. Upsides in
lockdown 2:
interest in
more active
travel

146. https://epha.org
/public-health-
must-be-
strengthened-
for-a-healthy-
post-covid-
world/
Global governance for health

147. Global governance for health- European Public Health Week Seminar May 18th
2020 European Public Health Association, World Health Organisation- Europe, American
Schools and Programmes of Public Health, Association of Schools of Public Health European
Region

148. Postscript
Don’t say you’ve cracked it ….
Trump-’no American deaths’
Ardern, New Zealand 100 days COVID free
Czechia Charles Bridge, Prague street party
Johnson ‘Beer, cricket on the green and haircut….’

149. Thank you
John Middleton,
President
Association of Schools of Public Health
In the European Region
John.middleton@aspher.org

150. Appendix
References

151. • Middleton J, ISIS, crop failure and no anti-biotics: what training will we need for future public
health? European J Public Health 2016; https://eurpub.oxfordjournals.org/content/26/5/735
• Middleton J, Weiss M. Still holding on: public health in the UK after Brexit. Euroheathnet
journal 2016; 22:no 4: 33-35. (ISSN 1356–1030)
http://www.euro.who.int/__data/assets/pdf_file/0010/325945/Eurohealth-V22-N4-2016.pdf?ua=1
• Middleton J. Public health in England in 2016—the health of the public and the public health
system: a review Br Med Bull (2017) 1-16. DOI: https://doi.org/10.1093/bmb/ldw054 and
http://academic.oup.com//bmb/article/doi/10.1093/bmb/ldw054/2871226/Public-health-in-England-in-
2016the-health-of-the?guestAccessKey=8f7a33a1-bdbf-4db4-948c-fd6b6293a259
• Middleton J, Saunders P. 20 years of local ecological public health: the experience of Sandwell
in the English West Midlands
http://www.sciencedirect.com/science/article/pii/S0033350615003303
Middleton J, Rae M. Health, wellbeing, and care should be top of everyone’s political agenda. BMJ 2019;367:l6503 available at:
https://www.bmj.com/content/367/bmj.l6503#; (accessed November 16th 2019).