Nick Hopkinson, professor of respiratory medicine
The philosopher Derek Parfit, introducing his 1984 book Reasons and Persons, sets out a few basic concepts—that we have reasons for acting, that some ways of acting are morally wrong, and that some outcomes are good or bad in a sense that has moral relevance.1 Reaching for what he presumably judged to be an uncontroversial example of a poor outcome, he notes that “it is bad, for example, if people become paralysed.” Whatever hopes one might have about the arc of the moral universe bending towards justice, the US elections have placed enormous power in the hands of a Republican Party intent on sabotaging vaccination programmes and medical research, while withdrawing support from international programmes funded by USAID.2 This threatens the health and wellbeing of millions of people risking the resurgence of polio (and thus paralysis) as well as other existing and novel infectious diseases.
While basic human decency calls for action to try to ensure that such policies, which will shorten the lives of many of the most vulnerable people, can be stopped, mitigated, and ultimately reversed, it is easy to feel right now that this is too hard or perhaps impossible. Bobbie Jacobson’s recent memoir Against the Flow provides a powerful example for these dispiriting times of what can be achieved by committed people and of how to get things done.3 A public health physician, she began her career in 1973 as deputy director of the campaigning charity Action on Smoking and Health (ASH), before going on to train in medicine, becoming a director of public health in East London and then director of the London Health Observatory.
ASH was born out of government failure to tackle the huge harms being caused by smoking, set out a decade previously in the Royal College of Physicians’ 1962 report Smoking and Health. Key goals—to secure a ban on tobacco advertising and reduce the affordability of cigarettes—may be taken for granted now. But indifferent and sometimes hostile policy makers had to be pressured to act. Against the Flow describes some of the agile media activity that was needed to maximise public awareness of the harms from smoking and thus increase the political pressure to act, as well as exposing tobacco industry tactics to obscure or deny the science. Another target was the absurd position that respectable health bodies held shares in an industry that promoted death. Progress also required substantial effort to refocus attention from treatment to prevention, tackling the upstream causes of disease, not just treating the consequences. In the world of tobacco control, at least, some balance has now been achieved, with measures in the Tobacco and Vapes Bill currently going through the UK Parliament that focus on these twin objectives—to “stop the start” and “support to quit.”4
The tobacco industry was increasingly using targeted marketing to persuade girls and young women to take up smoking. Philip Morris’ brazen co-option of feminism with its slogan “You’ve come a long way, baby” to promote its “women’s cigarette” Virginia Slims was an obvious example.5 Despite this, Jacobson faced a struggle in the 1970s to persuade an almost entirely male establishment that this was a problem requiring any specific attention or solutions. She describes being warned off or discouraged from manifesting feminism by various pillars of the public health establishment. Undaunted, in 1981 she published The Ladykillers: Why Smoking is a Feminist Issue, setting the scene for the 1992 ban on magazine advertising, although a full ban on tobacco advertising and sponsorship was not achieved until 2005.6
Having left hospital medicine in 1985, she worked at the London School of Hygiene and Tropical Medicine to produce The Nation’s Health. A strategy for the 1990s.7 There is an entertaining section on the efforts needed to circumvent obstructions from committee members intent on taking the performance of a kind of academic neutrality to the point of absurdity. The “no such thing as society” ideology of the Thatcher government was a barrier too. A series of carefully orchestrated leaks fed media interest and put ministers on the spot about key recommendations such as taxing the ill health industries (tobacco, alcohol, and food) and properly financing health education programmes. This helped to develop support for action on prevention and health inequalities, with the report quickly selling out. A journalist friend congratulates her that “rarely in the field of human journalism has so much publicity been achieved by so few.”
The last section deals with the challenges of being a public health practitioner, meeting the local and specific needs of a city blessed with enormous diversity but facing stark inequalities; choosing priorities against a background of perpetual NHS restructuring and the perverse introduction of an NHS internal market. There is ebb and flow. The “New Labour” government introduces targets and takes steps to reduce health inequalities, including bringing NHS funding up to the EU average and introducing the Sure Start programme to support children under 5.8 The creation of a Greater London Authority makes space for action at a larger scale. 2010 brings cuts and then the calamitous disruption of the Lansley Bill.9
A key message from the book, honed though Jacobson’s career, is that effective public health requires “deep prevention.” The UK went into the covid-19 pandemic with social structures, institutions, and populations all weakened by the political choice to pursue austerity policies and transfer wealth and resources from the worst off to the richest. Writing in the wake of this, Jacobson draws lessons learnt from successful public health campaigns about what will be needed for an effective response to the next pandemic: clear and honest communication, use of local expertise, messaging that people can understand, and persuasion rather than coercion.
Footnotes
Competing interests: NH is chair of Action on Smoking and Health ASH (UK) and medical director of Asthma+Lung UK.
Provenance and peer review: not commissioned; not peer reviewed.