After the disturbances: does public health have a role?

This post also forms the Editorial for Birmingham’s Health Matters, Issue 7, 2011. August/September

As you have all heard over and over again, I love Birmingham. It’s an amazing city of wonderful people, and arguably the most diverse place I have every lived or work, even more so than East London. But we have many challenges, from the ongoing challenge of reducing inequalities in disability, ill-health and death to the more multifacted – the short and long term measures we need to take after the disturbances in our Cities.

I think public health has a role to play in helping our City meet its ongoing ambitions. Lots of people I come across do.

Against this background, work is currently nearing completion to produce a new revised health profile for every electoral ward and every constituency in Birmingham. We will be able to identify a snapshot of the health of our population, across the Lifespan, at electoral levels. These are part of the work of creating the new style JSNA, so that you can look at the City or any part of it and understand the health and social care challenges at a glance.

 Birmingham now has a library of needs assessments (deep dives into health and social care issues) covering 36 different topics. This has been a huge task, but the next task is to bring these together into one summary. That will be done by Christmas.

So why are we renewing the ward and constituency profiles at this point?  Is this not an odd thing to do? Why should this be important when we are in the middle of massive change in health and social care configuration, Dilnot has reported on social care funding, and many are still reeling from the shocking experience of civil disturbance?

I believe the answer to renewing information profiles is that it takes us to the heart of one aspect of what we want Public Health in Birmingham to do. Providing easily accessible, high quality information on the health of our local area is one part of the public health cycle. It enables us to identify what we need to address. In other words it gives us very clearly an overview of what’s not right, or if you want the jargon, areas of inequity and inequality.

The next steps of this cycle are about identifying evidence of what can be effective in addressing inequity and inequality and working with commissioners to implement and deliver this. Public health “science” means we need to know what the problem is and what can be done about it. Public health “art” is about getting it done. In that sense, our elected members and NHS non execs are among our greatest “public health artists”. The “scientists” should support the “artists” in achieving change.

This public health cycle (or one form of it at any rate ) is actually conceptually simple:

  1.  identify need, 
  2.  identify greatest inequality, 
  3.  identify effective interventions, 
  4. agree priorities, 
  5. support commissioning of them and
  6. evaluate what difference it made.

This is what the heart of public health should be about. The specialist training of public health consultants is intended specifically to help us do this. It’s a corny joke, but when we don’t use the public health cycle properly, it’s no surprise that sometimes the wheels come off what we do.

Let’s take an example – stroke. Stroke causes avoidable disability which limits the quality of life of people with stroke and takes a great deal of effort to recover from, and is a substantial avoidable cost on the public purse. We need to adopt a whole system approach. Clinicians and the Cardiac and Stroke Network have done an amazing job of identifying interventions at ambulance, entry to hospital and first 72 hours. What we need to do now is sort out the other ends of the system – stopping people getting strokes in the first place (we know the evidence – addressing Atrial fibrillation, diet, exercise, smoking) and rehabilitation for independence afterwards (social care, recovering activities of daily life.) Unless we know populations at highest risk for stroke, we can’t intervene. These profiles will help us.

But it’s a partnership, and public health works best in this cycle when it knows its role, supports the commissioners in their role, and supports elected members and decision makers in their “art” of public health.

So does public health and its cycle have anything to say about civil disturbance? 

Certainly the City’s formal and informal leaders (from the loving Father preaching peace through searing loss, to the sikhs and muslims who guarded each others places of worship, to those of us who simply took brush and shovel to help with the clean up) have been clear they expect us all to play our part, and follow their lead.

Laying flowers on Dudley Road in memory of Haroon Jahan, Shazad Ali and Abdul Musavir made me wonder what my contribution as a public health specialist might be, in addition to being a (relatively recent) citizen of this city is , both professionally and personally. I believe public health does have a contribution, and it seems to me that this contribution lies across four sets of issues. So here is a starter for ten. Do feel free to disagree with me, and correct me where I am wrong:

    1. Victims of disturbance – the long term effects of being a victim of disturbance in riots is reasonably  well documented. Post traumatic stress (whether short  or long term) is important to look out for, along with  other health effects (stress leading to psychological  or physical health issues like anxiety or heart disease, for example). We need to monitor peoples health and  intervene early.
    2. Communities – identifying how the disturbances  have affected our communities health, confidence and resilience (socially and economically) and then helping identify what can be done, and how to target resources for recovery. Identifying what builds health and social resilience, confidence, and cohesion in our communities can help our colleagues working there. This is in addition to building the healthiest communities we can, and prioritising our communities with the worst burden of ill-health. Health is not “the” answer, but it is a part of it.

    3. Offenders – working to identify effective interventions which rehabilitate and prevent re-offending could be a contribution here alongside criminology.

    4. Root Causes – the method of identifying evidence and analysing root causes is something public health could bring to the table, along with the other disciplines, when we sit down and reflect why this happened.

Ok, so information isn’t everything. But if we believe public health has a role, surely the public health cycle is something we bring to the table, and knowing the situation we face is a part of that.

Ten years ago I worked for a national crime reduction charity applying public health science to crime reduction and community safety.  I still remember the eleven year old boy in a particularly challenging area of South London, who was one of our peer researchers on a research project run by and for young people, to identify their experience of crime and disorder.  He used to go out every night when his dad came home in the taxi with that day’s takings.  He, armed with german shepherd dog and baseball bat, escorted his dad up to the family flat.

That experience – and many others – has stayed with me, not least because he and his mates (the youngest was 9) asked me one night what it was I felt my skills did. He was my first, and most searching “what use are you?” review.

The “big tent” discussion of different disciplines which went on while I worked in that role,  in places as various as the Criminology Journals, the streets and the then Home Secretary’s table helped, I believe, address some issues on drug related crime and on violence against women, and sexual violence. We can and must bring our best expertise from all our disciplines to this challenge. That’s what our citizens – rightfully – expect from us.

So, perhaps we can make a contributon to the recovery from the disturbances, as part of what we can do? My thoughts above are what the discipline of public health can bring.  It is a truism that many social problems have no simple easy solution. Nancy Krieger’s new book Epidemiology and the People’s  Health (Oxford:2011) should tell us that.  But it is equally true that we have to and can start somewhere. The debate about the nature of psychology (is it science, social science, moral science or all three) rages. In public health at least we recognise our work is blend of art and science.

So, can public health find the “start somewhere” evidence and point for the victims, communities, offenders and root causes?  Our predecessors would have sought to do so.  Birmingham will be hosting (as cheaply as possible in these straightened times) a series  debates later this year about what goes into our health and wellbeing strategy. I invite you to come along, take part, or even just email me your views. Jim.McManus @  (sorry the email link isn’t fully done. It’s to prevent spam . )






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