In plotting the ‘arc of history’ of public health policy and practice at a European level in recent decades one can see an accrual of power, resource and legislative influence for the cause of public health as policy makers accepted that “comparatively few of the major determinants of health can be controlled at the nation state level in the world”.(1)
Tracing the development of European public health we can see nascent efforts to plan and implement policy taking place on a voluntary basis owing to the paucity of the Treaty of Rome in providing a legal grounding for pan-European public health activity.
Such efforts on a voluntary basis did eventually bear fruit however. Article 129 within the Maastricht Treaty amended the Treaty of Rome to make allowances for European-level public health planning, policy and activity. Article 152 followed as part of the Amsterdam Treaty- providing further powers in two key areas: firstly a requirement to analyse the public health implications of all EU policies and programmes, secondly the harmonisation of public health protection in certain limited areas (e.g. collection of human tissue products and veterinary and phytosanitory health). (2)
Legislative progress may have shown relatively steady progress over the past three decades, however when we examine the policy and practice at a European-level, a more disparate, fractured picture emerges. Initially at least, ad-hoc programmes emerged at the expense of a comprehensive ‘European Public Health Strategy’. To compound this situation, no serious health impact assessments were carried out in respect of these early programmes and policies (the prospect of consolidation arose in a 1998 discussion paper). (3)
Institutional frailties aside, the growth and establishment of public health at a European-level has had a profound impact upon public health practice. More incisively, “these changes have to be viewed in the context of, and with consideration to, public health practice at a local level.” (4)
Why these changes are (and where) necessary becomes clear when one examines the macro-environment in which public health practitioners now operate. The rise of globalisation, free trade and the easing of cross-border capital controls (amongst a multiplicity of other factors) now means that “national, European and international actions govern local food systems etc” (5), taking control away from the nation state. As trans-national organisations and agreements have emerged- so too have opportunities to lobby and cajole decision makers. Hence the need for public health professionals to “develop the skill of integrating public health… influence at all levels of the economy”. (6)
A recognition of these supra-national factors (and the urgent need to mitigate their impact upon the health of the public) has arguably forced policy makers to consider ‘upstream’ factors; “The causes of the causes” (7) (e.g. non-communicable diseases, poor lifestyle factors such as excessive alcohol and tobacco consumption, poor diet and physical inactivity). The social gradient of health, progressive universalism, gender inequalities in health and inter and intra generational inequalities in health have now risen to the top of the European public health agenda. (8)
A tough task then; made tougher by the financial crisis of 2008 with its attendant social problems. (The economists Reinhart & Rogoff have found that financial crises typically produce rises in unemployment that persist for 4 to 6 years (9)). As governments across Europe have sought to rein-in their debts, reduce their deficits (and in the case of the UK, introduce significant liberalising supply-side reforms to welfare systems) debate has erupted within the public health community as the correct response to what has been dubbed ‘austerity’.
The Stuckler & Basu analysis (10) offers a cogent and compelling case that ring fencing not just healthcare, but also social welfare systems through government stimulus will protect health, “Adults in secure and safe employment, receiving wages above the level needed merely to survive, are less likely to adopt hazardous lifestyles… and can expect to live longer”. (11)
Looking ahead, it will be interesting to see how European public health responds to the immediate challenge of reduced public spending and rising health issues, but also the perennial challenge posed to all policy makers by what F A Hayek called the ‘Catallaxy’: the ever-expanding exchange and specialisation of the economy that can produce innovations and ideas that would not ordinarily be arrived at by a small group of policy makers.
Equally, the rapidly approaching (or recently arrived, depending on your perspective) era of big data (12) and quantified-self (13) may provide huge challenges and/or opportunities to European public health policy makers and practitioners. Sorting the signal from the noise may prove to be a primary challenge as European policy makers move from possessing a dearth of data to a glut. (14)
The rapidly changing ecology of public health policy making was summed up well (albeit in a niche context) by Viscount Ridley in a House of Lords debate on electronic cigarettes “The tobacco companies are worried… they are facing their Kodak moment, the moment when their whole technology is replaced by a rival technology…” (15) The tobacco industry has resorted to the blunt of hammer of litigation in response to European public health legislation (e.g. the European Tobacco Products Directive), or has focused on product innovation (e.g. moving into electronic cigarettes).
Although it is possible that the tobacco industry will avoid ‘creative destruction’ by such means- as well as using the brute force of its significant capital assets to diversify, purchase electronic cigarette manufacturers etc it seems less likely that public health policy at a European-level will face its own ‘Kodak moment’, given the secure nature of its funding and isolation from disruptive forces.
The key question for the future of public health policy at a European-level is whether or not it can keep up with ‘free market solutions for health’, resisting the temptation to suffocate very promising developments such as electronic cigarettes, whilst also dealing with changing attitudes to European collaboration and co-operation. As Clive Bates has pointed out- “culturally, the public health establishment is inclined to paternalism, and state-based or not-for-profit interventions. It instinctively distrusts the private sector and capitalism, and is ill at ease with the idea of consumers as empowered agents.”
Tackling this mindset may be key to nurturing European public health policies that are fit to meet the challenges of the 21st century.
1) Birt CA, “The Onward March of European Public Health”, editorial in the Journal of Epidemiology and Community Health, 52, 12, 770-771, December 1998
2)Birt CA, “A Widening Horizon for European Public Health Practice”, editorial in the Journal of Epidemiology and Community Health, 59, 0-1, 2001
3) Birt CA, “The Onward March of European Public Health”, editorial in the Journal of Epidemiology and Community Health, 52, 12, 770-771, December 1998
4) Birt CA, “A Widening Horizon for European Public Health Practice”, editorial in the Journal of Epidemiology and Community Health, 59, 0-1, 2001
5) Birt CA, “A Widening Horizon for European Public Health Practice”, editorial in the Journal of Epidemiology and Community Health, 59, 0-1, 2001
6) Birt CA, “A Widening Horizon for European Public Health Practice”, editorial in the Journal of Epidemiology and Community Health, 59, 0-1, 2001
7) Marmot M, Allen J, Bell R, Bloomer E, Goldblatt P, “WHO European review of social determinants of health and the health divide”
8)Marmot M, Allen J, Bell R, Bloomer E, Goldblatt P, “WHO European review of social determinants of health and the health divide”
9) Reinhart C, Rogoff K, “The Aftermath of the Financial Crisis” Working Paper 14656, NBER Working Paper Series, National Bureau of Economic Research, January 2009
10) Basu S, Stuckler D, “The Body Economic: Why Austerity Kills” Allen Lane 2013
11) BMJ 2010; 340 doi: http://dx.doi.org/10.1136/bmj.c3311
12) “Big data is the term for a collection of data sets so large and complex that it becomes difficult to process using… traditional data processing applications”. Wikipedia
13) “The Quantified Self is a movement to incorporate technology into data acquisition on aspects of a person’s daily life in terms of inputs (e.g. food consumed, quality of surrounding air) states (e.g. mood, arousal, blood oxygen levels), and performance (mental and physical)”. Wikipedia
14) The issue of sifting through large volumes of data and making predictions affecting public health is covered in Chapter 7 of Nate Silver’s “The Signal and the Noise: The Art and Science of Prediction”, Penguin 2012
15) HL Deb 17 Dec 2013, Grand Committee, Col GC264