Pernicious Moralising: When Public Health Fails

Pritpal S Tamber

February 24, 2014

The last few weeks have been exceedingly busy as we finalised the Wellthcare Manifesto, interviewed more Wellth Creators, and started work on what a meeting on ‘health creation’ might look like. One question has surfaced a few times and I wanted to reflect on it here: “How is Wellthcare different to public health?”

Public health, according to Wikipedia, is:  

the science and art of preventing disease, prolonging life and promoting health through the organised efforts and informed choices of society, organisations, public and private, communities and individuals

It sounds awesome but my experience of it – as a citizen and an observer of health and health care – is that when it comes to lifestyle diseases it’s heavy on the ‘what needs doing’ and very light on the ‘how’. Without knowing the ‘how’ the ‘what’ becomes almost pointless or – when it’s constantly reiterated – runs the risk of being a form of pernicious moralising.

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I see examples of this moralising all the time but my favourite one in the past week was reported in Slate. In San Francisco’s Bay Area a group of ex-convicts are being taught about fruit and vegetable in the belief that the knowledge will help them make better decisions about their diet. The article makes the point that the belief is not matched by the evidence and cites a number of studies that illustrate no connection between access to grocery stores and more health-creating diets.

The article goes on to describe how it’s the actual stress of poverty that contributes to why low-income people die earlier, not the bad health choices they make. They are, it says,  “preoccupied with very different choices than wealthier people are: Should I pay my electricity or my water bill? Can I pay my rent and buy my kid a pair of school shoes?” Against such stark choices I ask myself how a public health message on what fennel is even matters.

Is that to say, then, that the insights of public health have no role to play in low-income communities? No, of course not. But there is something about which insights are delivered, and how, that is, in my view, simply failing. 


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Two days after the Slate article there was an NPR broadcast on how fixing poverty was more complicated than handing out cash. In it, Mauricio Lim Miller, the founder and CEO of the Family Independence Initiative, talked about how he helps people pull themselves out of poverty by trusting them to make their own decisions. His organisation gathers families wanting to change their circumstances, asks them what they’d do, encourages them to do it, and then shares their stories with the other families in the programme. By sharing what worked and what didn’t work, the families learn from each other.

It’s important to note that Miller asks the families in the programme: “what would you do to change your own life ’cause you’re not going to get help from us?” He describes his Initiative as being in the information-sharing business, enabling families to share experiences and learn from each other, not in the giving-people-stuff business. And it’s important to note that the information being shared is created through the experiences of the families involved, not some central organisation.

This example makes me reflect on the tactical part of the definition of public health above: “organised efforts and informed choices”. 

Now that lifestyle-related chronic conditions are huge concerns for many middle- and high-income countries, surely the people who should be in charge of the “organised efforts” are those that truly understand the lifestyles involved? Can a public health professional really understand the plurality of behaviours that make up the numerous and overlapping lifestyles that exist in modern communities? It seems unlikely. Surely, then, our greatest resource, as Miller has realised, is the people themselves.


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Also, as a former academic editor and publisher, I am obsessed with the power of information and hence the term “informed choices”. We all know that people tailor information to suit their needs, whether it be a child trying to explain how his kicking a football at the window was not directly related to the broken glass (my Mum somehow never saw it that way) or a government claiming economic recovery based on debatable employment statistics. My question, then, is who decides if a choice is “informed”? 

A choice can be described as informed when it is made in context. But is it really possible to understand context through cold, nuance-ignoring epidemiological analysis? Can number-crunching at a population level really create an understanding of the lives that people lead and the choices they have to make? Going back to the low-income people above, does an epidemiologically-informed choice even matter

It’s hard to see how. 

So, if the “informed choices” don’t matter and the “organised efforts” are formulated without any real understanding of the lifestyles involved, what use, then, is public health in lifestyle-related diseases? If the answer is ‘not much’, then surely the broken record of public health messaging crossed into pernicious moralising some time ago. 

At Wellthcare we start from what people want to do with their lives. We’re well aware that we’re yet to ‘do’ anything, as such, but our contention is that if we’re to find new forms of value in health we have to start from a radically different way of seeing people, their behaviours, networks and communities. We have to understand what they want and not be slave to what we think we know from our spreadsheets. That’s how Wellthcare differs to public health. 

We’d love to hear your thoughts. 


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This post was first published in MedCrunch and then in MedCity News. Wellthcare is being fuelled by Guy’s and St Thomas’ Charity, a catalyst for innovation in health. It . To learn more about the relationship between Wellthcare and the Charity see the announcement

Pritpal S Tamber

Independent Writer, Researcher & Consultant | pritpal@pstamber.com

I'm an independent writer, researcher and consultant focussing on community health and medical information. I'm a former physician, medical editor and medical publisher, and also the former Physician Editor of TEDMED. I began my career at The BMJ. For more information, see the About page.

15 thoughts on “Pernicious Moralising: When Public Health Fails”

  1. ‘Pernicious moralising: when public health fails’, great piece. It made me think of Performing Cures.
    When I tell the story of Performing Cures I usually give a spiel that begins something like this: ‘Back in October 2002, while working as a junior doctor, I founded a social enterprise called Performing Cures that brought live music and drama in the public spaces of hospitals. Street musicians and homeless people gave the performances. And the hospital agreed to pay for it.’ This spiel, captures the essence of what we did, but the real story, the how and the why of it all very much speaks to the ‘health creation’ and Wellthcare concept you promote here in the magazine and in your most recent article about public health.
    Why live music and dramatic performances in the public spaces of hospitals? To bring a spirit of joy and possibility to patients and the people who serve them; people create health through systems. How? By using our imagination to find innovative ways of caring for the ‘whole people’ and ‘whole systems’; we know we’ve made a difference when the ideas we put into actions resonate with ordinary people.
    People love the idea of Performing Cures. Gavin Yamey, a Deputy Editor at the BMJ at the time covered it in a profile article about me back in 2004. It came up again five years later when I was a guest on Libby Purvis’s BBC Radio 4 show in March 2009 after my 2009 solo art exhibition in London’s Mayfair district.
    The impact of this form of health creation also resonated with the performers, patients, their families and healthcare professionals working in the hospital. For the street musicians and performers, many of whom live on the fringes and are homeless, it was a healing to perform indoors, being paid £50 for a performances (approximately 1 hour) and feel as if they made a difference to someone’s life; 3 performers donated their fee to support the founding of Performing Cures.
    Quite apart from the performer, hundreds of people wrote in spontaneously to Guys and St Thomas’ hospital with positive feedback. Here are some of the comments they made.
    ‘I heard some of the music as I was passing through the hospital on the Guys Day and it was uplifting. I was pleased to see the performers in the main foyer of the hospital: it created a lovely atmosphere as people came through the main entrance. The music was ‘gentle’ jazz which I liked.’
    Patient at Guys Hospital, London, UK
    ‘I enjoyed the classical trio first thing in the morning in Tower reception. I enjoyed the music very much – it was wonderful to come in after a hectic child-to-school an cycle ride through the ghastly, stressful traffic, to some lovely soul-enhancing music! Many thanks for arranging it!’
    Healthcare professional at Guys Hospital, London, UK
    ‘Just want to ‘thank you’ for having organized the most excellent day of music…it bought a lovely atmosphere into the hospital and I overheard a couple of visitors saying the most complimentary things, they’d never seen anything like it in the hospital before!’
    A woman visiting her husband, a long-term patient at St Thomas’ Hospital
    When I scrolled to the bottom of your article I noticed that ‘wellth’ was funded by Guys and St Thomas’ Trust; they also funded the Live Music Days that lead to Performing Cures.
    Dr Desiree Cox, BSc(Hons), MBBS (Oxon), MPhil, PhD (Cantab), Honorary Professor of Creativity and Heath (University of Exeter), Consultant (Healthcare and Strategic Communications)

    1. Pritpal S Tamber

      Dear Desiree,
      Thank you for sharing.
      I think the key question for many people in health is how to value this kind of work. Although there are pockets of philanthropic money that fund it now and then, the question is whether the value being created is so important that we can invest in it.
      Such investment may not follow the usual rules of investment, such as the speed of return, but there is still the need to make the case for spending the money here rather than elsewhere. I have no doubt that this kind of effort creates health-related value; the questions are how much, how sustaining is it, who pays, and where does it sit in the ecosystem of health creation and health care?
      Lots to think about this. Thanks for putting it on our radars.
      Pritpal

  2. Not being provocative at all. Just being factual. Given that 60% of the UK population is overweight, and 25% obese…and given that the NHS is England’s largest employer (pun intended), NHS employees are a representative sample. They shouldn’t be. In the private sector you are expected to ‘eat your own dog food’. In a competitive free market, you would not buy dentistry from a dentist with bad teeth, so you would hope that the NHS would develop a culture that promoted personal responsibility. Instead you see hospitals with Burger King in the foyer.

    1. Pritpal S Tamber

      All good points, Clive.
      Sometimes, I think pointing out the obvious *is* being provocative, but it’s very much needed for the reasons you’ve outlined above.
      Pritpal

    2. <<Not being provocative at all. Just being factual. Given that 60% of the UK population is overweight, and 25% obese…and given that the NHS is England’s largest employer (pun intended), NHS employees are a representative sample. >>
      So you’ve inferred that hospitals are ‘full of’ overweight people, because 60% of the UK population is overweight? By that reasoning, 60% of people in gyms are overweight too.
      <<In a competitive free market, you would not buy dentistry from a dentist with bad teeth>>
      There are many desirable qualities in a dentist, and I wouldn’t put nice teeth at the top. In a competitive free market, I’d choose a caring, practiced dentist with a crooked smile, over a buff dentist with a great smile.
      Fortunately our dentists, doctors, nurses are willing to sacrifice their own health and quality of life for their patients. Ever worked a night shift? http://www.hsph.harvard.edu/nutritionsource/sleep/
      My experience is that hospital staff are generally a health-conscious bunch, who work too hard and don’t get the recognition they deserve. Certainly not from what I’m seeing here.

      1. Pritpal S Tamber

        Gents,
        Some fair points in both directions.
        Having worked night shifts in the NHS, it’s pretty clear how little the organisation really care about its staff, both from the way schedules are handled and the food that is available to staff overnight.
        Most health care employers have a lot to learn about respecting their workforce.
        Pritpal

      2. According to a study carried out by The Nursing Times, “over 50% of Nurses are overweight”. So now we have established the facts, I’m not sure what point you are trying to make Tom, or indeed what working a night shift has to do with it…by the way, yes I have! All I’m saying is that if we are to value public health, it deserves more recognition and kudos from the healthcare establishment. And if clinicians want to be taken seriously about promoting an agenda of good health, they need to practise what they preach. The evidence suggest they don’t. I’m not saying they aren’t kind, don’t care or work hard. I’m just saying they are poor role models when it comes to promoting healthy behaviour.

  3. We’ve dropped from 60% to 50%, which suggests that nurses may be significantly less overweight than the general population. And that’s on top of pressures like night shifts that are associated with obesity and diabetes.
    <<All I’m saying is that if we are to value public health, it deserves more recognition and kudos from the healthcare establishment.>>
    If that’s all you are saying, then I absolutely agree. It just seems odd to promote this agenda by using sweeping generalisations to sneer at an entire healthcare workforce. Many healthcare workers *do* live healthy lifestyles.
    <<As the American’s say, you have to eat your own dog food>>
    Yet they still suffer the same issues:
    http://onlinelibrary.wiley.com/doi/10.1111/j.1745-7599.2008.00319.x/abstract
    The truth is that mobilising a workforce to change lifestyles is a bigger challenge than convincing a bunch of Google staff to avoid Bing.
    Tom

  4. I’m sorry that you feel the need to be so defensive. You are exactly right that changing lifestyle behaviour is easier than changing browsers. But I stand by my original assertion that if we are to change health behaviour, then the employees of the NHS need to lead by example. And my experience as an employee and a patient is that they don’t lead by example. Nicholson admitted as much. I suspect that his successor will be a little more aware that a cultural shift is a prerequisite to any meaningful change in behaviour and will ‘walk the talk’.

  5. As usual, thought provoking if slightly conceptual piece. The crux of the issue is how we ‘value’ health/Wellth, especially in the UK where the majority of people have no idea how much things cost, let alone how much they feel it is worth. Re Public Health, I note generally that the value of something can often be determined by the kudos and esteem it receives. Public Health offices are generally found in the back or basement of a building, and its Executive/Clinicians often the lowest paid and least respected by their peers. This leads to a downward spiral of quality people and quality outcomes. The % of budget is also a good indicator, and if my memory serves me correctly, that is about 5% in the NHS. If we really believe that promoting and enabling ‘good health’ is as important, if not more so, than treating illness then CEOs and clinicians must walk the talk and put their budget where their mouths are and measure the RoI. Alas. We have a departing Head of the NHS who admits he contracted diabetes because of poor lifestyle management, and hospitals full of overweight healthcare workers who often smoke. Lead by example is not something the healthcare system seems to believe in. As the Americans say….you have to eat your own dog food. If we want a healthy public, our Leaders need to practice what they preach about Public Health. Imagine the Executives of Google using Bing, or of BA flying Virgin. Which reminds me of the story that Proctor &Gamble, makers of soap powder, promoted dress down Fridays because it meant that once a week everyone went into work in clothes they washed at home instead of the dry cleaners. That is what competitive pressure does for innovative thinking!

    1. “Public health workers are often least respected by their peers”. Is this true? And are hospitals really “full of overweight healthcare workers”?
      Tom

      1. Pritpal S Tamber

        Dear Tom,
        I can’t really say whether public health professionals are less respected by their peers, although I do think they are fundamentally putted against them, as suggested in this recent post:
        http://www.wellthcare.com/pioneers-log/seeing-beyond-the-bio-medical-model
        I think Clive was being provocative when he suggested that hospitals are “full of overweight healthcare workers”, although there is a lot to be said for the NHS understanding that their economic power (as an employer) could be used to influence better lifestyles, as suggested by the Democracy Collaborative:
        http://community-wealth.org/content/hospitals-building-healthier-communities-investing-outside-institutional-walls
        Pritpal

    2. Pritpal S Tamber

      Thank you, as ever, for your thoughtful comments, Clive.
      Thank you, especially, for explaining where dress-down Fridays come from. What an excellent example of an organisation forcing its employees to walk the talk.
      We’re starting to move from conceptual to real and practical here at Wellthcare. We’re looking into creating some kind of event at which we can start putting meat onto the bones of how we value health. I think starting that dialogue, including how health-creating interventions are evaluated, will give us the option to invest in more than just health care.
      And perhaps by doing so public health professionals will be let out of the basement. Let’s hope so!
      Thanks again.
      Pritpal

      1. Look forward to participating in the event…please no live performances though….unless they are from clinicians practising what they preach!

  6. Thanks Clive, just standing up for the many employees of the NHS who do lead by example, and who deserve to be recognised.
    Tom

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