We need real public health

From pronouncements from the UK’s chief medical officers last week on how many units of alcohol it is safe to drink (none apparently) to the ongoing panic-mongering about the non-existent dangers of vaping – which, I’d argue, is potentially the biggest contributor to improving the public’s health in a generation – public-health busybodies have been making a bit of a show of themselves recently. They seem hell-bent on banning anything that even looks like a threat to public health – even when it plainly isn’t.

But what is public health anyway? Is it really about guilt-tripping us over our festive indulgences this Dry January? Or about banning two-for-one food promotions and calling for a sugar tax to tackle obesity? Or about supporting mothers to breastfeed their babies in public? Well, public health used to be about scientific breakthroughs, sanitation and slum-clearance. It was about building massive infrastructure like the sewers that carried away the stench and disease that blighted 19th-century London. It was about mass vaccination against once-killer diseases. In other words, it was about big, far-reaching changes that helped us to live longer, happier, healthier lives.

Today’s campaigners, by contrast, are obsessed with intervening in the minutiae of our once-private, everyday lives. Even the genuinely big threats to our health, like diabetes, which is thought to affect more than four million people in Britain, are framed as a problem of lifestyle, and become another opportunity to lecture the obese masses. Diabetes is not, according to today’s public-health campaigners, a challenge to be met by medical science – not to mention a side effect of living in an ageing and well-fed society, made possible in no small part by historic public-health interventions. Instead, they argue, on very dubious grounds, that our unhealthy diets, lifestyles and childrearing choices will lead to disease, death and disadvantage. That is, unless the fear and anxiety generated by public-health campaigns (otherwise known as ‘awareness-raising’) persuade us to take the official advice and change our ways.

Indeed, what really drives the officially endorsed breast-is-best campaign is not support for women’s right to breastfeed – it is contempt for women’s right to bottle-feed – the allegedly less-healthy alternative. There is no campaign to destigmatise those mothers who would rather not go through the discomfort and exhaustion of ‘natural’ feeding, and who opt for the convenience of bottle-feeding their babies with formula milk instead.

Not only is this sort of hectoring objectionable in itself, but this petty, paternalistic turn, in which public health has become synonymous with intrusive meddling in people’s lives, is also, to my mind, not a good use of public money. It was announced in the last Comprehensive Spending Review that the NHS budget is to rise over the next few years – not least to get cash to the increasing numbers of hospital trusts which are in serious financial trouble. However, the £15 billion of the Department of Health’s annual £116 billion budget which is spent on particular departments and quangos, including Health Education England and Public Health England, is to be cut by a quarter.

It is not clear how this will impact on public-health activities. Public health is more than the projects backed by the Department of Health, with other government departments and the charity sector also being keen advocates of protecting us from ourselves. But the threat of cuts to student nurses’ bursaries, which brought them on to the streets at the weekend, can only make the existing nurse shortage that much worse. Add to that the junior doctors’ strike over seven-day working, planned for tomorrow, and you get a sense of the real crisis facing the public’s health.

While blaming people’s unhealthy lifestyles for the crisis in the NHS is commonplace, there is a growing recognition that practical initiatives designed to prevent ill-health can also have a real impact on the wider health economy. By, for instance, reducing the incidence of falls and infections among the older population, or improving the management of long-term conditions, which too often end in a deterioration that can easily rob people of their independence, we can avoid the expense of hospital admissions and residential care down the line.

Public health as it stands today rides roughshod over people’s liberty. And this is all despite the fact that it is our longevity, rather than our lifestyles, which poses the biggest challenge to provision today. It is the side-effects of getting older, brought about by the past gains of public health, and the costs that come with treating serious conditions that people used to die from, that are responsible for bankrupting the system.

Beyond the billions supposedly spent on it, the biggest cost of public health today is the continual undermining of personal autonomy and our capacity to make our own choices. The sooner public health stops patronising people, leaves us alone to run our own lives and gets back to focusing on those interventions that really make a difference, the better.

First published in Spiked

If people choose to smoke, vape or drink too much that should be up to them

How the headlines have changed: British smokers urged to start vaping by health officials; E-cigarettes ‘should be prescribed on the NHS’. Anexpert independent evidence review from Public Health England (PHE), recognises that e-cigarettes are not only practically harmless, they are already helping people to give up smoking and are, to quote the author of the review, a “game changer” for the public’s health.

Vaping, says the review, is 95% safer than smoking cigarettes. Who could object to the view that smokers be encouraged to get vaping, especially if they are already thinking of giving up what is well understood to be a bad habit?

But the World Health Organisation and European Union are set on banning e-cigarettes, and just a couple of months ago the Welsh government announced it wanted to ban e-cigarettes in enclosed spaces, arguing that they act as a “gateway” to the tobacco-filled variety. These dubious claims – rubbished in PHE’s review of the evidence – have been used to justify threatened clampdowns.

Meanwhile in Britain, something like 2.5 million smokers have taken the lead by switching to this much safer alternative. In other words, they have proved more adept at looking after their own health than those charged with the public’s health. As many as half a million smokers, according to Ash, have switched in the last year alone. On the face of it, a section of the public health establishment has come to its senses and followed suit.

But while making e-cigarettes available on prescription is quite a turnaround, it is more in keeping with the urge to regulate than to promote smokers’ health. Indeed this new-found enthusiasm for vaping is as likely to raise prices, as e-cigarettes acquire medicinal status, as help smokers do what they are already doing anyway.

The case of vaping is not atypical of a confusion at the heart of health policy. On the one hand, promoting people’s “independence, choice and control” has become a mantra in health (and social care) circles. On the other, the assumption that the public cannot be trusted to make even the most basic decisions about how they live their everyday lives dominates public health thinking. As one GP pleaded recently, her waiting room of patients is already impossibly demanding without also “trying to remember that [she’s] meant to tell smokers to stop smoking, drinkers to stop drinking, and to wave a wand at obesity” too. And that’s just three items on a very long list.

Hasn’t general practice got enough to do without having to prescribe e-cigarettes as well? The controversy over vaping is just one of many instances where public health dogmatism is coming up against people’s autonomy. With the exception of GPs helping those patients who need it to manage a long-term condition, or to prevent one getting worse, are the lifestyles of patients really anybody else’s business?

It is one thing to rightly insist that the NHS change from being a “sickness service” that reacts rather than prevents (reducing infections, preventing falls and avoiding unnecessary hospital admissions). It is quite another to insist that people must be kept well whether they like it or not. The health service is supposed to be in the business of promoting, not robbing people of, their capacity to run their own lives – and that means recognising their ability to make unhealthy choices.

There is a contradiction at the heart of the policy agenda, where a rhetorical commitment to patient choice turns out to be fatally compromised by a paternalism that the health service claims to have abandoned. Patronising people and protecting them from themselves just won’t wash anymore. If we choose to smoke or vape, or drink or eat too much, that should be up to us.

First published in The Guardian

Don’t Blame It on the Baby Boomers

It is all too tempting to blame the young for not having enough ‘go’ in them, for their self-pity and endless moaning about the housing ladder and tuition fees. As if they really are the most put upon generation there ever was. I’m guilty of blaming them for that. They are hardly setting the world alight with their ambitions to change the world, something that Jennie Bristow alludes to in her book about a generation that really did change the world – but she also questions whether such ‘generational thinking’ is helpful.

According to Baby Boomers and Generational Conflict, far from thanking the Boomers for the Pill or The Beatles, for civil rights or sexual equality, Boomer-blaming is all the rage today. When they’re not overburdening the welfare state with their pensions, free TV licences and bus passes they are held responsible for creating an ‘ageing problem’ and a global economic crisis too. As Bristow’s own research shows, they are portrayed as the large, lucky, affluent, selfish, reckless generation.

They are resented for squandering their wealth when times were good; running up enormous debts (both economic and ecological) for generations to come, and crowding out the young in the competition for jobs now that times are that bit harder. Boomers are blamed for both the rise and the demise of the welfare state, for the fall of family and church, and pretty much everything else, too; as the freedoms they won are deemed to have brought with them an overwhelming sense of uncertainty and uprootedness. But this ‘moralising’ of the Boomers’ legacy is a recent development in keeping with today’s ‘downbeat cultural mood’ Bristow explains.

There was a pessimism at work in the seventies and an appetite for ‘crisis-thinking’. There was reaction against the ‘liberalism, relativism, postmodernism and permissiveness’ of the sixties generation in the Culture Wars of the 1980s. But today there is a much wider ambivalence, at best, about the values and the decades (the cultural and economic excesses of the sixties and nineties, respectively) associated with the Boomers. There are too many ageing Boomers – so goes the ‘responsibilising’ narrative – hospital bed blocking on account of their past excesses. The party is over and now their older selves are having regrets as the children (the ‘babybusters’) are forced to clear up the mess. The poor things.

While, as Bristow explains, the Boomer narrative confuses the post-war generation – itself hard to pin-down – with ‘a handful of educated, middle-class young people’, the influence of the latter is not to be underestimated. They dominated Western culture since their sixties heyday, and voted in Boomer-friendly Third Way governments like Blair’s New Labour and Clinton’s Democrats in the nineties. While their managerial magpie-like politics was (and is) uninspiring, the student protest movement and counterculture that followed the ‘silent’ generation, the Beats and the Angry Young Men, dejected by the materialism of their own society as much as the uninspiring Soviet alternative to it, just shows they had more ‘go’ in them than the generations between which they were sandwiched.

But they were pushing against the proverbial open door. Underlying the generational conflict of the sixties, says Bristow, was the ‘relatively weak character of traditional norms and institutions’ and a ‘wider crisis of meaning and authority’. Despite its genuinely radical and liberatory character, and its role in the ‘major social, cultural and political changes’ of the period, the new ‘politics of age’ was not all it was cracked up to be. Because it was also a retreat to the narcissistically personal and narrowly cultural spheres, she argues. Its self-regarding adherents abandoned mass class-based politics and the consumer society in favour of the intellectuals of the New Left as much as they opposed the stuffy elite.

Whoever the Boomers are or were, that they are criticised today not for their contribution to the emptying out of politics of its transformative character, but because they ‘recklessly pushed the boundaries of knowledge and experimentation’, says a lot about the low horizons and diminished expectations of the generations that have followed. Blaming the boomers for the housing crisis or the pensions time-bomb is also to evade the business of getting to grips with ‘wider structural problems’ and ‘ideological confusion’, as Bristow puts it. Which brings me back to today’s complaining youth. There is something very childish about blaming everything on your parents. Instead of a grown-up debate there is a rather nasty and intensely personal attack – with the young in particular feeling very sorry for themselves.

First published in Huffington Post

Eno, Gaza and the Politics of Long-Distance Emoting

I don’t usually write about international relations. Or about music for that matter. My thing is social policy, whether its welfare, health and social care, housing or education; the Big Society (wherever that went) or nudging (which is ever present). Another favourite, if that’s not too inappropriate a way of putting it, is vulnerable children. Or, rather, the way in which certain children’s charities – we all know who they are – seem to like nothing more than to exploit our anxieties about our children and our suspicions of our fellow adults. All done with a dubious use of research and statistics, and vile adverts featuring supposedly bruised and battered children, to create the impression of widespread child abuse. Which there isn’t. So outraged was I by one of my musical heroes – and another by association – for using that same approach for gaining sympathy and support, that I felt as compelled as he to make my feelings known on a subject about which I hope I know just a little more. Though that, apparently, wouldn’t be difficult.

In the seventies and eighties David Byrne and Brian Eno practically reinvented popular music with their avant-garde takes on the genre, playing critical roles in the development of everything from world music and ambient to sampling. That was after they had taken on tired rock clichés with their respective legendary bands: Byrne as the nervy WASPish lead singer of Talking Heads, and Eno as the professorial cross-dresser who so upstaged the other Bryan in Roxy Music. But more recently they have conspired to create something that could only disappoint this long-time fan of their work. I don’t refer to Eno’s collaboration with the unbearably awful Coldplay; or to the fact that Byrne is as likely to be found these days designing bicycle racks as making groundbreaking music. (They are actually rather lovely.)

No, it is their politics, or ‘beyond politics’ as Eno puts it, and their uncharacteristic eagerness to jump on the Israel-bashing bandwagon, that really grates. Even if, assuming the latest ceasefire holds, the bombardment of Gaza looks to be coming to an end. Thankfully. In a letter to his American friends – including and initiallly published by Byrne on his website under the title ‘Gaza and the loss of civilization’, and latterly in The Independent – Eno despairs at an America that he thinks should be doing more to save Palestinian children from Israeli bombs. The reference to horrific images of children where an argument should be is not only shamelessly emotive and dangerously simple-minded, but it is a cynical way of encouraging the mighty Western powers to throw their weight around too. All under the cover of a peacable intent with regards the Palestinians who also, as it happens, are portrayed as vulnerable and child-like in their helpless suffering. With government ministers resigning, and trade embargos against Israel being considered, one wonders if these one-time rock stars just miss the limelight a little too much to care about the consequences of their pontificating on things about which they know not much. While Byrne, at least, has the good sense to acknowledge that ‘no one has the moral high ground’ on Gaza, Eno has no such reservations only – astonishingly, given his very public statement on the matter – admitting his ignorance: ‘I really don’t get it and I wish I did.’

Not that his lack of understanding matters much. His outburst is not about Israelis or Palestinians, it’s about people like him. And the fact that he doesn’t recognise, as he puts it, this America in his no doubt duly flattered ‘compassionate, broadminded, creative, eclectic, tolerant and generous’ friends across the water. Eno is not only nauseatingly self-aggrandising on behalf of this once trailblazing set. The letter is the political equivalent of post-Punk Byrne renouncing his opposition to lengthy guitar solos; and legendary producer Eno working with the likes of Coldplay. (Okay, so he already did that.) It is that slavish in its adherence to the wrong-headedly commonplace. It is also, ironically enough, an example of the dangerous combination of emoting, cluelessness and self-important meddling that keeps their respective countries recklessly posturing about such far-away conflicts too.

First published in Huffington Post

There is more to welfare than a broken IT system

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The implementation of the government’s Universal Credit, already proceeding ‘carefully’ according to welfare minister Lord Freud, is now slowing to a crawl with just one new area joining the scheme this month. By now it was supposed to be well on the way to a national roll-out. Instead, it continues to be dogged by the difficulties with the project mismanagement of an IT system subject to scathing criticisms from the National Audit Office and the parliamentary public accounts committee.

So far just a few thousand people are claiming the new benefit that merges six means-tested working-age benefits and tax credits. It will, once it is eventually rolled-out across the country (still scheduled for 2017), affect something like 8 million households. One might reasonably ask whether it makes much sense spending tens of millions of pounds on a gigantic and failing technical solution to what is a deeply ingrained cultural (as much as an economic) problem? In order to ‘make work pay’ (let alone save a projected £38 billion), the government are going to need more than a computer system no matter how big or clever it gets; if they are going to undo the damage done by a welfare state that maintains millions of people, including entire communities, in a state of miserable, unproductive passivity. But it seems the critics too are missing this most fundamental of points

Despite one controversy after another about how ministers are calling benefit claimants names (‘scroungers’, ‘shirkers’, etc); or how ‘the vulnerable’ are being victimised by the bedroom tax, the benefit cap, the work programme, and anything else to do with the reform of the welfare system; there is next to no debate about the underlying substantive issues. It is the implementation, not the rationale, of Universal Credit that comes in for most criticism. So not only have the critics delighted in anticipating the inevitable problems with the ‘over-ambitious’ IT system; they also like nothing more than to anticipate the inadequacies of the supposed beneficiaries of the shiny new benefit. It is outrageous to expect claimants to apply online because they just won’t understand it, or to expect them to get their money monthly (rather than weekly) because they are too feckless to manage it properly. Such are the arguments used by the supposed defenders of the welfare dependent.

Indeed what both sides seem to have in common is contempt for those entangled in the welfare net. While blaming welfare claimants for the mess won’t do, nor will the patronising words of commentators and lobbyists who worry over the inadequacies of those in need of little more than a job. For all the venom directed at benefit claimants on the one hand, and at incompetent political managerialists on the other; there is little prospect of an end to dependency and worklessness, or of the government’s failure to tackle it being properly exposed.  What is really outrageous is that rather than having an argument about the rights and wrongs of welfare, both sides are projecting the welfare problem onto the supposed deficiencies of individual claimants – whether they blame them or feel sorry for them.

First published in Institute of Opinion