Not Hippocrates But Marx
Updated: Mar 17
by Dr Paul Walker
Picture: Working Men Of All Countries Unite! - The Karl Marx monument in Chemnitz,
former East Germany DDR / Credit: Matthias Rietschel/Reuters
Please note: This blog was first published as part of Dr Walker's regular column in the Western Mail on 25th April 2004. Read on for a postscript below.
In 1996, in these columns, I suggested that the adoption in the 1974 NHS Reorganisation of consultant status and the rejection of the manager / politician role of the former Medical Officer of Health was a serious mistake and explained the failure of our discipline to make any significant impact over the last 30 years. Retaining the trappings of the medical profession and accepting that bauble of medical establishment status, the merit award, were clear evidence, I suggested, of how far we had strayed from the visions of Chadwick, Duncan and Simon.
My proposed remedy was that we drop the doctor title and role – when I took up what was then called medical administration I accepted that I was no longer a doctor in any meaningful sense – and pursue one or more of three non-professional paths; the scientist / technician applying epidemiological method to health and healthcare research and evaluation; the manager making public health things happen; and, for the more heroic, the politician campaigning to change society through healthy public policy.
Revisiting these issues from the vantage point of someone who is now fast approaching the finishing line, with no more merit awards or other prizes to beget silence I ask myself what has changed? Very little actually. The masonry of medical professionalism still dominates; and the numbers of public health practitioners who are managers or politicians can be counted on the fingers of two hands. And what we still have is a discipline wedded almost exclusively to the scientist/technician role, happy to give advice but seemingly averse to taking responsibility for any resultant action. Leadership is remarkable only for its absence.
But as doctors surely we are about doing things for our patients, not about just observing them? Having swapped the individual patient for the population equivalent we should be about doing something for that population. Which, with what we now know about the underlying determinants of health, means doing something about reducing inequalities in health, wealth, education, power and opportunity. Or, to put it in more positive terms, we should be promoting the cause of the socially excluded, fighting against the power and vested interests of the establishment, big business and the professions; and about promoting the sovereignty of the people and their absolute right to determine what happens to them and what is done in their name.
Picture: Statue of Hippocrates the "Father of Medicine" / Credit: Medium
It took many years of public health practice and the publication of the Black Report in 1980 for me to realise that the public health agenda is in truth nothing more or less than socialism in action.
Socialism in action to we public health practitioners is the equivalent of pharmaceuticals to the physician and the operating theatre to the surgeon. It is a necessary if not sufficient tool of our trade. Surgeons can be conservatives – they usually are - and it doesn’t affect their ability to practice. Ditto physicians. But we can’t be other than socialists unless we are content to be merely diagnostic technicians like radiologists and pathologists. Of course we need diagnosticians. But as in clinical medicine we need the majority of practitioners to be therapists. It is not as if there is no scope for therapy in public health!
Interestingly, it is my perception that our health promotion colleagues are much more therapy oriented; as are environmental health practitioners. And so their increasing prevalence and influence within the greater public health community is to be welcomed and will lead eventually, one can but hope, to our separation from the medical establishment with the replacement of the Faculty by an appropriately secular organisation - a Chartered Institute of Public Health or some such, perhaps.
So the discipline will be begin to justify its existence – throughout most of my career justifying its expensive existence has been a continual subtext - and the medical influence, once so important but long since dysfunctional, will wither on the vine. Edwin Chadwick would smile. But how long will it take? The evidence of my own experience suggests that it will not happen quickly or without a determined rearguard action on the part of the reactionary tendency. But with so much to do and so much lost time to make up for we cannot afford any delay.
I am happy to report some time after* I wrote the above the Faculty of Public Health at last removed itself from the hegemony of the Royal College of Physicians. Public health became a discipline open to both medical and non-medical professionals. A muffled retrospective"Hurrah!" is probably justified, but remember this move took more than thirty years! And perhaps even more remarkable is that Public Health has been put back into local government. But whereas the old Medical Officer of Health role was a senior one within the local authority top management structure – second only to the Town Clerk or equivalent - the current Directors of Public Health are second rank officers of the authority. They lack the broad all encompassing influence on all the many non-medical levers of public health and wellbeing of the old Medical Officer of Health.
Until this misunderstanding of the breadth of the public health role is corrected; and until public health is firmly embedded in general practice to develop social prescribing (but that's another story!) the impact of the public health discipline will be confined to the traditional medical elements. So in spite of the removal of the Faculty from direct medical influence, public health will continue to fail to deliver on wider determinants of public health i.e. the public wellbeing agenda.
* In November 2010 the UK's Coalition government published the White Paper, "Healthy lives, healthy people" promising"a new era for public health, with a higher priority and dedicated resources". The King's Fund's verdict in a 2015 general election review was: "...the government has delivered its commitment to reform public health and provide dedicated resources, but it has not given public health the priority it promised."
Dr Paul Walker
Image: The front cover of From Public Health to Wellbeing
by Paul Walker and Marie Joan / Credit: MacMillan Education
Dr. Paul Walker is an independent public health consultant with 50 years experience of working for the NHS, local government and academe as a public health specialist and manager. He is the co-editor of Public Health Matters and the co-editor of From Public Health to Wellbeing: The New Driver for Policy and Action.
Synopsis for From Public Health to Wellbeing: There has never been more awareness of the public health agenda, as policy-makers stress the importance of 'wellbeing' to the general public. Charting the history and evolution of the public health agenda, this insightful reader argues the place of wellbeing in local and national strategy. It identifies some of the critical events that have influenced the development of public health systems, and looks at the challenges for policymakers and professionals in the formulation and delivery of effective strategies for the future.
This text explores the challenges of defining and promoting wellbeing across the lifespan, from childhood and youth to older age, through a range of approaches, such as town planning and partnership working. It is a valuable resource for students of public health, health promotion, the social sciences and social policy, as well as for any practitioner supporting health promotion within the public, private or voluntary sector.