Against the Flow: Pandemic lessons from inside the wider battles for prevention

By Bobbie Jacobson

Bobbie Jacobson’s honest and deeply personal story brings home her passion for preventing ill-health. Not just for individuals, but for whole communities. It is a passion too often thwarted by governments, vested interests and imposed on an obedient health management system.

Her personal accounts of the tragedies, comedies, triumphs and setbacks of a woman doctor, partner and mother start deep in the gender wars of the 1970s and move on to a future in public health and family life she never dreamt was possible.

She goes backstage to tell untold stories of what really happens in government, the NHS and local communities. Drawing on four decades as an international activist and public health director in London’s East End, she uncovers new truths about how to overcome the Groundhog Day of failed prevention.

She sheds new light on tackling the persistent health gap in a future pandemic. Her stories show what really can be achieved when public health teams work hand in glove with local communities.

• Language: English
• Publisher: Troubador Publishing Ltd
• Release date: Mar 28, 2024
• ISBN: 9781805148395

Bobbie Jacobson

Bobbie Jacobson has had four decades of experience as a public health doctor and activist. She was one of the earliest international leaders in smoking prevention in women. She was Director of public health in London’s East End in the 1990’s, and of the London Health Observatory from 2001 to 2013. Bobbie has written widely in the scientific and popular media and recently on Covid-19. She was awarded an OBE in 2005 and lives in London.

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9781805148395.jpgAgainst the Flow. Pandemic lessions from inside the wider battles for prevention by Bobbie Jacobson

Copyright © 2024 Bobbie Jacobson

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ISBN 978 1805148 395

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For Lucy, Guy and Esmeralda.

Om mani padme hum

Contents

Foreword

Author’s note

Acknowledgements

And a final word on why we need a strong public health system

Foreword

Bobbie Jacobson has been one of our most passionate advocates for preventing ill health over four decades. She has been an astute observer of the ups and downs of public health in England. During that time she has been a pioneer at the centre of things, successfully calling out the malign behaviour of the tobacco industry, campaigning as the director of public health of the multicultural melting pot of east London, one of the most deprived communities in the country. She has led a respected analytical institution, making sense of the data that reveals how diversity and inequality affects health. Her intensely honest and personal account in Against the Flow brings the realities of life as a woman doctor, partner and mother centre stage.

Her memoir allows us to share this ringside view of the evolving challenges to the health of the public at all levels. At a national level, she describes the challenge of getting those in authority to commit to act on the major causes of ill health. At a local level, working with one of London’s many communities that exist on the margins of mainstream society, she shows how it is possible to overcome a legacy of distrust to engage successfully in mutual action. She chronicles the changing disease challenges, especially the AIDS pandemic during the 1980s, that offer vital lessons for future pandemic prevention. And she explores the often-complex interface between academia and practice, working with some of the UK’s leading research centres.

These perspectives make Bobbie exceptionally well qualified to comment on how the UK, a country with world-leading scientific expertise, managed to perform so badly during the Covid-19 pandemic, in terms of both lives lost and the economic damage done. She points to the solutions for future prevention that have been missed from the repeated lessons of the recent past. While the official Covid-19 inquiry will take time to report, we already know a lot about what went wrong. As many observers have noted, most recently Anthony Seldon in his biography of Boris Johnson, a combination of disengagement by the prime minister and disagreements among his advisers delayed the initial response, costing many thousand lives. But, as Bobbie shows, the problems began long before. An effective response to a crisis is only possible if the national infrastructure is sound. Yet, for at least a decade, it has suffered sustained underinvestment that left it weakened and broken. The social safety nets once provided by the welfare state were torn to shreds, with growing numbers of people living in substandard and overcrowded homes, dependent on foodbanks. The public health system had suffered additional harm from a disastrous reorganisation of the NHS. As David Cameron says of Andrew Lansley’s plans in his autobiography, ‘it was like an artist unveiling a piece he’d spent years on, and everyone wondering what on earth it was.’ Yet as prime minister he still went ahead with it.

Bobbie is a role model for the next generation. I’ve had the privilege of working with her, on and off, for several decades. I hope that those young people who want to speak truth to power and make the world a better place will also be inspired by Bobbie’s story, set out in her fascinating and excellent memoir.

Professor Martin McKee CBE

Professor of European Public Health

London School of Hygiene and Tropical Medicine.

BMA president

May 2023

Author’s note

Words. Words. I play with words, hoping that some combination, even a chance combination, will say what I want.

Doris Lessing

As I sat poised at my blank screen in 2020, I could feel the untold stories of a life in the prevention of ill health itching to be unleashed. But doubts clouded my view. Was my panegyric on prevention really needed? Had I somehow missed a vital link to the catastrophic handling of the Covid-19 pandemic as I watched it unravel from a distance? Yet, as I reflected on pushing the public health boat out for four decades, the obvious lessons from past struggles for prevention of our biggest killers began to seep in. Repeatedly. I can only hope the lessons for future prevention won’t be lost on the UK inquiry into Covid-19.

The inquiry will have the last word on the immediate failures and successes in tackling the pandemic. My book is not about restating what will already be plain. Mine is a deeper dive into the evidence of action and inaction that lies beneath the lives that could have been saved. It is a long look in the rear-view mirror of what can make or break the prevention of ill health. The clues for avoiding future pandemic tragedy speak loudly.

For me, the evidence of what works or fails can never be complete until we look beyond counting the tragedies and their causes. Yet we often have neither the time nor research tools to measure complex actions in a public health emergency. We must act on imperfect knowledge tempered by proper debate. These are the rules of democracy. Muir Gray, a public health doctor, helped my thinking about this when he likened health evidence to the organised flow of water. It reaches us through three channels: intelligence, research and experience. My story is about the experience of using what we already know to improve health. It is not a painting by public health numbers. I have tried to illustrate the bumpy journey that defines such action. It is flecked with the realities of personal ups and downs.

Against the Flow is my homage to the countless, unsung public health foot soldiers who have devoted their energies and skills to improving the life chances of some of the most diverse and disadvantaged local communities in the UK. Unearthed here are the stories of how some of our health battles were painstakingly fought deep within the system, not by giant lunar steps for ‘mankind’ but rather by what Angela Merkel called ‘Die kleine Schritte’ (the small steps). It is my way of shining a light on how preventing future ill health and pandemic tragedy can sink or swim in perpetually restless political seas. The behaviour of governments and the systems they create might sound like opium for bureaucrats, but they can also save or squander lives.

I know too that I am a woman of my time, lucky to have been born into a unique post-war moment that created the NHS and welfare state. I am lucky to have thrived under its protective shield that is now under greater threat than at any time. Achieving better health, for us all, has become ever more urgent.

1

Ask John Snow

I loved clinical practice but in public health you can impact more than one person at a time. The whole society is your patient.

Dr Tom Frieden

A man is crossing some stepping stones over a raging river. He falls in and is dragged downstream shouting, ‘Help! I’m drowning!’ A passing doctor sees the man needs help; she dives in and saves him. Shortly afterwards a woman falls in and the doctor dives in again and saves her too. As more and more people fall in the doctor becomes overwhelmed. An engineer passes by and immediately sees what needs to be done. She builds a bridge upstream over the river, saving many more lives and a great deal of the doctor’s effort. This is the public health parable of ‘refocussing upstream’. Its relevance today couldn’t be stronger. Preventing ill health for everyone saves more lives than treating individuals alone. And it helps the health system to cope. By implication, the authorship of much of the preventive action lies outside the health care system. This is the belief that brought me into public health and kept me there. Even though I came also to see that great advances in medical treatment have an entirely complementary part to play, I was schooled in the temple of prevention.

Public health is almost as widely misunderstood as the EU, both before and since the Brexit vote. I have been asked too many times what on earth today’s public health doctors and scientists do. ‘No,’ I always reply, ‘we are not like GPs; we don’t have surgeries or clinics where we see individual patients; no, we don’t fix the drains and no we aren’t overpaid administrators.’ The best description I can give is: ‘My patient is not an individual, but the whole population.’ To make it easier to grasp, I will give the population an individual name. Let’s try Omnes Nos. Which means all of us.

Underneath the public health umbrella also lies a lot of left luggage about what we really mean by prevention, where action should be taken and by whom. If you are someone with high blood pressure and are overweight, you know that your GP, practice nurse and sometimes hospital specialist will treat you and will try to help prevent the worst consequences like a heart attack or a stroke. This type of prevention – let’s call it light prevention – will all be in the NHS. But public health action for Omnes Nos – let’s call it deep prevention – is wider and more powerful and works for us all, like healthy food and drink, open space, decent housing and education. To have any positive effect, this involves new laws and action coordinated across several government departments and industries.

#deepprevention

The UK has set up a public inquiry into Covid-19, which is underway at last. By 2026 it will be ready to document the lessons learned for preventing future pandemic tragedy. It has declared a special interest in tackling future health inequality too. As I write, public health experts and practitioners will soon be giving evidence on behalf of Omnes Nos. What are we to make of this? Will it really take heed of the ‘deep prevention’ needed to tackle poverty and disadvantage or will its focus be on ‘light prevention’ within the NHS and social care? It is, of course, too soon to say.

Should we worry that hardly anyone knows of the existence of the invisible foot soldiers of public health working in every local community? I think so. Who are their leaders? Do we know their names like we do our GPs and hospital consultants? For a while we got to know today’s chief medical and scientific officers as they faced the endless media barrage alongside today’s politicians in the battle against Covid-19. But they are probably forgotten by now. Perhaps the only names that might ring a bell are Florence Nightingale and John Snow, who lived almost 150 years ago.

Take John Snow. He was a physician in the 1850s with a practice in London’s Soho. During a deadly local cholera outbreak, he noticed many people were becoming ill and dying. He took two actions fundamental to public health practice. First he consulted his patients and carefully mapped the cases and deaths from cholera. It showed that they clustered around where people collected water from the Broad Street pump. This marked the first fundamental step of public health action: understand the pattern of disease – the who, where and when. This became known as the epidemiology. But he didn’t stop there, like so many do. He got permission to remove the handle of the Broad Street pump and the cholera outbreak soon ended. It is astonishing to think he took this action 30 years before the cholera bacterium was even identified. ‘Removing the handle of the Broad Street pump’ has become a metaphor for public health action for Omnes Nos.

#complexmodernpumphandles

Although we have far better evidence today that can identify patterns of inequality, and point to action, it is far harder to identify and remove the multiple modern pump handles that would be needed to prevent today’s public health challenges. The pandemic has illustrated this only too well with the rapidly changing picture of Covid-19’s spread. It was clearly not about vaccination alone, but a complex mesh of personal protection, testing and tracing contacts, travel and social restrictions, economic support and detailed population monitoring. It is the combination of all of these actions by many government departments, researchers, industries, primary care and local public health teams alongside a well-informed public that faces us today.

The pandemic is by no means the only modern population health emergency. And it is intimately connected to others waiting in the queue for action. Take obesity and diabetes, which put Omnes Nos straight into the Covid-19 firing line. To have a chance of success we’d have to remove the ‘pump handles’ now firmly grasped by the farming, food, trade, retail and advertising industries well before local public health teams, parents, schools and the NHS can have a lasting impact on health for Omnes Nos. Even if our focus is solely on preventing future pandemics, reducing the obesity epidemic is still vitally important. Researchers call this mix of factors a ‘syndemic’. I’d call it modern life.

The impact of celebrity, fuelled by the oxygen of media publicity, complicates things further. While our consultations with our GP are rightly protected by a confidentiality shield, public health concerns are not. They are often fuelled by misleading messages from multiple media and an obsession with fame. Yet today’s public health solutions are too complex to depend on a single celebrity. They involve the invisible brains and patient cooperation of many more. Footballer Marcus Rashford’s successful schools campaign to limit childhood food poverty was an important initiative, as was Jamie Oliver’s before him, but there is much more to do. Getting ‘deep prevention’ done in today’s society seems also to need big names like Malala Yousafzai and Greta Thunberg to catalyse sustained action.

Back in the 1960s, I, along with nearly everyone else, obsessively watched TV’s Perry Mason, the weekly US courtroom drama. Every week, Perry Mason, the brilliant defence lawyer in a wheelchair, would beat his opponent Hamilton Burger, the district attorney – played by William Talman. In 1968 an American Cancer Society public service ad featured Talman telling the world – posthumously – to give up smoking as he had died of lung cancer. Americans were so shocked that it resulted in a huge – 10% – fall in cigarette consumption in the US. In the UK, too, when reality TV star Jade Goody was dying of cervical cancer in her late twenties, her brave effort to encourage women to be screened resulted in a 12% increase in screening in one year. These big population changes could not have been achieved so quickly by quiet, behind-the-scenes campaigns. But it is our public health foot soldiers who continue the unfinished work when celebrity moves on.

You could say that public health is on the tip of everyone’s tongues today. Covid-19 has ensured that the wise words of public health professors and academics reached us every single day via countless routes. Yet the reality is more complex. Public health doctors and experts are, in practice, divided into those who lead the research and have little experience of getting things done and those who turn research into action, the public health teams who usually work locally with their populations. Both are essential. Crucially, the public health front line is largely invisible. It works mostly outside the media glare to implement new knowledge and reduce unfairness.

When I think of public health action at its best, it is like being part of an orchestra. You can’t play a symphony without a team. Everyone has a unique part to play – be it as a doctor, economist, researcher or community activist. But none of us can function effectively without the other parts. You could also say we have a shared musical language, which in public health would be the scientific evidence. As with an orchestra, each public health player has to develop their own instrumental skills and learn to use them at the right time. In public health this can involve many skills. Analysis, research, decision-making, writing, listening and speaking with many competing interests, ranging from local community groups to the minister for public health, all play their parts. Such skills take some five years of specialist training to learn. If you don’t meet the standards required you don’t progress or, rarely, are asked to leave the orchestra altogether.

The quality and impact of the symphony produced depends on the interplay of many different instruments. Sometimes the soloists carry a lot of weight. But, just like a community orchestra, every public health team looks to its conductor, the director of public health, to bring in every instrument to create the right sound at the right time. Often it is best to bring in the community choir to reinforce the strength of local feeling. The orchestral analogy stops short at the behaviour of the audience. If the conductor and orchestra get it right, the audience will clap. However, when the public health orchestra gets it right for its population, there is no need to thank anybody. Ill health is prevented and healthy life is prolonged, and often achieved without any awareness of the huge, behind-the-scenes battle led by unsung public health campaigners.

For more information on what public health directors and their teams really do, see: And a final word on why we need a strong public health system (p250).

2

Public health baptism

Never doubt that a small group of thoughtful, committed citizens can change the world. Indeed, it’s the only thing that ever has.

Margaret Mead

Picture me. I am shaded by the enormous canopy of an ancient Suffolk oak at the 2019 Latitude Festival. Lights twinkle in its branches above me. I am enveloped by a vast expanse of green, open space heaving gently with 40,000 revellers melting into the magic of the music, theatre and performance. My eyes fix on the one solitary, young smoker and one vaper I notice among the throng. They look out of place. Then I think back to the hard-won battles against the tobacco industry that took nearly half a century to get us this far.

Back in the early 1970s, the bold acts of a few committed doctors and campaigners pushed the prevention of smoking into the limelight. They were ultimately responsible for fuelling a new movement saving countless lives worldwide. Their work was without precedent in a climate where preventing smoking was the neglected child nobody – not even the big cancer and heart disease charities of the day – supported. It was Charles Fletcher, a celebrated respiratory physician, who wrote the world’s first report on Smoking and Health for the Royal College of Physicians (RCP) in 1962. It hit an unsuspecting smoking public like a bomb. It was followed by many more. Charles also had the foresight to see that this august doctors’ body was not equipped to fight the tobacco industry, which rode roughshod over the medical evidence. He subsequently persuaded the RCP to establish a charity called Action on Smoking and Health (ASH), with a shoestring budget, to lead a more political mission.

ASH’s first director, Mike Daube, was a brilliant campaigner who became a longstanding friend. Charles always described Mike as the man with ‘the apologetic tic’. Mike always prefaced his requests for action from his imposing boss with a ‘Sorry, but I hope you don’t mind…’ In practice, Mike’s combination of political astuteness, media savvy and huge intellect was what the tobacco industry feared most: a David against a Goliath. His uncanny ability to provide instant advice on health policy earned him a long line of admiring health institutions and even political parties. On one occasion, I overheard the Scottish Health Education Group consulting him about a slogan for a campaign they were planning to help increase the uptake of cervical cancer screening. ‘Cervix with a smile’ said Mike instantly. Mike’s leadership was a vital step in the long war against the global tobacco industry.

My first serious job was with ASH. Although I wasn’t aware of it, ASH marked the beginning of my future path into public health. At the time, I was interested in a campaigning job; the health part was accidental. ASH, as it turned out, was looking for a campaigner rather than an overzealous non-smoker. It was only by chance that a non-smoking boyfriend had encouraged me to stop smoking two years earlier as the midnight bells welcomed the New Year in Trafalgar Square.

It was easy to be inspired by ASH’s top-notch doctors.