document

In this issue> Interview with Tony Jewell, CMO for Wales. > Did Twitter really save Coventry from swine flu?> A transfat ban that works - in Denmark. The magazine of the

UK’s Faculty of Public Healthwww.fph.org.uk

March 2010

Swine flu sagaWhat lessons have we learned?

Up Front 3

Interview with Tony Jewell 4

Special Features – Swine Flu 6

When it was too scary to watchthe television 6

Modellers not public health doctors had lead in flu planning 7

Flu-fatigue next major challenge 7

Swine flu – is there an app for that? 8

Pigs did fly…a PEST analysis 8

Canada copes with SARS then flu 9

Flu brought us under pressure‘never seen before’ 10

Team worked ‘night and day’on flu 10

Europe’s schizophrenic pandemic 11

Flu pandemonium 12

Swine flu throws new NI agency inat the pandemic deep end 13

Lessons from the front line 13

Twitter and blogs helped putCoventry ahead on flu 14

HPA was “like a scene fromThe West Wing” 14

Books & Publications 15

Endnotes 16

Noticeboard 19

The Final Word 20

FROM THE PRESIDENT

Contents Welcome

Public Health TodayThe magazine of the UK’s Faculty of Public Healthwww.fph.org.uk

March 2010

T he dreadful images of horror andsuffering in Haiti have cast a hugeshadow over the opening weeksof this new decade.

These were made all the more disturbingdue to the difficulties faced by therescue effort in getting equipment,medial supplies, basic water, food andshelter to the survivors of this mostdreadful of disasters.

Many lessons have been learned, atthe cost of over 200,000 lives, withcountless others made homeless anddestitute. Some lessons have been aboutproviding much better and faster help inthe first hours and days of a crisis.Further lessons include: n The need for more rapid deploymentand larger stockpiles of essential suppliesand equipment in the immediateaftermath.n The need for more effective logistics ingetting essentials dispatched from adisabled airport and harbour to wherethey are needed most.n The need to mobilise emergencyrescue and relief, including a multitudeof NGOs, in a more co-ordinated andefficient way.

Other lessons concern less immediateissues. Could Haiti’s resilience have beenimproved before the earthquake struck?What can other earthquake-pronecountries learn from Haiti’s misfortune?How can the international communityhelp countries like Haiti rebuild theirinfrastructure? What can healthprofessionals do to improve ourcapability of responding to crises likethis?

More specifically, how can we helppoorer countries improve the capacityand resilience of their public healthsystems, so they are better able to copewith the various challenges, large andsmall, cataclysmic and gradual, thatmight befall them?

Already the shock of Haiti hasspawned many articles, seminars andconferences on disaster relief andresilience. The analysis is well under wayand, hopefully, the lessons are beinglearned.

This subject will no doubt be discussedin session at our annual conference onpreparing for heatwaves, floods andnatural disasters.

In addition, our Head of InternationalDevelopment, Rosy Emodi, is workingwith a number of poorer countries tolook at the longer-term issues ofimproving public health capacity,capability, standards and professionaldevelopment.

This work is something I personallyfeel very strongly about – I have pushedhard to expand the FPH’s internationalrole – and I know our President-elect,Lindsey Davies, is keen to build on thismomentum. So too are our AcademicRegistrar, David Williams, and Head ofEducation and Training, Russell Ampofo,who are working to adapt our curricula,assessments and service placementprogrammes, to better suit the needs ofoverseas PH colleagues.

The UK Faculty of Public Health is aglobal organisation and potentially animportant global resource. Of course, Irecognise that we face more thanenough challenges at home (and youcan rest assured that neither I nor mysuccessor will let up on this point). But Ibelieve we must also step up to theplate, when it comes to helping needycountries build the strongest, mostrobust and most resilient public healthfunction they can, using the bestprofessional and educational tools andexpertise that we can provide.

Perhaps this will go some way toensure that the people of Haiti have notsuffered in vain.

Alan Maryon-Davis

UP FRONT

MARCH 2010 3

News in brief

Do you have an interest in riskmanagement and/or finance? If so,we want to hear from you.The FPH‘s Risk Management, Audit andFinance Committee and are seeking anenergetic and committed FPH member tojoin its team. For further details, contactHerbert Thondhlana,[email protected] / tel 0207935 0243).

Call for contributionsThe Royal Society for Public Health iscalling for contributions to a project,looking into making public healtheducational resources available freelyacross the world. To contribute a resource,contact the project athttp://phorus.health.heacademy.ac.uk orcall Rosie Cannon on 020 3177 1621.

Tax health plan – new campaignfrom HM Revenue and CustomsMedical professionals are being offered atax health plan, to ensure they are payingthe correct amount of tax. For moreinformation please visit:www.hmrc.gov.uk/tax-health-plan

Recovery & Reconstruction: Therole of public health in conflict &humanitarian disaster situationsAll around the world, at any given time,there are millions of people inhumanitarian need. The FPH would like tohear from any members and fellows whohave been, or are currently involved in,assessing the role and impact of publichealth in disaster situations. For moreinformation please contact Rosy Emodi [email protected].

Election resultsWarm congratulations to Lindsey Davies onbeing elected as our next President, and toSteve George and John Middleton as Vice-Presidents.

Remembering Jerry MorrisA memorial day to celebrate the life ofJerry Morris is to be held on Wednesday 12May 2010 at the London School ofHygiene and Tropical Medicine. The day-long meeting will include tributes from SirLiam Donaldson, Prof. George Davey Smithand Dr Melvyn Hillson amongst others.Lunch and a reception will be provided andthose wishing to attend should contactIngrid James ([email protected])

Danish pastries now contain less than 2% of transfats

Danish transfat ban“cheaper” thanmonitoring intake

As Britain considers the argumentfor a transfat ban, Public HealthToday hears from Danish expertsabout the impact of a ban there.

After years of resistance the EUCommission finally bowed to increasingscientific evidence, and approvedDenmark’s legislation to ban industriallyproduced transfats in 2007.

The ban, introduced in Denmark in2003, protects its citizens from the harmfuleffects of transfats to cardiovascularhealth. The EU Commission’s decision wascause for celebration in Denmark, butcuriously has not led to a blanket ban inthe EU to protect all of its 500 millioncitizens, even if an average daily intake ofjust 5 grams is associated with a 25%increase in risk of heart disease.

Before the ban, popular fast foods inDenmark could contain up to 30 grams oftransfats. There were vulnerable groupswho were particularly exposed to transfats,such as truck and taxi drivers, found to beeating cheap fast food regularly. Ratherthan monitoring their intake and producingexpensive public information campaigns, itwas deemed cheaper to introduce a totalban that would remove the problem alltogether.

When the ban came into force, themillions of Danes enjoying their usual

afternoon coffee with a Danish pastry,didn’t even notice the difference. Theywere as tasty as before and didn’t cost onekrone more. However, there was onecrucial change: a typical Danish pastry,usually high in transfats, now containedless than 2% of these harmful man-madefats.

The ban in Denmark has led toconsiderable societal and consumerpressure to cut down on transfats in theEU. A major step was taken in 2006 whenMcDonald’s and KFC declared that withintwo years they would remove ”arteryclogging transfats” from their products.

Heart disease mortality rates have beenfalling in Denmark and most WesternEuropean countries since the mid-eighties,in parallel with the reduction in transfatsintake, as well as the decline in other riskfactors such as smoking. However,transfats still pose a health risk withpopular high transfat foods easily andlegally available in every other EU country,except Denmark.

Not everything that tastes nice has to bebad for your health. Contrary to belief,transfats can be replaced. Not only bysaturated fat, but also by mono- and polyunsaturated fat in many foods, providing ahealthier product for the consumer. Whyshouldn’t the 60 million UK consumers beallowed to have their Danish pastry andeat it just as their Scandinaviancounterparts do?

Steen Stender, MDJørn Dyerberg, MDProfessorsGentofte Hospital,University of Copenhagen

Not everything thattastes nice has to bebad for your health‘

‘

4 PUBLIC HEALTH TODAY

INTERVIEW

Tony Jewell, ex-GP turned Chief Medical Officer for Wales,tells Public Health Today that he wants to bring backanticipatory care and make Wales one of the healthiestcountries in Europe.

“Let’s get GPs tTen years on from the Welsh Assembly’s aspiration toachieve a level of health in Wales that matches thebest in Europe, has it happened?I have to say the answer is no. Health has been improving steadily– we’ve seen improvement in life expectancy and lower infantmortality - but the speed hasn’t been fast enough to catch up withthe best in Europe.

Why is this?Historically Wales has been a relatively unhealthy place. Heavyindustries such as coal mining, exposed certain communities toparticular chronic disease risks, the legacy of which lives on. Whenthese industries were closed, communities suffered greatly and thatcontributed to the general ill-health. Significant economicinvestment has gone into regeneration, but the effects are still felt.

The NHS in Wales has recently undergone areorganisation – how has this affected healthcare?Our health system is now considerably simpler with seven healthboards across Wales. Planning and delivery have replaced internalmarkets. We’ve also tried to move away from the usual primaryand secondary care divide, and the mental health and acute trustdivide. The real benefit is that we’re now able to offer trulyintegrated healthcare.

A Nuffield Trust report recently criticised the NHS inWales, Scotland and Northern Ireland for spendingmore on health, but having poorer quality care than inEngland. Is this true?Some of the data used was quite controversial. For instance, ouraccess targets that were delivered in December 2009 are nowcomparable. But the main issue is that socio-economic conditionsdetermine a lot and in Wales we have this legacy of ill-health. So

one has to consider the historic socio-economic factors beforemaking comparisons.

How is Wales going to cope in the years of famine thatare predicted for the NHS?We currently have a mixed picture of how far health will beprotected, but there will certainly be less resrouces

However, I’m quite confident that we’ll cope. We looked at oneof the integrated health systems around the world – Valencia inSpain – to learn best practice. With our joined-up health system,we now have a clear line of sight: from the government, to areduced number of health boards, all the way through to theclinicians leading teams. So I know we can manage optimally withwhatever resources are available.

Having a non-market health economy is also an opportunity toreduce waste in the system. However, I’ve never thought that theNHS is overly managed. It takes time and commitment to get thebest value out of clinical staff and patient care.

Earlier this year the FPH published its manifestorecommendations for better public health – what arethe key steps for Wales to take in the next decade?

Tobacco remains a big issue. One in four adults still smokes inWales and that’s far too many. Regulation on point of saleadvertising and vending machines is currently being drafted andthat’s a great step forward, especially to protect young peoplefrom taking up smoking. But my personal view is that we can’tduck the issue of banning smoking in cars and homes, particularlywhen children are at risk.

Obesity is another. We have a new action plan to make cyclingand walking easier for everyone, by creating better access to greenspaces and promoting changes to the built environment. We reallywant to get this nation moving and encourage people of all ages

MARCH 2010 5

INTERVIEW

o play a part”A lot to live up to: Wales has a rich public health history, something Jewell aspires to continue

to take up sports and join clubs. The Welsh rugby player JPRWilliams was playing rugby until he was 55!

A healthier nation is a greener nation. The Welsh Assembly’s‘One Wales - One Planet’ plan to become world-leaders insustainable development is very important from a public healthpoint of view.

What work are you most proud of?I’m proud to have been involved in the development of the ‘OurHealthy Future’ framework for public health in Wales. It’s a bigpiece of work with lots of buy-in from various stakeholders, andaddresses the issues of Wales lagging behind the rest of Europeand creating a fairer society.

To help deliver the strategy, we have created the new PublicHealth Wales Trust. We’ll have a stronger health informationobservatory function than before and an institute of public healthwith a focus on teaching and research. The Trust puts us in abetter place to relate to local government, to the local healthboards, and directly to the population through the observatory.

What would you like your legacy to be?I would like to build on the strengths of the Welsh public healthheritage. The NHS model was partly based on the tradition of themedical aid societies in the valleys, which provided coal miners andsteel workers and their families with healthcare in return for acontribution. In fact, Aneurin Bevan – born in Tredegar, Wales –said that creating the NHS was like ‘Tredegarising’ the UK.

Another giant of healthcare, who did all of his work in Wales,was Archie Cochrane. He led groundbreaking research inepidemiology, addressing the real health needs of coal miners inthe valleys. We now have Cardiff University committed to appointa Cochrane chair to re-establish the strong tradition of Welshepidemiology.

But essentially it’s the public health and primary care connectionthat I’m interested in, partly because of my background as a GP.I’ve been inspired by Julian Tudor Hart, who was a GP in a smallmining village in Wales, and an ardent advocator of anticipatorycare. His research interest was hypertension and he would measurethe blood pressure of all adults on his surgery list. He’d go to theirhouses, meet them at the bus stop or just collar them in thesupermarket. Tudor Hart’s commitment to the residents of this verypoor mining village, raised their health to levels equivalent to thosein middle-class suburbs of Swansea.

I’ve been pushing this link between public health and primarycare, trying to reinstigate the principles of the 1978 Alma-AtaDeclaration, that primary care could and should play a key part inachieving good health for all.

Interview: Suvi Kingsley

Essentially it’s the publichealth and primary careconnection that I’minterested in, partlybecause of mybackground as a GP.‘

‘


SPECIAL FEATURE SWINE FLU

‘Are we going to die?’ asked our ten yearold son. It was the last weekend in Apriland my husband (a microbiologist) and Iwere glued to the television. Wall-to-wallmedia coverage of a newly emerged fluvirus in Mexico made us more and moreconvinced that ‘this could be it’.

Amid the media frenzy, our first monthwas taken up with following testingalgorithms and ensuring, the first fewcases were sensitively and confidentiallymanaged.

Month two saw our first school outbreakin the West Midlands. One third of theprimary school was clinically affected withrespiratory and gastrointestinal symptoms,but the illness was generally mild. The out-of-hours service was able to provideexcellent support, but as more and morecases occurred, things became gruelling.Every new case needed public health

assessment, testing, prophylaxis ofcontacts, and sometimes airline flighttracebacks. More than 200 schools wereaffected, each requiring an individual riskassessment and advice about prophylaxisand closure.

By month three we had the evidence toshow that the virus had spread to thecommunity. After experiencing over 30%of the national cases and testing morethan 10,000 people, we moved fromcontainment towards providing treatmentonly.

Despite the rapid spread of the virus tothe community, we were ready. Years of

collaborative work to establish nationalsystems such as NHS Direct and QSurveillance meant that our syndromicsurveillance systems for a pandemic werein place. So, when the pandemic started,these systems were ‘switched on’ straightaway. This monitoring was particularlyimportant after the initial stages when westopped counting individual confirmedcases. Our small syndromic surveillanceteam has been providing national data ona daily basis ever since.

There were certainly trying times, butdifferent teams came together to putprevious experiences to use in new ways.For instance, with Centre for Infectioncolleagues, we were able to model apatient self-sampling scheme for the callersand web users of the National PandemicFlu Service, based on an earlier system thatwe created with NHS Direct. This allowedus to track the flu rates throughout thepandemic.

We learned a lot from the pandemic,but, thankfully, it’s now safe to turn thetelevision back on.

Gillian SmithRegional EpidemiologistHPA West Midlands RegionalSurveillance Unit

It has been called the fake pandemicand a scare generated to boost sales forthe drug companies. This was a virusthat wasn’t the next Spanish flu, but itwasn’t just another seasonal flu either.

Did it catch us unawares? It camefrom swine not birds, it was anotherH1N1 strain not a new subtype, and itarrived from Mexico, not the Far East.

Or did we panic? It was not as deadlyas feared, but it did spread around theglobe, displacing previous flu strains.And it did kill, causing deaths in healthyyoung people.

Why then are large stocks of antiviralsand vaccines left over? Pandemic planswere geared up for the worst. Whenthis didn’t happen, they proved

inflexible. The antiviral stockpile wasalready in place and the nationalpandemic flu service went aheadanyway. Some people probably gotunnecessary antiviral treatment, manywho might have benefited didn’t get itsoon enough.

As for the first ever pandemic fluvaccine, in our desire to protecteveryone, we didn’t think enoughabout the logistics of offeringvaccination. Now GP reimbursementsare being negotiated and parents feelemotionally blackmailed to immunisetheir children.

But all the controversy aside, thepandemic did demonstrate what a well-organised public health profession can

achieve. Health protection units rose tothe challenge early on, and support andadvice was offered to the NHS, local,devolved and central governments.

In this issue, public health expertsreflect on their experiences of thepandemic, and offer insight into thelessons learned. Next time we need tobe smarter than the virus and ready torespond whatever form the pandemictakes.

Dr Meirion EvansRegional EpidemiologistPublic Health Wales

When it’s tooscary to watchthe television

The March edition of Public Health Today focus es onswine flu, Chair of the FPH Health Protection Committee,Dr Meirion Evans is the Guest Editor.

Gillian Smith tackling swine flu © Gillian Smith

“How are your plans for the next flupandemic going?” asked a Germancolleague with whom I was sharing a taxiin 2007. He said that in Germany much ofit seemed to involve emergency plannerswho were, in his view, at a loose end sincethe fall of the Berlin Wall and the end ofthe cold war.

Perhaps this explains the very militarystyle of many pandemic flu plans. Itundoubtedly calls to mind two othermilitary truisms: ‘plans never survive thefirst contact with the enemy’ and ‘Generalsare always inclined to plan for the lastwar’. Swine flu turned out to be not unlikeseasonal flu, if rather milder than usual. InWales, the attack rate was around 10%and case fatality around 0.1%. So why didit come as a surprise? And for which lastwar did the Department of Health andBritish government prepare?

In Whitehall circles, the 2001 foot andmouth disease epidemic casts a longshadow. There is a widespread belief thatthe contiguous cull of cattle onneighbouring unaffected farms – a policyessentially promoted by academic groupsof mathematical modellers – hadterminated the epidemic. Although thisexplanation looks increasingly doubtful, itmeant that mathematical modellers, ratherthan public health doctors and healthservice managers, had primacy in the earlystages of pandemic flu planning. Hencethe rather baroque assumptions of a 2.5%case fatality ratio and a 50% clinical attackrate. The latter estimate required animprobable combination of two rareevents: a rate of overall infection and arate of clinical infection at the highest endof the observed distribution. This wasqueried by the Welsh Assembly in 2006,but to no avail. Once these assumptionswere set in stone, it led to pandemic plansfor an Armageddon scenario thatsubstantially bypassed the normal providersof healthcare, the NHS. The stage was setfor the National Pandemic Flu Service, or‘Flu Line’ as it became known.

It‘s easy to be critical after the event andrisk snatching defeat from the jaws ofvictory. It also fails to give credit to theleadership shown by the DH in obtainingsufficient stocks of both antivirals andvaccines. Nevertheless, the emphasis on acentral phone-line solution hampered

engagement with the usual health careproviders: general practitioners, communitypharmacists and hospital clinicians.

In the event, ‘Flu Line’ wasn’t readybecause a number of key legal,administrative and contractual bridges stillremained to be crossed. So we had theCanute-like ‘containment phase’ which,despite exhausting the Health ProtectionAgency, did little demonstrable to containthe pandemic, but did provide apparentpolicy coherence whilst ‘Flu Line’ wasbeing prepared.

Wales was fortunate because its initialwave trailed much of the rest of the UK bysome four weeks. Yet it is much to thecredit of the Welsh Assembly and thehealth community in Wales that, from thestart, solutions involving usual healthcareproviders were pursued. This engageddoctors, health service managers and civilservants in a response that was botheffective and intelligible to the public. Italso cast people in their usual professionalroles; always a good idea in any crisis.

We are still reflecting on the lessons, notleast about demarcation of the boundaries:health and emergency planning, WelshAssembly and local health boards, devolvedadministration and Whitehall. However, thenetworks established during the pandemicpromise to be a valuable resource and toprovide a more reliable and realistic modelfor the future.

Roland SalmonDirectorCommunicable Disease SurveillanceCentre, Public Health


MARCH 2010 7

“Modellers not publichealth doctors hadlead in flu planning”

Flu-fatigue isnext majorchallenge

On Monday 27 April a Scottish couplewere confirmed as the first European casesof swine flu.

They had just returned from holiday inMexico, where a new strain of H1N1 fluassociated with severe illness and deathhad emerged. Health protection teamsacross the UK were already on high alertfor the early identification of travellers withflu-like illness. As fate would have it, thefirst known travellers with ‘swine flu’ hadarrived in Scotland.

What followed was the NHS Scotland’smost prolonged and intensive public healthresponse to any infectious disease in livingmemory. But fortunately we wereprepared.

Before the pandemic, we had plannedfor several new surveillance componentsproviding comprehensive daily and weeklyupdates on the impact of the flu across theNHS in Scotland. These included clinicaldata from nearly all Scottish generalpractices (together with some virologicaltesting), NHS24 data on telephone triage,descriptions of confirmed hospitaladmissions, and deaths.

We now know the pandemic was far lesssevere than anticipated in most pre-pandemic scenarios. Our response ensuredrapid identification of clinical cases,allowed immediate antiviral access, andoffered vaccination to at-risk groups assoon as it became available. Most flu caseswere self-limiting or settled with antiviraltreatment at home. Only a small numberof cases needed hospital treatment andthere have been few deaths.

The major challenge now, during therecovery phase, will be the threat posed by‘flu-fatigue’. There is a limited window ofopportunity to identify the key lessons anda new benchmark for seasonal respiratorysurveillance activity.

And when the spotlight comes aroundagain we must be sure that the lessonslearned have been translated into concreteaction.

Dr Jim McMenaminConsultant EpidemiologistHealth Protection Scotland

The pandemic was farless severe thananticipated‘

‘

A PEST analysis of the HealthProtection Agency’s response andthe wider social and politicaldimensions of the pandemic,yields valuable insights.

Notwithstanding political influences,which are beyond the scope of thisarticle, the environmental context of theHPA is complex. Visibility is a bigproblem. The public, and even clinicalcolleagues, often don’t understand whatthe HPA does. Explaining its function atthe school gate is never an easy task.The organisation interacts with a myriadof partners, but is rarely called upon totake centre stage. Nevertheless, the HPAdecisively and quickly widened its circleof influence. Everyone recognised itsexpertise, upheld by the dedication andcommitment of its staff.

Then the sociological considerations:adverts depicting hapless people,spreading larger-than-life bugs, ready toprey on unwitting children, sanitisercampaigns focusing on the parental

desire to protect their children. In spiteof this, a common gripe in the flu-response centre (during the containmentphase) was that attempts to contactpatients with positive flu test resultswere often futile - patients were not athome, but presumably ‘out and about’spreading flu.

And finally, there are technologicalinfluences. We had flu test kits,stockpiles of antivirals and, for the firsttime, a pandemic flu vaccine. Yet thetechnology is so easily undermined bylogistic issues and public attitudes.Constraints on the availability anddelivery of swab kits to general practices,led to significant delays. The public’sreticence to embrace antivirals and thevaccine, reflected the mismatch betweenthe dire forecasts of severe illness andwhat actually happened. There is stilllingering public uncertainty around risksand benefits.

Technology on its own is not enough,good risk communication is needed toovercome sociological barriers.

My own journey through thepandemic was one of contrasting roles. Iparticipated in the regional flu-responsecentre and sympathised with my clinical,

frontline colleagues. As a part-time GP,working for NHS Direct, I found myselftaking charge of algorithm updates.

I also experienced the real challengesof maintaining safe phone triagepractices and with it, the role of part-gatekeeper of appointments and visits.Balancing the risks of putting cases incontact with colleagues and the public,with the risks of over-diagnosing flu andmissing serious illness, was particularlystressful

Then there was the minefield of casualdiscussions at the school gate, strikingbalance between the rational publichealth professional versus my empathyas a mum.

However, for a short time at least,people actually understood what I didfor a living. They stopped thinking that Iwas one of those crackpots who seemobsessed with the risks of ‘bird-flu’ andthinks we’re all doomed. For a briefperiod at least, pigs did fly!

Sophie EgertonSpecialty Registrar in Public HealthNHS Yorkshire and The Humber



“You can call it influenza if you like”, saidMrs Machin. “There was no influenza inmy young days. We called a cold a cold.”So says Mrs Machin in the The Car byArnold Bennett. It’s a quote that resonateswith aspects of the swine flu pandemic.

For many, mild symptoms haveperpetuated the notion that the virus is noworse than a cold, but there have beenthose who haven’t been fortunate enoughto fight off the illness. However, one thingis certain, without science, an evidencebase and the advances of the last centurywe would still be calling a cold ‘a cold’.

Without worldwide communication,internet discussions and media-hype, therewouldn’t be such a period of internationaldebate and reflection. Such is‘postmodernity’. So how was it for us inpublic health?

Sometimes it’s difficult to comprehendhow fast our profession has changed: anantigenic shift of the virus is picked up, aworldwide alert is issued within days and

Swine flu – isthere an appfor that?

the public health workforce dash torespond.

Our surveillance systems serve theirfunction and the pandemic containmentphase swings into action. This buysvaluable time for primary care trusts to pickup the mantle and implement local plansand preparations for the treatment phase.

The sheer willingness of public healthcolleagues to help during the initial stagewas staggering: from staying late to coverantiviral collection points to manning thephones, or dealing with the barrage ofmedia enquiries.

As we have moved into the treatmentphase, some ‘postmodern’ doubts haveemerged, for example, with the online fludiagnosis and the rapid prescription ofantivirals. We all accept a mechanism torelease pressure on primary care wasparamount, but was the NationalPandemic Flu Service the best response?Maybe in the future, we’ll all have a self-diagnosis swab kit. Or maybe there will bean iPhone app for that.

For me personally, being called intobattle during a pandemic was exciting.Helping to plan and implement a localresponse was invaluable career experience.One of the greatest challenges was toidentify high-risk care-home staff andpatients. Some of those staff highlightedthe very ‘postmodern’ effect of the media:the word ‘pandemic’ quite simply scared

the living daylights out of them.Finally, it was interesting to witness the

effect of the flu campaign. Many a time ona packed West Yorkshire commuter train, Isympathised with the sneezing, coughing,sniffling individual at who the rest of thecarriage looked menacingly. We allthought it at the time, even the MrsMachins amongst us: “You best getyourself online to the flu service.Otherwise, you’ll kill us all.”

Matthew DaySpecialty Registrar in Public HealthNHS Wakefield District

Pigs did fly…aPEST analysis

Image courtesy of Apple

Toronto, Canada, was put on thepublic health map in 2003, when itexperienced the largest outbreakof Severe Acute RespiratorySyndrome in the Western world,says Natasha Crowcroft.

A new Ontario Agency for HealthProtection and Promotion was created inJuly 2008 in order to help renew theprovincial public health system post-SARS.My team of three made up the departmentfor surveillance and epidemiology.

In the spring of 2009, taking a breakfrom recruiting, I was in Helsinki, Finland,teaching on a vaccinology course for theEuropean Centre for Disease Preventionand Control, when the news of theinfluenza outbreak, started to fill up myinbox. No-one in Helsinki seemed to haveheard anything, even by the time I startedmy journey back to Canada. The next day Iwas conscripted to our EmergencyOperations Centre.

Since then I’ve had numerousconversations and email exchanges withcolleagues at the Health Protection Agencyabout the different approaches in the UKand Ontario. These conversations havebrought home to me how strong the UK’spublic health system is to be able toattempt interventions that weren’t feasible

elsewhere. However, they have also raisedquestions about whether the heroicmeasures taken in the UK had aworthwhile public health impact.

Take school closures and widespread useof prophylaxis, for instance. Theycontinued far longer in the UK than in theUS, as did individual case follow-up andhousehold prophylaxis. Did it make anydifference to the rate of spread, morbidityor mortality?

Ontario did not consider containment asa strategy. We went straight to mitigationstrategies because the outbreak wasquickly widespread, linked to the arrival of45,000 travellers from Mexico betweenMarch and April 2009. Householdprophylaxis and school closures were neverseriously considered, and public healthunits stopped following up individual casesearly on. In Ontario, oseltamivir prophylaxisis only routinely used for controllingoutbreaks in long-term care facilities, andthe national stockpile was purchased fortreatment only. In all these areas Ontariodiffered from the UK.

We are now able to start comparing theimpact of different access to prophylaxisand early treatment in the differentjurisdictions, which is likely to provideuseful lessons.

On a personal level, being able to speak

directly with colleagues working in anothercountry has been helpful in many ways.Such conversation is often blocked byformal procedures, which require contactto be between people working at federallevel. In fact, 40% of the world’spopulation lives in federal jurisdictions,creating tiers of bureaucracy betweenpublic health practitioners in differentcountries. We should break down thesecommunication barriers between Europeand North America through exchanges,secondments and joint training atprovincial, state and regional levels.

A year later, I have 27 people in my teamhere in Toronto and virtually all of our timesince April 2009 has been spent onsupporting the response to H1N1. Whenthe media announced that things werebetter than with SARS it was a measure ofour new organisation’s success. The wholeteam - epidemiologists, statisticians,veterinarians, biostatisticians, physicians,researchers and a geospatial specialist -could breathe a sigh of relief, at least for alittle while.

Dr. Natasha S. Crowcroft Director, Surveillance and Epidemiology Ontario Agency for Health Protectionand Promotion


MARCH 2010 9

Canada copes withSARS then flu

The OAHPP Emergency Ops Centre in action © Natasha Crowcroft

Some dates are etched on the memory.Tuesday 27 April 2009 is one of those. Thefirst call of the day came from a generalpractitioner seeking advice about a couplewho had returned from Mexico and had‘flu-like’ symptoms. Suddenly the floodgates opened. We had to quickly set upsystems to manage calls and cases – fromestablishing guidance for the on-call staffbased on Health Protection Agencyalgorithms, to liaising with the regionalHPA laboratory to test and source viralswabs. The pandemic had started.

Eight days later our health protectionunit in south east London was faced withthe first school outbreak in the country. Itinvolved a large secondary school and wehad to offer prophylaxis to 1,500 peopleon a Bank Holiday Monday. The sense thatwe might not be able to cope waspalpable. We managed only by mobilisingstaff from the HPU and Primary Care Trust(PCT), GPs and others who were all willingto ‘go the extra mile’.

Over the following weeks there weremore school outbreaks. Our phone linecrashed because of the volume of callscoming through. At one point our unit wasdealing with between 30% and 50% of allthe cases in the UK.

Around three weeks after the pandemicresponse started, the London Flu ResponseCentre opened. It helped, but a huge inputfrom us at the HPU was still necessary.

None of us had ever experienced thekind of pressure and intensity that wasrequired during the containment phase.With other outbreaks you can usually see

the task ahead and define the end point.That wasn’t possible with the pandemicand it was incredibly hard to sustain theresponse.

The learning curve was steep. Ourpandemic flu plan needed to be moreoperational and the response expectedfrom us was slightly different from whatwe had planned. We didn’t have muchtime to reflect on what we were doing, butsimply had to respond. Business continuitywas a real issue. Although we stopped allother routine work, we still needed toensure that urgent work to deal with,cases of meningitis, etc., carried on.

We managed solely because of closeworking with schools, surge capacity fromPCT colleagues, public health trainees andHPA colleagues, and close links with theHPA regional laboratory. Not forgetting theinvaluable response of our own staff.

Rachel HeathcockConsultant in Communicable DiseaseControlSE London Health Protection Unit



Flu brought us underpressure ‘we hadnever seen before’

Team worked‘night and day’on flu

At first, I doubted the need to set up theCentre for Infections EmergencyOperations Centre on hearing of cases ofswine flu in Mexico. After all, pigs get fluand humans in close contact aresometimes infected but, rarely, infectious.But it was soon clear that this was a majorthreat.

When cases began to be identified in theUK, the influenza season (October - May)was almost past. Surely, I imagined, thearrival of warmer weather would preventthe new infection taking hold at least untilautumn. What in fact happened is nowwell known: the infection affected thecountry until it was curtailed in late July bythe school summer break.

By July many CFI staff and colleaguesacross the Health Protection Agency wereon their knees. The EOC was running inshifts of 18 hours a day to organise theflow of information. A series of teamswere formed (or reinforced) to provide theresponse - surveillance, epidemiology,policy and so forth. The statisticians andmodellers were in their element but alwayswanted more data - particularly from thenewly formed system of detailed follow-upof cases and contacts called FF100, ‘firstfew hundred cases’. The Respiratory VirusLaboratory team was expanded andworking night and day to processspecimens and develop new tests. Caffeineand warm food from the caterers, patienceand support from colleagues kept usgoing.

In the middle of all this I developed acough and sore throat. A phone call onemorning advised me not to come to work.A swab had shown I had flu. But, perhapsto spare my blushes, it was not swine flubut a seasonal influenza A (H3N2). It was acertain sign that I needed to rest - but whoat that time didn’t? One soldier was down,whilst an army of others battled on.

John WatsonHead, Respiratory Diseases DepartmentHPA Centre for Infections

Over the followingweeks there weremore school outbreaks.Our phone line crashedbecause of the volumeof calls comingthrough

‘‘

Swine flu has been a rather schizophrenicpandemic, lethal for some, but mild formost. It was, as the Director General of theWorld Health Organisation said:“amoderate pandemic”.

The waves of infection progressed fromwest to east and north to south. There wasa spring/summer wave, most felt in Spainand the UK. By early 2010, theautumn/winter wave, which began whenschools reopened i n September, hadsubsided in Western Europe, but continuedin Eastern countries such as Poland andBulgaria. As of early February, just over2,500 confirmed deaths in Europe werereported by EU/EFTA member states.

The pandemic has differed significantlyfrom the seasonal flu of the last fourdecades. Around 25% to 30% of thedeaths have been in healthy individualswhile older people have been relativelyspared from infection (though those whowere infected did poorly). Very severe,often lethal, cases of acute respiratorydistress syndrome were far more commonthan in seasonal flu. The main stress hasbeen on hospitals, especially paediatricdepartments and intensive care services.

Europe was well prepared for thispandemic, aside from it not being aschallenging as those of 1889, 1918, or1957. Led by a triumvirate of European

Centre for Disease Prevention, WHO andthe European Commission, there havebeen co-ordinated preparations since 2005.Every European country has conductedstandardised pandemic preparedness self-assessments with ECDC and WHO.

Then there were the early experiences ofNorth America, the Southern Hemisphere,Spain and the UK from which to learn.

Pandemics are not all the same andcountries had to adapt their ‘worse case’plans to fit this particular pandemic’sfeatures. Multi-sectoral actions wereunnecessary, proactive school closureswould have been excessive, but intensivecare services had to be reinforced.European countries were not thatsuccessful in sharing unpublished analyses,but the Swedish presidency in the secondhalf of 2009 overcame this by a series ofurgent EU-wide meetings. The journalEurosurveillance also provided a unique

service for rapid publication.The greatest confusion and disparities

have arisen over vaccination. Newadjuvanted vaccines were developed inrecord time, through arrangements madeunder WHO, the EU Health SecurityCommittee, manufacturers and the leadEuropean Medicines Agency. Activesurveillance found them to be very safe.However, their use and acceptability havebeen highly variable with populationuptake ranging from 70% to almost zero.

So what now needs to be done? It’smost important to realise that thispandemic is not necessarily over. The 1968pandemic was considerably worse in itssecond winter of 1969/70 when it wasmore transmissible than in 1968/9.

Countries may have to adapt to a newseasonal influenza, possibly affectingdifferent risk groups. Lessons need to belearned for future pandemics, especiallyover vaccine policy, whilst also avoidingexhaustion from too many inquiries andevaluations. Even if the pandemic isschizophrenic, the response needs to beunited.

Angus NicollInfluenza Co-ordinatorEuropean Centre for DiseasePrevention and Control


MARCH 2010 11

So what now needsto be done? It’s mostimportant to realisethat this pandemic isnot necessarily over.‘

‘Europe’s“schizophrenic”pandemicLessons need to be learned, especially over vaccine policy says Angus Nicoll.



Flu pandemoniumThe 2009 outbreak was moderate in comparison to the Great Influenza of 1918,Dr Dyfed Wyn Huws looks at what can be learned from pandemics of the past.

On 18 September 1918 Trooper TomWilliams survived the decimation of abungled attack on the Macedonian Frontagainst a rallying Bulgarian force.

Only 18 of his South Wales Bordererslimped back to their Greek base. A fewweeks later the same enemy surrenderedat Thessalonica.

Tom lay still on his narrow bench in theflimsy military hospital, erected not for theinjured, but in panic ahead of the arrival ofthe Great Influenza. His chest lifted to raspa few times each minute. His skin fused tothat of his sick neighbours. Their elbowslinked to form a barely-living chain-mailcarpet across the tent. Gowned clinicianscowered impotently in the corners, likesacrificing druids in an Eisteddfod pavilion.

Eyes wide open, Tom tried to hold on tolife by counting the bellowing of the dirtycream canvas above. He mimed thenumbers with his blue, crusted lips. Alone,before five, he coughed more blood andshuddered. The secondary bacterialpneumonia killed him on 28 January 1919aged 19. His unit demobilized four dayslater. My great uncle Tom’s infected bodynever returned home to Treorci.

The Flu Pandemic of 1918-19 causeduntold devastation. We were blinded byignorance and war, and its grim mistswiftly shrouded the globe. We funnelledits droplets into hundreds of thousands ofdefenceless recruits, viral vials crammed

into the hellish hulls of Atlantic troop ships.Human biohazard cargo bound forEurope’s killing fields. This biological warhad no mandate.

But we weren’t totally ignorant, eventhen. When the US finally joined the FirstWorld War, millions of fledgling troopswere cooped into factory-hen trainingcamps awaiting Atlantic migration.American physicians Reed, Sternberg,brothers Mayo, Welch, et al. had surveyedthe first wave of a new ‘flu-like epidemicspread by soldiers moving bases. It couldkill them. But military authorities ignoredtheir public health advice. Pandemic fluadded far more deaths to the usualinfective battlefield killers and munitionssacrifices.

On today’s pandemic home-front, publichealth advice was heeded by politicians intheir emergency bunkers. In the wake ofSARS, chief medical officers andcommunicable disease specialists madetheir case. The first Mexican wave rosethen fell as resources flowed and dailypress conferences were choreographed.

However, we in public health should notbe complacent. Yes, clinicians and scarcepublic health professionals workedheroically with others. But we’ll still need apandemic post-mortem, a health economicone at that. The concerns of the public,politicians and clinicians need to beaddressed.

“A media-hyped load of b*******” onepaediatrician fumed at me. “Bloodyendless email essays from public health!”my general gractitioner friend ranted.

Of course we had to respond andrespond hard. We like prioritisinghealthcare in public health. But what aboutprioritising public health prevention? Weknow that public and media give moreweight to “invisible” infectious healthrisks, but we should be objective in ouradvice. Other, arguably more important,public health and clinical activity, came toa virtual standstill during the first wave.Imagine if we committed the sameresources and effort year on year, totackling the largely untouched root causesof our more common premature mortalitydiseases, chronic health problems, andacute hospital admissions.

Did we overstate the case? Did wespend too much (maybe in the wrongplaces)? Were our interventions effective?Were they cost-effective? I don’t know, butwe certainly shouldn’t remain ignorant.

Paul Flynn MP might be right to crushthe Oseltamivir mountain for gritting roadsinstead. I say he should wait for the nextwave before he grits the pavements too.And we shouldn’t cry wolf too often either.

Dr Dyfed Wyn Huws Freelance Consultant in Public Health


MARCH 2010 13

Southwest London’s HealthProtection Unit weathered theswine flu storm, and is stronger forit, according to Anna Bryden andYvonne Young

Investigating 104 suspect cases, identifyingand arranging prophylaxis for 550 contactsof the four schools that were closed,organising swabs and antivirals, answering40 enquiries a day. Our HPU was on thefront line from the start of the pandemic.

From this unique experience emergedsome key observations.

Effective and clear leadership was inplace early, but internal communicationscould be improved.

Many extra out-of-hours staff should beconsidered. Early rotas, with plenty of resttime, are needed, and dedicated timeshould be allocated for incidentmanagement.

Good relationships with local PCTs, acutetrusts, and laboratories are essential. PCTsneed more support to communicateeffectively with general practices andstronger partnerships with out-of-hoursprimary care services.

National updates on the rapidlychanging events weren’t always promptlycommunicated to the local level. Localorganisations should be allowed tocomment on practical aspects ofimplementing guidance.

A central log of patient identifiableinformation would help to organisecommunications, and identify who wasresponsible.

The pandemic was unprecedented in itsintensity. The unit staff needed all theirgeneric and specialist skills, but weemerged a stronger and more cohesiveunit with valuable lessons for the future.

Anna BrydenSpecialty RegistrarSouth West London HPU

Yvonne YoungCCDC South West London HPU

Lessons fromthe front line

Swine flu throws newNI agency in at thepandemic deep end

When the flu pandemic arrived in NorthernIreland, the country’s Public Health Agencydid not have a complete seniormanagement team and no agency-specificpandemic response plan.

The agency had been launched threeweeks earlier in April 2009, replacingfunctions of the four health and socialservices boards that had existed for over 30years. The appointments and the responseplan were still on the “to do” list. Little didwe know that within days we would beleading the operational response to apandemic.

A single emergency eperations centrewas immediately created, through whichall swine flu calls were received, triaged,and actioned. Prisons, ports and personalprotective equipment, vaccinations andsurveillance were all addressed throughworkstreams led by public healthconsultants. The centre provided greatresilience, particularly during thecontainment phase when the public healthworkforce, trainees and other colleagueswere working a seven-day week.

There were many challenges. The initialflu case definitions quickly became lesssensitive and many patients were put onantiviral medication while still waitinglaboratory results. There were the logisticsof taking swabs, tracking swabs, andgetting results back to the patient. Andonce a pandemic vaccine became available,we had to rapidly organise vaccination

programmes to protect the mostvulnerable.

The daily local and national situationreports added a considerable pressure onthe already stretched resources, for a fulleight months. Fortunately, we were able todraw upon well-established seasonal flusurveillance programmes. What also helpedour fledgling organisation considerablywere the regular conversations with healthprotection colleagues in the UK and theRepublic of Ireland. Informal briefings,sharing draft guidance and epidemiologicalstudies, and discussing practical issues ofsurveillance, infection control andvaccination were a great support.

On reflection, the public healthworkforce did meet the challenge. We didnot experience school outbreaks likeLondon or the West Midlands, orcommunity outbreaks like those aroundthe Clyde estuary.

We were fortunate that morbidity andmortality were not greater. Nonetheless,our new organisation was under significantstrain and the wellbeing of our staff wasseriously affected. Next time we are facedwith a public health emergency we mustensure that we have good staff supportarrangements are in place, and that wetrained, practised and ready.

Brian SmythRegional EpidemiologistHealth Protection Service

Many extra out-of-hours staff should beconsidered‘

‘



several dry-runs of both our telephone callcentre and antiviral distribution centreswere undertaken, including shipping inlocal mother and toddler and olderpeople’s groups for true testing of stresslevels.

But we were in charge. We had effectiveleadership - a director of public health whowas prepared to say “these are myassumptions, so this is what we are goingto do”.

Our collaboration with different agenciespaired expert knowledge with practicalsolutions. We took heed of the nationalguidance, but ultimately made decisionsthat were right for the local people inCoventry. Our PCT board and the WestMidlands Local Resilience Forum providedus with governance and oversight in casewe were in breech of emerging nationalguidance.

We also recognised early that lookingafter and organising staff was important.This meant, for instance, allocating staffmembers to trawl through internationalwebsites for up-to-date information andsending people home when not well. Andwe kept the communication channelsopen, informing GPs, board members andstaff either daily or weekly as necessary,feeding back to the strategic healthauthority and so forth.

Crucially, we also used newcommunication tools such as blogs andTwitter, which proved to be invaluable in arapidly evolving situation where nationalguidance was trickling down too slowly.

The blog that was set up by the flu leadat the strategic health authority providedus with immediate feedback from nationalmeetings and with a heads-up of thedirection to take. The Twitter updates bythe Centre for Disease Control also kept usabreast of emerging findings.

With a little help from blogs and tweetsand a large dose of staff commitment andcourage, Coventry was able to take chargein a globally challenging situation.

Caron GraingerJoint Director of Public HealthNHS Coventry

The Monday after hearing tales ofhundreds dying in Mexico our primary caretrust in Coventry, had received noguidance or direction as to how the NHSwas to respond to the pandemic.

Much to the apparent horror ofcolleagues at the Health ProtectionAgency, we decided to act on theassumption that what we were witnessingwas the first week of a pandemic. Thedecision bought us three to four weeks toset up a local multi-agency pandemicgroup and to transform paper-based plansinto operational actions. We were preparedfor a surge in activity, but with a view thatoperations could be scaled back tobusiness as usual if necessary.

Within a very short period of time, mostof our public health workforce wasworking almost solely on swine flu. Only alimited amount of national informationwas still available and our teams spentsignificant amounts of time trying tounderstand the national and internationalcontext, trawling the internet daily for dataabout cases and deaths. Others startedworking at the detail of antiviraldistribution centres and creating a localtelephone assessment line, in case thePandemic National Flu Line failed to golive. Given that the West Midlands was inthe containment phase, we also had tosupport a regional flu response centre, andrespond to local cases, contacts, andoutbreaks. Most routine work was put toone side, causing some tension with therest of the organisation, which was yet tobe convinced the pandemic was ‘real’.

Sometimes our speed was, in hindsight,perhaps too quick. For instance, we wroteto all our residents to inform them of theirNHS number to use on the National FluLine. This cost us £80k, and wasn’tnecessary in the end, but provided us withan up-to-date GP registration list. Also,

Twitter andblogs helpedput Coventryahead on flu

I had just started working at the HealthProtection Agency (HPA) in March 2009when I had to attend an urgentteleconference on a Friday evening.Concern was rising about cases of a newflu virus across the pond.

By Monday, emergency plans had beenactivated and a series of meeting roomshad been taken over as our NationalEmergency Co-ordinating Centre. The HPAheadquarters resembled something out ofThe West Wing.

For the following weeks, the HPA wascentral to the national pandemic response.Teams around the country worked hardunder difficult, highly visible conditions.The willingness of staff to work long hours,and to do so flexibly and with unswervingcommitment, is what has stuck with me.

We all breathed a sigh of relief in mid-July when the need to manage outbreaksand provide antiviral prophylaxis ceased.The summer period allowed staff to rest,but the HPA remained busy until the NewYear when the pandemic began to recede.

Inevitably, the post mortems are nowbeginning. Did the UK get it right? Whatwent well and what didn’t? Suchevaluations are vital. But it is alsoimportant not to forget that little wasknown at the time. An urgentprecautionary approach was needed todeal with what was a national publichealth emergency – and what wasunquestionably, for me and many others, abaptism of fire.

Professor Anthony KesselDirector of Public Health StrategyHealth Protection Agency

HPA was “like ascene from The West Wing”

The blog that was setup by the flu lead atthe Strategic HealthAuthority provided uswith immediatefeedback‘

‘

An ageing global populationmeans health policy needs toadapt, argues Peter Lloyd-Sherlock.

The number of people aged 60 and overis projected to increase by 1.5 billion by2050, reaching 22% of the world’spopulation. The majority will be living inAsia, Africa, Latin America or theCaribbean. Health policy has a majorbearing on how people in developingcountries experience later life, and on howpopulation ageing will affect patterns ofnational development.

In April 2009, as part of a larger study, Iinterviewed two older women living on thesame street in Cape Town, South Africa.Both were in their early 60s and received abasic pension from the government. Thefirst woman was paralysed, having suffereda series of strokes. She was depressed andgave a confused account of her life, hadbeen frequently hospitalised and wasdependent on her immediate family. The

second woman was in good health, with apositive outlook on life. She helped carefor several grandchildren, ran errands forother family members and was a regularchurch-goer.

These contrasting experiences are typicalof the huge diversity of situations faced byolder people around the world. If themajority of people in developing countriesexperience reasonable levels of health inlater life, then the wider consequences ofpopulation ageing may be benign.Unfortunately, there is growing evidencethat many experiences more closely matchthe first woman’s.

Just to focus on the issue of stroke:while rates fall in developed countries,there have been substantial rises across thedeveloping world, where the average ageof first stroke is 15 years younger.Epidemiological data is limited, but arecent study from rural India reported thatstroke was the leading cause of death forthe population as a whole. Stroke andother non-communicable diseases remain alow priority on global health agendas, andpublic health campaigns have made littleheadway. Across the developing worldaccess to effective treatments such asthrombolysis is negligible, increasingstroke-related fatality and disability.

Population ageing demonstrates theneed to substantially re-orientate health

policies in developing countries away fromcurative, hospital-based care towardsinterventions that promote good healththroughout the life-course. These policieswould benefit all age groups, young andold.

For someone who believed anddeclared himself to be a specialist(a sociologist), the late PeterTownsend was a polymath withwidely divergent interests.

A bibliography published by LSE a yearbefore his death ran to 67 pages, andTownsend was a hugely prolific writer, onany number of topics relevant to publichealth, from older people’s wellbeing tothe perils of high-rise housing.

It is testament to Townsend’s reach andlucidity (and possibly the editing skills ofDavid Walker and colleagues) that ThePeter Townsend Reader provides acoherent and (at over 650 pages) relativelyconcise primer on his life’s work.

Thematically arranged, the book toucheson, in turn, sociology and its relation tosocial policy, the welfare state, poverty andits measures, inequality and socialexclusion, health inequalities, older people,disability and human rights. Beneath thesebroad headings, Townsend covers a vast

amount of territory, always grounded inpragmatism and compassion born out ofexperience. Townsend’s influence spreadfar beyond the cloistered walls ofacademia, as vice-president of the FabianSociety and as co-founder of both theChild Poverty Action Group (in 1965) andthe Disability Alliance (in 1974). He also co-authored the somewhat infamous BlackReport, excerpted here.

Of particular interest to public healthpractitioners are his thoughts exploringindividual social responsibility forpremature death, how health inequalitiescould be affected by the (re)structuring ofhealth services, and the endemicrelationship between deprivation and poorhealth. His deprivation index, is of courseinternationally reknowned, and is exploredin some detail, particularly in chapter III.These ideas, around the concept of“relative poverty” are still somewhatcontroversial, and Townsend’s argumentswith, amongst others, Amartya Sen, arenot glossed over but extensivelydocumented here. Townsend’s oftenchallenging thinking is however madeeasily comprehensible by crisp prose andclear logic.

Conceived before Townsend’s death inJune 2009, the reader nonetheless providesa fitting tribute. This book, and Townsend’s

life in general, provides an object lesson inthe importance of making theory relevantto practice. It’s only apt then that apersonal testimonial should provide the lastword, from Townsend’s colleague at theLSE, Hartley Dean: “He was an intellectualgiant with a quintessential human touch”.

Peder Clark

BOOKS & PUBLICATIONS

MARCH 2010 15

Heady journeytoward makingpoverty history

The Peter Townsend readeredited by Alan Walker et al

Published by Policy Press 2010ISBN 978-1-84742-404-4RRP: £24.99

For details of our competition see page 19.

Growing oldhealthily? Whypolicy needs toaddress ageing

Population Ageing andInternational DevelopmentPeter Lloyd-Sherlock

Published by Policy PressISBN 9781847421920RRP:£22.99

From the CEO

Welcome to a new decade and also anew look FPH quarterly, Public HealthToday. We hope that you like the newformat and find that we continue toprovide a useful publication that helpsyou as members in your professionallives.

ph.com has served us well for manyyears – but like so many things it’s good

to take a look at what we produce andreview both content and appearance.

Through a process of membershipconsultation we have listened to yourviews and hopefully managed tocapture your suggestions and ideas inwhat you now see before you. Ourthanks to all of you who contributedthrough the consultation to help usform your ideas into what, I hope youfind a modern, readable and accessiblequarterly. Of course, we hope tocontinue to develop the publication andwould welcome your further thoughtsas Public Health Today goes fromstrength to strength.

As part of our programme of listeningto members we are also about tolaunch a new look website – againguided by you from the recentconsultation. We have tried to make itmore accessible, easier to navigate, andalso carried out an audit of the content,to ensure that it provides the most up-to-date and relevant information aboutthe FPH and public health. Watch thisspace for the launch date!

In the last few months, RussellAmpofo and I travelled to Washington

DC to follow up the board’s proposal toinvestigate the FPH’s role inaccreditation of masters courses inpublic health. We visited the Council onEducation for Public Health whogenerously shared with us informationabout their years of experience. A fullreport was presented to the FPH’saccreditation working group, who haveasked us to develop this programmefurther.

Many of you will have seen that theFPH has gained considerable publicityfollowing the publication of itsmanifesto 12 Steps To Better PublicHealth, which you can find on ourwebsite. Working in partnership withthe RSPH, we have receivedunprecedented support for thisdocument, and are delighted to seeparliamentary questions being asked byMichael Meacher MP, in support of ourcall for a ban on trans fats. Otherparliamentarians and NGOs have alsobeen in touch.

Paul ScourfieldCEO


ENDNOTES

Internationalupdate

LSE Health is to establish andmaintain the new Council forHealthcare Regulatory Excellence(CHRE) International Observatoryon the Regulation of HealthProfessionals

LSE Health has been awarded acontract by the CHRE to establish andmaintain the new CHRE InternationalObservatory on the Regulation of HealthProfessionals. The objectives of theObservatory are to advance understanding,enable learning across countries andfacilitate the spread of good practice in theregulation of health professionalsinternationally.

The Observatory’s work programme willinclude country reporting, commissionedresearch, a rapid response facility toprovide information and policy advice, andthe production of analytical reports on keytopics such as revalidation, fitness topractise, trends in regulatory reform and

the impact of payment reform onprofessional behaviour.

Observatory research will also addressbroader topics relating to the identificationand adoption of good practice and to howcountry context affects the potential forregulatory reform. Working closely withCHRE, the work at LSE Health will be ledby Professors Alistair McGuire and EliasMossialos and will be co-ordinated byThomas Foubister. Professor Julian LeGrand (Chair of LSE Health) will sit on theObservatory’s strategy group and ProfessorRobert Baldwin of the Department of Lawwill be an advisor to Observatory researchactivity.

HIFA2015 campaign puts thespotlight on community healthworkers for 2010 challenge

The global Healthcare Information for Allby 2015 (HIFA2015) campaign andknowledge network is focusing its effortson the information and learning needs ofcommunity health workers in 2010.

1.3 billion people lack access to basichealthcare and many more are at risk ofreceiving unsafe treatment. Community

health workers save lives, but to do so theyneed access to appropriate informationwithin a robust health system. The‘HIFA2010 Challenge’ will highlight thebarriers (such as lack of internet andlearning resources) as well as theopportunities (such as the use of mobilephones) to learning and informationdissemination amongst community healthworkers.

The challenge is being supported byHIFA2015’s 3,000 health professionals,researchers, publishers and librarians from1800 organisations in 150 countries. Thegoal? That ‘by 2015, every communityhealth worker will have access to theinformation they need to learn, todiagnose, to provide appropriate care andto save lives.’

To join HIFA2015 or to find out more, visitwww.hifa2015.org

ENDNOTES

MARCH 2010 17

Sir Donald Acheson FFPH1926 – 2010

Chief Medical Officer for England from1983 to 1991, Sir Donald found himselfleading the fight against the emergingthreat of AIDS in the mid-80s. Notedepidemiologist and skilled consensus-builder, he brought together a wide rangeof experts – scientists, clinicians, publichealth and lay – to develop acomprehensive strategy, arguably the mostadvanced in the world at the time, totackle HIV.

Following two high profilecommunicable disease outbreaks, SirDonald chaired an inquiry into the publichealth function in England and his report,published in 1988, provided the blueprintwhich firmly established properly staffedPH departments at local level. His otherhuge contribution was his 1998 report onhealth inequalities, which became the coreof New Labour’s public health policy,including extra funding for schools andcommunity projects in deprived areas, extramoney for low income families andsmoking restrictions in public places. Quietof manner, twinkly of eyes, gentle butfirmly persuasive, a stickler for evidence,methodical and thorough, Sir Donald wasone of our truly great CMOs.

Professor Maurice Backett1916 – 2009

Maurice was an outstanding academicwho, among a small group of pioneers,established the first departments of socialmedicine in medical schools from the1950s onwards. He held the first Chair inSocial Medicine in Aberdeen beforemoving to the foundation Chair ofCommunity Health in Nottingham. He wasable to bring his unique skills andenthusiasm to a curriculum where “thecommunity” was a central theme. Hecreated multi-disciplinary departments withstrong international links.

Maurice was an inspiring teacher, anoutstanding communicator and a moststimulating colleague, always seeking tobring the best out in people. A foundationfellow of the FPH, he attended his lastAnnual Conference in 1998. He inspiredlarge numbers of colleagues and students,who not only have become leadersinternationally in public health andepidemiology, but also hold top posts inuniversity administration, internationalorganisations, research and health services.

In memoriam

Royal Collegestatus update

FPH is making good progress in the workto move to independent status as a royalcollege. This programme of work is beingled by the College Status Working Groupon behalf of the FPH Board. To date workhas included:n Holding a membership ballot to obtainapproval to seek royal college statusn Obtaining written support from all threeparent royal colleges and from the fourchief medical officers n Reviewing FPH governance documentsand developing new governancedocuments and a memorandum for thepetition for a Royal Charter.

An informal application for a RoyalCharter was submitted to the Privy CouncilOffice (PCO) in January of this year. Theworking group is now liaising with thePCO to refine the application, ensuring theformal petition meets with success whenformally submitted before the summer.

A separate process is being undertakento seek permission to use the word 'royal'in the name of the new organisation. Thisapplication will be made to the Ministry ofJustice.

A third area of work is to liaise with ourcurrent parent colleges and clarify howbest to maintain and develop the specialrelationship with the three colleges.

While work is under way on all workstreams it is still difficult to give a cleartimetable for completing the move toRoyal College status. Further updates onprogress and copies of the draftgovernance documents will be shared withmembers in due course.

Conferencedebates nextdecade forpublic health

Registration is open for the most importantpublic health event of the year.

The 2010 UK FPH annual conference on7 July will include two exciting keynotespeakers, themed panel debates and lotsof question and answer sessions.

A range of speakers have already signed-up including London School of Hygiene’sMartin McKee and EuroHealthnet’s CliveNeedle. You also won’t want to miss ourexciting panel debate: UnhealthyHeadlines: How To Avoid The Next MMRScare – with The Guardian’s DenisCampbell, Welsh CMO Tony Jewell, and

The Daily Telegraph’s Mary Riddell.The day will culminate with The Cuts

Debate, an action-packed interactivesession with proposals from membersbeing debated by an all-star panel.

For the first time the conference will takeplace in London at Imperial College, one ofthe UK’s leading universities, with manyhistoric links to scientific breakthroughs.

A mixture of plenary panel debates andparallel sessions will include themes suchas: climate change; healthy cities; EUhealth policy; and our ageing society.There will also be a DH-sponsoredworkshop on PH workforce issues.

With public health very much on thepolitical agenda, the conference will be anopportunity for leaders in public health tojoin the conversation about the nextdecade’s public health policy.

A limited number of early bird tickets areavailable, so book early and save. For allthe latest details on the conference and toenter the abstract poster competition forthe conference, visit our websitewww.fphconference.org.

WORKING FORCHANGE: GLOBALHEALTH ADVOCACY

Thursday 10 June 2010, 9.30am – 4.30pmThe University of SheffieldAdmission: £75

A one day conference that will explore how trainees inpublic health and other health-related fields can work forchange on a variety of key global health issues such asglobal health governance, climate change, capacitybuilding and partnership working with organisations andcommunities in low - and middle - income countries.

The conference will include plenary sessions and advocacyworkshops, providing trainees with an opportunity tonetwork, gain invaluable advice and present theirinternational work.

For further details and bookingarrangements, please email:[email protected]

Organised by: InternationalHealth Trainees’ Group (IHTG)


ENDNOTES

INTERNATIONAL PUBLIC HEALTHATTACHMENT IN SOUTHERN AFRICA

We are looking for an senior public health trainee who isinterested in spending a 6 to 12 month attachment in Swazilandfrom September 2010 onwards. This is a great opportunity todevelop personal public health skills and make a major impacton the health of the population in a rural African region.

Public health programmeOver the last five years a successful public health trainingprogramme has been developed in the Lubombo region ofSwaziland through a health partnership between NHS andacademic public health specialists in Bradford and Leeds. Theprogramme has been successful in assessing local health needsand planning and implementing community-based TB, HIV/AIDSand chronic disease programmes.

Training attachmentWe are looking for a motivated and dynamic individual who isinterested in gaining experience and training in internationalpublic health and specifically the implementation and evaluationof TB and HIV/AIDS prevention and treatment programmes.Flights and accommodation will be paid for by the programme,with SpRs seconded on salary from their existing trainingprogramme. The post has previously been accredited for trainingsecondments by PMETB.

For further details please contact: Professor John Wright,Bradford Institute for Health Research, Bradford Royal Infirmary,Duckworth Lane, Bradford BD9 6RJ. [email protected], Tel: 01274 364279

ContinuingProfessionalDevelopmentupdate

The General Medical Council formallyapproved the specialist standards forrevalidation in public health on 14December 2009.

This approval covers a series of standardsfor all professionals practising within theirspecialty.

The specialty standards are inline withthe generic standards and criteria outlinedin the GMC's Framework for Appraisal andAssessment which is an adaptation ofGood Medical Practice.

The individual colleges and faculties havealso identified a range of supportinginformation which is being considered bythe GMC and will form part of the GMC’srevalidation consultation in March 2010.

The FPH has also recently submittedthese standards to the UKPHR for approvalfor use by their registrants. It is expectedthat all public health specialists will worktowards similar standards for revalidation.

GMC approves newspecialist standardsfor revalidation

Updated FPH booklet launched: ‘Revalidation and Public Health’ The FPH has updated the booklet formembers and the wider public healthcommunity on 'revalidation and publichealth'. This booklet (enclosed with thisedition) contains vital information for allpublic health professionals on the impactof revalidation. It includes key changes andthe provisionally approved specialiststandards for public health.

The booklet can also be downloadedfrom the FPH website athttp://tinyurl.com/yjax72z

CPD returns for 2009 (or applications forexemption) must be submitted to FPH by31 March 2010.

CPD is a key component of revalidation.The international, national and regionalCPD co-ordinators are committed tohelping you get the most out of thescheme. They have huge experience in CPDand make sure the changes that we maketo policy and implementation, are practicalfor participants. For further details pleasevisit http://tinyurl.com/ygwaqjh.

Our most recent policies on CPD andaudit are available on the website for youto read. The CPD section also provides anonline diary for recording CPD activities.The reflective notes are a vital element ofCPD and best practice examples from thisyear’s audit are now availableat www.fph.org.uk/prof_standards/cpd/.

UK PublicHealth RegisterThrough Defined Specialist portfolioassessmentMr David MeechanMrs Alice Wiseman-OrdMrs Jayne Needham

Through Generalist Specialist portfolioassesmentMrs Heather ReidDr Joanne Claire CameronMr Matthew AshtonMs Trish MannesMs Rutuja Kulkarni

Through the standard FPH GeneralistSpecialist training routeDr Sarah JonesMrs Lynne McNivenMs Susan HirdDr Andrea DochertyMrs Lucy Heath

Welcome to new FPHmembersWe would like to congratulate and welcome the following newmembers who were admitted to the FPH between 17 November2009 and 22 February 2010

New diplomate membersChi-Wai Chan Man Chu Joanna Leung Siu Mak Lisa Stanway

New trainee membersBalsam Ahmad Robert Aldridge Louise Aston Lorna Bennett Louise Bishop Wendy Burke Katherine Conlon Michael Edelstein Helen Elsey Nigel Field Lynn Frith Anjan Ghosh Sarah James Frances Macguire Paul Madill Rachel Mearkle Clare Newman Douglas Noble Emer O'Connell Gillian O'Neill Katherine Russell Muhammad Sartaj Tharani Sivananthan Rosamund Southgate Thomas Waite Neil Wigglesworth

New membersBenjamin Anderson Fiona Bragg Anna Bryden Julia Burrows Michael Caley Colin Campbell Sanhita Chakrabarti Sudeep Chand Daniel Chandler Osman Dar Alisha Davies Gracia Fellmeth Rebecca Gait Anupam Garrib Louise Hurst David Ishola Benjamin Lacey

John Licorish Soo Lim Laura MacLehose Kirsteen Macleod Gayatri Manikkavasagan Julie O'Boyle Brendan O'Brien Alexandra Stirling Christopher Weston

New fellowshipsEdward Adams Karen Bradley Wai Chui Velena Gilfillian Angela Hardman Ulrike Harrower Anne Hinchliffe Nagpal Hoysal Ros Jervis Madeleine Johnson Sarah Jones Chi-Mei Leung Ching Leung Hamid MahgoubEdward Adams Karen Bradley Wai Chui Velena Gilfillian Angela Hardman Ulrike Harrower Anne Hinchliffe Nagpal Hoysal Ros Jervis Madeleine Johnson Sarah Jones Chi-Mei Leung Ching Leung Hamid Mahgoub Suzanna Mathew Kit Maw Mary McCallum Asmat Nisa Divine Nzuobontane Tanya Richardson Shuk So Angela Tinkler Justin Varney Aileen Walker Lynda Wearn Christopher Williams Tze-Kiu Yeung

The Annual GeneralMeeting of the Faculty ofPublic Health will be held onWednesday 7 July 2010at Imperial College London,South Kensington Campus,Exhibition Road, London,SW7 2AF.

The agenda papers will beavailable on the FPH’swebsite (www.fph.org.uk)from Friday 11 June 2010.

Hard copies will be availableon request.

NOTICEBOARD

Notice of AnnualGeneral Meeting

Donald Acheson

Saadoon Al-Tikriti

George Ball

Rosetta Barker

Roy Berry

Terence Brennan

Nairn Cowan

John Crofton

George Curtois

John Dale

Joan Davison

Mary Douglas

Ronald Elliott

Elizabeth Hawkins

Robert Jones

Monica Kerrigan

Wing Kong

John Lapper

David Lewis

Cyril McClintock

Jeremy Morris

Duncan Nichol

David Parry-Pritchard

John Pemberton

Deceased members

The following members have sadly passed away:

We have three copies of OUP’s Child Public Health (2nd edition)by Blair et al. If you would like a chance to win a copy, pleaseemail [email protected] by 9 April. Winners will be notifiedby 12 April.

Receive 20% off the publication by visiting www.oup.com/uk andentering the promotion code: webblair10 in the promo box at thepoint of purchase. Discount valid until 31/12/10.

Book Competition

THE FINAL WORD

‘ ’ The new government needs to include public healthleaders around the top table to tackle inequalities inthe next decade, argues Kate Green.

All articles are the opinion of theauthor and not those of the Faculty of Public Health as an organisation

Information

ISSN – 2043-6580

Editor in chief Alison Hill

Managing editorRachael Jolley

Commissioning editorSuvi Kingsley

Books editor Peder Clark

Production editorIain Brown

Editorial boardDavid DickinsonAndrew FurberCatherine HeffernanAmanda KilloranAshish PaulSam RamaiahPremila Webster

Contact us:[email protected]

Address:Faculty of Public Health,4 St Andrews Place,London,NW1 4LB

Switchboard: 0207 224 0642Education: 0207 224 0642Policy & Communications: 0207 935 3115

www.fph.org.uk

SubmissionsIf you have an idea or a suggestion for anarticle for the next issue, please submit a50 word proposal and suggested authorto: [email protected]

The link between poverty and inequalityand poor health has long beenunderstood. Recent analysis for theMarmot Review, from Richard Wilkinsonand Kate Pickett (showing the damagingeffects of inequality on individuals' healthand for society as a whole), and from twoUNICEF reports assessing child wellbeing inover 20 rich countries (which highlightedthe UK's relatively poor performance) hasreinforced the point.

The last decade has seen substantialinvestment aimed both at improving healthoutcomes and addressing poverty. Thegovernment's successful public health-related initiatives include the smoking ban,extended screening for bowel and breastcancer, and the Change4Life programme.Extra financial support (for examplethrough tax credits, extending free schoolmeals to more children, the health inpregnancy grant, and the Sure Startmaternity grant) has helped low-incomefamilies. Welfare reforms have beenintroduced to boost employment, includingfor those experiencing physical and mentalill-health - those in good quality workexperience better health, as last year'sreport by Dame Carol Black confirmed.

These policies have made a difference -though the pace of change is slow, andworse health outcomes for the poorestremain stubbornly hard to shift. Low birthweight, higher infant mortality, lower lifeexpectancy, disease, and poorer mentalhealth are all correlated with the relativelyhigh rates of poverty and inequality thatcontinue to be experienced in the UK.

The twin track approach that has soughtto tackle wider socio-economicdisadvantage alongside public healthmeasures, while addressing the rightissues, must go further to achieve asustained improvement in the health of thepoorest.

So policy needs to be more vigorous,more radical and more holistic. Narrowingthe gaps in income, employment,education and between neighbourhoodswill all have a positive impact on healthoutcomes for the poor - and save spendingin the long-run. Yet public health plannershave been largely absent from thedevelopment of policy to address thosebroader inequalities.

Now both the Marmot Review and therecent report from the National EqualityPanel, led by John Hills, create anopportunity, indeed an imperative, torealign health planning with the widerpolicy agenda, both in terms of whathealth could contribute to improvingsocioeconomic equality, and for the healthgains that could result.

Health planners should be clamouringfor a place at the policy top-table to bringthat about.

Kate Green Former chief executive of the Child PovertyAction Group, now Labour PPC forStretford and Urmston.

Yet public healthplanners have beenlargely absent fromthe development ofpolicy to addressthose broaderinequalities.‘‘

document

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