Column

When will governments put public health first?

The BSE crisis isn’t the first time that government has failed to act decisively to protect the health of its citizens, explains Charles Webster

The current ‘mad cow’ fiasco, with new cases of the human form — Creutzfeldt Jakob disease — being reported almost weekly, is the latest reminder of the inadequate central arrangements for dealing with important public health problems, especially where major economic interests and rival government departments are involved.

The problem has been evident since the beginning of the NHS, and it has never been satisfactorily resolved, with the result that the public rightly lacks confidence in the objectivity of the advice dispensed on crucial issues of public health. A glance at the problem of smoking and health, one of the first challenges to confront the government under the new health service, reminds us of some of the endemic weaknesses of the public health mechanism.

Ostensibly, the NHS was well prepared to deal with such issues: the Chief Medical Officer had a higher status than is now the case; there was a comprehensive central advisory mechanism, much of which was dismantled in the 1980s; finally, the Medical Officers of Health were still important in the field of public health — this office was abolished in 1974. All of this proved insufficient to guarantee a prompt response to the increasingly compelling evidence that cigarette smoking was responsible for the serious increase in lung cancer, and that it was also likely to constitute a wider threat to health.

The celebrated paper by Doll and Hill on this issue appeared in 1950. Already, in 1951, the annual rate of deaths from lung cancer exceeded that from tuberculosis. This issue was taken up by the advisory committees without delay, but the main committee involved, the cancer and radiotherapy standing advisory committee, displayed dogged resistance to recognising an association between smoking and lung cancer. It was only through the action of aq couple of vociferous members of the parallel medical standing advisory committee, supported by the Medical Research Council, that this issue was kept in play. It was not until March 1956 that the senior advisory body, the Central Health Services Council, advised the government that the public should be informed about the dangers of cigarette smoking and initiate a publicity campaign on the issue.

Interdepartmental considerations meant that health ministers were unable to take independent action. Indeed it was necessary for the CHSC’s advice to be referred to the full Cabinet, where the reaction ranged from lack of sympathy to outright hostility. In particular, sensitivities about losses from the yield of tobacco duty, which at the time was substantially greater than the cost of the entire NHS, persuaded ministers that the Minister of Health should be restricted to reporting that the possibility of a link between smoking and lung cancer had been raised in recent research findings.

This anodyne statement, made on 7 May 1956, was disappointing to the growing number of experts convinced that smoking represented a major public health hazard. Despite strong backing from a MRC report in 1957, the central advisory committees lost interest. Government responses accordingly continued to be evasive, and positive action was limited to a low-key health education campaign.

Given the complete loss of momentum in government circles, the activists turned to the Royal College of Physicians, which published its well-known report, Smoking and Health, in March 1962. This report provoked wide-spread public anxiety and media attention, almost on the scale of the current mad cow panic. Ministers were inundated with parliamentary questions and this led to the first parliamentary debate on smoking and health.

For the first time, ministers were forced to take the issue seriously, and a full-scale review was conducted by officials. MRC pressed for a more positive response from the government. The secretary of the MRC advised that the evidence concerning the health dangers of cigarette smoking was ‘massive in quantity and consistent in its implications’.

Once again Treasury considerations dominated the response of the Cabinet, which decided that the government’s obligation to inform the public about public health dangers was limited to the field of infectious disease. Accordingly, the response was limited to minor stepping up of health education publicity. Despite mounting epidemiological evidence, and more active intervention by governments elsewhere, the Conservative administration persisted with its evasive tactics up to its electoral defeat in 1964.

Smoking and health was not an isolated example of failure of the public health mechanism at this time. Similar limitations were evident over fluoridation, immunisation and vaccination, family planning, infectious disease control, and protection against environmental hazards. Public health cannot count as one of the major successes of the early NHS, and the structural weaknesses evident at that time have arguably become even more pronounced with subsequent developments in our healthcare system. The government’s handling of public health dangers has achieved the low level of credibility it deserves.