Interview

Connecting health and the environment

Environmental health is the unsung hero of our public health infrastructure. Brian Hanna spoke to Tracey Khanna about its potential role

Considerable excitement has surrounded the emergence of a so-called ‘new public health agenda’, which seeks to address the links between environmental quality and health within the context of a national sustainable development strategy. But just how does sustainable development link in to the health and wellbeing of the nation?

Brian Hanna is one man whose professional roots are deeply planted in both environmental health and sustainable development. Now widely associated with his commitment to the sustainable development agenda – he sits on the sustainable development commission, an independent advisory body for the government – he began his career as an environmental health officer in Belfast in the early 1960s. Progressing steadily upwards in local government, he held a number of senior environmental health posts until he became chief executive and town clerk at Belfast in 1994, a step that in effect extricated him from the day-to-day workings of environmental health.

This, coupled with a longstanding association with the Chartered Institute of Environmental Health, the professional body he of which is currently president, has meant that sustainability, public health and health inequalities have always been at the heart of his work. ‘In the 1990s,’ Hanna says, ‘the CIEH put out a very important piece of work – Agendas for change – and one of the key points of this report was that we needed to connect the public health agenda, the sustainable development agenda and the concept of environmental health, which runs through these things.’

As far as the UK government is concerned there are four main objectives, which if achieved at the same time would deliver sustainable development in the UK: social progress which meets the needs of everyone; effective protection of the environment; prudent use of natural resources; and maintenance of high and stable levels of economic growth and employment. Clearly, tackling society’s health inequalities and providing the same opportunities for health regardless of where a person lives or their social and economic circumstances is at he heart of these objectives.

While there have been many attempts to define sustainability and sustainable development over the years, this simple idea of balancing the social, economic and environmental impacts of this generation’s decisions over the long term is one that is perhaps most widely recognised. ‘If we take sustainable development at its simplest,’ says Hanna, ‘it is really about development which meets the needs of the present without compromising the needs of future generations’.

‘Ultimately, I believe that you cannot have sustainable development without promoting health and protecting the environment. We have to work to ensure that there is no competition between the environmental side, the economic side and the social side.’ But he does recognise that there are those who would argue that it is not possible to have economic growth without damaging the environment. ‘It is interesting that there has never really been any time in history when economic development has been possible without damaging the environment,’ he says. ‘But the government says in its sustainable development strategy that we need development that keeps economic growth, the production of jobs and economic benefit for communities and individuals in harmony with the protection of the environment’.

Ultimately, in terms of health benefits, Hanna acknowledges that if people are better educated they make better lifestyle and health choices. ‘We know that if people are working and have better income they have the opportunity to buy better food and live in a more healthy way,’ he says. ‘Not everybody does, but the opportunities are there.’ He frequently refers to the point that there is a major connection between social issues like education, job provision and income, health and sustainability.

As far as the environmental health profession is concerned, by addressing the wider determinants of health – such as food, housing standards, health and safety, air pollution and environmental protection – it can make a fundamental contribution to the maintenance and improvement of the public’s health. ‘Coming into winter,’ he says, ‘we know that there will be cases of hypothermia and unnecessary death because some houses are not heated properly, either because people cannot afford the energy or because the houses are not insulated properly’. But, while there are fundamental enforcement actions that local government can take to improve individual situations, only government policy can ultimately improve matters.

Referring to the Department of Health’s recently-launched cross-cutting review, Tackling health inequalities, Hanna says he finds the government’s current health policy ‘encouraging’. The report sets out a number of key goals for national public health policy:

Breaking the cycle of health inequalities through policies to tackle poverty and deprivation, education and employment;

Tackling the major killers, such as cancer and coronary heart disease, through policies that enable people to make and sustain healthy lifestyle choices;

Improving access to public services and facilities by providing targeted programmes and tackling transport issues;

Strengthening disadvantaged communities through building partnerships and developing community based approaches to dealing with health problems; and

Supporting targeted interventions for specific groups that are at risk of poor health or have complex needs, such as older people and vulnerable members of the black and minority ethnic communities.

‘Putting public health – the prevention side – in a much stronger position than has hitherto been the case is extremely important,’ says Hanna. ‘Alan Milburn, the secretary of state for health, pointed out when launching the cross-cutting review that uniformity of provision hasn’t in fact meant uniformity of outcome. You cannot have a NHS that is evenly distributed across the country, assuming that everybody’s problems are the same, because they are not, clearly.’

Hanna sees the need to ensure a better balance between prevention and cure as crucial from the point of view of the environmental health profession. ‘This is basically an acceptance by government that there has been too much emphasis on the curative side, and not enough on the prevention side,’ he says. But he recognises that ‘there is always going to be pressure on the government to deliver on the curative side – people want their operations and treatment now – and governments cannot simply say “things will be a lot better in 20 years time”’.

The government’s close attention to the ‘major killers’ like smoking, coronary heart disease and cancer has the biggest implications for environmental health. Smoking costs the NHS around £1.7bn per year, and one in five deaths in the UK is caused by smoking. Very clearly a preventable situation, according to Hanna. ‘There are some big issues in there,’ he asserts, ‘including environmental issues like passive smoking, which environmental health practitioners face constantly, due to the premises that they tend to deal with, like restaurants and bars.’

‘A huge amount of extra resources are being made available to NHS. The question is, to what extent will some of that money get into the prevention side?’ he asks. ‘Now, I would expect that we should be arguing to make sure that some of those resources do get into prevention,’ he continues. ‘I think that this is a battle that now needs to be fought by those who are more clearly on the prevention side.’

But he acknowledges that regardless of the funding issues, community strategies are the way forward if sustainability and health inequality targets are to be met. ‘It is interesting when you look at the Tackling health inequalities document that has been produced,’ he says, ‘as it talks about local assessment of needs and involving local people in the research process. Again, that takes us into areas like partnerships, community strategies and health improvement plans.’

He points out that to intervene successfully requires a collaborative approach. ‘We in local government, particularly through the community strategy process and environmental health practitioners involved in initiatives like Health Action Zones, could actually make quite a considerable contribution to this.’ He goes on: ‘I wouldn’t go so far as to describe all this as a revolutionary public health policy, but it is a very positive public health policy and this is why we have to connect with it in terms of environmental health.’

Equally, he accepts that environmental health has to connect with the sustainable development agenda as much of the work of environmental health departments is concerned with areas of the environment which are directly connected to sustainability issues, for example energy use and climate change. ‘We have had Johannesburg this year,’ he says, ‘and although a lot of people have been disappointed by it, there have been some good things to emerge, particularly in relation to third world issues like sanitation.’

While he admits that Johannesburg got very political, particularly over the Kyoto protocol, he thinks that one of the key issues to emerge from the summit for local government in the UK has been getting the Local Action 21 initiative back on the rails. ‘There has been a bit of a hiatus there,’ he remarks. ‘A lot of good work was done up to 2000, then there was a feeling that we had more or less done that and that we would move on.’

To the question of who is leading on which agenda, Hanna responds with the point that there is always a problem with people wanting to be seen to be the key player on a particular initiative. ‘But I think we have to be a bit more generous than that,’ he says. ‘There are certain things where some people should obviously be in the lead, but ultimately there should be a collaborative effort.’ Projects like Local Action 21 have a number of professionals who should be involved, but he says, ‘if you look at environmental health initiatives, the environmental health officer should be in the lead and then connecting up with the director of public health in the primary care trust.’

‘In the end,’ he says, ‘the important thing is that people work together and share objectives, hopefully to bring expertise to the table and perhaps share funding – and then try and reach the outcomes that everybody wants to see in a collaborative manner. We don’t want to get caught up in arguments about who is the most important professional at the table. That is not going to help anyone – particularly not the community’.