Feature

How Green is this paper?

There is a clear overlap between environmentalism and public health — but you wouldn’t know it from the government’s green paper, says Peter Draper

The government’s proposed health strategy for England, the green paper The Health of the Nation, has been widely criticised for its omissions, particularly for failing to acknowledge the role of poverty and unemployment in causing health problems. There are other gaps too, but I want to focus first on an aspect that has been relatively neglected: the management approach to health promotion.

This apparently ‘businesslike’ approach is well indicated by this extract from the green paper:

Not everything can be tackled at once. Central to a strategy for health must be a rational approach to identifying the current major problems, assessing where the action is most likely to be effective and concentrating resources on those problems. (p.20)

There are several reasons why we should not accept this approach uncritically. First, the apparently rational language throughout is disingenuous — or it betrays a lack of knowledge of what resources for health promotion are actually like in the NHS. Instead of a statement about the need for adequate funding, we get a rationing statement — in fashionable management jargon, admittedly — which is unnecessary and undesirable.

Second, for all the apparent rationality the government’s approach is full of concealed value judgements. For instance, there are the judgements that went into their structuring of problems — such as deciding to omit poverty and unemployment rates. Similarly, if we assume that mental illness can’t be prevented then we will omit preventative objectives, and have only targets for treatment and care (p.86) — despite the fact that an appendix notes that in young men, particularly those aged 20-24 years, there was a 7l% rise in the suicide rate in the period 1980-89 (p.107). Presumably not even the government believes the cause was genetic or viral.

As well as overlooking the stresses of poverty and unemployment, it is also possible to neglect the stresses of homelessness and other severe housing problems, all the while muttering something about stress not being measurable. The report goes for the ‘knowledge is limited’ kind of dismissal (eg p.57).

Third, the management approach is unacceptable because planned neglect is unacceptable. While it sounds businesslike on first hearing to talk about key areas of ‘greatest concern’ and ‘greatest opportunity’ (p.26), a moment’s reflection reminds us that relatively unusual problems — such as toxicara or tetanus — should not be neglected because they fail to make the front. If the management speak means what it says, only problems 1, 2 and 3 will get resources and staff time. Imagine a general practice which announced that its management advisers had ‘helped it sort out priorities’ and this week it would focus on cardiovascular disease — so if you don’t have such a problem, would you kindly wait until your turn comes up?

Finally, this approach is unacceptable because it puts unnecessary and undesirable power in the hands of central government. Central government issued the proposals and will decide how to react to the responses — which it is not even committed to publishing. And all this from a massively discredited authority that says nothing about poverty or unemployment rates while commenting, for example:

Legislation is in place to ensure the safe disposal of hazardous wastes (p.110).

The relationships between environmental quality, decent housing and health have long been recognised and environmental standards and pollution control policies have been shaped accordingly. As a result, the acute and gross longer-term effects on health from environmental factors such as pollution have largely been eliminated. (p.101)

Readers are asked not to show the latter quotation to environmentalists concerned about global warming and the ozone layer in case they injure themselves. Other examples press for attention but the point is that a government that has specialised in massaging and delaying embarrassing official statistics over a decade, and that has used tax concessions to benefit the most wealthy, is simply not credible as an authority when it comes to strategic judgements about peoples’ health.

If the proposed approach is unacceptable, what should be done? Broadly, there are two answers. One is that the determination of health promotion priorities should be kept local. There can always be collaboration in regional and national campaigns. Although a centralised approach pervades the green paper, when it discusses the role of health authorities, it suggests that local policy making is the pattern:

Each district health authority’s responsibilities... will include... collaborating with others on the development of joint policies and strategies for health promotion and disease prevention, including FHSAs on primary care, and with local authorities over wider environmental health, outbreaks of food poisoning and accident prevention. (p.48)

If the government insists on national decision making then a more balanced forum should be found. The Commons select committee on health is one possibility. Returning some power to the feeble Commons would be an added advantage.

There are other problems with the green paper, but perhaps the most important is that it does not take fundamental environmental issues seriously and it fails to appreciate the massive overlap between environmental and public health concerns. Nowhere is there even a mention of such a thing as a sustainable economy and its health implications.

The government can’t have it both ways: if it claims to be serious about green issues, it can’t at the same time pretend that all our current economic practices are sustainable. And once it admits that sustainable development is necessary then all sorts of changes are necessary that have far-reaching health implications. But sadly, like the equally coloured, weak on policy, and pointlessly wordy environment white paper This Common Inheritance, the health green paper is an important but not a serious document.