Public health activism: lessons from history?BMJ 2007; 335 doi: https://doi.org/10.1136/bmj.39399.612454.AD (Published 20 December 2007) Cite this as: BMJ 2007;335:1310
- Virginia Berridge, professor of history1
- 1Centre for History in Public Health, London School of Hygiene and Tropical Medicine, London WC1E 7HT
• The successes and failures of past public health campaigns can be used to inform strategy for health campaigns today
• Past campaigns show the importance of policy impact as well as of cultural change
• Conveying clear scientific messages through the media and creating networks of key organisations in strategic alliances have been effective strategies
• Attention must also be paid to the political dimension of a concern such as alcohol and possible alliances with industry
In a recent Guardian article the journalist John Harris speculated on what could change attitudes to alcohol consumption. His conclusion was pessimistic: “Faced with a titanic alliance of retail giants, brewers and pub chains—not to mention an electorate drinking for Britain—would any government dare make a move?”1 But governments have taken action on public health matters; the smoking ban is the most recent example of a set of interventions going back to the sanitary improvements of the 19th century. Are there any lessons from the past for current health campaigning? Here I present three models of activism from different historical periods and draw out their implications for future health campaigns.
The Health of Towns Association
The Health of Towns Association was an early example of a public health pressure group. The association was formed in 1844 in the wake of Edwin Chadwick’s seminal Report on the Sanitary Condition of the Labouring Population and was a key advocate of environmental public health interventions in Victorian Britain.2 The association existed only briefly, from 1844 to 1849. Its aim was to “substitute health for disease, cleanliness for filth, order for disorder, economy for waste, prevention for palliation, justice for charity, enlightened self-interest for ignorant selfishness, and to bring to the poorest and meanest—Air, Water, Light.”3
Today it is remembered chiefly as the vital pressure group in the campaign to promote sanitary reform in the rapidly growing cities of industrial Britain. Its work was to arrange public meetings and lectures; publish the Journal of Public Health; organise regional groups to further its cause; and lobby MPs, doctors, and opinion formers.3 The campaign culminated in the legislative milestone, the Public Health Act of 1848, after which the association was dissolved. However, historians have grown more sceptical of heroic narratives of sanitary progress, and they are now more critical of the association’s moralistic tone and more conscious of the class and financial interests that it represented in its crusade for reform. The pre-eminent historian of British 19th century public health Chris Hamlin has pointed out that the association kept to the Chadwickian party line, that the problem was sewers and not deprivation.4
But the association helped Chadwick to achieve his aims in the 1848 Public Health Act. It was an early example of investigation and activism, of science and political action. It was short lived and was using the wrong science (miasmatic theories of disease), but it did have impact, at a time when the public was suspicious of central government intervention.
The temperance movement
The temperance movement was a very different 19th century campaigning organisation. It is often equated these days with the prohibition of drink. Even in its heyday, however, it was never a monolithic movement. Initially temperance meant simply being opposed to spirits. The early supporters were from the aristocracy and the middle class. They opposed the drinking of spirits but not of beer. Temperance later meant total abstinence, and most of its support then came from working class interests.
At a temperance meeting on 1 September 1832, seven men from Preston took the abstinence pledge as an experiment for a year. The temperance movement thus concentrated on “moral suasion,” on the development of a mass movement that would lead working men to stop going to the pub and to take the pledge not to drink. As the historian Brian Harrison has written, “Teetotalism . . . flourished on the genuine desire for respectability and self-reliance which prevailed within the working class.”5 Moral suasion concentrated on reformation of the individual rather than on state intervention. Temperance advocates acted as missionaries for the cause, and a temperance culture emerged.6
For those who joined the movement there was a set of organisations inculcating sobriety and abstinence that in turn influenced a wider number in the general population. Although by the 1860s there were well under 100 000 temperance campaigners, their efforts led to least a million other adults becoming teetotal and probably many others reducing their alcohol intake.7 In addition, several hundred thousand child teetotallers were part of the Band of Hope. The temperance movement was also known for its cross class support. Non-conformist business men—and Quakers in particular—who had supported the earlier movement opposing spirits could see the value of a disciplined and sober work force.
The temperance movement prompted debates about public health strategy. The potential of political alliances came to the fore. By the end of the 19th century, the forces for and against alcohol were firmly corralled into two opposing camps—the brewers with the Conservative Party and the temperance movement with the Liberals. But there were also debates about wider strategy. Was it better to go for the “local option”—the possibility of local prohibition (on the model of the United Kingdom Alliance)? Or should there be cooperation with the drinks trade licensing reform, the reduction of licences, and the improved public house?
These debates split the temperance movement before the first world war, and the movement did not capitalise on the wartime restrictions on alcohol introduced by the wartime Central Control Board. These restrictions were the equivalent of the current Alcohol Harm Reduction strategy and its recent revision: this is one of the few policy documents since the first world war to take an overall view of alcohol policy.8 The temperance movement had a huge impact in terms of culture in the 19th century, but its long term role in policy was limited—in part, some historians have argued, because of its failure to make strategic alliances, including capitalising on the possibilities of action with the drinks industry.9
Smoking and public health pressure groups since the 1970s
The public health pressure groups that have emerged since the 1970s to campaign on lifestyle matters such as diet, smoking, and heart disease present a different model of activist organisation. ASH (Action on Smoking and Health), set up in 1971 after the second report on smoking by the Royal College of Physicians,10 is a key example here. ASH was not a mass movement like the temperance movement; rather it focused on using the media. In doing that, the role of science was of central importance.
Although the organisation was founded by doctors, including the charismatic and media conscious Charles Fletcher, the involvement of non-medics and radical activists made a difference.11 The arrival of the activist Mike Daube as director of ASH in the 1970s brought this new emphasis and style to the organisation. Daube had a campaigning stance derived from his previous work at the housing charity Shelter, which had pioneered a media and publicity conscious approach to social issues. He was strongly influenced by this new style of campaigning introduced by the director of Shelter, Des Wilson. Daube also had a background in student politics.
In an interview he gave to an Australian journalist in the mid-1970s, Daube showed his media style: “It seemed to me when I came into ASH that here was a pressure campaign that was ripe. It hadn’t been properly used. You had your villain. You had your St George and the dragon scenario, you had your growing ecology bandwagon, growing interest in consumerism. It seemed there were a lot of prospects of making something out of it.”12 Daube was expert at working up the issue in the media with eye catching stunts and spin.
The arrival of such intensely media conscious health campaigners brought with them the possibility of wider alliances for medicine and public health interests. In the 1970s an alliance developed between ASH and the central health education agency, the Health Education Council. In the 1980s this alliance widened into a network of different organisations in which the BMA was important. Subsequently these networks developed an international dimension: the organisation directed its activism at securing the recent Tobacco Framework Convention13 (which provides a mechanism for tobacco control measures worldwide) and at tobacco use in the Far East and in developing and eastern European countries.
Other health concerns show a similar pattern. For example, the initial media focus of the gay men who refounded the Terrence Higgins Trust in 1983 (after its initial foundation in 1982 under a different name and with a different function), the subsequent development of gay networks, and then international action.14 The harm reduction emphasis in drug policy has followed a similar route, with networks of organisations being developed at the national level and then an international network developed through the International Harm Reduction Association (www.ihra.net/HistoryandFounders), which now lobbies through the United Nations machinery of drug control.
These case studies help in designing strategies for current health campaigns. They show the importance of the role of science in communication: this was a key campaigning tactic in the 1840s and in the 1970s. Not all scientists have agreed with this role. In the 1950s, Austin Bradford Hill and Richard Doll, who discovered the relation between smoking and lung cancer, were averse to promoting these scientific results in policy making circles—Hill in particular thought that drawing policy implications from science was a job not for scientists but for policy makers.14 And the presentation of science has also changed—from the tracts of the 1840s to media spin on science. The media has become a crucial interface for public health campaigning: having a clear media message from science is important.
Dilemmas such as whether to cooperate with industrial interests are also still relevant today. The temperance movement was criticised for not capitalising on harm reduction tactics with industry and on losing influence as a result. Some of the early smoking campaigners did work with industry. Later on, largely as a result of ASH’s influence, a resolutely hostile attitude developed. Now attitudes to industry vary. In the smoking field there is hostility to tobacco interests but more dialogue with the pharmaceutical industry because of nicotine products. For alcohol, the dilemma over industry links is still contentious for some public health scientists and campaigners. Whether to work with industry is clearly a decision that depends on the prevailing conditions at the time.
In recent times, networks of health organisations and pressure groups have been important as they have first established the area of concern at the national (and sometimes local) level and then developed it internationally. In the 19th century, the movements against alcohol and opium also had a strong international dimension, which smoking campaigners have adopted in recent times.
Making use of politics is important but time dependent. Political divisions initially aided the temperance movement in the late 19th century because they gave momentum to the debate on alcohol. Later, though, the political connection of Liberalism with forces opposed to alcohol became seen as “old fashioned” as the alcohol debate waned. Seizing the moment is clearly important, as is using the possibilities of the political system. In the 1970s ASH obtained most of its funding from government, an early example of state funded voluntarism. Health pressure groups became useful at that stage to government, which could use them as a counterweight to pressure from elsewhere in the system. In the 1980s, smoking campaign tactics focused more on networks of organisations as the government became generally more sympathetic to the tobacco industry and less inclined to seek a non-governmental activist ally.
So the past is instructive. The current emergent health campaigns of today (such as that on alcohol) need to promote their case through the media but with scientific clarity; organisations need to work in a network of strategic alliances; timely consideration of the politics of the issue is important; and campaigners need to consider whether to work with industry. Such activities also have a wider dimension. Historically, they have helped to achieve political and policy change, but they have acted also in a more intangible way as engines of cultural change, helping to create a new climate of opinion. And without cultural change, few governments would consider political change, in particular where substance misuse and public health are concerned. Conservative and Labour governments in the 1950s and ’60s were far more concerned about electoral opposition to smoking restrictions than about the views of the tobacco industry. So activism has a dual and interconnected rationale—pushing for policy change but also helping to achieve cultural change. That change is a long process, as the history of smoking tells us.
Sources and selection criteria
The material in this article derives from research projects that have been funded by the Wellcome Trust and the Joseph Rowntree Foundation
This paper was originally given to the Epidemiology and Public Health section of the Royal Society of Medicine at the conference “The Art of Public Health-Lobbying in Action” held on 24 May 2007 to mark 10 years of the public health minister.
Funding: The Wellcome Trust and the Joseph Rowntree Foundation.
Competing interests: None declared.
Provenance and peer review: Not commissioned; externally peer reviewed.