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I hope 2019 has begun well and that the year ahead proves a good one for you all.  Despite the ongoing political uncertainty in the UK and increasing strain on budgets, with little hope of improvement in the near term, I remain surprisingly upbeat.  It may be the result of what seems to have been a successful London Christmas alcohol campaign, once the data firms up I shall certainly share more.  It could be the prospect of the forthcoming City Health International Conference in Liverpool on 22 March, which promises some great speakers.  Possibly it is a result of small, but welcome, signs of a willingness to explore new ways of thinking and working to reduce health inequalities in relation to mental health and hepatitis. Perhaps it’s having just secured funding to update our Safer Nightlife guidance, which aims to reduce drug related harms in the night time economy. I am sure the money has helped, you could say it has incentivised me.

There is nothing new about governments taking a view on the desirability, or otherwise, of the use of certain products or activities.  This has often influenced tax or tariff rates.  Government’s need revenue, income with a feel- good factor can seem particularly attractive.  More recently we have seen an increase around the world of penalties in the form of taxes and charges to discourage or encourage particular behaviours. These are often part of, or packaged as, being part of a public health approach.   The “stick” is for our own or societies good.   The use of “carrots” is less well established.

This use of the “stick” is not a new thing.  While the UK introduced a sugar tax on soft drinks in April 2018 there was a Sugar Act in 1764, which itself succeeded the Molasses Act.   While this 18th Century legislation was mainly about protecting existing British industry from foreign competition the likely impact on reducing alcohol consumption within the American Colonies was welcomed.  The beneficiaries of this revenue raising, sobriety boosting scheme were less than grateful to their masters in Westminster as it proved to be a significant contributory spark which would lead to war and the creation of the USA.  I can’t see the disgruntled Irn Bru drinkers of Britain breaking out into armed revolt.  However, the response to a mooted “pudding tax” do indicate that this might be taking the use of the stick beyond political acceptability. 

Personally, I think it a good thing when we can take public opinion with us.   Surely, we should be reflecting their concerns and priorities.  Through involvement in drug policy and more recently community safety I have spent years working alongside the police.  In Britain one of the underlying principles of law enforcement is “policing by consent”, that is having the approval and support of the public for what they do.  This may not always be achieved but it is an admirable ambition.   Work to improve the health of the populations we are meant to serve would surely benefit from a greater understanding of people’s views and concerns.

This is not to say we need to be reactive or, indeed, inactive.  We have some good examples of where community engagement and good public messaging have helped create an environment where work to counter HIV enjoys overwhelming support.  Needle exchanges are recognised as valid and important, drug and alcohol treatment, mental health services all enjoy support (although preferably not located in their own neighbourhoods).  Smoking is far less common or socially acceptable.  This has yielded tremendous gains, although it seems to be the one area where stigma is seen as a valid tool.  It also an area where our progress is almost stalled and highlights some worrying failures to help those most vulnerable.

London, like many urban areas, is working to reduce emissions from vehicles and is looking to further encourage people to use public transport, walk, cycle.  There are sticks being used here in the form of the congestion charge and the soon to be introduced Ultra Low Emission Zone.  It would be fair to say that there is considerable opposition but in general the public mood seems supportive, wanting to see air quality improve as understanding and concerns about the health imp.  Clean(er) air is a fairly attractive carrot, especially as most Londoners will not directly, experience the additional costs/penalties.

Rewards, or Contingency Management, to support behaviour change or engagement has a long track record and evidence base in drug and alcohol services.   From encouraging people to complete their Hepatitis B vaccinations (needing three injections) to rewarding regular attendance at therapeutic sessions we can demonstrate efficacy.  It doesn’t guarantee 100% outcomes, some approaches work better than others (cash is generally more attractive than vouchers - who knew?), but it is a valuable approach. And yet it has significant obstacles. It has been criticised as a reward for bad behaviour, it being unethical to pay people for what they “should do”, doubts cast over its long-term benefits (although these seem generally solid, with testing and vaccination benefits clearly being of ongoing benefit).  When resources are scarce it can seem hard to justify giving £20 to those who are often on the margins of our communities.  However, the efficacy of this kind of approach should be promoted and considered more widely.

Which brings me to the ice cream.  I have no idea of the opposition faced, or indeed of its effectiveness but the approach by Bologna should attract the interest of the world.  To encourage cycling, walking and the use of public transport citizens are rewarded with incentives such as ice cream, cinema tickets and even beer. It makes use of an app to see how people are travelling, which may seem an imposition, but for an ice cream, or a beer, I am sure I would adapt my behaviours. Let’s hope it helps Bologna achieve its air pollution goals, proves popular with its residents and so encourages fresh thinking in other cities about how to engage with our citizens. The carrot, or ice cream, may be mightier than the stick.

Wednesday, April 01, 2020
Everything is changed. COVID-19 and responses to it have seen dramatic and fundamental changes to how life is lived around the globe. International travel has come to a near complete halt, much of the world is under some form of lock down with businesses, schools, shops, pubs and cafes shut. Our economic and social reality is now unrecognisable from that of only weeks ago.
Tuesday, March 10, 2020
Clearly the current health focus is strongly centred on Covid- 19 and related issues, as it has been for the past few weeks. It is a demanding situation for politicians, officials, and indeed all of us, especially those working in our healthcare system. One of the major challenges we face is increasing understanding and encouraging changes in behaviour, while also avoiding panic and overreaction. Trusted and accurate information is clearly essential, both for those who have a key role and for the general public. We are certainly seeing more of England’s Chief Medical Officer and Chief Scientific Adviser in the media than usual. In the current situation, politicians are not only keen to hear from experts, but also happy to let them step into the spotlight. While we still see sensationalist headlines, there are also visible benefits of this approach, with more measured and informed elements within the media coverage- though this is less evident on the outer reaches of the online universe. Before I move on to other topics, let us reflect on the significant additional pressures being placed on our frontline health providers. They deserve our gratitude and, in many instances, much improved terms and conditions. Let’s hope that when this coronavirus issue passes the staff that so many rely on are not overlooked.
Monday, February 10, 2020
Public health is front and centre of the media currently, with concerns about the coronavirus outbreak, which was first identified in the Chinese city of Wuhan, splashed across almost every front page. With confirmed cases now reported in numerous countries across the world, we face the possibility of a pandemic. As several experts and commentators have pointed out, in our modern, highly interconnected world no epidemic remains a local concern. This, of course, makes for frightening headlines- which, in turn, calls for calm and informed responses.
Wednesday, January 15, 2020
So here we are: 2020. Let me start by wishing all of you the very best for the year ahead. I have, occasionally, been accused of an inclination toward cynicism and a failure to look on the bright side of things. So, for my first blog of the year, at least, I am going to be determinedly upbeat. You can judge for yourself how long it lasts. This sense of optimism is influenced by the fact that the end of 2019 saw some positive signs in the world of substance misuse. While it was something of a mad scramble against time, we managed to pull together a high quality and well-supported pan-London Christmas alcohol campaign. I am very grateful to colleagues who delivered the key elements of this work and to everyone who supported it. Some, in fact, went well beyond the call of duty to engage with our colleagues in the blue light services. Although we will not have any data in terms of its reach and impact for some months (I will update you), what I can confidently say is that many individuals and organisations liked the messaging and tone. I like to think it is helping contribute to Londoners having a more considered and healthier relationship with alcohol, though there is a way to go yet!

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CITY HEALTH INTERNATIONAL EVENTS

CHI Melbourne 2019

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CHI Liverpool 2019

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CHI Odessa 2018

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CHI Basel 2017

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CHI London 2016

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CHI Barcelona 2015

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CHI Amsterdam 2014

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CHI Glasgow 2013

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CHI London 2012

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City Health International
Founded in 2012 City Health International is a network of individuals and organisations engaged in the study of and response to structural health issues and health behaviours in the urban environment. For the first time in history the majority of the world’s population now live in urban environments and the proportion continues to grow. As national governments struggle to deal with the pressures and demands of growing urban populations against a backdrop of financial deficits and uncertainty, it is increasingly left to those working at a city level to provide the leadership and support needed to tackle key health issues.