City Health International


This is not the blog I was planning to write. My intention was to look at developments in managing the Night Time Economy across a number of cities, an area where there is innovation and positive developments. Instead I feel compelled to look at an issue where the UK and others are demonstrably going backwards. Battles we thought had been won in fact appear lost, progress has not just stalled but been significantly reversed. It poses hard questions for many organisations and for individuals, including myself. So, come with me as I look at drug related deaths.

Twenty years ago, I began working in drugs policy. At that time just about every measure of data provided a depressing graph. Overall prevalence, drug related crime, and deaths all showed significant increases. Numbers into treatment showed some modest increases, the most significant positives were to be found in the successful efforts to reduce the spread of HIV amongst injecting drug users. The UK Government didn’t ignore the situation, some significant policy responses were put in place in 1995, these were reinforced by a new government in 1997, who had backed their ambition to reduce drug problems (especially crime) with massive investment. It was an exciting time to be a Civil Servant (yes really!), the pace of change was palpable you could “feel” things were improving. While progress was unevenly spread, it was real, and the graphs started to tell a different story.

Money made a difference, but so did leadership. From Whitehall to the local town hall there were individuals who promoted the importance of reducing drug related problems. Across relevant agencies and amongst many communities we saw an increase in the understanding of drugs and activities that benefited communities and individuals. There were many barriers and arguments about the value of work with young people, scope of treatment, what should come after treatment, tinkering with the Misuse of Drugs Act, and where the borders of harm reduction should lie. It could be frustrating, but it was dynamic. And at the risk of repetition much did improve. Around the world there was an interest in what the UK had done and what lessons could be applied to their own issues.

More than one Prime Minister felt able to say our approach to drugs was working and this sense of achievement perhaps permeated the entire system. Certainly, when various red lights started blinking on our dashboard some five years ago, they were treated as a blip, nothing to be too worried about.

Well in 2019 we should be very worried. The latest drug related death figures for England and Wales were recently released. These have increased by around a third, some thousand deaths, since 2013. Scotland has also seen record drug related deaths. Explanations are often offered in terms of an ageing opiate using population and to a point its valid. But that suggests that these deaths are somehow inevitable when clearly most are not. It also ignores the fact that its not just the ageing, Trainspotting generation (those of my vintage) who are making up the numbers. Record numbers in their 30’s and 40’s are also dying. In the broader context we are also seeing rises in prevalence amongst young people. Deaths are of course just the most the most acute harm. The tip of an iceberg, the canary in the mine, an indication of massive problems in services for the most vulnerable communities and individuals.

Reductions in funding are of course a contributory factor. Core drug services are still to be found and formal waiting times for treatment remain short, but a lot of the “softer” services have reduced. Outreach and peer work which was once widespread is now relatively rare. Innovation is rare, other than in how to deliver services for less money. At the risk of upsetting colleagues, I would also highlight a loss of expertise and knowledge across a range of allied services. Training budgets are easy to cut. Reducing expenditure on conferences may be justifiable when trying to preserve core functions. But it comes at a price. Agencies and professions retreat into their silos. Mutual understanding and cross sectoral collaboration weaken, though these are incredibly valuable when money is scarce.

The gloom is not quite all pervasive. In terms of blood borne viruses we have managed to keep HIV rates amongst injectors low at 1.2% and 97% of those with it are aware. Over the last decade the numbers with Hepatitis B have halved. Hep C has seen more modest gains and prevalence remains around the 50% mark, but the new treatments offer an exciting opportunity to eradicate this virus (and as such is attracting valuable political support). Worryingly rates of those sharing equipment has increased but the above shows that it is possible to do valuable and meaningful work with people who inject drugs. They are not beyond our reach, we not only know what to do, it is actually happening.

Of course, the UK is not alone. The USA is seeing an opioid death epidemic of massive proportions. Australia too has seen significant rises and, like the USA and UK, a lot of this occurring in areas which have previously seen relatively low rates of drug problems. Australia was of course in the vanguard of drug harm reduction. I have read advocates there calling for a greater focus and effort from politicians, as well as a willingness to trial new health-based approaches. In Scotland there has been a political response and a taskforce established to consider existing drug laws and the potential of supervised drug consumption rooms. The latter clearly has potential for saving lives of those who use them, but I think they may also have a broader, totemic, impact in terms of encouraging other approaches to help populations beyond their geographic reach.

So far in England the response has been muted. No one has even claimed Brexit will improve the situation. Public Health England are doing what they can, but the overall the sense seems to be of grim inevitability. Which will surely guarantee that next year sees another increase. My hope is that we rediscover some of the sense of mission that was once prevalent in the drugs field, that the provider sector is reinvigorated, we manage to engage some politicians, maybe even find some money. In doing so we can save lives, protect our communities and validate what we do. Who’s up for it?

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!



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.