EHJ April 2003, pages 108-110 Is the biggest challenge for the public health movement getting its message across to a 'fatalistic' public? Tracey Khanna reports

For a conference that seemed at times in danger of becoming wholly obscured by events in the Middle East, the UKPHA's annual public health forum, held in Cardiff last month, nonetheless succeeded in getting its important public health messages across, with the help of a raft of high profile speakers. Speaking of that week's political events, Geof Rayner, UKPHA chair opened the forum with the sentiment that "war is anathema to public health", and that the resignation of Lord Hunt as Minister for Health was a sorrowful event. "Lord Hunt was a staunch supporter of the UKPHA and public health," he said, "and while his principles are supported, we are sad to see him go."

Mr Rayner, went on to tell assembled delegates that the crucial challenge facing the public health movement is tackling the public's own perceptions of health and the health profession, and the persuasive effects of advertising. The question was how to work with communities' own "fatalistic" view of health, he said. The "I might get run over by a bus tomorrow" attitude. Mr Rayner went on to say that public health had historically suffered from a close association in the mind of the public with the state. In place of trust, he asserted, there had emerged a press narrative base around health interventions - such as the MMR vaccine - rather than the diseases themselves.

In her opening address, Jane Hutt, the Welsh Assembly Government Minister for Health and Social Services, said that April heralds a new beginning for public health in Wales. The creation of the new national Public Health service will lead to Wales-wide standards, she prophesied, while the Welsh Assembly's proposed Wales Centre for Health would support public health functions and have a lead role in tackling community inequalities by monitoring disease and ill health.

Wales has significant health problems, with life expectancy on average two to three years lower than the rest of Europe, she said. But the Welsh Assembly has made a "clear and public commitment" to tackle health issues through the use of health impact assessment (HIA), a vital tool that is already in use by all 22 local authorities in Wales. This commitment is demonstrated, she added, by the establishment of the inequalities in Health Fund, which is currently supporting 66 projects across Wales, particularly in areas of greatest need.

Ms Hutt also referred to the success of the first meeting of the National Health and Wellbeing Council, held last month, which she said would be a "launch pad" for renewed opportunities for the promotion of health and wellbeing. Maris Challans, chair of PHA Cymru, also addressed the health situation in Wales, emphasising that the emergence of PHA Cymru in the 1990s and devolution had offered stronger than ever opportunities to influence the health agenda in Wales. She said that there is no excuse not to participate in healthy activities, and to much amusement exclaimed: "We have our own stars in sports - Ryan Giggs - and we have rugby - although I won't say anymore than we have a good stadium in Wales!"

The value of physical activity to public health was hammered home in a packed session on the second day of the three-day event. The key message to emerge was that physical exercise has been proven to reduce the risk of virtually all chronic diseases and can substantially increase mental health and psychological wellbeing. Dr Chris Ruddoch, from Bristol University, said that while our genes have evolved for an active lifestyle, our "cleverness" has evolved the active element out of or lives. Talking to delegates on the evidence base behind the Chief Medical Officer's review of physical activity and health, which is as yet unpublished but expected later this year, he said that "low fitness ranks up there with smoking in its risks for premature death".

On the issue of exercise and psychological wellbeing, Professor Adam Taylor told delegates that it is not easy to provide an evidence base to prove that "exercise is good for you psychologically and socially". But, he went on to show that various studies indicate that acute exercise reduces anxiety, physical inactivity can be linked to mental decline in old age, exercise can help in smoking cessation, and that aerobic and resistance exercise can be used to treat depression as an adjunct to standard treatment.

Describing the early conclusions of a project to examine physical activity and sedentary living in school children, professor Stuart Biddle, from Loughborough University, said that while contemporary children have reallocated their media, "new" sedentary pastimes like computer games have probably just replaced "old" pastimes such as reading comic books or listening to the radio. He pointed out that studies show most children on average watch two and a half hours of television a day. He suggested that most undertake some form of physical activity as well, and that contrary to popular belief, body fat is not actually related to television viewing in children. For a lot of kids, he said, there is time for both.

Moving from exercise to food issues, delegates were told of a three-year lottery grant-funded project in Leicester, which aimed to assess the eating behaviour of families on low incomes. According to Diane Talbot, food and health co-ordinator at Leicestershire Nutrition and Dietetic Service, the successful long-term development of food and health projects depends on time and secure funding. Ms Talbot said that food and health projects "do not occur in a vacuum". Successful projects need to gain the confidence of the community if they are to become established.

The Saffron Food and Health project was launched in 1997 and centred on the Saffron Lane Estate. With a population of around 8,000, one in five households is headed by a lone parent, commonly female, and 55 per cent of children are on free school meals. The project's main aim was to evaluate a community development approach to nutritional education in the area, and Ms Talbot highlighted the need to collaborate with other professionals, while engaging all areas of the community in the aims and outcomes of such a scheme, for long-term success.

Through a wide range of initiatives, the project worked in schools, nurseries and youth groups to introduce "cook and eat" sessions, and exercise and healthy eating classes. By the end of the three-year period, fruit and vegetable consumption within the community had increased, salt consumption had decreased, a wider variety of foods were being consumed, breakfast was being eaten more regularly and there was a greater understanding of food labels, she said. Importantly, the impact of the project has led to city-wide initiatives being rolled-out across Leicester.

Moving away from the impacts of food and exercise on health, Jody Foster of the communicable Disease Surveillance centre (CDSC) in Bristol, asked what had been learned from the foot and mouth crisis of 2001. She told delegates that the primary issue faced by the rural community in Devon was the magnitude and speed of the cull. At the beginning of the crisis, she said, farmers in Devon and Gloucestershire in general felt that the speed of the cull was not moving fast enough to restrict the spread of infection. However, this view changed dramatically between February and April, she said, when the south west was faced with thousands of culled animals and nowhere to dispose of the rotting carcasses.

The area had insufficient incinerators to deal with the situation, causing a huge disposal backlog, and on-farm burial presented a significant public health issue. In short, she made it clear that there was not enough guidance from the Department of Health and an inadequate decision tree, which meant the professionals and farmers dealing with the disposal issue had to "keep going round and round the cycle". Apart from the public and environmental health difficulties, she said, communication was a huge obstacle as the military was not used to negotiation at local level. However, the foot and mouth crisis, if it did nothing else, she said, did change the way cross agency and cross-government working now takes place.

Finally, in the lively UKPHA debate on a potential looming crisis in public health, Dr Pat Troop, shadow chief executive of the Health Protection Agency, was optimistic in her sentiment that the public health movement is not in crisis. "I am one of the world's optimists," she said, "but I do think we have a large number of problems that cannot be tackled in isolation." The HPA, she said, wants to create an integrated infrastructure for health protection to strengthen the ability to reduce ill health. But she stressed that there is a vital need for a better research base to back this up.

Health protection is a 21st century issue, she told delegates. Speed and means of travel is allowing disease to spread around the globe in record time, while information and communication technology is having a huge impact on health and society. Knowledge is no longer the privilege of the few, she stressed, which while genuinely empowering can also have a negative impact on people by exacerbating inequalities. Other important public health issues lie in "skills deficits" - which has an impact on people's ability to find the right employment and that had a knock on effect on health.

Dr Troop pointed out that due to climate change, the global increase in summer deaths is being counteracted by a decrease in winter deaths, leading her to question the paradox of fuel poverty in the UK. All these public health issues end up in the media, she said, while access to information means that the public's attitude and levels of trust are very different now. "The public expects to be an equal partner," she told the conference. A message that each and every delegate will no doubt have taken home with them.