EHJ March 2003, pages 68-70 The sanitary inspector laid the foundations for the public health improvements made in 19th century Britain. As Ian MacArthur explains, the approaches they pioneered are equally relevant today in tackling global public health challenges

Thomas Fresh was the first of a new breed – the sanitary inspector. He worked alongside Dr William Duncan, Liverpool’s first medical officer of health, and James Newlands, the city’s first borough surveyor. Together they delivered the vision and leadership shown by the city of Liverpool in the 1840s.

Their work, and that of their contemporaries, laid the foundations for the approaches used in public health for decades to come.

Sir Benjamin Ward Richardson, president of the Sanitary Inspectors Association in the 1890s, had this to say about the role of the sanitary inspector: “It was soon found by experience that the medical officer of health required a working hand, since it was impossible for him to go from his office to inspect every danger to health. In this way sprang up the sanitary inspector. Nothing could be more simple, if I may say so, than his origin.

“The medical officer of health wanted someone who would not be afraid to inspect any nuisance or other contagious disorders. It was necessary that he should be what was called a respectable man, and he had to be, to some extent, presentable in private houses. His duties were laborious, his salary contemptible. I designated him, in his first days, as the ‘forlorn hope of sanitation’, which my colleague, Edwin Chadwick, thought was a happy description.”

What had to be done was usually fairly obvious. The problem was to induce the person responsible to get it done, and this was primarily a problem of policing. Enforcement called for an inspector of robust physique and undaunted character. The reforming and humanitarian ideas of the period were accompanied by an often conflicting belief in laissez-faire, and the resistance of owners of unhealthy property was vigorous and unabashed.

So what does the work of Fresh, Duncan and Newlands mean for the challenges confronting us today and how can we best tackle them?

Many of today’s highly qualified and professional environmental health practitioners will see elements of their role in the description above – especially the salary. There is one difference, however: today, and to its great credit, the profession boasts a high degree of equity between the sexes.

Some things change, but others remain the same. I recall on one occasion driving past snow-specked fields of Slovakia, where I noticed a gypsy encampment, with children like those anywhere else playing football – only some of the boys were shoeless. Shocking enough, but as I drew closer I could see the shanties. Cobbled together from iron sheet and timber, they were chimneyless and had smoke billowing from the eaves. But I also noticed that one in three of these so-called homes had a satellite dish perched on the side.

This scene encapsulates the conflicts and dilemmas we face at the dawn of the 21st century. It highlights the stark inequities, reveals the extent of the anti-health forces pervading the planet and demonstrates how far we have to travel to reach the objective of sustainable development. We are often told, with some pride, that the UK has the world’s fourth largest economy. Yet, despite its apparent wealth, it labours under heavy health burdens.

For instance, the 200,000 new cases of cancer diagnosed every year cost the NHS in excess of £1bn. Heart disease is a major killer, with 1.25 million life years lost before the age of 75. Mental illness is estimated to cost this country some £32bn, and the recorded 4,500 suicides a year are equivalent to 400,000 lost life years before the age of 75. The UK has around one million Prozac users, with sales of the drug running at £100m a year.

Perhaps most significant of all is that the UK is a country of stark inequalities. The life expectancy of boys in Manchester is almost eight years shorter than that of their contemporaries in Kensington, Chelsea and Westminster in London; for girls, the difference is seven years. This is a sad indictment of the world’s fourth largest economy.

It is true to say that the world has witnessed, especially in rich and industrialised countries, a spectacular increase in living standards and longevity since that days of Fresh et al. Yet, to date, we have failed, despite having the knowledge, wealth and capacity to do so, to lift the absolute poor out of poverty, reduce the differences within and between societies. We have the resources, but we somehow lack the will to do it.

Credit is due to the recent analysis, vision and now action on health inequalities pledged by the Government. The leadership shown by the Department of Health and the Treasury gives hope for serious programmes of action nationally.

This will call for a new model of intervention, away from the traditional approach of health promotion and education. The world has changed radically in the past decade, perhaps more rapidly and more profoundly than at any time in modern history. It has changed not solely in the physical sense but also in the social sphere, through the development and reach of the information revolution. The general population has never been, at one and the same time, so well informed and yet so misinformed.

As a result, those seeking to improve public health, to change unhealthy lifestyles or to provide health protection need to work in new and subtler ways, mindful of the far-reaching cultural changes. How professionals – who aim to protect public health and develop health initiatives – can best act and interact with the public in this age of informed consumerism poses a fresh challenge. New professionalism cannot be based on the acquisition and retention of knowledge alone. Effective public services must rely on good interpretation and communication skills.

The way we approach future challenges will be as important as what we actually do. Many of the risks to health today are intertwined with lifestyle choices, which are in turn often determined by environmental, social and economic contexts.

Traditional health promotion and education activities have often focused on messages to the individual regarding lifestyle choices. Behind this is the notion that once people have understood what is bad and what is good for them, they will make the right choices.

We know from experience, however, that this approach has only a minor impact on public health. What is needed is a far deeper understanding of the factors that are detrimental to health and the forces that encourage unhealthy lifestyles.

Any new approach must recognise that not only does the environment have a direct impact on health – through pollutants in the air, water and food – but also that our environment affects the way we live, travel, get our food, access education, culture, and green space. It also determines to a high degree the level of our social interactions.

In turn, poor or unhealthy lifestyle choices impact further on the environment, both locally and globally. Unhealthy environments beget unhealthy lifestyles, which in turn beget unhealthy environments. This can lead to a depressing spiral of decline. Environmental change can be achieved only through billions of individual lifestyle decisions.

The way to begin to reverse this vicious cycle is by taking action to improve our environments. We intuitively feel healthier, calmer and happier in more natural, greener and leafier environments. Indeed, the results of research by Roger Ulrich of Texas State University led him to conclude that the human drive for life in a sustainable greener environment may be genetically driven. However, if this is the case, one has to wonder how we have got it so wrong so often in the past.

Health and environment have always been closely intertwined. Bad environments can be a cause of ill health and can affect mortality. Good environments contribute directly to a better quality of life and wellbeing.

In recent decades, the subjects have drifted apart. Health policy, resources and institutions have concentrated primarily on treating of ill health, with prevention activities taking a back seat. Environmental policy has at the same time broadened in scope and has at times given low priority to health-related objectives.

It is time for a reintegration of the subjects, not simply in partnership between the sectors – a new and integrated approach needs to emerge. The professional approach should strive to increase diversification and breadth, rather than specialisation and expertise – to create specialist generalists would not be a contradiction in terms.

The day is long since past when we could rely on the environment to provide for us and absorb our waste products. We must take serious steps to manage all our resources – human and natural – not in an ad hoc fashion but in a way that reflects the balance and integration that is apparent in all living things and systems.

Boutros Boutros-Ghali, the former UN secretary-general, once remarked: “We live in a world that we do not yet fully understand.” Over the past 25 years we may have made inroads into understanding our global environment but we have much to learn about our complex social and economic systems.

William Duncan, Thomas Fresh and colleagues understood the challenges and they gave us a model for today: explore the science – yes – but, ultimately, translate the findings into practical benefits for the poor and disadvantaged. Only by taking this route will we be able to contribute towards making the whole of society a better and healthier place. By taking this approach – together – we can make a world of difference to this world of differences.

Ian MacArthur is chief executive of the UK Public Health Association.

This is an abridged version of the 4th Thomas Fresh lecture, delivered to the Duncan Society in Liverpool on 16 October 2002. This article was originally published in Health Matters, issue 50, winter 2002/03.