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20 years of local ecological public health: the experience of Sandwell in the English West Midlands
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Available online at www.sciencedirect.com
Public Health journal homepage: www.elsevier.com/puhe
20 years of local ecological public health: the experience of Sandwell in the English West Midlands* J. Middleton a,*, P. Saunders b a b
University of Wolverhampton, United Kingdom University of Staffordshire, United Kingdom
article info
abstract
Article history:
A long-term picture of the economy and living conditions of Sandwell, an area of England's
Available online 26 September 2015
industrial Midlands, is presented to explore how these underpin and influence its ‘health economy’. Sandwell's experience illustrates how public health actors have to tackle industrial and other factors which shape human health. The paper explores how the
Keywords:
ecological public health perspective has helped inform the modern public health task in an
Ecological public health
area such as Sandwell. Some lessons are offered, including: the need to understand the
Tracking
specific economic legacy of a local area (in Sandwell, principally one of polluting and then
Inequalities
declining manufacturing industries); the continuing story of infection control; the complexity of tackling poor diet; and the importance of the built environment and town planning. Faced by such challenges, local public health action represents, in effect, an attempt to transcend unecological public health. This can be exciting, innovative and ultimately successful; but it also means being prepared to face daunting and politically charged obstacles and superior national or international forces over which local public health practitioners conventionally have little leverage. The paper argues that, in such unequal power circumstances, public health practitioners have to draw on the creativity within the local population and build a facilitative alliance of formal and informal propublic health actors. Despite the confounding odds and ever-present stretched resources, the Sandwell experience gives grounds for optimism, being a story of constant creativity and effective local alliances. © 2015 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.
Rusty Lane, West Bromwich, 1933 The whole neighbourhood is mean and squalid, but this particular street seemed the worst of all. It would not matter very much e though it would matter e if only metal were kept there; but it *
happens that people live there, children are born there and grow up there. I saw some of them. I was being shown one of the warehouses, where steel plates were stacked in the chill gloom, and we heard a bang and rattle on the roof. The boys, it seems, were throwing stones
Note: Dr Middleton was funded by the National Institute for Health Research (NIHR) through the Collaborations for Leadership in Applied Health Research and Care for Birmingham and Black Country (CLAHRC-BBC) programme. This paper was prepared under the auspices of the CLAHRC-BBC knowledge management programme. The views expressed are not necessarily those of the NIHR or the Department of Health. * Corresponding author. E-mail address: [email protected] (J. Middleton). http://dx.doi.org/10.1016/j.puhe.2015.08.011 0033-3506/© 2015 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.
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again. They were always throwing stones on that roof. We went out to find them, but only found three frightened little girls, who looked at us with round eyes in wet smudgy faces. No, they hadn't done it, the boys had done it, and the boys had just run away. Where they could run to, I cannot imagine. They need not have run away for me, because I could not blame them if they threw stones and stones and smashed every pane of glass for miles. Nobody can blame them if they grow up to smash everything that can be smashed. There ought to be no more of those lunches and dinners, at which political and financial and industrial gentlemen congratulate one another, until something is done about Rusty Lane, and about West Bromwich. While they still exist in their foul shape, it is idle to congratulate ourselves about anything. They make the whole pomp of government here a miserable farce. The Crown, Lords and Commons are the Crown, Lords and Commons of Rusty Lane, West Bromwich … and if there is another economic conference, let it meet there, in one of the warehouses, and be fed with bread and margarine and slabs of brawn. The delegates have seen one England, Mayfair in the season. Let them see another England next time, West Bromwich out of the season. Out of all seasons, except the winter of our discontent. J.B. Priestley1
Introduction In his book, An English Journey, from which the quotation above is taken, J.B. Priestley describes a visit to the Black Country. He contrasts the experience of the children of Rusty Lane, West Bromwich, with his Chamber of Commerce dinner with the burghers of Dudley later in the day. Had he returned at 10 year intervals to the present day, he might just have repeated his observations. Each new civic reform initiative has produced some progress, but Priestley may have commented on the same tone of self-congratulation by the local ‘Great and the Good’, when in reality, inequalities in health and life chances persisted within Sandwell and when comparing Sandwell with the rest of England. Sandwell's unsustainable industrial past stretches back over 250 years, best described perhaps as an example of unecological public health: humankind operating in extreme odds with a natural environment which has been constantly pummelled and degenerated over time. It illustrates too how the physical environment reflects human activity with health consequences, how in public health we have to unpick a complexity of factors, and how we must also be alive to the recognition that environment is not just an external force or property but is actually part of us. Indeed, that the environment permeates our human essence and existence. One might even suggest that whereas conventional public health sees the environment as an external factor impinging on health, ecological public health sees the environment as integrated into biology and human physiology. The Sandwell experience suggests how the reworking of local conditions permeates culture, quality of life and personal expectations, and not therefore just the objective indicators of life. Also we see, as did Priestley in otherwise very different times, that Sandwell's experience is infused with social dynamics, a very British illustration of how political economy, environment, culture and health intertwine. As Priestley himself understood, this was not a new phenomenon, but one continuously
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reworked and impressed into the health landscape. Local public health action can be exciting, innovative and successful, but it can also meet impossible obstacles from superior forces, which can only be tackled nationally or internationally. The Sandwell experience, however, is endlessly optimistic, one of constant creativity and local alliances.
Ecology and the industrial environment e the legacy of industry and environmental public health tracking Sandwell Metropolitan Borough was formed in 1974 by the amalgamation of the County Boroughs of Warley and West Bromwich. The 2011 Census recorded a population of 309,000 (June 2011), ethnically 65.8% White British, with a life expectancy of 75.5 years for men, and 80.8 years for women. Sandwell is in the centre of the West Midlands conurbation and is one of the four ‘Black Country’ districts, the others being Dudley, Walsall and Wolverhampton. The borough is the twelfth largest local authority district by population size in England, comparable in population size to Nottingham or Newcastle. It covers a relatively small area (8650 ha/ 21,150 acres) and comprises alternately, heavily built up industrialized areas, dense social and private housing, and areas of extensive dereliction.2 Since the industrial revolution the Black Country has been known for its heavy industry, for coal, limestone and iron ore used in its industries, its metal pressing plants and for its chemical industries. An extensive canal and rail network served the myriad of small factories extending to Birmingham, an area once internationally known as the ‘Workshop of the World’. The area also gained a reputation for some of the most appalling environmental and working conditions of Victorian England. The appellation ‘Black Country’ may have been taken from Elihu Burrit's book Walks in the Black Country and its Green Borderland, in which the writer described the place as ‘Black by day and red by night’.3 The historian Thomas Carlisle added that it presented “a frightful scene … A dense cloud of pestilential smoke hangs over it forever and at night the whole region burns like a volcano spitting fire from a thousand tubes of brick. But oh, the wretched thousands of mortals who grind out their destiny there!”4 It remained in this condition for much of the 20th century, with its residents living besides slag heaps and underground coal fires (see Figs. 1 and 2). The boom years of the early post World War 2 period profited its foundries by demand from the equally booming Midland car industries, but the poor environmental conditions and terrible health patterns persisted. If by the late 1970s there were still more than 40 foundries in Sandwell, the precipitate collapse of West Midlands manufacturing in Thatcher's Britain of the 1980s brought the demise of most. Across these years of rapid economic restructuring the number of foundries reduced to 18 and then slowly trickled down to just three. Those still in operation undertook the dirtiest and often the most dangerous forms of metal pressing, of the kind that South Korea, where foundries boomed, wouldn't accept, or elsewhere, as in France or Germany, where the quality of scrap used in Sandwell was unacceptable.
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Fig. 1 e West Bromwich, 1967. King George Playing Fields with ‘Elephant Rock’ in the background. This huge slagheap from the Hamstead Colliery and has now been replaced by the Sandwell Valley Country Park and Bird Sanctuary. Image courtesy of Express and Star.
Fig. 2 e Moxley, West Midlands, November 1956. In Minnie Page's backyard, acrid smoke seeps to the surface as old underground mine coal seams burn. The ground was warm to walk on and locally they called them ‘The Fiery Holes’. Image courtesy of Express and Star.
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Chemical cocktails from burnt engine oil and heavy metals from paints were liberated into the air, assaulting the lungs of foundry workers and the local community. Even in terminal decline, therefore, the poisoning of people and place persisted. If the nineteenth century housing stock was poor and insanitary, Sandwell also fell victim to post World War 2 experiments in mass housing and city planning. These placed the motor car before communities and side-lined the public transport systems, rail and canal, which had formerly been the backbone of the local economy.5 Even the success of the 1956 and 1968 Clean Air Acts was double-edged. Air quality improved dramatically, adding an estimated two years to life expectancy,6 but it also helped destroy industries where local people had found identity, pride, and a living.2,5 Stretching back over the century, the role of local authorities had been expressed through education provision, social institutions and hospital care; even the ambulance service was provided by the municipal authorities until the NHS was established in 1948. What is now called social housing was vital, indeed, the only practical solution to housing shortages. In contrast, early Black Country ‘town planning’, composed of speculatively built tiny and low standard ‘back-to-back’ houses, cramming in worker's families. Newer council housing, whatever its many defects, at least remained located within walking distance to industrial employment. Indeed, because of such close proximity, Sandwell might well have been considered the paragon of 21st century healthy cities and sustainable living; perhaps too healthy a contrast to car-based modes of living which elsewhere have atomised culture and reduced the likelihood of people walking and talking. In reality, in this multideprived area, so many stressors, material, social and environmental, have been bundled together that it has been all too easy to be reminded of Thomas Hobbes's words that so many people's lives are nasty, brutish and short. Nevertheless, in comparison to the past, there was progress to be seen. Britain's original 19th century public health movement had addressed a filthy, disease-ridden environment. The problem was that while the environment did improve considerably, it has continued to exert a powerfully negative effect on health. The Chief Medical Officer for England has shown that while men from affluent populations experience relatively good and similar levels of health irrespective of geographical region, mortality rates for men from deprived populations showed a marked north-south decrease.7 This relationship was also emphasized in Professor Michael Marmot's rigorous analysis of the distribution, scale and consequences of inequalities in England.8 Some of the differences in mortality are put down to ‘lifestyle choices’, such as alcohol consumption and smoking, or to other confounding factors, but the impact of environmental issues remains a plausible factor, given the evidence that there is something about the stress of being poor that makes people more vulnerable to hazardous exposures.9 Estimates of this burden vary and the environmental stressors have changed over the decades, with increasing research focus on more global and international issues such as climate change and the more subtle effects of low level exposure to hazardous chemicals. These are important but communities also
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consistently identify damage to amenity due to litter, fly tipping, noise, bonfires, housing disrepair, street lighting, and derelict land. These interferences on day-to-day life have an objective impact on health and life quality. In fact, it is through these dimensions that the public understands ecological public health. On the other hand, little is known or understood about the interactions between environmental factors and lifestyle, and certainly the impact of the contemporary environment on health is complex and multifaceted. More innovative methods are required for the targeting and management of interventions for the greatest health benefit and for the reduction of health inequalities, suggesting the relevance of a multidisciplinary confederation of surveillance, horizon scanning, exposure assessment, research, and the integration of data and intelligence on hazards, exposures and outcomes. These form the precise fundamentals of the Environmental Public Health Tracking system established in Sandwell, the first of its type in Europe.10,11 Through this system, Sandwell seeks to develop a more rounded and complete set of indicators than life expectancy alone, useful though that is.
Ecology and communicable disease Water disconnection and disease In the early 1990s, the then Conservative government privatized publicly owned Water Boards in the middle of the biggest dysentery epidemic in 10 years, leaving itself open to the allegation that water disconnection was its cause. Over 1000 local households were disconnected virtually overnight, resulting in a ‘dirty protest’ by the residents of Hamilton House (a large tower block, since demolished) and formed a stimulus for action by welfare rights and public health campaigners. A later Labour government outlawed domestic water disconnections,12,13 and today water use is shaped by volume -related charges and the business strategies of water companies, mostly internationally owned, which are forced to tackle decades of underinvestment under their former public and private owners.
The new ecology of industrial disease The foundries may have mostly disappeared, but remaining local industries are not without risk. The Solvay plant in Oldbury, formerly Albright and Wilson, is owned by one of the world's major producers of phosphorus products. Phosphoric acid forms an important constituent of everything from matchstick heads to fertilizers and toothpastes. The plant even appeared in the Sandwell food industry survey in 1990, since this chemical is also used in soft drinks.14 This chemical process involves the use of large quantities of phosphorus and chlorine. If the materials are not adequately cooled there is a risk of explosion. There have been three major phosphorus fires at the plant in the last 20 years. In 1989, a plume of white smoke traversed the City of Birmingham as far as the airport; further smaller incidents occurred in 1995 (pictured Fig. 3) and 2009. If the coolants themselves are not adequately maintained there is a further
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Fig. 3 e Albright and Wilson factory fire, 1995. Image courtesy of Express and Star.
risk of legionnaire's disease, with one outbreak in 2002.15 The legionella bug is a prime example of the modern ecology of health. Although this ubiquitous organism can be found anywhere from puddles on the roadside to every kind of watercourse, it is generally spread by water vapour via the diverse trappings of modern life, industrial air conditioning, industrial cooling and scrubbing systems, jacuzzis, car washes, fountains and domestic showerheads.16 Vapour mists can spread up to 500 m, affecting the unhealthy or the frail, and particularly smokers.
Health care acquired infection Health care acquired infection is another example of the ecology of public health.17 In Sandwell, a major drive on control of infection from 2004 saw clostridium difficile rates fall by over two thirds, with Methicillin Resistant Staphylococcus Aureus (MRSA) reduced to single numbers of cases. Clostridium difficile presents a classic case which needs to be viewed as a ‘whole system problem’ within the health and social care economy and not just a provider problem, as it was by the Care Quality Commission, the industry regulator. If any part of the system goes wrong, for example pharmacists prescribing loperamide (for diarrhoea), GPs prescribing too many or the wrong antibiotics, care homes not cleaning adequately (in one case coming to light in Sandwell, not changing mattresses for 20 years), or junior doctors not washing hands before or after touching patients, the problem will surface. Hospitals have blamed the community for causing the infection, rather than recognising themselves as being part of the community. The managerial culture post the Health and Social Care Act 2012 enshrines this thinking and arguably leaves the whole system at risk of more infection.18
Ecology, healthy town planning and the obesogenic environment It cannot be expected for citizens to live healthy lives if the general conditions which affect their lives are unfavourable. In an area like Sandwell, with a long history of challenging environmental conditions and poor health, sustained health improvement realistically requires much more than single, short-term interventions but rather a long-term commitment. Such a perspective conceives of health in terms of the public sphere and recognizes that risks to health go far beyond the influence of individualized choices or personalized health. While this perspective can open up public health to the charge of ‘nanny-statism’, on the contrary what it has achieved, to a degree, is the civilising of ‘raw’ capitalism, injecting some humanity and decency. In pursuit of this civilising role, there are a number of roles and traditions on which public health can and should again draw. One of these is town planning.
Healthy town planning After assessing the state of Sandwell's health in the 1980s, the positive health role of town planning was outlined in Sandwell's 1992 public health annual report.19 Sandwell Health Authority (SHA), now replaced in one of the seemingly endless reorganizations by central Government, found itself in a public enquiry concerning its support for the location of the bus station, some 200 m from the proposed Midland Metro, a regional transport scheme, and therefore in opposition to relocation proposals. The SHA argued in the 1993 public consultation on the Unitary Development Plan that an interchange for transport between the bus station and Metro was needed to promote the use of public transport. The SHA was
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opposed by the then owners of the existing bus station and the Inquiry Inspector upheld their view, but five years later a new bus station was opened opposite the Midland Metro station; and incidentally, in proximity to the new Lyng health centre in West Bromwich. The health press highlighted the role of health in town planning and Sandwell has continued to probe and develop this partnership with planners ever since, particularly through the promotion of cycling and walking.20,21 In effect this partnership prefigured ‘obesogenic environment’ thinking.22
The local food economy and the obesogenic environment The monitoring of an environment which fed people poorly is a further illustration of how Sandwell took an early interest in diet. Evidence on diet's impact on health is longstanding, but Sandwell saw that food retailing had an important gatekeeping function on food availability. It conducted local research into food deserts,23 and worked with retailers to redress the poor availability of fruit and vegetables. Sandwell also championed improved sourcing from nearby Staffordshire farmers, assisted by stock management and display by Fresh Solutions, a private consultancy supporting food growers in marketing their products.24 Before the official Department of Health Eatwell plate, Sandwell explored community agriculture and horticulture schemes, such as with the Malthouse Garden and Salop Drive experiments.25,26 These became beacon projects, showing what can be done in previously degraded environments. The Public Health department learned quickly that food and diet was multifaceted and complex, with few quick fixes. The Government Office for Science's celebrated Foresight Report on Obesity ‘systems maps’ certainly captured that with their depiction of the forces which surround the apparently simple (im)balance of energy inputs and outputs that tilt populations into obesity or protect them from it.27 Just to support healthy behaviour or provide health education would not be enough to transform deeply ingrained food cultures and poor dietary preferences. A longer-term approach was charted. Elements include the reestablishment of community food skills, the celebration of healthy home-grown fresh produce and the sharing of growing skills. The goal has been to give people of all ages an appreciation of where their food came from and to reconnect with seasonality. The act of growing food can be health-promoting in itself and impart a sense of community cohesion and fulfilment.25,26 Sandwell made a wider commitment to support investment in ‘environmental capital’ such as through access to green space, and by including Sandwell's Environmental Tracking programme, the principle being that measuring negative environmental factors required the supplementation of positive factors. Following the Foresight report, central government became more interested in the kinds of issues Sandwell had been analysing e the connection between obesity, environment and food supply. Hugh Barton and colleagues have scoped a new approach through the lens of healthy town planning.28,29 In 2008, that perspective was legitimated by the government's Healthy Towns challenge. Sandwell was unsuccessful in its bid to be part of that, losing out to neighbouring Dudley (which made a great fist of its good fortune.)
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However, Sandwell did create, by other means, what had been bid for: the Sandwell Healthy Urban Development Unit (SHUDU).30 Since 2008, Sandwell has responded to national planning consultations, staged a major national conference on healthy town planning including restricting fast food outlets and produced a supplementary planning guideline (SPG) on fast food outlets.31 A geospatial analysis of the density of fast food outlets was prepared, showing links with patterns of deprivation. In effect, Sandwell is saturated by hot food takeaways, with few residents more than a short walk away, revealing a significant association between close residential proximity to a hot food takeaway and deprivation.31 Research into the foods offered by Sandwell's takeaways in 2013e14 found large portion sizes and high levels of fats and salt. How can a healthy diet be promoted and achieved when all the signals point in the opposite direction? Residents have limited opportunities to break out of this highly compromising environment given high levels of deprivation, limited transport options and the dubious distinction of living simultaneously in a ‘swamp’ of unhealthy, readily accessible and cheap takeaways and a ‘desert’ of healthy options.32 From the food business point of view, profit margins are under pressure, with cheap ingredients undermining their desire to create a ‘good food culture’. This illustrates the limits to what can be done at the local level to transform food's impact on public health. Some food issues are far beyond local control. The use of ‘transfats’ (hydrogenated fats) in processing, for example, cannot be resolved by Sandwell. It needs national and European-wide action. Local authorities can do more, however, by using local planning and regulatory powers; addressing portion sizes; stimulating demand for healthier products; framing school food procurement policies; adapting the roles of Council enforcement officers to persuade the industry to promote healthy food preparation techniques; and local social marketing campaigns targeting consumers and businesses.
Air pollution and green canyons Through the 2010 annual public health report, ‘Three Greens for Health’, focusing on green space, employment and social dividends, the Director of Public Health and team trialled the Sandwell environmental tracking programme.5 Such reports stimulated regular public attention to the relationships and interactions between environmental stresses and deprivation and ethnicity. These have fostered an active discussion with regulators about the need to ensure that industries located in deprived areas comply with the law and improve performance. While air quality has improved dramatically in Sandwell over the last 30 years, hotspots remain. Traffic generated NO2 is now the most important pollutant. In some areas, there appear to be no technical fixes other than total pedestrianisation of busy high roads or to condemn living accommodation as unfit for habitation, neither of which are realistic or politically acceptable. What, therefore, could be done? One solution has appeared by thinking about the local environment as an eco-system and considering the implications of any one intervention on other domains. Firstly, evidence of
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health gain from early actions was needed to win over political support. Academics have helped create and pilot an exposure coefficient to estimate the health costs of current levels of NO2.32 Sandwell has also responded to community aspirations for more walking and cycling opportunities by assessing the potential impact of ‘greening’ some urban corridors. Academic literature suggests that such investment e creating green ‘urban canyons’ e improves air quality and urban aesthetics.33 Such arguments alongside the quantification of health impact has provided the means to recruit political as well as professional support and Sandwell is currently implementing the first phase of greening the most vulnerable locations.
Annual reports, environment and ecological public health In 1989, Life and Death in Sandwell highlighted the environmental legacy of ill health in Sandwell.6 In 1992, Sustainable Sandwell proposed new remedies.19 The 1992 Sustainable Cities conference in Brighton furnished ideas for self-build housing, food co-operatives, local growing and local exchange trading schemes. By 2009, with the Three Greens for Health report, Sandwell was looking at environment and ecology in an altogether more integrated way, with health promotion redefined as ‘green promotion’, incorporating cycling, walking and food for both health and environmental gain; greening the health service as a good corporate citizen; and ‘green industry’ proposed as the next industrial revolution delivering a ‘green dividend for health’, alongside environmental tracking. This was the application of 21st century public health and epidemiology methods to the old problems of environmental nuisance and hazards. This annual report was also the first to introduce biodiversity as something of relevance to human health, giving attention to slugs, rats, and pigeons, the beneficiaries of human waste at the expense of biodiversity.5 One can either view garden slugs as ‘needing’ agrichemical assault or as a problem solvable by the introduction of hungry ducks. Viewed in this way, there isn't a snail problem, but rather a duck deficiency.
Outcomes Improvements in health outcomes featured in Public health: a life course, the 2013 annual public health report for Sandwell.34 Heart disease related deaths reduced by an astonishing twothirds since the 1980s. Some of this is reflected in the longterm trends affecting all parts of the country, but improvements made in Sandwell have reduced deaths faster than the national rate and have reduced the gap in life expectancy with the national rate. Not all improvements are attributable to wide-ranging ecological and strategic interventions. The GPbased risk stratification system shows that more than 70 lives a year have been saved from cardiovascular disease. In contrast, heart disease related deaths actually rose in the mid2000s. The group of men thrown out of work in the 1980s were dying prematurely from heart disease, brought about by a lifetime without work, hope, and probably too much smoking, drinking and physical inactivity. Teenage pregnancy reduced
by 44% since 1998, attributed principally to rising expectations in education (from 2007, examination results rose as teenage pregnancy rates reduced). Over a number of years, it ceased to be acceptable to attribute poor results and low expectations for our children to ‘deprivation’; if one teacher, or one school, could achieve success in educating children under difficult circumstances, they were now all be expected to. In health, there were also some excellent services built up painstakingly over a number of years, in personal social education, young people's contraceptive services and morning after pill availability from pharmacists. The fact that teenage pregnancy has not increased since the recession is, plausibly, due to the insulating effect of the Surestart programmes, which began in 1998. Surestart gave support to parents from deprived backgrounds, plus additional support to teenage mothers. A Surestart maternity grant gave some financial support to pregnant mums. The Cabinet Office policy advisory team came to Sandwell in 1998. It expressly set out to support teenage mothers to break the cycle of babies born to teenage mothers and then becoming teenage mothers themselves some 16 years on. The benefits of this intervention are now becoming fully visible.44 This includes excellent dental health in the under 20s through a technological fix: water fluoridation.36 Over 25,000 Sandwell homes have been improved to a ‘Decent Homes’ standard. Local research found larger reductions in cold-related deaths than previously reported.37 A further improvement has been achievement of the lowest reoffender rate in the country by the Sandwell probation service in the context of a Safer Sandwell partnership which has contributed painstakingly and effectively to reducing crime. The health component of this initiative has been considerable, varying from tackling drug and alcohol related crime, responding to domestic violence, providing appropriate care for mentally disordered offenders and supporting community development programmes to combat violent extremism. The recovery effort for drugs and alcohol related offences has also been an additional contributor to the reduction in reoffending. It is difficult to measure and attribute changes in health indicators to a particular ‘ecological approach’. The essence of the ecological approach is that it recognizes the need for a complex series of interventions. Single interventions like control of fast food outlets or traffic calming or drug harm reduction programmes may have multiple outcomes in health, social care, crime prevention, safety and in economic spheres. Complex interventions in regeneration require partners to act in tandem and outcomes may become more diffuse. Other outcomes are apparent as process improvements; the environmental tracking system becoming a pioneer in Europe,10 later endorsed by the World Health Organisation and commended in international meetings. Integrated working with others and securing political support has led to projects that would not have happened otherwise. It has enabled the area to successfully pursue interventions through funding bids and as additions to mainstream budgets.
Conclusion By no means can the Sandwell story be painted as one of unalloyed success. Rather, it is one of constant struggle to think through problems, to innovate and to engage creatively
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with the local population. Perceiving human and eco-system health as linked has become integral to the local public health tradition. 21st century public health has many options; potential solutions can arise from theoretical choices. The implication is that new and different skills, investment and effort are needed. Sandwell in the 1990s had the appearance of more dereliction than New York's Bronx but also the reality of more canals than Venice. The Neptune forge that once made heavy chains for ocean liners was transformed into the Neptune Health Park, a pioneer of the healthy living centres that flowered in the 2000s, with GPs, pharmacists, dentists, a health information centre and Citizens Advice Bureau, alongside a newly established canal-boat mooring. In this manner, crises were transformed into opportunities. Ironically, some of the industrial waste from foundry works in the past may now be commercially viable for secondary mining of the residual metallic elements, potentially generating employment and income. The lessons from Sandwell turn on its continued capacity to apply the lessons of history to protect local people and their environments and to continue to seek to apply creativity and innovation to face the future. Sandwell has tried to chart a new basis of hope from ecological public health and from its social diversity. In the 1960s, it was an area scarred by ethnic tensions and problems of poor health among ethnic minorities. By the 2000s, economic success for some groups began to set these tensions in reverse. The Sikh community particularly (which composed 8.7% of residents in 2011) was forming into a new middle class, desiring higher standards in education and wanting its children to go to university (but also wanting them to live and work in the local community, occupying the new generation of five bedroom private houses). They rightly wanted a better environment. In contrast, a complex structural mix of de-industrialization, austerity politics, restrictions on local state action and squeezed living standards in the 2010s, all of which were revealed in health trends, required an effective long-term response.38e40 The Sandwell experience illustrates the fact that there are no quick fixes for long-term public health challenges. Its population deserves to be educated, skilled, knowledgeable and wise. This requires a new skill set, well beyond the conventional mantra of ‘embracing the digital economy’. We see the case for rebuilding Sandwell's culture around more self-reliance, drawing on ‘new economics’ e a more creative response to employment needs, rather than neo-liberal economics e and the building of food and health skills in place of passive consumerism. As with the national economy, of which Sandwell is in some part a microcosm (certainly for the nation's transition from its industrial past), the lesson is that society must create an economy which is less dependent on big banks and more on local exchange, community-level economics, and time banks which value a citizen's wage.41 Anticipating the coming crisis of food security, there is an evident need for more resilient, self-reliant communities, which can grow and trade more of their own food and protect and conserve water supplies and local ecosystems.25,26,41e45 Housing still requires major improvement and is therefore a route to job creation. Major new health infrastructure and development of higher education facilities offer job prospects in construction and health and care services.34
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The aspiration must be for more open, accessible communities, freed from the shackles of the internal combustion engine or the whim of oil-producing nations. A new industrial revolution based on green technology is needed, not least for secure employment.45 Germany's commitment to a green energy-based economy is one model. Local energy generation and conservation should be linked to retrofitting housing to raise energy efficiency and lower carbon emissions. If the Victorians could empty their waste into the backyard of the world in the 21st century, we neither have that right nor the opportunity. In effect, therefore, the sanitarian of the past must become the ecologist of the future,46 not just to survive but to prosper and generate healthy lives for all. If there is a lesson from the last three decades of public health experience in Sandwell, it is surely this.
Author statements Ethical approval None sought.
Funding None declared.
Competing interests None declared.
references
1. Priestley J. An English journey. London: Victor Gollanz; 1934. 2. Middleton J, Srivastava N, Donovan D, Rao J, Douglas J. Life and death in Sandwell: the first annual report of the director of public health. West Bromwich: Sandwell Health Authority; 1989. 3. Burritt E. Walks in the black country and its green border land. London: S. Low and Marston; 1868. 4. Marrs EWJ, editor. The letters of Thomas Carlyle to his brother Alexander. Cambridge, Mass: Harvard University Press; 1968. 5. Middleton J, editor. Three greens for health: the 21st annual health report for Sandwell 2009. West Bromwich: Sandwell Primary Care Trust; 2010. 6. Middleton J. Life and death in Sandwell: where public health and economic health meet. J Local Gov Policy Mak 1990;16:3e9. 7. Chief Medical Officer. On the state of the public health: annual report of the chief medical officer of the department of health 2001. London: Department of Health; 2001. 8. Marmot review e fair society, healthy lives. In: Marmot M, editor. Strategic review of health inequalities in England post e 2010. London: Marmot Review (University College London); 2012. 9. Scottish Executive Social Research. Public attitudes and environmental justice in Scotland. Edinburgh: Scottish Executive; 2005. 10. Saunders P, editor. The Sandwell environmental tracking system. Oldbury: Sandwell Metropolitan Borough Council; 2013. 11. Saunders P, Griffin C. Environment and health in sandwell: joint strategic needs assessment. Sandwell: Sandwell Primary Care Trust and Sandwell Metropolitan Borough Council; 2013. 12. Editorial. No need for a dry run. Lancet 1994;344:1e2.
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13. Middleton J, Corson J, Saunders P. Water disconnection and disease. Lancet 1994;344:62. 14. Maton K, Douglas J, Donovan D, Middleton J. Food, health and work. Local Econ 1992;7:64e73. 15. Bartlett C. A community outbreak of legionella infection in Sandwell in the West Midlands: report for Oldbury and Smethwick primary care trust. West Bromwich: West Bromwich, Oldbury and Smethwick PCT; 2002. 16. CDC. Legionnella (Legionnaires disease and Pontiac fever) l. Atlanta: Centers for Disease Control, http://www.cdc.gov/ legionella/about/causes-transmission.html; 2013. Updated February 5th 2013, (accessed 12.03.13). 17. CDC. Healthcare acquired infections. Atlanta: Centers for Disease Control, http://www.cdc.gov/hai/; 2013. Updated 5th March 2013, (accessed 12.03.13). 18. Middleton J, Reynolds L. Lansley's wonderful plan, by Clostridium difficile. Blog piece February 1st 2012, http://abetternhs. wordpress.com/2012/02/01/cdiff/; 2012 (accessed 12.03.13). 19. Middleton J. Sustainable Sandwell: the fourth annual public health report for Sandwell. West Bromwich: Sandwell Health Authority; 1992. 20. Pulford M, Middleton J. Street Talk. (Health policy and town planning). Health Serv J 1993;27. 21. Pulford M, Middleton J. Sick building syndrome. (Town planning for health). Health Serv J 1994;104:30e1. 22. Egger G, Swinburn B. An “ecological” approach to the obesity pandemic. Br Med J 1997;315:477e80. 23. Dowler E, Blair A, Donkin A, Rex D, Grundy C. Measuring access to healthy food in Sandwell. West Bromwich: Sandwell Health Action Zone and Warwick University; 2000. 24. Rex D, Blair A. Unjust des(s)erts. Int J Retail Distribution Manag 2003;31:459e65. 25. Davis L, Middleton J, Simpson S. Community agriculture initiatives in the metropolitan borough of Sandwell. In: Koc M, MacRae R, Mougeot L, Welsh J, editors. For hunger-proof cities: sustainable urban food systems. London: Intermediate technology publications; 1999. p. 162e6. 26. Davis L, Middleton J. The perilous road from community activism to public policy: fifteen years of community agriculture in Sandwell. In: Viljoen A, Wiskerke S, editors. Sustainable food planning: evolving theory and practice. Wageningen, Netherlands: Wageningen Academic Publishers; 2011. 27. Foresight. Tackling obesities: future choicesdproject report. London: The Stationery Office; 2007. 28. Barton H, Grant M, Guise R. Shaping neighbourhoods: a guide for health, sustainability and vitality. London: E&FN Spon; 2003. 29. Barton H, Tsourou C. Healthy urban planning: a who guide to planning for people. London: E&FN Spon; 2000.
30. Sandwell Council and Sandwell Primary Care Trust. Sandwell healthy urban development unit. London: Local Government Association website, http://www.local.gov.uk/web/guest/ health/-/journal_content/56/10171/3511175/ARTICLETEMPLATE; 2013 (accessed 13.07.15). 31. Sandwell Metropolitan Borough Council. Fast food takes away supplementary planning document. Oldbury: Sandwell MBC; 2002. 32. Walton H. Scoping the health effects of nitrogen dioxide. In: IEH annual air pollution research meeting 10the11th may CHaPD scan; 2010. 33. Pugh T, MacKenzie A, Whyatt J, Hewitt C. The effectiveness of green infrastructure for improvement of air quality in urban street canyons. Environ Sci Technol 2012;46:7692e9. 34. Middleton J. Sandwell health: a life course. The 24th annual public health report for Sandwell. Oldbury: Sandwell Borough Council; 2014. 36. Dental Public Health Epidemiology Programme. Oral health survey of three-year-old children 2013: a report on the prevalence and severity of dental decay. London: Public Health England; 2014. 37. Rudge G. Personal Communication (Unpublished); 2015. 38. Middleton J, editor. Crunchtime for health in Sandwell: the 19th annual public health report for Sandwell. West Bromwich: Sandwell PCT/MBC; 2008. 39. Middleton J, editor. 5% for health: the 20th annual public health report for Sandwell. West Bromwich: Sandwell PCT; 2010. 40. Middleton J, editor. Public health a new asset: the 22nd annual public health report of the director of public health for Sandwell. West Bromwich: Sandwell PCT; 2012. 41. Simon MA. Fair share of health care: Gloucester and West Bromwich: fairshares. Gloucester and Sandwell: Gloucester and Sandwell Health Action Zone; 2003. 42. Lang T, Rayner G. Why health is the key to farming and food. Report to the commission on the future of farming and food chaired by Sir Don Curry. London: UK Public Health Association, Chartered Institute of Environmental Health, Faculty of Public Health Medicine, National Heart Forum and Health Development Agency; 2002. 43. Middleton J, Saunders P. Paying for water: putting water back on the public health agenda. J Public Health Med 1977;19:106e15. 44. Middleton J. Environmental health, climate chaos and resilience. Med Confl Surviv 2008;24:S62e79. SHOES supplement. 45. Schofield S. Oceans of work: arms conversion revisited. London: British American Security Counci; 2007. 46. Ashton J. Sanitarian becomes ecologist: the new environmental health. BMJ 1991;302:189e90.
Available online at www.sciencedirect.com
Public Health journal homepage: www.elsevier.com/puhe
20 years of local ecological public health: the experience of Sandwell in the English West Midlands* J. Middleton a,*, P. Saunders b a b
University of Wolverhampton, United Kingdom University of Staffordshire, United Kingdom
article info
abstract
Article history:
A long-term picture of the economy and living conditions of Sandwell, an area of England's
Available online 26 September 2015
industrial Midlands, is presented to explore how these underpin and influence its ‘health economy’. Sandwell's experience illustrates how public health actors have to tackle industrial and other factors which shape human health. The paper explores how the
Keywords:
ecological public health perspective has helped inform the modern public health task in an
Ecological public health
area such as Sandwell. Some lessons are offered, including: the need to understand the
Tracking
specific economic legacy of a local area (in Sandwell, principally one of polluting and then
Inequalities
declining manufacturing industries); the continuing story of infection control; the complexity of tackling poor diet; and the importance of the built environment and town planning. Faced by such challenges, local public health action represents, in effect, an attempt to transcend unecological public health. This can be exciting, innovative and ultimately successful; but it also means being prepared to face daunting and politically charged obstacles and superior national or international forces over which local public health practitioners conventionally have little leverage. The paper argues that, in such unequal power circumstances, public health practitioners have to draw on the creativity within the local population and build a facilitative alliance of formal and informal propublic health actors. Despite the confounding odds and ever-present stretched resources, the Sandwell experience gives grounds for optimism, being a story of constant creativity and effective local alliances. © 2015 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.
Rusty Lane, West Bromwich, 1933 The whole neighbourhood is mean and squalid, but this particular street seemed the worst of all. It would not matter very much e though it would matter e if only metal were kept there; but it *
happens that people live there, children are born there and grow up there. I saw some of them. I was being shown one of the warehouses, where steel plates were stacked in the chill gloom, and we heard a bang and rattle on the roof. The boys, it seems, were throwing stones
Note: Dr Middleton was funded by the National Institute for Health Research (NIHR) through the Collaborations for Leadership in Applied Health Research and Care for Birmingham and Black Country (CLAHRC-BBC) programme. This paper was prepared under the auspices of the CLAHRC-BBC knowledge management programme. The views expressed are not necessarily those of the NIHR or the Department of Health. * Corresponding author. E-mail address: [email protected] (J. Middleton). http://dx.doi.org/10.1016/j.puhe.2015.08.011 0033-3506/© 2015 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.
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again. They were always throwing stones on that roof. We went out to find them, but only found three frightened little girls, who looked at us with round eyes in wet smudgy faces. No, they hadn't done it, the boys had done it, and the boys had just run away. Where they could run to, I cannot imagine. They need not have run away for me, because I could not blame them if they threw stones and stones and smashed every pane of glass for miles. Nobody can blame them if they grow up to smash everything that can be smashed. There ought to be no more of those lunches and dinners, at which political and financial and industrial gentlemen congratulate one another, until something is done about Rusty Lane, and about West Bromwich. While they still exist in their foul shape, it is idle to congratulate ourselves about anything. They make the whole pomp of government here a miserable farce. The Crown, Lords and Commons are the Crown, Lords and Commons of Rusty Lane, West Bromwich … and if there is another economic conference, let it meet there, in one of the warehouses, and be fed with bread and margarine and slabs of brawn. The delegates have seen one England, Mayfair in the season. Let them see another England next time, West Bromwich out of the season. Out of all seasons, except the winter of our discontent. J.B. Priestley1
Introduction In his book, An English Journey, from which the quotation above is taken, J.B. Priestley describes a visit to the Black Country. He contrasts the experience of the children of Rusty Lane, West Bromwich, with his Chamber of Commerce dinner with the burghers of Dudley later in the day. Had he returned at 10 year intervals to the present day, he might just have repeated his observations. Each new civic reform initiative has produced some progress, but Priestley may have commented on the same tone of self-congratulation by the local ‘Great and the Good’, when in reality, inequalities in health and life chances persisted within Sandwell and when comparing Sandwell with the rest of England. Sandwell's unsustainable industrial past stretches back over 250 years, best described perhaps as an example of unecological public health: humankind operating in extreme odds with a natural environment which has been constantly pummelled and degenerated over time. It illustrates too how the physical environment reflects human activity with health consequences, how in public health we have to unpick a complexity of factors, and how we must also be alive to the recognition that environment is not just an external force or property but is actually part of us. Indeed, that the environment permeates our human essence and existence. One might even suggest that whereas conventional public health sees the environment as an external factor impinging on health, ecological public health sees the environment as integrated into biology and human physiology. The Sandwell experience suggests how the reworking of local conditions permeates culture, quality of life and personal expectations, and not therefore just the objective indicators of life. Also we see, as did Priestley in otherwise very different times, that Sandwell's experience is infused with social dynamics, a very British illustration of how political economy, environment, culture and health intertwine. As Priestley himself understood, this was not a new phenomenon, but one continuously
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reworked and impressed into the health landscape. Local public health action can be exciting, innovative and successful, but it can also meet impossible obstacles from superior forces, which can only be tackled nationally or internationally. The Sandwell experience, however, is endlessly optimistic, one of constant creativity and local alliances.
Ecology and the industrial environment e the legacy of industry and environmental public health tracking Sandwell Metropolitan Borough was formed in 1974 by the amalgamation of the County Boroughs of Warley and West Bromwich. The 2011 Census recorded a population of 309,000 (June 2011), ethnically 65.8% White British, with a life expectancy of 75.5 years for men, and 80.8 years for women. Sandwell is in the centre of the West Midlands conurbation and is one of the four ‘Black Country’ districts, the others being Dudley, Walsall and Wolverhampton. The borough is the twelfth largest local authority district by population size in England, comparable in population size to Nottingham or Newcastle. It covers a relatively small area (8650 ha/ 21,150 acres) and comprises alternately, heavily built up industrialized areas, dense social and private housing, and areas of extensive dereliction.2 Since the industrial revolution the Black Country has been known for its heavy industry, for coal, limestone and iron ore used in its industries, its metal pressing plants and for its chemical industries. An extensive canal and rail network served the myriad of small factories extending to Birmingham, an area once internationally known as the ‘Workshop of the World’. The area also gained a reputation for some of the most appalling environmental and working conditions of Victorian England. The appellation ‘Black Country’ may have been taken from Elihu Burrit's book Walks in the Black Country and its Green Borderland, in which the writer described the place as ‘Black by day and red by night’.3 The historian Thomas Carlisle added that it presented “a frightful scene … A dense cloud of pestilential smoke hangs over it forever and at night the whole region burns like a volcano spitting fire from a thousand tubes of brick. But oh, the wretched thousands of mortals who grind out their destiny there!”4 It remained in this condition for much of the 20th century, with its residents living besides slag heaps and underground coal fires (see Figs. 1 and 2). The boom years of the early post World War 2 period profited its foundries by demand from the equally booming Midland car industries, but the poor environmental conditions and terrible health patterns persisted. If by the late 1970s there were still more than 40 foundries in Sandwell, the precipitate collapse of West Midlands manufacturing in Thatcher's Britain of the 1980s brought the demise of most. Across these years of rapid economic restructuring the number of foundries reduced to 18 and then slowly trickled down to just three. Those still in operation undertook the dirtiest and often the most dangerous forms of metal pressing, of the kind that South Korea, where foundries boomed, wouldn't accept, or elsewhere, as in France or Germany, where the quality of scrap used in Sandwell was unacceptable.
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Fig. 1 e West Bromwich, 1967. King George Playing Fields with ‘Elephant Rock’ in the background. This huge slagheap from the Hamstead Colliery and has now been replaced by the Sandwell Valley Country Park and Bird Sanctuary. Image courtesy of Express and Star.
Fig. 2 e Moxley, West Midlands, November 1956. In Minnie Page's backyard, acrid smoke seeps to the surface as old underground mine coal seams burn. The ground was warm to walk on and locally they called them ‘The Fiery Holes’. Image courtesy of Express and Star.
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Chemical cocktails from burnt engine oil and heavy metals from paints were liberated into the air, assaulting the lungs of foundry workers and the local community. Even in terminal decline, therefore, the poisoning of people and place persisted. If the nineteenth century housing stock was poor and insanitary, Sandwell also fell victim to post World War 2 experiments in mass housing and city planning. These placed the motor car before communities and side-lined the public transport systems, rail and canal, which had formerly been the backbone of the local economy.5 Even the success of the 1956 and 1968 Clean Air Acts was double-edged. Air quality improved dramatically, adding an estimated two years to life expectancy,6 but it also helped destroy industries where local people had found identity, pride, and a living.2,5 Stretching back over the century, the role of local authorities had been expressed through education provision, social institutions and hospital care; even the ambulance service was provided by the municipal authorities until the NHS was established in 1948. What is now called social housing was vital, indeed, the only practical solution to housing shortages. In contrast, early Black Country ‘town planning’, composed of speculatively built tiny and low standard ‘back-to-back’ houses, cramming in worker's families. Newer council housing, whatever its many defects, at least remained located within walking distance to industrial employment. Indeed, because of such close proximity, Sandwell might well have been considered the paragon of 21st century healthy cities and sustainable living; perhaps too healthy a contrast to car-based modes of living which elsewhere have atomised culture and reduced the likelihood of people walking and talking. In reality, in this multideprived area, so many stressors, material, social and environmental, have been bundled together that it has been all too easy to be reminded of Thomas Hobbes's words that so many people's lives are nasty, brutish and short. Nevertheless, in comparison to the past, there was progress to be seen. Britain's original 19th century public health movement had addressed a filthy, disease-ridden environment. The problem was that while the environment did improve considerably, it has continued to exert a powerfully negative effect on health. The Chief Medical Officer for England has shown that while men from affluent populations experience relatively good and similar levels of health irrespective of geographical region, mortality rates for men from deprived populations showed a marked north-south decrease.7 This relationship was also emphasized in Professor Michael Marmot's rigorous analysis of the distribution, scale and consequences of inequalities in England.8 Some of the differences in mortality are put down to ‘lifestyle choices’, such as alcohol consumption and smoking, or to other confounding factors, but the impact of environmental issues remains a plausible factor, given the evidence that there is something about the stress of being poor that makes people more vulnerable to hazardous exposures.9 Estimates of this burden vary and the environmental stressors have changed over the decades, with increasing research focus on more global and international issues such as climate change and the more subtle effects of low level exposure to hazardous chemicals. These are important but communities also
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consistently identify damage to amenity due to litter, fly tipping, noise, bonfires, housing disrepair, street lighting, and derelict land. These interferences on day-to-day life have an objective impact on health and life quality. In fact, it is through these dimensions that the public understands ecological public health. On the other hand, little is known or understood about the interactions between environmental factors and lifestyle, and certainly the impact of the contemporary environment on health is complex and multifaceted. More innovative methods are required for the targeting and management of interventions for the greatest health benefit and for the reduction of health inequalities, suggesting the relevance of a multidisciplinary confederation of surveillance, horizon scanning, exposure assessment, research, and the integration of data and intelligence on hazards, exposures and outcomes. These form the precise fundamentals of the Environmental Public Health Tracking system established in Sandwell, the first of its type in Europe.10,11 Through this system, Sandwell seeks to develop a more rounded and complete set of indicators than life expectancy alone, useful though that is.
Ecology and communicable disease Water disconnection and disease In the early 1990s, the then Conservative government privatized publicly owned Water Boards in the middle of the biggest dysentery epidemic in 10 years, leaving itself open to the allegation that water disconnection was its cause. Over 1000 local households were disconnected virtually overnight, resulting in a ‘dirty protest’ by the residents of Hamilton House (a large tower block, since demolished) and formed a stimulus for action by welfare rights and public health campaigners. A later Labour government outlawed domestic water disconnections,12,13 and today water use is shaped by volume -related charges and the business strategies of water companies, mostly internationally owned, which are forced to tackle decades of underinvestment under their former public and private owners.
The new ecology of industrial disease The foundries may have mostly disappeared, but remaining local industries are not without risk. The Solvay plant in Oldbury, formerly Albright and Wilson, is owned by one of the world's major producers of phosphorus products. Phosphoric acid forms an important constituent of everything from matchstick heads to fertilizers and toothpastes. The plant even appeared in the Sandwell food industry survey in 1990, since this chemical is also used in soft drinks.14 This chemical process involves the use of large quantities of phosphorus and chlorine. If the materials are not adequately cooled there is a risk of explosion. There have been three major phosphorus fires at the plant in the last 20 years. In 1989, a plume of white smoke traversed the City of Birmingham as far as the airport; further smaller incidents occurred in 1995 (pictured Fig. 3) and 2009. If the coolants themselves are not adequately maintained there is a further
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Fig. 3 e Albright and Wilson factory fire, 1995. Image courtesy of Express and Star.
risk of legionnaire's disease, with one outbreak in 2002.15 The legionella bug is a prime example of the modern ecology of health. Although this ubiquitous organism can be found anywhere from puddles on the roadside to every kind of watercourse, it is generally spread by water vapour via the diverse trappings of modern life, industrial air conditioning, industrial cooling and scrubbing systems, jacuzzis, car washes, fountains and domestic showerheads.16 Vapour mists can spread up to 500 m, affecting the unhealthy or the frail, and particularly smokers.
Health care acquired infection Health care acquired infection is another example of the ecology of public health.17 In Sandwell, a major drive on control of infection from 2004 saw clostridium difficile rates fall by over two thirds, with Methicillin Resistant Staphylococcus Aureus (MRSA) reduced to single numbers of cases. Clostridium difficile presents a classic case which needs to be viewed as a ‘whole system problem’ within the health and social care economy and not just a provider problem, as it was by the Care Quality Commission, the industry regulator. If any part of the system goes wrong, for example pharmacists prescribing loperamide (for diarrhoea), GPs prescribing too many or the wrong antibiotics, care homes not cleaning adequately (in one case coming to light in Sandwell, not changing mattresses for 20 years), or junior doctors not washing hands before or after touching patients, the problem will surface. Hospitals have blamed the community for causing the infection, rather than recognising themselves as being part of the community. The managerial culture post the Health and Social Care Act 2012 enshrines this thinking and arguably leaves the whole system at risk of more infection.18
Ecology, healthy town planning and the obesogenic environment It cannot be expected for citizens to live healthy lives if the general conditions which affect their lives are unfavourable. In an area like Sandwell, with a long history of challenging environmental conditions and poor health, sustained health improvement realistically requires much more than single, short-term interventions but rather a long-term commitment. Such a perspective conceives of health in terms of the public sphere and recognizes that risks to health go far beyond the influence of individualized choices or personalized health. While this perspective can open up public health to the charge of ‘nanny-statism’, on the contrary what it has achieved, to a degree, is the civilising of ‘raw’ capitalism, injecting some humanity and decency. In pursuit of this civilising role, there are a number of roles and traditions on which public health can and should again draw. One of these is town planning.
Healthy town planning After assessing the state of Sandwell's health in the 1980s, the positive health role of town planning was outlined in Sandwell's 1992 public health annual report.19 Sandwell Health Authority (SHA), now replaced in one of the seemingly endless reorganizations by central Government, found itself in a public enquiry concerning its support for the location of the bus station, some 200 m from the proposed Midland Metro, a regional transport scheme, and therefore in opposition to relocation proposals. The SHA argued in the 1993 public consultation on the Unitary Development Plan that an interchange for transport between the bus station and Metro was needed to promote the use of public transport. The SHA was
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opposed by the then owners of the existing bus station and the Inquiry Inspector upheld their view, but five years later a new bus station was opened opposite the Midland Metro station; and incidentally, in proximity to the new Lyng health centre in West Bromwich. The health press highlighted the role of health in town planning and Sandwell has continued to probe and develop this partnership with planners ever since, particularly through the promotion of cycling and walking.20,21 In effect this partnership prefigured ‘obesogenic environment’ thinking.22
The local food economy and the obesogenic environment The monitoring of an environment which fed people poorly is a further illustration of how Sandwell took an early interest in diet. Evidence on diet's impact on health is longstanding, but Sandwell saw that food retailing had an important gatekeeping function on food availability. It conducted local research into food deserts,23 and worked with retailers to redress the poor availability of fruit and vegetables. Sandwell also championed improved sourcing from nearby Staffordshire farmers, assisted by stock management and display by Fresh Solutions, a private consultancy supporting food growers in marketing their products.24 Before the official Department of Health Eatwell plate, Sandwell explored community agriculture and horticulture schemes, such as with the Malthouse Garden and Salop Drive experiments.25,26 These became beacon projects, showing what can be done in previously degraded environments. The Public Health department learned quickly that food and diet was multifaceted and complex, with few quick fixes. The Government Office for Science's celebrated Foresight Report on Obesity ‘systems maps’ certainly captured that with their depiction of the forces which surround the apparently simple (im)balance of energy inputs and outputs that tilt populations into obesity or protect them from it.27 Just to support healthy behaviour or provide health education would not be enough to transform deeply ingrained food cultures and poor dietary preferences. A longer-term approach was charted. Elements include the reestablishment of community food skills, the celebration of healthy home-grown fresh produce and the sharing of growing skills. The goal has been to give people of all ages an appreciation of where their food came from and to reconnect with seasonality. The act of growing food can be health-promoting in itself and impart a sense of community cohesion and fulfilment.25,26 Sandwell made a wider commitment to support investment in ‘environmental capital’ such as through access to green space, and by including Sandwell's Environmental Tracking programme, the principle being that measuring negative environmental factors required the supplementation of positive factors. Following the Foresight report, central government became more interested in the kinds of issues Sandwell had been analysing e the connection between obesity, environment and food supply. Hugh Barton and colleagues have scoped a new approach through the lens of healthy town planning.28,29 In 2008, that perspective was legitimated by the government's Healthy Towns challenge. Sandwell was unsuccessful in its bid to be part of that, losing out to neighbouring Dudley (which made a great fist of its good fortune.)
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However, Sandwell did create, by other means, what had been bid for: the Sandwell Healthy Urban Development Unit (SHUDU).30 Since 2008, Sandwell has responded to national planning consultations, staged a major national conference on healthy town planning including restricting fast food outlets and produced a supplementary planning guideline (SPG) on fast food outlets.31 A geospatial analysis of the density of fast food outlets was prepared, showing links with patterns of deprivation. In effect, Sandwell is saturated by hot food takeaways, with few residents more than a short walk away, revealing a significant association between close residential proximity to a hot food takeaway and deprivation.31 Research into the foods offered by Sandwell's takeaways in 2013e14 found large portion sizes and high levels of fats and salt. How can a healthy diet be promoted and achieved when all the signals point in the opposite direction? Residents have limited opportunities to break out of this highly compromising environment given high levels of deprivation, limited transport options and the dubious distinction of living simultaneously in a ‘swamp’ of unhealthy, readily accessible and cheap takeaways and a ‘desert’ of healthy options.32 From the food business point of view, profit margins are under pressure, with cheap ingredients undermining their desire to create a ‘good food culture’. This illustrates the limits to what can be done at the local level to transform food's impact on public health. Some food issues are far beyond local control. The use of ‘transfats’ (hydrogenated fats) in processing, for example, cannot be resolved by Sandwell. It needs national and European-wide action. Local authorities can do more, however, by using local planning and regulatory powers; addressing portion sizes; stimulating demand for healthier products; framing school food procurement policies; adapting the roles of Council enforcement officers to persuade the industry to promote healthy food preparation techniques; and local social marketing campaigns targeting consumers and businesses.
Air pollution and green canyons Through the 2010 annual public health report, ‘Three Greens for Health’, focusing on green space, employment and social dividends, the Director of Public Health and team trialled the Sandwell environmental tracking programme.5 Such reports stimulated regular public attention to the relationships and interactions between environmental stresses and deprivation and ethnicity. These have fostered an active discussion with regulators about the need to ensure that industries located in deprived areas comply with the law and improve performance. While air quality has improved dramatically in Sandwell over the last 30 years, hotspots remain. Traffic generated NO2 is now the most important pollutant. In some areas, there appear to be no technical fixes other than total pedestrianisation of busy high roads or to condemn living accommodation as unfit for habitation, neither of which are realistic or politically acceptable. What, therefore, could be done? One solution has appeared by thinking about the local environment as an eco-system and considering the implications of any one intervention on other domains. Firstly, evidence of
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health gain from early actions was needed to win over political support. Academics have helped create and pilot an exposure coefficient to estimate the health costs of current levels of NO2.32 Sandwell has also responded to community aspirations for more walking and cycling opportunities by assessing the potential impact of ‘greening’ some urban corridors. Academic literature suggests that such investment e creating green ‘urban canyons’ e improves air quality and urban aesthetics.33 Such arguments alongside the quantification of health impact has provided the means to recruit political as well as professional support and Sandwell is currently implementing the first phase of greening the most vulnerable locations.
Annual reports, environment and ecological public health In 1989, Life and Death in Sandwell highlighted the environmental legacy of ill health in Sandwell.6 In 1992, Sustainable Sandwell proposed new remedies.19 The 1992 Sustainable Cities conference in Brighton furnished ideas for self-build housing, food co-operatives, local growing and local exchange trading schemes. By 2009, with the Three Greens for Health report, Sandwell was looking at environment and ecology in an altogether more integrated way, with health promotion redefined as ‘green promotion’, incorporating cycling, walking and food for both health and environmental gain; greening the health service as a good corporate citizen; and ‘green industry’ proposed as the next industrial revolution delivering a ‘green dividend for health’, alongside environmental tracking. This was the application of 21st century public health and epidemiology methods to the old problems of environmental nuisance and hazards. This annual report was also the first to introduce biodiversity as something of relevance to human health, giving attention to slugs, rats, and pigeons, the beneficiaries of human waste at the expense of biodiversity.5 One can either view garden slugs as ‘needing’ agrichemical assault or as a problem solvable by the introduction of hungry ducks. Viewed in this way, there isn't a snail problem, but rather a duck deficiency.
Outcomes Improvements in health outcomes featured in Public health: a life course, the 2013 annual public health report for Sandwell.34 Heart disease related deaths reduced by an astonishing twothirds since the 1980s. Some of this is reflected in the longterm trends affecting all parts of the country, but improvements made in Sandwell have reduced deaths faster than the national rate and have reduced the gap in life expectancy with the national rate. Not all improvements are attributable to wide-ranging ecological and strategic interventions. The GPbased risk stratification system shows that more than 70 lives a year have been saved from cardiovascular disease. In contrast, heart disease related deaths actually rose in the mid2000s. The group of men thrown out of work in the 1980s were dying prematurely from heart disease, brought about by a lifetime without work, hope, and probably too much smoking, drinking and physical inactivity. Teenage pregnancy reduced
by 44% since 1998, attributed principally to rising expectations in education (from 2007, examination results rose as teenage pregnancy rates reduced). Over a number of years, it ceased to be acceptable to attribute poor results and low expectations for our children to ‘deprivation’; if one teacher, or one school, could achieve success in educating children under difficult circumstances, they were now all be expected to. In health, there were also some excellent services built up painstakingly over a number of years, in personal social education, young people's contraceptive services and morning after pill availability from pharmacists. The fact that teenage pregnancy has not increased since the recession is, plausibly, due to the insulating effect of the Surestart programmes, which began in 1998. Surestart gave support to parents from deprived backgrounds, plus additional support to teenage mothers. A Surestart maternity grant gave some financial support to pregnant mums. The Cabinet Office policy advisory team came to Sandwell in 1998. It expressly set out to support teenage mothers to break the cycle of babies born to teenage mothers and then becoming teenage mothers themselves some 16 years on. The benefits of this intervention are now becoming fully visible.44 This includes excellent dental health in the under 20s through a technological fix: water fluoridation.36 Over 25,000 Sandwell homes have been improved to a ‘Decent Homes’ standard. Local research found larger reductions in cold-related deaths than previously reported.37 A further improvement has been achievement of the lowest reoffender rate in the country by the Sandwell probation service in the context of a Safer Sandwell partnership which has contributed painstakingly and effectively to reducing crime. The health component of this initiative has been considerable, varying from tackling drug and alcohol related crime, responding to domestic violence, providing appropriate care for mentally disordered offenders and supporting community development programmes to combat violent extremism. The recovery effort for drugs and alcohol related offences has also been an additional contributor to the reduction in reoffending. It is difficult to measure and attribute changes in health indicators to a particular ‘ecological approach’. The essence of the ecological approach is that it recognizes the need for a complex series of interventions. Single interventions like control of fast food outlets or traffic calming or drug harm reduction programmes may have multiple outcomes in health, social care, crime prevention, safety and in economic spheres. Complex interventions in regeneration require partners to act in tandem and outcomes may become more diffuse. Other outcomes are apparent as process improvements; the environmental tracking system becoming a pioneer in Europe,10 later endorsed by the World Health Organisation and commended in international meetings. Integrated working with others and securing political support has led to projects that would not have happened otherwise. It has enabled the area to successfully pursue interventions through funding bids and as additions to mainstream budgets.
Conclusion By no means can the Sandwell story be painted as one of unalloyed success. Rather, it is one of constant struggle to think through problems, to innovate and to engage creatively
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with the local population. Perceiving human and eco-system health as linked has become integral to the local public health tradition. 21st century public health has many options; potential solutions can arise from theoretical choices. The implication is that new and different skills, investment and effort are needed. Sandwell in the 1990s had the appearance of more dereliction than New York's Bronx but also the reality of more canals than Venice. The Neptune forge that once made heavy chains for ocean liners was transformed into the Neptune Health Park, a pioneer of the healthy living centres that flowered in the 2000s, with GPs, pharmacists, dentists, a health information centre and Citizens Advice Bureau, alongside a newly established canal-boat mooring. In this manner, crises were transformed into opportunities. Ironically, some of the industrial waste from foundry works in the past may now be commercially viable for secondary mining of the residual metallic elements, potentially generating employment and income. The lessons from Sandwell turn on its continued capacity to apply the lessons of history to protect local people and their environments and to continue to seek to apply creativity and innovation to face the future. Sandwell has tried to chart a new basis of hope from ecological public health and from its social diversity. In the 1960s, it was an area scarred by ethnic tensions and problems of poor health among ethnic minorities. By the 2000s, economic success for some groups began to set these tensions in reverse. The Sikh community particularly (which composed 8.7% of residents in 2011) was forming into a new middle class, desiring higher standards in education and wanting its children to go to university (but also wanting them to live and work in the local community, occupying the new generation of five bedroom private houses). They rightly wanted a better environment. In contrast, a complex structural mix of de-industrialization, austerity politics, restrictions on local state action and squeezed living standards in the 2010s, all of which were revealed in health trends, required an effective long-term response.38e40 The Sandwell experience illustrates the fact that there are no quick fixes for long-term public health challenges. Its population deserves to be educated, skilled, knowledgeable and wise. This requires a new skill set, well beyond the conventional mantra of ‘embracing the digital economy’. We see the case for rebuilding Sandwell's culture around more self-reliance, drawing on ‘new economics’ e a more creative response to employment needs, rather than neo-liberal economics e and the building of food and health skills in place of passive consumerism. As with the national economy, of which Sandwell is in some part a microcosm (certainly for the nation's transition from its industrial past), the lesson is that society must create an economy which is less dependent on big banks and more on local exchange, community-level economics, and time banks which value a citizen's wage.41 Anticipating the coming crisis of food security, there is an evident need for more resilient, self-reliant communities, which can grow and trade more of their own food and protect and conserve water supplies and local ecosystems.25,26,41e45 Housing still requires major improvement and is therefore a route to job creation. Major new health infrastructure and development of higher education facilities offer job prospects in construction and health and care services.34
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The aspiration must be for more open, accessible communities, freed from the shackles of the internal combustion engine or the whim of oil-producing nations. A new industrial revolution based on green technology is needed, not least for secure employment.45 Germany's commitment to a green energy-based economy is one model. Local energy generation and conservation should be linked to retrofitting housing to raise energy efficiency and lower carbon emissions. If the Victorians could empty their waste into the backyard of the world in the 21st century, we neither have that right nor the opportunity. In effect, therefore, the sanitarian of the past must become the ecologist of the future,46 not just to survive but to prosper and generate healthy lives for all. If there is a lesson from the last three decades of public health experience in Sandwell, it is surely this.
Author statements Ethical approval None sought.
Funding None declared.
Competing interests None declared.
references
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