IV. Educating the public

Publ. Hlth. Lond. (1970). 85, 67-75

The Society of Medical Officers of Health Ninth Annual Symposium MEDICAL ETHICS AND SOCIETY IV. Educating the Public Chairman: Professor R. C. M. Pearson Dr. Yarrow, an M.O.H. who has moved to the Scottish Health Education Unit is our next speaker; he is showing a short film. DR. A L F R E D Y A R R O W M.B., CH.B., D.P.H.

Director, Scottish Health Education Unit My fihn is what is called a Public Service Filler and 1 refer to it about three-quarters of tb.e way tb.rough the paper.

Need for Health Education I was originally asked to give a paper on the theme of medical ethics in society, with particular reference to health education, taking into account considerations of communication and confidentiality. I could find very little relevant to confidentiality, b u t ' l t h o u g h t that communication is really the whole essence of health education and that I o u g h t to • be able to find something to say about that. Everybody today is a. seer, with , w h n" h e r health education?", or "whither health visiting?", or whither this or whither that. But ! f e a r i t i s absolutely essential to the thesis of my paper, that I should refer even if only briefly, to the future. We all know that medical practice in this country is about to undergo revolutionary changes; these are likely to happen regardless o f what occurs on June iBth, and health education is going to need to be fitted somehow into t h e emerging, pattern: :It: seems.to me that we shall in a few years, see the end Of the tripartite pattern of the National Health Service a n d we are going to see the emergence of the Area Health Board. We are told that leading the medical profession at a n y rate at Area Health. Board level, we shall see t h e community, physician. The j o b specification~ of the c o m m u n i t y physician, to use the current jargon, remains to be written; but it s e e m s t o m e t h a t t h e range Of activities that is going to have to be covered by-this individual will alm0st-eertainlymean-the:errier gence o f a team rather.than a person, for I really cannot:see o n e p e r s 0 n doing alLthe~ttfings tha~-this chap. is supposed to do. One of the.team's activities w i l l b e health educati0n a n d l put it to you for consideration that there should perhaps b e a.qualified: heaithleducator at each area health board level. We are n o t suddenly g o i n g t o b e comp!etely~cut~Off from the local authorities; this is .just too unthinkable for w o r d s , l~fedicai advice and:expe~ise will need tO continue to be provided both to the local sanitaryauthOrity whichWit!continue in being, the local education authority, ,~nd the social work. departnienL :andarrangetiients will have to be made for a health education colnponent to be fitted in here.

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P U B L I C H E A L T H V O . L 85 N O . 2

To my mind, however, and perhaps not only to mine, of less importance than lhe form of the restructuring of the National Health Service is the purpose: wl:at will be the strategy of the new N.H,S. and tb.e community physician? is its purpose, and his, simply to 'cater more eificiently for existing patterns of morbidity and mortality? This would be an 'advantage but a very strictly limited one. Or is the purpose of re-organization to permit the community physician to use techniques, some proven and some still unproven, to attempt to alter and improve these morbidity and mortality patterns. If this is the strategy, and hqpe it is, because as I say, otherwise one wonders wbat it is all about, what ;are some of the tactics ? Figure 1, which I have obtained from Professor Sir Dugatd Baird, will sb.o,v tb.e remarkable things tbat can be done by using the sociological, epidemiotogical, statistical approachl 70i

s

......... t

--1 .....

t .....

I

1

60

' - 7 ~ 1 7 0

?,0

17 :~50

50

Scotland 0 ¢0

n

| 9 5 9 - 4 0 41-43

4 4 - 4 6 47--48 50-,~2

55-65

56-68

59-r~ 6,2-E¢

Years

Fig. I. You can see here where Aberdeen was, in the 1939/40 period, statistically somewhere between Scotland a n d England,: Scotland always running very much higher in perinatal mortality, than England and Wales; and you will see also theremarkable change tgat came about during the war, when Aberdeen's figures began to r u n towards those of Eng!and and Wales, and at about 1948, actually crossed those of England and Wales, until we have the position now where Aberdeen is well below. You Can see tire period f r o m 1953 to 1959 where Aberdeen's figures slowed up a bit. 1 would remind Mr, Teeling-Smith, who was talking about mortality in the last session, the important thing about perinatal and maternal mortality figures is the quality, i f I may use the w o r d - - I would only dare use it in the dark of the breeding animal. The quality of the breeding animal was t h e n particularly poor because the girls who were born during the late Twenties and Thirties were then having their babies. When we got out of that period, and we got a better quality breeding animal coming forward, Aberdeen's figures began again to turn down. I would submit to you that this

MEDICAL

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69

is a very remarkable picture here which shows what.can be done. The Bible says "Can a man by taking thought add a cubi:t to his .slals.lre"~ .and ! wc~uld suggest that Sir Dugald .Baird has shown that you can_ Now to screening. The last thing .1 want to ,do i:; to g(~ in detail into screening techniques this morning, some of them proven, some of daern unproven, some of them very new. However, Figure 2 ,refers to one: at any .rate° iha~. was for a long time accepted as being welcome, namely .miniature mass radiography. Scotland's tuberculosis figures again ran "cell above those of England and Wales 'until the huge screening programme which took place during the !950's, which accounts for that great bulge in. male notifications and the similar but less exte;~sive beige in the .female side, after,which you see how the Scottish figures were moved down .this way to a level nearer the English figures.

_~

(a)'M0tes

(b} Females

150

-

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o" _o

,100 B 7_ 5 0

~ofland

Scow'land

eoo

I00

~'Wales ~ , ~

i t ! ! I ~ 1 ~5~ 55 55 57 5 9 61 65 65 6 7

Years

I

._d,_,J.._,L__L~_ J 3 ! -J F:Jf{ 55 55 57 59 61 6 3 ~5

Years

67

F i g , 2.

The tbArd .technique I would like t o mention i s by imp!ementing more effectively the existing methods o f preventive medicine, and one,thinks obviously of: fluoridation, :control o f air pollution, immunization etc. Health education isan:essential, conct,mitant o f all o f these~ An examination of.changes in patterns of morbidity~ over the .past 22 years,, since :the inception of the~N~H; S.;4 shows profound changes..whai iw0nderfut-.hopes ~ii~e'i!ail)had i.i~t i948 that-the Millenium was ~about to arrive, :but in.~faet the:Milleniu_ra-.did it0i~-arrive, Many of the diseases which filled thehospitai Wards m 1948 have vJrtuall,.dlsappeared, ~ut they have simply been replaced by others so that tb.e beds are as full asever.:The:things •~weare now looking at a~:ecarcinoma of the bronchus; chronic bronehitisl.atcoholism, etc. "i~able I is taken from a paper by Kemp in ,:The Lancet", which ] think was extremely wortl~whi!e to read. You can see the figures there; myocardial infarct, suicidaioverdose With huge numbers of patients, ~chest infection, peptic ulcer;- heart disease, alc0holism,~obesity, carcinoma and diabetes. The point that Kemp made in his paper; and the point thatb:am making to you now, is that a factor common tO the existing morbidity pattern'--aip, oint Which has bee ,nade before~is that much of it is self-induced by undesirable behaviour, either by the individual or by the community as a whole.

70

P U B L I C I-IEALTI~[ VOL. 85 NO. 2 "I'ABLE I

Diagnosis o~ dischar.ee of personal #tpatients JaouaJT/June 1966 Diagnosis

Male

Female

Total

~ ¢ l y o c a r d i a i ~infa rct Suicidal overdose Chest infection Peptic ulcer Cerebral vascular accident Heart-disease Alcoholism Asthma Simple obesity Carcinoma Diabetes Other

64

34 48 27 16 28 17 4 15 17 7 8 70

98 63 62 50 47 27 24 23 21 20 10 114

TOTAL

15

35 34 19 10 20 8 4 13 2 44 268

291

559

These diseases are hardly likely to yield dramatically to curative medicine. If they are to be tackled it must be 19y prevention and this means by change of behaviour pattern, which is really what health education is all about. It is to be remembered that preventive medicine is carried out Upon apparently !~eattby individuals. T h e n e e d to alter p a t t e r n s o f behaviour; both personal and-community,.is already posing e n o r m o u s problem~ for tb.e health, educator. The discovery of newer and more effectivescreening methods will also pose problems. No screening met!nod is more effective than the ablhty of the h e a l t h educators--all of u:;, at all leve~s--to deliver the patient f o r screening. To the healthy person preventive medicine is a marginal activity: he wants to watch football, he is interested in the World Cup, the General Election and so on but preventive medicine has to be sold to him.

Methods of Health Education I woula like now to go o n t o talk about the m e t h o d s Ofr health education, because you cannot really talk about, the ethics until you have talked about the methods. So let u,~ have a brief look at s o m e of the methods of health education. I :will first m a k e a point 1 have stressed on a number of occasions before. This is that health educators, if they arehonest, admit that they m a k e use o f propaganda techniques as well as truly educative techniques, and this has a bearing on a n y discussions of ethics, In a previous paper I quoted from J. A. C. Brown's b o o k " T e c h n i q u e s of Persuasion"r 1 d o not know a better definition, so I a m going tO quote it again; "Superficially:it is easy to distinguish between education a n d propaganda; since the former aims at independence of judgement, and t h e latter at supplying ready-made ~udgements for the unthinking. T h e educator aims at a slow process of development; and the propagandist quick results. The former tells peoPle how to think, and the latter tells t h e m w h a t to think. One strives to produce individual responsibility and an open mind, and t h e other, using mass effects, contrives to produce a closed one". That is the diffe;~ence between propaganda and'education, and I a m asserting to you here that all of us use propaganda techniques whether we admit it o r not. What are the various methods of health education that we use ? First there is health educatiqn on a person to person basis, the lraditional and effective technique of the health visitor, the public health'inspector and ourselves. Next come the techniques of group discussion. The aim of group discussion is to enable the group to come to a decision, which we hope is the right one, of its own volition ; there is evidence that when such a process takes place the individuals constituting the group

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reinforce each other in their determination to adhere to the decision that's made. Examples could be a local authority mothers' group at a clinic talking about immunization, or a weight watchers' group, or par excellence, Alcoholics Anonymous. In tb,e United States particularly, health educators are moving beyond working with groups into working with whole communities in so-called 'community development projects'. In this country too, the Home Oflice and the Department of Education irt England and the Department oI~Education in Scotland are also financing experiments on this basis. In the edueationalfield we call them educational priority areas, but.basically they are the same thing. Certain principles seem to be involved, and among these the first is that unless the community itself is involved permanent change is. unlikely to take place. I t is useless to go and d o a thing t o them, o r for them; it must be done with them. The Americans call this "the principle of maximum feasible participation": Secondly in order to produce rapport it may be necessary to recruit and maintain as workers, members of the community rather than to insert outsiders. There are also the audio-visual, non, personal methods ofcommu~tication, such as posters large and small, leaflets, :books, periodicals a n d the broadcasting media. Evidence from the United States is already showing that use of the mass media can create climates of opinion favourable to behaviour change. With some caution,~ one would say that it does appear likely that inthe U;S.A, the.turnlng p0int has been reached in the battle against the cigarette, and that cigarette smoking m a y pass out o f fashion m o r e rapidly than one could have predicted or hoped. Figure 3 is from a slide that ] received from Dr, Daniel Horn of the United States InterAgency Council. If you look at the .period from the Autumn of 1966 onwards, y o u wi!I see that there has been a continuous fall in smoking,~ a n d Dr. H o r n tells m e that this:fall is continuing and has corttinued to the.present day, going right through I969 and into 1970. ]2'0

~tO.O

9 - 0 : ..... t = ~ J I947 4 8 4 9 " 5 0 51

1 i . I } 52 5 3 54 55

1_ i 5 6 57

~ _ t

~

58 5 9

60

4 . t . . . . . L._=.L,__L__/_,_.L___,Z,.._ GI 6 2 6 3 6 4 65 6 6 6 7 68 ~969

Yea~s F i g , 3,

So the average number of cigarettes smoked per ~idult person in the UnitedStates has now dropped from 12 per day to 11 per day. As I Say one has to be very cautious about this, because the figure obviously bobbed up and down for the previous few years, but there has been a continuous decline now forwell over three years. The tobacco growers and processors know this, and are beginning to diversify into other fields. Tile health educators are very optimistic over there.

Ethics of Health Education Now to the actual ethics of health education itself. It is suggested--surprising perhaps to some of you, though I have heard this "from some M.O'sH. and from a good -many other dpctorsmthat we should not be doing health education at all and that it is every man and every woman's inalienable right to %at, drink, drug or smoke themselves to death, or if

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they want to, to get into a barrel and go over Niagara Falls, without any advice from us to the contrary. Nov¢ this is a.perfectly tenable position, which can be, and has been, very cogently argued by some philosophers. But it does not seem to me to be a tenable position for those of us engaged in preventive medicine, and indeed society as a whole passes lairs making it an offence to carry out some actions which may endanger ourselves and others. Freedom is not, and c a n n o t be, unlimited. The problem is where to draw the line. I do not for one .moment think thatthis is a soluble problem. The point at which you draw the line is going to move back and f o r t h according to the temper o f the times, and sometimes in what is apparently a quite irrational manner. It Strikes me as odd that the anti-fluoride lobby, which objects t o the .compulsory intake of fluoride into our bodies, • nevertheless accepts the 1870 Education Act, which could enable the State, if it so wished, to indoctrinate oar minds. Apparently indoctrination of minds does not matter, but you cannot have fluoride in your body. Those who oppose healti~ education seem t o think that our patients are, so to speak, clean slates, Let theni, t h e y say~ make up their own minds. But really is this a true picture ? Tens of millions of p o u n d s a r e .spent each year in persuading people t o behave in ways which are injurious to their health, and one could quote here--~tobacco, probably now 20 million a year and 10 million a year spent on persuading people tO eat confectionery, ls this a clean slate? Are any Of us clean slates w h e n we are surrounded and bombarded by this kind of effect ? The very least the health edticator can do,,and Ii would maintain it is his duty so to do, is to counteractthis awdanc~le of seductive advertising presented :witti great skill and professionalism, tf you are going to concede that the health educator should counteract them in this way what about .the.point I m a d e before about p r o p a g a n d a ? S h o u l d h e limit his activities solely to presenting tb.e facts; t o putting them on t h e slate and allowirtg the public to make u p their o w n minds., or should he say truthfully "these ~cl~aps a r e using propaganda and unless I use the same techniques as they do, or stop them using them, .t am bound to fail". I would submit to you t h a t we are going to have to use:the same techniques that they use. Some pe0ple--zagain this Seems to b e reallyquite inconsistent--do not mind propaganda if you p u t i t on a little poster and stick it.up in a clinicwhereitreaches only ttte converted but if it is set out on a big poster a n d pu t inplaces Where Pe0ple you want to reach see it, this is "brain washing" and is notacceptable. Personally I cannot see this. It has also been said that there a r e m a n y sections of the communiLvwho cannot be reached by conventional educational methods, or are for one r e a s o n , o r another impervious to rational argument, and b y a n d large; these are the folk most in need o f health education. What/~bout the techniques o f group process? The aim here i s said to be to i3resent the facts and allow them b y their own logic to be sorted out by the gro~p so as to produce the decision hoped for by the group leader. The group leader i s n o t supposed to manipulate the group~ and if the facts are right he should not need.to, I think this isa little naive, because I am afraid that in practice, the test of a good g r o u p leader is his ability to deliver:the desired group decision by whatever means come t.o .hand,whether these be good rational arguments in a parl;icular audience like this, emotional pleas or tactical judgement. I am not goirtg to .make any apolog~y when speaking to this particular audience for speaking in this way. ! have been an M.O.H., I have attended Health Committee meetings, and I know what you knov,,; you are there for a purpose, this is a group discussion, you know well what you want your committee to agree to at the end of the day, and you use every wile you can to produce it. Next, community development projects. The theory here is that among certain groups health educators carry out projects or campaigns but their effect, if any, is temporary,

MEDICAL ETHICS AND SOCIETY

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oecause there is no coincidence of aims and goals of the health educator and the community. What are the aims and goals of certain groups of the community ? They are not the same as ours. By and large we are middle-class and they are working-class. The community development worker attempts to secure a permanent change in the life style of the community. Changes in health behaviour are secondary; they follow. One American colleague that I met while 1 was touring tile States a few weeks ago, said to me that he could walk into any class in the United States a,nd tell me the social class of those children simplyby getting them to open their mouths and seeing how marry wore braces on their teeth. The middle classes accept tb.is kind of health behaviour. They accept that immunization is necessary "Six months old! O.K,, the kid's gotta go for his shots." That's it. The community development worker tries to make this Change by working with and through the community and sometimes, as I said before, by recruiting and training members of th.e community, and not doing i t directly themselves, The net result is a change in life style which in the case of the Western nations 'we call 'embourgeoisment'. I suppose if we were Communist and we were trying to make this.change we wouldn't call it that,:but 1 think basically we would try to do the same thing. This I think is basically also the aim of our so-called educational priority areas, an d some people have questioned whether this iS a desirable aim and in particular whether it i s an ethical activity. What gives us the right to go round and say "'Look, we don't like you, you're working class. You'd better become middle Class, and then you'll change your health behaviour habits"? Bernstein argued this cogently in New Society, on the educational side, a few weeks ago, and of course Richard H0ggart is Saying in a 10t of his books l~hat the working class has alot to offer and what right d o w e have to go around changing it. Others have argued that progressive social changes~industrialization, educational changes, i'edistribution Of weaith-'are in any case producing progressive enlargement of the middle class, arid I think, having been an M.O.H. in the South, in the n o a h of England, and in Scotland, I have seen this happening in front of my very eyes. We would Say that the community development worker is seeking only tO accelerate a p~;ocesswbJeh is going to take:place anyway.

The Mass Media Finally, i would like to turn to the mass media, and the use of the mass media by:heal/h educators, because I think thatthere is here another ethicalproblem of grea~timportance to the nation. For the purposes of argument I hope you wilt bear with me if I make Some statements which 1 would like you to accept as axiomatic. Otl another occasion you can tear them to bits if you wish, but just for todaY, perhaps youwould adeept them. Firstly, cigarette smoking is killing as many Britons per decade as died i n W o r i d War~iI:':an epidemic in the true sense, probably unparalleled inpeace time since the gin e13idemie o f the ~eventeenth/eighteenth centuries. Secondly, perhaps, you would accept, simply for the purposes of argument, that it can be shown that the mass media, and particularly the broadcasting media, can create climates of opinion within which health educators could turn the tide against the cigarette to the vast benefit of the public health; this is what Daniel Horn has Said that he has done in the United States and is doing via the mass media. We are then faced with certain problems. Neither the B.B.C. nor the Independent Television Authority are arms of government and there is no fight of access to them. I am a civil servant. My colleague down here in the south, Dr. Jones, is not a civil servant, but he is in a very similar position to myself and neither of us has right of access to these ,media. Both the B.B.C. and the Independents give, out of the goodness of their hearts, a certain amount of what is called 'public service time' for the brief television fillers which appear

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between programmes, tlxe author showed an example to the participants--Editor. Incidentally it is making exactly t!ie point that Mr Teeling-Smith was making that we ought to be telling the public, teaching the public, more about the things that they are entitled to and how to use the service, it is possible too, if one has a theme which strikes the television producer as attractive, to secure programme time, butagain this is not as of rigtlt. It is not possible in the United Kingdom tO buy programme time as it is in the United Statee of America. This is forbidden by the Television Act. It :is possible t o buy advertising time, but only on the independent. channels,.and then at enormous'expev'se. Those of us then, i n c h a r g e of the national health education bodies, are placed in the dilemtna that while tb.e medium exists which :would for purposes of argument enable us t o carryout our work efl'ecti~,jely,w e cannot get access t o it, or only partially and only at an expense that so far:government has not found acceptable. ! f we were at War, or if there was to be a pandemic of smallpox, threatening to kill 100,000 people in a week, instead of in a year, 1 h.ave n o doubt that though not legally arms of government, the broadcasting authorities would feel it their public duty to b e h a v e a s it" they were. t am quite Sure that when the last war broke out, the Prime Minister d i d not phonethe B.B.C. and s~ty ~'10ok, we want 5't~u to act on 6ur beha!f"; :The attitude must have been,~""~,e are all at. war, wllat can we do ?" and they b e g a n t0 pr0duce programmes like "Into Battle ~', and playing:the Nati0nal Anthem.after the nine o'clock news a n d so on. Should they. not do so now, faced as we are with a.national emergency, with regard to cigarette smoking? iOneCan : s e e tb.e ethical arguments against this; and they a r e very strong; please d o not imagine that I have not ~thought "of them.i The :broadcasting authorities could rightly-ask "where does this stop?" If: they agree to-an anti,sm0king campaign, must ttley give time free of .charge a n d a d lib to a nursing recruitment campaign/: or~ an Army reca-ultment campaign, o r :anything else that seems to be i n the public interest ? It Couldalso be argued as a.practical matter that the public Cannot be made t o Watch or listen to programmes, b u t this does not apply to t h e same exteiit to these fillers, providing theyare used effectively but judici0us|y~we must not Club-people to death over the head with them: There are ways :of:usingthem effectively a n d judiciously. All I would say here and now is ithat this is a matter 0f legitimate public interest which should be aired. The broadcasting authorities, quite rightly, object to being Strong-armed, but they do exist t o Serve the public, there is a n ethica! tug-of-war here between what we .need to do and what .they need to :do in. order to serve.the public. Service to the public has meant different things to differentpeople, and those people who lived through Reith's BIB.C., .and t h e B.B.C, that fo!lowed it, Greene's B.B,C,i and t h e present B.B;C.,know .that these are quite different Corporations. Serving the public .has meant quite different things: to different people, lithas meant entertainment, or enlightenment, or instruction, :and during the war it had to mean propaganda. Let us not pretend that it did not. W e m a y have talked of tile Ministry of Information, but i t w a s doing the same thing. Television already means education; all. I am arguing here, as a strictly personal- view, is that education could.now go further and include health education in the forms which are most .effective to carry out the task laid Upon it b y Parliament, Mrs Adams in h e r speech said: "Come along, let's see what the broadcasting people can do, together with you." I. have come from the "health" side to meet her. and we must hope 'that we do not both falt in a pile in the middle. All l am saying here raises no new ethical dilemma but it does pose an inescapable health problem, something we cannot all get away from, squarely in the context of modern methods of communication.

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Open Discussion Several speakers were concerned about the gaps between theory and practice in health education. There was need for better contact and better understanding between the central bodies and the local authorities and in particular .misgivings were expressed about the new Health Education Council. With greater resources in both expert staff and materials :it could work on a scale much greater than that of the old Central Council for Health Education, but its different constitution could make communications between the centre and the periphery less intimate. A distinction needed to be drawn between health propaganda and education in the stricter sense of the word, "Condhioning'" Was a term which many PeoPle looked upon with-suspicion, but if the way of life of the people was awhole was to be made healthier some form of conditioning was both legitimate and necessary.The function of propaganda was essentially to arouse interest and concern in both individuals and the community at large, it could be practically useful in short-term Campaigns, as for examp!e,,in Producing a better acceptance of immunization, but wherethe objective was t9 persuade the individual to Change his habits the initial alerting effectof propaganda mustbe reinforced by,something which would make him think and reflect. This made it essential that the message must not only be clear and cogent but must be based on ifirmscientific evidence. Only in this way could :the recipient come torealizethat the,idea behind the message, was not merely that Of rem0te experts ,but .~,ts something which he Could 'accept as sound and sensible in:relati0rt tohis own experience and ways of thought. The need for experts in health education was generally agreed, but it was dangerous to relyonly on experts. It is necessary that the indivi~lual should find that the people tO wliom he o~rdinar~lylooks for guidance and advice are of the same opinion as the~experts; sO that the G,P,; the public healthdoctor, the heaithvisi~or, the teacher and m ~ y 6thers faust speak with thesamevoice as thespecialist;health:edueator. An inipOrtan~,~rinCtion of the local a~ithority;S. 0fficers was to entist: the ~nderstanding,and,stipporii iof atl these people and consideration ought to begiYen t o theholdlng of discussions'and seminars which brought:the disciplines-t0gether for tb6s purpose,