S5E3
· 43:52
Hello, and welcome to season five of Public Health Disrupted with me, Xand Van Tullakan.
Rochelle:And me, Rochelle Burgess. Xand is a doctor, writer and TV presenter, and I'm a community health psychologist and professor of global mental health and social justice at the UCL Institute for Global Health.
Xand:This podcast is about public health. More importantly, it's about the systems that need disrupting to make public health better. So join us each month as we challenge the status quo of the public health field, asking what needs to change, why, and how to get there.
Rochelle:In this episode, we'll be exploring the idea of the nanny state and understanding the balance between government intervention and promoting public health and individual freedom. Our guests will help us to understand how policies aimed at improving public health can sometimes be portrayed as overreaching and paternalistic, even when the research suggests that public sentiment doesn't see it that way.
Xand:Our first guest today is Adam Briggs, a senior policy fellow at the Health Foundation. And Adam works across a range of public health policy areas, including risk factors for ill health and public health funding. He's also a deputy director of public health at Oxfordshire County Council and a visiting professor at the University of Southampton. Adam's background includes work in national government and the NHS with past research covering the impact of public health policies, including the soft drinks industry levy.
Rochelle:And from UCL, we're so pleased to welcome Professor James Wilson. James has been at UCL since 2008, originally as a lecturer in philosophy and health, and is now a professor of philosophy and co director of the UCL Health Humanities Centre. He also worked with the World Society on the Science as an Open Enterprise report, which laid out the principles, opportunities and challenges of sharing scientific information and made key recommendations for a socially responsible open data system. A huge welcome to Adam and James. Thank you both so much for joining us.
Adam:Thanks very much. Lovely to be here.
James:Indeed.
Xand:James, the nanny state is such an incredibly powerful kind of rhetorical tool. Can you talk about the phrase, what it means, and where it came from?
James:So it's generally thought to be brought into wide circulation by Ian MacLeod, the conservative politician in the nineteen sixties. He applied it to three initial cases in articles in the spectators. Many of them now seem things that we wouldn't think of at all controversial. So he used it to announce, proposals to ban cigarette advertising on television or to introduce a ban on smoking in cinemas in London or even, as he said, the perishing nonsense of a plan for 70 miles an hour speed limits even on motorways. And so there's something strange about this and something that we noticed that very often as soon as anybody wants to make a change in the direction of better public health, there'll always be somebody who wants to oppose to it.
James:Even if we look further back, then there's a wonderful moment in 1848 when we had the debate around the first UK Public Health Act or maybe English Public Health Act, as I should say. And the Times at the time, and I'll quote what the Times said, they said, we prefer to take our chance with cholera and the rest than be bullied into health. There's nothing a man hates so much as being cleansed against his will or having his floor swept, his walls whitewashed, and his pet dung heaps cleared away.
Rochelle:Take our chance with cholera.
Xand:I feel like anyone listening should just know that our facial expressions registered astonishment.
Rochelle:Oh my god.
Xand:Like Rochelle is about to fall out of her chair.
Adam:James, have you got the punch style cartoon that goes with that article? Have you seen that? I haven't. It's fabulous. It's all these people in top hats and tails snooping into people's windows and like down their drains and this kind of stuff as the odious creep makes its way across the nation.
Xand:Oh, that's so good. But the odious creep is a sort of bossy posh show.
Adam:In the picture? Absolutely. Yeah. Yeah.
Rochelle:Not the vile disease that was murdering hundreds and thousands of people. Okay, cool. Cool. Cool. Cool.
James:It strikes me that maybe nanny state or similar kinds of complaints, they maybe play a similar role to something like say woke. You know that when somebody describes something as nanny state they're against it and it somehow interferes with their freedom in ways that they don't want to. But usually there isn't always a very solid argument behind it. So maybe some of the questions we need to begin to think about and to unpack is like, well, you know, who loses by this piece of state legislation and who benefits? So that some of the examples I just gave say smoking in cinemas, it now seems absurd the idea that you know, know, where you couldn't see the cinema screen or you'd be choking just trying to enjoy a movie, the idea that somebody thought it was unfair to be stopped from smoking to your heart's content in a cinema or in a lift.
James:And so a lot of this requires us to sort of unpack this question about who has the right to impose risks on on whom.
Xand:And it's a very sticky phrase politically, isn't it? I mean, my I should say I have a a a kind of particular family connection to this phrase because my wife, her PhD was sort of in nanny statism and that she was looking at resistance to developing, obesity policy over the last thirty years, and she just did a report called Nourishing Britain where she interviewed a lot of the prime ministers and health secretaries and other prominent politicians from the last three decades to say, why haven't you done anything about obesity and diet related ill health? And almost everyone, almost everyone, including Cameron, Sadik Khan, I mean, Jeremy Hunt, Virginia Bottomley, William Aldergrave, these, you know, towering figures of British politics all said nannystatism is what I was beaten over the head with.
James:One thing I've attempted to do in my own work, it hasn't particularly caught on as a phrase, but I'll I'll use it here again to see whether we could get a bit more traction for it. I've often argued that from those who are interested in public health or speaking from the left, we should try to popularize the idea of the neglectful state, where the neglectful state would be cases where the state could have done something easily to reduce risks health and risks of death, but it just doesn't do anything. If you try to understand why it was that people were so angry in the aftermath, say, of the Grenfell fire, I think it was precisely because they perceived that the state had been neglectful, that the easy moves that could have been taken which would have reduced the fire risk and those lives could have been saved but they weren't taken. And so I think it's quite important to notice from cases like that that whilst in some ways the nanny state can seem very controversial, people don't like their their liberty being infringed on, one thing that they hate a lot more is the idea that that they could be sort of burned in their beds because the state was inactive when it should have done something.
Rochelle:I mean, that's really fascinating. I it leads people into interesting spaces of advocacy and activism when you think that actually, you know, you had a responsibility and you neglected your responsibility to your citizens and to the people who sort of put you in power. Let's hope that takes off because I dig that a lot. I think that's really powerful.
Xand:What I love is that I can I can use it? We can start using it immediately. Mean, that's we just do it on the podcast. There we go. The neglectful state.
Xand:That's Yeah. Great. Oh, so you're you're against the nanny state. So you must be in favor of the neglectful state. That's it's great.
Adam:One of the things that I think is interesting is what are we kind of free farm and what are we free to do? So part of the challenges around things like a neglectful state when it comes to building regs and protection against fires, you can understand a little bit about how stuff which is completely out within your control and your areas of expertise, etcetera, should be in some way maintained to a degree of standard to protect individuals exposed to it. But then when it comes to what's perceived to be individual responsibility, where supposedly you have the information you need, whether it's to smoke or to eat unhealthy food or to drink alcohol or whatever else that actually that becomes a perceived bit more of a political tension. The place where I think it gets really blurred at the moment is around things like obesity policy, where actually the differential in our exposure to stuff that makes us healthy. So our ability to then something that's unhealthy, sorry, and our ability to be able to buy more healthy products, to be able to look after ourselves in a way that ensures that we've got the access to the type of food that's healthy, that it's affordable in a way that's healthy, that advertising is done in a way that supports kids to make healthier choices and support their parents and making those healthy choices.
Adam:In terms of a functioning society that does require us often to work longer hours with less ability to have that kind of sanctioned family time historically that the ready meal options that you have available to you are generally all unhealthy. So where does that balance and that tension begin to get reconciled? And one of the interesting you touched upon at the start, Zan, is about the polling side of things. And actually, generally, the public's on board with this, they want a greater state action in supporting people to be able to make healthier choices. And that's not to say we're banning the idea of a treat.
Adam:It's simply to say that the norm has shifted so far towards a much more sort of high fat salt sugar environment. And you see it in the data, right? When we look at levels of adult and childhood obesity and inequalities that sit within this.
Rochelle:Adam, I wonder if you could talk a little bit more about just how much the role of a role media plays in sort of driving perception of different policies and driving that sort of shift in where we think responsibility lies.
Adam:So I guess there's maybe two different types of media that I try and disentangle. One is the sort of advertising media, which is a combination of stuff that's put on the side of the road, paid product placement, social media work, influences, that kind of stuff. And then there's also what we might think more so as sort of mainstream media, which in some ways still has a major role in dictating our political debate in this and maybe James will be able to say more on some of that sort of stuff. But with the advertising media, we know that there is a huge differential in expenditure between what you know, essentially healthy products being advertised and also to a certain extent the kind of advertising campaigns that we used to see, for example, in Public Health England's days around things like change the life and that kind of stuff. But the investment those things is an absolute fraction of what goes into spend on unhealthy products to the extent that the government has seen fit to ban television and online advertising in areas where children are going to be exposed.
Adam:And it's a recognition, I mean, there was a pushback to say that it'll be a different choice, right? We just tell you what's available. There is a recognition by the very fact that money is spent that the advertising influences behavior, right? And so our ability to potentially try and reorient some of the framing on that, I think is really important. And that's to also enable producers and industry who are making selling, formulating more healthy food options to be in that space more, right?
Adam:And to be able to get the kind of financial returns that you might see from unhealthy products. And so facilitating that healthier food environment and markets really important. The bit about this, the mainstream media stuff is a slightly stickier fish, right? And that's the idea that certain aspects of our mainstream media might be more or less prone to government or state intervention in our health. And again, I'll go back to the point I made earlier, that that doesn't necessarily align with what the public think is the role of the state in intervening.
Xand:I mean, that that just sort of can't be emphasized enough that the fears that politicians have about the nanny state accusation don't line up with what the public are demanding in this area, where I think the British public increasingly are desperate for help with food and do perceive the state as being neglectful. And I I think isn't mean, Adam, you can correct me, but my impression is that there is some polling data saying that when politicians invoke the nanny state, increasingly people see that as a sort of an excuse where the government's going, oh, we don't want to be the nanny state and people sort of go, well, it actually sounds like you're being the neglectful state. May not have used such a, that's a trademark phrase. Maybe
Adam:like, so push on a couple of examples, basically. Just before the indoor smoking ban and public space smoking ban came in, in England and Wales in 2007, the polling on that was around a 66% ish public support. And since then, the YouGov polling on that has every three to four years been repeated, and it's gone up every time. So the point is that there is this fear about what it's going to do to industry, what it's going to do to the pub sector, what it's going to do to the politicians of the day in terms of their electorability. And there's actually sport has increased as a consequence, people have seen the material benefits that that's led to.
Adam:And then when you look at some of the food policies, which obviously I think the argument about, you know, meeting a burger in front of you might have less of an impact than me smoking a cigarette in front of you. So I understand that side of things. But still in terms of being able to protect families, children and the public more broadly from unhealthy food products. With polling we did last year in Health Foundation, we asked about introducing a tax on foods that are high in salt and sugar. This is a tax that was promoted by National Food Strategy under Henry Denbigh a few years back.
Adam:And we found that 62% of the public support it and just 18% of the public oppose it. And one of the nice things that we've been able to do in this polling, which we do with IPSOS each, roughly every six months or so is break it down by age, by socioeconomic group, by region, by voting intention, and you can begin to pull out where those differences are. And I think some of the nervousness is around different voting intentions, potentially sitting differently within some of these policy areas. But for that particular policy, for example, across every way we cut those data, the support was greater than the opposition. And so some of those fears aren't necessarily backed up by the polling data that we've got.
Adam:And when you said what happens when
Xand:you say that to politicians? Do they go? Do they get excited?
Adam:Well, this is maybe getting on the edge of where I can speak, Zant. Objectively, that people are very interested in these data. Of course they are. And I think there's different ways that we can make arguments. Some of it is around data and numbers, but some of it is telling a better story, actually.
Adam:And I think that's the bit where the public health community perhaps hasn't necessarily helped themselves. And I think there's a point more broadly about how we talk about what drives health inequalities. What are the building blocks upon which a healthy, society is grounded that allows people to be productive, engage in the workplace, look after their families and, you know, support positive well-being in the broadest possible sense. I think we tell that story particularly well. And then it becomes easily dichotomized into this like us and then industry versus not industry left versus right, etc, etc.
Adam:Actually, whole point of it is nuance, there is no single policy that will solve obesity, that tax won't solve obesity. In fact, we know from the soft tech industry levy work, that it's quite hard to pick up signals from individual policies that are taking place within really complex messy challenges, like what drives obesity at the moment. And instead, what we really want to be able to have is a conversation with politicians and the public that says, these things are messy, they're complex, there are going to be a lot of things that are going to be needed to done that will all help us point in the direction in terms of tackling these challenges of narrowing the growing gaps and inequalities and this kind of stuff, of which some of it is yes, regulation, some of it is going to be about taxes and regulation that are going to help mean that our places that we live in are healthier places for people to live in. But also some of it is still providing individual support for people who are unwell. Some of it is providing, you know, the home ec plus in schools and stuff like there is a mix of things that are going to be and having that slightly more nuanced approach where we tell the story of why this is important to a family or to a community or to a place is something that I think we could do better.
Rochelle:James, did you want to come in on any of that?
James:Yeah, I think that one of the things that's really tricky sort of ethically and politically about public health is often that the benefits of public health activity tend to be quite diffuse, whereas the people who feel that they're losing out, they can point to something very particular. So that's, you know, often they're, for example, car drivers who get very incensed about the idea of the the EU layers. They'll be paying paying more money to come into Central London. They can point to something very specific, which is, you know they can see as a harm whereas you try to point out what's the benefits of improved air quality and you can give various statistics but because each and every individual who benefits from that they only do so quite marginally it's much more difficult to point to people, these people don't have asthma or these people are alive because of ULETS. And within democratic politics, if you have a small group of people who are very angry about something, it's much easier for them to mobilise, to oppose something, to get into the news as a result of it, rather than even when a majority will benefit somewhat or marginally from a policy.
James:I think that's maybe challenge that public health continually faces.
Xand:James, this feels like an area of public health maybe more than lots of other places that we've discussed, where having a philosopher is enormously valuable because these do become, I guess, moral choices. How do you go about structuring an argument around the government stepping in to perhaps limit people's freedoms, limit individual choice in return for overall good?
James:I think the one way as a philosopher we can help governments to think better about decision making about public health is, first of all, to begin by thinking through what do we think the goals of public health are? And I think it's only from quite an old fashioned view of public health that you think that the goals are effectively utilitarian, it's just about maximizing population health. Nearly everybody now would want to say well yes, it's about improving population health but it's also about improving health equity, the distribution of health in a society. And in addition to that, I think that most public health practitioners think that some kind of respect for individuals, respect for autonomy, empowerment is a crucial part of their activity as well. And if you realize that there are three goals of improving health, health equity and also empowerment, then I think that allows us to better shape and think about what a good public health policy looks like.
James:I mean, one thing it can point to is that sometimes it's legitimate to infringe on some people's liberty in order to improve health inequalities. If you can show that doing something will improve the health of people who are marginalised or worse off in other sorts of ways, can frame it as much more like what we do in redistributive taxation. Know there's no proper, it's not a very good moral argument against redistributive taxation say well I as a rich person have worse and worse off as a result of this. Yeah well of course you are, that's the whole point of redistributive taxation. The thing is, well how are the people who are worse off benefit from that?
James:And similarly, you know, even if your liberty is restricted in some ways that it wouldn't otherwise be, if that contributes to a greater health equity, that may be a price worth paying. And maybe last thing to say is that I think that any good public health activity has got to take autonomy seriously, so that one of the things that the state needs to think about is well, are there ways of getting a similar kind of improvement in population health or a similar kind of improvement of health equity while minimizing the kind of impact we have on people's liberty or interfering with people's lives in ways that they dislike less. So that insofar as can do that by effectively the state regulating corporations, for example, rather than interfering in individuals' lives, usually I think the better from the public health perspective, because those sorts state regulation then become largely invisible to individuals. They don't, you know, don't step into their lives, they don't annoy people. And then so far as the state can can help us to get towards improved population health, improved population health equity whilst not stepping on the toes of individuals too much, I think that it's doing its its job from a public health perspective.
Rochelle:So James, would you say that sort of feels like the responsibility of the state is to sort of build environments that enable people to make choices that result in good health? Yeah.
James:I think so definitely. But maybe there's a question about what sorts of choices is valuable to have so that maybe if we think about sort of road safety, it might be a really useful example. You think about all the ways in which cars have become safer over the last, you know, fifty or one hundred years, how difficult it was the fight to get seat belts into all cars, then to make wearing seat belts mandatory or now thinking about why it is that you have airbags in cars. You can see that there's a variety of ways in which manufacturers together with governments can make often sort of small incremental changes in order to make driving safer. Now some of those are about sort of as it were sort of making the healthy choices, the easy ones or or things of that sort.
James:But some of them are going to be more about just sort of ensuring that cars are designed in certain ways that that mean that, well, there has to be an airbag on it or there have to be seat belts in it. Which case it's not so much about empowering people to have choices, just making the environment as a whole safer, something like improving street lighting, maybe a similar case of that sort.
Adam:Yeah. I mean, I think there's a couple of bits there. So one is around what those policies are like. I think there's over the last sort of fifteen years or so there's been a real national preference, particularly we talk about public health policy related to things like risk factors for health, government to be trying to put funding in and supporting stuff that really perpetuates the individual responsibility lines. So if you are requiring someone to make a change in their own behavior, then that effort is going to be a barrier in the first place.
Adam:But secondly, across all the stages that relates to, let's say it's having to see how professional about your weight and then getting referred to a class of subscription turning up to that class, taking on the information that you have in that class, each of those steps, they're all easier if you are generally wealthier, live in a more comfortable set of social circumstances, you have greater family support, and you are generally more socioeconomically wealthy. And so it means that also these interventions not only are harder to engage with, but generally they tend to widen inequalities or at least they don't narrow them. Whereas the interventions that require less agency, that say it's an advertising restriction or things that make your air slightly cleaner when you're walking down the street, all those things don't require you to engage. And the subject industry lobby has a role in that this idea that you can do stuff that doesn't necessarily touch the individual, but means that the products that you're exposed to or the environment that you're living within is healthy in itself generally has a bigger population health benefit. And at the same time helps narrow inequalities.
Adam:And it's that policy space that I think is where we've seen perhaps a bit more of the neglectful state in action and where we might want to see a greater shift in the coming months and years.
Rochelle:It makes me think a bit about what's happening in The States at the moment, in large part because there has been this rolling back of legislation that sort of was doing that quiet work in the background. Right. So like to improve air quality by sort of doing work around what factories can and cannot emit and that type of effort and the removal of that under the narrative of independence and like sort of agency. So even though you've had that sort of quiet stuff in the background, because it felt like because it was so far removed from from everyday citizens, It comes back to that earlier discussion we were having. Don't realize how they've been benefited by those quiet things.
Rochelle:So there's a feels like there's this tension where the state needs to have a role where they're doing work to just make people's lives healthier and better in quiet ways that don't feel like they're infringing on your independence. But at the same time, if you don't know about them, you take them for granted. And then they're able to be sort of like mobilised and manipulated in ways that you then agree to giving them up. So, you know, I sort of feel like we're in this interesting space politically, and I don't think that's just an American thing. I think that's very much something that happens in The UK a lot through different sort of political cycles.
Rochelle:And I just wondered if both of you could reflect on that.
Adam:On that sort of one of the challenges that we have in public health more broadly, as you generally, it's quite hard to count what hasn't happened. And so, you know, in the NHS, and the NHS from a sort of political primetime position, you count waiting lists, you count operations, you count people who have brought back from the brink or who have died. And in public health, it's very difficult to say what some amazing public health act did in the late 1800s to protect health for generations moving forward. And so that's what I think some of that challenge of telling the story about why this stuff is important becomes really critical. And I think a good example of The US might gun laws and gun safety laws.
Adam:So in The US last year, there were around like forty seven thousand deaths from firearms, and I appreciate the populations about five times the size of the whales. But in the whales, they're about 20 something as in just like 22 I think it was. So like, and the difference in that is vast, yet you can legally own a gun in England and Wales, you just have to do it through a very kind of protected set of circumstances that has all this wraparound support and safety around it. And we don't generally get marches about the our freedoms to carry a gun or not. And so I think there is something about a sort of cultural aspect of how we engage with those sort of safety regulations or whatever else it might be that helps keep a population healthy or safe or whatever else it might be, as well as being able to try and tell the story as to why this stuff needs to be protected and maintained when for example, political differences might take us down a different route, which I think is what you're hinting at, Rachael, but maybe James can come in on that.
James:Yeah, the thing that really strikes me about public health and often how easy it is to roll it back is that often we're not very good at sort of selling what the benefits of public health are, because to my mind, one of the main benefits of public health is safety. Safety sounds very boring, you know, saying, well, who wants to be safe when you become risky exciting? But that maybe to be able to sort of find a way of articulating why it's important that people can be safe, they can be secure, they can breathe easily without having to think about it and to make that present in people's lives. I think that's maybe the important ethical challenge for us because unless and until we do that, then as soon as you have gains of public health, then they're so easy to erode because people forget about and they forget about what it was like for things to be unregulated. So there may be to my mind that's the great challenge for that art could set for public health or public health could set for artists that well how do you make palpable the importance of these small things without which the rest of life would go to pot.
Adam:The art and science, of public health, as is our definition of our profession.
Xand:I love that.
Rochelle:Art and science of public health. So all of this in mind, it sort of feels like we might need to reframe in the way that we talk about or focus on public health. This comes in The UK at a time where there's sort of a new plan that has a commitment to shifting focus from treatment to prevention. And I wondered if you if that sort of shift resonated with both of you and how we might best achieve that. Adam, why don't we start with you and then James, you jump in after?
Adam:Sure. Thanks, Michelle. So, I mean, I think I mean, absolutely resonates. I mean, the idea that we need to shift to prevention is something that it not this, not just this government has been talking about. And I think there's general, you know, cross party support and public support that we do need to be doing more to help to prevent disease.
Adam:And it's not just a health issue, it's a wealth issue, and it's a well-being issue. And it's a productivity issue as well. So all these things go hand in hand. And I think one of the things to set the scene is we did some projections for the next twenty years on what the society might look like in England up to 2040. And we anticipate there'll be about a one and a half increase in life expectancy.
Adam:But there will be a reduction in the same time period in healthy life expectancy. So all of that increase plus more is going to be people living with some kind of illness, some kind of illness that is potentially going to reduce their ability to productive or work might need caring support, might need clinical interventions, etc. So how do we get to a stage where actually, we're in a position where that growth in life expectancy is done with people staying well and healthy. Another thing that's really desperate about this is we are seeing these declines in healthy life expectancy, but those differences in healthy life expectancy by different socioeconomic groups stark. And the biggest differences in people living with some kind of illness are among working age adults.
Adam:So it's compounding this idea that generally people
Xand:who
Adam:are living in more socioeconomic, five parts of the country are also having great amounts of poor health. And that greater amounts of poor health are the relative differences are biggest among working age, which means this time they're unable to probably on low income jobs in the first place, able to work in them less generally will have more dependence, whether that's children or older age dependency. And so these things compound, we get into a cycle of inequalities that we need to try and get on top of. So my point about the way you do this is comes back to the issue that you can't think of a prevention in kind of soundbite policies. It needs to be an approach.
Adam:So that approach needs to consider the whole of government. We need to think about how we embed health at the heart of government decision making so that it's a real kind of guiding light to policy that's across all those building blocks like education, like treasury, like welfare reform, like our criminal justice system, similarly in health, of course, as well. And so to do this, what's needed, what's kind of infrastructure? Well, there needs to a guided goal, But there also needs to be ideally and one of the models we've been talking about has been UK Committee on Climate Change. So you've got a big hairy goal of what happens in 2050 in terms of net zero, but you also have some kind of independent accountability mechanism whereby there's some body that monitors government progress against this.
Adam:And in law, says you are not making progress against this like you should or you are. And this policy approach is coherent with that big hairy policy ambition on health or inequalities, or it's not. And this is what you see. And that bit of kind of independent scrutiny alongside ideally having the mechanisms across government, I think is really critical. And that's the bit that I'm not totally sure is going to come out of this ten year health plan, Michelle, that you alluded to.
James:From my perspective, it's obviously the right thing to do to try to shift towards prevention rather than treatment, but there seem to be a couple of huge challenges. One of them is the central one we've been discussing, which is about how and why it is that governments tend to frame the worry in terms of avoiding the nanny state rather than avoiding being the neglectful state. And so far as governments are worried about intervening in a sort of muscular way in terms of public health, it's going to be very difficult to make significant shifts towards prevention. The second point is one about budgets in the NHS, that it's politically extremely difficult to be seen, for example, to be cutting cancer care in order to improve prevention, and that providing intensive care in cases where people are already very sick is obviously of high priority. There's a question about how do you free up the budgets in order to make the shift to prevention within a sort of a health budget which is not rising in line with healthcare needs, it's extremely difficult to do that.
James:So my sense is it'd be much easier to make, if so far as you could leverage more health spending for a few years in order to make that switch to prevention, that might make things easier. Otherwise you can just see that government is likely to take the easy way out each year. There'll be a crisis in the NHS, more than the resources will be sucked towards that and you never really get to the shift to prevention, which is always trumpeted.
Xand:And James, can I just, because you're the philosopher, I feel like you're wrangling with these moral, these central kind of moral concerns, but how often do you find that the barrier is a deeply held ideological conviction, whether it's from a newspaper owner or a a politician? And how often is the barrier more like, you know, why don't why are we not tackling alcohol? Because the alcohol industry spends a lot of money making sure that we don't. Or, you know, why does the why does the spectator pursue particular, a particular kind of nanny state agenda? Because there's lots of money in doing that.
Xand:So do you do you often find that you're actually going, oh, this we are now having a proper moral debate, or is it are most of these things pragmatic short term issues about money and political expediency and potentially conflicts of interest?
James:I think that quite often there's what's really a sort of debate about sort of money and expediency is being sort of dressed up as a moral debate. Certainly quite a lot of the criticism to the moral of the nanny state or of state sponsored paternalism. You can see that people are sort of reaching for a certain kind of quite lofty sounding critique about the importance of liberty. But often if you look behind the way they're funded or join up the dots, then it's not hard to sometimes become a little bit more suspicious. But I guess what I want to do as a philosopher is to try and work out what are the best arguments that a libertarian or a sort of nanny state critic could have and then think about, well, how can we provide a good answer to those from the perspective of philosophy or from public health?
James:So in a way, I try to give as much intellectual credit as I can in order to defeat the best versions of physicians, even if it's quite often the case that in reality, things are rather sort of, you know, shadier than you might hope.
Xand:Yeah. And that wasn't to cast aspersions on anyone writing opinion pieces in The Spectator. And I mean that sincerely, like, think there are good it is important to have robust debates about freedom and government intervention. But, yes, that seems like a very important to go, okay, well, let's anticipate your best argument and have it at that level. Final question for both of you, we're interested in disruptive thinking in public health and elsewhere.
Xand:And and so we're interested in what piece of art or musical poetry has disrupted your perspective on things in life. James?
James:A short story that had an immense effect on me is is one by Stig Dagerman called To Kill a Child. It was one that was commissioned by the Swedish National Society for Road Safety. They they paid him a a pittance for it. But he he wrote this this story, maybe more powerfully than any other thing I've seen sort of allows us to see inside what it means for somebody to be kind of speeding carelessly and to kill somebody. Because he basically tells this story from the perspective where it's you can tell from very first paragraph that that this child is going to be knocked down by somebody who isn't intending to and and, you know, the the guy is just having a a carefree day as he's zooming through the through the village and and it it creates an incredible sense of inevitability and you can almost sort of feel yourself almost shouting out saying, you know, stop, stop.
James:And what I love about that is he manages to make palpable a sense of kind of risk and of and of how unlikely things can happen and and what it means to to take steps to avoid them in advance because he sort of allows us to see in the unfolding of a few minutes of time how two families lives are ruined forever. And it sort of allowed me to maybe to make vivid to myself and sometimes to students when I use in teaching a way of thinking about risk because often when we think about risk in position we sort of tend to think about it in a very abstract sense or we say oh there's a 1% chance of this so it would be okay. You never think about the case where the thing that we thought was unlikely actually does happen and then lives are shattered by that. And to my mind that's always maybe part of the how and why it is that safety is valuable and you take all the precautions that you can both in your own lives and when when you're, you know, doing things that could, harm other people.
Xand:That's amazing. I I I feel embarrassed to say I've never do you know this story, Michelle? I've never heard of it.
Rochelle:I have never heard of it. It's a fantastic I might ask you to email it to me, James, so I can also use it in seminars because that's it's it's fantastic. Even the title just sort of, like, reels you back. And
Xand:It seems to have kept resonating because it was published in 1948, and Alexander Skarsgaard directed a short film of it in 2003. So it it seems to have had this extraordinary life as a piece of work. Fantastic. Oh, that's great. Oh, well, thank you so much for that that recommendation.
Xand:Adam, what about you?
Adam:Feel frankly embarrassed by the example that I can now pull out the bag. So I've got far less high brow example, which was sort of mid COVID, I guess. So I grew up one of millions of kids who loved the Beno And Somerset House in the sort of autumn spring twenty one to ran an exhibition of some bespoke exhibition called Bino The Art of Breaking the Rules. And it's this real kind of expose for grown ups and kids alike to kind of go back in time and look at, like some of the cultural underpinnings of the Bino and this idea of, you know, mayhem and pranking and, you know, slightly being on the edge as a kid. And the poster that goes with it has got this, it's got many of the minks hanging out one of the windows of Somerset House with a sign saying art is the thing nobody asked you to do, right?
Adam:And it really, I went there with my kids. And the thing it provokes is this idea. So I think in this context, man state, but like the idea of like is public health, fun police, right? And so like fun is so important. And it's so important to our well-being.
Adam:And it's so important to say that we can kind of creatively explore these new ideas and do things that are a bit silly or, you know, just a little bit on the edge of what may or may not be classed as kind of mischief or rule breaking. And the point of public health, right, is not to create this kind of solace state whereby everybody has to live off, you know, cabbage leaves and walk around at a certain speed and not bump into one another, all these types of things. The point of public health is to create a place where people can live like life in their fullest extent. And that includes diversity and the textures and the color of what we enjoy and what we, you know, makes relationships and what like drives creativity and things. And so at the moment, it just feels like we're in a position whereby we've got such opportunity to allow more people to live a full, well, healthy life than we are doing at the moment.
Adam:And so this is what I'm talking about the story and the narrative, it's about how we allow a place where our kids can still go outside and play in safety, but also, know, explore their lives and kind of push up against those boundaries and understand who they are as people. And then, you know, for grown ups to be silly and to engage in that kind of stuff at times as well. So I've got in our house, our downstairs Lou it's got this post up, but it's also wallpapered with all my old binos from a kid. So you could sit there for hours if you like, enjoying old beanos on the wall. But it's this kind of reminder that you're like, there is a degree of like, you know, silliness and escapism that comes with childhood and comes with being able to live through these crazy characters that I wouldn't ever want to lose in this pursuit of public health.
Adam:And so when you're allowing, when you're seeing those inequalities in multiple ability or healthy life expectancy or life expectancy, full stop, then like the motivation is this, Rather than some kind of puritanical view of homogenous well-being.
Xand:I love that. I love that you underplayed it by saying it wasn't going to be highbrow, but I feel like I've never really brought my critical faculties to reading the Bino or the Dandy. You're both amazing. That was a fantastic two things to end on, and I'm looking at the poster that the be know the art of breaking the rules now. It's really, really magical.
Xand:Thank you both so much.
Rochelle:Thank you so much. It was really cool.
Adam:I'm really grateful to you guys for, you know, being able to commit some space to this.
Rochelle:You've been listening to Public Health Disrupted. This episode was presented by me, Rochelle Burgess and Xand van Tulleken, produced by UCL Health of Public and edited by Annabel Buckland at Decibel Creative. Our thanks again to today's wonderful guests, Adam Briggs and James Wilson.
Xand:If you'd like to hear more of these fascinating discussions from UCL Health of the Public, make sure you're subscribed to this podcast so you don't miss future episodes. Come and discover more online and keep up with the school's latest news, events, and research. Just Google UCL Health of the Public. This podcast is brought to you by UCL Minds, bringing together UCL knowledge, insights, and expertise through events, digital content, and activities that are open to everyone.
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