Is there still a message in the bottle?

Hugh Casey [1] has been at the center of Northern Ireland community politics for well over half a century advocating, managing and delivering services for children and young people in the once riven neighborhoods in and around Lurgan.

Now in his eighty-first year he is bringing a lifetime's experience and patience to the Together 4 All initiative [see: Lurgan comes together for together for all [2]] which embodies many of the scientific principles that also underpin Prevention Action’s work.

For Hugh Casey the adolescent, along with many of his contemporaries, "taking the pledge" was a significant formative experience. He did not drink until he was in his late sixties, when, as Mayor of Craigavon, he had to attend public functions night after night. As he puts it, he got fed up with drinking Coca-Cola and began to take the occasional glass of wine. When his term as Mayor ended he became teetotal again.

You would be hard-pushed to find many teetotal adolescents in Craigavon today. Like other parts of Ireland and the UK, the district is awash with alcohol and other drugs. And the forces operating when Hugh was young, which made teetotalism one of the badges of an aspirant and politically well organized working class, are long played out.

So what lessons for the twenty-first century can be learned from the history of the temperance movement that shaped Hugh’s early career? And what about that brief excursion into social drinking 20 years ago – is there a moral there too?

How public health campaigns have threaded their way through the politics of the last 150 years, sometimes fueled by improving science, sometimes by other considerations entirely, is tracked by Virginia Berridge [3], Professor of History at the London School of Hygiene and Tropical Medicine in a recent issue of the British Medical Journal.

She draws lessons from four significant public health campaigns of the last two centuries, beginning with the Health of Towns Association, which was established in response to Edwin Chadwick’s 1842 Report on the Sanitary Condition of the Labouring Population of Great Britain.

In this first case the science was flawed (it assumed that disease was airborne not water-borne) and the approach was paternalistic, focusing on sewers not deprivation. But the work was nevertheless life-saving. In the space of four years the Association created the Journal of Public Health and nursed into life the Public Health Act of 1848, which provided for sanitary reform in the UK.

By way of an analysis of temperance, a social movement, largely uninterested in science which led to about a million people in the UK taking the pledge, Berridge turns to a prominent, modern example of public health campaigning.

ASH - Action on Smoking and Health [4] - was established in 1971 following a damning report by the Royal College of Physicians. It was strategic – sealing important alliances with state health and professional organisations – and it was media savvy.

Berridge quotes Mike Darbe, the activist director of ASH: “You had your villain. You had your Saint George and the dragon scenario, you had your growing interest in consumerism. It seemed to me there were a lot of prospects of making something out of it.”

The science was important but the scientists responsible for it were uneasy. Austin Bradford Hill and Richard Doll, who share the credit for discovering the link between smoking and lung cancer, felt that policy making was best left to policy makers.

The effects were nevertheless very far-reaching. Cigarette smoke was everywhere in the 1950s. Taking the 25-34 age group as an example, 80% of men and 53% of women smoked. Half a century later those rates had declined to 39% of men and 33% of women.

Berridge's final example is the courageous work by the group of media-conscious gay men who founded The Terrence Higgins Trust [5] in London in 1983 and went on to transform perceptions of and responses to the emerging AIDS epidemic.

From her survey Berridge draws out several lessons.

First, public health works best when it builds on existing social behaviors or aspirations. Those who pioneered teetotalism gave focus and radical meaning to a working class desire for respectability and self-reliance.

Second, the role of media and science is becoming more central. The Health of Towns Association got the science wrong. The temperance movement had little science to go on. Some would say ASH manipulated the science. In public health matters there will always be a danger that moral imperatives or other factors corrode the value of research.

In recent times, advertising in mass media outlets has become an important public health mechanism. Few alive in the UK in the 1970s will not remember the Saatchi poster for the Health Education Council Campaign to reduce smoking among pregnant mothers.

Third, effective public health campaigns rest on important strategic alliances. Any attempt to reach the general populations will hit resistance, for example among popular attitudes, politically-motivated prejudice and vested commercial interest. Achieving change means negotiating and slowly altering strongly held beliefs.

Finally, Berridge reminds us that to be effective attitudes to public health must be embedded in culture. Society can pass laws to ban smoking in public places, but the demise of tobacco use will be the result of a shift in commonly held beliefs.

As for the example of Hugh Casey: no law stopped him drinking when he was young, and there was no reason for him not to continue to take the odd glass of wine after his term as Mayor of Craigavon. He altered his behavior to suit the context in which he found himself – and context is arguably a more a powerful shaper of our lives than, say, public health legislation.

As Together 4 All tackles the elevated levels of anti-social behavior among children in the four communities for which it is designing, implementing and rigorously evaluating prevention strategies, the long-term success or otherwise of other public health initiatives beyond their campaigning years may warrant further scrutiny.

References
Virginia Berridge, "Public health activism", British Medical Journal, 335, pp 1310-1312, 2007
Richard Peto, Sarah Darby, Harz Deo, Paul Silcocks, Elise Whitley, and Richard Doll, "Smoking, smoking cessation, and lung cancer in the UK since 1950: combination of national statistics with two case-control studies", British Medical Journal 2000;321:pp323-329