Training to be unpopular: five short steps to becoming a public health advocate

Josie Murray and Nicholas Leigh-Hunt

Coming to the end of their training, many final year public health registrars may reflect on whether they have been able to make a difference, or are equipped to do so in future. Public Health Advocacy is a core skill of public health, yet it scarcely features in the curriculum, and is rarely taught directly. [1,2,3]

To be a passionate advocate for the health of the population requires being prepared to become unpopular by challenging the status quo in order to tackle social injustice and the multinationals profiting from ill health. It may be easy to identify the issues that need addressing, be they problems of unequal access to healthcare for marginalised groups, a massive injustice such as a family evicted as a consequence of welfare reform, or a clear system failure like the Grenfell Tower fire. However many trainees may be unsure of where to begin advocacy work, as decision makers seem way beyond their sphere of influence.

Identifying a good role model may be a good starting point. [4] Ideally this should be someone whose influencing skills have proven successful, even in the face of opposition. Valuable insight into how to become a successful advocate may be gained from a supervised attachment with a role model, or having them as a mentor. Special interest groups in the Faculty of Public Health are also at hand to provide support and advice.

Public health advocacy is most successful when it involves coalitions of like-minded individuals and organisations with agreed priorities. For example, before different organisations and multi-sector agencies advocating for greater tobacco control joined forces, the tobacco industry was able to win the argument. [5] But once they were all united and presented a unified argument, they succeeded in ensuring anti-smoking legislation passed. Many non-government organisations have experts in advocacy and campaigning with the requisite knowledge of strategies to effect change, who will be an invaluable source of support. Identifying like-minded partners who share the same aims and objectives is a key step to defining a solution.

As well as having messages and priorities agreed across partners, it is vital to grasp the underpinning evidence. [6] Any advocate needs to be both familiar with evidence and aware of its limitations, in preparation for interrogation by the media. Where the evidence is not clear, it may be useful to enlist the help of local or national academics with a good track record who can provide that the necessary expertise to make sense of it. Most importantly, it is vital to recognise that the best evidence may change and that one’s own stance may need to change with new and emerging evidence.

While public health training gives essential preparation in how to explain statistical terms in lay language, budding advocates should seek to avoid claiming superior wisdom from statistical significance or boring decision makers with arcane details of confidence intervals. In contrast, adding in powerful case studies with which opinion leaders and the public can identify may be a better way to change minds. For example, at the beginning of the Syrian refugee crisis, the British press and public opinion were strongly opposed to providing shelter in the United Kingdom. Arguments about the scale of the problem or statistics on the health outcomes of displacement made no difference. However one picture of a dead child on a beach, taken by his father, moved hearts and minds. [7] A narrative, that is both strong and appealing to many different audiences, will help get the message across.

Having a great role model, a fabulous coalition with the third sector, as well as robust evidence supported by highly-respected academics, harnessed together with a great narrative may still be insufficient to support a clear advocacy goal. Courage is the other key ingredient in the recipe for success, and a lack of it may mean efforts to put advocacy into practice are doomed to failure. Timidity is one of the “seven deadly sins” of public health, defined as “the fear of being opposed, the fear of being wrong, the fear of standing up and standing out, and the fear of making change.” [8] While sound evidence must underpin practice, the antidote for fear is not knowledge, but courage. The word courage originates from the French meaning take heart. The ability to harness passion and understanding for courageous action is essential to improve population health.

In this age of austerity with ongoing debate over the recent causes of changes in mortality rates, there needs to be open debate over what the acceptable cost to society should be. [9] Prevention has been raised as a key issue for the healthcare system; in order to tackle the increasing burden to individuals and society of long term conditions there needs to be a change in focus from secondary to primary prevention. For this to be fully realised we need to challenge the vested interests of the corporate world who have undue influence over what we eat and drink, the air that we breathe and how we get from place to place. We need to trump smug corporations’ sense of entitlement as easily as they have quashed our meticulous, intellectual reasoning in the past. [10] It is as negligent to ignore our knowledge to improve lives for the population, as it is for the individual patient. [11]

Josie Murray is a Specialty Registrar in Public Health, Department of Public Health & Health Policy
NHS Lothian.Twitter: @PublicHealthStR

Nicholas Leigh-Hunt is a public health consultant. Twitter: @NickLeighHunt

Competing interests: We have read and understood BMJ policy on declaration of interests and have no relevant interests to declare.

Acknowledgements: We would like to thank Woody Caan for his encouragement to write this piece, and his helpful comments and review of the text.


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