We are all public health workers now, but politicians need to step up, says Graham Mackenzie

In the years before the covid-19 pandemic, I used to tell colleagues in other parts of the NHS, local authorities, and voluntary organisations that we are all “public health workers.” They didn’t work in public health departments, but they still had an impact on population health and followed a number of public health principles, even if they might not recognise them as such. 

The pandemic has demonstrated that across society we all need to understand public health. One simple model looks at three overlapping domains—health protection, health improvement, and quality improvement—always considering their impact at a population level, including inequalities and vulnerable groups. 

Health protection has become an increasingly familiar topic during the pandemic with lockdown, quarantine, vaccination, and other measures introduced to reduce the spread of infection both with individual cases and in outbreaks. Health protection includes communicable disease control and environmental health (e.g. air quality, food safety). The pandemic has highlighted the connections between these areas, for example, with large covid-19 outbreaks in meat processing plants spreading infection into rural communities. Some health protection measures such as quarantine have been used for centuries and much of the legislation we rely on to protect against communicable disease was first introduced in the 19th century with the 1848 Public Health Act, and has been updated since. Further legislation (e.g. the Clean Air Acts of 1956 and 1958) was passed as new environmental threats were identified. 

Health improvement encompasses the range of activities required to improve people’s health and life circumstances. While this is sometimes viewed narrowly as health education focusing on individual choices, this domain should also include the regulation, fiscal measures (price and tax), and legislation required to achieve health improvement at a population level. A good example of the combined individual and population level approach required for health improvement is provided by successes in reducing smoking over the past 50 years. Michael Marmot neatly summarises the perils of focusing on individual change without addressing population level factors as “lifestyle drift.” Just as an individual cannot readily improve the air quality of the community where they live (through no fault of their own), it is very difficult for somebody in precarious employment or damp housing to change their circumstances without considerable support. 

Quality improvement is sometimes called “health service quality improvement.” However, as public health needs to consider the social determinants of health—e.g. housing, education, employment, income, environment, and the economy—I usually drop the “health service” tag. Quality improvement can be summarised in six words—“think big, start small, test fast.” We start with an ambitious population level aim that we are struggling to meet (e.g. “zero covid”); identify areas where we can start work immediately (e.g. vaccine delivery in a local nursing home); and start testing ideas for improvement, measuring as we go (e.g. recording uptake, time taken to vaccinate, wasted doses of vaccine, illness and morale among staff and residents). To reach “zero covid” we would need to work across a range of areas—e.g. in achieving physical distancing in workplaces and public places, contact tracing, widespread uptake of vaccination. Approaches that work at a small scale are tested more widely, adapting over time, until they can be used with confidence at a population level. This approach could be applied, for example, to England’s test and trace system. In contrast to the government’s series of U turns during recent months, quality improvement work requires being connected, curious, and committed. 

There have been some grounds for optimism during the pandemic that illustrate public health in action. Marcus Rashford’s school meal campaigns have demonstrated that the UK government’s policies on child poverty can be changed after years of trying. The measures taken to support homeless people during the early stages of the first UK lockdown were invaluable while they lasted. The move by social media platforms to remove vaccine misinformation is also an important but long awaited first step. However, such measures are not an adequate replacement for effective and coordinated government action, and have often been too little, too late. 

We are all public health workers now, from the way we organise our work, leisure, and day to day tasks such as shopping. Politicians, however, need to take up their public health roles in full. Just as politicians in the early 20th century understood the importance of housing, nutrition, and workplace on health—and legislated effectively to improve people’s life circumstances—our governments must take steps to protect people in overcrowded accommodation (home and work), insecure employment (including during periods of enforced self-isolation to minimise risk of infection), and living in poverty. Our recovery from the pandemic relies on effective public health action, and that means whole-system planning and legislation, adapting to new circumstances as they arise, and adjusting approaches to meet the needs of different communities. 

Graham Mackenzie has been a doctor for 25 years, and is currently retraining as a GP. He has also worked in hospital medicine and was a consultant in public health medicine in NHS Lothian for 11 years, during which time his remit included women and children’s health and quality improvement. Twitter @gmacscotland

Competing interests: none declared.