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9 Public health: wider action 9.1 Our four priority areas address a wide range of public health issues, but there are further important threats to our health. We are tackling these as well, in a series of strategies complementary to Saving lives: Our Healthier Nation sharing its overall aims and focusing on specific problems. Like this strategy for health, they rely on Government-wide action and shared responsibility. Sexual health 9.2 In March we announced our plans to draw up a national strategy for sexual health which will encourage the development of more comprehensive sex and relationships education, more coherent health promotion messages and more effective service interventions. 9.3 Sexual health is an important public health issue. England has one of the highest teenage conception rates in the developed world and the highest in Western Europe. Such rates vary in severity round the country, with some local authority areas such as Wear Valley having conception rates for girls under 16 as high as 22 in every 1,000. Babies born to teenage mothers have death rates 50 per cent higher than the national average. Many young girls who fall pregnant and choose to keep their baby are likely to experience poverty and poor health and pass such disadvantages onto the next generation. Fig 9.1 Live births to teenage girls in Europe: UK has the highest rate in Western Europe 'clear goal to
cut the rate of teenage conceptions 9.4 Action is already in hand on a number of fronts. The Prime Minister asked the Social Exclusion Unit to develop an integrated strategy to cut rates of teenage parenthood and propose better solutions to combat the risk of social exclusion for vulnerable teenage parents and their children. Its Report set out an action plan comprising:
Fig 9.2 Under age pregnancies: a map of inequality 9.5 Sexually transmitted infections are increasing, particularly chlamydia and gonorrhoea (which can result in infertility), and particularly among teenagers. For 16-19 year-olds there was a 53 per cent increase in cases of gonorrhoea between 1995 and 1997, and 45 per cent for chlamydia. In 1997 there were nearly half a million new diagnoses of sexually transmitted infections in genito-urinary medicine clinics alone. 'support for teenage
parents to ensure they finish their 9.6 Chlamydia is the single most preventable cause of infertility in women, and screening pilots are underway. A national screening programme will be considered when results are available from these pilots. And there are a number of public health promotion campaigns for young people which aim to increase their understanding of sexually transmitted infections and how to prevent them. 9.7 HIV infection and AIDS remain serious threats to health. Because of early prevention efforts we have fared better than many other European countries. France, for example, has four times as many people with HIV as the UK. But we cannot be complacent. Last year saw the highest number of new HIV infections ever in the UK at nearly 3,000, almost twice the figure of a decade ago. So we must continue to promote messages about safer sex, both to the general public and those specific groups who are at particular risk of HIV infection. While new treatments are improving both the length and quality of life for HIV patients, there is still no vaccine or cure. And there are signs that some patients may not respond well to the new drugs, particularly over long periods. So our forthcoming HIV/AIDS strategy will cover issues of testing and treatment as well as prevention. It will be developed within the frameworks set out in The new NHS and Modernising Social Services. 'forthcoming HIV/AIDS strategy will cover testing and treatment as well as prevention' Tackling Drugs to Build a Better Britain 9.8 Drug misuse is associated with poor health both directly, for example through the effect of overdoses and the spread of infection (specifically HIV/AIDS and hepatitis B and C); and indirectly, because of the link with social exclusion through homelessness, poverty, unemployment and criminal behaviour. And the problem is frighteningly widespread. Fig 9.3 Percentage of young men and women who have taken illicit drugs 9.9 In Tackling Drugs to Build a Better Britain, published last year, we signalled our goal of shifting resources from dealing with the consequences of drug misuse to prevention and treatment. Our aims are to:
'shifting resources from dealing with the consequences of drug misuse to prevention and treatment' 9.10 Success will require concerted action at every level. At national level, the policies of different Government Departments are being brought together by the UK Anti-Drugs Co-ordinator, matched at local level by the Drug Action Teams on which a range of agencies are represented. 9.11 In May the UK Anti-Drugs Co-ordinator published his first Annual Report and Action Plan setting out his key performance targets for the next 10 years. Alcohol 9.12 Moderate alcohol consumption is a part of everyday life for many, bringing enjoyment and relaxation. For older people, drinking small amounts of alcohol can give some protection against coronary heart disease. But heavy drinking is harmful not only to individuals, but also to their families and to society at large. As well as directly causing illness such as cirrhosis of the liver, alcohol contributes to certain cancers and to stroke. Its misuse places families under stress, sometimes resulting in domestic violence, mental illness, and family break-up. Alcohol-related disorder and violence affect the wider community. It is a factor in many accidents.
'An effective strategy to tackle alcohol misuse in the year 2000' 9.13 In the Green Paper Our Healthier Nation
we undertook to develop a new strategy to tackle alcohol misuse. Our
broad
9.14 An effective strategy to
tackle alcohol misuse needs the co-operation of all those concerned
with alcohol: health and social services, schools, the alcohol industry,
law enforcement agencies, Government and the general public. We shall
carefully consider the views of all the above to ensure that our strategy
provides a coherent and balanced framework for action to tackle alcohol
misuse and its consequences. We intend to take this work forward, in
partnership with health and industry interests. Food safety 9.15 People are now generally well aware of the risks to health which may be carried through the food chain. Communicable diseases like salmonella can cause severe illness and sometimes death. Outbreaks of food-borne diseases largely result from poor standards in the production, preparation or delivery of food. And numbers of reports of food poisoning have been rising. It is therefore important that high standards are set and monitored. Fig 9.5 The rising trend of reports of food poisoning 'an independent
Food Standards Agency, responsible for setting, maintaining
9.16 Last year we published a consultation document setting out in detail the commitment we made in our manifesto to set up an independent Food Standards Agency, responsible for setting, maintaining and, with local authorities, monitoring food standards and safety. 9.17 The Agency will provide independent and authoritative advice to the public on all food safety and standards issues, as well as on a balanced diet, and on the nutritional value of foods, to help people make informed decisions about what they eat. Following consultation on the draft legislation earlier this year, the Food Standards Bill to give effect to these proposals was introduced into Parliament on 10 June. Water fluoridation 9.18 There are wide variations in dental health across the country. The Acheson Inquiry reinforced the fact that there is strong evidence that water fluoridation improves dental health and significantly reduces inequality in dental health. Children in deprived areas where the water supply is not fluoridated can have up to four times more tooth decay than children in affluent areas, or where water is fluoridated. Responses to the Green Paper were overwhelmingly in support of fluoridation in areas where the level of tooth decay was high. 'water fluoridation improves dental health and significantly reduces inequality' 9.19 It is clear that the present legislation on fluoridation is not working. No new schemes have been implemented since 1985. Once a health authority has established that there is strong local support for doing so it may request a water company to fluoridate the water supply. Over 50 health authorities have made such requests to water companies, but to date none has been agreed. The companies are reluctant to take this step when a small but vocal minority are opposed to it. As a result there is deadlock. 'the present legislation on fluoridation is not working' 9.20 We are conscious that the extensive research linking water fluoridation to improved dental health was mostly undertaken a few years ago. So we have commissioned the Centre for Reviews and Dissemination at York University to carry out an up-to-date expert scientific review of fluoride and health. If it confirms that there are benefits to dental health from fluoridation and that there are no significant risks, we intend to introduce a legal obligation on water companies to fluoridate where there is strong local support for doing so. And to ensure that the extent and validity of that public support is beyond all doubt we envisage transferring from health authorities to local authorities the requirement to undertake public consultation on fluoridating the local water supply. 'we have commissioned an expert scientific review of fluoride and health' Communicable disease 9.21 Communicable disease is one of the main causes of avoidable illness. In the past such diseases as polio, measles, whooping cough and diphtheria were the cause of many deaths in childhood. Fig 9.6 Vaccination conquers disease:the trend for diphtheria 'transferring to local authorities the requirement to undertake public consultation' 9.22 Now the impact of those diseases in our country has almost completely disappeared as a direct result of the success of the childhood vaccination and immunisation programme. Vaccination programmes have completely eliminated smallpox worldwide. But we cannot afford to be complacent. Notifications of tuberculosis had dropped to a steady 5,000 a year in England and Wales but there has been a recent rise in notifications which must be countered. Fig 9.7 An old adversary returning: the recent rise in turberculosis 9.23 In many cases the organisms which cause disease are evolving in ways which make our traditional defences ineffective. We are beginning to see old diseases return, this time resistant to antibiotics. And at the same time new diseases such as HIV/AIDS are emerging. To combat this threat we have asked the Government's Chief Medical Officer, Professor Liam Donaldson, to develop a strategy for tackling communicable disease to bring major reductions in the amount of illness, disease and death it causes. 'By 2003 the Human
Genome Project will have mapped all 100,000 The genetics revolution 9.24 As we approach the new millennium we are on the brink of one of the most important scientific achievements in the history of humankind. By 2003, perhaps earlier, the Human Genome Project will have mapped all 100,000 genes in the human body. Genes provide a code for the structure and function of our bodies. They also determine our risks and susceptibility to disease. They are made up of strands of DNA - a single sequence of body chemicals, which has been described as "the secret of life". The structure of DNA was discovered by British and US scientists in 1953. Fifty years later the mapping of our entire genetic make-up will have profound implications for health, disease, diagnosis and treatment. 9.25 We already know about many particular genetic disorders which will cause serious disease - for example haemophilia and cystic fibrosis. We know that some diseases can run in families - for example, breast cancer - and geneticists are gradually unravelling the genes which cause them. 9.26 At some time in the future it will be possible to map the genetic code of individuals and understand their risk of developing particular diseases through their whole lifetime. Most diseases are the result of a complex interaction between genes, environment, and lifestyle. So the opportunity will be there to provide an individual with detailed advice on how to reduce any health risks which might otherwise result from his or her genetic make-up. 9.27 This heralds a scientific and technological revolution. When it arrives, we will be ready to use the advances in ways which will enhance the opportunities for better health and prevention of disease, while taking account of the wider social, ethical and economic consequences. Effort will be targeted on those most in need. The new Human Genetics Commission, announced in May this year,will take on this task.
9.28 We will also establish a high level Task Force on Genetics and Disease Prevention which will work to the new Human Genetics Commission. Improving health for black and minority ethnic groups 'the death of black
teenager Stephen Lawrence has reinforced our commitment 9.30 We are determined to tackle racism and racial discrimination wherever it occurs. Since taking office we have already more than doubled the proportion of black and minority ethnic people appointed to the boards of NHS bodies, so that they are more representative of the local people they serve. We have changed the arrangements for deciding on distinction and merit awards for consultants and the number of black and Asian doctors receiving such awards has increased by 50 per cent. We have published an action plan Tackling racial harassment in the NHS which sets targets for reducing incidents of racial harassment, and we are supporting it through a major public awareness campaign to highlight the impact of such harassment. And in December 1998 we held the first awards ceremony for the NHS Equality Awards, rewarding NHS bodies which have taken clear and effective action to combat discrimination, including on grounds of racial origin. 'effective action to combat discrimination' 9.31 Our strategy of targeting prevention, treatment and care of those most in need is particularly relevant to people from black and minority ethnic groups. They include some of the people with the worst health in this country. We need to make sure that our plans for achieving the twin goals of this strategy address the particular needs of these groups. 9.32 At present some people from minority ethnic groups have difficulty getting access to health services - health promotion as well as treatment. And when they fall ill their illnesses are diagnosed later and treatment starts later than for others. Fig 9.8 Women in some ethnic groups have low uptake of potentially life-saving cervical cancer smears 9.33 There are also differences in the nature or incidence of illnesses which minority ethnic groups suffer. Some relate to the major killer diseases. For example people born in South Asia are at greater risk from heart disease than most other people in this country, while Afro-Caribbeans have high rates of stroke. Particular diseases such as sickle cell anaemia and thalassaemia occur mainly among specific groups. Taken together, this means not just that health workers need to be especially alert to spot early symptoms of disease among such people; but also that programmes must be tailored in ways which enable people in those groups to reduce their risk from the diseases. Fig 9.9 Relative mortality from coronary heart disease by ethnic origin 9.34 Communication is sometimes a barrier between minority ethnic patients and health professionals. Certain health authorities have appointed linkworkers and patients' advocates to address this problem. This has helped patients to access and understand health services, particularly when they need specialist help. Patients are better able to discuss their anxieties with linkworkers. Fig 9.10 High rates of suicide amongst young women born in the indian sub-continent and living in this country 9.35 Black and minority ethnic groups have certain well-established health and cultural practices. Failure to recognise, understand and be sensitive to differing cultures has been an area in which services have failed in the past. We must match services to the needs of all people, for example by making ethnic diets available in hospitals; by providing appropriate spiritual care; and enabling those who would prefer to see a female doctor to do so - a measure which would encourage more Asian women, for example, to take up potentially life-saving screening programmes. 'We must match services to the needs of all people' 9.36 Statutory organisations are working increasingly with individuals, families and communities from black and minority ethnic groups to understand diversity, the different cultural traditions and the various ways in which people from those communities express themselves. For example, health authorities and community organisations are working in mosques, gurdwaras and temples to set up health services including screening services. In this way the local communities have more say in the organisation and delivery of such services.
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9.29 In
addressing the health of people from black and minority ethnic groups
we need a new approach. It is now absolutely clear that some minority
ethnic groups carry a higher burden of poor health, premature deaths
and long-term disabilities than other groups in the population. We need
to address these issues. But simply to tackle them as a list of problems
is to fail to recognise the fundamental nature of the change of approach
which is required. The report of the Inquiry into the death of black
teenager Stephen Lawrence has reinforced our commitment to the root
and branch reform we had already begun in the way in which services
assess and meet the needs of those from minority ethnic groups. This
is equally so not just for health services but for local partnerships
and programmes of action aimed at improving the health of local communities.
There must be genuine involvement of minority ethnic groups in these
endeavours and programmes must be designed through their eyes, not on
an assumption of what seems right.
