As a cornucopia of languages greet me every morning in North London, I feel the world at my fingertips. It is like birdsong. While I feel privileged to be a lifelong Londoner, I know that the shadow of the divide- In health and in wealth--  remains obvious. 

Narrowing this divide is what got me up in the morning throughout my life just over the road as director of public health in London’s East End. It is partly what drove me to write my memoir Against the Flow. Pandemic lessons from inside the wider battles for prevention. After four decades in public health practice being  endlessly asked whether I was a GP or responsible for the drains, I decided it was time to set the record straight. My book pulls back the curtain of invisibility. It tells some of the behind- the- scenes stories about the vital role public health has played in the prevention of ill health and the reduction of the health divide.

Reduction you may say, what reduction? While it is true that the divide has been worsening over more than decade, it hasn’t always been the case. The media fill us with bad news every day. But their memories are short. They rarely ask about what has been achieved by our unsung  frontline professionals, preferring accounts from academics most of whom have little experience of turning their research into action. So I decided to take a longer look back to see whether there was more to be learned.

My passion has always been for preventing ill health in whole communities. The job of treating individuals is for those deeper inside the NHS. I had set my sights on what governments, industries and communities could do to improve health. Sadly the majority of politicians don’t know or care that most health is gained or lost outside the health system. In an election year, why is the talk still only of hospitals? I started writing in 2019 about what I, as a woman doctor, mother and partner had to weather over four decades. Including the ups and downs and comedies inside and  outside work. But I came to an abrupt halt in March 2020. This was when the world was turned upside down by  Covid19. It  was killing us on the scale of the main avoidable killers I had worked with all my professional life. 

By the time I picked up my virtual pen again in 2021  I had made a discovery: the Groundhog Day in failed prevention. It is where action on major threats to public health had been thwarted by a repeating pattern of Government failures. Failure to legislate, failure to fund, failure to follow a long term strategy and failure to devolve control. It didn’t seem to matter whether it was poverty, smoking, nutrition, alcohol, obesity or the chronic diseases that resulted.  It was then that I realised too  that these same barriers lie beneath the day to day, gross political mismanagement of the pandemic. 

For me it was the stories of success, forgotten and ignored  by the media and not known among the citizenry, that needed to be told. My own public health baptism began in 1973 when I got my first taste of public health campaigning at the charity, Action on Smoking and Health. There I learned how challenging it was to persuade governments to ban cigarette promotion and to raise the real price of cigarettes in the teeth of the tobacco giants’ opposition. It may have taken 40 years to get there, but smoking rates have since halved. A feat achieved through international activism and perseverance, not  by simply exhorting individual smokers to quit.

Although |I worked with women across the globe to create an international movement against smoking, other aspects of inequality remained unchallenged. It wasn’t until the Blair government used its three consecutive terms to support prevention and reduce health inequalities that  it became obvious that prevention in the NHS was only part of the equation. Every government department had a role to play. National targets for reducing child poverty were set  and health inequalities targets were set at every level.  And it worked. I felt proud to play a part in a strategy where the divide in child poverty, education and life chances at birth and throughout life were narrowed. It is all the more tragic, by contrast, that the divide has  been growing inexorably since. But an incoming government now knows what needs to be done.

Probably the key lessons for future pandemic prevention came after  the arrival of  the AIDS epidemic in the 1980s. Here was a new, deadly virus where, like Covid 19, there was no effective treatment initially. It was not an identical situation, but the comparison is an eye-opener. in the 80s Mrs Thatcher’s government, under the quietly persuasive advice from Donald Acheson her chief medical officer,  spent  large sums of money on treating and caring for people with AIDS. Its unique contribution was that  it also committed dedicated sums of money to every local public health team for prevention in their communities. Strength in prevention became the cornerstone in everywhere. A  massive national media campaign was launched and people quickly stopped worrying about misinformation about catching AIDS from sharing mugs or from toilet seats. The prevention programme was sustained over years. In the East End our newly expanded  health promotion team was able to target support for every major  community where the risk of HIV was high .Gay men, heterosexual  African women and men, pregnant women, sex workers and injecting drug users all benefited. Compare now with the pandemic period and the austerity before, when funding was being cut off for public health and local authorities and prevention was being decimated. Public health directors were barely involved in the decisions made by government and inequalities remained stubborn.

 I recall an unforgettable moment in Newham where the spread of HIV in  pregnant women in the African community was the highest in the country. A local HIV positive woman took courage and stood up in front of more than 100 people and explained why she had chosen not breastfeed her son, despite the stigma she felt in her community. Instead she proudly announced it resulted in her healthy HIV negative baby boy. With tears glistening on her cheeks we knew that such brave leadership from within our communities was more powerful in targeting local inequalities than any leaflet or action by health professionals.

I can only hope that the Public Inquiry into Covid 19 looks beyond the ideological behaviour of government and the narrow confines of infectious disease to the deeper reforms needed to curb the stranglehold created by one party, short term, centralised government.