Haringey resident Dr Bobbie Jacobson OBE on her mission to tell the story of health inequality

When I hear the cornucopia of languages that greets me every morning in Haringey, I feel the world at my fingertips. It is like birdsong. While I feel privileged to have lived here with my family for more than three decades, the shadow of the divide – in health and in wealth – remains. I see the “haves” in the west and the “have nots” in the east.

Narrowing this divide is what got me up in the morning throughout my working life just over the road as director of public health in the 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, being endlessly asked whether I was a GP, an administrator, or responsible for the drains, I decided it was time to set the record straight. I started to pull back the net curtain of invisibility to tell some of the inside stories about the vital role public health has played in the prevention of ill health and the reduction of the health divide.

You may say, what reduction? While it is true that the divide has been worsening over more than a decade, it hasn’t always been the case. The media fills 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 not had experience of turning their research into action). I decided to take a longer look back.

My passion has always been for preventing ill health in whole communities. The job of treating individuals is for those working deep inside the NHS. I had set my sights on what governments, industries, and communities could do to improve health. Sadly most
politicians don’t know or care that health is gained or lost outside the health system. In an election year, their talk is only of hospitals. I began writing in 2019 about what I as a woman doctor, mother, and partner had to weather both inside and outside work. But I came to an abrupt halt in March 2020. This was when the world was turned upside down by Covid-19.

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. Here, 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 smoking, nutrition, alcohol, obesity or the chronic diseases that resulted from it. It was then that I realised too that these same barriers lie beneath the gross day-to-day political mismanagement of the pandemic.

For me, it was the stories of success, forgotten or 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 tiny 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 been halved; a feat achieved through international activism and perseverance, not 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 and health inequalities 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 narrowed. It is all the more tragic, by contrast, that the divide has been growing inexorably since. But the incoming government now knows how it can be done.

Probably the most important 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 yet known. It was not an identical situation, but the comparison with Covid-19 is stark. In Thatcher’s government, the quietly persuasive advice from her chief medical officer Donald
Acheson resulted in large sums of money being spent on treating and caring for people with AIDS, as well as dedicated funding for
every local public health team for local prevention.

A massive national media campaign was launched too to stop people 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 expanded health promotion team was able to target support for every major community at risk: gay men, heterosexuals, Africans, pregnant women, sex workers, injecting drug users, and school kids all benefited. Compare now with the pandemic period when funding was being cut off for public health and local authorities. And public health directors were barely involved in the decisions made by the government.

I recall an unforgettable moment in Newham where the spread of HIV in pregnant women in an African community was the highest
in the country. A local HIV positive woman took courage and stood up in front of a meeting of more than 100 people and explained why
she had chosen to not breastfeed her son, despite the stigma she felt in her community.

Instead of becoming HIV positive, she proudly announced it resulted in a healthy six month old baby boy. With tears glistening on her cheeks, we knew that such brave leadership from 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 the
government to the deeper reforms needed to overcome the stranglehold created by one party.

To find out more:
Visit troubador.co.uk/bookshop/autobiography/against-the-flow

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