Keywords

In July 2006, the Labour Prime Minister Tony Blair gave a speech on healthy living. He began by stating that ‘Today I focus on what we call “public health” but which is really about “healthy living”’. Blair went on to set out the challenges to public health as he saw them. He asserted that ‘Our public health problems are not, strictly speaking, public health questions at all. They are questions of individual lifestyle - obesity, smoking, alcohol abuse, diabetes, sexually transmitted disease’. Whose responsibility, Blair pondered, was it to deal with such problems? The answer, he argued, was that ‘Government should play an active role in the way the enabling state should work: empowering people to choose responsibly’. Indeed, Blair went on, ‘in many cases government is not the organisation to persuade us to change some of our most personal behaviour. So Government needs to work with others - with industry, with the media, with civil society to have an impact on persuading more people to make more healthy choices’. The public’s health, the Prime Minister suggested, was the responsibility of individuals, the state, and private and voluntary organisations.

Blair’s speech offers a particular vision of how public health problems and solutions were seen in Britain in the early twenty-first century. But the speech is also interesting because of how it uses history. Blair contrasted the public health problems of the contemporary period with those of the mid-nineteenth century. He suggested that the ‘big state’ was needed to deal with epidemic disease and poor living conditions. State action was still required to combat the public health problems of today, but, Blair argued, the purpose of the ‘enabling state’ was ‘to empower the individual’, in contrast, he argued, to ‘command and control in the manner of 1945’ (Blair 2006). Historical example was being used to justify an apparently new view of the relationship between the state and citizen, between the public and public health policy and practice. In this book, we explore the extent to which this shift took place, and the reasons for it. We contend that the place of the public in public health changed over time, but much depends on the meaning of ‘the public’ and of ‘public health’. Neither of these entities were fixed categories, and as understandings of publics and their health shifted, so too did ideas about the rights and responsibilities of the state and its citizens.

The standard interpretation of this shift is the one exemplified by Blair’s speech: during the second half of the twentieth century, as public health problems became linked to individual behaviour, greater emphasis was placed on personal efforts towards securing good health. Historian Dorothy Porter argued that ‘By the end of the twentieth century states facing the inexorable rising costs of providing health services from increasingly aging and chronically sick populations transformed personal wellness into an individual contribution to the commonwealth’ (Porter 2011, 2). State action was still needed, but the ‘new public health’ required a new kind of citizen: one that lived in a prudent and vigilant way to guarantee their good health (Petersen and Lupton 1996). For some, the notion of this ‘entrepreneurial self’ threatened the ‘publicness’ of public health by individualising and privatising risk (Petersen 1997).

While there is much to be said for this narrative as a way of characterising the broad changes around public health from the nineteenth century to the present, we want to complicate the story. By analysing the changing meanings of the public and of public health in post-war Britain, we suggest that while notions of ‘the public’ encountered individuating forces, such as the rise of identity politics and risk factor epidemiology, ‘the public’ as a collective continued to matter. For instance, we will show that although there were tensions between individual rights and collective responsibilities surrounding population and personal health, most of the people most of the time accepted an ongoing duty to safeguard their own health and that of others. ‘Publicness’ in a larger sense, as a set of values, collective spaces, services and actions, retained a sense of importance for both the state and the citizenry. Moreover, not all of the changes to understandings of the public and public health were imposed from above. We draw attention to some of the ways in which the public, or rather certain publics, had agency and were able to ‘speak back’ to public health policymakers and practitioners, although some had more agency than others.

Indeed, it is clear that there was not one ‘public’ but many ‘publics’, as well as various ways of seeing these.

In this book, we get to grip with the nature of some of these publics and the scenarios in which they were created. To do so, we draw on our historical research, which has examined the place of the public in public health in Britain from the establishment of the National Health Service in 1948 to the ‘return’ of public health services to local government in 2012. Through this work, we present a new perspective on the relationship between state and citizen in the post-war period. Based on the papers of key organisations, government records, published sources and oral history interviews, we explore the dynamics of public-public health interaction in four areas. We focus on the changing nature of health education; the public health survey; the response to heart disease; and the development of vaccination policy and practice. These examples were selected as they encompass the key technologies and techniques of public health practice and research, as well as some of the main challenges to population and individual health. Analysing the response to chronic conditions like coronary heart disease, and the ongoing efforts to deal with vaccine-preventable infections, allows us to see how changes in patterns of disease and its aetiology influenced the relationship between public health and the public. Looking at the methods by which public health policymakers, researchers and practitioners addressed the public, through the survey and in health education campaigns enables us to explore the ways in which public health authorities conceived of the public. We are also able to use these sources to think about how various publics used these media to ‘speak back’ to public health. This allows us to see the public not as an inert or passive object only to be acted upon, but as a dynamic entity in possession of its own agency.

1 Outline of the Book

The concepts of ‘the public’ and ‘public health’ have been subjected to a range of interpretations and definitions over time. In Chapter 2, we consider historical and theoretical approaches to both ‘the public’ and ‘public health’. Neither concept has a fixed meaning, but by tracking some of the key formulations of each, we point to both change and continuity over time. Indeed, one of the constants is the fluidity of ‘the public’, which was never one thing, but many. Similarly, ‘public health’ encompasses a variety of projects, subjects and objects. We bring clarity to such a complex picture by sub-dividing ‘the public’ and ‘public health’ into categories. ‘The public’ can be seen firstly, as a collection of people; secondly, as a space for action; and finally, as a set of values. In a similar vein, ‘public health’ can be broken down into a set of different parts. We describe ‘public health’ as consisting of the challenges it faced or faces; the systems employed to deal with these; and finally, as a philosophy or outlook. To show how these worked in practice, and also to set our research in context, we also use Chapter 2 to present a brief overview of the changing nature of the relationship between the public and public health from the nineteenth century to the early twenty-first century.

The precise nature of the ‘public’ being imagined in post-war Britain is the topic of Chapter 3. In this chapter, we point to three ways in which public health policymakers and practitioners perceived the public. The public was sometimes seen as a collective, as a mass or the entire population. But this mass public was often broken up into groups, many of which aligned with well-established tropes, such as class, gender and ethnicity. Members of the public were also envisaged as individuals. Such neat categories were far from rigid and in this chapter we also point to instances when imaginings of the public overlapped or even conflicted with one another. For public health practitioners, the imagined public was never an entirely coherent entity.

In Chapter 4, we probe the nature of the public in more depth, specifically by turning things around and looking at how the public ‘spoke back’ to public health. We point to three modes of speaking back: resistance, complaint and reappropriation. Resistance could be ‘active’, like refusal to participate in a particular public health initiative, or ‘passive’, like being reluctant or hesitant to engage. Complaining about public health policies or practices, as with complaining within healthcare in general, was rare, but complaints offer a valuable insight into the concerns of the public. Indeed, some members of the public were able to go a step further, and reappropriate or re-ascribe meaning to particular public health messages. All of this indicates that the public was not a passive actor within public health in the post-war period.

The extent to which notions of ‘the public’ and ‘public health’ changed over time are alluded to throughout the book, but in Chapter 5 we interrogate this issue in more detail. Here we return to the question posed by Tony Blair in his speech in 2006: what was the role of the public in safeguarding its own health, and what was that of the state or other actors? We point to ways in which ‘the public’ was challenged by ‘private’ interests and factors as well as how it was reinforced. The linking of many chronic conditions to individual behaviour undoubtedly had an impact on the operation of public health as a practice, as a set of services, and as a philosophy. Individuals and their conduct were always important, but now they mattered more than ever. This undermined some elements of what had been ‘public’ about public health in the past, but, we argue, there was also a range of new ways in which ‘publicness’ was retained and even remade in the latter decades of the twentieth century. At the same time, there was also a plethora of other developments beyond the public/private dichotomy that nonetheless had an impact upon notions of the public and its health.

The changing relationship between public health and the public offers important insights into the nature of publics, public health and publicness in post-war Britain. In Chapter 6, we reflect on changes and continuities in the place of the public, the nature of public health and the relationship between these. We relate these developments to understandings of citizenship. In this way, we contend, the specific case study of the place of the public within public health has much to teach us not only about publics, their health and the people and systems that are supposed to safeguard this, but also about the interaction between state and citizen.