Last month, CGHH’s Deputy Director Dr Alexander Medcalf spoke on the WHO’s public information strategies at the ‘Photography and the Languages of Reconstruction after the Second World War’ conference at Cardiff University (www.cardiff.ac.uk/events/view/photography-and-the-languages-of-reconstruction-after-the-second-world-war,-1944-49). Drawing on his articles on the WHO in the Journal of Global History and Medical History, Dr Medcalf gives us a brief introduction to how the WHO used photographs as part of its public information activities.
"The WHO created a public information office (PIO) to address the section of its Constitution which specified that education and information for the public was necessary for the WHO to achieve its goals. For health measures to have lasting value, people of all ages needed to be persuaded to take an interest and responsibility for solving their health problems and those affecting their community. However, the WHO recognised that in order for this to be effective it needed to find ways to balance information that was timely, accurate and informative, but also interesting and engaging.
The WHO developed an array of means of inciting interest in the agency and the health situation around the world: exhibitions, publications and films. But photographs were especially useful and helped to construct a pervasive vision about what it meant to be healthy or suffer disease. The WHO disseminated photographic work through its own public-oriented magazine, the WHO Newsletter. Photos took pride of place in Newsletter, on the front cover and features inside. Through it the WHO sought to reach out to as many people as possible and encourage them to see the world ‘through the eyes of the WHO’.
Initially photographs were contributed by WHO staff working in the field, but these were deemed to lack professional quality. In May 1950 a visual media expert was assigned to arrange photographic missions on the WHO’s worldwide activities and the agency came to rely on well-regarded photographic agencies such as Magnum, and eminent photojournalists who were seen to provide better, hard-hitting and captivating imagery. That said, the appearance of individual photographs was the result of input from many individuals. Once each photo mission was authorized, photographers were supplied with background information on the countries and the topics in question. Sometimes we see very specific instructions and lists of preferred shots and topics provided to photographers. When the photographic material was returned to the WHO, PIO officials selected the shots for publication. This process wasn’t simply about gathering evidence or being an eyewitness, but about constructing a particular narratives.
We can conclude that the WHO's efforts to construct and disseminate visual messages were successful. Newsletter had a good reach, appearing the in tens of thousands and in multiple languages. Articles and photographs printed in Newsletter were made freely available for reproduction enabling the WHO to feature in many external publications. A report on public information projects undertaken between November 1953 and June 1954 recorded that several popular magazines had devoted long stories to the WHO. Regional offices worked to inspire international coverage by arranging for material to be placed in local picture magazines. But judging the effect of public information work on the intended audience was harder. The records do not suggest that a comprehensive answer was ever obtained. It remained difficult to estimate the size of the audience reached by WHO information, and even harder to assess the extent to which public attitudes were changed.
Thus the WHO was able to put its work and vision in front of millions. But that was not the end of the story. In the 1970s the WHO began to look more closely at the effects of this imagery and, as Joao Nunes and I explore in our article 'Visualising Primary Health Care: World Health Organization Representations of Community Health Workers' , there were many challenges in picturing certain topics."
Further reading:
Alexander Medcalf, ‘Between Art and Information: Communicating World Health, 1948-1970’, Journal of Global History 13, 1 (2018), 94-120.
Alexander Medcalf and Joao Nunes, 'Visualising primary health care: World Health Organization representations of community health workers, 1970-1989’, Medical History 62, 4 (2018), 401-24.
Thursday, 23 May 2019
Tuesday, 19 March 2019
Reflections on a year at CGHH
Today we are delighted to feature another guest post from Namrata Ravichandra Ganneri (a Commonwealth-Rutherford Fellow based at the Centre for Global Health Histories (CGHH) and the Department of History for 23 months (22 March 2018 to 21 February 2020)), reflecting on her first year spent researching at CGHH!
Having spent nearly a year in the UK as a Commonwealth-Rutherford Fellow on the project ‘India’s Smallpox Eradication as a Global Roadmap’ at CGHH, a trip home was to be a welcome break from all duties. Or so I hoped! –a chance visit to my employers brought a novel assignment- a talk on my fellowship experience for peers and students. The talk comprised my thoughts on the transformatory impact of the fellowship, which commenced in late March 2018 on my life and career. Now that I am back from annual leave and ease myself into a routine, I believe that sharing these thoughts may also profit both the followers of this blog and the wider online communities accessing this post. What follows is a brief account of the presentation, and my reflections since.
My annual leave to India early February 2019 was to revisit the smells and sounds of my home country, meet family and friends, plus afforded a much -needed break from the cold British winter! Indeed, most of my time was spent catching up with family, yet I yearned to see my workplace having spent nearly one third of my life teaching at S.N.D.T. College in Mumbai. A visit to the college brought joyful reunions with colleagues and students, although meeting the new head of the institution also brought in a new assignment - a short talk on my fellowship experience so far!
There were mixed feelings as I ascended the podium to deliver a talk on ‘My fellowship in the UK: some thoughts and learnings’ on 25 February 2019. It was the same place where I had greeted and introduced several visiting scholars and guests to our institution in the past and was then trying to distil a year of somewhat heady experience of my life in the UK. Living alone in a foreign country was an important first though 2018 had been eventful in myriad ways.
I spoke to my young friends in college about the beautiful student- friendly, as well as touristy, city of York, as well as my experience of living through ‘Brexit Britain’. There was considerable interest in the Commonwealth scholarship scheme as I shared information about the masters’ and doctoral scholarships awarded by the Commonwealth Scholarship Commission, and my own insights as a recipient of the postdoctoral Commonwealth- Rutherford Fellowship (which isfunded by the UK Department for Business, Energy and Industrial Strategy (BEIS) through the Rutherford Fund).
I was fortunate enough to avail this research only fellowship, awarded for a maximum of twenty- three months, for the whole period , due to grant of study leave by my Indian employer. The Commonwealth fellowship enables my training at CGHH, a globally renowned centre on medical history which works closely with the World Health Organization (WHO) being a long standing WHO Collaborating Centre at the Department of History, University of York. Extraordinary support from my host institution and supervisor eased transitioning into the relatively new sub-discipline of history of medicine and health policy. Moreover, the Centre has attracted research scholars from several nationalities with whom I have developed both camaraderie and collegiality despite only a relatively short period of association. The excellent opportunities to interact and liaise with academics, policy makers and health advocates from all corners of the globe, from China to New Zealand to Finland as they passed through the Centre helped internationalise my own research. I spoke about the exhilaration of devoting all my time to reading and writing (away from teaching!) and realizing a long-standing dream of visiting the British Library in London. As I saw it, the chance to develop expertise in a different research area, working with newer material and archives was adding to my métier. Additionally enriching were the enormous opportunities to participate in University level events. An important high was the invitation to deliberate on gender and social justice as a member of the Equality and Diversity Committee (EDC) newly constituted by the department of History in 2018.
I was especially pleased recounting the experience of representing my country as well as my host institution at the World Health Organization (WHO) ‘Global Conference on Primary Health Care’ in Astana, Kazakhstan in October 2018, commemorating 40 years of the Alma-Ata Declaration on Primary Health Care. The trip created special memories especially as I met greats like Prof. Sharmanov, the architect of the Alma-Ata Declaration and observed closely the crafting of a global health agenda. Additionally, the visit to Astana offered me the opportunity to co-organise and present my ongoing research on India’s smallpox eradication programme at a prestigious WHO Global Health Histories Seminar on 'Immunization for Universal Health Coverage' at Nazarbayev University and address a wide audience including delegates present in the young city to attend the historic conference.
Being based in CGHH has meant representing the Centre in key meetings and at Global Health Histories seminars in various parts of the world, participating in wide-ranging discussions on global health across geographical regions as well as disciplines-public health, medical practice, medical anthropology, visual anthropology, public policy etc and opportunities to both innovate and invigorate my own research skills. As questions poured in both from peers and students about life in the UK and the higher education and research environment abroad, I marvelled at my own felicity- commenting and reflecting- and finally, looking forward to another, nearly a year, in the UK.
My annual leave to India early February 2019 was to revisit the smells and sounds of my home country, meet family and friends, plus afforded a much -needed break from the cold British winter! Indeed, most of my time was spent catching up with family, yet I yearned to see my workplace having spent nearly one third of my life teaching at S.N.D.T. College in Mumbai. A visit to the college brought joyful reunions with colleagues and students, although meeting the new head of the institution also brought in a new assignment - a short talk on my fellowship experience so far!
There were mixed feelings as I ascended the podium to deliver a talk on ‘My fellowship in the UK: some thoughts and learnings’ on 25 February 2019. It was the same place where I had greeted and introduced several visiting scholars and guests to our institution in the past and was then trying to distil a year of somewhat heady experience of my life in the UK. Living alone in a foreign country was an important first though 2018 had been eventful in myriad ways.
I spoke to my young friends in college about the beautiful student- friendly, as well as touristy, city of York, as well as my experience of living through ‘Brexit Britain’. There was considerable interest in the Commonwealth scholarship scheme as I shared information about the masters’ and doctoral scholarships awarded by the Commonwealth Scholarship Commission, and my own insights as a recipient of the postdoctoral Commonwealth- Rutherford Fellowship (which isfunded by the UK Department for Business, Energy and Industrial Strategy (BEIS) through the Rutherford Fund).
I was fortunate enough to avail this research only fellowship, awarded for a maximum of twenty- three months, for the whole period , due to grant of study leave by my Indian employer. The Commonwealth fellowship enables my training at CGHH, a globally renowned centre on medical history which works closely with the World Health Organization (WHO) being a long standing WHO Collaborating Centre at the Department of History, University of York. Extraordinary support from my host institution and supervisor eased transitioning into the relatively new sub-discipline of history of medicine and health policy. Moreover, the Centre has attracted research scholars from several nationalities with whom I have developed both camaraderie and collegiality despite only a relatively short period of association. The excellent opportunities to interact and liaise with academics, policy makers and health advocates from all corners of the globe, from China to New Zealand to Finland as they passed through the Centre helped internationalise my own research. I spoke about the exhilaration of devoting all my time to reading and writing (away from teaching!) and realizing a long-standing dream of visiting the British Library in London. As I saw it, the chance to develop expertise in a different research area, working with newer material and archives was adding to my métier. Additionally enriching were the enormous opportunities to participate in University level events. An important high was the invitation to deliberate on gender and social justice as a member of the Equality and Diversity Committee (EDC) newly constituted by the department of History in 2018.
I was especially pleased recounting the experience of representing my country as well as my host institution at the World Health Organization (WHO) ‘Global Conference on Primary Health Care’ in Astana, Kazakhstan in October 2018, commemorating 40 years of the Alma-Ata Declaration on Primary Health Care. The trip created special memories especially as I met greats like Prof. Sharmanov, the architect of the Alma-Ata Declaration and observed closely the crafting of a global health agenda. Additionally, the visit to Astana offered me the opportunity to co-organise and present my ongoing research on India’s smallpox eradication programme at a prestigious WHO Global Health Histories Seminar on 'Immunization for Universal Health Coverage' at Nazarbayev University and address a wide audience including delegates present in the young city to attend the historic conference.
Being based in CGHH has meant representing the Centre in key meetings and at Global Health Histories seminars in various parts of the world, participating in wide-ranging discussions on global health across geographical regions as well as disciplines-public health, medical practice, medical anthropology, visual anthropology, public policy etc and opportunities to both innovate and invigorate my own research skills. As questions poured in both from peers and students about life in the UK and the higher education and research environment abroad, I marvelled at my own felicity- commenting and reflecting- and finally, looking forward to another, nearly a year, in the UK.
Friday, 4 January 2019
Procession and Pageantry in a disease eradication programme: A note on India’s ‘Smallpox Eradication Week’
Today we are delighted to feature a guest post from Namrata Ravichandra Ganneri (a Commonwealth-Rutherford Fellow based at the Centre for Global Health Histories (CGHH) and the Department of History for 23 months (22 March 2018 to 21 February 2020)). Her project, entitled ‘India’s Smallpox Eradication Programme as a Global Roadmap’, closely examines pilot programmes conducted in the Indian state of Goa to offer a fuller picture of the global history and narrative of smallpox eradication.
In the last quarter of 1962, India launched an ambitious National Smallpox Eradication Programme, following an epidemic cycle in 1958. At this stage, the primary strategy adopted was that of mass vaccination and the programme aimed to vaccinate the entire population of the country by March 1966.
There were obvious technical and administrative hurdles in vaccinating each and every individual in a vast and populous country like India, which contributed nearly half the number of smallpox cases in the world at that time. Another stumbling block was the general resistance and apathy towards vaccination among the populace. The success of this gigantic public health programme hinged on active and voluntary participation by the people. And, this was certainly difficult to count on in the mid-1960s.
Hence a ‘Smallpox Eradication Week’, a flurry of events to popularise the government campaign, was launched in the last week of September every year, though not much is known about the event in its early years. A ‘Smallpox Day’ was celebrated on 25 September 1962 just before the launch of the programme and since then there was a week of intensive publicity and canvassing for popularising the government programme beginning on the 25th September in the years 1963 and 1964.
Meanwhile, an evaluation conducted in the interim indicated that only 74 percent of the population was vaccinated, while a quarter of the population remained unvaccinated and therefore susceptible to the scourge. Health education was an important component of the eradication programme; its importance was never clearer to the authorities and the public health workers than in the face of falling targets.
Seemingly, the 1965 ‘Smallpox Eradication Week’ was specially mandated to shore up the programme’s vaccination targets, and these ‘celebrations’ are better known since they were reported in contemporary media. In fact, a special manual outlined all activities envisaged as part of the programme. All the federal states were mandated to participate and report their activities in the official mouth-piece of the programme The Smallpox Eradication News (English) and the Rashtriya Chechak Unmulan Samachar (Hindi).
A range of activities including lectures, debates, programmes on All India Radio (the public broadcaster) and cinema shows were organized throughout the country. However, interestingly, the dominant images that come to us today are those of public processions with men, women and even children carrying placards and raising slogans.
The tradition of prabhat pheris (an early morning procession with religious ballads) used during the freedom struggle in India to broadcast anti-colonial sentiments was reinscribed with smallpox eradication messages. Street theatre/ plays on the theme were performed in some parts of India. Importantly, these events were accompanied by mass vaccination drives.
The enduring images of the ‘Smallpox Eradication Week’, of people marching in procession, carrying banners etc. or performing at events, were perhaps meant to convey that the general masses welcomed the programme despite the evidence of obvious resistance in the large numbers of unvaccinated people towards the close of the first phase of the programme.[1]
This archive of images, relatively little known and under analysed, gesture towards the politics of popular representations of state managed schemes and programmes. Even as the eradication programme was faltering in achieving its targeted outcomes, the visuals remain celebratory and euphoric.
Pictures have usually been used to produce a narrative that conforms to what we already know. However if used ‘on their own terms’, as Pinney (2004:8) suggests, they might be able to narrate to us a different story about the Indian programme.
In the last quarter of 1962, India launched an ambitious National Smallpox Eradication Programme, following an epidemic cycle in 1958. At this stage, the primary strategy adopted was that of mass vaccination and the programme aimed to vaccinate the entire population of the country by March 1966.
There were obvious technical and administrative hurdles in vaccinating each and every individual in a vast and populous country like India, which contributed nearly half the number of smallpox cases in the world at that time. Another stumbling block was the general resistance and apathy towards vaccination among the populace. The success of this gigantic public health programme hinged on active and voluntary participation by the people. And, this was certainly difficult to count on in the mid-1960s.
Hence a ‘Smallpox Eradication Week’, a flurry of events to popularise the government campaign, was launched in the last week of September every year, though not much is known about the event in its early years. A ‘Smallpox Day’ was celebrated on 25 September 1962 just before the launch of the programme and since then there was a week of intensive publicity and canvassing for popularising the government programme beginning on the 25th September in the years 1963 and 1964.
Meanwhile, an evaluation conducted in the interim indicated that only 74 percent of the population was vaccinated, while a quarter of the population remained unvaccinated and therefore susceptible to the scourge. Health education was an important component of the eradication programme; its importance was never clearer to the authorities and the public health workers than in the face of falling targets.
Seemingly, the 1965 ‘Smallpox Eradication Week’ was specially mandated to shore up the programme’s vaccination targets, and these ‘celebrations’ are better known since they were reported in contemporary media. In fact, a special manual outlined all activities envisaged as part of the programme. All the federal states were mandated to participate and report their activities in the official mouth-piece of the programme The Smallpox Eradication News (English) and the Rashtriya Chechak Unmulan Samachar (Hindi).
A range of activities including lectures, debates, programmes on All India Radio (the public broadcaster) and cinema shows were organized throughout the country. However, interestingly, the dominant images that come to us today are those of public processions with men, women and even children carrying placards and raising slogans.
SCHOOLBOYS TAKE PART IN THE INDIAN VACCINATION CAMPAIGN (1963)
Copyright: WHO/ T S Satyan
The enduring images of the ‘Smallpox Eradication Week’, of people marching in procession, carrying banners etc. or performing at events, were perhaps meant to convey that the general masses welcomed the programme despite the evidence of obvious resistance in the large numbers of unvaccinated people towards the close of the first phase of the programme.[1]
This archive of images, relatively little known and under analysed, gesture towards the politics of popular representations of state managed schemes and programmes. Even as the eradication programme was faltering in achieving its targeted outcomes, the visuals remain celebratory and euphoric.
Pictures have usually been used to produce a narrative that conforms to what we already know. However if used ‘on their own terms’, as Pinney (2004:8) suggests, they might be able to narrate to us a different story about the Indian programme.
[1] Another image with the caption ‘The anti smallpox procession wends its way through Delhi streets’ , 1963, Image Credit: WHO/TS Satyan, can be viewed at the WHO Photo Library, WHO_A_010880, https://extranet.who.int/photolibrary/
Monday, 13 August 2018
Difference and Disease
The first title in the Global Health Histories book series (published by Cambridge University Press) is out now - Suman Seth’s ‘Difference and Disease: Medicine, Race, and the Eighteenth-Century British Empire.’ Before the nineteenth century, travellers who left Britain for the Americas, West Africa, India and elsewhere encountered a medical conundrum: why did they fall ill when they arrived, and why – if they recovered - did they never become so ill again? Suman Seth (Cornell University) explores forms of eighteenth-century medical knowledge, showing how geographical location was essential to this knowledge. In this period, debates raged over whether diseases changed in different climes. Different diseases were deemed characteristic of different races and genders, and medical practitioners were thus deeply involved in contestations over race and the legitimacy of the abolitionist cause.
We asked the author for his insights into the preparation and planning of the book. This was his enlightening response:
“I came to this project via a rather circuitous route. I published my first book in 2010, on theoretical physics in late 19th and early 20th century Germany. Given longstanding interests in science, race, colonialism, and postcolonial theory, I’d originally envisioned working on a project on the physical sciences and colonialism in the German concession at Kiautschou Bay, China, from 1897-1914. Beginning research, however, I came across material having to do with debates in Germany concerning ‘Akklimatisation’ and race. Following material on acclimatization led me backwards to the history of ‘seasoning,’ the term used before acclimatization replaced it—in medical contexts—after the 1830s and 1840s. And an interest in seasoning and race led me to the material that became this book. Within a couple of years, in other words, I had gone from being a historian of physics in Germany in the twentieth century to someone who needed to understand the history of medicine in the British Empire, in the eighteenth century. Needless to say, making that transition required the help on an enormous number of people, who were incredibly generous with their time, patience, and wisdom.”
You can find out more about ‘Difference and Disease’ via the Global Health Histories series page on the Cambridge University Press website.
The Global Health Histories series aims to publish outstanding and innovative scholarship on the history of public health, medicine and science worldwide. By studying the many ways in which the impact of ideas of health and well-being on society were measured and described in different global, international, regional, national and local contexts, books in the series will reconceptualise the nature of empire, the nation state, extra-state actors and different forms of globalization.
You can read more about upcoming titles in the series via our series announcement on the Centre for Global Health Histories news page.
We asked the author for his insights into the preparation and planning of the book. This was his enlightening response:
“I came to this project via a rather circuitous route. I published my first book in 2010, on theoretical physics in late 19th and early 20th century Germany. Given longstanding interests in science, race, colonialism, and postcolonial theory, I’d originally envisioned working on a project on the physical sciences and colonialism in the German concession at Kiautschou Bay, China, from 1897-1914. Beginning research, however, I came across material having to do with debates in Germany concerning ‘Akklimatisation’ and race. Following material on acclimatization led me backwards to the history of ‘seasoning,’ the term used before acclimatization replaced it—in medical contexts—after the 1830s and 1840s. And an interest in seasoning and race led me to the material that became this book. Within a couple of years, in other words, I had gone from being a historian of physics in Germany in the twentieth century to someone who needed to understand the history of medicine in the British Empire, in the eighteenth century. Needless to say, making that transition required the help on an enormous number of people, who were incredibly generous with their time, patience, and wisdom.”
You can find out more about ‘Difference and Disease’ via the Global Health Histories series page on the Cambridge University Press website.
The Global Health Histories series aims to publish outstanding and innovative scholarship on the history of public health, medicine and science worldwide. By studying the many ways in which the impact of ideas of health and well-being on society were measured and described in different global, international, regional, national and local contexts, books in the series will reconceptualise the nature of empire, the nation state, extra-state actors and different forms of globalization.
You can read more about upcoming titles in the series via our series announcement on the Centre for Global Health Histories news page.
Monday, 9 July 2018
Seminar report: Vaccine Hesitancy – why do some people not vaccinate?
On the blog today we have another guest post from Dr Victoria Turner (CGHH Associate & Public Health Specialty Registrar, Associate Clinical Fellow, Department of Health Sciences, University of York) who reports on the discussions at Global Health Histories Seminar 107.
On Tuesday 3rd July I was in Copenhagen attending the 107th Global Health Histories seminar with Sanjoy Bhattacharya (Director of the WHO Collaborating Centre for Global Health Histories at the University of York), who was chairing the session. The seminar showcased two excellent speakers: Robb Butler, Programme Manager for Vaccine-preventable Diseases and Immunization at WHO Europe, and Heidi Larson, Director of The Vaccine Confidence Project (VCP) and Professor of Anthropology, Risk and Decision Science at London School of Hygiene and Tropical Medicine.
To start, Robb Butler gave a very interesting overview of some of the factors affecting decision making, and how this applies to vaccination. He made the point that behaviour, as well as diseases, can be contagious (think of yawning!), and that in order to anchor the population into making positive decisions around vaccinations we need to move to a position where people are making well-informed decisions, rather than just following the crowd.
Robb discussed the ‘mental toolbox’ of tools we use to make decisions, including affect heuristics (i.e. being affected by emotions, a factor particularly used by anti-vax lobbyists) and negativity bias (i.e. people are more likely to make a decision based on the avoidance of negative side effects rather than gaining any positive benefits).
Vaccine hesitancy is affected by confidence, complacency and convenience. Examples were given of populations both of the general public and of healthcare professionals who had never experienced diseases such as measles, and therefore did not feel vaccination was necessary (‘complacency’). Other difficulties included the ease of getting the vaccine, with an example given of French healthcare that required multiple GP/pharmacy trips for a single vaccine (‘convenience’), and poorly-responsive technology (e.g. the failure to progress from fear-inducing needles).
Overall, Robb argued that vaccine hesitancy is complex, context-specific and varies across time, place and type of vaccine.
Following on from Robb’s discussion of how decisions around vaccination are made, Heidi addressed historical and cultural attitudes to vaccine hesitancy from across the globe. She started with the point that not only can we not prevent all vaccine hesitancy, but that we shouldn’t be trying to prevent all vaccine hesitancy; parents with children should quite rightly be asking questions about what is best for their children. She highlighted two key themes that most often lead to vaccine hesitancy: purity (i.e. ‘natural is better’) and liberty (i.e. ‘who are you to impose this on me?).
Heidi highlighted that discussions on vaccine hesitancy can be difficult, particularly when there is emotive polarisation of pro- and anti-vaccination groups (‘they’re stupid’ vs. ‘they’re lying to us’). She argued that we have to be better at how we discuss vaccines with the public – stock phrases like ‘its 100% safe’ and ‘vaccination is the most cost-effective intervention’ (not necessarily – depends on the vaccine/disease) can be unhelpful.
As a case study Heidi also referred to a particular incident involving HPV vaccination in Columbia, where full vaccine coverage in an area decreased from 88% to 5% after an ‘outbreak’ of anxiety symptoms in this area. This case also highlighted the fact that symptoms are not spread evenly throughout the vaccine-taking population; this leads to ‘clusters’ of vaccine hesitancy, linking back to Robb’s concept of behaviour as contagious.
The Q&A session also addressed some important issues. The first question raised the point that people’s first port of call when they have a medical (or other) question is usually Google, and responses are therefore particularly influenced by the top ‘hits’ (and by extension the companies that sponsor them). Robb acknowledged that challenging/working with ‘Dr Google’ was an area the medical profession had not spent enough time on, as well as emphasising the sizable impact a single individual could have on social media to counteract all the work done by health professionals.
Heidi also had advice for a medical student asking how healthcare professionals should discuss vaccination with their patients. Giving them the opportunity to ask questions and listening to their concerns is very important, particularly in maintaining the trust between patient and professional. However, making sure clinicians are confident in answering these questions (ideally with better training, e.g. at medical school) would also help.
The final take home message on improving our approach to vaccine hesitancy was that we all need to put down the guns, engage stakeholders and understand and address their perspectives if we want to move forward.
On Tuesday 3rd July I was in Copenhagen attending the 107th Global Health Histories seminar with Sanjoy Bhattacharya (Director of the WHO Collaborating Centre for Global Health Histories at the University of York), who was chairing the session. The seminar showcased two excellent speakers: Robb Butler, Programme Manager for Vaccine-preventable Diseases and Immunization at WHO Europe, and Heidi Larson, Director of The Vaccine Confidence Project (VCP) and Professor of Anthropology, Risk and Decision Science at London School of Hygiene and Tropical Medicine.
To start, Robb Butler gave a very interesting overview of some of the factors affecting decision making, and how this applies to vaccination. He made the point that behaviour, as well as diseases, can be contagious (think of yawning!), and that in order to anchor the population into making positive decisions around vaccinations we need to move to a position where people are making well-informed decisions, rather than just following the crowd.
Robb discussed the ‘mental toolbox’ of tools we use to make decisions, including affect heuristics (i.e. being affected by emotions, a factor particularly used by anti-vax lobbyists) and negativity bias (i.e. people are more likely to make a decision based on the avoidance of negative side effects rather than gaining any positive benefits).
Vaccine hesitancy is affected by confidence, complacency and convenience. Examples were given of populations both of the general public and of healthcare professionals who had never experienced diseases such as measles, and therefore did not feel vaccination was necessary (‘complacency’). Other difficulties included the ease of getting the vaccine, with an example given of French healthcare that required multiple GP/pharmacy trips for a single vaccine (‘convenience’), and poorly-responsive technology (e.g. the failure to progress from fear-inducing needles).
Overall, Robb argued that vaccine hesitancy is complex, context-specific and varies across time, place and type of vaccine.
Following on from Robb’s discussion of how decisions around vaccination are made, Heidi addressed historical and cultural attitudes to vaccine hesitancy from across the globe. She started with the point that not only can we not prevent all vaccine hesitancy, but that we shouldn’t be trying to prevent all vaccine hesitancy; parents with children should quite rightly be asking questions about what is best for their children. She highlighted two key themes that most often lead to vaccine hesitancy: purity (i.e. ‘natural is better’) and liberty (i.e. ‘who are you to impose this on me?).
Heidi highlighted that discussions on vaccine hesitancy can be difficult, particularly when there is emotive polarisation of pro- and anti-vaccination groups (‘they’re stupid’ vs. ‘they’re lying to us’). She argued that we have to be better at how we discuss vaccines with the public – stock phrases like ‘its 100% safe’ and ‘vaccination is the most cost-effective intervention’ (not necessarily – depends on the vaccine/disease) can be unhelpful.
As a case study Heidi also referred to a particular incident involving HPV vaccination in Columbia, where full vaccine coverage in an area decreased from 88% to 5% after an ‘outbreak’ of anxiety symptoms in this area. This case also highlighted the fact that symptoms are not spread evenly throughout the vaccine-taking population; this leads to ‘clusters’ of vaccine hesitancy, linking back to Robb’s concept of behaviour as contagious.
The Q&A session also addressed some important issues. The first question raised the point that people’s first port of call when they have a medical (or other) question is usually Google, and responses are therefore particularly influenced by the top ‘hits’ (and by extension the companies that sponsor them). Robb acknowledged that challenging/working with ‘Dr Google’ was an area the medical profession had not spent enough time on, as well as emphasising the sizable impact a single individual could have on social media to counteract all the work done by health professionals.
Heidi also had advice for a medical student asking how healthcare professionals should discuss vaccination with their patients. Giving them the opportunity to ask questions and listening to their concerns is very important, particularly in maintaining the trust between patient and professional. However, making sure clinicians are confident in answering these questions (ideally with better training, e.g. at medical school) would also help.
The final take home message on improving our approach to vaccine hesitancy was that we all need to put down the guns, engage stakeholders and understand and address their perspectives if we want to move forward.
Wednesday, 2 May 2018
Seminar Report – 'Tobacco Control: History and current global challenges'
On the blog today we have a guest post from Dr Victoria Turner (CGHH Associate & Public Health Specialty Registrar, Associate Clinical Fellow, Department of Health Sciences, University of York) who reports on the discussions at Global Health Histories Seminar 104.
Facing the Challenge: Tobacco Control in Sri Lanka
The first speaker was Dr Lakshmi Somatunga of the Sri Lankan Ministry of Health, who shared her experience of using policy to improve tobacco control. She took us on a journey from the situation in 2000 where 25% percent of the Sri Lankan population were daily smokers (although less than 1% of females), and where vigorous promotion of smoking occurred in the media, to the present where Sri Lanka has a successful National Programme on tobacco control, effective national legislation (National Authority on Tobacco and Alcohol Act, 2007) and has taken an international lead on ratifying the Framework Convention for Tobacco Control. By 2015 smoking prevalence in Sri Lanka had decreased to 19.9% in men and negligible in women. The daily average number of cigarettes smoked by men had also decreased, from 9.1 in 2007 to 3.7 in 2015.
Key factors influencing the success of the Sri Lankan approach to tobacco control included:
- Strong political commitment
- Very supportive media
- Multi-sector involvement, led by the health sector
- Strong promotion/prevention measures, such as early behavioural change in school children and the integration of tobacco control into health lifestyle messages
- Inclusion of grass roots societies at stakeholder meetings
- Visible and accessible state-run health services
Dr Somatunga. Credit: University of York/ Alex Holland
I was particularly interested to hear about the integration of tobacco control into the school curriculum, with compulsory questions on tobacco control in general knowledge exam papers (although as Dr Somatunga later pointed out, there is sometimes a difference between what you know and what you choose to practice!)
Smokeless tobacco use in South Asia: health risks and control measures
Dr Somatunga’s presentation was followed by a talk by Kamran Siddiqi, Professor in Public Health at the University of York, who discussed the prevalence, risks and diversity of smokeless tobacco usage in South Asia.
We discovered that smokeless tobacco use is a sizeable, if underappreciated issue; of 1 billion smokers in the world, 25% are smokeless tobacco users. Despite this, very few countries regulate smokeless tobacco, and they are also usually subject to lower taxes and less stringent health warnings than cigarettes.
Professor Siddiqi. Credit: University of York/ Alex Holland
The variation between different smokeless tobacco products also makes this situation more complex. It was not only enlightening to hear about the different types of smokeless tobacco products, but also to appreciate that they all carried different risks. Prof. Siddiqi gave us a brief lesson in tobacco chemistry and demonstrated that products with different pHs carry different risks; the more alkaline, the higher the absorption into the body (including of carcinogens). There are also many different production methods at different scales, including those prepared by individual users, custom made products or manufactured products (either on a small local or a large industrial scale). This persistent diversity makes it very difficult to have a single policy against all forms of smokeless tobacco.
Prof. Siddiqi also emphasised the deep rooted cultural associations of smokeless tobacco use in South Asia, where it is used at weddings, religious celebrations, and other family gatherings. This makes tackling smokeless tobacco use more complex; a new NIHR Global Health Research Group called ASTRA (Addressing Smokeless Tobacco and building Research capacity in south Asia) has been set up to try and understand and overcome some of these issues, with University York staff (including Prof. Siddiqi) particularly involved.
Continuing the conversation
Following the presentations, Dr Nils Fitje of the WHO Regional office for Europe chaired a discussion with both speakers, who answered a variety of interesting and thoughtful questions from the audience.
Credit: University of York/ Alex Holland
Highlights included Dr Somatunga’s response to how smokeless tobacco was being challenged in Sri Lanka, which involved trying to build smokeless tobacco control into the current ‘fashionable’ ideal of keeping the environment clean, with children and young people once again cited as key agents for change.
Both speakers also made interesting points on the role of community leaders in behaviour change. Prof. Siddiqi discussed how faith leaders (Imams) in Bangladesh had requested training on advocating for smoke-free homes, and who were now using sermons as powerful way of delivering messages to particular communities. Similarly, Dr Somatunga discussed the success in Sri Lanka of getting senior Buddhist leaders to remove tobacco from betel offerings; a key part of religious ceremonies.
Both the presentations and the Q&A session highlighted the influence of culture on tobacco use, and the importance of challenging social norms in innovative ways in order to overcome the tobacco use (of many kinds) ingrained part of South Asian cultures.
Monday, 9 April 2018
Historic Anti-Smoking Campaigns: A Brief Sketch
The second half of the twentieth century was marked by increasing efforts to curb tobacco consumption and exposure, and in the new millennium the 2005 WHO Framework Convention on Tobacco Control (FCTC), the first ever public health treaty, was developed to tackle the factors leading to ill health from tobacco. On 24th April 2018, the 104th Global Health Histories seminar will take as its theme the histories and current global challenges of tobacco control, with presentations by our expert panellists Dr. Lakshmi C. Somatunga and & Professor Kamran Siddiqi. The event will be held at the University of York, and attendance is free and open to all. Further information and registration details can be found at www.york.ac.uk/history/global-health-histories/events/ghh-104-tobacco-control/
Anti-smoking campaigns targeted at mass audiences have also constituted a significant part of the efforts to curb tobacco consumption since the mid-twentieth century. They were released to counter the promotional messages of tobacco companies, whose advertisements were well-funded and created an attractive and pervasive lifestyle around smoking. But the challenge extended beyond this: smoking has long been embedded in popular culture, glamourised and normalised, for instance, by icons of the cinema screen. Anti-smoking campaigns therefore relied on various techniques and designs to persuade people to stub out their cigarettes. Posters were a key component, but press advertisements, television commercials, comic books and book-marks were all deployed. It is these highly visual mediums which we turn our attentions to in this blog post, drawing upon the holdings of the Wellcome Collection.
Our first poster (by Reginald Mount, c. 1965) was part of a pairing, both of which are held in the Wellcome Collection. Depicting a young female smoker, it attempts to influence viewers by means of a rational argument based on the monetary cost of smoking, and what that money could be spent on instead. The argument outlined in the poster text takes the form of an imagined, one-sided conversation, and goes into a different register by suggesting that smoking can not only save you money and make you healthier, but lead to a better, happier life as a result (the character is presented as being unlucky in love because of her habit). The visual elements are similarly simple but effective: cigarette smoke is shown in the form of coins, emphasising money literally going up in smoke. The companion poster (again by Reginald Mount, 1965) shows a male smoker and makes a similar argument. The character talks about his friend’s new acquisitions (which include a gold watch and transistor radio) as well as his new found health upon giving up smoking. As well as the rational argument about saving money, the subtle humour of both posters encourages viewers/readers to compare their own attitudes and experiences with those of the poster characters, and reflect on the relative happiness of the smoker and non-smoker.
Our next image is striking in its simplicity yet forcefulness. The cancer bookmark, issued by Britain's Central Council for Health Education in the 1950s, displays a comparatively spare design where the modest inclusions are used to create a powerful message. The rising cigarette smoke which spells out ‘Cancer’ makes the point that smoking and disease are fundamentally intertwined. The design is all the more haunting for the subtle, and some might say, friendly way in which this is conveyed. On first sight the curved, flowing letters do not look threatening, but that is the ultimate message: cigarettes, the epitome of everydayness, cause profound health problems.
The next poster (designer and date unknown, though probably post 1950s) deploys a different take on this. It displays a design which came to be a common sight on many anti-smoking campaigns, as well as in connection with several other health problems. It conveys the unequivocal message that smoking cigarettes = death. This is achieved through instantly recognisable and understood symbols such as the skull, the skeletal hand grasping an open packet of cigarettes, and a grave. Yet if further convincing was necessary, the wording at the bottom of the design reiterates the point: ‘sure death’. Many anti-smoking posters display the common post-war trend of emphasising visual messages rather than extensive, descriptive text on poster campaigns.
Our final design, from Germany, calls upon smokers to spare their organs by illustrating the path that cigarette smoke takes straight to the heart, lungs and stomach. It represents an attempt to sensitise smokers to the deeper damage done by smoking, by visualising the invisible journey of the cigarette smoke. However, we should bear in mind that whilst poster designers may have intended a specific interpretation, rarely was it the case that everyone viewed and understood the designs in exactly the same way. Misinterpretation was a common problem in relation to other health campaigns, as Alex Mould shows in her exploration of alcohol, health education and the public in 1970s Britain.[1] In relation to this German poster, the body in question looks relatively strong and healthy, and the heart in particular looks to be bursting with life. To those unacquainted with the effects of cigarette smoke, or those who gave the poster but a passing glance, the point about the negative consequences of smoking may have been lost. Reception at the time is, of course, impossible to substantiate concretely for this particular poster, but the broader point stands that no matter the resources directed at public health campaigns, their ultimate effect was very much dependent on a range of factors.
These posters represent but a snapshot of the enormous efforts which were deployed to encourage people to stop smoking. Further designs can be viewed in the excellent WHO publication 'Public Health Campaigns: Getting the Message Across' which is available at www.who.int/about/history/publications/9789240560277/en/, and more recent efforts at http://www.who.int/campaigns/no-tobacco-day/2017/poster/en/.
Alexander Medcalf is a Research and Teaching Fellow at the University of York Department of History, and Deputy Director of the Centre for Global Health Histories. He teaches the MA option course A Picture of Health: The Mass Media and Public Health in the Twentieth Century.
Anti-smoking campaigns targeted at mass audiences have also constituted a significant part of the efforts to curb tobacco consumption since the mid-twentieth century. They were released to counter the promotional messages of tobacco companies, whose advertisements were well-funded and created an attractive and pervasive lifestyle around smoking. But the challenge extended beyond this: smoking has long been embedded in popular culture, glamourised and normalised, for instance, by icons of the cinema screen. Anti-smoking campaigns therefore relied on various techniques and designs to persuade people to stub out their cigarettes. Posters were a key component, but press advertisements, television commercials, comic books and book-marks were all deployed. It is these highly visual mediums which we turn our attentions to in this blog post, drawing upon the holdings of the Wellcome Collection.
'A young woman smoking; silver coins represent expense' by Reginald Mount. Credit: Wellcome Collection. CC BY
Our first poster (by Reginald Mount, c. 1965) was part of a pairing, both of which are held in the Wellcome Collection. Depicting a young female smoker, it attempts to influence viewers by means of a rational argument based on the monetary cost of smoking, and what that money could be spent on instead. The argument outlined in the poster text takes the form of an imagined, one-sided conversation, and goes into a different register by suggesting that smoking can not only save you money and make you healthier, but lead to a better, happier life as a result (the character is presented as being unlucky in love because of her habit). The visual elements are similarly simple but effective: cigarette smoke is shown in the form of coins, emphasising money literally going up in smoke. The companion poster (again by Reginald Mount, 1965) shows a male smoker and makes a similar argument. The character talks about his friend’s new acquisitions (which include a gold watch and transistor radio) as well as his new found health upon giving up smoking. As well as the rational argument about saving money, the subtle humour of both posters encourages viewers/readers to compare their own attitudes and experiences with those of the poster characters, and reflect on the relative happiness of the smoker and non-smoker.
'Flyer (bookmark) warning of the dangers of smoking' . Credit: Wellcome Collection. CC BY
'Have another! Sure death' . Credit: Wellcome Collection. CC BY
'German anti-smoking campaign poster' . Credit: Wellcome Collection. CC BY
Our final design, from Germany, calls upon smokers to spare their organs by illustrating the path that cigarette smoke takes straight to the heart, lungs and stomach. It represents an attempt to sensitise smokers to the deeper damage done by smoking, by visualising the invisible journey of the cigarette smoke. However, we should bear in mind that whilst poster designers may have intended a specific interpretation, rarely was it the case that everyone viewed and understood the designs in exactly the same way. Misinterpretation was a common problem in relation to other health campaigns, as Alex Mould shows in her exploration of alcohol, health education and the public in 1970s Britain.[1] In relation to this German poster, the body in question looks relatively strong and healthy, and the heart in particular looks to be bursting with life. To those unacquainted with the effects of cigarette smoke, or those who gave the poster but a passing glance, the point about the negative consequences of smoking may have been lost. Reception at the time is, of course, impossible to substantiate concretely for this particular poster, but the broader point stands that no matter the resources directed at public health campaigns, their ultimate effect was very much dependent on a range of factors.
These posters represent but a snapshot of the enormous efforts which were deployed to encourage people to stop smoking. Further designs can be viewed in the excellent WHO publication 'Public Health Campaigns: Getting the Message Across' which is available at www.who.int/about/history/publications/9789240560277/en/, and more recent efforts at http://www.who.int/campaigns/no-tobacco-day/2017/poster/en/.
Alexander Medcalf is a Research and Teaching Fellow at the University of York Department of History, and Deputy Director of the Centre for Global Health Histories. He teaches the MA option course A Picture of Health: The Mass Media and Public Health in the Twentieth Century.
[1] Alex Mold, ‘Everybody Likes a Drink. Nobody Likes a Drunk’.
Alcohol, Health Education and the Public in 1970s Britain’, Social History of
Medicine, Volume 30, Issue 3, 1 August 2017, Pages 612–636
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