The view from the Acropolis…

Outdoor pollution, worldwide, is estimated to kill 3.7 million people per year. This is not a typo. Combine these with deaths from indoor pollution and the total passes 7 million, or about 1 in 8 of all deaths according to Dr Maria Neira, Director of the WHO Public Health and Environment Department.

As I (EM) write this from an (austerity budget) hotel in Athens, those statistics on pollution-related deaths seem of a piece with the unending torrent of traffic. If the volume were not sufficient to generate a surfeit of particulates, the local style of driving—full speed between the traffic lights then slam on the brakes—surely exacerbates it. This may be of little consequence for me—as a jaywalking Englishman I am unlikely to survive the ‘red lights don’t count if you are turning right rule’ long enough for air quality to matter. But figures published by Public Health England earlier this year suggest around 25 000 English deaths per year are attributable to long-term exposure to particulates.1

So, why Athens?

Because the European and Global Healthy Cities Movement celebrates its 25th anniversary this year, and is meeting to mark the occasion with a conference on ‘Health and the City: Urban living in the twenty first century’. The movement now numbers 99 European cities within its networks, and is moving into its sixth phase with a feeling that city-level action and influence are set to grow yet stronger.

Pollution, traffic, and infrastructure provided the basis for many of the great public health interventions of the past, and there is every reason to believe that they will continue to be defining issues for the health of generations to come. By 2030, more than 70% of the world’s population will live in cities. City health will dominate the fate of the larger part of world population.

The meeting feels revitalized by the growing stature of city leaders and initiatives. Former New York mayor Michael Bloomberg looms large. ‘City health diplomacy’ is a phrase that recurs. Inequalities will not be solved by individual interventions. But they can, and have in the past, been narrowed by the kinds of population-based approaches that are the realm of local government.

In this issue, Gorsky et al. look at lessons from public health in England as it was practiced in the past, growing from the city-based health initiatives of the Victorians.2 Since public health ‘came home’ to Local Authorities in England in April 2013, it is pertinent to consider how its practice will differ not only from almost 40 (wilderness?) years in the NHS, but also how it might echo or depart from the great strides made in the time of Medical Officers of Health. Can modern Directors of Public Health and their colleagues live up to their forebears? Day, Shickle and colleagues propose five talents for public health leadership, and consider the challenges of engaging high-profile champions.3,4These are contributions to a debate that will continue to echo across the globe, since one of the great messages of the Healthy Cities experience is that the local is universal. If a problem exists in Preston, it is likely, in some form, also to exist in Lodz.

Following the news and Twitter feeds from back home during the meeting, the publication of the ‘Five Year Forward View’ leapt to the fore.5 The English National Health Service is currently funded at a level billions of pounds short of that envisaged in 2002 by Wanless in even his most optimistic (‘fully-engaged’) scenario, and Simon Stevens has now staked his claim on future governments to make good at least £8 billion of that shortfall.6,7 Even more significant, we would argue, is the emphasis placed on greater local powers to improve health, with a system-wide shift towards prevention.

While national politicians of all colours examine their fingernails intently and try to ignore the conclusion, obvious to the rest of us, that at some point we need to start talking about raising tax to pay for necessary services, local approaches can go at least some of the way towards amelioration of needs that will grow with demography.

Some aspects of public health are far from new, but others, such as social media, have no real precedent. Amelia Burke-Garcia and Gabriel Scally explore this new world in ‘Trending now: future directions in digital media for the public health sector’, with accompanying commentaries.8–10 We have placed this debate under ‘Wider Determinants’ because the rise of social media is a phenomenon that defies classification as an intervention. We may try to influence its direction but it has an immense and amorphous independence. Gabriel is in Athens, speaking on this and other issues from his long engagement with Healthy Cities. He describes its potential power, for a whole new type of public health engagement, but warns of its double-edged nature, as some of us have already found to our cost.

Finally, we are grateful to Jose Martin Moreno for his reflections on the still unfolding tragedy of Ebola—an avoidable disaster that demands reflection on our collective culpability, and on how, in the words of Denmark’s Crossing Borders ‘a virus turned into a racism outbreak’.11

1          Public Health England Estimating local mortality burdens associated with particulate air pollution, 2014 Chilton Public Health England

2          Gorsky M, Lock K, Hogarth S. Public health and English local government: historical perspectives on the impact of ‘returning home., J Public Health, 2014, vol. 36 (pg. 546-51)

3          Shickle D, et al. Mind the public health leadership gap: the opportunities and challenges of engaging high-profile individuals in the public health agenda, J Public Health, 2014, vol. 36 (pg. 562-7)

4          Day M, et al. Training public health superheroes: five talents for public health leadership, J Public Health, 2014, vol. 36 (pg. 552-61)

5          NHS England Five Year Forward View, 2014

6          Wanless D., Securing our future health: taking a long-term view, 2002 London HM Treasury

7          Wanless D., Securing good health for the whole population , 2004 London HM Treasury

8          Burke-Garcia A, Scally G. Trending now: future directions in digital media for the public health sector, J Public Health, 2014, vol. 36 (pg. 527-34)

9          Aspinall PJ. Commentary on ‘Trending now., J Public Health, 2014, vol. 36 (pg. 535-6)

10        Oyebode O. Commentary on trending now: future directions in digital media for the public health sector, J. Public Health, 2014, vol. 36 (pg. 537-8)

11        Santos C. Crossing Borders, 2014 Published: 26 November 2014
© The Author 2014. Published by Oxford University Press on behalf of Faculty of Public Health. All rights reserved. For permissions, please e-mail: