Reflections on a 38-year career in public health advocacy: 10 pieces of advice to early career researchers and advocates

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DOI: 10.17061/phrp2521514
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Abstract
There are many important principles and lessons that public health researchers and advocates who hope to influence policy and practice need to consider. In this paper, I set out what I consider to be 10 of the most fundamental of these. Together, these focus on the importance of preserving public confidence in the evidence base underscoring public policy; being clear and concrete about the policy reforms you support; emphasising the values on which policy is based; understanding the structure, conventions and subtextual features of news reporting; developing 'killer facts' with 'earworm' potential; appreciating that the advocacy process leading to policy change almost always takes a long time; and growing a rhinoceros hide to assist in the inevitable attacks you will face.
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Perspective
March 2015; Vol. 25(2):e2521514
doi: http://dx.doi.org/10.17061/phrp2521514
www.phrp.com.au
Abstract
There are many important principles and lessons that public health
researchers and advocates who hope to inuence policy and practice need
to consider. In this paper, I set out what I consider to be 10 of the most
fundamental of these. Together, these focus on the importance of preserving
public condence in the evidence base underscoring public policy; being
clear and concrete about the policy reforms you support; emphasising the
values on which policy is based; understanding the structure, conventions
and subtextual features of news reporting; developing ‘killer facts’ with
‘earworm’ potential; appreciating that the advocacy process leading to policy
change almost always takes a long time; and growing a rhinoceros hide to
assist in the inevitable attacks you will face.
Introduction
In the late 1970s, I worked with others to try to have the actor Paul Hogan
removed from Wineld cigarette advertising.1 It was, and remains, the most
successful tobacco advertising campaign in Australian history. Hogan had
immense appeal with teenagers. This made his role a clear breach of the
voluntary code of advertising self-regulation that was then operating.2
Our private, polite efforts to get something done through the complaints
system were virtually ignored until we went public through the media.
Ten-thousand watt lights tend to concentrate the attention of those with
responsibility to act. And so act they nally did. Hogan was removed
18months after we started complaining.1
I learnt a big lesson very quickly: sunlight makes a very strong antiseptic
for malodorous health policy. And there is no sunlight stronger than getting an
issue major media attention.
I soon discovered that there were remarkably few analytical histories
of how either large or small public health advocacy campaigns and policy
battles had been won or lost. So I set out to change that by writing books3–6
and dozens of papers on the process I had often been part of.
Below are 10 key lessons I’ve learnt in public health advocacy. There are
many more, but these 10 are absolutely critical.
Article history
Publication date: March 2015
Citation: Chapman S. Reections on a 38-
year career in public health advocacy: 10
pieces of advice to early career researchers
and advocates. Public Health Res Pract.
2015;25(2):e2521514. doi: http://dx.doi.
org/10.17061/phrp2521514
Key points
Media attention on a public health issue
is often more effective than private
advocacy in winning policy change
Advocacy must be evidence based, clear
and concrete
Speak out publicly, study the media and
be available to speak at all times
Use ‘killer (attention-grabbing) facts’,
but place them in the context of a
values system; care about what you are
advocating for
Use real people to illustrate your message
Use social media
Be patient; grow a ‘rhinoceros hide’
Reections on a 38-year career in public
health advocacy: 10 pieces of advice to early
career researchers and advocates
Simon Chapmana,b
a Sydney School of Public Health, University of Sydney, NSW, Australia
b Corresponding author: simon.chapman@sydney.edu.au
Public Health Research & Practice March 2015; Vol. 25(2):e2521514 doi: http://dx.doi.org/10.17061/phrp2521514
Reections on a career in public health advocacy
2
what is it they want to achieve. Almost invariably they
answer with a goal, such as reducing obesity or problem
drinking. Sometimes they talk about an important but
obtuse value like “reducing health inequalities” or “getting
greater attention to the social determinants of health”.
Talking about complex and worthy abstractions is
important and meaningful to small groups of specialists.
But this is not how ordinary people talk. Public health
is often mired in language with little meaning outside
the cognoscenti. A ‘policy’ to most people is something
you get in the mail once a year from your insurance
company. Policy change may be your goal, but policy
will not change unless you make it crystal clear what you
want from policy makers. That’s what we did with plain
packaging for cigarettes: every square centimetre of
the pack, the fonts, the colours, was specied following
research with target groups. It could not have been more
focused.
Take, for example, alcohol advertising controls. A
colleague, Andrea Fogarty, interviewed 28 of Australia’s
leading alcohol policy researchers, who offered
generalisations about the need for ‘controls’. But once
asked about precisely what sort of controls they wanted
introduced, there was little consensus. There was no
clear, sharp message for policy makers and the public to
consider.7
I try to focus colleagues by asking them to pull their
attention into the foreground. What precisely needs
to happen to reach the broad health goals so easily
articulated? Precisely what policies, legislation or funding
would they like the government to put in their Christmas
stocking next year? Once that’s decided, the meat and
potatoes work of strategic, policy-relevant research
can occur along with the precision ‘bombing’ of false
arguments from those opposed to change.
Lesson 3: “It’s better to be looked
over, than overlooked” (Mae West)
I’ve never seen sense in applying for grants, doing years
of work, and then parking the results in paywalled journals
where only other academics can access it. The attitude
that expertise carries no responsibility to ensure evidence
reaches the public and policy makers is bizarre.
A few years ago, a National Health and Medical
Research Council project I led with Wayne Hall
(Professorial Fellow at the University of Queensland)
interviewed 35Australian public health researchers
who had been voted by their peers as Australia’s most
inuential researchers working in six elds. Large
majorities agreed or strongly agreed that researchers had
a duty to inuence policy and to draw public attention to
their work.8
As researchers, we undertake research and
systematically review it to provide evidence to lever policy
and practice change or defend existing policies and
practices. But there is only a small number of people who
Lesson 1: always respect
evidence, and if the evidence
changes, so should you
Evidence must always be the granite bedrock of all
public health advocacy. Evidence evolves through
stages. It starts with hypothesis-generating claims and
observations, and moves through to the gold standards
of large-scale cohort epidemiology and randomised
controlled trials in real-world settings.
As evidence mounts, things that once looked true
or effective can sometimes turn out not to be. We have
seen the cancer screening and dietary areas slowly and
sometimes reluctantly coming to terms with the fact that
past doctrines are being eroded by the tide of incoming
evidence.
Careers are often built on lifetime commitment to
particular phases of evidence. But if the evidence
changes, it is absolutely critical for public trust in the
integrity of public health that we acknowledge the facts
have changed and, accordingly, that we have changed
our minds too.
It is important to note that the internet has changed
forever the politics of expertise. For a long time, expertise
was exercised in forums that were largely inaccessible
to the public and handed down to the populace as
advisories and campaigns. But today, access to
unprecedented amounts of research and the ability to
disseminate it to millions has opened up a kind of anarchy
of ‘expertise’ that poses a massive threat to continuing
public condence in public health.
Two illustrations of the advance of junk and low-
quality science are the resilience and inuence of
climate change denialism, and the current efforts by
e-cigarette interest groups to claim that e-cigarettes have
revolutionary potential to make smoking history.
The interest groups behind these two major issues are
succeeding in building momentum that may spread to
challenge decades of public health and safety legislation.
Public health practitioners today face unprecedented
challenges to preserve and strengthen public and
political condence in the evidence base for public
health policy. Challenging and confronting low-grade
and self-interested evidence from such forces will never
be more important. It is the very worst time to retreat into
unnoticed and inconsequential debates within the walls
ofacademia.
Lesson 2: be clear and concrete
about what you want to change
or support
People often say, “tobacco control has done so well in
changing policy to reduce smoking, what lessons do you
have for our issue?” My rst question to them is always
Public Health Research & Practice March 2015; Vol. 25(2):e2521514 doi: http://dx.doi.org/10.17061/phrp2521514
Reections on a career in public health advocacy
3
audience of half a million. I was curious about this and
emailed him for this presentation. He told me immediately,
“because you always answer your phone. The number
of people we rang and they missed out because they
didn’t realise tomorrow morning was their one shot was
incredibly frustrating”.
Lesson 5: use ‘killer facts’
Every year, people are exposed to thousands of facts,
claims and narratives about hundreds of health issues.
Much of it is like informational wallpaper, forgotten
moments later, contradicted by competing claims and
washed away on the tide of tomorrow’s more arresting
news. Some issues rise above the rest and compel
political action. Many plod along unchanging and others
sink without trace.
A basic goal in advocacy is to have your denition of
the issue in a policy debate become the dominant, top-
of-mind way people – and especially politicians – think
about that issue.
Killer facts12 are like musical earworms: once they’re
inside your head, it is difcult to get them out. They tend
to kill off competing denitions of the issue. If they employ
powerful and repeatable analogies, before and after
comparisons, and humour if appropriate, this can really
help. I heard one recently: “Public health is about saving
lives … a million at a time”.
Here are some examples:
The US has 13.5times Australia’s population, 5.9times
Australia’s rate of gun ownership and 305times
Australia’s gun homicide rate. So more guns make a
country safer?
In the 18 years before Australia’s 1996 gun law
reforms, there were 13mass shootings (ve or more
deaths, not including the perpetrator). There have
been precisely none in the 19years since.
For four of the past ve years, quad bikes have been
the leading cause of non-intentional injury death on
Australian farms. This is unique internationally, as in
all other Western nations, tractors continue to be the
leading cause of injury deaths.
Every advocate, for every issue, needs to stock up on
killer facts. Plan to use at least one of them every time you
are interviewed.
Lesson 6: values are everything
As stated, facts and evidence are the bedrock of public
health advocacy. But unless people care about an issue,
they are highly unlikely to pay attention to it, let alone act
on it. Caring about something is always a necessary, but
not a sufcient, precondition for support and action.
Public health issues often feature in the news because
they richly illustrate narratives about values: mini dramas
and secular parables about adversity and the solutions
needed. These include the humane imperative to reduce
have the power to effect change or defend good policies.
The most important of these are politicians. And guess
what? They don’t read research journals!9
During nearly 40years, I have had countless
occasions to speak to prime ministers, health ministers,
their cabinet colleagues, and thousands of inuential
people in every walk of life. I’ve done this as they lay in
bed, ate breakfast, drove their cars, sat in their living
rooms and relaxed in their shorts and T-shirts on holidays.
By contrast, I have had face-to-face meetings with
politicians perhaps 100times in my life. Let me explain.
When I rst met former health minister Nicola Roxon,
we shook hands and I said I didn’t think we had met. She
replied that she felt she had known me half her life. This
could have only meant that she had heard me and read
of my work in the news media. She was one of the highly
inuential people I had spoken to, often without knowing.
She was already very receptive to various issues that my
colleagues and I had been emphasising for years. If you
avoid the media, very few people will ever learn about
your work and what needs to be done. You and your
research are far less likely to be inuential.
If you care about making a difference, you will put aside
the regrettably still-prevalent attitude in some institutions
that you should not “dally with the Delilah of the press”.10
Lesson 4: study the media
If you want to be a potent media advocate for evidence
and policy change, you need to know how the media works
and how you can best be part of it. Many of you may have
taken days to prepare a 10–15minute presentation. The
lucky ones will speak to 300 or so in a plenary, most will get
only 40–50people in a breakout session.
But a few will be tapped by journalists at the
conference. If you get interviewed for radio or TV news,
your message might be heard by hundreds of thousands
of people – sometimes millions. To maximise these
unparalleled opportunities, you need to understand the
medium and programs on which you appear. On Australian
television news, the time anyone gets to speak in a
90-second item averages 7.2seconds, with an interquartile
range of 4.8–9.2seconds.11 Knowing that, you can plan
precisely what you are going to say andemphasise.
When print journalists request comments (and
this increasingly will happen via email), I try to drop
everything and send a selection of one- or two-sentence
options. This makes journalists’ jobs easier and they
appreciate that.
Again, knowing about length restrictions, you can
shape a message with Exocet precision. Try to make
every quote you send a potential ‘breakout box’ rather
than some anodyne, forgettable ‘memo to the public’.
This will mark you as ‘good talent’, and they’ll contact you
again and again.
Above all, be accessible. This should be so obvious.
For seven years, I was a regular guest on Adam
Spencer’s Sydney ABC breakfast program with a listening
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Reections on a career in public health advocacy
4
It has had nearly 124000downloads since 1996, with
86000 in December 2012 after I tweeted the link following
the US Sandy Hook massacre. It has been cited 109times.
A preprint of my much-tweeted paper on the nocebo
effect and wind farm health complaints17 is the most
downloaded item in the entire University of Sydney
eScholarhip repository and featured in a video that has
been viewed 4.02million times: www.youtube.com/
watch?v=O2hO4_UEe-4&feature=youtu.be&a
My most retweeted tweet was one I sent after Treasurer
Joe Hockey’s public remark about wind turbines being an
ugly blight on the landscape: twitter.com/SimonChapman6/
status/472132442032054272/photo/1. Ithas had
2894retweets, so given the exponential nature of retweets,
probably well over a million people have seen it.
Lesson 9: successful advocacy
takes time
Much public health research focuses on proximal
associations18 between interventions and outcomes –
weeks, months, sometimes a year or two. But advocacy’s
dividends often take decades to deliver.19
Smoking was rst banned on public buses and trains
in NSW in 1976. It took until 2006 – 30years later – before
such bans extended to working environments where the
problem was worst, and where, in a totally rational world,
smoke-free areas should have started. Even today, high
roller rooms in some casinos allow smoking: it’s apparently
a little known fact that second-hand smoke from wealthy
gamblers is unique in not posing health risks to others.20
Lesson 10: grow a rhinoceros hide
Finally, unless you are an advocate for an utterly
uncontroversial policy (I was going to say ‘for a mother’s
milk policy’, but of course even breastfeeding gets
attacked in some contexts), as soon as your work
threatens an industry or ideological cabal you will be
attacked, sometimes unrelentingly and viciously.
I’ve been called a veritable sewer of names on social
media, often by anonymous trolls and tobacco industry-
funded bloggers. I’ve been attacked in the coward’s
castle of parliament under privilege, and on the Alan
Jones radio program (and received a written apology and
legal costs paid), falsely accused of being an undeclared
paid advocate for the wind and pharmaceutical
industries, and sent white feathers each year on the
anniversary of the 1996 Port Arthur gun massacre.
My university administration is regularly deluged with
orchestrated complaints, yet I’ve had nothing but total
support from my university and colleagues.
But in all this nastiness, I take deep satisfaction and
pride in having worked with colleagues who are lifetime
friends to help make Australia’s smoking rates the lowest
in the world.6
early death and suffering; the injustice of inequitable
distribution of disease and access to services; and
stories about those who put nancial gain ahead of
populationhealth.
So after you’ve lled your kit bag with killer facts, you
need to then take an inventory of the values that make
these facts even more compelling. For example, killer
facts about tobacco industry expansion in nations with
low literacy are powerful because they evoke eons of
examples of the Pied Piper mythology: wolves in sheep’s
clothing who lead the vulnerable into illness and death.
Your facts and evidence should be anchored rmly to the
values that will make them resonate with what George
Lakoff calls ‘moral politics’.13
You also need to take an inventory of your vulnerability
to opponents framing your position as embodying
negative values, and then seek to strategically reframe
these as positives. The ‘nanny state’14 epithet, for
example, can be easily reframed positively by pointing
out all the benets caused by regulations and standards
that we all take for granted. As I stood in my narrow
hotel shower recess this morning, I whispered a silent
“thank you” to the public health nannies who ensured via
enforceable safety glass standards that if I slipped, the
glass would not shatter and cut me to ribbons.
Lesson 7: experts are ne, but
they are not ‘a living thing’
A journalist once said the above to me15, and I’ve never
forgotten it: people who live with the diseases we try to
prevent appear more in the news media than experts
orpoliticians.11
When an expert speaks, we may admire their
coherence, grasp of the issues and ability to simplify
complexity. But if a person suffering a problem speaks
and does the same, it can be doubly powerful. Ordinary
people can make amazing advocates, and we should
work with them far more. They bring a compelling
authenticity to an issue.
Lesson 8: use social media. A lot
The internet has utterly revolutionised our lives. And
utterly transformed advocacy. There are simply massive
global participation rates in social media. Anyone in
public health who is not part of this is the equivalent of
a scholar in the Gutenberg era who declined to show
interest in the potential of books.
I’m a heavy Twitter user. If you’re like I used to be and
thought Twitter sounded like some sort of time-wasting
indulgence for vapid twits, you may have already pulled
the shutters down. But look what you are missing out on.
Let me give you three examples.
The paper I published that has the most internet
downloads looked at the impact on multiple killings and
total gun deaths of the post–Port Arthur gun law reforms.16
Public Health Research & Practice March 2015; Vol. 25(2):e2521514 doi: http://dx.doi.org/10.17061/phrp2521514
Reections on a career in public health advocacy
5
Copyright:
© 2015 Chapman. This article is licensed under the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International Licence, which
allows others to redistribute, adapt and share this work non-commercially provided they attribute the work and any adapted version of it is
distributed under the same Creative Commons licence terms. See: www.creativecommons.org/licenses/by-nc-sa/4.0/
9. HaynesAS, DerrickGE, RedmanS, HallWD,
GillespieJA, ChapmanS, et al. Identifying trustworthy
experts: how do policymakers nd and assess public
health researchers worth consulting or collaborating with?
PloS One. 2012;7(3):e32665.
10. OslerWR. Aequanimitas with other addresses to
medical students, nurses and practitioners of medicine.
Philadelphia: P. Blakiston’s Son & Co; 1904.
11. ChapmanS, HoldingSJ, EllermJ, HeenanRC,
FogartyAS, ImisonM, et al. The content and structure of
Australian television reportage on health and medicine,
2005−2009: parameters to guide health workers. MedJ
Aust. 2009;191(11–12):620–4.
12. BowenS, ZwiAB, SainsburyP, WhiteheadM. Killer facts,
policies and other inuences: what evidence triggered
early childhood intervention policies in Australia? Evid
Policy. 2009;5(1):5–32.
13. LakoffG. Don’t think of an elephant! Know your values
and frame the debate. Vermont: Chelsea Green
Publishing; 2004.
14. DaubeM, StaffordJ, BondL. No need for nanny. Tob
Control. 2008;17(6):426–7.
15. ChapmanS, McCarthyS, LuptonD. Very good punter-
speak: how journalists frame the news on public health.
Sydney: University of Sydney eScholarship Repository;
1995 [cited 2015 Jan27]. Available from:
ses.library.usyd.
edu.au//bitstream/2123/10759/2/PUNTERSPEAK.pdf
.
16. ChapmanS, AlpersP, AghoK, JonesM. Australia’s 1996
gun law reforms: faster falls in rearm deaths, rearm
suicides, and a decade without mass shootings. Inj Prev.
2006;12(6):365–72.
17. ChapmanS, St GeorgeA, WallerK, CakicV. The pattern
of complaints about Australian wind farms does not
match the establishment and distribution of turbines:
support for the psychogenic, ‘communicated disease’
hypothesis. PloS One. 2013;8(10):e76584.
18. McMichaelAJ. Prisoners of the proximate: loosening the
constraints on epidemiology in an age of change. Am J
Epidemiol. 1999;149(10):887–97.
19. ChapmanS. Unravelling gossamer with boxing gloves:
problems in explaining the decline in smoking. BrMedJ.
1993;307(6901):429–32.
20. ChapmanS. How santa and the tooth fairy collaborated
to allow smoking at Barangaroo. Sydney Morning Herald.
2013 Nov29 [cited 2015 Jan27]. Available from:
www.smh.com.au/comment/how-santa-and-the-tooth-
fairy-collaborated-to-allow-smoking-at-barangaroo-
20131128-2ye0y.html
Many of you are doing fabulous work to achieve
similar goals in your areas. Clinicians are thanked every
day by grateful patients and relatives for their skills in
saving lives and limbs. In public health, we don’t have
people saying to us “I’ve not been killed or injured
because of your advocacy for road injury reduction
policy” or “I’ve not got diabetes, and I put it down to
you”. But our achievements can be seen in many areas
of declining incidence of disease and injury. We do
fantastically important work and I’ve been blessed to be
part of it for 40years. Thank you for all you do.
Acknowledgements
This article was originally presented as a plenary address
to the 43rd Annual Conference of the Public Health
Association of Australia, Perth, 17 September 2014.
Competing interests
None declared
References
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2. ChapmanS, MackayB. Good for the goose, good for
the gander: complaints and judgements about smoking
and anti-smoking advertisements under advertising self
regulation. Media Information Australia. 1984;31:47–55.
3. ChapmanS, LuptonD. The ght for public health:
principles and practice of media advocacy. London:
British Medical Journal Books; 1994.
4.
ChapmanS. Over our dead bodies: Port Arthur and
Australia’s ght for gun control. Sydney: Pluto Press; 1998.
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ChapmanS. Public health advocacy and tobacco control:
making smoking history. Oxford: Blackwell Publishing; 2007.
6. ChapmanS, FreemanB. Removing the emperor’s
clothes: Australia’s plain tobacco packaging. Sydney:
Sydney University Press; 2014.
7. FogartyAS, ChapmanS. What should be done about
policy on alcohol pricing and promotions? Australian
experts’ views of policy priorities: a qualitative interview
study. BMC Public Health. 2013;13:610.
8. ChapmanS, HaynesA, DerrickG, SturkH, HallWD,
St GeorgeA. Reaching “an audience that you would
never dream of speaking to”: inuential public health
researchers’ views on the role of news media in
inuencing policy and public understanding. JHealth
Commun. 2014;19(2):260–73.
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