Abstract
The power of narrative in achieving transformational change has been understood since the earliest of times. The Old Testament and the Koran are punctuated with stories and advice on health, wellbeing and good living. These were based on inference and observation, not all of which have turned out to be scientifically accurate. Subject matter has included plague, blindness, childlessness and leprosy, menstruation and a wide range of issues of everyday life. We are told that ‘Calamity will come upon the evil man and he will be broken beyond healing’, that ‘A wife who brings shame is like rottenness in her husband’s bones’ and that while ‘A cheerful heart is good medicine’, ‘a downcast spirit dries up the bones’. For most children, the words ‘Once upon a time’ will be among their earliest memories.
In public health, the story of John Snow, the 1854 cholera outbreak in Soho and the Broad Street pump will have been most students’ introduction to their studies. Now almost 200 years after John Snow’s historic intervention, we live in a world of scientific orthodoxy which Snow could only have dreamed of, 20 years before the germ theory of disease. However, recent world events in which so-called ‘fake news’ has literally been able to ‘trump’ evidence-based facts is making us aware that while data and intelligence may be necessary to win arguments for public health, they may not in themselves be sufficient. That devoid of social and psychological context and meaning they may become ‘scientistic’ and unable to take the public on a humanistic journey of insight and action. For that, something else is needed.
There is a story about a new prisoner who finds that the prisoners no longer tell jokes in full because they are all so well-known. Instead, they use numbers to identify the joke which they wish to share. When he tries this himself there is silence. Confused, he asks somebody why there has been no response. ‘Well’ he is told, ‘its not so much the story as the way you tell it’. As with prison life, so with public health.
To be effective in public health, you not only need technical skills, but also to be an excellent communicator, to be able to take people on a journey, ‘to be able to fill a room’, by capturing their attention, being credible and persuasive.
The determinants of health and wellbeing lie mostly outside of health services and the imperative of story-telling skills and the ability to influence others outside of health services into recognising their contribution is pressing. The author, Mark Twain, said that he had been writing prose for 20 years before he knew it because he hadn’t known what prose was. Many of those responsible for the promotion and protection of health don’t realise that they are, in fact, health workers. To achieve ‘Health in all Policies’, to get upstream of the determinants, it is necessary to make their contributions explicit and to make the invisible visible. It is also necessary for professional health workers to engage on equal terms with their lay peers. Story telling makes that possible. 1
There is a wealth of stories with the power to connect and influence. In practical work for health, practitioners must ask not only what we must do ourselves but also what we must do together with others and what we must get others to do. Story telling can play an important part in each of these domains of action.
In his book The tipping point, Malcolm Gladwell uses a number of practical examples to explore how trends take off. In discussing how the unfashionable ‘hush puppies’ suede shoes became popular again in the 1990s, and how New York reduced crime levels in the 1980s starting with low-impact crime first, Gladwell proposed a model based on context, the actor and the stickiness of the idea. This can be seen as a behavioural version of traditional public health concepts from infectious disease outbreaks of environment, host and organism. 2
In the behavioural context, the public health actor needs a more sophisticated range of skills and behaviours. This includes the ability to see round corners, to start a rumour and to gatecrash somebody else’s agenda. Epidemiological and qualitative data may be necessary but are rarely sufficient to launch 1000 public health ships.
Pekka Puska, the Finnish epidemiologist, whose work on the World Health Organization (WHO) ‘Seven Countries Heart Disease Study’ in 1971 led to the celebrated Karelia project to reduce premature deaths had that special factor to make a difference. Puska took the WHO data, which showed that Helsinki had a mortality rate four times that of Sofia, in Bulgaria, and exploited the fact that Karelia had the highest rates in Finland to motivate the population to petition the government for action. The Karelians demanded that action be taken to stop their men from dying prematurely. The Karelia Project has become a global case study in modern public health intervention. Killer data properly communicated can save lives. 3
In the WHO Healthy Cities Project, extensive use has been made of all the modalities of communication to take an abstract concept ‘off the shelves and into the streets of Europe’. Starting in 1986, this has involved engaging fully in the public arena working extensively with local newspapers, mainstream and other media, and exploiting opportunities for activities in other public spaces including film, cultural forms such as poetry, music and sculpture together with public lectures to create an urban movement for the places where ‘people live, love, work and play’, which now covers over 1400 cities in Europe. This is an open-ended story with plenty of opportunity for clinicians of all kinds to hone their story-telling skills. It is interesting that in recent years, and in the aftermath of the momentum for evidence-based medicine generated by the Cochrane Collaboration, the old idea of ‘narrative-based medicine’ has once again come to the fore. Now is the time to bring these two traditions, for the individual and for the population, back together.