This paper addresses one aspect of Fiona Stanley's remarkable career – her role in public health advocacy. It seeks to draw some conclusions that may assist other researchers to take on similar roles.
Public health campaigners have almost always faced opposition. When Edwin Chadwick proposed measures that led to the sanitary revolutions of the 19th century, the London Times thundered, ‘We prefer to take our chances of cholera and the rest than be bullied into health by Mr. Chadwick. …’
Nowadays, we face massive advertising campaigns for unhealthy products. As Peter Draper has pointed out, pollution of the drinking water has been replaced by pollution of the thinking water, and the opposition is even more powerful.
In 1905, Sir William Osler advised his medical colleagues, ‘Do not dally with the Delilah of the press’ – advice Fiona clearly decided not to take. In the middle years of the last century, the great epidemiologist Sir Richard Doll initially believed that scientists should not try to influence public policy, although the outrageous behaviour of the tobacco industry persuaded him to change his mind.
Over the past four decades, with increasing recognition of our capacity to influence communities, governments and decision makers through modern media, a new form of advocacy has developed that entails highly professional and skilled use of media and public pressure to generate action, especially in public health. The action public health advocates seek does not happen overnight, as our journeys generally require a long-term perspective, and our resources are modest, but we have learned that if we keep at it, we can achieve remarkable results.
The term ‘advocacy’ is derived from the Latin advocare, meaning ‘to stand beside’. One of Fiona's enduring characteristics is that she not only stands beside her colleagues but is also willing to be seen doing so. Advocacy has been defined as ‘the act of supporting or arguing in favour of a cause, policy or idea. … undertaken to influence public opinion and societal attitudes or to bring about changes in government, community or institutional policies’, or more simply ‘the pursuit of influencing outcomes. … that directly affect people's lives’. Media advocacy has been defined as ‘the strategic use of mass media for advancing a social or public policy initiative’.
The great American health and social advocate Michael Pertschuk, an establishment figure who used his standing unashamedly for advocacy purposes, points out that advocates generally succeed when someone, somewhere, has been made to feel uncomfortable. Or, as he put it, ‘Advocates are unabashed tellers of truth to power. … They may often be irritating and difficult, but they churn up our collective conscience and annoy us into action’.
Few Australians are unaware of Fiona Stanley's achievements as a researcher. Many are aware of her prominence as a campaigner for children's health and in Indigenous health.[8-10] But there may be less awareness of her achievements as a public advocate across many other important health issues, or how well she has combined the roles of a researcher and an advocate.
This paper focuses on three areas in which the author has had the privilege of working with Fiona, and identifies 10 characteristics of Fiona Stanley as the model researcher–advocate.
Tobacco control is now fashionable. There is massive public support; the tobacco companies in Australia are in disarray; Australia is the first country to have ‘plain packaging’ (which actually means packs with only grisly pictures and warnings on a nappy-brown backcloth designed to repel children, smokers and tobacco company executives); smoking is declining, accompanied by a decline in the myriad diseases it causes.
But in the mid-1980s, tobacco companies were rampant, smoking was still increasing among females, three quarters of children experimented with cigarettes and many continued as smokers. Some of our clinical colleagues failed to understand the concept of prevention: a photograph of the first four French heart transplant patients at a reunion showed three of them smoking (Fig. 1). Tobacco advocacy in Australia was in its infancy. While the innovative West Australian (WA) Quit campaign had recently started, public education on smoking was seen as being driven by middle-class, middle-aged males for middle-class, middle-aged males. The WA Health Department approached Fiona, seeking her involvement in a campaign directed towards women. She was the Deputy Director of the National Health and Medical Research Council Epidemiology Unit at the University of Western Australia and did not have a public profile, but recognised the urgency of making the community aware that smoking was an issue for women as well as men. She agreed to appear in a television commercial that drew her to public attention (Fig. 2).
Many health leaders who participate in public health programmes graciously consent to lend their names to a letter and then feel that they have done their job. Fiona was different. She understood instinctively that her role was not simply to appear in an advertisement but to complement this with media interviews and discussion. The advertisement was immensely successful in WA. It was used in other states. It became an exemplar for other countries, which developed similar campaigns on women and smoking. It remains one of the great pioneering tobacco control advertisements.
Since then, Fiona has been a constant supporter for campaigns on tobacco, always willing to support action, particularly in relation to children and Indigenous communities.
Fiona and Carol Bower carried out seminal research on folate, demonstrating beyond doubt the benefits of folate fortification. Most researchers publish research such as this, then leave it to someone else to follow up. Fiona and Carol instigated education programmes about the benefits of folate: while these achieved some benefits, further action was clearly needed. Despite clear evidence on the benefits of mandatory folate fortification from the United States and other countries,[15-17] Australian politicians were reluctant to introduce this important public health measure because of opposition from the powerful food industry. I was fortunate to be the Director-General of Health in WA when the Health Minister Jim McGinty asked, ‘What can I do for public health that won't cost anything?’ Fiona and I agreed that mandatory folate fortification of bread-making flour fell into this category, and the Minister was persuaded. The food industry opposed the measure fiercely.[18-20] Governments were hesitant to act, and the bureaucratic processes were cumbersome. Fiona led the charge unhesitatingly. She lobbied publicly and privately, making maximum use of both media opportunities and behind-the-scenes advocacy.
The turning point came when the junior Federal Minister responsible for food regulation, Christopher Pyne, told a journalist that he did not support folate fortification. I called Jim McGinty. He said, ‘Tell Fiona to phone Tony Abbott’ (then Federal Minister for Health). She did. Within hours, Christopher Pyne phoned the journalist back, saying that he had perhaps not made himself clear enough and he was of course fully supportive of folate fortification. It took more work, but the battle was won, and we have mandatory fortification.
None of that would have happened without Fiona – researcher, advocate and willing to be the ‘unabashed teller of truth to power’.
Fiona's research has made her acutely aware of the harms caused by alcohol, with a particular focus on not only alcohol and pregnancy and Fetal Alcohol Spectrum Disorders but also the broader impact of alcohol on young people.[22, 23] A wonderful team at the Telethon Institute for Children's Health Research has been doing outstanding work in this area over many years.
When the McCusker Charitable Foundation decided to support moves towards changing the binge-drinking culture among children and young people, Fiona immediately provided strong support. She became a member of the Board of the McCusker Centre for Action on Alcohol and Youth, is a co-convenor of the WA Alcohol and Youth Action Coalition, is a strong spokesperson for action to challenge the tsunami of alcohol promotion, to which children and young people are exposed, and is Chair of the new Alcohol Advertising Review Board, which is already having an impact, especially if judged by the reaction of the alcohol industry.[25-27]
When the Board was launched, with Fiona as the chair, the alcohol and advertising industries responded with no less than six critical media releases, along with letters to Ministers and politicians, and they have even stepped up their campaign since.
She is vocal publicly and privately about the need for action, and her involvement has been vital in ensuring that calls for action are starting to be heard. She understands that there is tough and determined opposition. She also understands well that the impact of advocates can be judged by the measure tobacco control advocates describe as the ‘Scream Test’: the louder the industry screams when action is proposed, the more effective it will be.
Just as tobacco plain packaging generated more screams from the global tobacco industry than anything else in tobacco control for more than two decades, so the present focus from Fiona and others on the exposure of children and young people to alcohol promotion generates more screams from the alcohol industry than anything else currently being debated in this area. Alcohol companies know the importance of being able to expose children and young people to glossy promotions and sports sponsorship. They know how many children start and continue binge-drinking with sugary confections designed to mask the taste of alcohol, and they know how much this is threatened when someone like Fiona takes them on publicly.
What are the characteristics that make Fiona a model researcher–advocate?
Science. Fiona's concerns, comments and advocacy are always based on sound science. She never goes beyond the evidence and always ensures that she is well informed. Too many health campaigns have been derailed because their evidence base was insufficiently sound, or presented by people who were not fully across the evidence. Fiona only campaigns if the evidence is there and she is well informed.
Personal involvement. Virtually all Fiona's advocacy arises from areas where she has been an active researcher. Fiona has been active in children's health, Indigenous health, folate, alcohol and tobacco, and can speak as a researcher who has made a genuine contribution to the science.
Focus. Many health campaigns have a strong rationale, but only few really focus on what will make a difference. There is also a tendency to be bought off by soft options or minimalist approaches, described by Mark Worden as ‘popular prevention’.
By contrast, Fiona has an unerring eye for the crucial question: what really will make a difference? She is not side-tracked by soft answers, soft policies and soft solutions, but identifies – on the basis of evidence – where action is needed and what the priorities for action should be.
Understanding policy and politics. In an ideal world, all politicians would read medical journals, and Ministers' preparations for cabinet meetings would entail reading all the best papers and reports. When this author attended an early meeting about action on smoking at the Royal College of Physicians of London in 1973, some of the leading doctors in the United Kingdom sat for 2 h discussing what they might do that would force the Government to act. Eventually, they decided on the answer: a letter to the Lancet.
Fiona is an evidence-based researcher, but she understands the policy environment. She understands that the evidence needed for political decisions is often different from what researchers might want to present in an ideal world, and that it must be presented in different ways to different target groups.
She understands how governments work and who influences decision making, when to lobby premiers and ministers or when to speak with people who may be further down the food chain but can make things happen.
Credibility. Fiona has extraordinary credibility in the Australian community. She knows how to use it and when to stand back. She displays superb judgement in deciding where she should use her considerable influence, implicitly taking into account criteria such as the scientific evidence on the nature of the problem, the importance of the issue, amenability to intervention and the likelihood of making progress.
Real passion. Along with Fiona's research and scientific credentials, credibility and policy sense, all those with whom she communicates know that her passion is genuine. The passion she exudes when she speaks about public health issues is real and not confected – that is what makes her so formidable.
Courage. Being a campaigner is not easy. There are many marshmallow advocates with a crisp coating but a soft centre – people who run for cover when the first shots are fired. Fiona is the real deal. She takes on the hard campaigns. She is not afraid of tough opposition, from racism to commercial interests. She stands up publicly for causes she believes in and stays with it. The sound of gunfire serves as an incentive to fight the battles that need to be fought. Fiona has shown true courage as an advocate, not only now, when her standing is unassailable, but from the earliest days.
Professionalism. Fiona differs from many other researchers in that she is as professional in her advocacy as she is in her research. She knows when to go public and when to lobby privately. She is equally effective in dealing with politicians, advisers, bureaucrats and the media. She understands when to communicate through a scientific journal or through front pages and TV news. She is available to journalists, as distinct from scientists and researchers who do not understand media deadlines. She appreciates that it is possible to be both an adviser to governments and a public advocate, so long as there is clarity about the way the roles are handled. She knows where the right doors are, how to open them, how to knock gently and walk in quietly and also when it is appropriate to put a shoulder to the door and push through.
Persistence. Just as research takes time so advocacy successes are generally not immediate. For many years, tobacco control advocates were told they were failing, despite the reality that they were working with minimal resources against massive opposition. In advocacy, as in research, success takes time. The true advocate has to stay with it, show patience, recognise that there will be hurdles and knock-backs and persist. One of Fiona's most important characteristics is that she is absolutely, doggedly and determinedly persistent. Whether pressing for support for the Institute, recognition of Indigenous needs or action on specific public health issues, Fiona is there for the long haul.
Reliability. Fiona's colleagues know that whatever her personal or professional pressures may be, she is always there when she is most needed, always reliable, always a tower of strength when it matters most, so this author is grateful for the opportunity to thank her for that, as well as for everything else she has done.
Fiona is the example par excellence of a researcher who understands that translation is as important in public health as it is in the clinical arena. She has a unique role in Australia as our leading researcher–advocate. Long may she serve as a model for other child health advocates.