Influence, not power: chief medical officer Dame Sally Davies on altruism, anti-vaxxers and winning the trust of politicians and the public
As she steps down after nearly a decade as the nation’s doctor, Davies talks to Beckie Smith about the delicate balance of influence and power, dealing with the tabloid press and why altruism matters in public health.
Photos: Louise Haywood-Schiefer
Among the many intriguing artefacts in Dame Sally Davies’s Whitehall office are two hefty black boxes stamped with the royal cypher. Her team has only ever managed to open one of them.
There’s also a forest-green hard hat, apparently modelled on a firefighter’s helmet, with an insignia depicting a crown, a wreath and the global symbol of medicine, the serpent-entwined staff – a combination that someone presumably felt communicated the rank of chief medical officer.
Hanging on a coat rack is a hi-vis jacket. Worn together, the two accessories were once intended to convey a sense of authority during public health crises. Like the boxes, they turned up in a cupboard when Davies moved in.
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“We keep them around for a bit of fun,” explains Davies, a haematologist and professor-turned-perm sec who joined the civil service in 2004. After nine years as “the nation’s doctor”, she will shortly vacate the office to become master of the University of Cambridge’s Trinity College, leaving these curious props behind.
Davies has used neither the hard hat nor the hi-vis during her tenure as England’s CMO, but she has faced no shortage of emergencies. A great many of these have occurred in the last two years alone. Writing for CSW last year, she called 2018 a “year of reactive incidents” requiring her intervention.
There was the 2017-18 winter flu, which caused a spike in hospital admissions and deaths; then the novichok poisonings in Salisbury last March and June. There were also emergencies the public didn’t see: a few cases of monkey pox, brought over from Nigeria, and a couple of incidents of Middle East Respiratory Syndrome, a viral illness with “quite a high death rate”.
“The people survived, but during these emergencies the public health community have to work almost as detectives: what is it? Where’s it come from? What’s going on? How do you protect everyone, and are there more contacts?”
When a live emergency is running, Davies’s day starts early. Once she gets the call there is little time to dwell. “You immediately think of the poor person who’s affected and then get down to working out what the risks are to everyone else, and how we deal with them,” she says.
There is a constant stream of questions to answer: “What’s the state of the patient? What’s the media saying? And what is the need for action, either immediately, or for preventing other things going wrong in the longer term?”
Then there are “innumerable meetings” with police and Cobra; ministerial briefings; media briefings. It can be, she says with characteristic restraint, “quite tiring”.
“I always was, even as a young doctor, extraordinarily calm and good during an emergency,” Davies says. “So I just move into emergency mode.
“Luckily, I’m very resilient, as it turns out, and I have quite a bit of energy. But clearly, you have to make sure you eat properly, you sleep properly. I get more worried about this team rather than me because they do even longer hours.” You can’t say she doesn’t practise what she preaches.
More likely to get used than the hi-vis on the coat rack is the spare suit hanging alongside it in case Davies needs to step in front of a camera at short notice. In health emergencies, she is the face of government addressing the anxious nation.
She prepares diligently, to avoid what she calls “elephant traps” in interviews. “I’m here to do a job for the public. I’m not here to make a mess,” she explains.
That mantra served her well when she flew back from a family skiing holiday in December 2014 to deal with the suspected arrival of Ebola in the UK. Heathrow’s screening process appeared to have failed when a British nurse who had contracted the virus in Sierra Leone made it through undetected.
Privately, Davies was appalled and says she “couldn’t believe that a nurse didn’t know she was ill”. That was one of the harder days of her civil service career. “I had to handle the media around that without saying what I really felt. That was stressful.
“I didn’t want panic. I didn’t want blame. And just because I had surmised as a doctor that that was the case, it didn’t mean I knew.” A doctor who had done the screening later admitted she had seen the nurse’s temperature was too high, but didn’t report it.
Thinking back to the front-page images of overloaded hospital services straining under the pressure of wintertime flu outbreaks, Davies says: “Everyone thinks that public health should have done more… But actually, there’s a limit to what you can do about vaccination unless you make it mandatory.”
While there will always be crises to deal with, much more of her time is taken up with trying to improve the health of the nation and prevent things reaching crisis point.
She says “of course” she’s worried about the rise of the anti-vaxx movement. “There are good public health reasons [to get vaccinated] and they’re safe, they’re effective. So why wouldn’t you? I don’t get it that people don’t.”
The latest figures show 87% of children receive their second dose of the measles, mumps and rubella vaccine by their fifth birthday – well below the 95% the UN says is needed to reach so-called herd immunity, which effectively prevents a disease from spreading.
“This is an issue related to populism. I think part of populism and consumerism is that we risk losing altruism and doing things for the whole of society,” Davies says. Herd immunity protects those who can’t be vaccinated, including children with cancer or other immune deficiencies.
But those arguments are easier to make when people remember what it’s like to see people afflicted by diseases that mass inoculations have all but wiped out. The problem, she says, is that people have forgotten what that’s like.
But she hasn’t. “I remember looking after children in hospital with measles and rubella,” she says. “I remember seeing two children die from measles. I saw another deaf for life from measles.”
In August, the UK lost its World Health Organisation measles-free status, after 231 cases were recorded in the first quarter of the year. After the announcement the prime minister promised “decisive action” to drive up vaccinations, including updated public guidance and a summit of social media companies to talk about how they can promote accurate information. Davies said the measures would be “vital” in protecting children against diseases.
“Part of populism and consumerism is that we risk losing altruism and doing things for the whole of society”
This summer, the Department of Health and Social Care opened a public consultation on a proposal to require manufacturers to fortify flour with folic acid. The NHS advises pregnant women to take folic acid supplements to reduce the risk of birth defects such as spina bifida, which damages a foetus’s spine and brain during pregnancy, and which can cause miscarriages.
The move would be a long time coming: Davies has been fighting for it since she became CMO. But it’s hard not to see the parallels with vaccinations, as more people push back against such public health measures on the grounds of personal choice.
“Vaccination is for yourself, your family and the community; folic acid is for yourself, your family and the community. Most people don’t have good enough folic acid levels, so people will be better if they’re folic acid replete, let alone the number of spina bifida cases and terminations and miscarriages that we will prevent,” Davies says.
“I can’t understand why it’s taken so long. This is a simple public health measure that many countries have done without problem. I do pray that we get it done.”
There is a lot of waiting in Davies’s world. Her influence over public health policy comes from her medical expertise and social capital – and an understanding “that there’s no point in me berating ministers in public. They’ll never listen to me again. They won’t trust me. They won’t do what I think they need to do.”
So she presents the evidence and gives her counsel, and accepts that sometimes it won’t be followed. It’s up to politicians to make the call, and to coax the public into supporting proposals where needed. “You do need the public to go with the politicians, because [politicians] are not going to do things that would result in them being voted out,” she says. “Turkeys don’t vote for Christmas.”
That said, Davies says she admires the way the government has overcome massive opposition to push through measures like plain cigarette packaging and banning smoking in cars with children in them.
“Those were difficult decisions. A lot of the public and newspapers said no, you can’t do it, and they’re now accepted as normal,” she says. “Leadership from the politicians did it. You’ve got to get to that balance where with some leadership, you can change the norm – so people come on board later, even though they weren’t on board at the beginning.”
Where is that political leadership needed now? One area Davies suggests is in preventative healthcare. In her most recent annual report, she said the government should reposition health as “one of the primary assets of our nation”, like GDP, contributing to both the economy and people’s happiness. She called on the Cabinet Office to look into developing a “health index” to track progress in improving health across England, taking into account risk factors such as economic inequality.
Prevention is a subject Davies returns to when asked about the biggest frustrations of her civil service career. Public health initiatives and campaigns have successfully driven down smoking across England, but there are still parts of the country where 28% of pregnant women smoke. It is one of many examples of health inequality. “Think about obesity in children. The most deprived are almost twice as overweight as the least,” she says.
Davies doesn’t blame politicians for being slow to recognise the links between social inequalities and health outcomes. She readily admits it took her some years to grapple with the evidence. But it is a running theme in other areas she’s concerned about: air pollution, for which she is seeking tougher regulations; vaccination rates; and vaping.
Davies has refused to give her blessing to e-cigarettes, except as a way to quit tobacco, as there’s too little evidence about their health impact. She worries aloud: “Is this a ticking time bomb? Will they turn out to have long term consequences?”
Does she ever wonder if future generations will look back on ours, enthusiastically embracing e-cigarettes, and think of us like the Victorian doctors who once said cigarettes were safe, even healthy?
“I think that about food and pollution. We will look back and think: how could we have let that happen?” she says.
In January, the government launched its cross-Whitehall clean air strategy, which requires departments to report on a wider range of air-pollution metrics, work together to implement the 25-year environment plan and ban the most polluting fuels. It is based partly on the recommendations of Davies’s March 2018 report on the same topic.
She is also worried about water pollution, saying she has learned there is a “terrific amount” of water polluted with infected organisms, some of which are resistant to antibiotics.
Davies is best known for determinedly leading the fight against antimicrobial resistance – the rise of antibiotic-resistant superbugs. Davies led the development of the government’s 2015 AMR strategy, which aimed to slow and contain the spread of AMR in people, animals, agriculture and the wider environment.
Since then, the use of antibiotics in healthcare has fallen by 7% and in farming by 40%. Davies is delighted. “I never thought that we would reduce so quickly and voluntarily the use of antibiotics in our animal husbandry.”
She will continue championing international efforts to curb the crisis even after she steps down as CMO. She co-convened the United Nations Interagency Coordination Group on AMR, which recommended a higher-level committee be set up to shape the UN’s approach and “push to make the UN system work as we do as a government”.
“We work across government across the different ministries; we need the UN system to do that. That needs chivvying and pushing, so I want to be part of that. Now is not the moment to give up AMR,” she says.
At the current rate, an estimated 10 million people a year will die worldwide by 2050 as a result of antimicrobial-resistant infections. In 2016, 490,000 people developed multi-drug resistant tuberculosis, and AMR is complicating the treatment of malaria and HIV. The UK’s first case of “super-gonorrhoea” was discovered last year.
“There’s no point in me berating ministers in public. They’ll never listen to me again. They won’t trust me”
“We’ve taken things a long way, but if we don’t keep going from Britain – and I’m a central part of that – then we might just fall back,” Davies says.
But she is ready to step back from many of her other projects. She was instrumental in setting up the 100,000 Genomes Project, the world’s largest national human genome sequencing initiative, and then in its transition into mainstream medicine, laying the foundations for an NHS genomic medicine service.
Another legacy she will leave behind is the National Institute for Health Research, the health department’s research arm, which she founded as a director general in 2006. With an annual budget of more than £1bn, it is the single largest clinical research funder in Europe. She counts it among her biggest achievements.
It’s not just the research infrastructure Davies is proud of. When she set up the NIHR, she decided it would only fund researchers at institutions that had been awarded a silver rating on Athena Swan, a charter to support the careers of women in science, technology, engineering and maths in higher education and research.
Her reasoning was pragmatic: it needed doing, and it was a simple structural change that could be embedded in policy from the start. She says the level of proactive support medical schools were providing at the time for women’s careers was an “embarrassment”.
Universities and medical schools didn’t appreciate the move. She describes their reaction to her proposal as “horrible”.
“They couldn’t see that you would want to tie research funding to diversity. But luckily, I’m fairly tough, so I toughed it out. And they’ve done it,” she says.
Davies has done a lot of toughing it out over the last decade. “Chief nanny comes to mind,” she says, wryly referring to her tabloid nickname.
Davies says she “can’t quite subscribe” to the view – expressed to her by one politician after a recent Daily Mail berating – that she should feel pleased to be having an impact.
“I particularly object when they bring my family into it. But otherwise, I’m developing a thicker skin,” she says. “If they want to call me chief nanny, if that makes them feel good, fine. But would they now please get back to what needs doing?”
It’s sexist too, she adds, recalling a time when Nick Robinson, interviewing her for the Today programme, asked about the balance between offering bland and ineffective advice and “nannying” the nation. “I wonder whether you would say that to a male chief medical officer,” Davies replied.
Davies was the first woman to be appointed to the role, which has existed for 164 years. She will also be the first woman, and the first non-Cambridge graduate, to become master of Trinity College – an institution that was founded more than 470 years ago.
While she says it’s doubtless “helpful” for other women to see her as a confident perm sec with a successful career and a family – Davies has two daughters – she has made no secret of experiencing the odd bout of imposter syndrome. She has learned a new phrase recently: “I didn’t know it, but I instantly understood it: ‘Fake it ‘til you make it’.”
As she told The Times earlier this year, her first thought on putting the phone down after she was offered the CMO job was: “Oh my God, how am I going to do it?”
One wonders if her successor Chris Whitty, now chief scientific adviser at DHSC, had the same thought. Davies doesn’t say what artefacts she plans to leave behind for Whitty, but asked what advice she would offer for when he takes up the CMO post next month, she says: “Remember that you’re independent. But it is also a delicate balance of being independent but trusted by the medical profession, the public and the politicians. It’s influence, not power."