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Dr Michael Joffe was chairman of EPHA when it was founded in 1993. Here, he explains why growing numbers of public health experts began to think it was important to work at European level, and describes some of the achievements of the first few years.

During the 1980s, the European Community, as it was then called*, became more active in legislating for its Member States. In particular, environmental protection seemed to be largely driven from Brussels, especially from the perspective of the United Kingdom where deregulation was the guiding principle in government. Later in the decade, preparation was being made for the completion of the internal market under the 1986 Single European Act, due for 1 January 1993, and this involved several areas relevant to health, such as food additives and pharmaceuticals.

Policy development involves a lot more than just civil servants and politicians. Industry lobbies had long been well established in Brussels. In the NGO (non-governmental organisation) world, environmentalists already had a track record of advocacy and engagement with the policy process, but NGO activity on health at the European level was confined to single-issue organisations, such as those working on tobacco control or on cancers.

How it all started

In September 1991, a small group of people met with the idea of setting up an NGO in Brussels with the purpose of providing a focus for health concerns at the European, and especially the EC, level. We were a group with diverse interests, including:

– BASP, the European Bureau for Action on Smoking Prevention

– Alzheimer Europe;

– The Netherlands Consumer Platform, which was concerned with democratising health care;

– The Public Health Alliance in the UK, with a broad interest in all aspects of health protection and health promotion, and especially in social inequalities.

This diversity initially presented a challenge, as the groups sometimes found difficulty in fully understanding and appreciating each other’s agendas. However as discussion progressed and we got to know each other better, it became a source of richness. We learnt more about health-related NGOs in other countries, as well as enlarging our own concepts of what we might aim to achieve at European level.

At that time, to many people the word “health” was applied only to health services. The idea that governmental or EU policy could influence citizens’ health status through action on the determinants of health was new to most people, in the institutions as well as among NGOs. Similarly, “public health” was routinely equated with public health services, and then in some people’s minds again with health-care organisations such as hospitals, that were in the public rather than the private sector.

Even those who realised the importance of prevention saw this as a matter of individual behaviour, not as something that public policy could or should influence. One of our immediate tasks was therefore to make the case for considering the determinants of health as important aspects of policy development in a range of policies, most of which had never been perceived as connected with health. This was done through the use of concrete examples, such as air pollution and road transport, the importance of food safety, and the absurdity of having a large CAP subsidy for tobacco cultivation.

Preventing “a race to the bottom”

The time was ripe for this in terms of the state of European legislation. The Single European Act, which was already in force, specified “a high level of health protection” in the setting of standards governing trade within the single market. This was important, as it could prevent “a race to the bottom”, in which the cheapest producers would succeed in under-cutting and thus driving out the higher-quality ones (a battle which is still being fought internationally, in relation to the World Trade Organization).

Secondly, negotiations were in progress for the Maastricht Treaty, the first European treaty to have an article on health, and which contained the sentence, “Health protection requirements shall form a constituent part of the Community’s other policies”. This unequivocally gave Europe a legal competence in health, and the focus was on health determinants; health services were explicitly excluded from European Union competence.

Attention to health determinants was also appropriate to the European health programmes that already existed prior to the legal competence, e.g. “Europe Against Cancer”, “Europe Against AIDS” and “Europe Against Drugs”, as the tobacco control example makes clear. This left open the question of to what extent our new organisation should also become involved in health service related issues, such as patients’ rights. It was decided that work on this issue would develop as the membership of EPHA came to include NGOs with this type of interest.

In the 18 months between those early meetings of the four founding groups and the formal establishment of EPHA in spring 1993, a small secretariat was set up with the help of the Euro-Citizens’ Action Service (ECAS).

EPHA’s first activities

Commission funding was obtained for a seminar in June 1992. This attracted a high level audience from the European institutions and from several member states, and gave a powerful impetus to the new organisation. The memorandum that served as the basic text for that seminar, and which was published in a revised version (1) taking account of the discussion, became highly influential in the development of future European health policy.

Starting in late 1992, another issue became apparent, which was not on the agenda of any of the participating organisations but which nevertheless was extremely urgent and important. The judicial affairs part of the Commission had published a draft directive on Data Protection, with the admirable intention of safeguarding citizens’ rights. Unfortunately it took no account of the requirements of health or other statistical needs, research etc, and in the original draft would have had the effect of making a large proportion of epidemiological research designs illegal in the EC. EPHA quickly organised a campaign (in collaboration with another NGO that was about to come into existence, the European Public Health Association, EUPHA) and in alliance with others, notably the Danish government. This succeeded in having the draft directive referred to the health Council of Ministers in 1994, which substantially mitigated its most serious effects.

EPHA was also active in publication in that early period, including another memorandum and seminar on the European health research agenda, several journal articles or book chapters, a report on the Fifth Environmental Action Programme from the health viewpoint, and a submission to the European Parliament’s hearing on public health policy after Maastricht. The British Medical Journal (BMJ) organised a discussion on how European health policy should develop, featuring two of us from EPHA, two from the Commission and one each from the Parliament and the Council of Ministers. The Green Paper on Social Policy was published around this time, and EPHA’s response making the case for a more prominent role for health was incorporated directly into the subsequent White Paper. In addition, EPHA jointly organised a conference with the BMJ and the British Medical Association on “What should be done about social inequalities in health in Europe”, funded by the Social Affairs part of the European Commission.

Building up strength

Between 1992 and 1994, EPHA was legally established as an NGO under Belgian law and the vital process of recruiting members began. These were drawn from the EC-level NGOs with an interest in health or related matters, and from national organisations of many kinds. Particular attention was given to attracting participation from countries with less of a tradition of NGO organisation and/or fewer resources, notably in southern and central Europe. It was through this building up of the membership base that EPHA developed into the broadly based and influential organisation that it has become.

(1) Published by ECAS in English and French, and then as Joffe M. “Future of European Community (EC) activities in the area of public health: European Public Health Alliance”. Health Promotion International 1993; 8: 53-61.

*The European Community (EC) became the European Union when the Treaty of European Union, signed in Maastricht, Netherlands, came into effect in November 1993.

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