Epidemics expose public health failures
The measles epidemic didn't need to happen. The University of Otago's Charlotte Paul lays out the avoidable lapses in public health caused by a lack of capacity, expertise, organisation, and political will - and calls for action.
The Health and Disability System Review Panel, chaired by Heather Simpson, is charged with deciding what needs to change in the whole health system to better serve the people. Their interim report is long. Probably few have read it. It says: “For the system to be more effective in the future, population health needs to be recognised as a foundational element of the whole system.” Yet the panel has not reached a view on how to do this.
Population health or public health is about the organised efforts of society to promote and protect health and prevent disease. In practice, this means monitoring the health of the population, delivering effective personal preventive services such as immunisation and screening, and taking collective action to protect health through developing sound public health policies. At present, we are failing in all three.
These failures represent avoidable lapses caused by a lack of capacity, expertise, organisation, and political will to act on major public health problems. The failures do not represent legitimate differences of opinion in public health. There is mostly consensus amongst experts about what needs to be done, and other countries are acting. New Zealand’s pitiful lack of an organised response to lobbying by industry only worsens the situation.
Moreover, because serious threats to health almost always have the greatest effect on people with the least resources, effective prevention and control is central to reducing inequalities and to addressing the health of Māori and of Pacific peoples.
As a public health physician and epidemiologist, I have watched the functions of surveillance (monitoring leading to action) and policy development in the Ministry of Health get progressively weaker. The reasons for this failure lie in the lack of a critical mass of public health experts, and of political independence to develop policy recommendations, as convincingly spelled out by Professor David Skegg in his recent book The Health of the People (2019). This is compounded by the fact that many public health functions are now divided among different groups (e.g. ESR for infectious diseases, MPI for food safety, EPA for hazardous substances, PHARMAC for the immunisation schedule) and there is a dearth of people within the ministry to interpret, integrate and act on their information and reports.
The review panel must seize the opportunity to recommend a public health agency and a strengthened ministry. Otherwise we must expect an even worse epidemic than campylobacter or measles.
The lack of integration of the surveillance function is shown starkly in the current measles epidemic. The US also has a measles epidemic in 2019, but up to November our measles incidence is 100 times greater. Further, we have exported measles to Samoa and there have been more than 70 deaths. Everyone is now working hard to contain the epidemic, but it didn’t need to happen.
It is still shocking that 100 years ago, a ‘death ship’ arrived in Samoa from New Zealand, bringing a devastating influenza epidemic. Professor Nick Wilson and colleagues, writing on this in Public Health Expert last year, called for strengthening of regional infectious disease control and surveillance systems. It doesn't appear to have happened.
When the Havelock North Drinking Water inquiry was released in 2017, Professor Michael Baker and colleagues called it a "wake-up call" to rebuild public health in New Zealand. All that happened was that drinking water safety became yet another function to be removed from the ministry.
The interim report gives surprisingly little attention to the development of policy recommendations, another crucial public health function. There are three important issues here: first, priority is not being given to work on health policy to address serious health issues New Zealand faces; second, the public is kept in the dark about what is recommended by the ministry; and third, the role of industries that stand to lose from good public health policy is hidden from public view.
For example, a ministry representative has stated publicly that it is currently not possible to work on alcohol policy. This means there are no proffered policy recommendations from the Ministry of Health to government on this vital policy matter, despite the major recommendation on alcohol control from the mental health inquiry. Not only have experts given advice, now the people have spoken through the inquiry, and still there is no action.
In relation to the case for effective policy to reduce sugar consumption (including a tax on sugary drinks), correspondence in the Otago Daily Times shows that lobbyists continue to thwart the public health function. As Professor Boyd Swinburn responded, New Zealand officials and politicians have not shown “the mettle to fight the big lobby groups to do something serious about childhood obesity” as other countries have. The evidence for action is currently hidden from public view while our obesity and diabetes epidemics worsen.
A public health agency has the potential to address the current serious gaps in both the surveillance and policy development functions of the Ministry of Health. Skegg provides cogent arguments, based on lamentable political interference in the past, for an arms-length public health agency.
The agency would consult with the public and publish its recommendations. It would be transparent whether the government decided to act on them. Of course, there are priorities other than health that might properly influence political decisions, but this process would mean industry lobbying happened after policy recommendations were made public, not before as happens currently.
The public health functions within the ministry also need to be strengthened if it is to work much more closely and effectively with existing agencies and the new agency, and if this new configuration is to endure into the future.
This is a watershed moment for public health in New Zealand. After years of neglect, there is ample evidence of serious consequences for communicable and non-communicable diseases. It is time to wake from our national slumber. The review panel must seize the opportunity to recommend a public health agency and a strengthened ministry. Otherwise we must expect an even worse epidemic than campylobacter or measles.
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