GUEST BLOG: Ian Powell – Neglect public health at New Zealanders’ peril
When one thinks of medical doctors what usually immediately comes to mind is those doctors who treat and diagnose patients.
This is hardly surprisingly given that this is what the large majority of doctors do, primarily in general practices and hospitals.
However, not all doctors use their medical training for providing personal healthcare. Others are involved in the health of populations. They are known as public health doctors and include epidemiologists.
Under-appreciated public health doctors critical for population health
Due to immediacy of demand and high visibility, public awareness of personal healthcare doctors is far greater than public health doctors. The potential outcomes of the latter are inevitably longer-term and largely invisible.
Addressing social determinants through strong public health measures
However, there is no doubt that if given sufficient priority public health measures will have a far bigger impact on the health and wellbeing of New Zealanders.
Social determinants of health biggest driver of health demand and costs
This is because the biggest drivers of health demand are external to the health system. They are known as the social determinants of health.
These include income levels and protection, housing, education opportunities, environmental, basic amenities, and healthcare access.
At last month’s Women in Medicine gathering in Wellington, an astute observation from a frustrated ear, nose and throat surgeon was reported.
To paraphrase, what is the point of doing hundreds of successful ear procedures on children if they then return home to poor housing.
If New Zealand had not adopted the firm public health measures that it had in response to the arrival of the Covid-19 pandemic in early 2020 and prior to the availability of vaccines the following year, thousands of lives would have been lost.
Instead, because of these measures, New Zealand’s response was world-leading. Population health, not personal health treatment, was responsible for this extraordinary achievement.
Disappointedly, the new National-led coalition government is trying to wipe this experience from historical memory.
To be effective public health requires long-term investment in areas such as child poverty and housing.
It presently suffers because this investment is seen as costs first, benefits later; a guarantee of short-termism decision-making.
Government’s budget failure
Given the above-mentioned pandemic experience, one would have hoped that the new government would have given high priority to public health in its budget for the 2024-25 year announced last month.
Economist Shamubeel Eaqub: a timely budget analysis
Sadly this was not the case. This is discussed in a timely analysis by economist and commentator Shamubeel Eaqub in the Otago University published Public Health Briefing (31 May): Budget neglects public health.
The Council of Trade Unions have published its own analysis of the whole Budget in its May Economic Bulletin: Analysis of 2024 Budget. It includes coverage on healthcare spending which is briefer than Eaqub’s deeper analysis but not inconsistent with it.
In the context of an economic recession, Eaqub observes that the Budget provides for decreasing tax revenue while consequentially increasing some costs such as unemployment benefits.
A high income earner will receive an income tax cut of around 2% compared with around 0.5% for a poor household. This inequity is not a recipe for improving the health of New Zealanders.
He gives the example of cardiovascular disease (CDV). If a single case of CVD could be avoided, according to Treasury, this would save $10,435 a year.
Eaqub continues:
Assuming a person lives with cardiovascular disease for 36 years2, the net present value of avoiding the disease is just over $173,000 today. That is, we would be indifferent between spending $173,000 today on a range of measures (which might include income support, nutrition, and housing) against the cost of that person living with CVD in the future.
However, a budget based on less revenue and less spending means two things for public health:
- Less money for clearly identified health programmes.
- Less money for the wider social determinants of health, especially for the poor and those at the margins of society.
In other words, funding to just keep the health system going is unlikely to match increased demand for healthcare, let alone invest in public health in order to reduce this same demand.
But it isn’t just health funding. Eaqub also identifies education, welfare, housing, environmental protection, and law and order.
In his words, “Budget 2024 plans to spend less on each of these areas over the next three years.”
Public health ‘funding envelope’ should be bigger, not smaller
Consequentially the ‘funding envelope’ for the prevention and protection that public health investment can provide will get much smaller rather than, as it should do, get much bigger. If this isn’t an alarm bell on its own, I don’t know what is.
Eaqub recognises that the Budget makes the job of public health professionals harder because:
…the many threads the sector works across will be in retreat, many public health services will patch protect, and we will see less collaboration. We know that public health is the right thing to do, but it is hard to do.
Advice from a thoughtful economist
The thoughtful economist has two bits of advice for public health professionals in this negative environment, which he readily acknowledges will feel inadequate.
First, continue to deliver “excellent public health programmes” but prioritise them within the limited funding available. Second, increase public understanding of the value of avoided costs.
Prime Minister Chris Luxon’s government has made public health work harder
Shamubeel Eaqub is not an ordinary economist. He sees economics in a wider context of social wellbeing and social justice. This insightfulness allows him to make the following concluding observation:
Public health is fundamentally about prioritising community and future generations above the individual today. Public health is dealing with a wider malaise in society, that of declining social cohesion. Budget 2024 is merely an expression of that. Our task remains important and valuable, but it just got harder.
He is right to suggest that his two above-mentioned bits of advice to public health professionals are inadequate. That does not make them wrong.
But they do highlight the wider more critical problem – the failure of short-term focussed political leadership.
Time to “learn” the government
I recall a story about New Zealand’s longest serving prime minister Richard Seddon (over 13 years from 1893 to 1906). He was also the minister of education.
The head of the education department raised with Seddon a sensitive problem concerning the latter’s nephew who he had arranged to be employed by the department.
What’s the problem asked Seddon. To paraphrase, “He’s illiterate” responded the departmental head. Well “learn him then” instructed Seddon.
Health minister Shane Reti needs to “learn” his government; no pressure!
As well as being fiscally irresponsible, neglecting the importance of investing in public health places the health of New Zealanders in peril.
As an experienced and respected general practitioner health Minister Shane Reti knows this well.
It is a huge challenge given the internal power dynamics of this coalition government. But Dr Reti needs to “learn” his government about this increasing peril facing the health of New Zealanders.
Ian Powell was Executive Director of the Association of Salaried Medical Specialists, the professional union representing senior doctors and dentists in New Zealand, for over 30 years, until December 2019. He is now a health systems, labour market, and political commentator living in the small river estuary community of Otaihanga (the place by the tide). First published at Otaihanga Second Opinion
Reti needs to learn from his own mistakes from when he was on his local DHB.hE ALLOWED HIS LOCAL HOSPITAL TO FALL INTO DISREPAIR.Then at election night he canned the new build that was well advanced to happen because it was put in place by a Labour government .He has also prevented a new hospital on the north shore from opening for the same reason .What a sad human being he is .
Like the no show for the cancer drug funding he and his fellow gang members promised he is complicit in failing at his job and should step down imeadiately .But who would replace him ?perhaps another low life human such as Sam or Barb .
Lets not forget the Hawkes Bay hospital he canned as well as playing funny games with the new Dunedin rebuild. Reti cant be trusted full stop.
Well said. The whole set of Ministers in this government are very sad examples of humans. They seem to have one focus and that is pandering to the nut jobs such as those who voted NZ First and Act closely followed by the wealthy donor group.
They have completely forgotten that Government is supposed to support and nurture the whole population not just those who may have voted for them.
As Ian points out the public health response to the pandemic saved thousands but that response did not just select those who may have voted for Labour or Greens. I wonder who would have been at the front of the queues if the current coalition had been in power. I am quite confident it wouldn’t have been the aged, Maori or Pacifika. They would probably have been the very last.
It’s obvious that universality of care and concern is not applicable right now, in fact it is just the opposite.
“Capitalism has always been a failure for the lower classes. It is now beginning to fail for the middle classes.” Howard Zinn.
When the middle class finds that it can’t afford, or is not getting decent medical care, then something will be done. Until then, the government knows that many of the people who suffer from the neglect of public health don’t vote. Although to be fair, if there is something that tugs at the emotions like the abandonment of cancer drugs, then there might be some movement. (Honestly Luxon might just as well have kicked a puppy in public as done that. Complete lack of political nous.)
Yep, re might just as well have kicked a puppy.
Although remembered, Howard Zinn is widely missed.
Thanks, Ian.
There is also a wider impact. The more the nations health system declines the less skilled people will want to reside here.
The fewer skilled people, I think you mean. (Pedant’s corner I know, but it does clarify things in this instance.)
This from RadioNZ.
https://www.rnz.co.nz/news/political/519654/half-of-hospitals-critical-it-hardware-out-of-date-government-warned
…It also advocated for freeing up private investment in digital health as part of the solution, noting it had “increased dramatically over the last 5 years, particularly in the USA”.
“We need to similarly unleash innovation in NZ,” Te Whatu Ora said.
“Embrace global standards + reduce local barriers to innovation.”
The briefing showed a five-year project of digital modernisation in the public health system was due to begin, on top of a new operating model for data and digital services introduced in November 2023.
But it was starting from way behind: “We’ve inherited significant tech debt which constrains performance – a new national approach was needed, but it will take time, effort and investment to rise above the legacy.”
The government is deliberately not doing the most to get more GPs on the ground. It should have a bonding system with free training and work in rural areas as part of the package for those students who are willing at the end of their course.
Great run down the Human Resource and say we have to have resource to machines and distant voices who are overworked at call centres until we give up and say waste of time. Yet we won’t be able to access a personal choice right to die because ‘they’ are worried that everything may not be tickety-boo to use an archaic 20thC phrase.
I have personal knowledge of my GPs and know all the nurses and receptionists who treat me well and thoughtfully. I also know carers that go to people in their homes and the ones I know are the best people there are in the community – hard-working, with high values, kind,tightly controlled but managing their tasks in time allowed most of the time, with varying support from the Office. Phone calls or videos with somebody eternally under watch by the Office isn’t good for morale of real people. Also we are increasingly dependent on these foreign communication systems which are open to scammers and rising costs and we should live in a way that is closer to what we had in the 20th century before being taken over by this ridiculous system which makes us increasingly vulnerable. Too much TINA.