GUEST BLOG: Ian Powell – Trumpian health leadership

On 18 March I received an email from a reader briefly stating that: “Boy, here’s something for you to get into!”. Included was a link to an article published the same day by Stuff journalist Glenn McConnell:

Doctors fear Govt instruction means they can’t talk freely about public health issues | Stuff

McConnell reported the worry of public (population) health doctors that the government was trying to suppress their expertise.

Stuff journalist Glenn McConnell broke story of attempt to suppress public health doctors

Political pressure from Minister of Health Simeon Brown had led to Health New Zealand (Te Whatu Ora) directing that medical officers of health (MOHs), who have regional population health responsibilities, would now require national sign-off from their employer (HNZ) before offering advice about issues in their regions.

MOHs are trained doctors who have specialised in public health. They have legal obligations to analyse how issues, such as alcohol policy, will impact people’s health in their regions.

Differentiate messenger from message

Dr Nick Chamberlain the unfortunate messenger of an unpalatable message from above

The unfortunate messenger of this (to the best of my knowledge) unprecedented decision was Health New Zealand’s National Public Health Service Director, Dr Nick Chamberlain; a former respected chief executive of the Northland District Health Board and a trained doctor himself.

At this point it is appropriate to provide a timely reminder to apportion blame to the message, not the messenger.

It is also timely to note that, such is the destabilisation and demoralisation within Te Whatu Ora, it was unsurprising that this message (and the messenger) were quickly leaked to Stuff.

What are medical officers of health

Medical officers of health are medical doctors who have specialised in population health. This is their area of experience and expertise.

They hold positions designated by the Director-General of Health under the Health Act 1956, which still continues in force, to exercise powers and duties within specific health districts, focusing on public health protection and promotion.

Until July 2022 MOHs were employed by district health boards (DHBs). Now, under the Pae Ora (Healthy Futures) Act,  they are employed by Te Whatu Ora. But the Director-General’s authority to designate these positions continues.

MOHs have an extensive statutory based brief. Their other key responsibilities and functions include:

• monitoring and controlling communicable and non-communicable diseases, taking appropriate action in cooperation with relevant authorities;
• identifying and addressing the impacts of environmental factors on public health, collaborating with environmental health professionals;
• advising various stakeholders, including local government, general practitioners, and other sectors involved in public health activities;
• being involved in licensing and regulatory matters related to public health, including enquiring into applications for licenses and renewals, providing information for local alcohol policies, and applying for suspension of licenses where there is evidence of non-compliance with public health requirements;
• contributing to assessing the health status of the population and developing information services to inform public health interventions;
• playing a role in developing public health capacity within the health system; and
• involvement in implementing preventive measures to address public health issues.

Dr Alister Humphrey’s experiences highlighted importance of medical officers of health

An example of the extent of the role of medical officers of health was in Canterbury in 2016 when local MOH Dr Alistair Humphrey took a successful landmark case to the Court of Appeal. The outcome was that alcohol sales in supermarkets could only be displayed in designated spaces.

Two years later Dr Humphrey in the performance of his duties aroused the anger of the Ministry of Primary Industries over his public comments when responding to an imported ‘rotting cabbages’ threat. This led to the Ministry of Health trying to pressure Canterbury DHB (as his employer) to take disciplinary action against him.

However, behaving like a good employer should, CDHB reached agreement with Dr Humphrey’s union (Association of Salaried Medical Specialists – ASMS) for an independent review over his advice to the at risk public that was so ‘inconvenient’ for MPI. That review upheld the quality of his advice.

A “chilling effect”

Glenn McConnell reports that both Dr Chamberlain’s and Minister Brown’s comments were having  “chilling effect” within Health New Zealand, particularly its public health teams. This is on top of the staffing cuts being imposed on these teams.

Brown has said that he wanted MOHs to stop writing about issues such as fast food and “leading advocacy campaigns” on public health issues. Instead, he said their focus should be on “technical advice” and immunisation campaigns.

This would impose a considerable limitation on the performance of their public health safety responsibilities.

Media work has been critical to the ability of these doctors to expertly advise the public of how social and environmental issues might detrimentally impact on their health.

This limiting decision also runs counter to the tenor and relative independence of their statutory based roles.

Their expertise can also offer advice on how the policies of central and local government might improve or harm health. Sometimes these are messages that both (or either) branches of government might not to hear, but nevertheless need to.

ASMS has correctly pointed out that any attempt to limit the ability for these doctors to speak publicly would be a breach of their collective employment agreement.

Specifically the agreement includes an entitlement protecting senior salaried doctors’ ability to offer their professional expertise and advice in public [in an earlier life I was the advocate who first negotiated it; just saying].

Health Minister wants medical officers of health to ‘zip it’

Brown used the case of a medical officer of health submitting against a resource consent application to open a fast-food restaurant in Wānaka to trivialise the issue.

Where does the line get drawn over what a MOH should not advise on (is it fast-food or drinking water safety, for example).

And who should draw that line; those with population health expertise and local knowledge or those at the top of the hierarchy or a politician? In the interests of ambiguity avoidance, this is a rhetorical question.

Acting Prime Minister maligns public health specialists

Two days later the persistent McConnell followed up with another piece this time focussing on population health leaders:

https://www.stuff.co.nz/politics/360620860/its-censorship-public-health-leaders-slam-trumpian-edict

David Seymour draws upon his success over school lunches to advise public health specialists what public health is and isn’t

But first, fresh from his successful performance in charge of school lunches, the journalist reports Acting Prime Minister and ACT leader David Seymour supporting Simeon Brown. He was “cheering on Simeon [Brown] putting those muppets back in their box”.

Ironically, in doing so, Seymour had inadvertently dobbed in his ministerial colleague who had been keeping his head down over whether the vetting directive had come directly from his office.

But Seymour then widened his attack beyond MOHs to the larger group of public health specialists (which includes epidemiology, nutrition, biostatistics and environmental health) accusing them of “…far too much hectoring and lecturing about our private health choices…”

As acting prime minister David Seymour maligns public health specialists

However, he raised the threshold of disingenuous conduct to an even higher level by suggesting that they “…had failed to focus on infectious disease, saying they’d been unprepared for the arrival of Covid-19.”

It is difficult to think of something more politically dishonest (providing Donald Trump is removed from consideration) than this. It was public health specialists who provided the right advice over the pandemic response at a time when the World Health Organisation was still trying to work it out.

They advised an elimination rather than mitigation response. The then Labour led coalition government’s accepted this advice and effectively both implemented and communicated it to the appreciative public.

Consequently tens of thousands of lives were saved when compared with the responses of most developed economies, including Europe and North America.

At least for the first 18 months or so, New Zealand’s response was based on the advice of these now maligned public health specialists.

Response of public health leaders

McConnell’s reporting of the response of public health leaders to this “chilling effect” begins with Sir Collin Tukuitonga.

Holding the positions of Professor of Public Health (Auckland University) and President of the New Zealand College of Public Health Medicine, he is well-qualified to evaluate. In an earlier life he was a public health director in the Ministry of Health.

Sir Collin Tukuitonga decries Trumpian censorship

Describing the government’s decision as “censorship”, he said it was “unheard of” to see such ministerial and bureaucratic interference in day-to-day public health work. In his words:

It’s a very Trumpian approach, with Government dictating to various agencies what they can and can’t say. It’s absolutely ridiculous. We must push back on this stuff. It is unacceptable in Aotearoa and I hope the public see it for what it is.

They’re being told they can’t do their jobs and they have to refer to ministerial officers for approval. I mean, it’s ridiculous. They’re being censored.

Professor Tukuitonga added that doctors who specialised in population health should not face vetting processes that no other medical speciality was subjected to. Emphasising this point he noted that:

It is unheard of. It is like telling a surgeon, ‘you can’t operate on that patient. You have to operate on this instead’. You have to trust people’s professional judgement.

Professor Michael Baker: its crucial for MOHs to be able to speak out

Professor Michael Baker (Otago University public health specialist) observed how crucial it was  for medical officers of health to have the ability to speak on issues impacting health across the country.

In his words:

The importance of that has been recognised for decades. Having to go through a centralised vetting process, which will be risk averse and potentially politicised, will ultimately reduce the ability of our system to respond to public health issues.

Health Minister Brown’s reported comment focussing on the Wānaka  fast-food incident was little more than a soundbite. He accused these statutory public health doctors were behaving like “health police”.

At first they came for the medical officers of health

Might Trumpian thinking extend further?

This kind of thinking and Health New Zealand’s regrettable response is straight out of the Trumpian textbook. It is an endeavour to prevent receiving inconvenient evidence-base advice.

If Trumpian thinking extends further it will be in the direction of strangling the experience and expertise of both other branches of medicine and other health professionals.

My reader’s email was right. Boy this is something for me to get into. Afterall, as the tragedy based expression goes, at first they came for the medical officers of health, then they came for…

 

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