At the heart of our Covid-19 response has been the recognition that health and economic goals are intertwined. We can cement those values in an independent Public Health Agency, writes Robert Beaglehole, a public health expert who is professor emeritus of the University of Auckland and formerly based at the World Health Organisation.
Covid-19 can kill: the threat of further deaths has resulted in urgent action by the government. Public health sciences have been critical to the control of Covid-19.
But the purpose of public health is the prevention of all diseases, not just infectious diseases, and the promotion of health across the whole population.
The case for rapid action on a wide range of health challenges is compelling. This is reflected in the Labour Party’s 2020 election promise of a new Public Health Agency to provide national leadership and consistency on public health activities.
This is exciting news. A Public Health Agency would undertake key public health activities that have been neglected and under-funded in the past. One priority is to tackle the common and preventable risks – cigarette smoking, unhealthy diets, and harmful alcohol drinking – for the main causes of death such as heart disease, stroke, cancer and diabetes/obesity.
Progress has been stalled, however, by powerful vested commercial interests, especially the processed food and alcohol industries, which have undue influence on public policies. These global industries are largely self-regulated and their aggressive marketing tactics present formidable challenges.
An independent New Zealand Public Health Agency, at arm’s length from government, would make the case for strong action which would protect the whole population, especially children. The shocking state of our children’s teeth, combined with some of the highest rates of obesity in the world, are a direct result of mass marketing of unhealthy foods and drinks.
In the last year, Covid-19 killed 26 New Zealanders and caused untold, and uneven, economic damage.
To place this in context, each year around 25,000 people die from chronic, non-infectious, diseases. These deaths are not inevitable. Many occur too early and Māori, Pasifika and the poorest in our society pay the heaviest price in lost lives and entrenched poverty. These deaths represent failed public health approaches to tackle the common causes; more generally, they are a political failure.
There is now a real opportunity for the government to strengthen the public health response to all health challenges. A Public Health Agency would be a key legacy of this government. It is of concern, therefore, that there is little sign of progress on the promise of a new Public Health Agency.
Another Labour election promise as an “immediate priority” is an action plan for Smokefree Aotearoa 2025. Cigarette smoking kills 12 people every day, around 4,000 a year. Reaching the Smokefree 2025 goal, that is, cigarette smoking rates of less than 5% for all adults, is not difficult, has wide public support and makes economic sense. There is a real chance of this important cross-party goal losing its sense of urgency in the absence of an Action Plan and strong leadership from the government. A Public Health Agency could lead a coordinated and concerted effort to reach the goal by encouraging more quitting, the wider use of much less harmful alternatives and supporting innovative community initiatives.
What are the options the Public Health Agency? Professor Sir David Skegg in his book The Health of the People suggested several. The first is to build public health capacity within the Ministry of Health. However, the Ministry of Health is already overburdened by Covid-19 and cannot take on strengthening public health given it will also be developing relationships with the Māori Health Authority and Health NZ, as recommended by the Simpson review of the health system.
The second option would be to establish a new agency modelled on the Public Health Commission of the early 1990s, and the third, and most appealing option would be to repurpose and strengthen the existing Health Promotion Agency/Te Hiringa Hauora (HPA/THH), moving it away from its current limited focus on social marketing, giving it much greater status and visibility.
The new agency would be responsible for monitoring and reporting on progress towards health goals and targets, providing policy advice to the government and engaging with the public, the “team of five million”, as well as strengthening the public health workforce. It will require independence to provide open and transparent advice, as well as significant funding from Vote Health. It will also need to be protected from the commercial interests which have consistently weakened health policies. And it will require an explicit mandate to reduce the impact of the major immediate preventable causes of chronic diseases and injuries – cigarette smoking, alcohol drinking and unhealthy food.
For now, with Covid-19 still requiring constant attention, responsibility for the prevention and control of infectious diseases should remain with the Minister for Covid-19 Response and the Ministry. However, as the threat of Covid-19 recedes, infectious disease control could be integrated into the Public Health Agency, leaving the Ministry of Health to focus on personal health services.
Critical to our Covid-19 response has been the recognition that health and economic goals are intertwined – a poor health response would be an economic disaster, as it is for chronic diseases. Hospitals are at breaking point: they are the “ambulance at the bottom of the cliff” and are not complemented by powerful preventive efforts.
Science cannot replace politics in deciding what to do, but science places an enormous responsibility on politicians to act in the best interests of all citizens by developing comprehensive and effective policies.
Trust in public health, and the government, has never been higher. Let’s not miss the opportunity to protect all New Zealanders from all common diseases, not just Covid-19, by tackling the preventable causes of these diseases. By acting now on the best evidence, our politicians, and the Public Health Agency, could readily improve health and reduce shameful health inequalities.