New Zealand’s public health infrastructure has swung wildly between comprehensive and chaos over the past century. Preventive and social medicine expert Dr Warwick Brunton says there’s never been a better time to learn from the past and reimagine public health in Aotearoa.
Anxieties about significant rundown of public health capacity in the Ministry of Health and DHBs have haunted New Zealand’s experience of Covid-19. They underpin calls for an inquiry into our preparedness and overall management of the crisis.
Former health minister Chris Hipkins acknowledged the value of an inquiry in due course. Labour pledged a public health agency to more closely link the 12 public health units and provide “national leadership and consistency around all core aspects of public health, including health protection, health promotion, and screening”. Although light on detail, the statement implied that DHBs and the Ministry of Health will lose some power and control.
The election result allows New Zealand to study in a measured and independent way the capacity and legislative framework needed in present and future epidemics, and epidemics of preventable chronic diseases. Transparent public scrutiny should precede significant reorganisation of our public health service. We’ve done so twice before.
In 1900, the government appointed qualified experts as “sanitary commissioners” in case bubonic plague arrived from the Pacific seaboard. An inquiry was inevitable after the 1918 influenza pandemic hit some 40% of New Zealanders and killed 9,000. The inquiry’s membership contained no experts. It relied heavily on advice from public health officials about how to tackle the mandate they themselves and the minister had set. An interim report anticipated another possible wave of the pandemic. The final report provided the official critique and recommendations.
Four lessons emerge from these long-ago inquiries.
Public health function
Public health philosophy and approaches should be pivotal to health discourse and policy-making. In 1900, New Zealand’s brand new minister of public health, Joseph Ward (later prime minister), said his portfolio elevated the health of all New Zealanders “to a first place in the consideration of the government”.
“Public health” has become a euphemism for public hospitals, but tired clichés involving ounces of prevention or cliff-top fences detract from the centrality of preventing disease, disability or injury. The public health function extends well beyond medical services and includes information-gathering about and monitoring of public health and risks, disease outbreak investigation and control, law enforcement, community empowerment and networks to solve health challenges, preventative services (like immunisation or screening) and public health research (to name only a few).
The Simpson report would allegedly put public health in “the driver’s seat”. Save for the short-lived Public Health Commission from 1993 to 1996, health sector reorganisations since the ill-fated White Paper in 1974 have sadly viewed public health operationally rather than strategically.
Public health organisation
Public health experts should be encouraged to design and organise a purpose-built national public health service. In 1900, they shepherded into existence a specialised technocracy with a “head”, district offices as “arms”, and legislative “teeth”. The Public Health Department embodied the public health function as then understood. Specially qualified staff we now call medical officers of health and health protection officers operated in a national chain of command. The organisation was built on principles of professional competence, statutory independence, public accountability, and dedicated public service (not private practice).
Retrenchment-driven “integration” in 1909 left the public health service in a “chaotic condition” to handle the pandemic. “Neglect and indifference” followed forced amalgamation into an omnibus Department of Public Health, Hospitals and Charitable Aid, leaving it “starved and cramped”, the 1919 inquiry decided. Arguing that the authority responsible for the accommodation of the sick should be also “responsible for those influences that are likely to cause or spread sickness”, the department transferred district health protection activities to hospital boards (the forerunner of DHBs) in 1910. But boards either showed “very little anxiety” or wanted out of that responsibility. Even Dunedin’s Dr Alex Falconer, the foremost medical superintendent and a public health specialist, lacked time for public health work.
Accepting that integration had failed, senior public health administrator Robert Makgill massaged the inquiry’s findings and more promising organisational and legal recommendations into practical proposals. The rebranded Health Department head office structure emphasised preventive programmes. Health protection officers rejoined revitalised district offices. Ethical walls separated the directly managed national public health service from central oversight of hospitals and medical care.
Seemingly oblivious of its history, the Health Department again off-loaded its public health services to let hospital boards become area health boards (1983-89) and the department a policy ministry (1993). Boards faced no transitional preconditions or reorientation for a health mandate. Public health organisation and funding were not safeguarded. Despite the rhetoric, regional integration was more take-over than marriage of equal partners. Multiple restructurings and the loss of institutional memory have since hollowed out public health capacity in the regions and in the ministry. Veterans of the long-forgotten Health Department and Public Health Commission (PHC) are not surprised at the ensuing neglect and marginalisation of public health.
The shake-up of public health organisation and resourcing now needed resembles that of 1900 and 1919. The WHO’s director-general calls for nations to increase investment in public health and “build back better” from Covid-19. In recent years, he says, many countries have made enormous advances in medicine, but neglected basic public health systems which are foundational for responding to infectious disease outbreaks. The Simpson report echoes that: “Improving the health and wellbeing of the population should not be driven primarily from within traditional health services.”
So why not liberate public health to achieve its function and destiny independent of medical care? The signal will be the extent to which the government is prepared to seriously tackle the present and comparable future pandemics and the hidden epidemics of preventable chronic diseases, injury and disability that pose the crucial health challenge buried deep in the Simpson report: “If New Zealand does not significantly reduce intergenerational poverty and act on the social determinants of health, little that happens in the health and disability system would have a lasting impact.”
It’s worth remembering that the Labour-led government rejected a key recommendation of its Inquiry into Mental Health and Addiction (2019). This called for a clear locus of responsibility within central government for strategic and policy advice on social wellbeing, oversight and coordination of cross-government effort to both tackle social determinants affecting multiple outcomes and social inequities, and to enhance investment in prevention and resilience-building.
A new public health act
Inquiries catalysed the internationally respected Public Health Act 1900 and Health Act 1920. Significant parts of the present Health Act 1956, date-stamped 1920, authorised lockdown measures. Pandemic management in 2020, however, has inevitably highlighted issues beyond the realm of our earlier statute draftspeople, and spawned myriad acts of parliament and subordinate legislation. Is it not time once again to design a contemporary and comprehensive Public Health Act to mandate and re-empower the public health function and service?
Let’s use the Covid-19 crisis to truly restore public health. Let’s reshape our organisation to effectively discharge the public health function nationally and regionally and to modernise and future-proof our premier public health statute. Now is the right time to do the right thing for public health by applying history, starting with a proper stocktake of organisation, resources and law. Give public health experts, with WHO input, the head-room to devise a new and properly resourced public health “body” complete with “head”, “teeth” and “limbs” rather than as some agency-appendage of the perpetually restructuring Ministry of Health. The framework should incorporate the traditions and culture of Aotearoa New Zealand and not merely copy-cat some fashionable overseas model. Then let that new organisation address the real and upstream socioeconomic, environmental and behavioural factors that affect 80% of our health outcomes and equity.
Only an independent and dedicated new organisation with real clout, proper resourcing, scientific and research back-up can move a talkfest into significant upstream action.
The rationale behind the latest cabinet changes demonstrates public health having “first place in the consideration of the government”. That same principle can open-sesame transformational change through the talents and tested skills of senior ministers and the recognised expertise of Ayesha Verrall in the cluster of health ministers. So let’s unlock once more the full potential of public health.