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The Covid-19 testing facility in Ōtara town centre, Auckland, in 2020 (Photo: Fiona Goodall/Getty Images)
The Covid-19 testing facility in Ōtara town centre, Auckland, in 2020 (Photo: Fiona Goodall/Getty Images)

SocietyNovember 9, 2020

We need and deserve fit-for-purpose public health policy

The Covid-19 testing facility in Ōtara town centre, Auckland, in 2020 (Photo: Fiona Goodall/Getty Images)
The Covid-19 testing facility in Ōtara town centre, Auckland, in 2020 (Photo: Fiona Goodall/Getty Images)

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.

Minister of public health, Joseph Ward; and sanitary commissioners in Wellington in 1900 (Sir Joseph George Ward. Ref: 1/1-001806-G. Alexander Turnbull Library, Wellington, New Zealand. /records/22871604; NZ ILLUSTRATED MAGAZINE, VOLUME 1, ISSUE 10, 1 JULY 1900, via Papers Past)

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.

A public health warning from 1919 (Ref: Eph-C-ALCOHOL-Continuance-1919-01. Alexander Turnbull Library, Wellington, New Zealand. /records/23128362)

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.

The new Labour health team, from left, Andrew Little, Aupito William Sio, Chris Hipkins, Ayesha Verrall and Peeni Henare at parliament last week (Photo: Hagen Hopkins/Getty Images)

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.  

Keep going!
People celebrate in the streets after it was announced that Joe Biden would be the next U.S. President, in Times Square on November 7, 2020 in New York City. (Photo: Stephanie Keith/Getty Images)
People celebrate in the streets after it was announced that Joe Biden would be the next U.S. President, in Times Square on November 7, 2020 in New York City. (Photo: Stephanie Keith/Getty Images)

SocietyNovember 9, 2020

‘Thank God, right?’: New York erupts in joy and relief over Joe Biden’s win

People celebrate in the streets after it was announced that Joe Biden would be the next U.S. President, in Times Square on November 7, 2020 in New York City. (Photo: Stephanie Keith/Getty Images)
People celebrate in the streets after it was announced that Joe Biden would be the next U.S. President, in Times Square on November 7, 2020 in New York City. (Photo: Stephanie Keith/Getty Images)

Yesterday’s celebrations over Donald Trump’s election loss were a rare moment of unalloyed joy in what has been a miserable year. But the happiness was tempered with fear for a bitterly divided nation, writes New York-based New Zealander Tess McClure.

It is 11.31am when Harlem erupts. Down the street, I hear a woman scream.

A moment later, floors above where I stand, queueing for coffee, someone begins hitting a pot with a spoon. The sound rings down the road. Then a man in a Gucci t-shirt and sweat-shorts rushes up the steps from his apartment, onto the footpath, arms raised above his head. “WE WON!!” he yells. “We won. We won!!”

The wave of sound builds as the city realises: it is over. After three long days of counting, wondering, hoping, the vote tally reached a point of certainty, and Joe Biden has been declared winner of the 2020 election. Car horns blare from Martin Luther King Jr Boulevard. People are laughing, clapping, embracing. A woman in blue pajama pants strolls down the road, singing “we are the champions”. Down the block, a young woman thrusts her fist in the air: “Donald Trump is fired!!” she yells, “Get that racist ass outta here boy!” From a balcony above, someone with a speaker starts playing Nipsey Hussle: Fuck Donald Trump. Outside the brunch spots, people are dancing in the street. At the crosswalk, a woman walking her dog turns to me. “Thank God, right?” She shakes her head. “It’s like everybody smiling for the first time in four years.”

Fireworks pop, barely visible in the bright sunlight. From a rooftop, I hear a woman yell: “Amen! AMEN!!!”.

People celebrate at Grand Army Plaza, Brooklyn, after Joe Biden was declared winner of the 2020 presidential election on November 07, 2020. (Photo: Michael M. Santiago/Getty Images)

As night falls, the party continues. For deep-blue New York, the night arrived like a pressure valve releasing; a moment of mass celebration in a year that has offered little else to celebrate. The streets swarm with people. In Washington Square Park, a crowd of thousands – too many to count – has gathered. On a park bench, a man and woman pop bottle after bottle of champagne, pouring out cupfuls for passersby. Outside the LGBTQ bars in west village, people block the street with dancing, singing Britney Spears. Every few minutes, a roar goes up somewhere in the crowd, and spreads like ripple, expanding outward across Washington Square.

The news of Biden’s win broke after three days of simmering anxiety. The day after the election, in the late afternoon, I’d taken a bike and pedalled to the centre of Manhattan. It was unseasonably warm, a last blast of mild air covering the city before November turned frigid.

Outside Trump Tower, police had parked five police-branded trucks and one NYPD bus. The sidewalks were lined with metal barriers, shop windows blanked out with plywood. Even the ornamental conifer trees had been wrapped in a thick layer of blue protective cling-film.

Around 25 police officers gathered outside the entrance, with more thronging on the sidewalk.

Someone had chalked the sidewalk in colourful pastels: Trump Triumphs! Four More Years to Make America Great Again!

“What are you doing here?” an officer says.

“I’m biking around,” I reply.

“Well, you can’t stay here,” he says.

Free champagne to celebrate Donald Trump’s loss (Photo: Tess McClure)

Two blocks away from Trump’s eponymous tower, I come upon a small group of his supporters trailing down 55th Street. At the head is a blonde woman wearing the signature Make America Great Again hoodie, a yellow “Don’t Tread On Me” flag draped over her shoulders, Guy Fawkes mask dangling from her fist. They pause for a round of drinks in the courtyard of an Italian restaurant, BiCe Cucina.

“I think there’s some frickin election fraud happening,” one of the women tells me. “Definitely.” She is African-American, wearing an embroidered Blue Lives Matter cap, and refuses to give her name, but says she’s from Queens – President Trump’s childhood home, where his support trends slightly higher than most of the city.

She taps through her phone screen, which is showing a series of results maps, reeling off vote counts. “That’s how I see it. They’re doing whatever they can to not let him into office, and it’s a total sham, it’s a sham.”

She says she voted Trump in the last election too, for the same set of reasons often relayed to reporters by Trump voters. Because he does what he says he’ll do, because he hustles, and because she was sick of seeing no results from Democrats.

“Democrats just want us to be dependent on them like, they’ll give us a little bone and we’ll just take it,” she says. “They want us to stay on the plantation. The Democratic plantation, as I call it.”

She looks away, back to refreshing her screen.

“Is there anything else,” I ask them, “that you would like to get across about tonight – about your hopes for what happens next for this country?”

“Yeah,” the blonde turns to me. Until now, she has been mostly silent. “I think once the election is final and if the Democrats cheat and say that Joe Biden is our next president, I think for the next four years, Republicans need to do what the Democrats have been doing for the last four years. And riot and loot and burn shit down and beat up Democrats and kill Democrats.”

I try to examine her face for a hint of tongue-in-cheek, a glimmer of amusement, but I don’t see one.

At Washington Square Park, New York, during last night’s Biden celebrations. (Photo: Tess McClure)

***

Biden spent months campaigning on the idea of an ending.

He invoked it over and over: “I’ll end Donald Trump’s chaos and end this crisis.”

“Together, we can put an end to the last four years of darkness, division, and chaos.”

“We can end this era of division. We can end the hate and the fear.”

But the banner that Trump has spent the last four years unfurling will not be stuffed back in the box easily. The vision that he presented is both new and old for America: threaded through with racism, patched with lies and conspiracy, stitched with resentment. Even if Donald Trump disappeared from public life, there will be no shortage of others seeking to carry the banner forward.

For the America that voted for Biden, the joy and relief is laced with anxiety and a bitter aftertaste. Those who hoped 2016 was a kind of political freak accident, an aberration, a correctable blip, have been disappointed. President Trump’s support has endured – even increasing in some Latinx communities, and among Black men. Millions more people voted for Trump in 2020 than did in 2016. Despite near-endless scandals, an impeachment inquiry, multiple sexual assault allegations, the death of  more than 230,000 fellow citizens, and a catastrophic economic meltdown, 70 million Americans wanted four more years.

In his acceptance speech, Biden promised he would be “a president who seeks not to divide, but to unify. Who doesn’t see red and blue states, but a United States.” He will have a difficult road ahead of him. Surveys last year found round 42% of American voters (both Republicans and Democrats) believe that those on the other side “are not just worse for politics — they are downright evil.” Around 1 in 5 agreed that that their political adversaries “lack the traits to be considered fully human — they behave like animals.”

And as Biden’s lead solidified, so did Trump and his supporters’ insistence that the election was being stolen. Outside vote-count centers, Trump-supporters have clustered, some heavily armed, some holding tiki torches and pitchforks, some chanting “Stop the Count”. Women in MAGA hats knelt and swayed, praying for divine intervention. The President has repeatedly claimed that the election is being illegally stolen from him On Thursday, Donald Trump Jr tweeted: “The best thing for America’s future is for @realDonaldTrump to go total war over this election.” For this small cluster of Trump supporters in Manhattan, that call sounds exactly right.

On the left, too, many believe the battle is far from over. Even in the midst of the celebrations at Washington Square, I see signs overhead:

“Kids are still in cages”

“Abolition Now”

“The War Goes On”

I think back to two nights ago, before the celebrations began, when I stumbled across “count every vote” protesters a few blocks from this park. That night, the sound of celebration was replaced by an automated voice blaring from a speaker. “This is the New York City Police Department,” it said. “You are unlawfully in the roadway.”

In front of me, a solid wall of officers stood, gripping batons in hand. I watched between their uniformed shoulders as across the road, the line moved forward, forcing crowds off the street and onto the footpath. The police were “kettling” – a technique they had spent past months practicing on Black Lives Matter protesters. The strategy is named for the old-fashioned water kettle. It accelerates water to boiling point by trapping steam inside, heat and pressure building.

Groups of demonstrators are trapped within a perimeter of riot police, and detained en masse.

Across the street, the line of police surged forward suddenly. There was nowhere for protesters to go: they hit the boarded up shop windows of a Wells Fargo. Teenagers toppled over in the crush. People started screaming. People were face-down on the concrete. I watched a young man look up from where he lay on the ground, officer cuffing his wrists, cheek pressing into the ground.

A sign at the Biden celebrations at Washington Square Park, New York. (Photo: Tess McClure)

This particular vision has become a familiar scene in New York. Enormous protests denouncing the killing of unarmed Black people by police have surged through the city for months. Tonight, as Black Lives Matter protesters mix with “count every vote” demonstrators, some of the slogans are different, but the overall picture is the same. And this, too, will be the inheritance of the Biden administration, both in New York and across the  country: a country streaked with conflict, unrest, long-festering inequalities, demanding a reckoning over racial injustice.

Biden is not a radical change candidate. Even if he was, winning the presidency but failing to flip the Senate will see the Biden administration struggling to produce the kind of comprehensive legislative reform – on criminal justice, on healthcare, on climate change, on immigration – that the left has been calling for.

Hours after a Biden win is announced, I talk to a woman who is standing outside a subway station with a sign: “Let’s put Joe and Kamala to Work,” it reads, “Make American Antiracist Now!”

I ask her how long she’s been standing there. “Five hours,” she says.

Hope you get a chance for a break, I tell her.

“I hope we get change, is what I hope,” she says. “But right now, this is a win. I celebrate this as a win.”