We are reminded by a turbulent year and Ayesha Verrall of the importance of an effective health system.

I have been teaching and researching health economics for over half a century, mainly in population-based health. (I am an Honorary Fellow in the Department of Public Health at the Wellington School of Medicine of Otago University.) It is the Cinderella of the health specialities because, as a rule, it deals with long-term issues. They can really matter. The biggest gain in the fight against cancer has been the steady elimination of smoking, although that gets forgotten when you turn up with a cancer tumour.

The public health profession has been thrilled with the progress made by new Minister Ayesha Verrall, including progressing the smoke-free campaign, fluoridating of water, mandating the folate fortification of bread, upgrading the breast cancer screening program and introducing a new cervical screening test. Her successes are indicative that what has been lacking in the past is commitment. One hopes her summer reading includes the unimplemented 2010 Law Commission report Alcohol in Our Lives: Curbing the Harm.

Another win for the doctor was advising Minister Kiri Allan to see her doctor. It was a pleasure to hear that Allan’s cervical cancer has been successfully treated and she compounded the win by reminding us all, women and men, to pay more attention to ‘down there’.

It is disappointing that we do not mention more the HPV (Human Papillomavirus Vaccine) immunisation program. Certain common cancers, including cervical cancer, are the result of a virus that is sexually transmitted (they are STDs).  HPV immunisation has been free for everyone, male and female, aged 9 to 26, since 2017. Coverage seems to be about two-thirds of recent relevant birth cohorts – certainly not 90 percent.

The big public health win in the last two years has been the campaign against the Covid virus. Compared with most other countries we have done bloody well. It has been partly our isolation, partly political leadership, partly a surprising degree of science literacy in the population (the anti-vaxxers are a small minority) but also that the public health profession, which includes Director General Ashley Bloomfield, have been just brilliant. Given the way that the previous government had run down the public services (it had higher priorities but not far away lurk commercial interests which profit from poor health practices), the university practitioners have stepped up to the mark.

The Covid War is not over and, to be brutally frank, we may be fighting it for decades to come as the virus mutates – a more malignant version of what we face with influenza. Albert Camus’ The Plague reminds us that the Black Death (bubonic plague) which arrived in Europe 650 years ago was still around 600 years later. Dr Rod Jackson, an epidemiologist at the University of Auckland, opined, ‘I’m not sure we [i.e. our Covid traffic lights] should ever go green’, was offering a salutary caution.

For me, 2021 was memorable because it involved my first significant brush with the health system in a personal capacity. I had an aggressive tumour of my larynx. It has been surgically removed, I am undergoing back-up radiotherapy, and the prognosis is ‘very good’.

People understandably get obsessed with their health crises. Forgive me for relating mine but it led me to reflect on how our health system works. Here are the lessons I learned or had reinforced.

First, a lot of people grumble about their treatment when their needs are urgent. (I’ll come to the waiting lists shortly.) There are two broad complaints. One is that the doctors did not seem to know what they were doing. Well, they don’t know everything and sometimes what we have is unusual. We should respect them when they say they don’t know. (Twice, my doctors told me my type of cancer in this site was so unusual that there was hardly anything relevant in the medical literature.)

But second, there are problems in the interfaces between the various parts of the health system. It is inevitable in large complex organisations – the same thing happens in the private sector. Obviously, we should try to make the system seamless but glitches will happen. I was lucky because I had a good caring GP; hope you have too.

This health economist wondered whether there were any resource savings to be made in the system. I certainly got a lot of resources. My observations are casual, and the only thing I wondered about was the costs of the generous social support I got (including, by the way, from the Cancer Society which is a reminder of how complicated the entire health system is). However, while I have had wonderful support from my personal network, others are not so fortunate. I get the impression that the support system is preparing me for the last weeks of the radiotherapy which may well be very tough. We don’t want to solve people’s physical conditions and leave them psychological wrecks.

Looking at my experience, I am struck how lucky I was. In mid-July my GP referred me to a Wellington ENT specialist. The public hospital was overloaded, so it was off to the private sector. The earliest I could get was mid-November! My GP, more concerned than I was at the time (I thought I had throat polyps), suggested I look outside Wellington. A Nelson ENT specialist looked at me and promptly referred me to Wellington Public Hospital which treated me as ‘urgent’. The main surgery was done in mid-September.

That was two months before I could possibly have seen the Wellington ENT specialist privately. Given what I now know about my condition, I think it is reasonable to assume that had I got to him, I would have been handled just as expeditiously but the treatment would have been two months later. In that time the aggressive tumour may have gone metastatic and would certainly have been more extensive in the larynx. I probably would have had to have reconstructive surgery of my voice box, possibly chemotherapy and ... Well, let’s not think about the awful possibilities; I was lucky. This economist notes that earlier detection substantially reduced my cost to the health system.

So, the lesson here is that we must give greater effort to early detection (as well as prevention); Kiri Allan would agree. It requires greater alertness by individuals and more resources for earlier investigation in the public health system. Perhaps we need a system of defined maximum waiting times with a requirement that the DHB refers the patient to the private sector if they have to wait longer. Since the DHB would pay, it would require more government funding.

So there are things that can be done other than redisorganising the health system yet again. Ministers of Health, please take note.

Reflecting on the year, may I thank the myriad of health professionals I have dealt with – they have been so competent and so caring. I am sure you would also want me to thank them on your behalf and that of your friends and relations.