The Health of the People begins with the reminder that in 2016 there was a campylobacter infection in Havelock North of unprecedented scale for a developed country. As many as 40 percent of the local residents were struck down, forty-five were admitted to hospital and three died, while an unknown number were left with chronic health problems. It arose from a contamination in the town water supply by sheep faeces.
It is a stark reminder of the importance of population-based health programs contributing to the nation’s wellbeing. When we are sick, we expect to be treated immediately. What we often overlook is that health promotion measures targeted at vulnerable groups of the population can prevent the illnesses.
The spectacular success in recent years has been programs which have reduced and eliminated smoking. Stopping smoking leads to immediate cardiac gains. Stopping wont stop the cancers already triggered and lurking there, but no more will be triggered. Best not to start smoking.
This is not the only example, although we tend to observe the failures and forget the successes. The recent outbreak of measles – there were 2161 hospitalised cases while two unborn second trimester foetuses died as a result of it in New Zealand; 81 died in Samoa – reminds of the importance of mass vaccination.
The enquiry into the Havelock North incident concluded there was a widespread systemic failure among water supplies throughout the country, in part a consequence of ‘a complete failure of leadership and stewardship’ by the Ministry of Health. Safe water supply is such a routine matter that it tends to be overlooked. Was it a consideration of yours when you voted in the local elections? What is required is expert top-down pressure.
The writer of the book, David Skegg, is our most qualified expert to comment on the state of public health. He was Professor of Preventive and Social Medicine at the University of Otago for a quarter of a century, before retiring to become its Vice Chancellor – a successful one, if that is not an oxymoron. In 1993 he chaired the newly established independent Public Health Commission which was disbanded in 1996. (More below.)
In Skegg’s judgement is that it is not just safe water supply which has suffered from inadequate public leadership. He thinks that public health generally has been ‘compromised by a lack of central leadership and commitment’. It is a judgement he made before the measles epidemic; other critics have since made the same point.
To use an old, but increasingly forgotten, wisdom it is better to put fences at the top of the cliffs than ambulances at the bottom. When we fail to build the fences – such as preventive public health programs – we end up with multitudes of ambulances at cliff bottoms, dealing with much unnecessary death, dying and suffering.
The urgency of the demands generated by past failures to provide preventive measures distracts from establishing fences in the future; instead we pour resources into dealing with the failures. To get a better balance requires an independent public health commission, advocating fences, ensuring they are built and maintained.
In fact the argument for long time prioritisation against short term pressures was not the reason for the 1993 Public Health Commission (PHC) established during the attempt to ‘Americanize’ our health system. The redisorganisation’s long-term objective was to privatise as much personal treatment as possible. But even those with neoliberal inclinations could see that population-based health could not fit into their model; the US has one of the worst public health regimes in the rich world. So they carved the PHC out.
The PHC did not last long. Its demise three years later, set out in detail by Skegg, was the result of two brutal forces. The first was that the Ministry of Health objected to not being directly responsible for population-based health. Presumably, the ministry advised the politicians it could do better; they may have had some doubts after the Havelock North and measles failures (among others).
But, second, there were private lobbies which objected to such a powerful agency as the PHC. For example, a PHC could not avoid advocating reducing smoking but that compromised the profitability of the tobacco industry.
The book describes the political story of the death of the PHC. It is unusual to be so explicit. Bismarck famously remarked one did not want to know how sausages or public policies were made. Academics and the public in general have taken this guidance, so there is surprisingly little written about the sausage-making of public policy. We rarely do a post-policy change evaluation, perhaps because we are fearful of finding that the policy change did not meet all the politicians’ (often widely exaggerated) promises.
One consequence is that when something goes wrong, the public wanting to remedy the failure is naive about what has happened and what can be done. It is a bit like complaining about your car not working, without any knowledge of how cars really work. So you ask the driver – the politician – to fix things up, without any awareness that, no matter how good her or his intentions, the problem is deep inside the engine. Which is how the bureaucrats seem to like it.
So even if you are not interested in population-based health – you don’t care about the water that comes from your tap – you might well read the book for its account of the sausage-making bureaucracy and politicians.
I wish there were more examples. One source is the reports of inquiries following failures, but typically the terms of reference are drawn up to minimise the possibility of the enquiry putting the failure in a wider context. We have to rely on the handful of David Skeggs.