When one thinks of medical doctors what usually immediately comes to mind is those doctors who treat and diagnose
patients.
This is hardly surprisingly given that this is what the large majority of doctors do, primarily in general practices and
hospitals.
However, not all doctors use their medical training for providing personal healthcare. Others are involved in the health
of populations. They are known as public health doctors and include epidemiologists.
Due to immediacy of demand and high visibility, public awareness of personal healthcare doctors is far greater than
public health doctors. The potential outcomes of the latter are inevitably longer-term and largely invisible.Addressing social determinants through strong public health measures
However, there is no doubt that if given sufficient priority public health measures will have a far bigger impact on the
health and wellbeing of New Zealanders.
Social determinants of health biggest driver of health demand and costs
This is because the biggest drivers of health demand are external to the health system. They are known as the social
determinants of health.
These include income levels and protection, housing, education opportunities, environmental, basic amenities, and
healthcare access.
At last month’s Women in Medicine gathering in Wellington, an astute observation from a frustrated ear, nose and throat
surgeon was reported.
To paraphrase, what is the point of doing hundreds of successful ear procedures on children if they then return home to
poor housing.
If New Zealand had not adopted the firm public health measures that it had in response to the arrival of the Covid-19
pandemic in early 2020 and prior to the availability of vaccines the following year, thousands of lives would have been
lost.
Instead, because of these measures, New Zealand’s response was world-leading. Population health, not personal health
treatment, was responsible for this extraordinary achievement.
Disappointedly, the new National-led coalition government is trying to wipe this experience from historical memory.
To be effective public health requires long-term investment in areas such as child poverty and housing.
It presently suffers because this investment is seen as costs first, benefits later; a guarantee of short-termism
decision-making.Government’s budget failure
Given the above-mentioned pandemic experience, one would have hoped that the new government would have given high
priority to public health in its budget for the 2024-25 year announced last month.
Sadly this was not the case. This is discussed in a timely analysis by economist and commentator Shamubeel Eaqub in the
Otago University published Public Health Briefing (31 May): Budget neglects public health.
The Council of Trade Unions have published its own analysis of the whole Budget in its May Economic Bulletin: Analysis of 2024 Budget. It includes coverage on healthcare spending which is briefer than Eaqub’s deeper analysis but not inconsistent with
it.
In the context of an economic recession, Eaqub observes that the Budget provides for decreasing tax revenue while
consequentially increasing some costs such as unemployment benefits.
A high income earner will receive an income tax cut of around 2% compared with around 0.5% for a poor household. This
inequity is not a recipe for improving the health of New Zealanders.
He gives the example of cardiovascular disease (CDV). If a single case of CVD could be avoided, according to Treasury,
this would save $10,435 a year.
Eaqub continues:
Assuming a person lives with cardiovascular disease for 36 years2, the net present value of avoiding the disease is just
over $173,000 today. That is, we would be indifferent between spending $173,000 today on a range of measures (which
might include income support, nutrition, and housing) against the cost of that person living with CVD in the future.
However, a budget based on less revenue and less spending means two things for public health:Less money for clearly identified health programmes.Less money for the wider social determinants of health, especially for the poor and those at the margins of society.
In other words, funding to just keep the health system going is unlikely to match increased demand for healthcare, let
alone invest in public health in order to reduce this same demand.
But it isn’t just health funding. Eaqub also identifies education, welfare, housing, environmental protection, and law
and order.
In his words, “Budget 2024 plans to spend less on each of these areas over the next three years.”
Consequentially the ‘funding envelope’ for the prevention and protection that public health investment can provide will
get much smaller rather than, as it should do, get much bigger. If this isn’t an alarm bell on its own, I don’t know
what is.
Eaqub recognises that the Budget makes the job of public health professionals harder because:
…the many threads the sector works across will be in retreat, many public health services will patch protect, and we
will see less collaboration. We know that public health is the right thing to do, but it is hard to do.Advice from a thoughtful economist
The thoughtful economist has two bits of advice for public health professionals in this negative environment, which he
readily acknowledges will feel inadequate.
First, continue to deliver “excellent public health programmes” but prioritise them within the limited funding
available. Second, increase public understanding of the value of avoided costs.
Shamubeel Eaqub is not an ordinary economist. He sees economics in a wider context of social wellbeing and social
justice. This insightfulness allows him to make the following concluding observation:
Public health is fundamentally about prioritising community and future generations above the individual today. Public
health is dealing with a wider malaise in society, that of declining social cohesion. Budget 2024 is merely an
expression of that. Our task remains important and valuable, but it just got harder.
He is right to suggest that his two above-mentioned bits of advice to public health professionals are inadequate. That
does not make them wrong.
But they do highlight the wider more critical problem – the failure of short-term focussed political leadership.Time to “learn” the government
I recall a story about New Zealand’s longest serving prime minister Richard Seddon (over 13 years from 1893 to 1906). He
was also the minister of education.
The head of the education department raised with Seddon a sensitive problem concerning the latter’s nephew who he had
arranged to be employed by the department.
What’s the problem asked Seddon. To paraphrase, “He’s illiterate” responded the departmental head. Well “learn him then”
instructed Seddon.
As well as being fiscally irresponsible, neglecting the importance of investing in public health places the health of
New Zealanders in peril.
As an experienced and respected general practitioner health Minister Shane Reti knows this well.
It is a huge challenge given the internal power dynamics of this coalition government. But Dr Reti needs to “learn” his
government about this increasing peril facing the health of New Zealanders.