On Newshub Nation: Simon Shepherd interviews public health expert, Sir David Skegg

Simon Shepherd: Welcome back. The measles outbreak shows no signs of slowing. Up to 900 people in Auckland may have been exposed, with 10 cases confirmed. In Canterbury authorities are dealing with 37 confirmed cases. So, how did this happen when two years ago the Ministry of Health declared the disease had been eliminated? Medical researcher Sir David Skegg, author of The Health of the People, says it's another example of a failing public health system.

David Skegg: I think it is really concerning that an outbreak of this scale has occurred in New Zealand. And so I certainly hope the Ministry of Health will learn some lessons from it.

Shouldn’t we already know those lessons? Because measles has been around forever.

Yes, it has. We’ve had some really bad epidemics. Twenty five, 30 years ago, we had two major epidemics with hundreds of people admitted to hospital. At least seven people died; some brain-damaged. So this is a disease that we’ve certainly known about in the past. We’ve been aware that some people are not fully immunised. And I think we have to expect that some cases will be introduced from overseas. But they should not be transmitting here in New Zealand.

Well, that’s right. There’s talk about stopping un-immunised children from going to school. Should that happen?

I think it would be wise if they didn’t go to school in Christchurch, because it does look as if there’s considerable spread occurring.

All right. The disease prevention is a key element of public health, but we’re only hearing now, during this outbreak, that 29 to 50 year olds may not be covered. They received one dose. So why didn’t they know that before we had this kind of outbreak?

I’m aware that some public health specialists have been calling for a public campaign to make people aware of this problem. But it just, I think, points up that we don’t really have a proactive approach to public health problems in New Zealand. The Ministry of Health doesn’t have a critical mass of public health specialists. There used to be an infectious disease advisory committee of independent experts. That was abolished some years ago. And the policy about vaccination has actually been farmed out to Pharmac, who will certainly be experts at procuring this type of thing, but they don’t have a team of public health people.

So, ideally, how should a public health system be coping with this kind of outbreak and those other kinds of diseases you talk about?

Well, I’d like to see the Ministry of Health have much greater expertise and strength in public health. There’s a Director of Public Health there. She does her best. She’s not even part of the leadership team of the Ministry. And we don’t have a separate public health agency, as many other countries have.

You talk about a vacuum in leadership in public health, don’t you?

Yes, well, the campylobacter outbreak in Havelock North really illustrated that. And the report of that outbreak pointed to a serious failure of leadership and stewardship by the Ministry of Health. And they referred to a complete vacuum of leadership.

And in that situation, the irony is that that had happened before from the same water source.

Yes.

How is that possible?

Well, it’s extraordinary. You know, in 2016, we had 5500 people affected by that epidemic. Some are still suffering from arthritis and so on. But there had been another epidemic of campylobacter in Havelock North traced to the same bore heads in 1998, and no effective action was taken.

There was an inquiry after the 2016 outbreak.

Yes.

Has anything changed?

Not so far, sadly. They made a number of recommendations. I understand the cabinet signed up to those and said they’ll be implemented, but things are happening very slowly indeed.

In your book, you talk also about providing colorectal cancer screening and how slack we are in that. Can you tell us about that?

Yes, I mean, I think the people involved in the programme are doing an excellent job according to the resources they’ve been given. But we were just so fatally slow. The United Kingdom and Australia introduced their national programmes in 2006. We’re hoping to have our programme rolled out nationally by the end of 2021. At the moment, about 100 New Zealanders are dying every year unnecessarily, in my view, because they would not have died if we had introduced screening at the same time as the UK.

We’re supposed to be a First World country with a First World health system, so why is that happening?

Well, we do have quite a reasonable health system for personal healthcare — it’s not as good as we’d all like, but it does a reasonable job — but public health has been neglected in this country for a number of years. And unfortunately, public health measures — things like prevention of diseases, protection from hazards like asbestos, promotion of health — they can actually provide greater and most cost-effective improvements in health than just treating people after they get sick.

So it makes economic sense to prevent or put the ambulance at the top of the cliff or the fence at the top of the cliff.

Absolutely. I mean, for example, the Australians have been able to calculate that their bowel-screening programme is going to save billions of dollars in treating people with cancer. So New Zealand made a poor economic decision, as well a heartless one.

Do you believe that the Ministry of Health at the moment is fulfilling its obligations to the New Zealand public?

I think the Ministry does its best according to its resources and its lights, but no. I think that the Ministry of Health is not, at the moment, capable of providing the leadership and expertise that we need in public health. They do a much better job in terms of personal healthcare. They’re almost totally taken up with overseeing personal healthcare, mainly through the district health boards with, you know, tightly regulated funding. But public health just tends to get neglected.

If we don’t have that whole-of-nation approach, it seems crazy when we’re such a small nation.

Absolutely, and we say we’ve got the population of Melbourne, and yet the Ministry actually tends to devolve a lot of the decision-making about public health to the 12 public-health units around the country.

What has prevented us having this kind of approach in the past?

Well, it’s a long-standing problem. We have been complacent about public health in New Zealand for a long time. Sadly, we had a Public Health Commission for a few years in the early 1990s, but it was actually disestablished, and—

You were part of that, weren’t you?

I was, yes. I was the chairman of the board of that commission. And it’s no pleasure to me to say that what we predicted would happen when it was disestablished has just happened. Public health has been run down to a dangerous degree since that time.

Okay, what were the problems that you encountered when you were chairing that? You were an independent body trying to provide advice. What happened when you provided that advice?

We encountered a number of problems. I mean, one, we had quite a lot of bureaucratic rivalry from the Ministry of Health, who weren’t that thrilled that we’d been set up. But we also had a lot of lobbying by the alcohol industry, the tobacco industry, parts of the food industry, and unfortunately, they were very effective in having the PHC nobbled.

Is that why we don’t have things like a sugar tax right now?

Yes, I think it is. I think the industries that produce products that may be damaging to health, naturally, want to sell their products, and they’ve got a legitimate right to do that. But there’s no public-health voice actually opposing them. There’s always going to be a contest between those who want to promote health and the commercial interests that are selling stuff that damages health.

Do you think the New Zealand public would be surprised to learn of this kind of covert lobbying?

I would hope not, because they actually see it, for example, when local authorities want to introduce liquor controls. Out come the breweries, the wine companies and the supermarkets; they’ve got tremendous clout in this country.

So in your view, what is the fix?

I think the Ministry of Health itself needs to be strengthened in public health, and I also think we need a separate public-health agency, as we had in New Zealand in the early ‘90s, as Canada has, as Norway, Sweden, England, Wales, Northern Ireland, Scotland. They’ve all set up separate agencies that can provide a real focus for public health and make sure that that voice doesn’t get lost.

Okay. David Skegg, thank you very much for your time.

Thank you.

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