A central public health agency is a good idea, but keep it highly focused on planning for and preventing contagious disease like Covid-19, not other health targets, writes Eric Crampton
New Zealand was not caught entirely flat-footed last January when Covid first began making itself known. But we were several steps behind Taiwan, whose Central Epidemic Command Centre was alert to the risk very early. Taiwan’s early response ensured that lockdowns were never needed. The virus was kept under control right from the start.
Last week, the Government proposed a set of reforms to the health system that would include a centralised Public Health Agency. Marc Daalder reported that the agency would be a legacy of the pandemic but it may have a much broader remit. Associate Health Minister Ayesha Verrall suggested that the agency encompass noncommunicable disease, like tobacco-related illness and obesity, and perhaps also include parts of maternity care.
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But pandemic preparedness and contagious disease more generally pose rather different risks than noncommunicable disease. Placing the functions in the same agency risks leaving New Zealand, after Covid has passed, in a situation like the one at the end of 2019. To put it bluntly, the Ministry of Health and public health funding, before Covid seemed to have forgotten about contagious disease while focusing resources on more immediately pressing concerns around non-contagious illnesses.
In 2019, Newsroom’s Eloise Gibson wrote, with some surprise and dismay, that nobody in the health system seemed to know anything about the vaccination status of medical staff in the middle of a measles outbreak. District Health Boards varied considerably in vaccination rates and in knowing staff vaccination status.
And childhood vaccination targets for District Health Boards seem aspirational at best; childhood vaccination rates have been lagging badly.
The problem could not solely be due to a fragmented DHB system. While the Ministry of Health will evade responsibility for operational matters of this sort, it does have some authority over hospitals. When central government views an issue as a priority, it can order DHBs to comply. Under Health Minister Jonathan Coleman, all District Health Boards were ordered to cease on-site soda sales.
A central government that ensured that nobody could buy a Coke at a hospital cafeteria saw no reason to protect patients from unvaccinated staff. They could not even be bothered to gather statistics to know whether it might be a problem. Does central government care more about what is on offer at the hospital cafeteria in Gisborne than that only 78.8 percent of 8-month-olds in Tairāwhiti DHB are vaccinated on time when the target is 95 percent?
The problem was not a fragmented DHB system. Rather the problem was that public health efforts from the Ministry of Health and granting agencies focused on non-communicable disease at the expense of communicable disease.
And it is all too easy to see how that problem emerges.
Governments have a harder time dealing with things that impose longer term risk than with things imposing present costs. Hospitals must deal, all the time, with the costs associated with diabetes, with smoking, and with harmful alcohol use. While smokers pay a lot more in tobacco excise than they cost the government, the health system still bears the burden. And health professionals who deal daily with those suffering the longer-term consequences of poor diet, heavy drinking, and smoking can be powerful advocates for focusing on those problems.
So, it is always tempting, when resources are scarce, to shift focus away from workstreams dealing with longer term risks towards ones dealing with current problems. For a public health system, contagious disease is a bit like sewage network maintenance for a city council. There is always something that is a more pressing concern until suddenly there is not.
That is one reason that a dedicated agency, like Taiwan’s, can provide impressive results. Having only one job means less chance of being diverted into other tasks.
And our Ministry of Health, pre-Covid, was frequently diverted.
During 2019’s measles epidemic, I worried that lack of attention to vaccination in public health research funding could be partially to blame. There will always be communities that are nervous about vaccination. Research into different kinds of public health messaging or different ways of encouraging vaccination could be important.
But there seemed few Health Research Council grants for research in the area. You might see a $5,000 grant examining parental decision-making about childhood vaccines, but $1.2m grants on encouraging smoking cessation among roll-your-own tobacco users. Or $125k grants for research figuring out what might help refugee children catch up in their childhood vaccinations, but $1.2m grants supporting informed e-cigarette use. Reducing the harms of smoking is laudable, but should there not be some focus, somewhere, on contagious disease as well? Smoking is bad but has never resulted in country-wide lockdowns and border closures.
So, I asked the Ministry of Health to provide me with detail on any research it had commissioned or undertaken, or work undertaken by PHOs known to the Ministry, on encouraging vaccination uptake. The Ministry refused to provide me with any list of grants but did note eight pieces of research from 2012 through 2019. Just over one per year, and not all were entirely on topic. Prevention of infectious disease through encouraging vaccination seemed far lower priority than dealing with noncommunicable disease.
The Ministry should perhaps have pointed me to some of the excellent work undertaken at Auckland University’s Immunisation Advisory Centre, some of which is funded by the Ministry of Health. As of August 2019, the most recent grant they had received in excess of $100,000 had been in 2015-16, from MBIE.
It seems almost inevitable that any agency with responsibility for both low-probability, high-consequence events, and more day-to-day concerns will, over time, shift attention from the former to the latter unless it is under very tight mandates. There will always be a more pressing concern of the moment.
If the Government wishes New Zealand to have a durable agency monitoring public health risks and developing strategies around communicable disease, and wants a broader public health remit encompassing noncommunicable disease, it would do well to split its proposed Public Health Agency into two parts.
One agency could focus exclusively on communicable disease. It could monitor vaccination trends, ensure the reinstatement of vaccination programmes in schools, undertake or commission research into vaccine hesitancy and encouraging vaccine uptake, coordinate the continuing public health response to Covid and watch for future pandemic threats. If vaccination rates in one part of the country started lagging, it could be tasked with figuring out why that had happened and what could be done about it.
And a separate agency could deal with research and policy around noncommunicable disease.
Separate budgets, separate mandates, and separate targets would help ensure transparency and accountability. It would be harder for work in noncommunicable disease to come at the expense of pandemic preparedness. And we would be more likely to be ready next time.