Opinion: Whatever happens in this year’s election, the Labour Government can point to some real progress by Minister of Health Ayesha Verrall in improving public health, such as adding folate (folic acid) in flour to prevent neural tube defects, the fluoridation of our water supplies to prevent tooth decay, and the new world-leading legislation for tobacco control.

All these public health policies have been preceded by years of advocacy from health professionals and yet ironically, I’d say perversely, Verrall’s predecessor, Andrew Little, clamped down on the voices of those calling for strong prevention policies when he should have been clamping down on industries creating health harm, such as the tobacco, alcohol and ultra-processed food industries.

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In late-2022, two senior health leaders were admonished by the then Health Minister Andrew Little for supporting an important piece of preventive legislation – Chlöe Swarbrick’s Private Member’s Bill to strengthen Local Alcohol Plans and buy out alcohol sponsorship of sports and events.

Little argued that Dr Gary Jackson, Director of Population Health at Counties Manukau Health, and Rob Campbell, then-chair of Te Whatu Ora’s Board, had overstepped the mark in voicing support for a non-government bill. That sent a palpable chilling effect through the health sector about speaking up for health.

Little also shut down the ability of the new health structures to continue to provide a range of public submissions on government consultations, including select committee processes. This came as a shock to the sector. It closed off a critically important avenue for various parts of the healthcare sector to publicly comment on consultations that involve the underlying determinants of health such as justice, housing, education, tax, and social welfare.

Mechanisms are apparently underway within Te Whatu Ora to collate expert comments across the government-funded health sector into a single, corporate position on matters outside healthcare that affect health.

This is the opposite of what my hopes were for population health under the Pae Ora (Healthy Futures) health structures a year ago. Then we were entering a new phase for health as the Simpson report was implemented on steroids, with its explicit prioritisation of population health and joined-up health structures for improved health equity.

A variety of voices for health used to be heard from within and outside the healthcare system, but the centralised messaging that worked so well during the early phases of Covid now seems to be locked in place.

This one-size-fits all approach risks burying the diversity of evidence, stories and perspectives within a single, centralised position. For example, the impacts of alcohol policies are experienced very differently in emergency departments, mental health services, licensing processes and paediatric wards, and their individual experiences and voices are likely to be diminished.

Health Coalition Aotearoa, which I co-chair, argued strongly for the two new health entities, Health New Zealand (Te Whatu Ora) and the Māori Health Authority (Te Aka Whai Ora), to have a legislative responsibility to address the underlying social determinants of health.

It was pleasing that the Pae Ora Bill was amended to explicitly include these responsibilities. As the Simpson report noted, about 80 percent of our population’s health and health equity status is determined by factors outside the healthcare system, so the healthcare system should be a strong advocate for prevention policies – the ambulances at the bottom of the cliff should be the strong vocal advocate for fences at the top of the cliff.  

We desperately need policies to prevent the huge harm incurred from alcohol and ultra-processed foods, but for decades efforts to develop and enact such policies have been stymied by powerful and well-organised lobbying from these industries seeking to protect their commercial interests. Their voices have long dominated the political power dynamics. This has meant no government policies have been enacted for many years that could reduce the harm those industries do.

The obesity epidemic and appalling dental health in this country have remained untouched by government policies to tax sugary drinks, ban junk food marketing to children, require healthy food provision in schools or even have a useful front-of-pack food labelling system. The voices for public health action have historically been swamped by industry opposition and now this imbalance is even worse.

Health Coalition Aotearoa was established in 2019 to bring the voices of the health sector together for improved health and health equity through reductions in harm from tobacco, alcohol and ultra-processed foods, as well as through strengthening public health infrastructure to better address the commercial causes of ill health.

These three harmful products cause almost a third of our population’s premature death, disease and disability. Many evidence-based policies recommended by the World Health Organisation, and New Zealand’s own experts and government reports, could be enacted to reduce the damage these products do. Yet they haven’t been.

The loss of advocacy voices or activities from within the new health structures makes it less likely they will be enacted, and runs counter to the promises of joined-up action for improved population health and health equity under the new Pae Ora health system.

The commercial lobbyists for products that make people sick, or kill them, not only get direct, non-transparent access to ministers because of New Zealand’s lack of lobby regulations and monitoring, but they now face a diminished homogenised public health voice of opposition.

This is an edited version of a commentary that originally appeared in the New Zealand Medical Journal, August 4, 2023.

Boyd Swinburn is Professor of Population Nutrition and Global Health at the University of Auckland's Faculty of Medicine and Health Services

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