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A former Health Minister asks, what can we learn from past public health reform successes (and failures)?

Introduction by Croakey: Former Federal Health Minister Nicola Roxon called for urgent action to address the harms caused by vaping in a keynote presentation to the Population Health Congress yesterday.

She also challenged the public health community to seize opportunities created by the pandemic to push for increased strategic investment in preventative health as well as systems and structural change to promote health across many portfolios, address the social determinants of health, and tackle harmful industries.

“There has never been more appetite for good public health initiatives, and never a better time to engage the community, the media, governments and leaders to take the next clever steps to improve our health for the future,” she said.

“It’s a true chance to shape more equitable health outcomes – improving more peoples’ lives and saving future budgets from burgeoning health costs.”

Her presentation is published below.


Nicola Roxon writes:

What an interesting time to be speaking on public health!

The effects of pandemic still being lived and felt. Our settings/ systems/ support have been under a spotlight and, importantly, the costs of dealing with a public health crisis are fresh in everyone’s minds, and still in flashing lights in budgets across the country

So – in theory – this should be an excellent, fertile moment to think really strategically, and to successfully argue for heavier investment in health promotion and disease prevention. But will it be?

Over the last two years, public health academics have filled the airwaves and comment sections of our newspapers – saturating the media in a way we have not seen since the HIV AIDS, more than 30 years ago.

We waited breathlessly for the release of daily COVID figures, learnt what an epidemiologist was (and how to pronounce it) and fretted over ways to protect ourselves in the absence of a vaccine. Chief Health Officers became cult-like figures – mostly of admiration, but occasionally also to be parodied – in Victoria, Brett Sutton cushions and bedspreads were selling like hotcakes online!

Opportunities for change

Crises, and their aftermath, can often drive change and reflection. Some of our most successful public health responses have been in response to crises, the HIV epidemic is a great example.  Today I’d like to share a few thoughts about how we can use the COVID-19 pandemic momentum, layer it with what we’ve learned from the past and push for the action that will most improve the health of our communities.

We will need to think about both infectious and non-communicable diseases, we’ll need to more fully engage with the systems and drivers of poor health that reach beyond the health sector itself and we have the chance to change the dialogue with more Australians, linking our ideas more with issues they already relate to.

Over the last few years, the pandemic threw existing fault-lines in our communities into sharp relief. Those already disadvantaged, were worst hit – in terms of exposure though multiple or precarious jobs, those living in crowded housing, those with language barriers or those locked down in communities with less public space for restricted recreation.

There was little talk of heart disease, cancer, growing respiratory disease, poor mental health, although these diseases can also congregate in many of the same communities. These slow, stealth killers have always fought for – and lost – the battle for attention against the voracious demands of hospitals and ambulances, the demands of doctors and specialists, the momentum created by accidents, incidents and global crises.

The AIHW’s recent [Burden of Disease Report] revealed that nearly half of all Australians (47 percent) have common chronic health conditions like diabetes, respiratory disease, cancer or poor mental health. So our focus on the slow moving devastation caused by these chronic diseases is as important as ever.

Learning from the pandemic and strengthening our system to be more ready for future outbreaks is vital, because we know with certainty there will be another outbreak – we just do not know what shape it will take or when it will come.  But – importantly, if we frame our reactions to the pandemic carefully, we can strengthen our public health “muscles” in the broadest sense.  We must seize upon the sense of urgency the pandemic has created and use this momentum while we can – to look at preventative health as a whole.

A perfect example is the commitment by the new Federal gGovernment to develop a national Centre for Disease Control. Done well, this sort of smart national infrastructure has potential to advise, lead or amplify successful public health measures across the country. Its ability to inform and support local networks that are in tune with the needs of communities they serve could have a huge impact – understanding barriers to good health for particular communities can aid in both crisis response and long term care.

Pandemic experience

So this is really the first of three areas I want to focus on today – how can we lean in to the recent pandemic experience to ride the momentum for change?

Our community has been changed in so many ways by the pandemic:

  • there is a renewed sense of collectivism – we are all affected by others’ poor health
  • the recent, lived experience of so many has highlighted the unequal impact of disease, and
  • there is a new awareness, especially in Treasuries around the country, that if we don’t take prevention seriously, and reimagine what is needed to maintain good health, we will inevitably spend more in the long run.

So now is the time to build the public health “infrastructure” of the future, like the CDC I have already mentioned.  Much of the soft infrastructure – improving our health literacy, effective community engagement, communications, screening and health hygiene are just a few examples of the protective platforms that can be mobilised in battling infectious diseases, just as much as NCDs.

It would be terrific for a CDC to harness the expertise of governments, researchers, health promotion bodies, relevant not-for-profits and leading community organisations. We must ensure we build the interface between ‘experts’ and communities.

I cannot emphasise enough the importance of CSIRO’ “Our Future World” Report (released only in July 2022) which specifically calls out “The promotion of health in the face of rising demand, demographic ageing, emerging diseases and unhealthy lifestyles” as one of only a handful of key megatrends all Australians must pay attention to.

This is not a health document, or a science or education or commercial document – but a forecasting tool for the whole country – identifying seven major trends that will affect everything we do in the next 20 years. To see the burden of chronic disease and the social and economic determinants of health up in lights amongst only a handful of key megatrends should be music to the ears of everyone in this room who have too often fought for attention. We need to use these external sources to bolster our arguments for action – as they stretch well beyond the health department or health providers.

The sharp description of this trend makes the CSIRO report compulsory, not just recommended, reading.  If we ever needed a jolt to action, this is it.   (Seeing the latest figures showing a drop in American life expectancy might also focus the mind. Can you imagine how we will feel when we see such data ourselves?)

It’s time to seize the moment and get better at explaining the economic good sense of acting – the common sense of disease prevention saving the country money needs to find its way into budget language.

What we effectively “prevent” needs methodology in order to be counted as a saving to the budget. More work on how good health enables fuller participation in society is especially potent in this time of low unemployment. Perhaps [Treasurer] Jim Chalmers has some of this investment mindset in his thinking when he talks of a “wellbeing budget” for the future?

Climate and system change

Secondly, we should use the community’s current interest (especially the younger generations) in climate change in favour of a step change in our approach to public health – and the community’s engagement in it.

This reflection has a few different points.

The call for Climate Action provides a strong example of the need for both individual action and systems change. The global impact of climate change is now so clear, that the need to act across business, government, communities and individuals is well accepted and understood, even if each measure is not.

A similar across-the-economy, system wide approach was our response to death and injury from car accidents – the solutions have stretched across car safety design, compulsory seat belts, alcohol limits, drink driving campaigns, speed limits, bicycle helmets etc- and continue as we design our roads, bike paths and cities into the future.

We have put decades of energy into our behaviour change messages – from eating your daily serves of vegetables to Life Be in It – that have primarily had an individual focus, a call to action for you.

But if we use the climate change comparison, this is putting all our focus on kerbside recycling, or even household solar – good measures on their own – but not enough without considering our energy distribution or industry consumption. In short, it needs other government and business action to really move the dial.

When these behaviour change campaigns are counteracted by contemporary social media (with its endless fitness and wellbeing marketing) and a relentless diet of fast food and alcohol advertising, we know these messages will increasingly struggle for impact.

Individual behaviour helps, but we’re up against it without system change.

It’s also possible that this focus has taken some pressure off business, government and the community to look broadly at the structural barriers to good health – in food production, agriculture, transport, urban design and so much more and to take responsible action. Perhaps we can learn from the global, multifaceted approach to climate change and tackle the systems changes that are needed to make healthier lives possible.

There is also substantial common ground between climate activism and public health campaigning that can be used as part of any engagement and motivation of a new generation. There are so many good opportunities to kill two birds with one stone here – getting better climate outcomes and better health outcomes.

A simple example might be focussing more on highly processed and heavily packaged foods? Bad for the climate and generally bad for the waistline too. Or query whether young people might be more energised about the packaging and rubbish produced by vapes, than the risk of lung disease and heart failure?

There are echoes of our efforts against big tobacco, when we hear climate change activism focusing on the “big emitters”, but we’ve struggled to galvanise our focus on the big contributors to heart disease and obesity. It is probably a fair criticism to say our food and alcohol labelling has not had the sharp edge to deliver this sort of cut through – although they are doubtless a base to build from.

How can we target some work here, looking for the food equivalent to reducing emissions?  Some other countries are introducing or exploring sugar taxes, or regulating food composition more tightly.  Is there more opportunity here?

Social change campaigns

Thirdly, I’d like to consider whether we can reframe and refresh our long standing knowledge about the social determinants of health, and use the community’s interest in current movements – like #meToo #BlackLivesMatter #UluruStatementFromTheHeart – to re-engage on those issues that can help us lead a healthier life?

These current, social change campaigns all have something in common – they each highlight longstanding, systematic social problems and seek to explain the harm they cause. Whether it is sexism and sexual violence, racism or the brutality of colonialism, each of these campaigns have identified issues that also create structural barriers to good health.

I would argue we are seeing a new readiness from the community to really tackle some core, substantive issues – so we can add a deliberate healthy life lens too.

I’m not sure the language of social determinants of health will necessarily resonate but I am optimistic that the freshness of these movements (despite the long history of the issues) gives public health folk a chance (and a challenge) to step up and engage more meaningfully with the affected groups.

CSIRO describes this megatrends – as the need to “unlock human potential” to its fullest.

We’ve known, pretty much forever, that poverty, racism, isolation and poor housing (to name just a few) have a huge impact on our health. In fact, the majority of our good health or poor health, does not come from the service we have from our doctor or even what we put on our plate. Yet we spend a lot of public health time talking healthcare language, or trying to fix our own habits, and consequently may have been less critical of all the system factors that work against us.

If we think our lifestyle and community are too sedentary, how do we get councils and builders and planners to take the health impact of urban design seriously? We can still run campaigns about being active, but we need to reduce the barriers stopping people making that choice (ie a shortage of parks, bike paths, small shopping centres in walking distances etc etc).

In the same way we now understand that to tackle violence against women, we need to tackle sexism against women. What are the equivalents in other areas? I don’t have the answers how to do this, but I see the potential. (And its why a well set up CDC could be so important for decades to come!)

Sounding the alarm on vaping

And, finally, we must think about how we tackle harmful industries – those that actively reduce public health and well-being. This is really important work – ensuring tobacco stays out of our lives, reducing the harms from alcohol, considering how and where we combat high sugar or highly processed foods. All our interventions and programs can only have so much impact, if harmful industries keep dragging the community in another direction in simple pursuit of their profits.

These particular threats can change overtime. For example, it is well recognised that a shift to eating more vegetables and pulses and less red meat would be good for our health (and for the environment), but are highly processed, and sometimes highly artificially sweetened and flavoured, plant replacements the best way to do this?

In a similar vein, I am really alarmed about vaping in Australia. I know some people see it as a safer alternative to smoking, but this false dichotomy has set up a war of words between smokers and vapers that has obscured the real issue – whether heating and inhaling nicotine and other chemicals and flavours are good for us?

The boom in vape usage is amongst teenagers in Australia who have never smoked, so I simply cannot accept the harm reduction argument. These teenagers are using an untested product, sucked into their lungs at a young age causing untold and unknown damage we may not see for many years. Alarmingly there are also growing examples of immediate and severe health impacts, including death, around the world.

How is this being sold to us as safe? Safer than what? Russian roulette? Kick boxing? Swimming with sharks?

What on earth are we doing here, letting this continue? Every data point shows Australians have growing respiratory problems, growing allergies and growing mental health problems [AIHW] – can anyone really imagine that vaping can help any of these? Common sense tells us they will, in all likelihood, make each of these trends much, much worse.

Then add to this potent mix the fact that the tobacco industry is buying up e-cigarette and vaping businesses and products … and alarm bells should be ringing at high volume. Surely the one thing we have learned over the decades is that the tobacco industry cannot be trusted to tell us what they already know about the risks from consuming their products.

Let’s not leave a ticking bomb for the next generations.

Let’s not be naive about how the industry will behave.

Let’s better protect our young people from being manipulated, and sacrificed to the industry’s avarice and deceit.

There has never been more appetite for good public health initiatives, and never a better time to engage the community, the media, governments and leaders to take the next clever steps to improve our health for the future. It’s a true chance to shape more equitable health outcomes – improving more peoples’ lives and saving future budgets from burgeoning health costs.

Let’s build and buttress the public health infrastructure wisely, so it can be trusted and mobilised and can deal with both infectious and chronic diseases.

Let’s use evidence-based insights and programs that are delivered in partnership and using the wisdom of those closest to local communities and attuned best to their needs.

And let’s look at systems and structural changes (like we are doing in the climate debate) to ensure we have the broadest impact that can be enhanced by individual action, but not entirely dependent on it

And – for heaven’s sake – let’s act with urgency on vaping. We should take Mark Twain’s warning seriously here ‘History may never repeat itself, but it does often rhyme’.

Let’s not wait and see if vaping is safe, let’s use all opportunities stop it wherever we can, until it is proved so.

• Nicola Roxon is chair of HESTA and VicHealth but this speech is published in a personal capacity.


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