Former Federal Health Minister Nicola Roxon will join a panel of experts discussing ‘where next for prevention’, at a webinar this week hosted by VicHealth as part of its Life and Health ReImagined initiative.
Marie McInerney writes:
Health experts are warning that we cannot expect or imagine a “post-COVID19 world” as the pandemic continues to threaten a “global regression in human health”.
“This pandemic is dismantling the foundations for protecting and advancing health,” says the Editor-in-Chief of The Lancet, Dr Richard Horton.
In an editorial castigating global leaders for a “lamentable response”, he said the pandemic was threatening the “trinity of [global health] values”: the right to health, health equity and social justice.
It’s a fear shared by many in Australia, watching as the pandemic delivers a disproportionate blow across poorer nations and groups already suffering social, economic and racial injustice, and as leaders like US President Donald Trump subvert health evidence, prioritise economies over health, and threaten the work of the World Health Organization (WHO).
But while the novel coronavirus and associated economic shocks are devastating lives and livelihoods across the globe, many also hope that the effective responses of some governments, including Australia’s, may lead to real action on climate change and chronic disease and be transformational for public health.
“This is a prime example of where prevention is better than cure,” said Rob Moodie, Professor of Public Health at the University of Melbourne and the University of Malawi.
Moodie, who helped spearhead tobacco control in Australia for decades and is a former CEO of VicHealth, said he has never before seen “closer dialogue” between public health officials and decision-makers, and with the public.
“We’ve never had celebrity epidemiologists before,” he told Croakey.
Similar observations were made by former Prime Minister Julia Gillard on ABC TV’s Q&A last night, when she said the pandemic was generating a renewed appreciation for the importance of government and of evidence.
Moodie said the challenge and opportunity now for public health professionals is to “use the benefits” of those new relationships and understandings.
That was important not only for relationships with politicians and bureaucrats, but also with clinicians, some of whom have in the past seen prevention as in competition with treatment instead of “mutually reinforcing and complementary”.
That’s manifested in some clinicians seeing patients in hospital as “proof that prevention doesn’t work”, says Moodie.
“Obviously it does, but it’s not cost free. It costs money and it costs political capital too,” he said of efforts to address major public health initiatives like junk food advertising to children, effective food and alcohol labelling, and taxation reform.
To that end, the Public Health Association of Australia is calling for Australia to set up a central national public health and disease control agency, a “CDC-like agency”, to boost public health spending from the current two percent to five percent of national health spending, and to invest heavily in the public health workforce.
Moodie’s hopes for a major shift towards prevention are echoed in a paper written for a VicHealth webinar this week by Melbourne academics Professors Anna Peeters and Lisa Gibbs.
They argue that transformation might come from the unprecedented responses of governments, workplaces and communities to the pandemic – particularly in their recognition of the “inter-connectedness of social, financial, political, build, natural, human and cultural influences on health and wellbeing”.
Like many others, they have almost marvelled at the way the Australian Government responded in the early days to the threat of the pandemic: “rapidly responsive, cohesive in purpose, collaborative, evidence-based, and representing an understanding of the functional levers and multi-level complex systems of influence and impact”.
“That’s what we’ve been really wanting for obesity prevention for over a decade,” says Peeters, Director of the Institute for Health Transformation at Deakin University.
The challenge is to convince governments and other stakeholders to apply the same focus to other complex health challenges, like climate health, health equity, mental health, chronic disease prevention, family violence and population nutrition, their paper says.
“Building a transilient prevention system will mean taking the learnings from our experiences in 2020, along with the broader learnings from disaster research, and responding to volatility, uncertainty, complexity and ambiguity,” they write.
Former Labor Health Minister Nicola Roxon will join the VicHealth webinar this Thursday which is asking, ‘Where do we go next with prevention?’.
In its early days of planning the final topic, VicHealth intended to pose a more optimistic question: What does the future of prevention look like, in a post-coronavirus world?
No going back
Overnight, WHO Director-General Dr Tedros Adhanom Ghebreyesus warned that “there will be no return to the “old normal” for the foreseeable future”, acknowledging the terrible pain involved, including that an additional 130 million people may face chronic hunger by the end of this year.
The lesson to be learnt is that “there is no post-COVID-19 world”, says Professor Andrew Wilson, Co-Director of the Menzies Centre for Health Policy at the School of Public Health at Sydney University.
Wilson says that, regardless of when or if we manage to control and contain the novel coronavirus, “new viruses or variations on old, and other communicable agents will continue to emerge”, exacerbated by climate change and population growth encroaching into nature.
He says National Cabinet has recognised this with new planning for Australia’s Public Health Capacity and COVID-19, to improve long-term sustainability of the public health workforce.
But he would like the new plan to recognise that, while Australia needs surge capacity to meet threats like the coronavirus, “prevention of non-communicable disease, addressing issues of climate change and sustainability will be the day-to-day prevention work” needed.
“The impact of COVID-19 is substantially higher in communities with high rates of chronic disease and we can make our communities more resilient to such threats by making them healthier,” he says.
Wilson too has been heartened through the pandemic by recognition of “the critical inter-dependency” of public health and clinical care, as well as its lessons that “much of prevention” depends on working with agencies who have responsibilities outside of health.
But he says Victoria’s worrying new outbreaks, which have been concentrated in lower socio-economic areas of Melbourne, and particularly in nine public housing towers which were locked down under police guard, show the big gaps still to be addressed.
The best designed public health systems combine centralised and local capacity, he said.
“You can know about low socio-economic, Indigenous, CALD [culturally and linguistically diverse] and geographic difference but you are a lot more sensitive to it if you are embedded in it,” he said.
Wilson said he couldn’t believe it when he heard one of the Mayors of a Melbourne “hot spot” say she had learnt her area was being locked down from the news.
“This would not happen if you were invested in the community,” he said.
Australia has also much to learn, when it comes to disasters and the pandemic, about the experiences, strengths and resilience of Aboriginal and Torres Strait Islander communities, says Australian National University researcher, PhD candidate and Euahlayi man Bhiamie Williamson.
Williamson says there is still a great deal of anxiety in Aboriginal communities about the coronavirus pandemic, but their knowledge and resilience have shown the way in its early stages, “because we know what introduced diseases can do to our people”.
“Aboriginal health leadership knew early that prevention was the only strategy and they went hard,” he said of the quick and resolute response from Aboriginal community controlled organisations, Land Councils, and local communities that got many Indigenous people back on Country and locked down remote communities.
“They have done an extraordinary job in protecting and safeguarding our communities from COVID-19 so far, and there is a great deal of trust and confidence that they will continue to manage and to go hard at prevention,” he said.
But there is more to learn, he said. Williamson has been researching the impact of the 2019-20 bushfires on Aboriginal people and communities, and reporting how little they are heard across the bushfire planning, preparation, recovery, and response spectrum.
With an estimated one-quarter of the Aboriginal and Torres Strait Islander population of NSW and Victoria living in the bushfire-affected areas, he and fellow researchers wrote in January, as the fires still devastated parts the states:
“How do you support people forever attached to a landscape after an inferno tears through their homelands: decimating native food sources, burning through ancient scarred trees and destroying ancestral and totemic plants and animals?”
Yet, as Williamson recently told the Bushfires Royal Commission, Aboriginal people have been “relegated to an historical footnote” in such investigations in the past, referred to as ‘pre-colonial land managers’, or people who ‘used to have these knowledges’, even as recently as the 2009 Black Saturday bushfires in Victoria.
“It was an extraordinary oversight,” he told Croakey.
“What was missing was engaging with them as contemporary residents, as First Nations people with distinct rights and interests and attachments to the land”.
Williamson has welcomed more interest this year but remains worried the focus might still be too narrow, focused only on Aboriginal fire management or cultural burning.
What inquiries into both bushfires or the pandemic need to recognise and would benefit from, he says, is “the experience of First Nations peoples, their knowledge of the land, how it’s changed over time, and what’s required to live in a world that’s been impacted by disasters and (to which) societies have to change and adapt”.
Professor Lisa Gibbs, who is Director of the Child and Community Wellbeing Program in the Centre for Health Equity at Melbourne University, has also been looking at the pandemic through a bushfire lens, from her long-term work on the Beyond Bushfires program.
Preparing the webinar paper with Peeters, she was not surprised to learn from a yet unpublished VicHealth survey that participants who were still dealing with the impacts of the 2019-20 bushfires were “showing significantly lower levels of wellbeing” during the pandemic than those who had not.
While they represented only eight percent of those in the study, 42 percent of those affected by bushfires reported symptoms indicating psychological distress compared to 20 percent of those not affected by bushfires, she said.
It’s an important reminder that we need to be particularly mindful of the needs for support of those who have experienced multiple disasters this year.
And while this year’s disasters have been “biblical” in scope, they’re likely to happen again, Gibbs said, amid warnings for years from climate change specialists that we will not only see more frequent and more severe disaster events, but “cascading hazard events in rapid succession”.
Research from Black Saturday showed that while the initial mass emergency event is dangerous and often frightening, it’s the ongoing disruptions to come, to income, accommodation, and relationships, for example, that really undermine people’s wellbeing.
“What we know is that, for many people, it’s life changing and there is no going back to what was before, but [the need] to look to where we’re going next,” she said.
Gibbs and Peeters say disaster research shows that many things that make a difference. For example, belonging to a community group contributes to better post-disaster mental health and wellbeing for years, and the benefits extend beyond the group to others in the community.
However, they say, that while there is much people can do as individuals and collectively, systemic changes are also needed for health-promoting changes to succeed.
Peeters shares broad concerns that the pandemic has stopped many people from keeping up with routine prevention practices.
Fewer people are attending cancer screening, as well as primary care, emergency departments and mental health clinics, risking “a spike in chronic disease problems in the years to come”, she says.
She urges services to innovate to address these concerns and also to deliver long-awaited better access for large groups of people already “disenfranchised from these services”, whether because of language, distance, disability, mental health issues or other reasons.
With the pandemic now only really reaching “full speed” in Africa, Rob Moodie has no expectation of returning to his work in Malawi for a couple of years, where he teaches public health leadership skills and health promotion.
He is deeply concerned about the disruption of public health initiatives in developing nations, and that this will be exacerbated by countries like Australia pulling back further on foreign aid.
Now in lockdown in Melbourne, he says we are in this for the long haul with the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2).
The notion of ‘let’s get to the other side on this’ is “diminishing pretty rapidly”, he says.
“It’s such a disruptive virus. It’s almost like the planet is fighting back.”
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