Croakey is closed for summer holidays and will resume publishing in the week of 9 January 2023. In the meantime, we are re-publishing some of our top articles from 2022.
This article was first published on Wednesday, October 12, 2022.
Introduction by Croakey: As the Victorian election campaign is reminding us, politicians generally prefer to be photographed and filmed making announcements about new hospitals than doing anything significant for primary healthcare, prevention or public health.
During a recent week of energetic tweeting for Croakey’s @WePublicHealth account, public health physician Dr Laksmi Govindasamy identified six pressing priorities deserving far more investment and attention during the Victorian election campaign, including the state’s public health workforce.
As well as her reflections from the frontlines of emergency medicine, don’t miss the wide-ranging responses to her query: “I’d love to hear from YOU on your WHY for getting into and staying in a public health career”.
Govindasamy, who lives and works on the unceded lands of the Wurundjeri People of the Kulin Nation in Naarm Melbourne, also shared useful tips for clinicians and others interested in a public health career. Below is a summary from her week at @WePublicHealth.
Laksmi Govindasamy tweets:
As we countdown to the Victorian State Election, I’m going to talk about the big public health priorities I’d like to see more action, investment and energy focussed upon!
Public health priorities aren’t quite capturing attention the way a shiny new hospital announcement does.
1. Prevention
The commitment I’d like to see is to investing five percent of total government health expenditure on preventive health by 2030. Currently, Victoria spends about two percent of the health budget on prevention, with no real growth over time.
We often say it is hard to measure the events that are prevented. But there are so many ways that prevention and public health action can positively impact on the lives of individuals, our families and our communities.
So tell me – which prevention campaigns mean most to you?
I’ll start, though as a Public Health Nerd I can’t just choose one! Let’s celebrate the incredible work Australia and Victoria has done on tackling tobacco.
We have been global leaders in tobacco control – from bans on advertising, excises and regulation, to world-first plain packaging laws as outlined in this report by the Victorian branch of the Public Health Association of Australia, ‘Public Health in Victoria: Ten Successes to Guide a Healthier Future’.
I can’t help myself, I’ll probably end up celebrating a prevention success for each day I’m here at @WePublicHealth. Close to my heart is Australia’s world leading efforts to end cervical cancer. I am so grateful to be among the first generation to be vaccinated against HPV.
But, as ever, addressing health inequities is about getting to the causes behind the causes. See this important paper by Professor Lisa Whop and and colleagues on elimination of cervical cancer among Indigenous women.
It says: “The drivers of cervical cancer inequities need to be addressed, including differences in determinants of health, access to care, quality of care, and data monitoring, that are impacted by institutionalised racism and health system structures.”
2. Fund local public health units
The second priority I’d like to see all parties commit to at the Victorian election: a minimum five-year funding for Local Public Health Units (LPHUs) to deliver health promotion, protection and prevention activities.
LPHUs were introduced in Victoria in October 2020 to improve COVID-19 pandemic response capacity. More information on the context for this decision is here but essentially decentralised and locally tailored responses support effective outbreak management.
There are now nine metropolitan and regional LPHUs, which are funded by the Victorian Department of Health and are affiliated with local public hospital services. As of this year they are broadening their remit beyond COVID, but…
The 2022-23 budget did not provide funding commitment for LPHUs beyond 2022-23. Without sustained funding they cannot be expected to expand their remit to include locally tailored prevention efforts and attract and retain public health workforce.
This year in Victoria we’ve seen infectious disease risks from COVID-19, Monkeypox and Japanese Encephalitis. We should invest in LPHUs so they can lead prevention, health promotion and health protection activities that help keep our Communities safe and well.
3. Invest in Public Health Officer training
My third priority is: establish a multidisciplinary Public Health Officer Training Program.
Our public health capacity is only as strong as our workforce. Victoria urgently needs to invest to build back a bigger and stronger public health workforce and a PHO Training Program is an evidence-based way to achieve this.
Full disclosure: I’m an ex-NSW PHO Trainee.
Read this 2021 article, ‘Public health physicians: who are they and why we need more of them – especially in Victoria’.
Finkel’s Review into contact tracing recommends: All states and territories should employ a permanent workforce for tracing and outbreak management, with senior public health leadership, and should have an additional surge workforce trained and at the ready.
The Victorian Parliament’s Inquiry into COVID revealed concerning data about the Victorian Department of Health staffing early in the pandemic. The following quotes are taken from this report:
“At the outset of the pandemic, the contact tracing team employed by DHHS had 57 staff, which was expanded to 230 individuals on 19 March 2020…The contact tracing team had expanded to 1,891 staff in June 2020,118 and at 10 August 2020 was made up of 2,600 individuals.” p34.
“The contact tracing team was composed of public health officers, authorised officers from DHHS, ADF personnel, and ‘a significant number of people from Helloworld, Stellar and a number of health services.’” p.34 cont.
“Helloworld is an Australian-based travel company with 2,000 independent franchised travel agents, and Stellar Asia Pacific is a customer experience management organisation.” p34 cont.
“The Victorian Government currently holds two contracts with Helloworld and Stellar Asia Pacific to provide contact tracing call centre services…valued at $7.62mil and $9.02mil respectively & run from 20July2020-21 January2021. A public tender was not issued for these contracts.”
Now, I didn’t work in the Victorian response at this time and want to be very clear that I am not being critical of public health staff whom I am certain were working incredibly hard despite their limited infrastructure, IT and human resources (please read the report in full!)
But I think all of us will agree that effective contact tracing and outbreak management require a highly skilled workforce. A case interview is complex and requires experienced staff to tease out the relevant information and identify meaningful epidemiological links.
Complex individuals and families may need escalation, sometimes to appropriate medical treatment, other times to social supports so they can better manage isolation at home. This is bread and butter for highly trained and skilled contact tracing workforce.
The Victorian branch of the PHAA estimates that establishing a three-year Victorian PHO Training Program for 10 medical and non-medical trainees per year would cost $7 million p.a. The Helloworld contract cost the same for six months… whereas this [training program would] build up Victoria’s public health workforce.
For more on NSW training, see here. Victoria also has some MAE positions and AFPHM training sites are listed here but not all are annually funded.
4. Increase mental health spending on prevention
My fourth priority is: invest five percent of total government mental health expenditure on prevention by 2030.
There’s been a Royal Commission into Victoria’s mental health system. A key recommendation is for funding to tackle the causes of poor mental health and keep our community mentally healthy.
The Royal Commission estimated that only about one percent of the Victorian mental health budget is spent on the prevention of ill mental health. There are evidenced based ways to invest in population-level prevention and reduce the individual impact of mental illness.
5. Invest in self-determination
My fifth election ask is: support self-determination of Aboriginal Community Controlled Health Organisations or ACCHOs.
The Victorian Aboriginal Community Controlled Health Organisation is the peak representative group for their 32 member ACCOS that provide healthcare and support to over 65,000 Aboriginal and Torres Strait Islander people across Victoria.
Self-determination is fundamental to closing the health equity gap for Aboriginal Victorians and to empower the ACCHO sector to conduct business sustainably. Ongoing funding ensures ACCHOs can self-determine and respond to community priorities and provide culturally safe care.
The lifetime health impact of interventions delivered by ACCHOs is 50 percent greater than mainstream health services. On average, the cost benefit of ACCHOs per dollar spent is $1.19, but in some remote areas there can be up to a four-fold cost benefit.
Beyond the dollars, we have seen how the outcomes of community-led pandemic response by ACCHOs has been monumental during COVID-19.
Here’s a great read from @KristyCrooks and colleagues on how the First Nations Community Health sector’s response to COVID was crucial and informed by experiences from H1N1.
We all need to #VoteForPublicHealth to secure ongoing and sustainable investment and support for the ACCHO Sector! The Community’s health should be in Community’s hands.
6. Sustainability matters
My sixth and final election ask is: a committment to establish a state-based Victorian #Sustainability Health Unit.
WA Health established a Sustainable Development Unit following the invaluable Inquiry into Climate Change and Health.
Victoria should commit to net-zero by 2030 and supercharge efforts for the health system to transition, mitigate and adapt. The current strategy is not ambitious enough. We need to vote for a better one.
On access block
Read the SMH article here.
The first victims are our patients. We know what to do to help but can’t because they’re stuck in the waiting room. The second victims are their family and carers. Trying to advocate for their family and facing the limitations of a broken system.
The third victims are ED clinicians. It is not just a Sisyphean task – that’s ED in good times! We feel powerless and unable to protect our patients. Sometimes the thing that breaks you is the kindness of our patients and their carers when we know we are providing inadequate care.
The fourt victims are the families of ED Healthcare workers. We carry home this moral injury, the anxiety, depression and burnout. We are shells of our former selves and, if we are fortunate, our loved ones help to fill us back up
The fifth victims are our whole community who lose trust in our health system. Who can’t have faith in the safety net of universally accessible Emergency care for when we and our loved ones need it. Who are frightened by the wait room & headlines & defer care until it’s too late.
In a functioning democracy, the sixth victims should be any political party and politician that isn’t wholly committed to improving the health system. We need urgent health system reform We all need to vote for it.
Motivations for a career in public health?
Career tips
My tip for clinicians interested in a public health career: start local!
Do things like: quality improvement projects; review a guideline/policy/protocol; audit or analyse locally produced data; join ethics and other committees. Learn how your department works.
Of course, a Masters of Public Health is a great way to build up academic knowledge but these activities will help you start putting these theoretical skills into practice. Things like: critical appraisal; writing for different audiences; learning health system levers.
And once you start knowing which field of public health interests you most, seek out mentors and guides. Public health people are a friendly bunch!
@PHAA Mentoring Program and the Student and Young Professional Networks @PHAA_SYPPH are great places to start!
I’m a public health physician and also training to be an emergency physician. I’m about two-thirds of the way through the @acemonline FACEM training. Lots of doctors-in-training ask me about what my public health career looks like, so here’s some thoughts on balancing a clinical/PH career.
Firstly, it isn’t for everyone! Lots of public health people are very happy to work solely in non-clinical roles and that’s great too. It’s vital to ensure you meet CPD/skills/rego requirements for both if you wish to pursue both.
Equally, lots of public health physicians and other clinicians wish to continue their clinical work. I really seeing patients and find lots of fulfilment in direct patient encounters. This keeps my cup full for the sometimes slow burn public health policy and advocacy work.
Likewise working on health systemr eform and policy change can be very satisfying, especially on those clinical days when it feels like there are nothing but barriers produced by a broken system. Access block and burnout are wicked problems that need big picture systems thinking.
So what do I do day to day? I work part-time (0.5FTE) as an ED doctor. This is where I get my clinical fix and get to enjoy learning from and working with our amazing multidisciplinary ED Team. For my PH work, this also keeps my finger on the pulse of the hospital system.
I’m a PhD candidate – my research is supported by @acemonline and explores Gender and Leadership Development in Emergency Medicine in Australia and Aotearoa New Zealand. The crossover with health management and gender inequity aligns nicely with public health too.
I’m a @PhaaVic Public Health Cadet. I work with their prevention subcommittee on their #VicVotes2022 Election Campaign: #VoteForPublicHealth. They supported me to attend #PopCongress2022 in Adelaide recently, which was a great chance to reconnect with the latest research!
I try to pay it forward by supervising and supporting trainees and mentees – for @TheRACP ‘s AFPHM program and for @_PHAA_’s mentorship program. This is great for bidirectional learning and exploring new topics and issues in public health.
I have been the Trainee Rep on @acemonline’s #PublicHealth & Disaster Committee, chaired by Dr @heng_foong. It’s a chance to shape ACEM’s advocacy agenda & work with inspiring role models like: @ACEMPresident @JudkinsSimon @drhumki @First_do_noharm @_sofistry.
Wandering this meandering training path takes time and saying yes to chances as they arise, which are often unpaid. This can become unsustainable and finding healthy ways to unwind, rest and& rekindle motivation are key. The system that depends on unpaid labour also needs to change!
I don’t have any “secret tips” for productivity. I’m not “doing it all” and am conscious things are easier as I have no caring duties. I confess: I procrastinate, put off for tomorrow until the deadline looms and am often late, stressed and anxious as I scramble to get it done!
But my public health secret is I try to cultivate a sense of wonder, curiosity and love for the beings, human and others, with whom we share this marvellous planet! We can be critical, without being overly cynical. There’s always more to learn, explore, change and improve!
Follow @LaksmiSg for more public health and ED content, with lots of food and books thrown in for good measure.
See other articles by @WePublicHealth guest tweeters
