The latest edition of the Public Health Bulletin of SA has an interesting report on a roundtable debate about some of the difficulties and dilemmas confronting the prevention agenda.
It’s interesting because the report – rather than massaging the discussions into bland, politically acceptable speak, as so often happens – has retained what sounds like a real sense of the conversation that took place. At the table were Preventative Health Taskforce members Mike Daube and Paul Zimmet, the Uni SA’s Robyn McDermott, Adelaide Uni’s Konrad Jamrozik, and SA Health staff.
They debated, amongst other things, the relative merits of tackling risk factors vs the broader social determinants of health, the drivers of political action, and some of the barriers to their agendas, especially in obesity.
One of the most gob-smacking statements was the prediction that in SA, within ten years, the health department will need 50 per cent of state revenue.
Here are some of the quoteable quotes that leapt out, from their discussions and written papers:
Mike Daube: “Prevention is a pimple on the periphery of health. Less than 2% of health funding goes to public health. Prevention practitioners are an endangered species and will be even more so as Treasury comes harvesting in these hard economic times…Advocates for prevention are few enough. We have active and passive opposition pretty well wherever we look, so we can’t afford the distraction of arguments over philosophies. Prevention is about equity and action on social determinants; it is about educating our colleagues in the health system and elsewhere about paying more than lip service to prevention; it is about opposing anti-health interests; and, of course, it is, and has to be, about acting on risk factors.”
Paul Zimmet argued the need for a global approach to obesity prevention: “One group, you could call them ‘the food Taliban’, are pushing for bans in junk food advertising to kids and they think that this approach will fix up the obesity problem. I think that, while this is important, we need a much more global approach – for instance better urban planning. Poor footpaths, inability for people to exercise, perceived danger for people walking at night and getting mugged – all of these issues need to be taken into consideration in the obesity prevention situation.”
Kevin Buckett (SA Health): “…I still don’t think we know what we need to do to tackle the determinants of health properly. They don’t reside within the health sector’s control….In the past our approach has generally been an advocacy role, and we have wagged our fingers and told those people in other areas – education, urban development and transport, and so on – what they need to do. But health is not the business of these agencies and they don’t necessarily care too much about it. The issue we have to deal with is how we make health the business of those sectors that can really materially influence the determinants.”
Paul Zimmet: “…it would be good to talk about the drivers that will actually activate the preventive agenda. It is interesting to me that the main drive in the obesity area has come from Treasury and not the federal health department. And the driver for this was the perceived negative impact on workforce productivity through premature disability as a result of an obese population.”
Robyn McDermott: “I think it is really significant that the driver for obesity has been Treasury and that the driver for tobacco control was not. We have managed to do really well with tobacco control but we have only just started on the obesity question.”
Kevin Buckett: “I think it is the economic argument that has brought Treasury along. Health budgets and hospital costs afe increasing at a far higher rate than state revenue. In SA, for instance, within ten years, the health department will need 50 per cent of state revenue. This seriously inhibits other areas of govenrment with their own agendas. I think that is a really strong argument. It is in other sectors’ own self-interest to actually do something about prevention where they can, so that the health budget blowouts are reduced or to some extent contained.”
Mike Daube: “..I think it is wrong to say that the push on obesity emanates from Treasury. Treasury is concerned about it because people like Paul and others have been banging on about obesity for a long time. You may not feel you are getting anywhere, but if you keep banging on hard enough and with enough scientific evidence, standing and eminence, change can happen.”
Mike Daube: When you look at why some of these things don’t happen, consider what it is that drives our leaders. When I was running a health department (Mike was previously ceo of WA Health Dept), I can remember a lot of early morning and late-night calls from ministers and premiers about various issues, but I can’t remember a single late-night call because something preventive hadn’t happened.”
Stephen Christley (SA Health): “..I think the political environment as it is at the moment provides great complexities for political leaders, and not a huge number of opportunities.”
Mike Daube: “I’ve been in tobacco control for 35 years. For the first 25 years people said that we had failed, and now we are having an overnight success! An overnight success takes time!”
Michele Herriot (SA Health): “It is interesting to think around legislation in the food industry for instance, which is one of the more complex areas in the obesity agenda. From the evidence base, we would argue that the approach should be to legislate. But it is clear that all governments aren’t ready or willing to make legislative change yet, although SA and Qld have made a little tiny step. So should we be pushing for legislation or should we be trying to give governments some other way of doing things or other things to do?”
Konrad Jamrozik: “We need to be savvy about how far ahead of public opinion you get, because if you are too far ahead you can’t take people with you. It took me a long time to start talking about the end game in tobacco, which is that smoking be an activity engaged in by a minority of adults, consenting and in private. That’s where we are going. Similarly with obesity. Obesity is ecologically unsustainable. Saying that is not victim blaming – obesity is people consuming in excess of their calorie needs.”
Kevin Buckett: “The proposal to ban junk food advertising during children’s viewing time is an important first step, but not the only answer. Further, if we are not careful with the junk food issue, we are in danger of attracting a lot of politicians to ahve a very high-profile fight with a very robust and vehement industry lobby. And once they have fought that battle, they will think that they have done enough in this area, which is of course far from the case. I think it is important to recognise that going for an icon approach, like the junk food advertising ban, can backfire if we are not very careful. This is not to say we don’t do it, but that we are really careful and strategic.”
Robyn McDermott: “…we have a huge amount of the worried well going to GPs consuming fee-for-service money on a totally uncapped budget – unlike public health funding. I think there is a piece of work to be done to look at the cost effectiveness of all these screening activities, and all of the probably well-intentioned Medicare-funded initiatives, which probably are reaching the people that don’t need to be reached and not reaching the ones who do; and whether there is a better use for that money.”
Stephen Leeder’s article in the bulletin: “…politicians tread warily in relation to prevention – doing and spending little on it compared with treatment or repair services that the public is constantly demanding. Why get into supporting prevention which only public health types want and make yourself unpopular when you could be spending the same dollars on acute care services that everyone likes and will remember you for? You can cut a ribbon at the opening of a new lung cancer ward, but not when you reduce passive smoking in pubs!….Public transport that is clean, punctual and safe wins no media marks. Nor does prevention. No preventionist wakes on Christmas morning to discover crates of champagne waiting on his or her doorstep – gifts from grateful people who have not suffered traffic crashes or who have not started smoking as a result of the preventionist’s professional actions. Compare this with the gratitude (and the Christmas champagne) of the patient whose life has been saved by surgery or medical care, or even psychotherapy.”
These are the sort of internal public health discussions that the broader community could benefit from hearing. Hence this post….