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2008 vol. 32 no. 6 AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH 505© 2008 The Authors. Journal Compilation © 2008 Public Health Association of Australia
doi: 10.1111/j.1753-6405.2008.00299.x
Public health – moving forwardMike Daube
Professor of Health Policy, Curtin University of Technology Deputy Chair, Preventative Health Task Force
The French military hero Marshall Foch is credited with saying,
“my centre is giving way, my right is in retreat. Situation excellent.
I shall attack”.1 Public health in 2009 may need a similarly
confident approach.
Now, as in previous years, public health, generously defined,
attracts some 2% of Australia’s national health expenditure.2 This
figure was rightly described by Prime Minister Kevin Rudd at the
2020 Summit as “crazy”,3 and the new Government’s commitment
to prevention is manifest. But public health retains its Cinderella
status, and public health practitioners must continue to press for
craziness to give way to common sense.
As we move into the second decade of the millennium, public
health faces all the traditional obstacles, with some new challenges
to keep us on our toes.
While there is some recognition of the great health gains that
have come from prevention, ours is the least glamorous aspect
of the health system, and generally only becomes a priority for
Governments when there is intense public pressure or when things
go wrong in the public arena and a scapegoat is needed.4
It remains as true as it was in 1973 that most health professionals
“pay lip service to prevention but few of them do anything about
it”.5
Australia has some outstanding health and medical reporters,
but the front pages and headlines that motivate politicians are
much more likely to be about patients who have waited too long
in emergency departments or for elective surgery than measures
that will improve the health of the community.
If organisational seniority is a measure of importance, public
health fares poorly across Australian and New Zealand Health
Departments where senior dedicated public health officers are
rare even at the second tier.
There is still some philosophical opposition to public health
approaches, exemplified by the silly but readily quotable ’nanny
state‘ epithet that is often dragged out by commentators in search
of a cliché.6
Public health faces continuing opposition from those whose
motivation is to sell as much as possible of a potentially harmful
product to as many people as possible, whatever their ages.
Reports on Indigenous disadvantage have been regular features
of journals such as this, and even of mainstream media, but we
are still not making the inroads into the life expectancy gap that
have been seen for many years in other countries.7
Many people simply do not like facing up to public health
messages, whether about overarching themes such as equity,
climate change and the social determinants of health, about
individual behaviours such as eating, drinking and smoking, or
about measures that impose constraint, such as speed limits or
licensing hours.
Anything new in public health almost invariably faces calls for
evidence at a level that is rarely required for clinical interventions
or, indeed, other public policy initiatives.
The full implications for prevention from a change in
government in New Zealand are not yet clear, but it is worrying
that the National Party election documents appear to make only
token reference to prevention, with no specific commitments and
an approach that focuses almost exclusively on ’individual choice‘,
while disparaging the role of government.8
To complement these and other traditional obstacles, we have
a new set of 21st century challenges.
Climate change is not solely a public health prerogative – but
how can public health and the PHAA not play a role when the
health of our populations, our continent and our planet is at
risk?9
Discussion on the social determinants of health has moved to a
new era with the recent publication of a WHO report10 that seeks
to set out what we can and should do.
The ramifications for public health of the global economic
crisis will take many years to play out. A short-term concern
must be that as money gets tighter, Governments will harvest
funds from any areas that look soft – and to those who are only
interested in today’s waiting lists and tomorrow’s headlines, public
health is soft.
A consequence of increasing public concern about alcohol
problems, obesity (and inappropriate nutrition) and tobacco is
that the industries involved have become much tougher and more
streetsmart in their lobbying, and even more determined to resist
change.
So public health will not be without its challenges in the coming
years.
The Rudd Labour Government was elected with a strong
commitment to prevention. The Prime Minister stated early that,
“Federal Labor’s commitment today to put preventative health
care for our families’ front and centre writes the next chapter of
Labor’s health story”.11
In April 2008 the Health Minister, Nicola Roxon, established
the Preventative Health Taskforce.12
The Taskforce, chaired by Professor Rob Moodie of the Nossal
Institute, is charged with developing a National Preventative
Health Strategy. While the Taskforce has a three-year initial term,
the first report will be published by mid-2009. For this first stage
the Minister has asked the Taskforce to focus on obesity, tobacco
and alcohol.
The Taskforce released an initial Discussion Paper13 and
Technical Reports14-16 in October, setting out the case for action and
some proposed approaches. In the Discussion Paper, the Taskforce
propose the following targets to be achieved by 2020:
• Halt and reverse the rise in overweight and obesity;
• Reduce the prevalence of daily smoking to 9% or less;
• Reduce the prevalence of harmful drinking for all Australians
by 30%; and
Editorial
506 AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH 2008 vol. 32 no. 6© 2008 The Authors. Journal Compilation © 2008 Public Health Association of Australia
• Contribute to the ’Close the Gap‘ target for Indigenous people,
reducing the 17-year life expectancy gap between Indigenous
and non-Indigenous Australians.
Submissions in response to this Discussion Paper can be made
through the Taskforce website (www.preventativehealth.org.au
), and consultations, facilitated by PHAA, are being organised
around the country.
This is a time for all those in public health to make their views
known. What do you think should be done? Who should do it?
How should it be done? Where should the Taskforce focus after
its first report?
It will be important for PHAA and its members to play a
leading role in generating a culture where prevention, remedying
disadvantage and the many specific issues so diligently pursued
by our Branches and SIGs become the first, not late resorts for
governments.
Development of a national preventative health strategy will not
solve all the problems we face, or magically make our old and new
challenges disappear; the first report will not cover all the issues
of concern; and even the best of strategies will require support if
they are to be implemented. But with a Government committed
to supporting prevention and to introducing the strategy, there
could be no better time for the public health community to
contribute, provide comment and ideas, help to construct the
strategy, play a major role in support and implementation, and
point decision-makers to other areas where action is needed. It
is time to attack.
References1. The Encyclopaedia of World War I: a political, social, and military history
[monograph online]: ABC-CLIO; 2005 [cited 2008 Nov 6]. Available from: ABC-CLIO.
2. Australian Institute of Health and Welfare 2008. Public health expenditure in Australia, 2006-07. Health and welfare expenditure series no. 34. Cat. no. HWE 41. Canberra: AIHW.
3. Moore M. Submission from the Public Health Association of Australia to the National Health and Hospitals Reform Commission [homepage on the Internet]. c2008 [updated 2008 Sep 26; cited 2008 Nov 6]. Available from: http://www.nhhrc.org.au/internet/nhhrc/publishing.nsf/Content/429.
4. A public health risk that can no longer be of private concern. The Age [serial online]. 2007 [cited 2008 Nov 6] Apr 23; 10. Available from: Factiva.
5. Fletcher CM. The Rock Carling monograph 1972: communication in medicine. London: Nuffield Provincial Hospitals Trust; 1973.
6. Daube M, Stafford J, Bond L. No need for nanny. Tobacco Control. In press. 7. Ring I. Inequalities in health: the challenge for the 90s: the 1992 Elkington
Oration. Queensland Health department; 1993.8. Ryall T. Better, sooner, more convenient: health discussion paper: The Office of
the Leader of the Opposition, New Zealand; 2007 [cited 12 Nov 2008]. Available from: http://www.national.org.nz/files/__0_0_HEALTH_lowres.pdf.
9. Garnaut R. The Garnaut Climate Change Review: final Report. Melbourne, Australia: Cambridge University Press; 2008.
10. Commission on Social Determinants of Health. Closing the gap in a generation: health equity through action on the social determinants of health. Final Report of the Commission on Social Determinants of Health. Geneva: World Health Organization; 2008.
11. Rudd K, Roxon N. Fresh ideas, future economy: preventative health care for our families and future economy. Canberra: Australian Labor Party; 2007.
12. Roxon N. New health taskforce on prevention - tobacco, alcohol and obesity priorities [press release]. Canberra: Commonwealth of Australia; 2008 Apr 9. Available from: http://www.health.gov.au/internet/ministers/publishing.nsf/Content/mr-yr08-nr-nr046.htm?OpenDocument&yr=2008&mth=4.
13. National Preventative Health Taskforce. Australia: the healthiest country by 2020 A discussion paper. Commonwealth of Australia; 2008.
14. National Preventative Health Taskforce. Technical report No 2. Tobacco in Australia: making smoking history. Commonwealth of Australia; 2008.
15. National Preventative Health Taskforce. Technical Report No 1: Obesity in Australia: a need for urgent action. Commonwealth of Australia; 2008.
16. National Preventative Health Taskforce. Technical Report No 3: Preventing alcohol-related harm in Australia: a window of opportunity. Commonwealth of Australia; 2008.
Editorial