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

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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.

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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.

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