I have been teaching and researching health economics for over half a century, mainly in population-based health. (I am an Honorary Fellow in the Department of Public Health at the Wellington School of Medicine of Otago University.) It is the Cinderella of the health specialities because, as a rule, it deals with long-term issues. They can really matter. The biggest gain in the fight against cancer has been the steady elimination of smoking, although that gets forgotten when you turn up with a cancer tumour.
The public health profession has been thrilled with the progress made by new Minister Ayesha Verrall, including progressing the smoke-free campaign, fluoridating of water, mandating the folate fortification of bread, upgrading the breast cancer screening program and introducing a new cervical screening test. Her successes are indicative that what has been lacking in the past is commitment. One hopes her summer reading includes the unimplemented 2010 Law Commission report Alcohol in Our Lives: Curbing the Harm.
Another win for the doctor was advising Minister Kiri Allan to see her doctor. It was a pleasure to hear that Allan’s cervical cancer has been successfully treated and she compounded the win by reminding us all, women and men, to pay more attention to ‘down there’.
It is disappointing that we do not mention more the HPV (Human Papillomavirus Vaccine) immunisation program. Certain common cancers, including cervical cancer, are the result of a virus that is sexually transmitted (they are STDs). HPV immunisation has been free for everyone, male and female, aged 9 to 26, since 2017. Coverage seems to be about two-thirds of recent relevant birth cohorts – certainly not 90 percent.
The big public health win in the last two years has been the campaign against the Covid virus. Compared with most other countries we have done bloody well. It has been partly our isolation, partly political leadership, partly a surprising degree of science literacy in the population (the anti-vaxxers are a small minority) but also that the public health profession, which includes Director General Ashley Bloomfield, have been just brilliant. Given the way that the previous government had run down the public services (it had higher priorities but not far away lurk commercial interests which profit from poor health practices), the university practitioners have stepped up to the mark.
The Covid War is not over and, to be brutally frank, we may be fighting it for decades to come as the virus mutates – a more malignant version of what we face with influenza. Albert Camus’ The Plague reminds us that the Black Death (bubonic plague) which arrived in Europe 650 years ago was still around 600 years later. Dr Rod Jackson, an epidemiologist at the University of Auckland, opined, ‘I’m not sure we [i.e. our Covid traffic lights] should ever go green’, was offering a salutary caution.
For me, 2021 was memorable because it involved my first significant brush with the health system in a personal capacity. I had an aggressive tumour of my larynx. It has been surgically removed, I am undergoing back-up radiotherapy, and the prognosis is ‘very good’.
People understandably get obsessed with their health crises. Forgive me for relating mine but it led me to reflect on how our health system works. Here are the lessons I learned or had reinforced.
First, a lot of people grumble about their treatment when their needs are urgent. (I’ll come to the waiting lists shortly.) There are two broad complaints. One is that the doctors did not seem to know what they were doing. Well, they don’t know everything and sometimes what we have is unusual. We should respect them when they say they don’t know. (Twice, my doctors told me my type of cancer in this site was so unusual that there was hardly anything relevant in the medical literature.)
But second, there are problems in the interfaces between the various parts of the health system. It is inevitable in large complex organisations – the same thing happens in the private sector. Obviously, we should try to make the system seamless but glitches will happen. I was lucky because I had a good caring GP; hope you have too.
This health economist wondered whether there were any resource savings to be made in the system. I certainly got a lot of resources. My observations are casual, and the only thing I wondered about was the costs of the generous social support I got (including, by the way, from the Cancer Society which is a reminder of how complicated the entire health system is). However, while I have had wonderful support from my personal network, others are not so fortunate. I get the impression that the support system is preparing me for the last weeks of the radiotherapy which may well be very tough. We don’t want to solve people’s physical conditions and leave them psychological wrecks.
Looking at my experience, I am struck how lucky I was. In mid-July my GP referred me to a Wellington ENT specialist. The public hospital was overloaded, so it was off to the private sector. The earliest I could get was mid-November! My GP, more concerned than I was at the time (I thought I had throat polyps), suggested I look outside Wellington. A Nelson ENT specialist looked at me and promptly referred me to Wellington Public Hospital which treated me as ‘urgent’. The main surgery was done in mid-September.
That was two months before I could possibly have seen the Wellington ENT specialist privately. Given what I now know about my condition, I think it is reasonable to assume that had I got to him, I would have been handled just as expeditiously but the treatment would have been two months later. In that time the aggressive tumour may have gone metastatic and would certainly have been more extensive in the larynx. I probably would have had to have reconstructive surgery of my voice box, possibly chemotherapy and ... Well, let’s not think about the awful possibilities; I was lucky. This economist notes that earlier detection substantially reduced my cost to the health system.
So, the lesson here is that we must give greater effort to early detection (as well as prevention); Kiri Allan would agree. It requires greater alertness by individuals and more resources for earlier investigation in the public health system. Perhaps we need a system of defined maximum waiting times with a requirement that the DHB refers the patient to the private sector if they have to wait longer. Since the DHB would pay, it would require more government funding.
So there are things that can be done other than redisorganising the health system yet again. Ministers of Health, please take note.
Reflecting on the year, may I thank the myriad of health professionals I have dealt with – they have been so competent and so caring. I am sure you would also want me to thank them on your behalf and that of your friends and relations.
Brian Easton, an independent scholar, is an economist, social statistician, public policy analyst and historian. He was the Listener economic columnist from 1978 to 2014. This is a re-post of an article originally published on pundit.co.nz. It is here with permission.
38 Comments
Thanks Brian for a refreshing article that lays out what we have, and why we count our lucky stars, our health system and outstanding leadership.
I also had a pubic proceedure to my ear. Getting in was tricky but once in the care I got was really good. I had to rate the medics 1-10 and gave a 9. I asked my ENT how they get a 10, I really dont know. A poem, a song??
In my own family we,ve had much rejection of western medicine, embracing extreme religion, antivaxx, 5G conspiracy etc etc. Its created a lot of hardship for the individuals who would have done so much better if they had trusted their Doctors.
Interesting to watch the medical profession and professionals with all its knowledge, skills and wisdom seem to be sidelined in the past 2 years in the mass hysteria orchestrated.
It’s near impossible to get to visit your GP face to face for even a regular consultation now.
Thank you Brian.
I’m a medical Specialist in Auckland and it’s been a challenging 24 months.
It’s heartening to hear your great care. It’s such a shame that the nurses have been dealt to so roughly in their collective agreement negotiations. Specialists have been told this week that they are expected to “experience a year of pain” with a pay freeze. Given the runaway inflation that means a 4-5% pay cut in real terms.
So while the M of H are generous with their accolades while we continue to deal with the Covid fallout, behind the scenes the long knives are out.
I’m expecting our advanced trainees to be looking across the ditch as pay and conditions like so many other professions are simply light years ahead - another example of how this Government should be judged on its actions and not it’s words.
There is a disconnect between the media savvy face of the health system provided by the MOH and the realities at the coal face but unfortunately Specialists are mostly restricted on what they can publically say. Highly centralised government seeking further control by abolishing DHBs. Health Minister sidelined and real power is Treasury and Office of PM. Huge unmet needs, understaffing and risks in system. Pay cuts in real terms for doctors - during a pandemic! It’s not just the trainees who will move to aus (they earn twice as much) when their training is complete it is the current specialists too. 28 nurses have resigned from one Auckland emergency department in the past month and there are now routine shortages of staff. Next winter will be the worst with omicron, abolition of dhbs and low staff morale. Good luck seeing a GP then and expect much delayed diagnosis.
https://www.asms.org.nz/news/2021/12/16/hospital-investment-needs-to-be…
What a load of utter bollocks Golfer. The MOH sets policy and the DHBs 'interpret' it as they see fit. The MOH has no control whatsoever over the DHBs who operate however they please and fight amongst themselves. Covid has brutally revealed their gross inefficiencies. In fact they provide an excellent demonstration of how the 1990s Gibb reforms of the health system, which introduced a competitive commercial model to NZ health, have utterly failed. Competition is fine for airfares and toasters, but when it’s contrived for national healthcare, just look at the inefficiencies it rewards. Stacked with layers of useless overpaid mangers and ineffective boards stripping out scarce funds from nurses salaries and operations.
If you imagine that the efficiencies of the market is law, look at today’s price of milk in Sydney when you’re paying significantly more in NZ for almost everything. That situation goes back to the reforms of the 1980s and 1990s as well.
Our health system is far from perfect but could also be a lot worse. I think where possible every kiwi should take some personal responsibility in looking after their own health first and foremost. Obviously issues still occur in healthy people but staying fit and healthy is still a huge mitigating factor. There are some fantastic people working within the health system who really do care and work very very hard. As a border worker I get a covid test every fortnight and the nurses are fantastic. Rain, hail or shine they are there, polite and caring every time. Where would we be without such people.
Written by a left winger !
What about the appalling absence of detail from the damage caused by lockdowns particularly in Auckland, failed businesses, a life time of work down the dunny from trying to save a business, the destruction of relationships, the appalling mental health facilities available, the scaring on a generation of hard working people, the 50% rise in property prices under this Government, come on Ardern patting herself on her back makes me sick !
When I here of a 90 year old with underlying health conditions dying of Covid well really ?
What was the cost of all these deaths, called covid deaths per head ??
Whilst it has been a potential threat the bullshit and scaremongering form Ardern has been extreme !
No wonder I see it referred as Convid ? Yes I've had my jabs complying so far but enough is enough !
I would be surprised if Ardern continues to live in Auckland.
The folate in bread thing I never quite understood.
Who's to say pregnant women eat enough bread? What about all the people eating bread who aren't even pregnant?
Why not educate pregnant women on the importance of folate instead, and provide supplements?
Why are so many of our public health policies "scorched earth" policies, rather than focusing efforts on those most at risk?
Homo sapiens' greatest strength derives from its advanced social abilities. Language, cognition, that sort of thing. A lone human is fairly useless, but as a group, well you only need to look around and see phenomenal achievements across a range of disciplines and technologies.
Having children with severe neurological problems not only impacts the immediate family, but also wider society, as we all share the burden of decades of care, health treatment and lost productivity of both the disabled individual and those tasked with caring for them.
Sounds like you're from another school of thinking about this sort of thing.
You're trying to pretend that there are only two options - the scattergun approach, or nothing at all - so that you can accuse anyone opposed to the former of not caring about neurological problems in children.
I'm not quite sure why anyone would behave like that, other than just wanting to argue for arguments sake.
You'd probably find there's a lot of people who'd find questioning putting folate in bread arguing for arguments' sake.
The previous status quo was as you seemed to infer/prefer; pregnant people manage folate intake themselves.
Another system I guess would be identifying people as they get pregnant, and administering folate to them.
It's likely cheaper and way more effective to put it in the bread.
Many years ago in the UK I met a senior nurse who worked at a hospital ward for seriously ill children. She said she had been criticized by the scientists who had interviewed her about the effects of adding folate to bread because her answer of "it's a miracle" was insufficiently scientific. She said that was the only way of explaining a drop in seriously handicapped babies from over a dozen every year to just one mild case of Spina Bifida.
Chebbo - It IS the most efficient approach, as shown by the RIS (regulatory impact statement), which assesses the costs and benefits of a range of options (ref- https://www.mpi.govt.nz/dmsdocument/3919-Fortification-of-Bread-with-Fo…).
The efficiency of this approach is also why we put iodine in salt (although that was done many decades ago, pre the requirement to prepare and publish a formal RIS), and also put fluoride in water. I understand we also put minerals into animal feed to address deficiencies in our soil eg Cobalt.
Initially you posited "Why not educate pregnant women on the importance of folate instead, and provide supplements?".
The document highlights issues with this approach, namely high percentages of unplanned or unidentified pregnancies, making retrospective administering of folate problematic - women need to take folate leading up to conception as well as after.
So for your approach to be properly effective, you'd want every fertile woman not on long term contraceptives to take folate supplements. You need more data to tell you that's not as efficient as everyone just spending an extra 20 cents or so a year on bread?
The comment I was responding to claimed the RIS shows that fortifying bread with folate is more efficient than other approaches. It doesn't show that.
Now you're making up some ridiculous alternative approach and claiming that's what I must be advocating for instead.
You're obviously not interested in having a proper discussion about this.
I'm not saying folate for all fertile women is what you're advocating, I'm telling you that's what would be needed to make your ad hoc position (i.e why don't pregnant women address this directly) effective. As you say, it's a ridiculous proposition, so that's why there's no in depth efficiency stats for that option compared to the whole country spending a million or so a year extra on bread.
The document shows a range of options, and why they're excluded in favour of fortified bread.
We are now at an impasse where I don't know what extra information you are expecting.
I have never understood why first response ambulance and emergency helicopter services in New Zealand are not fully government funded. For too long successive governments have relied on the likes of St Johns and the various rescue helicopter Trusts for what is an absolutely essential component in our emergency health system whilst providing only part funding for these services.
These days, public hospitals are only found in the major centers, which is fine because acutely ill emergency patients can be quickly transported from more remote locations to these centralised hospitals by helicopter. However, if the government is saving on overheads by operating a lot fewer hospitals then the least they could do is fully fund the only means to get the now more distant patients to those hospitals in an emergency; i.e. by rescue helicopter. However, they seem to have overlooked that this is an essential part of the new age health system or that it should be their responsibility to provide for this access. Perhaps this is just another example of their urban-centric thinking.
It is also a concern and a shame on the government that first responder ambulance services are also not fully integrated into the public health system. Certainly in rural areas the St Johns ambulance crews are all volunteers who get called out from home or work to attend to all the emergency health needs of their community. I know in our rural area St Johns struggles to recruit enough of these volunteers so these few are virtually always on call which is pretty tough.
Surely the government should completely fund New Zealand's emergency first response services if we aspire to have a true public health system.
All you armchair epidemiologists and virologists on here might enjoy the Royal institute christmas lectures this year... (might need a vpn. They start on dec 28th)
To back up the comments by Caughtinthemiddle, I am also a specialist (in a cancer-related field), though not in Auckland.
The situation is dire. My DHB has said we cannot recruit more specialists to make our job plans compliant - we have been told we must decline a larger proportion GP referrals and discharge patients earlier. We are actively rationing certain life-saving cancer therapies due to inadequate resourcing to meet demand.
On a personal basis, we are facing a 5-10% pay cut through tax increases and sub-inflationary pay rises (if any) this year, our secretarial/admin support has been cut, and some of us are losing hospital parking rights. Many of us are quite despondent, and I, for one, am actively making plans to leave NZ clinical medicine in 2022.
Is the rationing due to limited nursing staff running iv infusions?
If you are a medical oncologist, vote with your feet. Go private. Screw the DHB. An acquaintance in Cardiology had a gutsful of the new PC approach at Auck DHB and is now private only. Dont get me started on race based funding for medicines....
Here is a little Covid response madness from the US. Ban unvaccinated health workers because they are a real health risk. Create a shortage of workers, then allow the sick vaccinated workers back to work early to help with the shortage of workers. The reason given, they are all trained in infectious practices and wear full PPE. Logically then, the unvaccinated worker would be just as safe doing the same thing. The Covid response across the world has been nothing but mass hysteria, and destruction of the quality of life for most.
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