Public health & Covid: The old is suddenly new again
27 July 2021
ADELAIDE - In 1979, my first job in the public health system was as a senior administrative officer in South Australia’s public and environmental health service.
In those days public health was seen as a backwater in the overall health system.
People who worked in public health were seen as second tier types whose contribution to the community’s health was much less important than that of people working at the ‘sharp end’ of the system - which meant in hospitals.
Public health’s major interests were often disparagingly described as being ‘disease, dunnies and drains’ but, in fact, its interests and expertise extend well beyond the alliterative.
I soon learned this when I was assigned to the time-consuming and demanding job of preparing responses to ministerial and parliamentary inquiries.
This necessarily involved close collaboration with public health experts whose knowledge was needed to collect and organise the information required to prepare complete and correct responses.
Coming from a non-health background, my job became a huge learning experience and I soon began to acquire knowledge from the expansive and multifaceted catalogue that is human health.
I learned about such matters as food and drug standards, public dentistry, radiation protection systems, effluent drainage schemes, communicable disease control and also, at the time, an obscure branch of medical and health statistical analysis called epidemiology.
All this I found to be thoroughly fascinating.
I learned that the writing of food standards was the subject of intense political lobbying by those in the industry: sometimes to resist what they saw as unwarranted restraints upon their ability to make money, and sometimes in an effort to exclude other companies from a lucrative market.
Similarly, I learned that the pharmaceutical industry was a powerful lobby group that was always manoeuvring to entrench its products in the largest possible market whether they were needed or not.
These efforts could take the form of minimising the safety issues associated with their products. Or maximising the supposed effectiveness and benefits they possessed.
To this day, determined and relentless lobbying of politicians and doctors by the makers of medicines remains an integral part of the industry’s approach to making money.
When the AIDS epidemic struck in the 1980s, I found myself catapulted into the world of gay men and women I had known little about. I learned much about them and their lifestyles, as well as how an insidious and deadly communicable disease could spread rapidly.
AIDS could spread in a limited number of ways, such as unprotected sexual activity or intravenous drug use. Once this was understood, effective preventive measures could be put in place quickly. And there had to be prevention at this time, because there was no cure.
Australian public health workers became recognised internationally for their expertise and successes in this area.
Over time, the medical science and pharmaceutical industries succeeded in developing drug treatments that could turn AIDS from what had been an acute and invariably lethal disease into a manageable chronic illness.
In the world’s present formidable public health challenge, Covid-10, this has not yet occurred and no universally effective treatment exists.
By the time I left public health, I had developed a great deal of respect for the people who worked within it.
In particular, I understood that the risks of a pandemic of lethal communicable diseases were very much higher than most people imagined.
I knew what this might entail because I had seen first-hand the impact of the Hong Kong influenza epidemic in Papua New Guinea.
So had several of the public health doctors I worked with in South Australia, many of whom had worked in PNG and involved in the efforts to protect Papua New Guineans against the ravages of what was then a novel and especially virulent form of influenza.
I had also seen the impact of even very basic public health measures - such as a clean water supply and safe and effective human waste management - on both illness and death in PNG, both of which improved dramatically in the colonial era.
After Papua New Guinea, the balance of my working life was mostly spent in the hospital system.
In all that time, I never fell into the intellectual trap of assuming that our excellent acute health care system was more important than basic public health measures.
Now, in the current pandemic, it is clear that in public health what was old has become new again.
Those basic public health measures that we have long taken for granted have become front of mind issues.
Communicable disease control, and one of its principal tools of trade, vaccination, has abruptly emerged from relative obscurity to become the single most important health related activity in the world.
And the even more obscure academic discipline of epidemiology has revealed just why it is so important for us to both understand the true nature of a disease threat and what must be done to manage it.
It turns out that basic public health measures that were well understood by the mid-19th century - including personal hygiene, sanitation, social distancing, quarantine and mass vaccination - are the essential requirements for tackling Covid-19.
None of this should be a surprise because these measures were amongst the first and most important public health strategies ever devised. They have proved their effectiveness time and time again.
What strikes me as particularly sad is just how difficult it has been for governments and communities to implement these measures globally.
For reasons that largely escape me, far too many people seem unable to grasp the necessity to temporarily sacrifice their personal freedoms for the sake of the greater good.
As a direct consequence, this pandemic will be much longer, much more deadly and much more costly than it should have been.
These problems of hesitation, reluctance, suspicion and denial have been compounded by a toxic combination of corrupt and incompetent governments and ideological, religious or crazy zealots whose bizarre world views are causing untold harm.
Sadly, PNG seems to have succumbed to all these influences. And Australia is not doing so well either.
The PNG government has proved incapable of conducting the large scale vaccination campaign the country desperately needs. The Australian government is now desperately trying to clamber out of the mess that is its own vaccination program.
In both countries, mixed messaging from governments and the misinformation and sheer nonsense spread through social media has resulted in too much vaccine hesitancy in the population.
Through generally capable public health management, the pandemic in Australia has been well controlled. But PNG did not have the benefit of an efficient and well-resourced public health system.
The true scale of the disaster unfolding in PNG is unknown because the system required to collect relevant information does not exist.
In a health system barely worthy of the name, there has long been no incentive for the government to collect health data. Its existence would serve only to underscore the government’s ineptitude.
The contrast between PNG and other Pacific islands countries is quite striking.
The people of Solomons, Tonga, Samoa and Nauru have had few cases and no deaths, having so far escaped unscathed because their governments were able to isolate them from the outside world. Vanuatu has had only four cases but sadly one death, for a similar reason.
A rapid and comprehensive vaccination program in each of these countries should see them remain safe and easily able to reopen to the wider world when the pandemic subsides.
But in the two largest countries in the region, Fiji and PNG, the situation is far from glowing.
Fiji (with 14% of its population vaccinated) is presently going through a rough patch. Overall, it has recorded 25 cases and 0.2 deaths per thousand people.
The Delta variant is rampant in Fiji and the government has ordered and enforced a large-scale lockdown of about 70% of the population in an effort to prevent its further spread.
PNG (with 0.04% of its population vaccinated) is much worse off. Overall it has reported 25 cases per thousand people (the same as Fiji) and 0.5 deaths.
You can see the difference vaccination makes. In Fiji, vaccination is mandatory and the evidence is that it is saving many lives.
In Papua New Guinea, the government’s efforts look very inadequate in comparison with its Pacific neighbours.
The lesson from this is that the time-tested principles of basic public health devised more than a century ago still apply. It is a question of implementing them effectively.
Truly, what was old is new again.
I can recall encountering an outbreak of cholera in Lae in 2009. My immediate response was to approach MSF (Doctors Without Borders) who promptly allocated a team of nurses and medical assistants to our factory.
They were consummate professionals and visited our site regularly and conducted public health awareness sessions across each shift and helped me establish hygiene protocols to contain the outbreak.
Go big and go early.
Posted by: Bernard Corden | 27 July 2021 at 11:47 AM
The Covid situation in Papua New Guinea is curious because the pre-independence grass roots health system using aid post orderlies and their patrols and clinics emphasised basic public health principles.
The patrols by aid post orderlies did two things, treat sick people and conduct information sessions on health.
The system wasn't perfect but it worked and was seen to work. By 1975 the health system had become a national institution. People relied on it and its existence had become ingrained in the public psyche.
Why this relatively cheap but highly effective system was abandoned after independence is a mystery.
Then again other sorts of effective systems in other fields of public administration were also abandoned.
The aid post orderly system was based at the outstation and village level and controlled from there. Central government provided training and drugs but the system was effectively run from the grass roots.
Maybe that's where the problem lies. Centralisation of health services like many other services have taken the initiative away from the grass roots and destroyed their effectiveness in the process.
Posted by: Philip Fitzpatrick | 27 July 2021 at 09:31 AM