PHA NEWS ONLINE – 13 November 2009

Vol XII, No 3

PHA President Richard Egan presents Cheryl Brunton with the Public Health Champion 2009 Award

Public Health Champion 2009 – Cheryl Brunton

A bullet in her letterbox is one of the more unusual features in the life of Medical Officer of Health, Dr Cheryl Brunton, Public Health Champion for 2009.

Paying tribute to Dr Brunton, PHA President Richard Egan said that despite quite personal attacks she remained a courageous advocate of gun control on both a local and national level.

"She used a similar determination to bring national awareness to the issue of hepatitis C, and it has driven her work over the last 20 years, with injecting drug users and the needle exchange programme. This is a public health practitioner who takes on unpopular issues and never gives up doing everything she can to improve the health of those affected by them," he told delegates to the recent Public Health Association Conference.

Dr Brunton received the Public Health Champion award after several months of frantic activity. As Medical Officer of Health for the West Coast and Canterbury, she's had to cope with the demands made by the triple threats of swine flu, whooping cough and measles.

"Public health services have been stretched responding to these epidemics but good planning, dedicated staff and leadership by people like Dr Brunton have contributed to an effective response," Richard Egan said.

Dr Brunton is also a senior lecturer in public health at the University of Otago in Christchurch and, says Richard Egan, many students are indebted to her inspiring, expert guidance and encouragement,  particularly those in the Master of Public Health programme to whom she was a mentor.

"This is a public health practitioner who takes on unpopular issues and never gives up doing everything she can to improve the health of those affected by them."

Dr Brunton's work with hepatitis C began when she investigated an outbreak at Christchurch Prison in 1991. This led to an ongoing interest in hepatitis C research and advocacy. She helped establish the Auckland and Christchurch hepatitis C support groups, was instrumental in founding the Christchurch Hepatitis C Resource Centre and was the inaugural chair of its trust board. She also took part in the development of the first national Hepatitis C Action Plan.

She helped establish the Hepatitis C Community Clinic in Christchurch, and remains part of its advisory group. She continues to arrange conferences, workshops and training on hepatitis C.

"Stemming from her work in hepatitis C, Cheryl has also worked with injecting drug user groups and the needle exchange programme for almost 20 years. She helps to conduct national needle exchange serosurveys and has led and encouraged research into blood-borne viruses among injecting drug users. She's advocated for needle exchange as a public health measure and worked to counter the stigma and discrimination towards hepatitis C, injecting drug use and needle exchange," Richard Egan said.

Dr Brunton's other recent research interests have included the impact of the reform of prostitution law, influenza in travellers, a survey of vaccine-preventable disease and a hand sanitiser study.

As if all this did not make her busy enough, she's also been an active member of the Public Health Association's Canterbury branch since it began.

Conference 2009 reflections

Richard Egan, Co-convenor, (President, PHA NZ)
Charlotte Paul, Co-convenor

The organisers were very pleased with the PHA Conference, held in Dunedin in early September. We had planned keynote presentations and workshops to encourage new thinking about research and values in public health and their relation to practice. This happened, with plenty of lively discussion.

The conference received particularly good media coverage this year. A number of journalists attended and we had a bumper crop of stories and interviews as a result.

The "trickle-through" effect has been noticeable with specialist websites and mainstream media picking up the stories and running them again with their own angle some days after the conference. I would like to thank the organising committee and Liz Price's media team for their hard work in achieving this very satisfactory result.

Again we want to thank everyone who attended and all those who presented papers or were involved in a workshop or the panel discussion. It was not easy to present on behalf of the Ministerial Review Group or the Ministry of Health and we thank those speakers especially.

"The Public Health Association: the most important association for supporting public health research, policy, and practice in New Zealand."

We hope people left the conference with new ways of thinking about public health, including international dimensions. They should also have come away with a sense of resistance and defiance to keep the spirit of public health alive at this difficult time. We need to engage more widely with the public rather than retreat. One important idea for reinvigorating public health that came out of the conference was developing our values to reframe the debate.

Two specific next steps are: to finalise the code of ethics for public health – which is to go to the Māori caucus next; and to look toward the development of a new structure for public health in New Zealand. This might be a Public Health Commission.

In the meantime we need to support the development of the Prior Centre for Public Health and Policy. Most of all we need to build on the present strengths of the Public Health Association: the most important association for supporting public health research, policy, and practice in New Zealand.

Conference 2009 reflections

Dr Imogen Thompson, Public Health Registrar, University of Otago
PHA Wellington scholarship recipient

Thanks to a scholarship from the Wellington branch, I was able to attend the PHA Conference 2009 in Dunedin. As a public health trainee based at the University of Otago, Wellington, I was grateful for the chance to broaden my understanding of public health in both a national and international context.

It was a privilege to meet and listen to public health experts whose names I had previously only seen published. I was particularly glad to meet the Christchurch-based teacher of one of my academic papers, and hear her speak with passion and insight on her subject (and provide handy tips for the current assignment). She was so motivating I wanted to go and do more research at once! So it was especially pleasing to applaud her as Public Health Champion for 2009. Congratulations to Dr Cheryl Brunton for her outstanding work and commitment to public health over the years.

The conference had an important international flavour, with keynote speakers sharing their insight on significant global public health concerns. Professor Stephen Kunitz discussed the importance of the historical and cultural context and the roles of federal and state governments in determining health outcomes for ethnic minorities, in particular Native Americans and Afro-Americans.

Dr Michael Selgelid explained the importance of global justice and ethics in tackling the massive international burden of infectious diseases.

"The conference strengthened what it means to be within the public health community – committed to the common good, part of a team, pursuing health and justice for our people."

Professor Wendy Rogers from Australia shared recent research understandings on the philosophical and ethical aspects of medical and social vulnerability. These sessions generated a sense of global collegiality in understanding and tackling common public health issues.

The workshops and lecture series provided stimulating opportunities for debate and reflection on issues close to home. The scope of research in New Zealand was impressive. From the ethics of HPV vaccination to paternalism, gardens, and 'smart cards', the underpinnings of public health were explored.

Local keynote speaker Professor Neil Pearce provided a timely reminder to keep looking beyond the narrow lens of re-emerging "old" public health thinking toward the scope and potential of the new public health. Such themes were continued at a lively discussion panel on the final morning. During this challenging season for public health, an encouraging sense of strengthened common purpose was expressed. The core values of interconnectedness, justice, equity and leadership were reinforced as fundamental drivers for our practice.

Dunedin shone as a venue – its university and people welcoming, its weather clear and crisp. The conference was a wonderfully refreshing experience that will provide genuine inspiration for me in the years to come. Meeting lively and dedicated people from the wider public health community was a real highlight. Discovering new concepts and strategies in public health provided food for thought.

But aside from the social and academic benefits, the conference strengthened what it means to be within the public health community – committed to the common good, part of a team, pursuing health and justice for our people.

Conference 2009 reflections

Lil Convery, Canterbury-West Coast Sports Trust
PHA Canterbury scholarship recipient

One aspect that impressed me most about this year's conference was the range of international keynote speakers who were invited. Dr Michael Selgelid's address on globalisation and communicable diseases was very engaging. He spoke of how tuberculosis has been largely underfunded given its threat, compared with diseases such as HIV.

I related this to one of my areas of interest, mental health. It reminded me of the relative inattention given to mental health in comparison to other health issues, so I was really pleased to see a stream dedicated to this area during the conference.

One of the eye-opening presentations I attended was Belinda Borrell's talk about the advantage of privilege. Before this, I had never considered the concept of systematic advantage in society, as we are generally only fed research about the disadvantaged. Belinda raised a valid point that we need to understand both sides of the coin in order to gain an ecological view of disadvantage and its impacts on public health.

"I recall someone noting how refreshing it is to be around others who care about the same issues they care about."

The take-home message that came out the streams I attended was the issue of framing when putting research into practice. Because the way issues are framed to other stakeholders and through the media can make or break efforts for change, we need to present our ideas in ways that demonstrate the advantages to others.

I would like to thank the Canterbury branch of the PHA for sponsoring me to attend, and the Otago/Southland branch for organising a varied and entertaining event, as well as allowing me the honour of sharing my own research.

I recall someone at the conference noting how refreshing it is to be around others who care about the same issues they care about, a thought which captured my own sense of alliance with other delegates and reinvigorated my passion for public health advancement.

The future of public health

This is an abridged version of the address given by the Health Promotion Forum's Alison Blaiklock who was part of a panel at the PHA Conference 4 September 2009.

How do we ensure that there is a strong future for public health?

Leadership – We've lost the Ministry of Health's institutional leadership for strategic direction so it's up to us, particularly those of us in national workforce non-government organisations and academic positions, because we have more freedom and flexibility than those of us in statutory or issues-focused organisations.

Accordingly PHA, Hauora.com and HPF have been developing a close working relationship and discussing how we can work together on common causes.

Communication – We must communicate the value and effectiveness of health promotion and public health.

A lot of the dissatisfaction with the previous government was framed as being about a "nanny state" and health promotion and public health got caught up in this.

We need to reframe the debate, show that promoting and protecting health reduces avoidable admissions and pressure on hospitals – and benefits employment, educational achievement, economic productivity, the environment and so on – the co-benefits that Philippa Howden-Chapman and her colleagues used to persuade this government to invest heavily in healthy homes.

"We need a symphony of voices – from the influential stories of experiences of community organisations to the rigorous analysis of academics."

We have to point out the dangers that would accompany the failure of our public health system – the risk of pandemics and other disasters.

We need a symphony of voices – from the influential stories of experiences of community organisations to the rigorous analysis of academics, and we need to look at developing new voices such as the Prior Centre for Public Health and Policy.

Workforce – We have serious issues around workforce, lack of critical mass, lack of senior practitioners in parts of our workforce, fragmentation, and so forth.

The implementation of the Ministry's Te Uru Kahikatea plan for public health workforce development has provided a very useful framework and we are making considerable progress. Check out www.hauora.co.nz and www.publichealthworkforce.org.nz.

And we need to give priority to bringing on board young people and strengthening the Māori workforce.

Effectiveness – Let's find opportunities to develop a more effective public health system. The Ministerial Review Group report wants a "strong public health and disability system which provides world class quality care, both now and in the future."

The report talks about national, regional and local levels. So here's an opportunity for us to talk with government about what should happen in public health at all three levels.

Let's challenge the ethics and evidence behind the suggestion in the report that it may be cheaper to cure people than prevent them getting ill in the first place.

Let's reframe the value for money proposition in a way that better reflects the values (and therefore benefits) inherent in good public health and health promotion practice.

Relationships – Let's build alliances with:

• our colleagues in Māori health
• politicians – in government and across the political spectrum
• clinicians in primary care and specialist services
• the communities who want our work to continue – and with the wider public who appreciate that some cliffs need fences
• the children's, human rights and environmental movements.

Read Alison's address in full at www.hauora.co.nz.

Rugby as metaphor:
How to strengthen the public health game to win

Rugby and public health are not usually associated with each other. However, a keynote presentation at the PHA Conference by Leigh Sturgiss and Louise Signal entitled Rugby as Metaphor: Playing the Public Health Game to Win, asked conference participants to record what they considered would help them strengthen their game.

Around 50 responses were collected, with the main response related to long-term funding, and strategic leadership.

Coaching and mentoring also featured strongly, along with training opportunities for both researchers and practitioners. One suggestion was that researchers, policy and decision makers and advocates should be seconded to an area they are not familiar with to "see how the other half lives".

Attending annual PHA Conferences was seen as important, as was financial support to attend. The opportunity for collaboration during the course of the year was also recommended by some.

It was suggested the PHA News feature successful health promotion stories, including what has worked well in the past and what didn't work so well.

Other ideas included:

• the need for better intelligence about how to access and influence politicians
• a forum where advocates and researchers can talk together
• involving practitioners in the development of research
• access to research that has already been published
• better access to research funding.

Leigh and Louise say thanks to everyone who took the time to provide their ideas. They hope these ideas will be followed up by the PHA, university public health departments, researchers, the Ministry of Health, public health units, non-government organisations and public health practitioners.

Leigh Sturgiss is the Executive Director of the Obesity Action Coalition. Louise Signal is Director of the Health Promotion and Policy Research Unit and HIA Research Unit, Dept of Public Health, University of Otago.

Ensure a strong focus on prevention of illness, say public health clinical leaders

Ensuring a strong focal point for prevention of illness is essential if Ministry reforms are to be effective, say three leading public health organisations.

The Minister of Health has announced structural changes in the health sector aimed at improving the quality and performance of the New Zealand health system.

Speaking for Hauora.com, the Health Promotion Forum of New Zealand, and the Public Health Association of New Zealand, Grant Berghan said a clear single point of accountability is needed for public health services to achieve the Minister's goal of greater coordination and stronger, better planned decisions.

"We need a long-term framework that lays out what should be provided at different levels – national, regional, local."

"The decisions announced today give very little attention to public health. To reduce fragmentation and improve productivity in preventive services we need a long-term framework that lays out what should be provided at different levels – national, regional, local. This then needs to flow into good planning and funding for services and future capacity. These are the functions outlined for the National Health Board, along with sector performance monitoring."

The three organisations say that public health within the National Health Board will need a critical mass of high-level skills, and should have a Chief Public Health Officer and a Chief Māori Public Health Officer.

"Effective and efficient health services have a focus on helping keep people well in the first place, and this provides an essential foundation for a strong economy," Mr Berghan said.

Media release, 21 October 2009

See the Minister's release at www.beehive.govt.nz/release/major+push+lift+public+health+performance.

Comment from the PHA's Dr Gay Keating: "I think all of us in public health are going to have to be active in contributing to the formation of the National Health Board to influence it so that it helps rather than hinders what is needed for effective public health services."

PHA backs call for action on climate change

The Public Health Association says a call from leading public health physicians, medics and academics for New Zealand to halve its greenhouse gas emissions, shows the high level of concern at the impact of climate change on health.

Acting National Executive Officer Keriata Stuart says the article, published recently in the New Zealand Medical Journal, calls for this country to commit to substantial decreases in its greenhouse gas emissions, to avoid the worst impacts of climate change on human health, both here and internationally.

Ms Stuart says climate change is a huge threat to health.

"Without a reduction in global carbon dioxide levels, we could see an increase in vector-borne diseases such as dengue fever; a greater number of severe storms and floods, which can cause injury and death and trigger infectious disease outbreaks; an increase in illness and death from heat stress during heat waves; and an increase in the risk of infectious disease transmission if greater numbers of environmental refugees move from Asia and the Pacific to New Zealand."

She says the PHA believes government needs to introduce a rational system of carbon user charges, and consider ways to increase public acceptability of these charges. This could be gained by using the additional revenue to fund improvements in public transport, lowering income tax rates for low-income citizens when new carbon user charges are introduced, better educating the public about the impacts of the current unsustainable use of fossil fuels, and ensuring that the actual charges, when introduced, are not too high.

"New Zealand has the fourth highest per capita greenhouse gas emissions in the developed world, and one of the biggest increases in gross emissions since 1990."

"We also believe central and local government must continue to promote energy efficiency and reduce emissions. This can be done a number of ways, including making government-owned building and housing stock more energy efficient, providing funding for routine emissions tests on vehicles when they get a warrant of fitness and looking for ways to reduce methane emissions."

She says that, as pointed out in the New Zealand Medical Journal paper, New Zealand has the fourth highest per capita greenhouse gas emissions in the developed world, and one of the biggest increases in gross emissions since 1990.

"The PHA calls on government to commit to substantial decreases in greenhouse gas emissions, without delay."

Media release, 9 October 2009

Heroes of public health

In this issue of the PHA News, we are beginning a series of profiles of pioneers whom present day public health folk regard as heroes of public health practice. We hope you find it interesting and inspiring.

In this first instalment, PHA National Executive Officer Dr Gay Keating lists her champions of old.

John Snow

John Snow undertook the first documented epidemiological outbreak study – of a cholera epidemic in London 1854 – which was thought at the time to be due to miasma or bad air. He investigated cases (including deaths) and identified that people whose water supplies came from a particular water pump were most at risk of the disease.

Despite opposition from those who sold water sourced from that pump, he went on to get that water pump disabled by the local council.

John Snow changed the world by:

• changing how we think about the causes of (and intervention options for) a particular disease
• applying statistics to pinpoint a highly probable cause
• influencing decision-makers to take regulatory action to control a health hazard
• being instrumental in controlling an industry that was a direct (if unintentional) cause of death and disease.

Richard Doll

Richard Doll was an epidemiologist who was key to the discovery of the link between smoking and lung cancer, at a time when he and others were of the general opinion that the increase in lung cancer was due to air pollution from cars.

He was also instrumental in identifying the link between many work substances and cancer. He was very active in ensuring that health services were available to all, and that there was good information on what the preventable causes of many cancers are.

Richard Doll changed the world by:

• carefully collecting the evidence on what are causes of disease, even when the results went against his own earlier notions
• influencing decision-makers to take regulatory action to control several health hazards
• being instrumental in controlling several industries that were a direct (if unintentional) cause of death and disease.

Ettie Rout

Ettie Rout took a 'health outcomes' approach to New Zealand soldiers and sexually transmitted infections in Europe during the First World War. She advocated for the availability of prophylactic kits to enable safe sex. She sought to provide the best information from researchers and practitioners to all who needed it and even persuaded some brothel operators to operate in ways that would reduce the spread of venereal diseases.

For her pains her work, and even references to it, were banned in New Zealand. Those who opposed her approach believed New Zealand soldiers away from home needed to practice abstinence and to make sex safer promoted immorality.

Ettie Rout changed the world by:

• carefully seeking out the best available evidence on what can be done to improve health outcomes
• adopting a risk-reduction approach
• advocating to individuals, organisations, government and industries to adopt healthier environments and increase personal safety skills
• not allowing abuse, which was sometimes vicious, to distract her.

Edward Jenner

In the eighteenth century it was known that, although dangerous, people could have a planned immunisation against smallpox, with smallpox itself, and develop some protection against catching the epidemic form of the disease.

Using others' observations that people who had caught cowpox did not then develop smallpox, Jenner actively tested his theory that giving people cowpox would protect against smallpox in a way that was much safer than the smallpox immunisation.

He then went on to report a case-series of successful vaccination. His success was finally recognised and eventually there was public health regulatory action to rule out the more dangerous smallpox immunisation.

Edward Jenner changed the world by:

• testing a hypothesis based on careful observation and recording and presenting his findings
• actively and successfully advocating for safer immunisation and achieving free immunisation.

Russell Worth

Russell Worth was a neurosurgeon at Wellington Hospital. He was concerned that too much of his surgical workload was made up of head injuries from bike crashes. (Today it would probably be discussed in the context of growing surgical waiting lists). He became convinced that it was possible to safely ride motor bikes, and commuted each day on his own.

He was a key advocate for compulsory crash helmets. He carefully documented the engine size of bikes and related that to crashes, including following the outcomes for the purchasers of a shipment of very large-engined bikes (all crashed, most died).

Russell Worth changed the world by:

• testing a hypothesis based on careful observation and recording and presenting his findings
• actively and successfully advocating for the use of safety helmets and public health /safety legislation
• living as a role model.

World Health Organization Director-General calls for fairness in international health policies

With a growing recognition that "blind faith in economic growth and gain as the be-all, end-all,  and cure-for-all has been misplaced," World Health Organization Director-General Dr Margaret Chan says it is time to build policies based on fairness – using differences in the health status of populations within and between countries – as the "key measure of how we, as a civilised society, are making progress."

"The world is in such a great big mess," she says.

"In the last year, this warming world has suffered a fuel crisis, a food crisis and a financial crisis. This list of challenges recently grew with the addition of pandemic influenza.

"The impact of these crises is not felt equally. Pandemic influenza, for example, will hit hardest in developing countries, which have large vulnerable populations. With their weak health systems, these struggling countries will take longer to recover. In many ways, developing countries facing the pandemic are virtually empty-handed.

"Fairness, I believe, is at the heart of our ambitions for global health."

Dr Chan says fairness is in short supply. Differences in income, life expectancy, and opportunities are greater now than at any time in recent history. These extremes of privilege and misery are often "a precursor for social breakdown".

She says the soul-searching following the financial crisis has led to a questioning of blind faith in economic growth.

"From this self-examination, leaders are calling for a restoration of other values, especially fairness, to a central role in policy formation.

"A focus on health as a worthy pursuit for its own sake is the surest route to the moral dimension."

"We hear clear calls, from leaders around the world, to give the international systems a moral dimension to redesign them to respond to social values and concerns.

"A focus on health as a worthy pursuit for its own sake is the surest route to the moral dimension, the surest route to a value system that puts the welfare of humanity at its heart. Greater equity in the health status of populations, within and between countries, should be regarded as a key measure of how we, as a civilised society, are making progress."

She suggests that one method for achieving fairness would be for more countries to embrace primary health care.

"A primary health care approach introduces greater fairness as well as efficiency, and allows health systems to reach their potential as cohesive, stabilising social institutions."

Government needs to plan now to avoid a bleak future

Many of New Zealand's older people could slip below the poverty threshold during the coming decades, warns a social policy expert.

Charles Waldegrave, Social Policy Analyst and Researcher, was speaking at the Age Concern New Zealand/New Zealand Association of Gerontology Conference in October.

He has jointly led New Zealand's first national study into ageing and wellbeing, using a random sample of 65- to 84-year-olds. He says findings show New Zealand's next generation of older people could face major financial difficulties.

"Ageing is a critical driver in the demographic changes taking place in New Zealand over the next decades. Currently, the majority of older people depend on NZ superannuation for their wellbeing – 48 percent of study participants were found to have incomes of superannuation plus five thousand dollars or less per annum.

"Older New Zealanders also have very high levels of homeownership. New Zealand Super is just enough to keep people out of poverty if they have low housing costs. The combination of mortgage-free homes and universal superannuation has been critical in preventing many of them from dipping below the poverty threshold.

"The population of older people will double from 12 to 26 percent over the next few decades."

He warned that the combination of decreasing levels of home ownership and the decision to withhold payments into the New Zealand Superannuation Fund pose a serious threat to the future wellbeing of older New Zealanders.

From 2011 onwards, post-war baby boomers will begin moving into the 65+ age group. This means the population of older people will double from 12 to 26 percent over the next few decades.

Mr Waldegrave believes these issues need to be planned for and addressed now, both by national and local government.

"The government needs to plan for these changes to prevent major problems in the future. The issues of sustainable income adequacy and ongoing contributions to the New Zealand Super Fund need to be addressed. Affordable housing and a sustainable and accessible health service are also critical factors.

"Local government also needs to look at how it can support the baby boomer generation further down the line. Sustainability of social, community and home based services, urban planning that allows easy access to amenities, and reliable and safe transport services are just a few of the issues to be considered.

"The need for forward planning, widespread public debate and consultation with older New Zealanders is essential to ensure a decent quality of life for them in the future."

Social Policy Research Unit Media Release, 8 October 2009

Around the branches

Planning for 2010 PHA Conference well underway

The Waikato group planning the 2010 PHA Conference has been meeting for more than six months. Our planning committee has about 10 members and we have good representation from NGOs, the Waikato District Health Board and Waikato Tainui. The Waikato branch has paid for the membership of those NGO committee members who were not current members of the PHA as a thank you for their input.

The PHA Conference will be held from 21-24 September 2010, at Turangawaewae, Ngaruawahia. Its theme is "Tomorrow for tomorrow's people – He ao mō ngā whakatupuranga o āpōpō."

Streams within this theme are:

• health and the environment
• sustainable development
• making the connection.

As part of the first evening after the powhiri and dinner Waikato Tainui will set the scene and will share the Waikato journey.

Recently we met with event planner Justine from Corporate Events and Marketing who is in the process of developing a project plan and the allocating of various responsibilities.

Debbie Petersen
PHA Council Representative, Waikato

Media activity roundup

The PHA has issued the following releases since June 1 this year.