A recent seminar at the University of Sydney examined the legacy of the Australian National Preventive Health Agency (ANPHA) in an event also billed by some as “a wake for preventive health”.
In the article below, Stephen Leeder, Emeritus Professor of Public Health and Community Medicine at the University of Sydney and Editor-in-Chief of The Medical Journal of Australia, explains why some industries will celebrate this loss for public health.
We need national leadership to provide “a counterweight to the big-time, burly avarice that drives health-destroying profiteering”, he says.
Does the non-government sector have the capacity to pick up the slack?
Stephen Leeder writes:
Among the proposals for saving money in the recent federal budget was one to abolish the Australian National Preventive Health Agency – ANPHA.
Australia faces major problems with potentially preventable disorders such as obesity, diabetes, and heart disease due to problems such as smoking and alcohol abuse. These are national problems demanding national solutions.
ANPHA was a move in that direction. It was not manufacturing iron lungs for polio victims. It was up to the minute. So abolishing it was a pretty dumb thing to do.
The functions of the ANPHA were to act as a clearinghouse for information about preventive programs that work, to foster research and the trial of new ideas, to promote the use of social marketing and social media as ways of communicating preventive messages to the community (modern-day Grim Reapers for example) and advocating nationally for changes that need to be made nationally, say to food, and that cannot be done at state level.
Although a creature of government, it was meant to have independence. It raised hopes that, for once, we might have an institution to support prevention, rather as universities have lecture halls, research workers have laboratories and clinicians have hospitals.
ANPHA grew from the recommendations of the National Preventive Services Taskforce that reported to the federal government in 2010. The report of that taskforce stated that:
Obesity, tobacco and alcohol feature in the top seven preventable risk factors that influence the burden of disease, with over 7 per cent of the total burden being attributed to each of obesity and smoking, and more than 3 per cent attributed to the harmful effects of alcohol. Along with a range of other risk factors, and accounting for their interactions, approximately 32 per cent of Australia’s total burden of disease can be attributed to modifiable risk factors.
Its proposals, carefully thought through and debated as good policy should be (not announced in a budget speech as incoherent thought bubbles and sound bites), included:
1. Shared responsibility – developing strategic partnerships – at all levels of government, industry, business, unions, the non-government sector, research institutions and communities.
2. Act early and throughout life – working with individuals, families and communities.
3. Engage communities – act and engage with people where they live, work and play; at home, in schools, workplaces and the community. Inform, enable and support people to make healthy choices.
4. Influence markets and develop coherent policies – for example, through taxation, responsive regulation, and through coherent and connected policies.
5. Reduce inequity through targeting disadvantage – especially low socioeconomic status (SES) population groups.
6. Indigenous Australians – contribute to ‘Close the Gap’.
7. Refocus primary healthcare towards prevention.
We are not coming off a low base with regard to prevention and have an international reputation to maintain.
As I wrote back in May in Australian Doctor the decline in heart disease in Australia in the past half century is deeply encouraging. Through a combination of better treatment, less smoking and dietary change, we’ve more than halved – considerably more in the case of the under 65s – death rates for heart disease. Lung cancer death rates among men are falling. These disorders have a major preventive element in them.
The risks for heart disease relate closely to what we eat, how much we drink, our physical activity and more. Yes, these behaviours are ultimately matters of choice: we are, as GW Bush would say, the deciders.
But we’re not entirely. The shopping environment influences what we choose to buy. The advertising environment powerfully influences our purchases of alcohol. The economic environment determines where we can afford to live.
These are the shapers, the causes behind the causes. And we must attend to these things if prevention is to work.
Without legislation, kiss goodbye to tobacco control. Other countries legislate for labels on foods so that people – not just robots – can work out which are the healthiest.
New York has eliminated trans fats – by legislation – from all prepared food. More broadly in the US, man-made trans fat consumption fell by 600 million tonnes between 2005 and 2012 as Dow and other vegetable oil producers acceded to the expectations and legislative urging of American citizens and governments that they would produce stuff that was health-promoting.
Set yourself a preventive agenda that seeks to achieve these lifestyle opportunity-promoters and you need strength including at a national level. Individuals struggle to win these battles. Groups such as the National Heart Foundation, cancer societies and others have been zealous.
But the thought behind ANPHA was that it could become a counterweight to the big-time, burly avarice that drives health-destroying profiteering. No wonder the alcohol industry will declare drinks all round in celebration when the bulldozers demolish ANPHA!
Most of the prevention that leads to a decrease in non-communicable disease is big picture, usually nationally. This was essential in dealing with tobacco. Unless the national goals are declared, states and territories are not able to prevent. Immunisation and epidemic control are similar. The track record of states acting without national leadership in relation to Indigenous health is not good. National leadership was required to move things along.
The politics of prevention are what made ANPHA so important to our health future and so hated by those who, like the tobacco barons of yore, want free rein to push their wares no matter the health costs.
Of course, a new institution will take time to reach its full potential – five years as a minimum. Many people expected too much from ANPHA. Naturally there are things that could have been done better and many of these could still be affected by adjustment if ANPHA had been allowed to live.
But this is not a day when ideological whims and fancies are subjected to even superficial rational scrutiny. Data overboard. The non-government sector will need to pick up the slack.
• Stephen Leeder is Emeritus Professor of Public Health and Community Medicine at the University of Sydney and Editor-in-Chief of The Medical Journal of Australia