IAN WEBSTER: Public health and the nanny state.

Behind our backs, public health became the poor cousin of biomedicine and was dismissed as ‘drains and sewerage’. How wrong we were!

Walking on a hillside outside Eyam in Derbyshire there are two weathered rocks with holes on top. Coins were placed in the holes under vinegar by the village rector to pay for the food neighbouring farms delivered. In the “village of the damned” forty-two deaths from the plague had occurred. The rector persuaded his parishioners to quarantine themselves to prevent the plague spreading to the villages of Sheffield and Bakewell. They stayed, facing death. In a population of 350 to 800, 260 people died – a fatality rate of 30% to 75% from human-to-human transmission albeit through the intermediary of flea bites. That was 1666, shades of today with lockdowns, physical distancing and quarantining.

These measures, with personal hygiene, are the tested and effective measures that must underpin the control of epidemics. As Stephen Leeder said in Pearls and Irritations 15th of April, “old ways of managing epidemic illness – social distancing and quarantining – have been dusted off and put to good use”.

As medical students we thought infectious disease had all but been defeated by antibiotics and vaccines – penicillin for pneumonia, streptomycin and BCG for TB, vaccinations for smallpox, tetanus toxoid and the Salk vaccine just around the corner. Since then, the mycobacterium, the staphylococcus and other bacteria have thwarted our interventions.

Behind our backs, public health became the poor cousin of biomedicine and was dismissed as ‘drains and sewerage’. How wrong we were!

Control of contagious disease has always been the stuff of public health. Quarantine started with the First Fleet in 1788, later formalised by State (1830-50s) and Federal (1908) legislation. Smallpox became available in 1804 and campaigns started in the 1930s, pasteurisation of milk was introduced in 1950s – pasteurisation being discovered in 1860s, mass TB campaigns started in 1945 – the tubercle bacillus being discovered in 1882, and polio vaccination commenced – Salk in 1956, Sabin in 1966, Triple Antigen in 1953 and MMR for mumps, measles, rubella in 1989. Vaccinations for the rotavirus, pneumococcus, meningococcus and Haemophilus influenzae and for hepatitis A and B then followed. Influenza vaccination became available in 2015. And drugs to treat HIV/AIDS and hepatitis C have also provided opportunities for prevention.

Public health has benefited from social reforms as well – the eight hours day, the minimum wage, women’s suffrage, infant welfare, aged and disability and ‘TB’ pensions, sickness and unemployment payments were all gains for public health.

These achievements are to be celebrated as Australia has always been at the head of the pack in public health and social reform, with the possible exception of Nordic countries and NZ. Our response to the coronavirus is again at the head of the pack and this should be celebrated.

At some point, the coronavirus will give way to the ever-present non-communicable diseases, the ‘diseases of affluence’ and the “diseases of despair and hopelessness” – addictions, alcohol abuse, suicide, unremitting pain. Australia has done well here, too. Deaths from heart attacks, strokes and other conditions, fell before the UK, US and most other countries. The “Slip, Slap, Slop” campaign for skin cancer is an example of the early take-up of health promotion. National plans and strategies for mental health and suicide prevention and the national drug strategy have all been in the vanguard internationally.

Beyond the nation’s boundaries, the world around us – the environment, climate change, populations, global conflicts, food and water supply and economic inequality – threaten human and planetary survival. Recent revisions of state Public Health Acts will enable government policies to shift in these directions. And readers of Pearls and Irritations are indebted to the weekly updates from Peter Sainsbury on climate and the environment.

There is no easy path for public health. In the US protestors wave “nanny state” placards and carry threatening firearms as they agitate against lockdowns and social distancing.

The pejorative ‘nanny state’ first appeared in 1965 from the one-time UK Health Minister, Iain McLeod, a heavy smoker – a criticism of government public health actions which were taken up with alacrity by the tobacco industry and Margaret Thatcher.

A Google search will find a myriad of references in Australia to the ‘nanny state’ – tobacco and alcohol restrictions, gun and drug control, food labelling, speed limits, ‘random breath testing’, pool fencing, ‘fluoro vests’ and much more – voiced by “shock jocks”, conservative think-tanks and shadowy websites; among them the libertarian former senator, David Leyonhjelm. Some in the media even went so far as to deny the existence of an epidemic, let alone acknowledge the developing pandemic.

What then of Australia and the pandemic? The ‘nanny state’?

As the Guardian Weekly 1st May said, ‘Ronald Reagan’s wisecrack – “‘The nine most terrifying words in the English language are: I’m from the government and we are here to help” – would not get a lot of laughs today. In much of the world, people are desperate for the government to show up and rise to the challenge of the coronavirus pandemic.’

Australia will not experience the loss of life as heavily as other countries, but this should not lead to complacency as, we too, must re-evaluate our public health and social systems. Prevention is not a priority for the government, or the community, and preventive actions are usually too late, “catching those who fall at the bottom of the cliff” rather than anticipating future events.

There is much to be done:

  • The role of the WHO and national governments must be reformed to ensure that each country’s health and social structures are self-sufficient and less dependent on help from outside.
  • The WHO needs more certain funding and to be less reliant on a capricious US President. (Our own Prime Minister, acting as an echo chamber for Donald Trump’s attack on the WHO, was not helpful.) Without an international organisation which can be trusted to monitor global health and to recommend and coordinate actions, the world’s health will be in a more parlous state.
  • Universities and medical faculties, with their enthusiasms for biomedical research and publications, should invest in teaching and research in public health, social systems and social psychology to levels comparable with the more prestigious disciplines in biomedicine.
  • Community medicine was introduced into medical schools to bridge the gap between clinical practice and public health; if future public health crises are to be managed effectively, this vision needs to be recaptured

Public health is important as it reflects our values – communal and personal – and the way we shape our working and living environments and above all, our connectedness to each other and the community.

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Ian W Webster AO is Emeritus Professor of Public Health and Community Medicine of the University of New South Wales. He has worked as a physician in public and regional hospitals in Australia and UK and in NGOs dealing with homelessness, alcohol and drug problems and mental illness.

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