Upturn: A better normal needs a focus on health, not just healthcare

14/02/2021

Professor Paul Torzillo discusses the lessons for healthcare in Upturn: A Better Normal After Covid-19. The volume of essays would have benefitted from a more comprehensive analysis of what a “better normal” in health, rather than just healthcare, would look like. But the plea for ensuring the “humanity of medicine” will resound. 

As Torzillo makes clear in his introduction, his essay does not aim for comprehensiveness but focuses on the issues that need immediate attention in healthcare. That is at once understandable and regrettable.

While healthcare and the clinical responses to the pandemic (intensive care beds, respirators, drug treatments, vaccines) are critical, so too are public health measures (social isolation, masks, testing and tracing). The importance of quarantine measures in protecting Australia from imported infections is made obvious daily.

At the same time, it is clear in Australia and internationally that the social determinants of health (income, type of employment, housing, ability to access needed healthcare, health literacy, racism and discrimination) are key risk factors for mortality and morbidity from COVID-19 and drive population health. Torzillo would be acutely aware of this from his work with Indigenous communities.

This criticism does not undermine the value of the eight points he highlights as needing more attention, but this volume of essays would have benefitted from a more comprehensive analysis of what a “better normal” in health, rather than just healthcare, would look like.

1. Leadership

It is clear Torzillo means political leadership – and at the federal level this has been in short supply. Scott Morrison has left the difficult decisions to the states and territories. In November, I wrote: “Morrison gets a pass grade for the initial months of the pandemic response, but he has failed to sustain this and has reverted to his true form – more partisan, more narrowly focused and much less visionary than the country needs or deserves.”

The vaccine rollout will provide yet another test of the Morrison Government’s commitment to public health resources, health equity and transparency about decision-making.

In times of crisis, leadership must also come from individual experts and professional bodies. Australia has benefitted from a cohort of experts like Professor Raina MacIntyre, Professor Mary-Louise McClaws and Dr Norman Swan, whose knowledge and communication skills have helped Australians understand the issues.

2. Universal healthcare and public health systems matter

I assume that Torzillo is referring to the fact that public hospitals have assumed almost the total burden of caring for people with Covid-19. He is correct. Australia’s ability to respond effectively to the pandemic is in large part due to its publicly funded healthcare system and the people who work in it. At the same time the pandemic has highlighted the fragmentation of healthcare (federal and state; public and private; physical health and mental health; acute care and primary care; community and residential care), how under-resourced it is, and how its purported universality has been undermined.

We have also seen the concomitant importance of public health measures in preventing the spread of infection – a key aspect of health that is often misunderstood and is perpetually, pathetically underfunded. There are no recent, publicly available figures for federal spending on public health and much of this is left to the states and territories.

I worry that politicians do not truly appreciate the extraordinary extent to which the public healthcare and public health systems and workers have stepped up to respond to the pandemic. I am concerned that – because they have withstood these testing times – there will not be sufficient efforts to reform and better support them in the future.

3. Beware the politicisation of the bureaucracy

This is linked into leadership, and we have seen the harms done when health advice is delivered through a political filter – most egregiously by the Trump Administration. The fact that research delivers new and changing scientific evidence almost daily, in combination with enormous levels of misinformation, means that trust in public pronouncements is readily eroded, and political leaders must manage this.

4. Protect those who protect others

This refers to the endless issues over the availability of the appropriate personal protective equipment (PPE) that have beset healthcare workers, carers and first responders from the very beginning of the pandemic. It continues even today, with information emerging about the lack of PPE for security personnel at quarantine hotels.

One key omission is that protection must extend to support for their mental health and emotional wellbeing.

5. Changing how we work

Torzillo makes a very interesting point about how healthcare facilities are built influences the way care is delivered, especially in times where infection control is paramount.

But there is so much more that could be said. It extends well beyond the training of clinicians (mentioned) to the upskilling of current clinicians and healthcare workers and better use of skills and full scopes of practice for every healthcare worker category. Workforce planning and resourcing has never been more crucial.

6. Telemedicine should supplement, not replace, face-to-face medicine

Simply expanding telehealth services will not be sufficient to meet the needs of those who seek care, especially in mental health, and evaluations are needed to drive the most effective targeting and use of such services.

Telehealth in pandemic times has been described as “a blessing and a curse” and Torzillo states “let’s not pretend emergency compromises represent long-term solutions”. Torzillo’s criticisms of telehealth surely extend to the recently reported situation in a regional NSW hospital where no doctors were physically present after business hours and treatment was via video-link.

He does not refer to the trialling of virtual “hospital in the home” services which have been used for both Covid-19 patients and for older, chronically ill patients.

7. Science and research need support

The Morrison Government is lauding Australia’s vaccine and epidemiological expertise at the same time as its support for high school science, tertiary education and research (especially in areas like health services and primary care) is falling. In 2020 non-coronavirus research, especially clinical trials, was badly impacted.

Like Torzillo, I worry that there are links between declining support for education, the suppression and rejection of medical science, and a retreat from liberal democracy.

8. Invest now for the challenge of climate change

My earlier chiding for failure to consider the social determinants of health is modified by this inclusion of climate change. Torzillo rightly describes this as “the greatest contemporary threat to population health” and it’s an area where Australia consistently gets a failing grade. Leadership from medical and public health experts must counter government failure to act.

A raft of reports and analyses discuss what we can learn from the pandemic and how we can build back better (see this summary on the Croakey blog). The most salient points are that culture (civic mindedness and trust in government), leadership, appropriate experts informing policy decisions, and the willingness of the public to follow expert advice are as important as national wealth, sophisticated healthcare systems and technology, research and scientific knowledge. Compare Australia and New Zealand to the United States and the United Kingdom as evidence of this.

You can almost get to this conclusion from Torzillo’s essay – it is just not spelt out in any detail.

The book contains excellent essays on health-related topics – June Oscar on remote communities and First Nations people, Linda Burney on safety nets, and Rebecca Huntley on neighbours and communities. Plibersek asks in her introduction “what matters to Australians?” and I would like to think that a common theme emerges here, that it is more than jobs, housing, education and healthcare, and includes humanity, neighbourliness and dignity for all.

It is there at the conclusion of Torzillo’s essay, where he makes a plea for ensuring the “humanity of medicine”. It is in Burney’s point that safety nets should protect vulnerable Australians and provide them with dignity. And Huntley makes the case for community. This is reinforced by a recent report from Health Justice Australia that points to the value of collaborative relationships across otherwise siloed service settings to support people who are most vulnerable to the health and social impacts of disasters like bushfires and pandemics.

Plibersek quotes Arundhati Roy who sees the pandemic as a portal that forces people “to break with the past and imagine their world anew”. Oscar provides a vision of this upturn, this better normal: “It is timely to reconstruct a nation that reflects the humanity and diversity of its citizens and embraces First Nations societies and culture as foundational to Australian identity.”

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