THEO MURPHY (AUSTRALIA) HIGH FLYERS THINK TANK
Preventative health: Science and technology in the prevention and early detection of disease
University of Sydney (Eastern Avenue Complex), Thursday 6 November 2008
Professor Mike Daube
Mike Daube is professor of health policy at Curtin University and Director of the Public Health Advocacy Institute of Western Australia. Before moving to Curtin in January 2005 he was director general of health for Western Australia and chair of the Australian National Public Health Partnership. He has played a leading role in public health, health policy and health advocacy in Australia, the UK and internationally since 1973. He has been a consultant and adviser over many years for WHO, International Union Against Cancer, Bloomberg Philanthropies, governments and NGOs in some 30 countries, as well as an author or co-author of many major reports. He is a regular commentator in the media on health issues.
Mike is currently deputy chair of the Australian Government's Preventative Health Taskforce, president of the Public Health Association of Australia, the Australian Council on Smoking and Health and the Heart Foundation of Australia (WA), chair of the Western Australian Alcohol and Drug Authority, and a member of many editorial boards and committees including the NHMRC Public Health Research Review Advisory Committee. He has received awards for his work from organisations including WHO, the Australian Medical Association, the National Heart Foundation, the Public Health Association of Australia, Healthway, Australian Council on Smoking and Health, Curtin University and the Australian Red Cross.
I would also like to acknowledge the traditional owners of the land.
It is a privilege to follow all these terrific speakers and then John Chalmers' summary.
I am very appreciative to the Academy for setting up this meeting. As Kurt pointed out, even despite the hard economic times, the timing for this meeting is immaculate in that the work of the Preventative Health Taskforce is now well under way.
(If any of you want to know – and I have been asked this, I think, more than anything else about our work – why there is that extra syllable in 'preventative', the answer is that it was in a speech of the Prime Minister's before the election. So that's it. Okay? No more debate. It is 'preventative'.)
There is a real opportunity to contribute to our work and strategies now and later. If it occurs to you that you have any thought or comment that you should have said or what the French call 'l'esprit d'escalier' – the thing you think about as you are going up the stairs at night – don't just sit on it; let us know about it.
You have had all the sessions and the summaries and then John's terrific review, so I am not going to review the whole process again. I will just make 10 points.
First, Ian Hickie was a bit disappointed that mental health was not one of our first three areas; he was a bit dispirited about that – I wouldn't say that he was depressed, because that is his area. Graham Brown also made the point that infectious disease should be up there; he made that point with equal passion, because as he noted there are some lower hanging fruits to be picked from that tree – things that can be done.
But we had to start somewhere and the government asked us to look first at chronic diseases – in particular, at obesity, tobacco and alcohol. So that was our remit for the first report, and you can't do everything straight away. But that is just a starting point. One of the things that we need to know from you is what we should do next. So, when you are writing to us or making comments and so on – and plenty of you know members of the taskforce individually as well as through the formal processes – please let us know what you think should be our next set of priorities. We need that information from you.
The next point I want to make is about the context of prevention. Graham asked me in one session what percentage of the prevention budget should go to global health, and it was a very fair question. There is another context though, which is that prevention currently gets about two per cent of national health spend. The prime minister described that at the 2020 Summit as crazy. Indeed, that is based on a generous definition of prevention; it even includes some alcohol treatment and prevention. So what does that mean? It means that McDonald's in Australia spends each year on advertising alone as much as the federal government spends on all its public education programs – everything. It means that junk food and alcohol companies spend more on advertising their products than NHMRC does on all prevention research in this country. So I just want to make the point that there is a context about prevention funding. We need to be pressing for more support for prevention, and I will come back to that later.
My third point is that I want to refer you to an American writer on drug issues, Mark Warden, who has written about 'popular and unpopular prevention'. Popular prevention is the stuff that looks attractive. It is the kinds of programs that sound good but don't actually achieve anything. It is the sort of thing that is often attractive, frankly, to politicians because it makes it look as though they are doing something, but it can be very short term and doesn't achieve anything in the longer run.
My favourite example of this is with tobacco. Richard Doll used to tell the story that, at the very first meeting he went to that the British Government had organised in the early 1950s to consider what should be done about tobacco, there were two gentlemen at the back of the room who said, 'What you need is school education on tobacco' – and, indeed for years we have heard people saying, 'What we need is school education on tobacco.' The two gentlemen at the back of the room were representatives of tobacco companies. The reality is, at its harshest, that there is no evidence from anywhere that school education on tobacco does very much. But it is popular; it is soft, particularly when done in isolation.
So this isn't a tirade against all school health programs, as I think some of them are genuinely really important, but I do want to make the point that unpopular prevention is the hard stuff. It means taking on commercial interests. It means spending money. It means confronting inconvenient issues such as climate change. It means recognising that there are still some fundamental issues in indigenous health that we haven't even properly recognised as a community, not the least in that responsibility rests so far beyond health.
It is greatly to the credit of the government that, in picking people for the prevention taskforce, they included people like Rob Moodie, myself and others who don't actually like soft options; and they made us an independent group, so we report independently to the minister. And in this context, as well as the work you do, I want to caution about relying on population prevention and to argue that unpopular prevention is where quite a lot of our effort needs to go.
My fourth point is that there will always be opposition to prevention.
There is opposition from colleagues who feel threatened. One of my favourite slides – you're lucky that you're not seeing them all – is an old picture of the first four French heart transplant patients at a reunion – and three of them are smoking.
There is philosophical opposition. In 1851, London's Times ran an editorial that said, 'We prefer to take our chances of cholera and the rest than to be bullied into health by Mr Snow...every man is entitled to his own dung heap'.
So there is philosophical opposition. We get it even now; we get people who talk about the 'nanny state'. If you actually look back to the nanny state, it was invented by a British politician, Iain McLeod. Iain McLeod was the health minister who, in 1954, smoked his way through a press conference about the dangers of smoking and died tragically young of heart disease. But we get clichés like the 'nanny state' thrown up at us. There is what you might describe as opposition which, in Peter Draper's wonderful phrase, 'is no longer pollution of the drinking water but pollution of the thinking water'.
There is commercial opposition – tobacco, alcohol and other industries. When you see any of that, you just need to ask yourself about something called the 'scream test': if they are screaming about it that is all the evidence you need that it is going to have an impact.
My fifth point is that prevention can take time. Some of you may know I have spent a lot of my time working on tobacco, so I will remind you that it was as long ago as in 1950, that we had Doll and Hill and Wynder and Graham publishing their seminal papers. Then we had the first major reports from the Royal College of Physicians of London and the US Surgeon General in the early 1960s; I have been in tobacco for 35 years. Most of the time we have had people telling us we were failures – 'You've failed; people are still smoking', and so on. Suddenly, we are a success story. We just have to recognise that, in prevention, very often overnight success takes time and we have to stay with it.
For my sixth point, I was going to make some comments about our perceptions of evidence. But there has just been some discussion on that issue, so I will leave it, other than maybe to say that we can't wait forever for perfect evidence for prevention; it is just not there. I do not know if you are familiar with a book by WH Cornford called Microcosmographia Academica, which was published in 1908; it's a wonderful read – a guide for academic politicians, but equally valuable as a textbook for bureaucrats. Cornford describes there 'the principle of the dangerous precedent', with which all bureaucrats are familiar. This reads:
Every public action which is not customary, either is wrong, or if it is right, is a dangerous precedent. It follows that nothing should ever be done for the first time.
The demands for evidence for prevention are often much greater than for all kinds of other interventions. But this does not help prevention in the real world of policy – as some of those who call for ever more evidence either know or should know.
If we had waited for evidence that advertising bans, public education, health warnings or others measures to reduce smoking, those ad bans, education and warnings would never have happened. We used all kinds of other evidence, not least the industry's own material, and they did happen. Frankly, I don't think we should be waiting so long for that kind of evidence again with cognate issues like tobacco and junk food.
I am especially delighted by this initiative of the Academy because it does seek to bring fresh thinking to prevention. Prevention is far too important to be left to those of us in public health. It needs all health disciplines, but it needs more. I think that again – as Graham Brown and various others have pointed out during the day – we need to engage with much wider disciplines. It terrifies me as the father and the son-in-law of engineers to say that we should engage with engineers, but we should – with other scientists, social scientists, and so on. I think it is crucially important that people outside just the direct public health area are getting involved. So I do hope that this is just very much the start of the Academy's foray into prevention and that will broaden out into those other disciplines that you represent.
From the perspective of the prevention taskforce – this is my seventh point, so there are only another three to go – there is a pragmatic issue. We have an initial three-year life span. We have to develop a national preventative health strategy. We have produced a discussion paper, and one or two people have asked me where they can gain access to it. It is at www.preventivehealth.org.au. What we have to come up with next is not just recommendations. You could wallpaper any number of rooms with the recommendations that are around. We have to come up with a strategy. So we need to be very specific – not just broad recommendations, but what should be done in a year, in two years, in three years and in five years. Frankly, I think that is about as far as the political horizon will make it sensible for us to go. We need to develop a strategy and we also need to indicate how then governments and others can be judged: 'If this is the strategy, how are we going to score them against that strategy so that the community can see whether they have succeeded or failed?' So we need to look at what can be done by a wide range of groups, not just health departments and others but all those across government and people well outside the health arena and into the community.
So, as I have said, I would ask you to look at our website and, as individuals or through your organisations and departments, to make submissions. They do not need to be long; but, if you don't tell us, we may never know. A few people have come up to me today and said, 'I think you should look at this and I think you should look at that.' I have tried to be blotting paper, but I'm not going to remember it all. It doesn't need to be a long submission but, if you do not tell us what we should be thinking about, whether now or the future, we will not know about it. So please do let us know. Do not feel limited; refer to the discussion paper. But, if you think there are other areas or overarching issues that we should also be looking at, from indigenous disadvantage – which we have tried to cover in our three themes – to climate change, please tell us.
My eighth point is the concern that prevention can be competitive. I will just say very, very briefly here that in prevention, as in other areas, we should not be looking at 'either/or' approaches. Prevention is not about covering this issue or that – but not both. It is not doing this or that – but not both. We should be looking at a range of issues and not competing amongst ourselves.
My ninth point is that many years ago Francis Crew, who was then professor of public health at the Edinburgh University, wrote, 'The House of Commons is the pharmacy of preventative medicine.' We know a lot of what needs to be done. The challenge is that a lot of it does require action at the political level – and that includes making happen some of the research that you want to happen and having it funded, getting it supported. But I want to emphasise that we know a lot of what needs to be done – we need your help, as we need the help of all those concerned for the public good – to make it happen.
That takes me to my tenth and final point. Here, in a sense, I want to take off my prevention taskforce hat and speak from a personal perspective. Prevention is not just about ideas and recommendations; it is about implementation. Change only happens if somebody somewhere presses for it. Prevention needs advocacy. Prevention isn't immediately top of mind for politicians. As Phil Kuchel said, I used to run a state health department, which is where all the grey hair came from. I can remember innumerable late-night and early-morning phone calls from premiers and health ministers about crises. Some were really catastrophic, such as the Bali bombings. But it was usually issues like waiting lists, emergency departments, and secure mental health beds; important, but almost invariably not overnight urgent. Nonetheless, that is what I would get the calls about. I cannot remember one late-night call from a panicked politician about why we hadn't prevented something.
So, if you want to see action, I think there is a role for pretty much everyone here in some form of advocacy for prevention. That doesn't mean that everybody goes around waving flags. But, whether it is developing policy, determining targets, working as individuals, working through organisations or sometimes even taking a public role, there is something that we can all do.
There was a paper that some of you may have seen quite recently in the American Journal of Public Health called 'Researchers and policymakers: travellers in parallel universes'. That may be a bit harsh, but it makes an important point: we do now know a lot about how to influence policymakers. There is big literature out there about it, there are plenty of areas where we have actually succeeded and there are people here who are pretty good at it. You are influential; as you are now, you are influential and politicians will listen to you.
John Chalmers rightly made the point that early- and mid-career research is often the time when researchers have the passion and whatever else it takes to make things happen. Bruce Armstrong has just gone, so I can point out that, as an activist, he was incredibly active on tobacco control 20 or 30 years ago – or a bit more – when he was an early- and mid-career researcher. Very often that is the time when people can help and can push to make things happen. But, of course, you can keep going right through your career (as Bruce has done).
The observation I want to make here is that, for those of you who do feel that something should be happening – whether in one of the areas that we are working in or an area of your own – there is a responsibility not just to hope that somebody else will do something about it but either to get involved yourself or to find the people who will get involved and play an active role.
Finally, back to my prevention taskforce hat. On behalf of the taskforce, I thank the Academy very sincerely for taking on prevention and I thank you all for your ideas and contributions. We have heard some terrific discussions and some terrific ideas. We look forward to receiving the outcomes of the meeting and to further input. As various people have pointed out, this Academy has the status that makes it influential, whether with governments or in bringing together other disparate groups together from different backgrounds, so it really is important that you have taken this area on. But, as I have said, I also hope that all of you as individuals will let us know what you think and will then advocate for it.
Times are hard and who knows where global economic catastrophes are going to take us. But, even despite all of that, I genuinely believe that, with a prime minister and a health minister who genuinely understand and are concerned about prevention, there is still a once in a generation opportunity to get some traction for prevention. If we are going to make that happen, we will certainly need all your ideas and support. Thank you.