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15 Aug 2019

BY PROFESSOR STEPHEN LEEDER, EMERITUS PROFESSOR, PUBLIC HEALTH, UNIVERSITY OF SYDNEY

The 50th anniversary of Apollo 11 refreshes and amazes us with its boldness, commitment, and quaint computing power. Another, much quieter, 50th anniversary is also in progress. What is now the Public Health Association of Australia began in 1969. It has grown into a strong collective of people, many of them health professionals, committed to improving the health of our communities. The formal celebration is scheduled for Adelaide next month.

It is interesting to note how much of the energy of formation came from people who had worked in Papua New Guinea. The lessons they learned, written large in the highlands and townships of that country, of what may be achieved by immunisation and networks of aid posts providing basic care of first contact staffed by ‘doctor bois’ and basic-trained indigenous maternal and child health nurses, encouraged them to consider what more could be done in public health in Australia.

From the outset, the Association sought to foster fellowship among public heath ‘believers’. It honoured and nourished research, especially epidemiology, and its application. Its diversity was reflected in the cumbersome name – the Australian and New Zealand Society for Epidemiological and Research in Community Health or ANZERCH. While admirably inclusive, the title was awkward and media-unfriendly.

In the mid-1980s, encouraged by support from the then Federal Minister for Health, Neal Blewett, it was changed to the Public Health Association – PHA. A similar association was soon formed in New Zealand and hence ours become known as PHAA, the last A obviously standing for Australia. Today it is a robust organisation with 1700 members from over twenty disciplines and in all States and Territories and 18 special interest groups. It has produced a plethora of policy statements to be used in advocacy.

The PHAA recently listed what it perceives as major achievements in Australian public health over the past 50 years. Every one of these successes required collaboration and PHAA claims no monopoly. The list includes:

  • Folate helped reduce neural tube defects.
  • Immunisation and eliminating disease.
  • We helped contain the spread of HPV and its related cancers.
  • Oral health: we helped reduce dental decay.
  • Slip! Slop! Slap!: We helped reduce the incidence of skin cancer in young adults.
  • Fewer people are dying due to smoking.
  • We helped bring down our road death and injury toll.
  • Gun control: We worked to reduce gun deaths in Australia.
  • HIV: The spread was contained.
  • Finding cancer early: Screening prevented deaths from bowel and breast cancer.

Another aspect of reflection, beyond the milestones of achievement ‘on the ground’, is to ask about the overarching goal. What did we seek to achieve through our efforts, and of course by no means ours alone, and how much of that goal is durable, applicable today as a guide and stimulus to future action?

Amartya Sen, born in Santiniketan, India, and aged 86 in November, was awarded the Nobel Memorial Prize in Economic Sciences in 1998. He has made inspiring contributions to development economics. Famously, he asserted that famine (not undernutrition) is a political construct. During the Irish potato famine, Ireland continued to export food to Britain, for example. The crucial underpinning of community development in Sen’s thesis is freedom – from poverty and other captivating social circumstances.

One sentence from Sen’s writing struck me when I considered PHAA turning 50. He wrote: “Our task is to create the conditions for people to have the freedom to lead lives they have reason to value.”

It is worth parsing that statement. Contributing to the conditions that allow all our citizens the freedom to lead lives they value is quite a goal, but surely a good one for public health.

There’s a precondition. People will have the freedom to lead lives they have reason to value if they live in a society that values their lives. In New York in 2003, I met a health educator who told me that disadvantaged Harlem youth were resistant to all her efforts to reduce their smoking. “Why should we quit?” they asked, “when we’ll be dead in five years?”

If health is not regarded as a resource to be shared among all citizens, or quality education is restricted to those who can pay, or where the environment is a resource to be stripped naked for the wealth of a few, or where our hearts are closed to strangers, then we send a negative message to all our people. By contrast, a society that values its citizens motivates them to value themselves. Such valuation can happen anywhere, any time. It is relevant to general practice.

My youngest son is completing his third year of medicine and was recently attached to a rural Aboriginal medical service for three weeks. He was deeply moved by the dedication and professionalism of the staff, which included general practitioners, and the value they attached to often extremely challenging and difficult patients, some with very low self-esteem. Something kept these people at it.

I suspect that the staff in such settings take strength from statements such as Sen’s where he defines our mission as creating the conditions for people to have the freedom to lead lives they have reason to value. This can partly be ‘big ticket’, done by policy makers and politicians. It can also be done by us as individuals. That is the grand opportunity of medicine and public health.

 

Stephen Leeder was national president of PHAA 1985 to 1988 and again 1994 to 1998. He is an emeritus professor of public health and community medicine at the University of Sydney.


Published: 15 Aug 2019