The research looked at the differences in health benefits of using a bicycle sharing scheme run in Barcelona compared with travel by a car in an urban environment. The results were clear: public bicycle sharing schemes can improve public health.

In particular, the study found that physical activity lead to the avoidance of death producing a benefit to risk ratio of 77:1.

Using bicycles was also good for the environment. Annual carbon dioxide emissions in Barcelona were reduced by an estimated 9,062 tonnes.

The study adds to the growing body of evidence (from a public health perspective) for central government to subsidise bike sharing schemes in our major cities.

Kevin

The theme of International Nurses Day 2011 is increasing access and equity, and it is particularly timely. Next week’s budget will see cuts across a range of social services and income support such as Working for Families, and it is reasonable to assume these cuts will have a flow on impact on access to health care. This is on the back of cuts to primary health funding in last year’s budget. Less income and a lack of funding make health choices harder.

25% of New Zealand kids live in poverty and there is a direct correlation between their economic status and their poor health outcomes.  Last year Dr Nikki Turner, from Child Poverty Action Group, put together a presentation called Poverty Leads to Poor Health that shows overall a child from a low-income household has a 1.4 times higher risk of dying than a child from a wealthy household. She also shows that after hour emergency costs for kids can be over $50 depending on where you live. That is a lot of money if you are on a low income.    

Nurses are on the frontline dealing with these issue day to day. So it is great to see their union,  the New Zealand Nurses Organisation (NZNO), again leading the charge for a better health system. Their 2011 election manifesto sets out a series of recommendations that would make our system better and improve access and equity.  Universal access to primary health care, greater investments in the nursing workforce and addressing the drivers of poor health outcomes are essential to building a happy and healthy New Zealand.

Nurses’ historic pay equity campaign showed that they and their union are capable of winning the changes they want. Let’s all get behind their campaign Vote Well for a Healthy Future to win the health system we need.

In Porirua the Mayor (my tour guide Nick Leggett) is 31 years old and the Deputy Mayor Liz Kelly is tangata whenua. A quick glance at local government statistics will show how unusual this is. Porirua City Council is an active partner with some great initiatives such as three I visited: Trash Palace, Pacific Health Services, and Pataka Gallery.

Trash Palace is adding 30 years to the life of the Porirua landfill, employing a range of people with illnesses and disabilities, and educating the next generation about resource recovery. Their Manager Elizabeth Caluzzi (‘Queen Elizabeth’) is a wonderful advocate for the multiple benefits of valuing ‘trash’, and valuing people.

'Queen Elizabeth' at Trash Palace

Pacific Health Services trustees with Porirua Mayor Nick Leggett

Pacific Health Services is facing cuts from the PHO, which is false economy as they have the people and the skills to reach a vulnerable population and inspire then to be healthy. I don’t believe the hospital model can achieve the same success they have.

The Pataka Gallery is a world class art gallery and as well as a lively and valuable community venue.

Its no wonder Porirua has won several ‘International Liveable Communities’ awards. It’s not like they’ve got no issues but at least their Council and communities are talking the same language about community-led development.

In Nelson, I spoke with the large community of practitioners working on disability support who make up the New Zealand Disability Support Network, at their first ever national conference. Their challenge to the politicians is clear. They want a coherent plan to ensure the New Zealand Disability Strategy is properly resourced and implemented. I couldn’t agree more.

I also met with Penny Molnar, a community development leader and nurse who is part of the great work at Victory Village. Victory Village is an example of how to combine a Health Centre and a Primary School to build a stronger community. Their innovative practice has been recorded in a very interesting report called Paths of Victory and a national forum is being held at Victory Village in April.

These two days reminded me that despite cuts and catastrophes we have some exceptional strength in the flaxroots and the grassroots and we need to back them up with both resources and respect.

The Bill is a very very very small itsy bitsy step in the right direction, but it does not go anywhere near as far as what Geoffrey Palmer and the Law Commission suggested in their report Alcohol in Our Lives: Curbing the Harm.

Simon Power is only tackling the easy bits and scapegoating youth in the current legislation. He hasn’t nearly gone as far as the 3000 or so submissions to the Law Commission show the political will to be.

So if you’re going to make a submission on this Bill—which I highly recommend you do—here are some topics to concentrate on.

• The current Bill only tinkers around the edges while the Law Commission asks for comprehensive reform. This means addressing a broad range of problems from regulating the supply of alcohol, to price, advertising, reducing demand and increasing treatment options.
• The Bill totally neglects the impact that advertising and sponsorship have on peoples’ drinking. We’d like to see proper enforcement of advertising standards for liquor and a move to remove all alcohol advertising and sponsorship from our TV screens, billboards and sports stars chests within two years.
• More than 19 countries require health warnings on alcoholic products. We don’t and the Alcohol reform Bill doesn’t even touch the subject. We think that with over 500 babies being born in New Zealand every year with Foetal alcohol spectrum disorder that a small reminder on the side of the bottle is worth it.
• Importantly the bill does not address price. Literally hundreds of public health studies show that the easiest way to reduce excess alcohol consumption is to increase price.

So if you want to help change New Zealand’s heavy drinking culture for the better please submit by this Friday.

I went to a hastily organised public meeting up the hill from my house last night about a proposed cellphone tower in Hataitai, Wellington. Vodafone want to put a cellphone tower on top of a street light pole among a bunch of houses near the school.

Vodafone only notified two local residents, and they in turn notified some of the local community – one of those notified was Fiona Kidman and she ended up in the DomPost yesterday about it. 

The meeting at the school, organised at short notice, had 30 or so people at it. They resolved to ask Vodafone to talk to the community about the tower before they built it. We were fortunate to have someone come along from the fight over towers in Titahi Bay to give us some support and advice.

Health and precaution

The issue of concern is the potential health risk associated with chronic exposure to non-ionising radiation, or radio frequency radiation, being emitted by these towers, or base stations. A French Court, for example, forced a telecommunications company to take down a cellphone tower in 2009 on the grounds that 

While the scientific discussion remains inconclusive, the company Bouygues Telecom has not demonstrated in the present case either the absence of risk nor the respect of any principle of precaution…..Considering that, while the reality of the risk remains hypothetical, it becomes clear from reading the contributions and scientific publications produced in debate and the divergent legislative positions taken in various countries, that uncertainty over the harmlessness of exposure to the waves emitted by relay antennas persists and can be considered serious and reasonable

There is a lot of evidence out there that casts some uncertainty over the safety of these masts and enough uncertainty to suggest a precautionary approach to the issue.

And yet, as I will demonstrate, NZ’s approach has been the exact opposite of the precautionary principle. How cellphone towers are put up in our neighbourhoods is a case study in how corporations exercise power and how the Labour Party is complicit in this.

Your rights and Labour’s NES

The extraordinary fact is that you have no legal right to have any say over the placement of cellphone towers on street poles on the road reserve. You have no legal right to stop them putting a cellphone mast one metre outside your kids’ bedroom if that’s where the street pole is. Period.

Your legal rights were all removed by the Labour Govt by regulation on Sept 8, 2008.

Labour removed all of your legal rights while calling it something rather positive sounding – they did it by enacting a National Environmental Standard. Sounds good doesn’t it; say it aloud and you’ll feel positive about our government: National Environmental Standard.

Trevor Mallard was the so-called Minister for the Environment who pushed through this so-called National Environmental Standard (NES) for Telecommunications Facilities.

The NES says that, so long as the telcos meet certain rules around the size of the cellphone towers and boxes, and meet a NZ Standard (NZS 2772) on the radiation coming out of the equipment, the telcos don’t have to get any permission from the local council or the residents to put up as many cellphone towers as they like on street poles on the road reserve. You can read the cabinet papers here.

Normally you think of an environmental standard as a minimum standard of environmental protection. Instead this standard is a maximum standard – councils are not allowed, for example, to say that they want to have a more precautionary approach to radiation in their district and require the towers emit less radiation than they are allowed to under this NES.

I think it’s wrong to impose a maximum standard of protection. If a local community, as represented by their elected council, wants to reduce the radiation coming out of cellphone base stations in their area then they should be allowed to.

Telcos and the NES

Now, Labour’s NES is pretty draconian, forcing people to accept devices around their homes and schools that continuously emit radiation, so if you were going to impose such a draconian set of rules on people, you’d want to be pretty confident that independent people with a strong health focus wrote the rules wouldn’t you?

Think again. According to the Parliamentary Library, Labour got the following people together to form the  Telecommunications Industry Reference Group which wrote the report which formed the basis of the NES:

• Alistair Dixon, TelstraClear Limited
• Chris Horne, Incite (Auckland) Limited, Resource Management Consultant for Telecom
• Christine Turner, formerly Telecom New Zealand Limited
• David Willetts, Enfocus Planning Limited – Ministry for the Environment Consultant
• Harry Hopkinson, Telecom New Zealand Limited
• Ian Hutchings, Ministry of Economic Development
• Irene Clarke, Local Government New Zealand
• Karl Mischewski, Vodafone New Zealand Limited
• Pat Holm, Local Government Advisory Group
• Poul Israelson, Harrison Grierson, Resource Management Consultant for Vodafone and TelstraClear
• Richard Hawke, Ministry of Economic Development
• Sally Gilbert, Ministry of Health.

As you can see there was just a single person who was there to represent a health perspective, the rest were either the telcos, or govt agencies supporting the telcos,. or local govt. The telcos had an interest in lowering the cost of putting up towers, the government departments were there to help lower costs, and Local Govt NZ was not there as a health expert. It was a jack up.

Labour then used the report of these people as the basis of the National Environmental Standard. Feeling safe and secure?

The NZ Standard

But I hear you say, what about the New Zealand Standard 2772 that underpins the NES. That’s gotta be legitimate right? I mean a New Zealand Standard just sounds solid and proper doesn’t it? We’re the most uncorrupt country on the planet, surely a New Zealand Standard, is the gold standard of health protection?

OK here is the group that decided on the New Zealand Standard, NZS 2772: Part1: 1999, Radiofrequency Fields, Part 1, Maximum Exposure Levels, 3kHz to 300 GHz (according to the list at the front of the standard):

• Adopt Radiation Control
• Broadcast Communications NZ
• Local Govt NZ
• Ministry of Commerce
• National Radiation Lab
• NZ Assoc of Radio Transmitters
• NZ Inst of Occupational and Environmental Medicine
• Telecom NZ

Again, another committee dominated by industry and government departments with one health professional. A group dominated by those trying to reduce costs for telcos.

The telcos, and government departments supporting the telcos, wrote the New Zealand Standard that underpins the NES, and ‘guarantees’ its safety. Or does it guarantee its safety? It has this rather disturbing little disclaimer at the start:

There is scientific research, including epidemiology, which has suggested associations between some adverse health effects and exposure to RF [radio frequency] fields at levels lower than the basic restrictions specified in this Standard, however causation has not been shown.

So they haven’t guaranteed that it’s safe. You may remember this language – it is the same language that the tobacco industry used about smoking . They were forced to agree that there was a correlation between smoking and disease but quite correctly said you can’t prove “causation”. Of course eventually causation was established but the tobacco industry used exactly this argument for years to fight off attempts to regulate tobacco.

The NZS 2772 Committee said that, while there was uncertainty as to the safety of radiation from these cellphone towers, they would “continue to monitor the results of this research and, where necessary, issue amendments to this document.”

That was in 1999. There has been only one minor amendment in November 1999, which looks like a correction but has no explanation. So much for amending and updating the Standard. It hasn’t changed.

Now the paper on which this NZS 2772 relies is by the International Commission on Non-ionizing Radiation Protection (ICNRP) from 1998.  Yet, there has been lots of research questioning the level of radiation allowed by the ICNRP in the more than a decade since it was written but the ICNRP standard has remained unchanged. A number of countries have abandoned the ICNRP standard and have required lower radiation levels from the towers. But not NZ.

Summary

So, in 1999, a committee dominated by the telcos and the Ministry of Commerce wrote the NZ Standard 2772 that set the levels of radiation allowed from cellphone towers. Then a committee dominated by the telcos and MED used this NZ Standard as the basis for the National Environment Standard that the Labour Government adopted in 2008. This NES forces us all to have cellphone towers on any street pole in the country without any legal right to object regardless of how close it is to people’s houses or schools.

I would wager that 99% of New Zealanders know almost nothing about this story and if they did they would be furious. But they will only find out when the tower goes up, and that happens pole by pole. The Government should have protected us from the telcos and operated a precautionary approach, instead they did their dirty work and willfully tied the hands of citizens and councils. The corporations have taken hold of our government, and Labour happily aquiesced.

If the Nats really wanted to show that they weren’t in the pockets of the telcos like Labour, they could publicly review the NES and the NZ Standard, but I don’t like the chances.

These Youth One Stop Shops have mostly grown up in the health sector from the ground up, where needs have been expressed from young people and, usually, the health professionals who work with them for a centre that:

• is a youth friendly place to go
• is not the same place that their parents or other family members get health services
• have a range of health services (and preferably other services, like legal advice and housing) under one roof so that young people don’t have to navigate complex and fragmented systems to get the help they need.

I worked a lot in the past in youth health, sexual health and mental health, and was involved in this establishment of these one stop shops. For me the prime motivation was that for sexual health, family planning, mental health and alcohol and drug issues, in particular, young people would often be too embarrassed to access mainstream services, especially if these were the same health professionals they had seen as children, or too worried about whether the services that they went to would tell their parents about the issues they had. The result was all too frequently that young people went without much-needed health services. So our aim was to increase access to services by giving young people choices, enabling them to choose the mix of services that they felt comfortable with. Very often, for example, they would choose to continue to go to their traditional family general practice for less embarrassing health issues (sore shoulder, flu vaccination, upset stomach) but to the one stop shops for genital rashes, contraception, depression, addiction etc.

Because these services grew out of particular communities, they tend to be extremely varied, with different ranges of services, structures and funding arrangements. Now a new zeal for minimising costs is putting some excellent services at risk. The pioneer and flagship one stop shop, 198 in Christchurch, has already closed, as have several others, and more are under threat. The precise nature of the threats in each case vary, but fundamentally the problem is that if we want to maximise access by increasing the options available to more at-risk populations (and the Greens certainly do) then it will cost more.

For example, Primary Health Organisations are paid a fixed amount for each person who enrols with them, and are expected to provide a full range of services with this (plus limited patient ‘co-payments’ when they visit). District Health Boards would say they have already paid the PHO for all the health services the young person needs, so why should they also pay the one stop shop for some ? Some argue that the solution is simple: we just get the PHOs to pay the one stop shops for the services they provide. Theoretically this could work, but in practice most PHOs are still largely associations of privately-owned small businesses who want to see as much income flow through to practices as possible, and it also would create a very uncertain funding situation for the one stop shops, which are unlikely to be manageable.

So there is a trade-off here: youth one stop shops set out to increase access by providing choice. This inevitably involves some duplication of funding. Eliminating the duplication will see most or all of these youth one stop shops close, with the result of decreased access by young people to important health services. It seems obvious to me that we need to retain these services, and therefore important that the Minister should signal this at a national level, rather than simply leaving it to DHBs to decide – his current approach.

One study has linked a brief exposure to a small amount during pregnancy can contribute to diabetic symptoms in a mother and her sons. This is due to the chemical interfering with normal hormone activity.

It is banned Denmark. Being phased out in Canada (baby bottles) and Australia (baby bottles). However, in good old Aotearoa New Zealand, the Food Safety Authority says “it is not regarded as safety risk”.

Good on Sue Chetwin from the Consumers Institute who is calling for a temporary ban until we can make sure it is safe.

The Green Party is very concerned about a number of chemicals in household products which are toxic, BPA being one of them. These chemicals include PVC (poly vinyl chloride) in guttering, plastic bottles, toys, wall paint, vinyl flooring and flame retardant products.

There are safe alternatives for all these products and we would like to see a shift to chemically safe household products. Our first step in this campaign is join with the Consumer Institute and call for a ban on the toxic baby bottles, or as the Europeans say – put it on the SIN (substitute it now) List.!

First up was his appearance before the Health Select Committee to answer questions about the Budget (although in practice questions tend to be very wide-ranging). I started by asking whether his statement on Budget Day that the increase in Vote:Health would “help protect” DHBs from real terms inflation meant that he accepted that the Budget increase was insufficient to fund the drivers of health costs (inflation, population increase and aging) to enable the sector to stand still. He answered “no”. The Ministry had calculated that $509m would be necessary to stand still, and the Budget had allocated $512m. And anyway, DHBs are expected to make efficiency improvements so even if inflation was 2%, the Government wouldn’t give them 2% but would still claim that it had funded them for inflation.

I asked about the calculation by the Association of Salaried Medical Specialists and the CTU that $555m would have been necessary to stand still — what was wrong with their analysis? He couldn’t tell me but will provide detail later. Should be interesting.

I pointed out that a substantial part of the new $512m allocated was, in fact, for new initiatives, so wasn’t even available to help keep up with inflation and demographic change. He responded by talking about how Spain and Ireland were making really big cuts to their health budgets. I asked about his response to the fact that Treasury and the Reserve Bank are forecasting inflation of nearly 4% (before the GST increase is factored in) adding another $58m to the amount necessary to stand still. More about Ireland and Spain.

Then in the House I asked about his response to the recommendations of the Public Health Advisory Committee on improving child health outcomes. Well of course he hasn’t decided yet. Further questions are batted away with blithe assurances that the Government is improving child health by having an immunisation target which the sector is doing well against. Oh to have had enough questions to ask about the other child health targets he has scrapped, or to probe his belief that immunisation was an adequate response to the socioeconomic inequalities driving poor child health! He, alone amongst New Zealanders I think, doesn’t believe the Budget will worsen socioeconomic inequality.

I asked him about rheumatic fever. It’s largely a disease of poverty. The report highlights a massively disproportionate impact on poor, Maori and Pasefika kids, and an overall rate 14 times the OECD average. 14 times! Why hasn’t the Government done anything about it? He claims they have done “various things” about rheumatic fever, but when asked to be specific responds with vague generalisations. Oh to have more questions again!

Let’s be clear: this government has adopted a Budget which will increase socioeconomic inequalities, and these will make most New Zealanders, including children, sicker. At the same time they have cut health funding in real terms and, to make matters worse, have especially cut community-based health services in order to fund their flagship services at the shiny, expensive, high-tech end of the services spectrum, heedless of where value for money lies. If the Government were even slightly interested in improving child health then the PHAC report is a great starting point, which has at its heart reducing socioeconomic inequalities. Ryall does not have other advice to the contrary, and I await with great interest, but little hope, his response to the report’s recommendations.

What Cuba Can Teach Us About Health Care

Just a morning’s boat ride from the tip of Florida is a place where medical costs are low and doctors plentiful. It’s Cuba – and Stanford University physician Paul Drain says it’s time for the United States to pay attention to our neighbor’s shoestring success.

Despite a 50-year trade embargo by the United States and a post-Soviet collapse in international support, the impoverished nation has developed a world-class health care system. Average life expectancy is 77.5 years, compared to 78.1 years in the United States, and infant and child mortality rates match or beat our own. There’s one doctor for every 170 people, more than twice the per-capita U.S. average.

Not everything is perfect in Cuba. There are shortages of medicines, and the best care is reserved for elites. But it’s still a powerful feat. “In Cuba, a little over $300 per person is spent on health care each year. In the U.S., we’re spending over $7,000 per person,” said Drain, co-author of Caring for the World and an essay published April 29 in Science. “They’re able to achieve great health outcomes on a modest budget.”

With Fidel Castro’s reign as Cuba’s leader ending two years ago, relations with the United States have thawed. President Obama eased restrictions on travel to Cuba last year, and the oft-introduced Free Trade With Cuba Act finally has a chance of passing Congress. Drain would like the Institutes of Medicine to conduct a full study of the island nation’s success.

“There are so many lessons we might be able to learn from Cuba’s health care and medical education system, but we don’t know too much about it,” said Drain.

Wired.com: How does Cuba keep health care costs so low?

Paul Drain: Partly by keeping physicians’ salaries low. Obviously, given the government they have, they can do that. But they also emphasize primary care and preventive care, addressing diseases and problems before they become major. It’s a very different approach to health care.

In the United States, we essentially do the opposite. We treat diseases when they occur. We’re not very good at the preventive component, which causes the costs of our health system to be much higher.

Wired.com: What are the origins of Cuba’s approach?

Drain: Starting in 1964, they encouraged all medical school graduates to do at least two years of service in a rural area. That program became so popular that by the mid-1970s, almost all new physicians were doing rural service. From there, almost all medical graduates were channeled into a three-year family medicine residency. That’s where they do clinical training, making the transition to full doctor from medical student.

Almost all their residents do family medicine. They focus on primary care for all ages. Once everybody learns primary care, about 35 percent go on and specialize. It’s quite the opposite of what we have here.

Wired.com: How so?

Drain: Our medical students choose what they want to do. Only about 7 or 8 percent go into family medicine, which is our primary care system. In Cuba, everyone becomes a primary care doctor. They learn to prevent diseases.

Cuba also provides very good access. In the mid-1980s, they created a system of neighborhood doctors’ clinics. One doctor is responsible for a catchment area of a couple of city blocks. They get to know their patients well. If somebody has a problem, they can see the doctor in the clinic that day.

Wired.com: Could the U.S. government ever mandate a system like that?

Drain: It would be a big leap, but there are smaller steps that could be taken. We’re the only developed country without universal access to a nationalized health care system. Other countries have seen health care as a basic right and insured everybody. Everyone gets primary care. That would be a first step.

I saw someone in my clinic yesterday who hadn’t seen a doctor in 10 years. Her blood pressure was through the roof, and it’s probably been like that for a decade. She’s at tremendous risk for having a stroke or heart problems. If she’d seen somebody back when this started, it could have been controlled. But because of her high blood pressure, who knows what her future medical bills will be like.

If she were in the Cuban system, she would have had a visit scheduled yearly for the last 10 years. If she hadn’t shown up, someone would have gone to her home to see if she was OK. Blood pressure is an easy thing to check. It would have been controlled.

Wired.com: One problem in the United States is the shortage of doctors. How does Cuba train physicians?

Drain: Education is paid by the government, so students don’t have debt. In the United States, medical students come out $200,000 or $300,000 in the hole, which deters them from going into primary care. Cuban doctors are making a fraction of what we make in the U.S., but most Cubans aren’t going into medicine to earn money. They’re going into it to treat people in their communities.

In 1999, Cuba created a school of medicine for Latin America. They bring students in, train them for six years, give them room and board and a stipend. Afterward the students are required to go home and practice in poorer communities. It’s a remarkable program, with 10,000 students now from 33 countries, and an interesting model for developing health care workers.

Wired.com: Do President Obama’s health reforms move the United States toward what’s seen in Cuba?

Drain: What we’re passing is starting to move us in a better direction. I’m an advocate for universal health care, and there’s still a long way to go. But I think we’ll eventually catch up to our western counterparts, and realize that we’re the only country not providing full equity in terms of accessing health care, and that’s reflected in health outcomes. When you compare us against most developed countries, we’re near the bottom in most health indicators. Our life expectancy isn’t as good, our infant mortality rates are higher, and we’re spending twice as much money.

You can read the original here.

Terminal problem

Inequality kills. Those at the bottom of the heap in New Zealand die sooner than those at the top of the heap.

A meta-analysis of 169 published studies by Wilkinson and Pickett showed that there is a relationship between average standards of health tend to be better in rich countries with low income inequality.

In a recent article in The Listener, Philippa Howden-Chapman looks at how health inequality is gearing up to be one of the big issues in the upcoming British general election.

Howden-Chapman singles out two reports (PDF here and link here) which found societies that try and stop the transfer inequality and privilege from generation to generation and society as a whole, are the ones that do better economically and in terms of health. The two reports also acknowledge the Green Party initiative of making homes more energy efficient as a way of reducing costs and promoting good public health.

The pop-out quote, “There is an explicit recognition that getting people off benefits into low-paid, insecure and health-damaging work is not a desirable option,” stands in stark contrast with the Key Government’s bashing of beneficiaries. Forcing beneficiaries to find jobs and eroding workers’ rights is a step in the wrong direction. If we want to live longer we should not only be pushing for a more progressive tax system, but for the government to promote green jobs.

The Situation in New Zealand

The name of this paper is self explanatory: Geographical inequalities in health in New Zealand, 1980-2001: the gap widens [PDF], by Jamie Pearce looks at how mortality in the most impoverished areas in New Zealand has increased.

In the above graph, Pearce et al point out that as a whole we’re living longer, but our relative index of inequality is rising. They compared all District Health Boards and saw that from 1980 to 2001 risk of death in the poorest DHB increased from 1.15 times greater to 1.25 times greater than the wealthiest DHB. This means if you live in Whanganui, your time on this planet is mostly likely going to be shorter than someone in Canterbury.

They conclude with a simple plan of action,

“If policy makers are committed to reducing health inequalities then more redistributive economic policies are required.”

The newly elected Labour Government got off to a promising start in 1999 when Michael Cullen put the top tax rate up to 39 percent. In 2001, then Minister for Health, Annette King put reducing health inequalities as her number six goal for primary health care. The Ministry of Health then set about doing a report titled Monitoring Health Inequality Through Neighbourhood Life Expectancy [PDF].

The problem that the Ministry found was that there really wasn’t enough data in New Zealand. We knew when people were dying through life expectancy, but we didn’t have a “health expectancy”. The report itself does not analyse causes of inequality, but they point out that once we start measuring health expectancy we will be better informed.

Monitoring Health Inequality reported that there were startling inequalities between DHBs. Here is another graph that shows what the Ministry found.

The inner circle is where the MoH want all DHBs to be. The further to the bottom left you go, the more unequal the coverage is and the lower the life expectancy.

Killing you softly

So what, other than helping to generate a few risky, health adverse jobs, is the National Government doing?

Health Minister Tony Ryall has mentioned inequality zero times in releases since becoming minister. In fact none of the associate health ministers have mentioned it either..

The way forward is not to stretch budgets, it is to address inequality – we know that income inequality is related to health inequality. We know that the healthier people are, the more productive they are. It is simply just better for everyone if we live healthier, longer lives.

I want my daughter to grow up in a New Zealand where every one lives long and healthy lives. I want her to be able to live anywhere in New Zealand and get the best health outcomes possible. We need to address these issues today so the next generation can.

I leave you with this thought from George Bernard Shaw,

“Between persons of equal income there is no social distinction except the distinction of merit. Money is nothing: character, conduct, and capacity are everything. There would be great people and ordinary people and little people, but the great would always be those who had done great things, and never the idiots whose mothers had spoiled them and whose fathers had left them a hundred thousand a year; and the little would be persons of small minds and mean characters, and not poor persons who had never had a chance. That is why idiots are always in favour of inequality of income (their only chance of eminence), and the really great in favour of equality.”

EDIT: The end of the sentence of the first paragraph under the subtitle The Situation in New Zealand has been removed because, well it didn’t make any sense. An editing error on my behalf — Frog

“Unfortunately jandals are really bad for your feet, legs and back. The answer is to lose the shoes altogether,” Green Party co-leader and podiatry spokesperson Metiria Turei said today. “I’m a jandal lover like a lot of New Zealanders, but we have to adapt.

“Even if we don’t value our own health, we have to change habits for the sake of our children.”

Recent research from the United States of America shows that jandal wearers alter their gait, which can result in problems and pain from the foot up into the hips and lower back. The study at Auburn University’s Biomechanics Laboratory, found that jandal wearers took shorter steps and that their heels hit the ground with less vertical force than when the same walkers wore athletic shoes. Jandal wearers did not bring their toes up as much during the leg’s swing phase, resulting in a larger ankle angle and shorter stride length, possibly because they tended to grip the jandal with their toes.

Ms Turei said a joint initiative from the Ministries of Health and Economic Development could stamp out New Zealand’s jandal problem: “We need a major education initiative so Kiwis understand the danger they are in and we need financial support for local manufacturers as we phase out jandal production.”

The jandal eradication program would cost up to $194 billion according to Green Party research, Ms Turei said. “It’s expensive, but we must act in the interests of public health. I don’t know where we’d find $194 billion but we must find it. The Government will have to dig deep.”

The MED project should also look at ways to re-purpose jandal-making factories, the Greens said. “Preliminary research suggests that we could use jandal rubber as a softer, gentler footpath material,” said the Green Party’s associate podiatry spokesperson Kevin Hague, “and we could lay tracks to encourage New Zealanders to walk barefoot. I will suggest to the Prime Minister that we also put a rubber path alongside the national cycleway for tourists.”

The jandal crisis was new and required new thinking added Ms Turei: “We hope John Key’s Government figures out how to handle the jandal problem. His people are very focused on balance for New Zealand and very focused on step change, so they should understand.

“The Prime Minister needs to take the first step, commit funding for the footwear phase out and stick to it regardless of what Treasury or Finance Minister Bill English thinks – this is one area where we can’t afford to flip flop.”

The Jandal study: http://wireeagle.auburn.edu/news/359

Green Party Health Spokesperson Sue Kedgley has been collaborating with Health Minister Tony Ryall and Associate Health Minister Jonathan Coleman on the proposal. This work is part of the Memorandum of Understanding (MOU) signed between the Greens and National in April 2009.

In this podcast, Sue speaks about the proposal – why it’s needed, what it sets out to achieve, and what the process is from here.

Co-Leader Russel Norman also reflects on the MOU between the Greens and National in light of the announcement.

You can read the consultation document here.

This week’s music is from Auckland-based “chamber pop” outfit Canadia, off their most recent EP Beg Steal and Burrow.

You can now subscribe to our podcasts on iTunes – search for “green party” in the podcast section.

Click to play

If you’re having problems with our Flash player, try this alternative site.

This work is licenced under a Creative Commons Licence.

It’s hard to work out how representative that survey truly is but 80% seems unbelievably high. Raising the age to 18 would be a huge step up from the current age of 15.

It’s more likely the government will raise the driving age to 17. They’ll also probably give young people living in highly isolated rural areas the ability to apply sooner.

You’ll find out when the government releases their new Road Safety Strategy till 2020 in February.

It’s great to see Joyce taking such a strong line on road safety. However, as Kevin’s submission outlines, the Transport Agency’s current focus on how to improve road safety seems a little unbalanced.

The Greens would like to see a stronger focus on improving pedestrian and cyclist safety.  Also a wider understanding of what road safety actually means. For example, scientists estimate air pollution from motor vehicles kills as many people in NZ prematurely as road accidents. So why doesn’t the road safety discussion document mention them at all?

What do you think the drivers age should be? And what would your top priority measures to improve road safety be?

Cell tower springs up in Christchurch

Every week someone contacts me about an unwanted cell tower, mast or antennae, that are being erected near to where they live.

Last week I got a call from a woman in Herne Bay, Auckland – who had discovered that a cell phone mast was about to be erected on a telephone pole outside her home.

She was distraught – even more so when I had to inform her that she had no legal right, under present regulations, to be consulted, and that there was little she could do other than make an almighty fuss about it.

I was also contacted last week by a Christchurch woman about a cell tower that had been constructed next to her child’s school. In the morning when she took her child to school, there was no cell tower. But when she went to pick her child up at three o’clock, a cell tower had been erected, directly across the road from the local school (see picture above).

Nobody in the community had been consulted, not even the school –despite the fact that other countries (for example, France, New South Wales) do not permit cell towers to be erected next to schools.

Speaking of cell towers, who are we to believe? The Mayor of Manukau or the Prime Minister?

Earlier this month, the Mayor of Manukau, Len Brown, told the Howick and Pakuranga Times that the Prime Minister had assured him he would be recommending to Cabinet that the National Environmental Standard on Telecommunications be reviewed, particularly the need for consultation. (He was referring to the present standard which allows telcos to erect cell phone masts and antennae on virtually any telephone pole in New Zealand, without have to inform or consult anyone first).

So the Wellingtonian (one of the only media to cover the cell tower issue) decided to ring up Mr Key’s office to find out if this was correct.

He couldn’t get a straight answer from the Prime Minister’s office, but Environment Minister Nick Smith said he ‘wouldn’t give too much credence’ to the report of the Mayor’s comments in the Howick Times.

So the Wellingtonian rang Len Brown, to see if he had been correctly quoted. Mr Brown’s office assured him that the Mayor had been correctly quoted, and that the Prime Minister had undertaken to take the present radio frequency rules to Cabinet and look at changing them.

So the Prime Minister can’t wriggle out of this one, or renege on this promise – even if he is being heavied by the telecommunications industry, who certainly won’t want a review.  The present regulations are causing upset and distress all around New Zealand, as people discover cell phone towers have been erected without their knowledge or consent.

Even the Local Government and Environment committee recommended, in their recent report on cell towers, that “telecommunications companies should consult local communities on the location of cellphone towers, cellphone sites, cabinets and other EMR equipment in an area, and seek to come up with sites that have the least impact on nearly residential dwellings and schools.

While particular structures can either help or hinder (and sometimes both) the truth is that the people working in almost any system can usually find ways of providing good services. The problem is that it takes a little time following a reorganisation to work out ways to do this, so there is inevitably a loss of impetus. For over a decade New Zealand’s health system suffered like a sailing boat “in irons”: successive structural reorganisations followed so quickly that the system was never able to rebuild forward momentum and sat more or less paralysed.

It is precisely this paralysis we should anticipate from the changes proposed for the Ministry of Health – paralysis we certainly can’t afford.

District health boards have both good and bad points, but their pre-eminent virtue is that they have now been left in place for eight years, creating a stable platform from which to provide services, and some great innovation is now beginning to appear.

So far Health Minister Tony Ryall seems to have taken on board the strong message from the sector to leave structural settings intact when it comes to DHBs, but the same can’t be said for Primary Heath Organisations (PHOs) – the organisations that contract with DHBs to provide primary health care services. The Minister seems perfectly willing to wade into regions and lay down the law on the number and size of PHOs he wants to see.

He needs to be careful. The Ministry of Health has previously carried out research on whether or not it should require a minimum size for PHOs, and concluded that it should not. There can be advantages for both large and small size. Large PHOs can often harness efficiency through economies of scale, and are more likely to have a pool of patients large enough to cope with extraordinary costs of care for a few. On the other hand small PHOs are more likely to have strong community involvement (and are thus more likely to be able to deliver effective health promotion programmes), and seem better able to deliver the multi-disciplinary model of care envisaged by the primary health care strategy.

By trying to require larger PHOs, the Minister makes the system less likely to deliver some of the key goals that have been set out for it. Whose interest does this serve? Perhaps he needs to ask that question when he receives advice from those recommending changes.

It is obvious that different sizes of organisation will be best suited for particular functions, so how to choose? The debate over how many district health boards we should have was invited by the previous government who, in introducing the new system, indicated that they anticipated amalgamations may ensue in the future.

But this threat of amalgamation has been an unhelpful distraction. When district health boards encounter problems, all too often commentators have looked straight to amalgamation as a possible solution, leaving more creative options unexplored. With the structure left intact, these more creative solutions are starting to percolate through anyway.

The more cynical amongst us have always viewed DHBs as mechanisms for Government to retain central control over the health sector, while devolving the risks associated with it. If we want DHBs to be responsive to the needs and preferences of local communities, then maintaining all 21 boards gives the system the capacity for community responsiveness.

For functions where economy of scale suggests larger aggregations of population or services, then DHBs are starting to show a real willingness to collaborate and share. All DHBs are collaborating on various procurement projects (e.g. clinical supplies, motor vehicles), and in joint or shared health services, or ‘back office’ functions (like IT or Payroll). Some combinations of DHBs have taken this much further, with Otago and Southland DHBs, for example, having a conjoint senior management team, as well as joint arrangements at almost every level.

This has been hampered by the law, which requires each DHB to act in the interests of its own population. This was being interpreted to permit collaboration only when all participants benefit, whereas we should expect collaboration where there is net benefit, even if some individual participants will be worse off. This obstacle is being overcome through maturing in the sector and clear expectations from successive ministers.

What is emerging is a flexible and adaptive network in which each DHB is a node, able to act independently or in concert with others, depending on need. Some of the links between DHBs will be explored and discarded. Others will prove successful, be further refined, and provide templates for other parts of the network. Decision-making about what level of collaboration best suits different issues will also develop and improve.

The biggest threat to success for this network is the risk of Ministerial restructuring, either through DHB amalgamations or some more fundamental reorganisation. What the Minister instead needs to do is commit to further stability in structural arrangements, and to encourage and facilitate innovation and as much collaboration as possible.

It is perhaps not as dramatic and eye-catching as throwing all the cards in the air again, but a much better way of serving the public good.

Hypervigilance

Of course this initial period of Labtests’ operation was always bound to be subject to intense scrutiny, both arising from ‘hypervigilance’ on the part of funders and an anxious public, and from an intent on the part of the previous provider, DML to oust Labtests and reclaim its previous role. Had this level of scrutiny been applied to DML’s performance for a comparable period in the past, it remains to be seen how many errors or adverse events would have been detected.

Service deterioration

Nonetheless, some deterioration in service quality seems incontrovertible. It seems clear that doctors have experienced unacceptable and dangerous delays in accessing test results and speaking with pathologists. The reduction in collection centres (certainly justifiable in some areas) has resulted in whole areas being left without collection centres. Some collection centres are in entirely inappropriate locations (for example, the one I saw on Waiheke Island – the only one – that requires scaling two steep flights of stairs to get in).

Achieving savings by cost-shifting

Certainly saving $15 million on the contract (if indeed the promised savings are realised), to be made available for other health services, is not to be sneezed at, and at least one columnist has suggested that the previous service was inappropriately ‘gold-plated’. However, where a provider is able to reduce its price for a service by reducing access to that service or compromising timeliness then these savings are achieved by shifting cost  to users of the service, and thus shifting the boundary between publicly and privately-funded health services, without consultation with the public.

This doesn’t just apply to the health sector, but to all public services. We need to find ways to ensure that we receive as much value for money that we can where services are contracted out, without achieving this simply by shifting costs onto those members of the public who need those services.

So far the National Government has virtually ignored primary health and in some areas actively undermined it – so while  it would normally be great news to hear that the Government intends to prioritise primary care in 2010/11 - all indications are that  Tony Ryall is heading in the opposite direction and has got the priorities all wrong.

Meeting the unmet goals of the Primary Health Care Strategy is a great idea but the Minister’s statement this week bears no relation to the under-delivered parts of the strategy and instead seemed to be signalling  the restructuring of Primary Health Organisations.

The Minister’s announcement suggest that he is either unfamiliar with the vision of the strategy and the Vic Uni research just published, or is committed to his own direction, irrespective of them. Some of the Government’s actions have been helpful, such as the bonding scheme for rural health professionals, and the intent to permit a wider range of diagnostic testing to be ordered from primary care, but overall the Minister seems to have missed the point.

If the Government is truly concerned with how we are going to afford to pay for New Zealanders health needs in the future, in the face of aging population, epidemics of chronic disease and increasingly expensive new health technologies, then the role played by primary care will be critical. At the moment the Government is in reverse gear on these priorities (as can be seen in the scrapping of successful diabetes programmes, and healthy eating activities).

The reports published this week from Victoria University confirm that the Strategy has seen a diverse range of Primary Health Organisations (PHOs) develop, with varying approaches. These organisations have been extremely successful in enrolling New Zealanders and giving them significantly cheaper access to primary care, and good progress has been achieved on some of the other key directions.

The priorities for primary health care at the moment should be:

• Improving multidisciplinary teamwork
• Improving health inequalities, especially for Maori
• Working with their enrolled populations to keep them well in the first place, especially preventing chronic conditions like diabetes; and
• A concerted programme to improve quality and safety

But Tony Ryall seems to be ignoring these and instead pushing for restructuring of PHOs.

‘Shooting the messenger’ is a classic case of the kind of unhealthy politics that the Greens are trying to reform. While we believe debate can be robust, we nonetheless believe in treating others with respect and debating ideas rather than allowing an exchange of insults to substitute for grown-up behaviour. In consequence I won’t be responding to these smear tactics. We also believe that Ministers should actually have to answer questions, so for the sake of those for whom National’s tactics may have obscured the issue, here’s what we learnt this week:

• Despite Tony Ryall’s rhetoric about involving health professionals more in decision-making he did not consult the Association of Salaried Medical Specialists (essentially the NZ organisation of senior doctors) before deciding that DHBs should contract more of their surgery to the private sector. His reason for not doing so was that he had talked to them about National’s health policy before the election.
• There is a long-standing set of rules for DHBs contemplating contracting out surgery to the private sector. In amending these to facilitate more private surgery he has removed the explicit requirement previously placed on DHBs to consult their health professionals before doing so. His explanation for this was that he expected DHBs to be consulting health professionals all the time, so no special protocol was necessary.
• The Government refused to answer whether they had any information about how much public hospital operating theatres are used before Mr. Ryall made the decision to contract out more surgery to the private sector, but it appears this was not something they had considered.
• In fact analysis undertaken by the Ministry of Health comparing theatres in NZ public hospitals to a benchmark from Victoria Australia found that the theatres in 10 out of 26 hospitals were used at less than 60% capacity, while just 4 were used at full capacity. The Government is now aware of this information and argues that this under-used capacity will be insufficient in the future. This explains why more theatres may be needed in the future (although that decision looks rushed and ill-considered too) but has no relationship to the private contracting decision.
• The Government dodged questions about whether they believed more people should have private health insurance and whether they were deliberately weakening the public sector to engineer this outcome, to shift health cost away from Government.

The take-out message is that Government was determined to contract out more surgery to the private sector. This determination was not based on evidence, but either some promise made to the private health sector or simply ideology. They are entirely prepared to remove obstacles to this decision (like consultation with doctors!) should they stand in the way.

The other action sought by the private health industry from Government was encouragement of more New Zealanders to take out private health insurance (who knew?). We haven’t yet been able to confirm that this is what Government is trying to deliver – it could just be inadvertent – but their actions so far seem to fit this agenda.

Neither the Minister of Health nor the Ministry of Health has been able, under questioning at the Health Select Committee, to say how well the current operating theatres in New Zealand’s public hospitals are being utilised. For that reason I have written directly to all DHBs to ask.

I am aware, from my own experience as chief executive of a DHB and familiarity with many hospitals around the country, that many of these operating theatres stand unused for significant amounts of time. For example, they’re almost all unused at weekends; most hospitals would have at least one theatre “on standby” to deal with emergencies; and often theatres aren’t being used because there are insufficient staff in key roles, or because the staff and the patients aren’t both available at the same time that the theatre is free. It seems to me that we should have considered this information before Mr. Ryall committed to building another 20 operating theatres around the country and funding the private sector to deliver more surgery.

The practical effect of the change will be an increase in the uptake of private health insurance, representing a significant rollback of the Government in funding healthcare.

Of course it is legitimate to debate how much of the cost of healthcare should be shouldered by the State, and how much by you and me personally. But Health Minister Tony Ryall has not bothered with such debate, instead opting to substantially shift these costs without hearing others views.

This year’s Budget, while providing for increased Health costs in the current year, signals intent to decrease spending in future years. For those people who have been paying attention, this will have struck an ominous chord, as the need for health services continues to increase, and indeed to accelerate, due to an aging population, development of new (and more expensive) ways to treat, and epidemics of long term conditions such as diabetes and heart disease.

One way of managing the increasing need is to increase investment in programmes aimed at improving health in the long term. That is clearly not the Government’s strategy, as it has instead chosen to take the axe to exactly such programmes. For example, the substantial investment in Healthy Eating, Healthy Activity programmes by the previous Government has been decimated by the new regime. There is no evidence to support this decision; it is purely ideological. Unfortunately these were programmes aimed at producing gains in the long term, and their loss won’t be felt until well beyond the tenure of this Government.

At the same time, it has become apparent that Government instead plans to deal with the problem of increasing demand for health services by making more of us take out private health insurance.

Government has put pressure on district health boards to contract out more surgery to the private sector, as if this will enable the overall system to produce more operations. However, there is a fixed number of professionals in the system, and the Government’s decision won’t create any more – it will simply shift professionals from the public system to the private sector (where pay rates are substantially better). There isn’t a bunch of surgeons, anaesthetists and members of theatre teams standing around idle in the private sector waiting to do more.

This approach will further reduce the capacity of public hospitals, creating more and more hole, and increasing reliance on the private sector. Some cost in the public sector will fall although not as much as Government might think, as many of the costs are sunk in underutilised buildings and equipment.  Just enough however to enable the Government to meet its promises of decreased expenditure, while more and more of us are forced to take out private health insurance and thus perpetuate a vicious spiral.

Of course there is another theory: Tony Ryall doesn’t understand the system well enough to realise the consequences of his decisions. Perhaps there is not yet evidence to support this theory, but when the Surgical Hospitals Association presented to the Health Select Committee recently calling for more public contracting to private hospitals, and more Government encouragement for people to take out private health insurance, was some kind of debt was being called in?  Certainly this would explain the Budget.

There is no doubt that it will be more and more challenging for the sector to meet the increasing need for elective surgery. But there is another way: no attempt has been made to match up people in need and specialist skills against our existing theatre capacity.  Instead the system is saddled with the inefficiency of 21 separate queues. With collaboration, we could extract more efficiencies from the publicly-provided health sector in New Zealand before we give up and shove the cost burden back on to individual citizens.

While the experiments used in the item were not scientific the research that prompted the kiwi journalists to highlight this issue caused shockwaves when it was released in the United Kingdom in 2007.

The research – which was undertaken by the University of Southampton – found a link between hyperactivity in children and artificial food colourings.According to one of my favourite news sources European regulators are now working on a continent wide ban of the food colourings.

However in New Zealand we seem to be taking a cruisier, more relaxed attitude to kids’ health and safety.

Our own Food Safety authority considers New Zealand kids are unlikely to be putting their health at risk from consuming synthetic food colourings. The research cited backing up this statement is nearly a decade old and the page hasn’t been updated (at time of writing this blog) for 10 months.

Sue K highlighted this issue last year and it is worth noting that many teachers consider dietary intake does indeed have a great impact on behaviour in the classroom. Of course earlier this year our school canteens which had been on a road to good health are now back in the business of outdoing Willy Wonka with the ability to sell any and all manner of food.

Time to sign the school food petition [PDF] and remind the Government that kids’ health and learning is being jeopardised with the decisions of those in Government and the inaction of public service watchdogs.