Public health: adapting to change Martin McKee London School of Hygiene and Tropical Medicine European Observatory on Health Systems and Policies Christchurch, August 2014 Twitter: @martinmckee 1
Report on the Typhus Epidemic in Upper Silesia • The law existed, the civil servants were there—and the people died in their thousands from starvation and disease. The law did not help, as it was only paper with writing; the civil servants did no good, for the result of their activity again was only writing on paper . The whole country had gradually become a structure of paper, a huge house of cards, to be toppled in a confused heap when the people touched it. . . . • The bureaucracy would not, or could not, help the people. The feudal aristocracy used its money to indulge in the luxury and the follies of the court, the army and the cities. The plutocracy, which draw very large amounts from the Upper Silesian mines, did not recognize the Upper Silesians as human beings , but only as tools or, as the expression has it, “hands.” The clerical hierarchy endorsed the wretched neediness of the people as a ticket to heaven . Rudolf Virchow 2
“ Medicine is a social science, and politics is nothing else but medicine on a large scale …. The physicians are the natural attorneys of the poor, and social problems fall to a large extent within their jurisdiction. ” 3
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" The government should hang its head in shame over today’s immigration figures with 140,000 Kiwis out of work and a housing crisis in Auckland” "The pressure on housing, jobs, our hospitals, schools and our welfare system from a near record 41,000 people settling here in the past year is unbearable and will squeeze these services for hardworking New Zealanders.” Winston Peters 5
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Two views “epidemiologists are not social engineers” Ken Rothman “Unfortunately, for many epidemiologists the study of social factors is considered too political… it is necessary for epidemiology to affirm its connection with policy and to reject scientific isolation” Ruth Bonita & Robert Beaglehole 7
Good • Aristocracy • Timocracy • Oligarchy • Democracy • Tyranny Bad 8
“If the term is taken in its strictest sense, true democracy has never existed and never will. It is against the natural order that the majority should govern and that the minority should be governed” Jean-Jacques Rousseau The Social Contract 9
Voter turnout in New Zealand general elections 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 1946 1954 1963 1972 1981 1990 1999 2008 10
“Society can and does execute its own mandates: and if it issues wrong mandates instead of right, or any mandates at all in things with which it ought not to meddle, it practices a social tyranny more formidable than many kinds of political oppression , since, though not usually upheld by such extreme penalties, it leaves fewer means of escape, penetrating much more deeply into the details of life, and enslaving the soul itself.” 11
Divided societies spend less on social welfare… 12 Alesina & Glaeser (2004)
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“When it comes to paying contractors, the sky is the limit; when it comes to financing the basic functions of the state, the coffers are empty.” 15
“Welcome to the world of sexed-up medicine, where patients have been turned into customers, and clinics and waiting rooms are jammed with healthy people, lured in to have their blood pressure taken and cholesterol, smear test, bowel or breast screening done.”
Has the Canterbury health system been transformed? No. Is it transforming? Yes. Is what it is doing transformational? Certainly. 17
““Manufacturers know better than anyone that tobacco control legislation is designed to succeed, but voluntary agreements are designed to fail, and in that they succeed brilliantly.” Mike Daube 18
Denialism • cherry-picking the evidence • moving the goal posts by setting impossible standards of proof • paying false experts • promoting logical fallacies McKee M, Diethelm P. BMJ 2010; 341: 1309-11. 19
"Books of this genre are expected to have a happy ending…. Alas, however, we speak here of a democracy of those with the least sense of urgency to correct what is wrong… " 20
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““The philosophers have simply described the world, our task is to change it” 22
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A mountain of debt? 24 Source: Paul Krugman
“Before accepting large cuts in public spending, it is important to contrast the lack of evidence for such short-term fixes with potentially dire repercussions for population health and welfare.” 25
A simple mistake, with important consequences… 26
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Russia in context 80 Life expectancy at birth (years) European Union 75 Czech Republic Poland 70 Hungary 65 Ukraine 60 Russian Federation 55 1970 1980 1990 2000
Surrogate spirits in Russia 29
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“Mining production was associated with higher population TB incidence rates (adjusted b=0.093; 95% confidence interval [CI]=0.067, 0.120; with an increase of mining production of 1 SD corresponding to about 33% higher TB incidence or 760000 more incident cases), after adjustment for economic and population controls.” Stuckler D, Basu S, McKee M, Lurie M. Mining and risk of tuberculosis in Sub-Saharan Africa. Am J Publ Health 2011; 101: 524-530. 31
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We the undersigned doctors, nurses, scientists, health workers, psychologists, health academics, health managers and other concerned individuals call on the Howard Government to immediately release and process all people detained, who are seeking refuge under the United Nation's Convention relating to the Status of Refugees, on the following grounds: 36
An enemy of the people? “Should I let myself be beaten off the field by public opinion, and the compact majority, and such deviltry? No, thanks. Besides, what I want is so simple, so clear and straightforward. I only want to drive into the heads of these curs that the Liberals are the worst foes of free men; that party-programmes wring the necks of all young living truths; that considerations of expediency turn morality and righteousness upside down, until life is simply hideous. . . . I don't see any man free and brave enough to dare the Truth. . . . The strongest man is he who stands most alone.” Dr Thomas Stockmann 37
“Never doubt that a small group of thoughtful, committed citizens can change the world. Indeed, it is the only thing that ever has.” Margaret Mead 38
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