Public Health Lecture - University of Otago
Public Health - Lessons from New Zealand’s COVID-19 response and opportunities for the future
E nga mana,
E nga reo,
E nga iwi.
Tēna koutou katoa.
Ka huri ki nga mana whenua o te rohe nei.
He mihi hoki ki a tatou kua tau mai nei I raro I te kaupapa o te rā.
No reira tēna koutou katoa.
It’s a pleasure to be back at the University today. Thank you to Richard Blakie for hosting me, and the chance to meet new and established researchers. As we’ll discuss, science based policy is a priority for me so the chance to meet with your researchers is very valuable.
I would like to begin by acknowledging the many staff, researchers, and University of Otago alumni who have contributed to the COVID-19 response. Recently we’ve been lucky to have epidemiologist Professor Trish Priest seconded to the Ministry of Health assisting with COVID-19 modelling. We’ve benefited from the collaboration between Gemma Geoghegan and ESR on whole genome sequencing of COVID-19 isolates. Alongside incoming VC Professor Murdoch, James Ussher and others have served on technical advisory groups. I am sure there are many others.
It is also a pleasure to be back on campus, because, like for so many New Zealanders, this University played an important role in helping me become who I am today (you may or may not want to take the credit for that). And while I am sometimes still surprised to find myself in the role I’m currently in, if I think of myself as an erstwhile medical student and OUSA student president, perhaps I should acknowledge there were clues I might have a role in health politics. And crucial to my readiness to enter Parliament and Cabinet during a pandemic, was the rigorous training in medicine and epidemiology I received here in my undergraduate and doctoral studies. And I’m immensely grateful for the teaching of epidemiologists like Professors Skegg, Dickson, Paul and Hill from whom I developed a structured approach to disease prevention.
Today I will outline some of the initiatives I’ve led in the field of public health. I’ll then discuss the COVID-19 response and transition that we are currently going through. I’m most interested though to reflect on what I think are lessons we should take for public health from the COVID-19 response. Finally, I will discuss how we can embed these lessons in our reformed health system.
Progress in public health
Earlier this month, I was extremely proud to be part of a Government that passed the Health (Fluoridation of Drinking Water) Amendment Bill. As you know, evidence has shown since the 1950s that fluoride prevents dental caries - and our country’s oral health is poor. In 2019, 6270 children under the age of 14 were admitted for operations for dental caries. I’m aware Otago has been home to strong advocates for fluoride.
The Bill entered Parliament in 2016 and, as originally drafted, sought to pass decision-making from local authorities to DHBs. One of my first decisions as minister was to take the opportunity to amend the Bill by supplementary order paper, to instead have the Director-General of Health as the decision maker. This is long-standing Labour Party policy, and it is - in my view - a vast improvement.
Community water fluoridation should never be a political decision - and we are only able to achieve equitable health outcomes, if evidence-based public health decisions are not re-litigated by a raft of different local authorities.
Now the Director-General of Health will make decisions about fluoridation of community drinking water supplies, potentially extending coverage from about 50 percent of community supplies to more than 80 percent, and improving the oral health of tens of thousands of New Zealanders.
From December the MOH will be writing to water suppliers to gauge, among other things, their readiness to commence fluoridation - and the Director-General will be able to make directions to fluoridate from mid-2022. As I’ve mentioned, we have some funds to assist local authorities with this transition. I hope the local authorities in the Southern region will take that opportunity to act quickly.
Another area of progress has been the mandating of folate fortification of non-organic bread making wheat flour.
We know this vitamin is crucial to the healthy development of babies in early pregnancy, often before a woman even knows she’s pregnant. Around half of pregnancies in New Zealand are unplanned, so it’s not possible for all women to take a folic acid supplement one month before they conceive - to reduce the risk of their baby developing a neural tube defect such as spina bifida.
This is another public health measure for which the science was unequivocal. Yet New Zealand had opted out of a joint Australia-New Zealand food standard to mandate fortification in 2009. This followed a scare campaign led by the Food and Grocery Council, which forced then-Minister Kate Wilkinson to abandon the proposal.
Both Folate and Fluoridation are reminders that misinformation has been a potent weapon against public health action in the past. That’s why I approached my work on these issues very carefully. Our progress this term has been enabled by high-quality reports on both issues by the Prime Minister’s chief science advisors, and some good journalism. But also by the Government’s prioritisation of child wellbeing. Science is essential information for how to solve our most pressing problems. But how you act on it is ultimately a matter of values, and politics.
Breast and Cervical Screening
Earlier this year I announced a major upgrade of the breast cancer screening system, and a new primary cervical screening test, to help reduce the number of women dying from these diseases.
Breast cancer touches the lives of many families in New Zealand, and I’m committed to ensuring New Zealand women can access the healthcare they need. The upgrade to the Breast Cancer Screening Register will ensure women aren’t falling through the cracks, by reaching out to the 271,000 women who are eligible to access breast screening but are not currently being screened - directly inviting them to get screened, and running targeted campaigns.
In other words, by moving from an “opt in” to an “opt out” register we will improve the reach of breast screening into Māori and Pacific communities.
And while our cervical screening programme has been a very effective tool for reducing cervical cancer, only about 65 percent of eligible wāhine Māori access it because of the acceptability of the smear test, whakamā associated with the current procedure, time and cost.
I had been working on a budget bid for months when Kiri Allan told me she was unwell. Sadly, these same barriers led to her developing stage III cervical cancer. It was a bittersweet achievement to get more than $100 million in funding for these two programs.
We’re funding an effective, simple and quick swab women can choose to do themselves - reducing barriers and making screening services more accessible, particularly for Māori and Pacific women. Again, information technology upgrades are an important enabler of this change - a new system will track a woman through the appropriate clinical pathway and generate an alert when a swab or appointment is missed. And I’m pleased to say that Kiri is back at work, in the Beehive office next to mine, recovered, working hard, and always there to discuss a difficult problem or share a laugh.
The COVID-19 response
But throughout my first year in Parliament, the most acute public health issues have been those relating to COVID-19. Let’s reflect on New Zealand’s experience to date.
After this virus first appeared in China in late 2019 and began to rapidly spread around the world, it became clear New Zealand’s standard pandemic preparedness plan - based on influenza - would result in us missing an opportunity to control the disease. For me, this realisation followed the release of the WHO special mission report into the Wuhan outbreak on February 28th, 2020. The report mentioned important differences between SARS-CoV2 and influenza, including a lower rate of asymptomatic disease, and a longer incubation period - both important factors for the success of contact tracing.
In late March, following the detection of cases in the community in New Zealand, the Government introduced a new four-level alert system, to clearly indicate the current public health risk and the necessary measures required to protect New Zealanders and eliminate the virus from our shores.
This approach evolved into New Zealand’s elimination strategy - a sustained approach to keep it out, find it, and stamp it out. Our elimination strategy protected the majority of our communities from the virus for more than 18 months, something that’s evident in the relatively few hospitalisations and deaths here, compared to overseas. From the start of the pandemic until the Auckland Delta outbreak this year, there were only 26 deaths from COVID-19 in New Zealand, out of 2,517 cases.
New Zealanders enjoyed relative freedoms in the face of COVID-19, something that was rare globally as other jurisdictions faced lengthy lockdowns and high death rates with significant strain placed on health systems.
I want to reflect on some of the reasons for that success, because those lessons are useful as we transition our COVID-19 response, and as we restructure the health system.
Role of science
The centrality of science to our COVID-19 response is undoubtedly a reason for the good outcomes New Zealand has enjoyed. But what makes for successful incorporation of science into policy, during the pandemic?
Clearly having a critical mass of technical expertise in house is a fundamental, and the Director-General has built that up over the pandemic. And we have processes to capture insights from domestic experts, international posts, scientific literature and modelling.
I’ve sought to strengthen these linkages through the announcement of a strategic scientific investment fund focused on infectious diseases. I’ve also worked with COVID-19 Response Minister Chris Hipkins to commission advice from the Strategic Public Health Advisory Committee - chaired by Professor Sir David Skegg. One of the challenges we face is being able to plan ahead in a dynamic environment. You will recall in August Professor Skegg’s group gave us advice about safely reconnecting New Zealand. That began a work programme that included developing methods to evaluate and manage risks posed by returning travellers, developing vaccine passports, and altering the quarantine duration and settings. A key feature of the advice was three categories of returning traveller - those from high, medium and low risk countries. It is that work that has enabled the phased reopening Minister Hipkins announced on Wednesday. However, it is also fair to say that every single aspect of the work has had to adapt as circumstances changed. Most notably the emergence of delta around the world has meant that the number of ‘low risk’ countries has become very small indeed.
Build strong public health systems
Another vital lesson from this pandemic, is the need to build strong public health systems. In fact, we need to build public health systems as if our lives depended on them - because they do.
That is what we have done with the contact tracing system. We have turned around decades of under-investment in public health units and invested in the workforce. We built information systems that connected case and contact data across the country. This was a practical necessity to fight a rapidly spreading virus, and because the devolved model of health protection services essentially meant small Public Health Units could not afford purpose built information systems. The Ministry of Health has led the development of much better-coordinated systems and protocols. We have developed a telehealth service - the national contact tracing solution. You might call these changes centralisation - there is certainly greater coordination, leadership and provision of enabling resources like staff or IT systems. But we continue to value the expertise of public health professionals who know their community well and are able to lead the response on the ground. Collectively these measures meant we have been able to contact trace at an industrial scale - remember we traced more than 2000 contacts when a single traveller with delta visited Wellington in June. And in the early part of the August outbreak we had 30,000 contacts under active management in the system.
Develop our ability to work with community
The need to work hand in hand with communities, using their local knowledge and expertise, has been highlighted by the pandemic.
We’ve seen this in our vaccine roll out. We have had to work carefully with communities to overcome barriers to access, but also to build up trust in a vaccine that has been subject to misinformation.
Māori and Pacific health providers have been the stars of the vaccine roll out. They have been reaching out to whānau who we have traditionally underserved, by door-knocking, going to workplaces, places of worship, sports and recreation grounds to vaccinate people. We have learnt lessons on the way. Successful campaigns have focused on trusted faces and familiar spaces. We are also commissioning these services directly, rather than through DHBs.
The spirit of these initiatives was best captured by Super Saturday. Somehow the call out to community leaders, minor celebrities, MPs and an earnest eight hour live TV broadcast inspired more than 2.5 percent of the population to get vaccinated on a single day. We unleashed the power of our aunties, principals, rugby coaches and pastors to protect our people.
These measures are making a difference. In a short time, the percentage of Māori vaccinated with their first dose has increased from the mid-50s to 80 percent today.
We’re not where we want to be yet, but things are improving.
Meanwhile, Pasifika peoples are now vaccinated to almost the same level as the general population - at 90 percent for first dose and 80 percent fully vaccinated.
Maintain a whole of government approach
And lastly, we have mobilised all of government around a single health objective.
A key element of this whole of government approach, has been the standing up of managed isolation and quarantine - to form a defence at our border, and keep COVID-19 out of the community.
The MIQ system is led by the Ministry of Business, Innovation and Employment in collaboration with the Defence Force and a workforce provided by DHBs.
While there is an understandable urge to remove the need for MIQ, it is important to remember since March last year more than 189,000 people have been through our MIQ facilities - with 1,400 cases of COVID-19 identified among them.
The MIQ workforce - nurses, hotel staff, defence and security guards, cooks and cleaners - can claim a large share of the responsibility for the exceptional public health outcomes we have enjoyed during the pandemic.
Adapting to the challenges of delta
However, tools that were effective against the original variant - including the world’s most stringent lockdown, wide-scale testing and contact tracing - have not been as effective against the delta variant. An R value that is twice as high, a shorter incubation period, and a foothold in vulnerable communities has made delta impossible to eliminate.
So we are shifting from the strategic goal of elimination to minimisation and protection, under the new COVID-19 Protection Framework - which will come into effect around the country in a week, on December 3rd. The minimisation and protection goal, as articulated by Professor Skegg’s group, sets a goal of minimising the prevalence of COVID-19, and protecting people and the health system from its impacts. It is not mitigation or “learning to live with it”, it is perhaps closest to what other countries call tight suppression.
Vaccination is the foundation of this new protection framework - colloquially known as the traffic light system.
We have access to one of the world’s most effective vaccines.
So far, 84 percent of eligible New Zealanders are fully vaccinated - and 92 percent have had their first dose.
Other countries, such as Israel and Singapore, have achieved high vaccination rates and seen breakthrough infections. We are ready in case the same happens here. We have already provided access to a third primary dose of the vaccine for people with lower immunity, and booster vaccines will be available in just a few days’ time.
Boosters are strongly recommended for anyone who has had their second dose at least six months ago. Vaccination clinics, pharmacies and GPs will provide booster doses from November 29th.
Children as young as 12 are able to be vaccinated against COVID-19 and our technical experts are currently advising on whether children aged 5-12 should be vaccinated. We hope to have more information in this space in the coming weeks.
Vaccine passes & mandates
Vaccination remains our strongest and most effective form of protection, and we need as many workers as possible to be vaccinated - so sectors can respond to the pandemic and deliver everyday services with as little disruption as possible.
So we have made it mandatory for workers to be vaccinated across the health and disability sector, our education workforce, border workers, Corrections, members of the Police, and all New Zealand Defence Force staff.
We have also mandated vaccination for workers at businesses where customers need to show COVID-19 Vaccination Certificates - in order to make those workplaces as safe as possible, and give confidence to staff and customers.
It’s estimated the vaccine mandates will soon cover 40 percent of the New Zealand workforce.
In addition, we’ve provided a clear, legal framework to help businesses make decisions about requiring vaccinations in the workplace.
And another protection which will allow life to return to something much closer to normality, is the My Vaccine Pass. This is an official record of a person’s COVID-19 vaccination status and will provide access to places within New Zealand that require proof of vaccination under the new COVID-19 Protection Framework.
You’ll need a vaccine pass if you want to go to places such as hospitality venues, close-contact businesses, large gatherings, events, gyms or on a plane.
COVID-19 Protection Framework - working across government
The COVID-19 Protection Framework will enable us to move more freely, and live with less disruption, and it provides the stability businesses need to plan for the future.
However, strong public health protections will remain. I’m not aware of other countries whose plans for the post-vaccine roll-out make room for escalating public health restrictions, like ours does. In fact others just call their plans, “re-opening plans” or “freedom day”. We’ve learned from countries “reopening” and then being forced to re-implement restrictions, as is currently happening in Europe. We know that might be necessary. But - it would not happen as abruptly as previously.
The COVID-19 Protection Framework builds on existing mask and record keeping mandates. It places limits on gatherings in the situation that we need to protect the health system. It very clearly gives an extra nudge to those who need further encouragement for vaccination. I have been working with colleagues on the detailed guidance that underpins the Framework - advice that spans various businesses, community sectors, city and primary industries. We are still mobilising the whole of government, and by extension the community, around a public health goal.
Strengthening public health systems
With the introduction of the new COVID-19 Protection Framework, systems and processes which were designed with the previous goal of elimination, now need be adjusted to reflect our new goals of minimising the spread of COVID-19 in the community and protecting those most vulnerable to the disease.
That’s why I announced yesterday an almost $1 billion dollar investment to strengthen our testing and contact tracing system.
We will boost laboratory PCR testing capacity across the country, reaching 60,000 daily tests in the first quarter of next year. PCR testing will remained the preferred diagnostic test.
We will expand the use of rapid antigen tests as screening tests for health workers including in aged residential care, in workplaces, and enable the public to purchase a rapid antigen test at a pharmacy and then conduct the test under supervision.
We have also extended funding for Public Health Units, who will focus their efforts on complex outbreaks which might occur in vulnerable communities or places where people congregate. Their expertise and knowledge of their own community is invaluable here. We will take care to learn the lessons of working with marginalised communities during this outbreak, and to provide a service that integrates public health, welfare, and clinical needs.
The efforts of public health professionals and community providers will be complimented by further investment in telehealth services - both boosting our contact tracing capacity and bringing in a new telehealth case investigation service. We are also developing a digital portal to enable a case to upload their own exposure events. This enables us to operate a differentiated model where those comfortable with technology, with resources and relatively few needs, will be managed more efficiently - and we’re able to provide more intensive support to those who need it most.
We continue to strengthen the public health response to COVID-19, and in doing so we are creating new models for future public health programmes.
The health reforms
How do we build on the lessons learnt in the pandemic response, as we restructure the health system?
We need to:
- Strengthen public health expertise and structures to make scientific input into policy more routine
- Continue to build strong public health systems
- Continue to strengthen our ability to work with community
- Transition our whole of government pandemic response to strong systems for addressing the social determinants of health
The most important shift in the health reforms is reorienting the whole system towards achieving pae ora - healthy futures for all … so all people, their whānau and communities are supported to achieve their health and wellbeing aspirations.
Overall, this signals reorientation of the whole system towards population health, and a greater focus on prevention of disease, harm and injury.
This is the biggest change in the health system in a generation, and the difficulty and complexity of this challenge cannot be under-estimated. Alignment of every lever will be required to build a sustainable system capable of delivering health gain and health equity.
Strengthening expertise and institutions
The new Public Health Agency will be at the heart of the Ministry of Health and will be responsible for leading population and public health, in partnership with the Māori Health Authority and the National Public Health Service.
In particular, the Public Health Agency will lead population and public health strategy, policy, regulatory, technical specifications for public health programmes, intelligence, surveillance and monitoring functions across the health system.
We have seen the pivotal role of science in the COVID-19 response. We want to make this approach of linking science and health much more routine and systematic. The strength of the new public health system will come from consolidating technical public health expertise and leadership, and building strong connections with local communities.
The Public Health Agency will develop a public health strategy and policy framework, which will contribute to the New Zealand Health Plan.
This will incorporate a long-term view, recognising that to achieve pae ora and equity we need to focus on the environments we live, work and play in; the important factors that often sit outside the health system; and challenges and opportunities that are often inter-generational.
A core foundation for the public health system will be a more effective and fit-for-purpose knowledge and surveillance system, which will be led by the Public Health Agency. In particular, there will be a stronger focus on ensuring intelligence directly informs decisions and actions in a timely way.
This system will draw on both the technical expertise of people in universities and local, community experience and knowledge.
The system will bring together a broad range of data - scientific public health data, as well as insights from engagement with communities and matauranga Māori.
This joined-up approach offers the best opportunity to help all New Zealanders live longer, healthier lives.
The Public Health Agency will provide secretariat support for the new Public Health Advisory Committee, which will play a critical role in the system. This committee will provide independent advice to Ministers, and will also help to ensure early and effective responses to public health issues.
They will be expected to provide public health advice to the Minister which reflects the perspectives of Māori and wider community views. The advice includes taking a systems-based approach to public health, and to reporting annually on system enablers such as information systems, workforce, and regulatory settings. The committee will be expected to prioritise equity-based approaches, including considering the factors underlying the health of people and communities.
This will be an additional source of public health advice, rather than replacing the Ministry of Health’s primary advice role. The committee will be expected to consult with the Director-General, Director of Public Health, and Director of the Public Health Agency on its annual work programme before seeking Ministerial approval.
An expression of interest will shortly be released seeking interested people wanting to be considered for membership of this committee.
Working with communities
As we have learnt through the COVID-19 response, collaborating with - and supporting - communities, is vital in order to achieve public health impact.
We can achieve this through a locality model of care. Through the health and disability system reforms we want to see service provision through locality networks, where different strands of healthcare are integrated - so Kiwis can easily access support and treatment tailored to their needs. Focusing on localities centres our approach on the strengths of each community, including its iwi and community providers. It encourages siloed government programmes to collaborate to meet local needs.
What would that look like?
Well, take our vision for Well Child Tamariki Ora.
A review of this programme found services across the early years should be strengthened to keep pace with the needs of whānau, and be more integrated across health, maternity, social and early learning services.
This could include simplifying the pathways for screening and early interventions, and providing more responsive wrap-around services. This is particularly important for New Zealanders with the highest needs, including whānau with child care and protection issues, or drug use. They are more likely to accept support, if it’s from someone familiar. These types of models are already being tested, including through enhanced support pilots - otherwise known as Nurse Family Partnerships - in Lakes and Counties Manukau DHB regions.
Similarly, I’ll soon be releasing the Smokefree Aotearoa 2025 Action Plan, which will seek to empower communities to mobilise around the smokefree goal. Working at the community level we can change the environment so that smokers feel better supported to quit, and de-normalise smoking so that young people don’t start. We will only achieve the goal if we enable Māori leadership of this work, and we will. But, communities will also know we have their back, and we will regulate to protect communities from the intrusive presence of big tobacco.
Building strong public health systems
A new Public Health Agency will be at the heart of the Ministry of the future, Health New Zealand.
This is an exciting opportunity to strengthen public health with a stronger focus on population health.
The Director of Public Health will be based in the new agency and will provide direct leadership to both it and National Public Health Service, reporting to the Director General of Health.
The Public Health Agency will lead population and public health policy, strategy, regulatory, intelligence, surveillance and monitoring functions across the health system.
A key focus will be developing technical specifications for public health programmes, which will be commissioned by Health New Zealand together with the Māori Health Authority.
Initially the new agency will bring together the country’s 12 public health units who have been working together in response to COVID-19. Being part of one national service will continue to strengthen how they operate cohesively.
Work across government to address social determinants of health
The health reforms provide opportunities to more extensively take into consideration the socio-economic determinants of health and wellbeing.
We must have a “health in all policies” approach, because sectors outside of health have public health implications. We have laid the foundations for this approach. Finance Minister Grant Robertson has brought wellbeing into the core of our budget setting process. Last term Public Service Minister Chris Hipkins enabled cross-agency work through public sector reforms - which enable novel collaborations such as the ‘joint venture’ structure to bring together officials to work on preventing family violence. The Public Health Agency will be a focal point for this type of work across agencies.
However, we aren’t waiting for the reforms to be complete. The Government has an ambitious work plan on housing, and health officials are actively ensuring that housing is healthy, connected to services, and transport. We work collaboratively on the Prime Minister’s Child and Youth Wellbeing Strategy. We work closely with Local Government Minister Nanaia Mahuta on the Three Waters reform, because until water entities are financially sustainable they will never make the required investments to ensure safe drinking water for all, no matter where they live.
We should be proud of what our pandemic response has achieved to date, and as we transition to a new approach to COVID-19 you can be confident our determination to protect people is as strong as ever.
It is important that we continue to learn from our experiences and continuously improve, in the pandemic response and as we reform the health system. We have a lot of work to do, but there are many opportunities and I feel optimistic about our future.
Ngā mihi nui kia koutou katoa.