Beyond the recent publicity around cuts to health and other portfolios, something deeply disturbing – even sinister – is occurring in Queensland.
The state government is implementing health policies on the run and cutting health jobs and services. This has happened before around the country and will eventually be turned around, albeit not before a deal of harm has been done.
Even this week, there is news of yet more cuts to prevention programs. But more disturbing still, and a move that should send alarm bells ringing around the country, is the Queensland government’s decision to gag health organisations, health professionals and public debate on health issues.
A number of of Queensland Health’s recent problems – from Bundaberg to payroll disasters – followed historical underfunding of key control processes, and came to light in part because concerned people had the courage to speak out.
There is a long history in public health of measures that were initially resisted or opposed, speedily becoming accepted as part of a modern, civilised society. We would not be one of the world’s longest-lived populations without advances in public health such as sanitation and safe water, safe food, safe environments, immunisation, control of infectious diseases, screening, speed limits, seat belts, random breath testing, and tobacco control.
Each of these advances met initial resistance. None of them – not a single one of the public health advances we now regard as vital – would have been implemented without public health advocacy.
A troubled history
There is nothing new about opposition to public health advocacy. When sanitary reforms were being debated in England in the 1850s, led by the pioneering epidemiologist John Snow, the London Times thundered, “We prefer to take our chances of cholera and the rest than be bullied into health by Mr. Snow”.
But Snow persevered, achieving changes that led the way to advances there and elsewhere. Since then, we have seen a plethora of public health advances because of pressure from health groups, whether professional organisations such as the Australian Medical Association (AMA), or issue-based non-governmental organisations (NGOs), such as the various cancer councils and the Heart Foundation.
These external pressures are often encouraged by health ministers who need help generating support for action in Cabinet and the community: after legislation or other action, they frequently express their appreciation to the organisations concerned.
It is reasonable and normal for governments to expect that public servants follow conventional protocols in relation to public comment. It is also reasonable to expect that NGOs engaged in advocacy do so in a sensible and civilised manner. It is, however, unreasonable and dangerous for governments to gag health NGOs, and to take action that will specifically preclude them from advocating for change.
Health departments traditionally fund large numbers of NGOs to carry out crucial work in the community. Queensland Health Department contracts with these NGOs will now be subject to censorship. Any NGO receiving 50% or more of its funding from the state will be precluded from advocating for state or federal legislative change – even from providing website links to other organisations’ websites that do so.
NGOs justifiably fear that the 50% figure is just a starting point, and that this censorship may ultimately apply to any funding. Many now dare not speak out. Even those not currently in receipt of funding but thinking of applying will feel constrained.
The condition relating to websites means that funded NGOs may not be able to provide links to organisations such as Cancer Council Australia, the Heart Foundation, or even the AMA and the World Health Organization, all of which advocate for legislative change.
Government-funded NGOs are often also funders of research, which may conclude that legislation or regulation is appropriate. The new Queensland Health approach will preclude reputable health organisations from even discussing the implications of such research.
An important 2007 paper showed that there was already cause for concern about suppression of information in the health sector. It noted international precedents where exposure and comment from outside government were crucial in preventing further public health catastrophes, such as the 1980 Black Report in the United Kingdom, the Chernobyl disaster in the Soviet Union, the SARS outbreak in China, and harmful mercury blood levels in the United States.
So what justification has the Queensland Government offered for its descent into the dark ages?
First, they assert that NGOs should focus on their “core activities”, not advocacy. But seeking action that will protect the health of the community is the most fundamental core activity for public health organisations. Even if they cannot understand this, it is outrageous that a government providing only some of an organisation’s funding should prohibit action carried out with funding from other sources.
Second, they state in relation to funded groups that “we would expect that organisation to conduct itself with the political impartiality of any other government sector.” This verges on the bizarre, given that by definition NGOs are not part of the “government sector”.
A third rationale now offered is that this condition will prevent abuses, such as the “Fake Tahitian Prince” scandal, and funding of NGOs to pursue political agendas. But any concerns in these areas should be addressed by protocols common to all governments (and indeed other funding agencies) about proper, well-monitored use of funds.
The fourth rationale is that the government is seeking “health outcomes, not political outcomes or social engineering outcomes”. The government is entitled to seek health outcomes from activities that it funds: but that is no justification for gagging the non-government sector.
It is desperately depressing that any health minister should use pejorative phrases such as “social engineering” to describe the aims of health organisations, and, by implication, the aims of his own and other health departments around the country.
No explanation has been offered as to why health, where advocacy has been so fundamental to our well-being over the years, is being singled out.
The Queensland government’s approach has already met with some success. It has created a climate of fear. Beyond the AMA, whose Queensland president, Dr. Alex Markwell, has shown herself to be a true health leader, and some courageous public health academics, few in the state are willing to speak out, lest they be victimised and lose their funding.
These are dark days for public health in Queensland. The public health advocacy that has made our community so healthy will be hard to find. By contrast, commercial interests – in areas such as alcohol, tobacco, gambling, junk food, even firearms – are free to pressure governments at will.
Queensland, of all states, should have learned that gagging people in health from speaking out is a recipe for disaster. Censorship is the hallmark of a totalitarian regime; censorship in health sends out the signal loud and clear that the government neither understands public health nor cares for the future health of the community.
Other governments should condemn the Queensland approach though the Standing Council of Health Ministers; the Federal Government should bring all possible pressure to bear; and health professionals around the nation should use every available opportunity to make clear their distaste for this fundamentally unhealthy approach to public health.
Public health has been described as the conscience of the health system. It should be a matter of great concern for the entire community that any government is seeking to silence our conscience.