Late one evening, I am reflecting on my inpatient list. The first patient, a middle-aged man, has been admitted with an “all-over” rash.
Since every other patient was sicker, this patient had slipped from my mind and I had left the hospital without seeing him, thus breaking my own rule.
Now, struck by a dreadful thought, I text the medical fellow.
“Could the rash be measles?”
“I don’t think so …” she replies.
The ellipsis worries me.
In my head, I see a bevy of patients and staff exposed to contagion. Shouty headlines and public outrage swim before my eyes and I prepare to go in to the hospital again – better late than never.
My fellow’s second text, “I also ran it past dermatology”, proves no more reassuring.
She has never seen measles. In fact, I have seen it only once and that too, with its most feared consequence, disabling encephalitis. To young doctors, measles is a “textbook” disease, such as scurvy or pellagra. They would be excused for not even considering the diagnosis – until now.
With an outbreak in parts of the United States afflicting hundreds of patients, measles is back in the news. Almost all the affected are unvaccinated, of which a few have died.
Hand in hand with measles reporting are the concerns about slashed US funding for public health measures that threatens to spur the spread of infectious diseases around the world.
Thanks to the world really being a global village, an infection in Texas or Tanzania could easily reach Tasmania. Given the giant contribution of American aid (and intellect) to global public health, the rolling announcements about cuts to those endeavours have caused a global shiver.
But in challenging times, I think that it also pays to understand what we can do to help ourselves, a philosophy especially relevant to one of the richest countries on the planet, Australia.
I recently met a usually measured public health doctor who didn’t mince his words lambasting my home state Victoria’s management of the Covid pandemic as an inevitable disaster whose spillover effects were still reverberating five years later. I would have made less of his comment but for hearing it repeated in different contexts thrice that week.
His words, coupled with reading this Grattan Institute report, reignited my indignation or, more truthfully, my guilt at the price society paid for the country’s complacency about public health.
Everyone has a painful Covid story and doctors have thousands, but this one is emblematic for me. During one of our many harsh (and questionable) lockdowns, I walked into the ward to find a non-English speaking elderly patient dying alone. After charting morphine, I noted that he lived locally and called his wife in. The rule that month allowed in one relative to see a terminally ill patient.
The next thing I heard was that she had been stopped at the entrance because in the time it took her to dash to the hospital the patient had died. The second part of “the rule” was that a relative could attend an actively dying patient but not a dead one.
I still don’t have the right words to describe those minutes when my attention flitted from the unknowing wife stuck at the door to the still-warm body of her husband and back to the administrator who expected a doctor to tell the wife.
I felt compromised and dirty and cruel. I refused – and since I wouldn’t allow any of my horrified interns anywhere near that job, the administrator quickly relented and the wife was allowed in.
I think about that family even today as I absorb the litany of failures of public health management laid out by experts since that time.
We must own those failures but when the next health emergency strikes, Australians deserve better. Better intelligence, better advice and more evidence-based rules with room for adjustment. To avoid another disaster, we must arrest down trending vaccination coverage and combat misinformation with education.
The time to stock up on well-trained professionals and modern infrastructure for contact tracing, data collection and analysis is now, not in the middle of a crisis. Similarly, the socioeconomic determinants of health such as housing and employment are not soundbites but real issues all too easily neglected until we start paying the price.
Of course, it all costs money. Of the $250bn (9.9% of GDP) Australia currently spends on health expenditure, most of it goes to hospitals. As someone who works in one, the amount of waste, believed to be as much as a third of the expenditure, through low-value care is eye-watering.
Meanwhile, a paltry 1.8% is spent on sporadic and piecemeal public health initiatives, where arguably the greatest returns are.
A robust public health system would not only keep Australians safe from preventable and avoidable conditions but also meet Australia’s oft-stated obligations to its vulnerable neighbours in the South Pacific whose diseases could easily become our diseases.
I have long been drawn to the intellectual rigour and can-do attitude of my American colleagues, which is why they make such superb collaborators. This underlying sentiment and mutual respect is not about to change.
American cuts to public health measures will affect many countries but Australia can and should meet this occasion with its own clear vision backed by its own wealth.
In doing so, we might recall the words of President Theodore Roosevelt: “Do what you can, with what you have, where you are.”
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