Finding Hope in Chaos

During my time in Auckland I have often reflected on the U.S. healthcare system. I have tried to make sense of why it is so expensive, why people are consistently dissatisfied, and why we have so much trouble insuring everyone.

In some ways it is easy to look at the problems and the current mess and conclude that we're in a crisis. I used to use that description in all of my discussions about the U.S. healthcare system, but I'm beginning to think it's too easy of a description, a platitudinous cop-out.

If one looks back over the course of American history, he or she might conclude that the American healthcare system has been in a perpetual state of crisis (and acknowledging a state of crisis for anything is an essential part of the American consciousness). One health scholar, noting this issue, likes to think of the American healthcare system as facing a maelstrom, a maelstrom of information, data, priorities, values, contexts, opinions, etc. I would add that most health systems around the world are facing similar maelstroms.

Paradoxically, I find hope in this description, as one might find hope and inspiration in the chaotic nature of the cosmos. We spend incredible amounts of resources trying to alter and improve the system, which, I think, shows that we care deeply about health. It's an issue we like to keep lively and in the news. And, for me, that's reassuring. That tells me something about what we think about health, and what we think about the health of our population.

I know this is an anti-climactic ending, but by spending a significant amount of time (but less than 10,000 hours--the amount it takes to become an expert on a topic) on public health leads to a nuanced understanding that ultimately stirs up more questions than it firmly answers. And so, with only a subtle understanding, one must find ways to cope with the chaos until more time and energy can be spent searching for answers to remaining questions, and solutions to persisting problems.

User Fees and the Underpriviliged

User fees (e.g., co-payments, deductibles, cost-sharing) for health services are a common feature of many healthcare systems around the world.

One of the main arguments for the implementation of user fees is that it makes patients/consumers more cost conscious about the services they are using. That is, user fees reduce the overutilisation of health services. Overutilisation is often seen as a major contributor to rising healthcare costs. A study carried out by the RAND Corporation in the 1970s initially found that not only did user fees reduce utilisation of health services, but they didn't alter health outcomes.

The problem with this argument is it entails that patients know which services are necessary and which are unnecessary. It entails that patients have access to all the information they need. Contrary to pop economics, this is not the case in the health sector: doctors act on behalf of the patient to decide which services are necessary and which are unnecessary. With user fees, the decision is placed on the patient, and he or she will likely forgo both necessary and unnecessary services. Additionally, even when health information, like provider performance, is made publicly available, people either don't search for it or fail to know how to use it if they do have it.

The second problem is that user fees are worse for lower-income groups. This is fairly straight forward: lower-income groups are more effected by cost increases. So if user fees are implemented at the doctor's office, some groups of people are going to be deterred from seeking care, which in turn can increase health expenditures down the road. When primary care services are forgone we see an increase in the need for secondary and tertiary services, which are typically more expensive. This is called cost-shifting.

By the same token, user fees widen the health disparities between income groups (the rich are not as effected by user fees), and thus inequality is reinforced. And, as we've already established, health inequalities are bad for society.

Lastly, recent re-interpretations of the RAND study found that the elderly and those with chronic conditions actually ended up with poorer health outcomes when they were subjected to user charges at the point of care.

Social Health Insurance vs. Tax-Financed Systems

I'm currently finishing up an essay on the differences between the financing mechanisms of Social Health Insurance systems (SHI) and Tax-Financed systems (TF). The Netherlands, Germany, Belgium and a few other western European countries are good examples of the former; the UK, New Zealand, and Canada are a few examples of the latter.

SHI systems are defined by employer/employee contributions to "quasi-public" institutions called Sickness Funds (SF). The SFs in SHI systems are usually responsible for collecting contributions and paying service providers to care for their members. Contributions are scaled based on income, membership is typically compulsory and the government usually pays the contributions of the unemployed and disabled. Sometimes there is just one SF that all of the population is enrolled in, or there are various SFs that are employer- or geographic-specific. Sometimes members are allowed to move between competing SFs, thus introducing an element of competition to drive down costs.

For the most part, countries that have SHI systems get good quality care at a reasonable price. SHI systems are good are getting near-universal coverage. And, it is generally thought that SHI systems have more public support because of solidarity and transparency. For instance, individuals can see their earnings-related contributions going straight into a SF that pays for health services.

In contrast, TF systems are defined by centralised control, where the government allocates part of the total tax revenue to a Ministry of Health (MoH). The MoH then reallocates the money either directly to hospitals and providers or to secondary institutions (like District Health Boards in New Zealand) to pay for health care. Because the bulk of the financing comes from direct taxation, TF systems are generally considered the most equitable of all health systems in terms of financing. This equity arises because TF systems operate on a progressive tax system, which means that as income rises, the proportion that is taxed goes up. (So higher-income earners pay a larger proportion of their income as taxes).

In general, TF systems spend the least amount on health care of the health systems in high-income countries (without sacrificing quality, by most estimates). This is because the power to collect funds and purchase services is wrapped up in one agency, so spending can be reigned in fairly easily. Furthermore, centralised control can focus efforts on the non-medical (social) determinants of health, which don't make a lot of money but do improve the health of populations. One of the drawbacks of TF systems is that the link between funding and services is less transparent because the funding comes out of general tax revenue. But, TF systems theoretically get the most universal coverage.

After reading through the literature on these two systems of financing, I was struck by two things in particular.

The first interesting point is that the power of competition can be introduced to drive down costs in TF systems. Even when the government controls the financing of health care, elements of competition can be introduced in the provision of services. This is what the literature calls a purchaser-provider split. That is, the purchaser (the government) can be separated from the provider (hospitals, clinics), and thus the providers have to compete with each other to get access to the government's health care dollars. (The evidence is mixed whether this is actually successful at driving down costs and maintaining quality). However, this is interesting because the myth in most debates about health care is that involving the government automatically eliminates the benefits of competition and the market. And this turns out not to be the case.

Second, very few authors even consider widespread private insurance (via for-profit corporations) as an efficient alternative to SHI or TF. It was implicitly assumed that one wouldn't consider moving to a system of private insurance, because the evidence suggests it increases costs for the whole systems, becomes more inequitable for the population and often sacrifices the quality of care. Therefore, most of the articles I read contrasted SHI vs. TF systems, as if they were the only options.

However, I don't want to suggest that countries without SHI or TF systems can simply switch systems and everything will be all right. Country-to-country comparisons are very problematic, obviously. This is because countries vary widely in terms of not just wealth, but also specific historical contexts, cultural attitudes, political will/ideologies and public expectations. In fact, countries are bounded by these factors. For example, when considering the best way to allocate resources for a healthcare system, commentators, economists and policy makers argue on the basis of values such as equity, solidarity, autonomy or efficiency.

The combined force of these factors (history, politics, culture, values) makes changing health systems extremely difficult and divisive.

Climate Change: Inequalities, Urbanisation, and Food Systems

I went to a lecture today delivered by Sharon Friel, an epidemiologist and public health expert. She set the framework for her lecture about climate change by first referring to the vast inequalities that exist around the world, no matter whether the outcome is life expectancy, morbidity, income or green house gas emissions. The fact is that climate change (the most pervasive threat facing humanity, and incidentally the most trendy public health topic) exacerbates these inequalities and social gradients. Through both direct (rising heat indices) and indirect (desertification) factors, climate change impacts our health. According to Friel, there are two main factors that complicate this matter even further.

The first is urbanisation. The urban sprawl in middle-income countries and the growing slums at the periphery of the world's largest cities are a serious issue for health. Just recently we passed the 50% mark: now more people are living in cities than in rural areas for the first time in human history.

Cities face something most scholars like to call the double burden of disease. On the one hand the world's largest cities have massive slums (like the favelas in Brazil) where people subsist on less than a dollar a day, many lack basic amenities like clean water and most do not have access to basic health services. In these areas, infectious/communicable diseases are still rampant. On the other hand, we have the sprawling suburbs, fast food restaurants, heavy traffic, and the glorious car (or what some like to call the metal coffin). All this leads to chronic diseases like diabetes, cardiovascular disease, and the diseases of the rich.

The juxtaposition of these styles of living, this relative inequality, is dramatic. When across the fence from a massive slum is an apartment complex where the individual balconies have swimming pools, the notion of a Tale of Two Cities takes on a whole new meaning. One interesting point Friel made was that urban density is inversely correlated with car use, obesity and consumption of energy dense foods. And, this brings me to another point: Cities are going to have to be a part of the broader strategy of making it through these problems. Cities can be efficient. I remember reading an article in the NYT about the fact that New Yorkers have lower carbon footprints than most other people in the United States. In fact, carbon footprint is probably inversely correlated with urban density.

Lastly we have food systems, which I have touched on in previous posts. Friel brought up the point that the relationship between food systems and climate change is bi-directional. That is, our food systems (especially livestock) is main contributor to greenhouse gas emissions, and climate change affects our agricultural production (desertification in Africa, especially). This is a vicious and scary cycle, and one of the issues that hits at the heart of the fact that poor countries and poor farmers are hit the worst by the affects of climate change while the rich are largely able to adapt (or just keep paying more and more for their food).

The Religion-Health Interface

I have been thinking about the interface between religion and health in New Zealand for one of my assignments. This relationship is extremely complicated, but researchers in the U.S. have found that religious participation and involvement are at least associated with lower rates of morbidity and mortality. Very little research has been done in other countries. From my reading, it appears religion works on two key fronts when it comes to health.

Firstly, religion can serve as a protective force against ill health. This occurs because religious institutions explicitly (Mormonism) or implicitly prohibit/restrict the consumption of alcohol, tobacco or other drugs that often lead to morbidity and mortality. In some cases (Seventh-day Adventists, explicitly), religious institutions can impact the diet of its members, which naturally can improve health and lower morbidity and mortality rates. More indirectly, religion is protective because religious affiliation typically brings about social, emotional and psychological benefits to adherents. This isn't new: Durkheim detailed this benefit in his analysis of the lower suicide rates in community-oriented Catholic societies in the 19th Century.

Secondly, religion can serve as a coping mechanism for individuals who are sick. Sickness naturally leads us to ask questions about life's meaning and purpose as well as seek explanations for why we've become sick. Sometimes the explanation "you have a genetic mutation causing abnormal mucus secretions" just doesn't cut it. We are meaning-seeking beings; and as such sometimes we need narratives from which we can draw hope, meaning and comfort. Religion is therefore a tool in our cultural baggage, a resource that can be utilised in times of distress. Also, a congregation can be tapped into, especially for comfort and hope (or financial support), in times of ill health. By no means do I wish to suggest that religion is the only coping mechanism or that it works for everyone. Rather, I simply wish to suggest that it is a significant factor in many peoples' lives and therefore it should be taken seriously.

The essay question asked whether or not religion is an important factor in the health field in a "secular" society. Setting aside the question of whether or not New Zealand (or other Western, industrialised societies) are truly "secular", it seems fairly obvious that even with low rates of religious adherence or church attendance, religion and spirituality are significant factors when it comes to health. And in New Zealand, where (roughly) 75% of the population claims a religion and 20% attend church on a weekly basis, I think religion is an important consideration for anyone in the health field.

(I say this after taking notice of the ghostly churches scattered throughout downtown Auckland. I say this after passing (daily) the bustling, modern hospital across the street from my flat with its big clean windows that I can see into and glimpse families huddled around hospital beds. Where does sanctity exist today?)

Beating the Dead Horse

The horse is the outrageous amount of money we in the U.S. spend on health care. And I'm shamelessly beating it while it's lying on the ground by showing you yet another graph. But this one is really good. I got it from my health care organisation professor. It shows the percentage of GDP that each country in the OECD spends on health care.

Interestingly, it's divided into both public and private expenditures. Public funds are the biggest contributor to health care expenditures in all countries in the OECD except for the U.S. and Mexico. Among the OECD countries, Mexico, Turkey and the U.S. are the only countries that do not have universal or near-universal coverage. The other thing to note is that the level of expenditure is for insured persons only, and not for the total population of each country. As you know by now, the U.S. spends almost double what the average is, as is clear from this graph. And U.S. expenditures on health care are greater than any other country, being five percentage points above the next country (France).

Public Health as the Socio-economic and Political

In an article in the New York Review of Books, which draws upon a book entitled "The Spirit Level: Why More Equal Societies Almost Always Do Better," there is series of graphs that speak to the relationship between public health and the organisation of society. In public health we call this the social gradient to health, and we use it to describe how social/environment factors often dictate health outcomes. The graphs compare industrialised, wealthy countries, and unfortunately the United States comes out looking not-so-stellar.

The first graph shows the level of income inequality in relation to ill health and social problems. Income inequality here has to do with the gap between the wealthiest and the poorest members of society. The author notes how this gap has increased dramatically over the last couple of decades.

The second graph details the gradient between a society's income inequality and the percentage of individuals with mental illness in that society (Last year I devoted a whole blog to mental illness and society).The last graph is slightly different in that it shows the relationship between health expenditures and life expectancy. The point here being that the two are not necessarily related, i.e. you don't necessarily see greater life expectancy if you spend more on health expenditure (I have written about life expectancy in New Zealand before).Another point to made from these graph is that the process of deregulating markets and privatisation appear alongside the worsening of a country's health statistics. The countries in the worst positions (USA, UK, Australia, New Zealand) are those that adopted neoliberal economic policies with the most fervour over the past four decades. During this same period we saw a vast separation in rich and poor incomes in addition to worsening health statistics, even as health expenditures increased.

A population's health outcomes are not independent of broader societal and global forces. Thus, if we want to improve health outcomes we must look beyond the traditional confines of medicine, sanitation, and immunisation, and examine the way countries organise their economic, social and political realities.

Finally, I should add a caveat. The caveat is that these graphs are what those in public health call ecological studies. That is, they attempt to draw inferences from broad societal correlations, and because they take such a wide-angled perspective, they are often considered the least descriptive of all data. The actual causal factors of these gradients are much more difficult to sort out, as was explained well in a recent article in the Boston Review. This means we should take these studies with a grain of salt, and try not use them to make sweeping conclusive statements about health and inequality, but simply use them as a platform to generate discussions and further research about the possible causes and relationships.

(You can find more information like this, and more of these graphs, here.)

U.S. Farm Bill of 1973: The Beginnings of a Public Health Nightmare

In high income countries infectious diseases are now almost non-existent. The current health risks for these countries are non-communicable diseases (diabetes, cardiovascular disease) and smoking. Fifty years from now public health experts will be looking back and trying to decide the impetus for the dramatic rise of non-communicable diseases in the 20th century. I think they will particularly examine the rise of obesity which began in the 1970s.

In some ways, I think future experts will see the U.S. Farm Bill of 1973 (spearheaded by Earl Butz) as a transformational moment for public health, and ultimately the starting point of the dramatic rise in obesity, diabetes, and cardiovascular disease. The Farm Bill marked the moment when the U.S. government started subsidising agricultural production, which was a radical departure from what had previously happened. We went from rewarding farmers not to grow (i.e. letting their lands lay fallow) to rewarding farmers to grow as much as they could. Thus spawned the growth of industrial farms, confined feeding operations, cheap grain, and the absurd proliferation of corn (which is now in everything).

All of the cheap, subsidised grain, rice, and corn needed a market. First we started developing products, massive amounts of products, into which we could unload this extra grain and corn. Obviously this had implications for the food industry, like portion size and the rise of empty calorie snacks (as you can see around you).

Additionally, the Farm Bill of 1973 marked the time when food trade became truly international. We started trading and selling these crops to other countries. This has displaced many farmers in low-income countries who simply cannot compete with all of the government subsidised rice coming in from the U.S. This had implications for the world food market, especially in terms of making poorer nations exposed to the ebb and flow of the world food market. You might not think of rural Midwest farmers as immersed in international affairs, but the livelihood of a grain farmer in Kansas is intimately linked to the forces of globalisation (like the wildfires in Russia).

Public Health and Biomedicine

This snapshot from a book of mine details the decline of infectious diseases in the U.S. between 1900 and 1973. As you can see from this image, in each of these cases, from measles to diphtheria, the medical intervention (vaccine, antibiotic) came after a prolonged decline in the disease's prevalence in the population. For example, if you look at typhoid, there was a rapid decline in the rates of the disease from 1900 to 1940. The treatment for typhoid (chloramphenicol) didn't arrive until the late 1940s, after the disease had virtually disappeared in the U.S. Thus, the treatment for typhoid has had little to do with its virtual disappearance when we're look at it from the societal level.

I have come across this argument, in one form or another, in almost every class that I have taken here. This is the quintessential example that public health practitioners, sociologists of health, and medical anthropologists use when discussing the importance of context and environment when it comes to health. It is also frequently used in critiques of biomedical approach to disease and illness. The point of these graphs is to show that rapid improvements in health (especially with infectious diseases) occurred because of better nutrition, housing and sanitation, and not because of biomedical interventions as many people (falsely) believe. Naturally, this also is the example people cite when they claim that public health is the antithesis of medicine.

But my concern is broader. What does this say about resource allocation? If the point is to improve the lives of people in a society, shouldn't we be allocating more money to those broad, environmental public health strategies rather than small, narrow-focused biomedical interventions? How do we consider both of these together? What does it say about our values and our priorities when we allocate more of our resources to biomedicine rather than public health? Do we have a moral responsibility here?

Source: McLennan, G., Ryan, A., and P. Spoonley. (2004). Exploring Society: Sociology for New Zealand Students. 2nd Ed. p. 217.

Also, check out Professor Szreter's account of why Britain's mortality decline in the 19th C. was not due to medical interventions. Here's a more general analysis of the arguments for public health over biomedicine as explanations for increasing LE in Britain. And here is an updated version of the argument for public health to motivate social change.

Dental Care Details

Your eyes and mouth aren't covered in New Zealand, as my professor of health care organisation said last week. In New Zealand, medical visits to a GP are free or very inexpensive ($0-$45 copayment), and a visit to the hospital is always free (even if you have international insurance, they won't accept it). However, dental care and optometry visits are not free, and can be quite expensive.

Last week I called up the dentist and said I needed to make an appointment. They scheduled me in, and told me how much it was going to cost: NZ$112.50 (which is about US$80). They fit me into the schedule for this morning. There was no question about insurance or employer, they just expected me to come pay for my service. And I checked my insurance policy, which I have through the university, and indeed there is nothing about dental coverage. I also found out that dental services are free (government subsidised) until the age of 18, and after that you have to access the services as a private patient. Low-income residents can get a government subsidy for dental services.

None of this struck me as abnormal. I knew what I was getting into. The thing that did interest me was how upfront the woman at the front desk was about the the pricing. I said I needed to have a routine cleaning. She said I could I see the hygienist for 45 minutes and that it would cost $112.50. I had to pay on the spot; no bill would be sent to my address. In comparison to some of my experiences in the U.S., this was quite refreshing.

Another important thing to note is that most New Zealanders receive fluoride through the water system, as residents do in the U.S. The process of fluoridation of the New Zealand water system began in the 1960s. What is interesting is that most other countries around the world, even in Europe, have very low rates of water fluoridation than both the U.S. and New Zealand. The fluoridation of water is not without controversy, but I have heard several older individuals in New Zealand cite the lack of fluoride in the water during their childhood as the reason for their poor dental health.

The bright red color indicates that 60-80% of the population receives fluoride through the water. The grey color indicates where the data is unknown. The lightest pink color is 1-20% of population. Source: The British Fluoridation Society; The UK Public Health Association; The British Dental Association; The Faculty of Public Health (2004).

Guns in New Zealand (or the lack thereof)

Police officers don’t carry guns in New Zealand, although Sergeants do have guns in their cars. I was talking to a former police officer and I found out there is some debate about whether or not police ought to carry guns. According to him, most police do not think it would be a good idea.

The former officer half-jokingly told me police officers are on the anti-gun-carrying side of the debate while “people who don’t know what they’re talking about” are on the pro-gun-carrying side of the debate.

He also told me the story of his friend, a former detective, who was in a scuffle and his gun ended up on the ground (some detectives carry guns). The gun was out for anyone to pick up and shoot. It was the first time the detective had ever been scared for his life. Having a gun can turn a small brawl into a serious and life-threatening encounter.

In New Zealand you’re generally not allowed to own a pistol or carry any kind of gun with you. Machine guns are illegal. Even pepper spray is illegal. Guns are used for hunting and that’s it (however, there are gun clubs where you can have pistols but you have to register it, be a member of the club, keep in a locked safe). It’s all highly regulated. Just recently I found out that even carrying a certain kind of concealed knife can land you in prison for three years.

A simple google search shows that New Zealand has a fairly high guns per capita rate: there are about 27 guns per 100 citizens. Compared to the United States, where there is a shocking 90 guns per 100 citizens, it's not that high. (For comparison: in China there are 3.5 per 100 citizens.) I don't know if these statistics still hold today, but even if they're off by a few guns it's still an enormous difference.

The people I talked to who hunt and own guns here are absolutely shocked about the lax laws we have in the U.S. about gun ownership in general, and more specifically about the types of guns one can own. The people who don't hunt or own guns are even more shocked.

Toxic and Touchy (or 1080 in NZ): Conservationists vs. Farmers

My brother and I were driving down the west coast of the South Island (a part of New Zealand that is home to only 1% of the population) when we came across a fascinating scene. We were trying to reach Okarito, a small town on the coast, to camp that night. We had left Nelson five hours earlier and by this time it was dark outside. We hadn’t seen another car for two hours. It was pitch black outside and the densest forest I'd ever seen lined both sides of the road.

All of sudden we came up to a one lane bridge. At the bridge the sign indicated that we had to give way to the oncoming cars, so we slowed to halt because I could see headlights on the other side of the bridge. There was a group of people with headlamps on our side of the bridge, appearing as if they might be getting ready to go Kiwi-spotting.

Then we noticed on the other side there were lots of headlights and commotion. I hesitated, but as I slowed to a stop one of the individuals with a headlamp and a beanie motioned us to go across the bridge. We drove slowly across. There was this surrealness about the whole thing: here in the middle of nowhere we had come across a huge group of people. It was something out of a horror movie.

Nervously, we crossed the bridge. It was on the other side that we noticed the people were holding signs as if they were protesting something. We didn’t read the whole message but it was something about poison. One individual was videotaping us as we passed the small crowd. We drove off wondering what in the world we had just witnessed.

The Department of Conservation (DOC) is attempting to rid the National Parks of non-native predators in an effort to save the native birds (read: Kiwi). Rats, stoats, ferrets, and possums (brought here by the Europeans) have been the main cause for the decline of the Kiwi and other endangered birds. Uncontrolled dogs and cats are also problematic. The Kiwi nests on the ground (as do many other native New Zealand birds), making it, the eggs, and the chicks extremely vulnerable to predation by these mammals. In some of the National Parks DOC drops small pellets filled with the poison 1080 (Sodium fluoroacetate) in the hope that these predators will eat it and die. The poison was used on Motutapu to make the island pest free, as I reported a few months ago.

The problem is that 1080 is extremely poisonous (so much so that it is banned in many countries) and it can get into the waterways and spread out into the surrounding farmlands next to the parks. Farmers producing beef for foreign markets complain they might have trouble selling their product if buyers know 1080 was dropped near their farms. The other issue is that there are accidents in transporting and dropping the pellets. That is why so many people, like those we met at the one-lane bridge, are out in force protesting the usage of 1080 (the picture above is from a DOC toilet building near Castle Hill on the South Island).

DOC workers sometimes have to get police escorts to protect them against protesters. DOC is relentless in their pursuit to eradicate these predators from the parks. In the words of one Wanaka resident, “there are some real Nazis in the DOC.” The debate is really between conservationists at the DOC and the hunters and farmers.

The day after the bridge incident we were hiking along a coast trail near Okarito and there were small traps set up along the trail. I had seen these before. But one of them actually had a dead ferret or stoat on top of it, clearly dead from the poison (likely 1080) that was inside the trap (see picture below).

So the protesters at the bridge were protesting the DOC’s use of 1080, as we began to piece together over the course of our tour throughout the South Island. Conservationists are trying to save endangered species, but their methods are conflicting with the livelihood of farmers.

There are similar controversies going on in countries around the world. In U.S. we have the re-introduced wolves in the west which are creating problems. So it's a debate that's not unique to New Zealand. I can see the concerns on both sides, yet maybe the protesters' efforts on the bridge that night clouded my judgement.

Correction (14 Sept 2010): This picture is of a dead stoat that was caught in a trap. It was probably not killed via 1080 because DOC apparently doesn't lace the bait with 1080.

Nukes in New Zealand (or the lack thereof)

New Zealand is nuclear-free. Prime Minister David Lange enacted the policy in 1984, but grass-roots movements like Green Peace and Friends of the Earth started speaking out in opposition more than a decade before that. New Zealand later led the way in establishing a nuclear-free zone in the South Pacific, which includes several other countries in the region.

There were several incidents around this policy, one of which involved a ship called the Rainbow Warrior and French nuclear testing on the island of Moruroa. The Rainbow Warrior was a Greenpeace ship that was used to advocate against certain policies concerning seal and whale hunting. The ship was also used to protest nuclear weapons, especially in Moruroa where the French were testing nuclear weapons. In 1985 French operatives sunk the ship in a New Zealand harbour in response to the protests, and one Greenpeace activist died in the process. (The Rainbow Warrior was re-sunk for a dive site and divers can now go and explore the remains.)

New Zealanders are quite proud of their nuclear-free policy, as evidenced by this picture I took of a mural in Christchurch. At one point as many as 92 percent of citizens were opposed to nuclear weapons in New Zealand. The fact that New Zealand is nuclear-free has been a point of contention between New Zealand and the United States, as Ambassador Huebner pointed out to us in Wellington a few months ago.

Apparently the main contention lies in the nuclear-free zone surrounding New Zealand, and the requirement that ships and submarines in New Zealand waters declare what kinds of weapons are on board. Vessels carrying nuclear weapons are not allowed in New Zealand ports or in New Zealand waters. The U.S. military obviously doesn’t want to reveal whether or not they have nuclear weapons on certain ships and submarines. So effectively no U.S. ships can be in New Zealand waters, or harbours for that matter.

Naturally, the U.S. still puts pressure on New Zealand to repeal the legislation so that U.S. military ships can dock in New Zealand harbours. However, there doesn’t seem to be any evidence that the Labour Party or the National Party will budge on the legislation.

(Here is someone doing a PhD on nuclear disarmament and his three case countries are Norway, Mexico and New Zealand.)

Healthcare in NZ: The Breakdown

I'm studying for a final exam and I thought you might like to join me in learning about the New Zealand health care system. This post is a continuation of an earlier post about the history of health care in New Zealand. The majority of this information came from a lecture delivered by a health economics professor here at the University of Auckland.

To start, health care makes up 9.3% of New Zealand's GDP (in the U.S. it's 16-17%).

The main health care entities here in New Zealand are the 21 District Health Boards (DHBs) (Actually there are now only 20 DHBs because two of them merged). These DHBs get funding from the Ministry of Health (MoH) to purchase health care for their constituents. DHBs purchase the health services from "private/NGO providers" (doctor groups, Maori providers, rest homes, etc.). The DHBs also have a "provider arm," which contains the public hospitals and community health services. The DHBs are made up of 32,000 to 439,000 people, and get funding depending on geographic location, need, and ethnicity of population.

The other major player is the Accident Compensation Corporation (ACC) which also gets funding from the central government and it purchases services directly from the private/NGO providers through contracts. The ACC covers all health bills from accidents. Most people I talk to seem to think the ACC works pretty well.

The NZ population pays for this whole apparatus through taxes which go to the government, and through fees/copayments that they pay to their GP (General Practitioner), who is usually part of a Primary Health Organisation (PHO) with other GPs. In fact, 95% of GPs belong to a PHO. So New Zealanders usually do pay a small copayment when they see their doctor ($0 - $30). These copayments, along with prescription charges, etc. make up 17% of total expenditure. Also, you can't go to a specialist without getting a referral from your doctor so the GP is the "gate-keeper."

PHARMAC is the government-owned Pharmaceutical Management Agency, which is basically the single purchaser of all pharmaceuticals and it decides which drugs the DHBs can subsidise. PHARMAC controls the subsidisation of new drugs and has a monopoly on the purchasing of drugs. This programme also seems to be popular, as it is instrumental in controlling the costs of prescription drugs. One drawback that I can think of is that this regulated system stymies growth and innovation, thus making NZ dependent on other countries for the research and development of prescription drugs.

Although 77% of healthcare is funded by the central government, there is private health insurance available for New Zealanders to purchase on their own (5% of total healthcare GDP). The private insurance companies can then purchase services from the private and NGO providers on behalf of their customers (just like the DHBs). This allows people with insurance to queue jump so they don't have to wait for services.

Hopefully you have a better understanding of the way health care operates in New Zealand. If nothing else, writing this helped me think through the system, so thanks for reading.

Living Longer, Living Better

Today I attended a lecture by Alistair Woodward, the Head of School at the School of Population Health. The title of his lecture was "Will we be living longer and better?" The answers, as he said in the outset, are yes and probably. I thought I'd share a few of the interesting points from the lecture.

First, from 8000 B.C.E. to 1800, worldwide life expectancy (LE) remained stagnant, at about the mid-20s to low-30s. This seems remarkably low, but you have to remember that high infant mortality rates were the main factor in keeping LE down down. Since about the mid-19th century there has been an exponential increase in LE, mostly as a result of sanitation and not biomedical intervention, as public health researchers always like to point out. Huge decreases in infant mortality rate is also a factor, which is related to improved sanitation.

Second, from 1840 to 1920, New Zealanders (excluding Maori) consistently had the highest record female LE in the world, and it's unlikely that medical services played a serious role. There are several ways to explain this. First is the healthy worker/healthy migrant effect, which says that the early British emigrants to New Zealand were healthier, younger and fitter than the average person living in Britain. Second is the fact that New Zealand has a more health-promoting climate than the UK and the land is extremely fertile (for vegetable-growing and grazing). (Obviously the land requisition came at the expense of Maori, who saw a huge decline in LE as well as total population numbers when their land was taken.)

Thirdly, is the future projections and challenges for New Zealand. It looks like LE is going to increase over the next few decades. A study showed that this is likely to come from a 1.5-2% per annum decrease in mortality over the next three decades. There are still significant challenges ahead for New Zealand. First, there are huge disparities in LE: a wealthy neighbourhood in Auckland (Remuera) has a LE of 86 years, a poorer one (Mangere) has a LE of 67 years. That's a huge difference. A significant contributor to mortality is the smoking rate, which is hovering around 20% of the population.

Budget Pros and Cons

The New Zealand budget, which was issued today, is generating a lot of talk here. The most dramatic change is that the G.S.T., or the sales tax, is set to increase, while the income tax is set to decrease. In October, the sales tax is going to increase from 12.5 percent to 15 percent, and the income tax is going to decrease for all income brackets, with the top bracket decreasing from 38 to 33 percent.

The general idea is that the higher sales tax (GST) will encourage saving, while at the same time it will hopefully allow the government to maintain its much-needed revenue. It's a common tax-reorganisation strategy to encourage saving during a global recession; although some commentators say that by decreasing the income tax and putting more money in the pocket, you will actually encourage more spending. Policy makers here are hoping this is going to encourage growth at a time when New Zealand's economy has sort of flat-lined, and even saw a shrinkage in 2009.

Another part of the proposed plan includes a decrease in the corporate tax rate, from 30 to 28 percent. Again, as the thought process goes, this is to encourage business growth and maintain the competitiveness of New Zealand businesses. As a small and vulnerable economy, people are saying it's important to keep the corporate tax rate close to the levels in other countries, particularly Australia. I've read that the New Zealand dollar improved marginally after the release of the budget this morning, and Wall Street continues to give the New Zealand economy a "stable" credit rating.

The general criticism that I'm hearing is that this sort of tax reform, which is laissez faire in orientation, is going to widen the gap between income brackets. The lower income tax rate is more advantageous for the wealthier income brackets, as well as for corporations, while the higher sales tax rate is more detrimental to the families in the lower income brackets. This is because GST is generally considered a regressive tax. That is, the burden of the tax falls disproportionately on the lower income people because they spend a higher proportion of their income (on Goods and Services) than wealthier people do.

And this income gap is a serious factor when looking at health of populations. There's evidence that "absolute" poverty is not as detrimental to health as "relative" poverty is because of the psychological and social factors leading to higher rates of stress and disease. This sort of widening between the rich and the poor puts strain on social cohesion as well. A regressive tax change is going to affect critical health choices about general services (like going to a doctor), education, and food. It might be worth looking into excluding food, or especially fruits and vegetables, from the GST increase. There are definitely opportunities to make health-promoting incentives in all of this.

Individualism versus Collectivism

This morning I was speaking about the differences between Pacific Island/Maori and European/American worldviews with a Rotarian who is the head of a community foundation. The first point was about gender roles, and the second, related point, was about individualism versus collectivism.

Maori and Pacific Island cultures are more matriarchal. Some attribute this to the fact that in the distant past the men were hunters, fishermen, and warriors, and therefore sometimes did not return home after expeditions. The women on the other hand were the stability in the family, the tribe, and society. Therefore, boys from these cultures were/are more afraid of their mothers than their fathers. Similar to this is the finding that even today, in co-ed boarding schools with boys and girls from Maori/Pacific Island cultures, administrators have to keep the girls out of the boys' dormitories.

European/American culture has traditionally been much more patriarchal, with the father being the head of the individual household, and men being the head of societal institutions. Wives have been thought of as subordinate in this culture, and women traditionally haven't held leadership roles in societal institutions. This means that boys have typically been afraid of their fathers. Furthermore, in co-ed boarding schools (to compare to the previous example), boys typically have to be kept out of the girls' dormitories.

When someone from Maori/Pacific Island culture gets up to speak in front of a group he or she will typically acknowledge past ancestors and start out by "putting his or her back to the future." There is an appreciation of the wisdom of elders. Old institutions and structures of society are not torn down but held together by each successive generations. The focus is more on the collective unit of the family, tribe, and society over the individual.

In more European/American cultures, most people approach work, relationships, and institutions with an emphasis on the future. The old is discarded and broken down to build anew with each new generation. The formative experiences which have culminated in a particular time and place are not dwelled on. The emphasis is on the individual over the collective. This is most emblematic in America's "rugged individualism."

I realise I could get into some trouble with these simplistic and over-generalised statements. I apologise if this has offended someone. I realise it misconstrues reality, but at the same time I think these distinctions hint at some important cultural differences between the many peoples living in New Zealand today.

Weekend in Wellington (or Huebner's "Ambassador")

Over the weekend I was in Wellington attending an Orientation Seminar for my scholarship. Wellington is the capital of New Zealand, but it only has 400,000 people (Auckland, where I'm living, has 1.3 million).

Saturday morning two other scholars and I ran along the bay. The cool morning air was still and the water in the bay was unusually tranquil. On the return we saw the sun bursting over the mountains. The morning light spread around the buildings along the bay, waking up the quiet city.

On Saturday after lunch we got a tour of the government buildings and parliament. Sunday afternoon we went toTe Papa, Wellington's expansive 3-floor museum. We only had time for the first floor, but we got to see the famous and fantastically large Colossal Squid.

The seminar was held in the Old Government Building, which is situated across the street from the Beehive and Parliament house. The majestic old Government Building is one of the largest wooden buildings in the world, and now hosts Victoria University's law school. At the seminar we heard from David Huebner, the US Ambassador to New Zealand, and from Anand Satyanand, New Zealand's Governor-General.

Ambassador Huebner gave us some excellent pointers about living in another country, representing your own country, and being "ambassadors." There were a couple points in particular that I'm going to try to incorporate into my actions here in New Zealand.

First, he said the biggest enemy in life are expectations. They're problematic because you'll either have them validated or you'll be disappointed. By not expecting anything you will be able to adjust to the new environment and experience it for what it is, not for what you hope(d) it to be. If you do this, you'll be able to analyse and reflect and experience more pristinely.

Second, the ambassador said never judge, never be critical, and never validate the myths perpetuated by others. He said it's way too easy to be critical and negative. It's harder, yet absolutely essential to be self-reflective and honest. He said it's critical as ambassadors that we learn how to deflect criticism, and learn how to steer critical conversations into productive and valuable experiences.

Presentation by Prime Minister

On Friday I attended a lecture by Prime Minister Michael Somare of Papua New Guinea (PNG). Sir Michael Somare has been prime minister of PNG since 2002, but he's been involved with politics in his country since the late 60s and has served as prime minister twice before this term.

The occasion for the lecture, which took place in a conference room in the business school, was apparently to reaffirm the PNG-NZ relationship and co-dependence as leaders in the South Pacific. PNG is dependent on New Zealand for foreign aid, and they have a fairly close relationship in terms of economics, politics, and security issues. PNG has a close relationship with Australia as well, from which it gained its independence in 1975. And Sir Michael Somare had a pivotal role in the granting of his country's independence.

I wasn't overly enthralled by his presentation and he didn't come across as an especially charismatic person. However, for someone who doesn't know a lot about PNG, the content of his speech made his country sound like a success story in terms of former colonies, and it made him appear to be a confident, pragmatic, and successful leader of his country.

The most interesting part of the afternoon was the Q&A period that followed the speech. There were questions about some islands seeking autonomy from PNG, as well a few questions about university education, leadership, and economic independence. He handled all of these quite diplomatically. In fact, it was clear that Sir Michael has spent a lifetime fielding such divisive questions with prolonged and slightly round-about answers.

However, the last question clearly put Sir Michael in a tough situation. A woman from Amnesty International asked about human rights abuses by police in PNG. Apparently there have been some reports of such abuses in recent months, although I haven't read anything about this. Prime Minister Somare addressed the question with half-seriousness and added that these reports were most likely overplayed. He said PNG is a very safe country, much safer than many other countries in the world. He said PNG police are very respectable. He also added that the woman may have been reading the "wrong newspapers," making it sound as if Amnesty International isn't an organisation that he has been fond of over the years.

Amazing Agathis Australis

We drove north out of Auckland to see the famous Kauri trees, some of which probably germinated around the time of Jesus. The two most spectacular Kauri trees are the Tane Mahuta (Maori for "Lord of the Forest") and the Te Matua Ngahere (Maori for "Father of the Forest"), which are respectively the first and second largest Kauri trees in New Zealand.

Situated in the depths of the Waipoua Forest, these trees were thankfully spared from the intensive logging of the 19th century. Agathis australis once blanketed the rain forests of northern New Zealand, but were logged for ship building (particularly masts), wood panelling, furniture making, and the like. It is said that only 10% of the original kauri forests remain. There are now restrictions on the logging of these trees. Good thing too, for the powerful and majestic nature of these beasts gives us a glimpse into the ancient flora of this beautiful country.

Tane Mahuta: Circumference: 45 ft; Height: 168 ft.

Te Matua Ngahere: Circumference: 52 ft; Height: 98.5 ft.

The circumference, or girth, of the largest Kauri on record is 87 ft. The tree was known as the Great Ghost and was consumed in a fire in the late 1800s. There was also one that reached 185 ft, but it fell in the 1970s.

Building footpaths, hiking up volcanoes

Motutapu is an island in the Hauraki Gulf. It's about a 30 minute ferry ride from Auckland. There's a camp on the island called the Motutapu Outdoor Education Camp (MOEC) which sees close to 12,000 students a year from Auckland schools. The kids learn about the island and the outdoors, and they get to go kayaking, snorkelling, sailing, tramping and swimming.

I went out there over the weekend with some Rotarians to do some volunteer work. We were there to build a brick path from the driveway to a rock climbing wall. We set up boxing with 2x4's, spread gravel and sand on the path and lay brick on top of it. There was lots of brick-carrying and brick-laying and lots of digging and hammering. We spent most of Saturday and half of Sunday building this path and by the end of it all the path was basically completed. It was hard work but gratifying nonetheless.

Another Ambassadorial Scholar and I set up a tent on a grassy patch fifty feet from the ocean. We went swimming after working all day Saturday, camped Saturday night, and then we went on a hike around the island on Sunday morning. Duncan, the facilities manager at the camp, went with us. He showed us some of the ruins from the WWII military installations that were set up on the island. He also told us all about the pest eradication project being done on the Motutapu.

Since New Zealand didn't have any mammals (besides bats) before the Europeans came most of the indigenous birds were free to nest on the ground. And so they evolved to be ground-nesting birds. The rats, mice, possums, and cats that the Europeans brought with them in 18th century feasted on these birds and pushed some of them to the brink of extinction.

There has been a huge push to poison and hunt down the pests in protected habitats like islands (like Motutapu Island) and peninsulas (like the Tawharanui Bird Sanctuary) so that the native birds will return and begin nesting on the ground. There is obviously some controversy about using poison to kill dogs and cats and rabbits in the name of saving some indigenous birds.

Either way, the pests have been unofficially eradicated on Motutapu Island and some native birds, like a certain native parrot, have been returning to the island to nest.

After we finished working on Sunday we hiked up to the summit of a neighbouring volcano called Rangitoto. The islands are separated by a tiny causeway with a bridge. Motutapu is hundreds of thousands of years old and was inhabited by Maori before Rangitoto erupted 600 years ago. Rangitoto has a 60 meter deep crater in the middle and it's only about 120 meters high. Most of the island now has vegetation but there are still some lava fields with dark black, thorny rocks.