Top 10 public health successes over the last 20 years: what have they done for rural health?

The Public Health Association of Australia recently released its report on the Top 10 public health successes over the last 20 years. The report highlights some of the major public health success stories in the past two decades and the dramatic impact they have had on our health.

Public health measures are often inexpensive to implement and more than pay for themselves in savings to the health system and increased productivity. But public health is also about equity, and achieving good health and wellbeing for everyone, not just those with better resources – or those in metropolitan areas. With the complexities involved in health and health service provision in rural areas, the challenges are significant, and distinctly different to metropolitan areas. One-size-fits-all approaches won’t necessarily work, and so some of the highlighted success stories clearly had major positive impacts on regional and rural communities, but for others, it is less clear.

Folate: reducing neural tube defects
In the past decade, we have dramatically reduced the prevalence of neural tube defects (NTDs) in Australia. NTDs (anecephaly, spina bifida, encephalocoele) are severe birth defects, with high mortality and lifelong morbidity. They are a major cause of perinatal and infant death. Up to the 1990s, these conditions affected 20 in every 10,000 births in Australia.

It has been known since the early 1990s that adequate maternal folate intake before and during pregnancy reduces the risk of NTDs by about 70 per cent. Since the mandatory fortification of bread flour with folic acid from September 2009 there have been dramatic improvements with NTD prevalence decreasing by 74 per cent among Aboriginal and Torres Strait Islander people, and by 15 per cent in isolated communities. This is one of the few success stories of Closing the Gap.

Immunisation
Australia’s National Immunisation Program (NIP) is another area with clear outcomes for regional and rural communities. The NIP provides free vaccines against 17 diseases and has seen full coverage for children increase from less than 80 per cent 20 years ago to 94 per cent in 2017. At five years of age, the coverage for Aboriginal and Torres Strait Islander children is 96.6 per cent which exceeds that for children overall (94.6 per cent).

Water fluoridation
Community water fluoridation programs began in the 1960s but uptake around the country has progressed slowly and been variable. Lifetime access to fluoridated water from an early age is associated with reduced tooth decay in adults. Compared with their parents’ generation, Australians born after 1970 when the majority of water fluoridation programs commenced, have about half the level of tooth decay.

Around 89 per cent of Australians now have access to fluoridated drinking water. However, this is an area where benefits to regional and rural communities have been reduced. Not all local councils have fluoridated their drinking water supply, and even with 100 per cent coverage, it will not affect the thousands of Australians in regional and rural areas who have no access to town water.

Gun control
In response to the Port Arthur massacre in 1996, the Howard Coalition Australian Government led all state and territory governments in adopting strict controls on the civil ownership of firearms. Under the National Firearms Agreement (NFA), gun ownership and trade in Australia is limited to legitimate professional or sporting purposes, and ownership of automatic and semi-automatic weapons in particular is strictly limited. The annual rate of total gun deaths fell from 2.9 per 100,000 in 1996 to 0.9 per 100,000 in 2016. Although the relationship between the NFA and changes in rates of injury and death are complex and interact with other changing societal factors, the rate of decline was more rapid between 1997 and 2013 than prior to 1997.

In particular, the rate of firearm suicide after the NFA was less than would have been expected given the rate prior to the NFA. However, this is another area where despite the improvements, a gap remains - rates are still higher for people living in rural and remote areas.

Tobacco control
With smoking still the world’s number one preventable killer, one of Australia’s greatest health achievements is that smoking prevalence in Australia has fallen significantly over the past 20 years.

Around 20 per cent of adults smoked daily in 2001, but the rate fell to under 13 per cent in 2016. Significantly, fewer and fewer young people are taking up smoking. In 2016, 97.6 per cent of 12-17 year olds had never smoked. These declines have been achieved through multiple measures including plain packaging, introduced in 2012, and increases in tobacco excise.

However, rates of smoking remain high in particular communities and population groups, including those in regional and rural areas, where 20 per cent continue to be daily smokers.

Road safety
All of Australia’s  governments cooperate in maintaining the National Road Safety Strategy, first established in 1992, which provides a framework for national collaboration on road safety improvement.  Sustained policies on road and roadside infrastructure improvements, safer vehicles, lower speed limits, graduated licensing and a range of behavioural programs targeting drink driving, seatbelt usage and speeding have achieved major reductions in road trauma and related public health improvements.

But with road deaths, injuries and damages still costing an estimated $27 billion annually, and targets for the 2001-2010 Strategy not being met, it’s not entirely a success. Remote and very remote areas know this all too well – with rates of deaths due to land transport accidents still being 5.4 times higher than in major cities.

What’s missing from the Top 10?
There are some stark omissions from the report on the top 10 successes – neglected domains of population health where more activity is urgently needed, especially for regional and rural communities.

Access to affordable nutritious food and the reduction of the influence of a profit-driven food industry remains a major problem.

Mental health has seen significant improvements in recent decades, with the reduction of stigmas which prevent people from seeking care, and knowledge and services increasing. However,  there is far too much still to be done, especially for reducing the gaps between urban and rural areas in mental health status and access to services.

Environmental health and the impacts of climate change have been inadequately addressed – air, soil and water contamination continue. People form rural and remote areas know all too well the health challenges of the increased heat waves, droughts, cyclones and floods that we are already witnessing.

Finally, the 2019 Prime Minister’s report on Closing the Gap confirms that we are still a long way from reaching health equity for Aboriginal and Torres Strait Islander people.

The successes in public health are the result of years of work and advocacy by researchers, public health professionals, clinicians, advocates, public servants and politicians. The challenge for us all lies in directing where the successes of the next 20 years will be found.