The past, present and future of chronic disease prevention research

Gretchen Miller: This is Prevention Works, the podcast of The Australian Prevention Partnership Center. I’m Gretchen Miller and I’m really delighted to bring you this interview with the Director of the Prevention Centre himself, Professor Andrew Wilson. He is also Co-Director of the Menzies Center for Health Policy at the University of Sydney.

We ranged across a few things in our conversation, in particular, the past, present and the future of prevention, as well as a little of the background that brought Andrew to us. And it has to be said, we recorded in June 2020 during a quite unprecedented time for health across the world – the global pandemic of COVID-19 which infuses its way throughout our conversation.

Lifestyle-related chronic disease is without a doubt the biggest cause of poor health, almost three quarters of global deaths are down to chronic disease, which comes out of four main risk factors in our behavior, smoking, drinking too much, eating poorly, and not exercising.

In Australia, the figures are even higher, 87% will have some sort of chronic disease contributing to their death. These are daunting figures to be wrangling as Director of the Prevention Centre. So, I asked Andrew in this context, what exactly is prevention?

Andrew: Prevention is our global approach to how people are affected by disease and mortality. The deaths from disease associated with, in this case, chronic diseases. Prevention means different things to different people. If you are somebody that looks at it from my perspective, then I’m thinking about our population, the Australian population, the world population, and what are the things we can do together, that we can do at a higher level, that will lead to a reduction in new disease and the incidence of disease, or reduces the burden of disease for people who actually already have the disease.

So, I’m thinking about the way the health system can respond to that. I’m thinking about factors that influence that at a population level. So, the quality of nutrition which is available, the smoking rates in the population, and the rates of hypertension in the community, the physical inactivity in the community. And I’m thinking about what are the things we can do as a society to reduce those risk factors and thereby reduce the impact of this disease. And that will include things like, what’s the role of the law, of regulation, as we for effectively done for example, in reducing smoking rates, that we’ve effectively used to reduce drink driving, these sorts of activities.

It includes promotional activity where we try and encourage people to become more physically active. It includes trying to create environments where these things are easy to do, having better lighting for example, in areas we know improves the fact that people will walk after hours.

Having more green space has very positive impacts not only on people’s physical activity but also on their mental health. So that’s how I think about prevention. But if you’re a clinician and you’re seeing an individual person, then you’re looking at the person in front of you and you’re thinking to yourself, hmmm, this person has high blood pressure, or this person has an existing chronic disease. What are the things that I can help this person with that will lead them to reduce their risk of either developing disease or reducing the complications of that disease. So, how do I help this person? How do I, to use a term, empower this person to be able to take control of these things from their own perspective?

So, you get these different lenses. These different ways of thinking about prevention, depending on where you sit within the community. If you’re the person sitting on the other side, or if you’re a member of the community, equally when you look at these things you might say, why is the government putting these laws in place that limit my freedom to smoke, for example, or limit where I can smoke, or whether I can use e-cigarettes.

These things, I’ve seen from the other side, we have to be able to communicate to the community and explain to the community why these things are important and why they’re an important part of preventing what is our major source of illness and disability in our community.

Gretchen: Your answer is really interesting because it brings up two critical factors. I think. One is working together. So, communities working together, communities of clinicians, communities of the public, but also it’s not just up to the health sector, it’s also a part of town planning to consider chronic disease prevention.

Now we are at quite a unique time. As I mentioned in my introduction, we are in Australia starting to get control of the coronavirus, but it’s still a global pandemic, and that pandemic has actually erased an experience which we all went through in Australia and which was quite extraordinary this summer. We had this severe bush fire drought summer, which had a profound effect on health, and threatened the very basics of the environment we exist in, clear air, running water, livable temperatures, and it was a shocker for public health. I wonder what this summer triggered for you as you went about your work?

Andrew: [00:05:50] Well, as we are now in winter, it’s not just summer and winter when one takes into account the bush fires, floods, and now COVID-19, we have certainly had an extended period, of really, disruptive and those impacts, have had and will have profound impacts in terms of our health. I’m very concerned in looking at this in that we know there are immediate impacts in the case of fires, obviously there were people who were harmed by the fires themselves, but there were also people who will have some long-term impacts because of the exposures to both, smoke and other inhalable exposures that they had during that period of time. But they also had their lives disrupted. They lost houses, they lost jobs.

Gretchen: [00:06:36] It was profoundly stressful, day after day, in the heart of the city to have the place blanketed by smoke, wasn’t it? I found it psychologically distressing as well as physically distressing.

Andrew: [00:06:48] And, now, with the impacts of COVID again, there are the acute impacts of COVID, people who are actually affected by this disease and we will continue to see people in our community effected by this disease, but we’ve also had profound impacts in terms of the economy. People out of work, people who will not find work again after this for extended periods of time. It’s had impacts on people’s incomes and we know from other recessions elsewhere that these events do have long-term implications for people’s health, and they do have impacts on people’s risk of chronic disease and on their mental health. And we do need to be thinking about that from a prevention point of view. What are the things that we can do to, to assist people, to get through this process?

Gretchen: [00:07:34] Has it changed the way you personally are thinking? So, you went through these experiences too. And because of your position, you would have observed the population impact and hearing reports from on the ground. Has it changed the way you personally, professionally, work and think?

Andrew: [00:07:54] Look it hasn’t changed it, but it has been a very powerful reminder to me that we have to think about the health of our population and the health of individuals in terms of their broader environment. The broader physical environment in terms of where we live, but also our social environment. Now this has been an aspect of prevention and public health, which has always been there, we can trace the roots of this back to the late 1800s where there was profound social unrest, and part of that social unrest was associated with issues of inequality. And a lot of the people who were frontline at that point in time were people from health backgrounds, doctors, although in the case of Florence Nightingale a nurse, who they were very concerned about issues of public health but they were concerned equally about issues of the social environment, social inequality, and they were reformers. They were advocates for change because of the recognition of that link between the physical and social environment and people’s health and every so often we have to be reminded about that.

We tend to drift off at times and start to see very sort of biomedical perspective on health and on disease. and going with that as an intense focus on the individual and in prevention terms, in an individual responsibility. But every so often we need those reminders that actually it’s not just that, that individuals are parts of communities, they’re parts of societies. they’ve got cultural factors that they bring to their lives, that they live in societies which have inequalities within them, that have rules that may not be as fair as they could be and that these things impact greatly on the choices that people can make, we don’t all have the luxury that somebody such as myself has of great freedom and choosing what we can and can’t do that other people are simply not in that situation.

When I think about Australia’s Aboriginal and Torres Strait Islander communities, the level of choice which exists within many of those communities is much more limited. They live with inequality every day. They live with profound loss, with the frequent loss of people within their society. Sorrow is something they live with every day and they live with the whole disempowerment and loss of their land and everything that is important with them. And then when we think about that from here we are trying to prevent chronic disease, which is markedly overrepresented in Indigenous groups about Torres Strait Islander and Aboriginal communities have much higher rates of most chronic diseases. And we think about the issues of individual decision making about behaviors in those situations … if we don’t recognise and deal with those other aspects of it, if we don’t recognise it is not a supportive environment for these people, then we’ll never be able to be effective in our prevention of chronic disease in those communities.

Gretchen: [00:11:00] It’s very clearly a dance between considering the individual and the individual circumstance and then the larger social environment in which people live. And it’s a constant back and forth I think that as a health researcher and a health policy maker one has to consider. You speak about Indigenous populations, now might be the time to ask you about your own personal experience with Indigenous populations. Tell me a little about what informs your understanding of Indigenous communities?

Andrew: [00:11:33] I have had a very fortunate life on many, many fronts. I’ve been very, very fortunate, but it is important to me that I grew up in a small country town in North Queensland, which had very high Aboriginal population. I went to a primary school where the majority of kids in my classes were Aboriginal kids and at the time, they were just locals. They were our neighbors. They were people we played with.

The notion of inequality was not something that I really understood. And I certainly had no understanding of the profound, even though I knew what had happened to many of those families in terms of their loss of land, their co-location on Mona Mona Mission (also known as Monamona) and then the loss of the Mona Mona Mission. Through decisions which they had absolutely no control over, being shifted to camps along the railway line between Kuranda and Mareeba, and then subsequently decisions again, not of their own making of being shifted out of those camps back into Kuranda and Mareeba and other places, which further dislocated them.

Even though I saw that happening at the time. I had no understanding of what that was about. It wasn’t really until I started to go to university and particularly once I started to think about these issues of social inequality and health that I actually then started to reflect back on my own childhood and understand some of those issues, that impacted there.

I started to think about my first year of primary school and think about the kids in the school with me. I mean the number of those kids who are dead, it’s extraordinary. When I look back on that and that has had a profound impact on the way I think about these issues. It’s actually only just in reflecting on it – I still have family who live there and who are very connected to those communities and I don’t see it as unusual and I don’t see it as special, that’s just what it was, it was my life.

Gretchen: [00:13:36] Perhaps it’s fortunate for communities like that and for other communities that you’re now in the position you’re in because you have this inherent understanding from your childhood?

Andrew: [00:13:47] It certainly makes me much more sensitive to these issues. It’s broader than just an appreciation of issues in the health of the first nations people. It’s an appreciation of the importance of the social and cultural determinants for people’s health. And these things cannot be disconnected and then when we respond to this, when we think about what we’re doing in terms of prevention, or for that matter in the way we deliver healthcare, we have to recognise that you need to work with communities, that they’ll want a say in it. Now, getting to that point was where I started to think about the whole notion of community engagement in decisions and then decision-making and more recently, the whole notion of co-production and how you actually achieve these sorts of things.

I’m not fond of the term of co-production because it sounds like we’re sort of building a house together or something. And maybe that’s true, but it sounds a little intellectual. I think it really is about accepting that the community and individuals have a right to participate in and have a say in the decisionmaking process, which is more fundamental when you think about it. That’s really what underpins democracy. And so it goes beyond just our engagement in the health environment.

Gretchen: [00:15:05] It has to be more than a buzzword. In other words, it has to be a genuine invitation for partnership?

Andrew: [00:15:11] I think these terms help us conceptualize what the issues are. They help us actually think about what’s involved in it and how we’ve gone about doing it, et cetera. But there is a risk whenever you create these words that they become buzzwords and that people just articulate them rather than actually fundamentally understand what it means.

The nature of my work is not one which every day puts me working with communities. And I’m very conscious that I’m not in a role anymore where I’m engaged every day with communities in the way that many health workers and particularly people in a public health and prevention community, many of them work very, very closely with their communities and when I talk with these people, I learn so much from them about that process of engagement and what it means to actually do this on a day-to-day basis. And that hasn’t changed in the 30 plus years that I’ve been involved in public health, every time I talk to people about these things that comes across as an important part of it.

And if you think about our success in relation to COVID, at least controlling COVID, the issues of communication and issues of trust have been an important part of what’s happened in Australia. If you look at, let’s say, the US, the issues of the failure of trust, the failure to communicate, the failure of leadership, is absolutely profound in terms of the consequences for that country from COVID and it points to some very difficult problems that they’re going to have to deal with.

Gretchen: [00:16:42] I wonder if the shared experience that we’ve all been through is changing the way you are talking with policy makers and the way that policy makers are listening to conversations around health. What changes are you seeing on the policy level?

Andrew: [00:16:57] Yes. Look, the first thing to say is we are not over it yet in terms of COVID-19, we’ve been very fortunate. Some of that’s a consequence of our relative isolation that we’ve are able to turn off a large proportion of the importation of cases but it’s not over and it won’t be for quite some time in relation to that. I guess most important thing for me so far is you couldn’t have got a clearer statement about the importance of public health and prevention. We have controlled this disease because of things that we’ve done in trying to reduce the rates of transmission of the disease within the community and it’s a profound reinforcement of the need for a strong public health and prevention component to our health system.

The places which have suffered in some ways, comparable countries, one of the things which I’m sure will come out of it will be the fact that they have disinvested in public health. So, I think this, for example, is one of the things which will come out when the United Kingdom reflects on what happened there, in relation to it.

But of the things that I think that are coming through for me, the lessons from it. I won’t reflect here on the public health ones. I’d like to reflect a little bit broader than that because I think some of the lessons beyond that are important. I think the way it has brought together the clinical and public health community has been really, really important. And it just shows the importance of the synergies and those different things. We work in prevention activities, we work on a spectrum between what happens in a prevention population health level and at the individual level and COVID-19 has made that really, really clear about the importance of those have that synergy between those different sectors.

An aspect of it which I think is also really important is one of the things that know in the prevention of chronic disease, something that we know we don’t do well at the moment is engaging other sectors in the journey, having difficulty getting the buy-in from other areas, like transport and the food industry et cetera, to the prevention of chronic disease. With COVID-19 what we’ve seen is that there has been a very active involvement of those other sectors in responding to COVID-19. Other sectors have had to become involved in this. And that has been a positive thing and I would hope that will be something which will have a lasting benefit.

Gretchen: [00:19:26] How will you go about ensuring that you bring all those sectors into the public health fold into the future and in an ongoing way? What plans do you have to make sure that the door doesn’t close, that’s been opened?

Andrew: [00:19:41] Well, first a caution, I am a very tiny part of the system and I don’t have a large amount of influence about these things. I think we need to recognize the importance of those groups and we need to understand why they’re engaged in it. They weren’t necessarily engaged in the COVID-19 response because it was COVID-19, they were there because the profound impacts that it had on their sectors. So, we have to learn in the chronic disease community, how do we get that same message across that there are implications here for you and you should be engaged in this because there is a benefit for what you have to do. And this is what the whole again, buzzword is co-benefits. A whole notion that there are different benefits for different sectors from this and how we spell out and how we articulate those co-benefits will be an important part of achieving that ongoing engagement.

Gretchen: [00:20:39] It’s a pretty exciting time in that way isn’t it? Because, although we’ve been through this terrible trauma there’s also an opportunity to remake things and I wonder if given Australia has managed this quite well, if there’s already rumblings from the international community and taking an interest in that. I want to reflect for a moment. My father worked in public health and health design and I grew up in the seventies in England. And my understanding which is inherent in me, a bit the same as the way you grew up is inherent in you, that I’ve brought with me, is that a systems approach is the logical, rational approach. I think that that’s how people were thinking in the seventies, it shocks me that we haven’t developed from that but in fact we’ve moved back a little to what you called the clinical model, the individual model. I want to understand a little bit about what’s happened in the overall picture of public health and chronic disease management, how that thinking ebbs and flows and how shifts come about?

Andrew: [00:21:47] Certainly the history of the last hundred years has been showing this pendulum between a focus on the biomedical and an individualistic approach, then it will swing in the other direction and we will see this interest in the broader community. We’re in a period at the moment where the really extraordinary discoveries which are going on in biomedicine through, genomics, proteomics, metabolomics, all this really quite detailed understanding of human and other biology in terms of what’s going on. I mean, this is going to have large benefits. At the moment it features very, very highly in terms of, the press loves it, the community loves to hear about these things.

Gretchen: [00:22:33] We want to understand ourselves from the inside out, don’t we?

Andrew: [00:22:37] It’s like our sort of ongoing interest in astronomy, which I always find a bit unusual but there is a profound interest in the beyond and this is with the profound interest on the within and we are just at that point in the pendulum at the moment where, there’s an intense interest in it. I would be very surprised if there isn’t a bit of a swing back in the other direction. That’s what I’ve seen over the [00:23:00] last a hundred years and given all the other things which are going on in the social and physical environment at the moment.

However, there is also an opportunity here, in a sense that we’ve never had before, of actually starting to understand better the relationship between those higher order factors, what we talk about as the upstream determinants of health, and these other basic biology aspects of it. So that interaction between these things is clearly important. And we’re getting to a point where we’re actually going to be able to understand those things a lot better. And maybe, if we do sort of actually understand that we’ll understand overall in terms of prevention, we’ll actually benefit when we take in both of those perspectives from what it is, it’s not one or the other.

Gretchen: [00:23:47] Because we know, for example, that chronic stress or stress events in somebody’s life actually has a generational effect.

Andrew: Yes, traditionally people would have thought that there was no impact, if you or your parents had been exposed to some calamitous event, we wouldn’t assume that two generations later there will be impacts on that. But in fact, there is data that suggests that that is the case, that we get changes in, which in some way become intergenerational in that regard.

I mean, if you think about intergenerational poverty, if you think about the intergenerational loss that goes on for Indigenous communities, it goes beyond the physical in terms of these impacts. And, there’s this notion if we don’t address those intergenerational issues we end up with embedded and ongoing inequality, which becomes increasingly difficult to address as you go from generation to generation.

Gretchen: What you were talking about before in terms of what we’re talking around systems thinking here without necessarily articulating it, but when we talk about needing to bring in town planning, public transport, all these other things you might not immediately associate with public health until you think about it, for about three seconds, but then we also talk about the ground-up approach. How do you work between those two spaces, the ground up and the big system thinking?

Andrew: Just word of caution that people use the term system, you need to understand what they’re talking about because we use this term systems thinking to mean different things. Sometimes we’re talking about biological systems and sometimes we’re talking about something like the healthcare system, about the way we organise our health care and public health system, sometimes we’re talking more profoundly about the relationship of individuals to their ecological environment and those aspects. And sometimes we’re talking about systems in terms of way of talking about the complex and interwoven relationships between many of the things that we have.

So, the first thing when people start talking about systems is to understand what they’re actually talking about. What do they mean by this? I don’t think I ever take my system’s hat off but sometimes we have to make decisions which means we reduce aspects of the system that we’re contemplating at any point in time so that we can get within a decision framework, which was workable. I think for me, the notion of working bottom up and top down is part of what we have to do in the social and cultural and political environment that we work. You actually need to do both those things. That’s one of the ways you can actually get change within complex systems that if you think any one little action is going to result in change, the chances are, well, it might do for a short term or it might do in a way that you hadn’t predicted. But working top down and bottom up to me is a way of trying to get multiple changes that might be necessary to achieve an end, such as getting a more nutritious food environment, for example.

Gretchen: [00:27:10] I’d like to talk a little now about The Australian Prevention Partnership Centre, which you head up. It’s a really interesting partnership model where you have researchers in universities all over the country working with policy makers and practitioners across the country. What does that national reach give the Centre and the work that you do?

Andrew: [00:27:30] We have been extraordinarily fortunate in the Prevention Centre. We were given this opportunity to work in that interface between research and the practice and policy environment. And the partnership centres were envisaged by the NHMRC as an experiment, as a different way of looking at the whole notion of research translation and as we were one of three that were established at the time. And our focus has obviously been in the prevention of chronic disease, incredible foresight in terms of the people who actually put forward the notion and created this opportunity for us to do it. And it’s been an extraordinary privilege in leading that endeavor. The team of us who are in the leadership team, we recognize this is something which has been a unique opportunity to try and demonstrate this particular model. Now, it’s been learning journey. Many of the things that we thought we could do it at first have turned out not to be the way to go. We’ve had to be flexible.

And, the extraordinary part of it is that we’ve had this group of funders who have been prepared to come on this journey with us, and support us, as we’ve looked at different ways of undertaking and trialing this work and, as you say, the other interesting part is that we’ve been able to take a relatively narrow focus even though we’ve had over one hundred different researchers at different times working on different projects. There would be more than 40 projects we’ve run over that period of time. Now, it’s still only a very small proportion of the prevention and public health community in Australia in relative terms and that’s something I’d love to think, going forward, that will continue to bring people in because our raison d’être is really about how the more that we can involve more researchers in this process, the more we can deliver on what it is that we were on about, which is trying to get research to influence policy and practice in a more effective way, but it has been one of the largest national efforts to do this, if not the largest and that’s been a big privilege.

Gretchen: [00:29:45] So you say that it’s been a learning curve for you. It’s been since 2013. What’s changed in the way that prevention research has been undertaken in that time? What are some of those learnings?

Andrew: [00:29:58] So, one of the things about working in the research translation space is that you’re not in a static environment. You’re in an environment where both sides are changing the whole time. So, the evidence base that we are working with is changing because, not just our researchers, but the whole research community, both here and, internationally, is driving and changing the evidence base during that period of time.

On the other side of the equation, there have been major political changes and always will be, to changes to the political and organisational environment in which we work. When we started one of the groups which really initiated the call for this partnership centre, was a national agency, which no longer exists that was dissolved about the same time as we came into being because there was a change of government. We’ve had several changes of government in the period of time that we’ve been there. In fact, we’ve probably been in one of the most stable periods in terms of health ministers, that there has been for quite a while. The longevity of the health ministers in some of the states at the moment is quite unusual, in a political sense.

So, that’s part of what we’ve had to learn to deal with. The fact that we had this vision and that we could embed researchers within government agencies to influence things. Well, what we found was that it was easy to say that but when you actually had to come up and deal with the practicalities of having somebody working within a government agency, within a different construct to an academic environment. So, we’ve done that, and we’ve had some very successful examples of that but certainly not at the level that we thought we could do. It was one of those learnings we had to deal with and we’ve had to find other ways of doing that. So, it’s not that there has been one change, there is ongoing change So, it’s about how do you work within that.

Gretchen: I guess the experience of this past summer plus the COVID-19 phenomenon might have shifted things a little for you in your thinking?

Andrew: I think there is a lot more scope for us to involve a broader range of people on both sides. We have been progressively increasing the number of governments that have been involved so we’ve almost had to add another two governments to the two at this time round. I would hope we could actually get to a situation where all governments in Australia are involved in it.

We’ve got one non-government and one independent government agency. I think there’s a lot more room to engage more of those organisations, which to me, the NGOs are one of the great strengths of public health and prevention in Australia. We have this really strong NGO sector that is independent and holds government to account around issues around their particular areas that they want to. And I’d like to see us engage more strongly with those groups.

We’re going to have to look at some different models on the research side, we’ve been really fortunate up to now that we basically got essentially a one-line grant, where we had a series of projects that had been committed to but it was up to us how we manage that. Going forward, we are not likely to be in that situation again, we’re going to have to have a range of other ways of getting research funding and tying it to different things that we need to happen.

Gretchen: And you’re also focused on developing new measures and tools. What can you tell me about that?

Andrew: Yes, probably the most important of those was in our long title that we had at the beginning, which was a centre for system’s perspectives on the prevention of lifestyle related chronic diseases. I think it’s probably one of the longest titles ever given and I could never come up with a snappy, acronym for that and we never found one that we were satisfied with. But inherent in that was notion that people felt that systems perspectives was important. And in the first five years of our work a large proportion of our time was spent looking at did we need to do to get people more familiar with and accepting of systems perspectives in their work. And so, we developed a number of tools to do that. We developed educational packages around it. We spent a lot of time running workshops around the whole notion of it. And we undertook some projects which were specifically focused on understanding the systems better. The systems that influenced both using the systems term as in, the way the health system organised, the prevention system organised, but also that broader concept of systems. I think that package of things that we achieved during that first period of time was a real success from our point of view.

Gretchen: I wonder then to bring us to a close, what are the biggest challenges for prevention currently in Australia? And I wonder if climate and climate change factor into your thinking?

Andrew: Climate change is in broader public health terms is probably the issue that we’re going to have to deal with. It is going to have impacts both directly and indirectly on health. Directly, in terms of the actual physical environment changing around us, impacts on food, systems, et cetera, and indirectly because those things will not occur equally across the community and some aspects of the community are going to be more impacted by that earlier than others. And so, again it’s going to impact on issues of equality in a strong way – no doubt about that.

But, from the prevention point of view, it is understanding how some of these things linked together, that the changes to our physical environment, albeit whether it’s from climate change or other things that that might impact in changing our physical environment have impacts on our social and cultural environment and have in fact, on how people respond and what people do in their personal decisions will be impacted by those other changes. It will have impacts on things like the food supply and water and these things have consequences for chronic disease risk in our community. So, while we’ve had some really spectacular successes in the prevention of chronic disease, for example, mortality from heart disease has more than halved. In fact, it’s a lot more than halved since the late sixties. We still have a long way to go with that. There are many other chronic diseases where we’ve barely touched the surface in terms of preventing it.

So while we’ve had successes in other areas, there’s a long way to go in terms of what we do and we will need to think about what are the broader factors that are influencing the risks of illness in those areas.

Gretchen: Professor Andrew Wilson, it has really been a lovely chat. Thanks so much for coming on to your very own podcast Prevention works with me, Gretchen Miller, and listeners, if you would like to know more, do check our website.

There are so many more interviews for you on topics as diverse as the impacts of hate on public health to the complex problems of chronic pain as well as a deeper discussion about systems thinking. We also talk about climate change and public health. We would love to hear from you. Do drop us a line and we will see you next time.