Why prevention policy is better than cure

This episode features Dr Paul Kelly, the ACT Chief Health Officer and one of the Prevention Centre’s original Funding Partners. Gretchen Miller talks to Paul about all things public health: from how we can confront obesity, to his recent successful pill testing trial in the ACT, countering nanny state arguments, and how he makes the case for prevention to politicians every day.

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Episode: Why prevention policy is better than cure

Dr Paul Kelly: Obesity is one of what I would call the big five risk factors for chronic disease in Australia and many other parts of the world at the moment. It is in itself a disease, but it’s also a risk factor for other things. I would put it down to the force feeding experiment that we’ve been embarked on for the last 20 or 30 years.

Gretchen Miller: Force feeding on Prevention Works, the podcast of The Australian Prevention Partnership Centre.

Dr Paul Kelly: So, the first thing is I’m not afraid to say that prevention is better than cure, and people kind of get that. But it’s easy to say and difficult to prove.

Gretchen Miller:Today, Professor Paul Kelly in conversation with me, Gretchen Miller. Now, Paul’s a polymath, and to introduce him therefore is quite tricky. But officially, he’s Chief Health Officer at ACT Health. Also, Professor of Public Health at ANU. He’s run a hospital in Malawi. He’s a Scottish dancer. And he quite recently introduced pill testing at a music festival, which saved two people that day from dying.

Dr Paul Kelly: The null effect of not doing anything, that’s not a null effect. That’s a definite choice, and kids are dying at these festivals. They are putting themselves in harm’s way. And so if we continue to do what we’ve always done, we will continue to get that result. And so deciding not to do pill testing is a decision. And people will have to live with that.

Gretchen Miller: So that’s preventative health in action, something Paul’s passionate about. In fact, Paul is one of the funding partners of The Australian Prevention Partnership Centre, and he’s been involved right from the beginning. We’re speaking at his office in Canberra about everything public health, from obesity to pill testing to the nanny state, and as senior decision maker in the ACT government, how he makes a case for preventative health all the time. And we begin talking about what Paul’s been busy with lately.

Dr Paul Kelly: Well, just today, I’ve just been in a meeting where we’re plotting out a major restructure of the health department here in the ACT, splitting health services from more ministry or directorate roles. There’s a lot of complexity there. People tend to forget about population health and health regulation and various things that happen outside of healthcare. And so my role has been very strong and strident in relation to that. So that took a fair bit of my time.

I’ve just had a meeting with the acting director general around PFAS, an environmental toxin which is causing issues around the country, including in Jervis Bay, where we have some responsibility in relation to population health and public health. I’ve been dealing with the next phase of our Healthy Weight Initiative and our preventative health strategy and how we’re working across government in relation to that. I’ve had a meeting about a couple of HR matters. That’s just this morning.

Gretchen Miller: So you have a role as a kind of a mediator, or perhaps even a translator, between the people on the ground, the specialists, the physicians, the health planners and ministers and the general public, and you are the mediator between all those people. And you’re a Scottish dancer, and I’m just wondering if the parallels have something to do with fancy footwork.

Dr Paul Kelly: Yes. Okay. So Scottish dancing, first of all, it is a passion of mine, and there is complicated footwork. But there’s also a wonderful joy in the dance, as well as a lot of geometry and teamwork. So from the geometry point of view, I guess that’s my interest in mathematics and modelling, which I’ve just mentioned. In terms of teamwork, I think that’s the key to your question, what is it about me that allows those skills to be used to bring groups of people together? And to translate between very different viewpoints.

So to bring a Scottish dancing metaphor in again, I dance on a regular basis with people as young as six and as old as 90, and people come with different abilities and different understandings of music and of dance. And so I see that translation role as important in my personal life, but also in my professional life.

Gretchen Miller: So much in health is about political gestures. Health research and evidence-based research is gathered over a number of years, but a political lifespan might only be three or four. And during which, it’s quite important to make a lot of gestures that are extremely visible and understandable by the public. How do you persuade policy makers to use that long-term gathered evidence in their decision making?

Dr Paul Kelly: Well, firstly, public health in particular is inherently political, and I’m the Chief Health Officer of the ACT, so there are seven equivalents of my role around the different states and territories. And if I look at the personalities of my colleagues around Australia, the one clear commonality is that we’re not afraid of politics and are skilled, must be skilled, in the way that we put our arguments across.

So the first thing is I’m not afraid to say that prevention is better than cure, and people kind of get that. But it’s easy to say and difficult to prove, and so whenever we go about, for example, working through programs to look at major issues in our health here in the ACT, we do gather the evidence, first of all. And so last week I presented the Chief Health Officer’s report to our minister that talks about the major risk factors for chronic disease. And that gives the rationale for why we concentrate on obesity, on alcohol, on tobacco, on physical activity and on good nutrition.

So at that meta level, gathering the evidence to say “this is a problem”, and then coming up with potential solutions. And that’s where that comes back to the dance where some of this footwork is actually quite tricky because everyone has their views. It’s extraordinary to me how little people understand around the wider determinants of health, and people always rush to hospital care. And people in the political sphere and in high level policy makers in government are no different from the rest of the population from that point of view.

The first thing is, okay, there’s an obesity problem. We need to set up an obesity service and do bariatric surgery. Now, that would be a really valuable thing for a few people. But it’s not going to actually change the obesity situation of a population like the ACT, where there’s several tens, if not hundreds, of thousands of people who are in the overweight and obese category. There’s no way you could offer that sort of intensive care to everybody. So you have to look at other solutions.

So we come up with possibilities. We look what’s been done elsewhere, we think about what could be feasible in the ACT, and then we test it out. One of the great things working with TAPPC group is that we can use dynamic system-based modelling to thought experiments, rather than having to wait sometimes for years and outside the current political cycle to come with a positive effect.

So back to the Chief Health Officer’s report, the CHO report, we’ve some years identified obesity as being a major issue here in the ACT. We had a Healthy Weight Initiative, which started back in 2013, and so it’s now been running for five years. So it’s taken us that period of time, of course, we made some very strong advances on some of the risk factor issues early. But it’s taken five years for us to actually get some really solid evidence that it’s working.

And it’s a struggle. A new health minister comes in, they always want to show their mark, and they want to have something new. It’s much more difficult to say, “Well, let’s just build up a program in primary schools,” for example, which might not show any effect in any particular way across the population for five years, at which time you may have a different portfolio or have been voted our altogether, Minister. How do you like that? It’s a difficult conversation sometimes.

But the more solid the evidence and the more sort of obvious it is, people get it. And when one succeeds in that situation of that translation of evidence to good policy and to practice programs and eventually outcomes, it’s an extraordinarily satisfying part of my work. But my background in health services, in clinical medicine, in epidemiology and in research allowed me to bridge those gaps and to assist people along the way to come to a common understanding.

Gretchen Miller: What are some of the things that you put in to play when you do something like that? How do you bridge the knowledge gap?

Dr Paul Kelly: Well, some general principles. I guess first of all, one would be: make the space a jargon-free zone. It’s extraordinary how people who have strong expertise in a matter have a lot of assumed knowledge of everyone understands what their jargon or their acronyms, their shorthand, is about. And I see that all the time, and whenever I’m in those conversations, I make that very clear. It’s the ground rules from start. And I pull people up on it. It’s extraordinary to me how people always think doctors are full of jargon and try to exclude others through that use of language, but actually management people are far worse. And researchers can be, too. Sometimes it’s deliberate, but usually not. It’s just not having that sense of having a conversation with a person and putting oneself in their shoes.

Gretchen Miller: Okay, so a shared language or a simplified language, and then what?

Dr Paul Kelly: Listening. Listening to others. When they’re not brought along on the journey or if there’s very specific things they feel very strongly about, trying to make sure that they have that opportunity to express that. And some sort of ground rules, again, to say let’s make sure that we come to a common understanding with all of these things.

That, I guess, has always been in my role right through my career. I’ve always, I think, been fairly well known for the Kelly middle way, that there is no extreme one way or the other. Or if there are, then to get people on the same page, you need to compromise. And so coming with something that might not be the perfect for everybody, but at least it’s a way forward. It’s how I’ve generally approached my career and life actually.

Gretchen Miller: Here on Prevention Works, Paul Kelly, leading preventative health expert. So there’s so much pressure in the general media to be fit and healthy, and it’s particularly around body image. So with all that pressure, why do we still have issues around obesity?

Dr Paul Kelly: Yeah, so obesity is one of what I would call the big five risk factors for chronic disease in Australia. And it is in itself a disease, but it’s also a risk factor for other things. I would put it down to the force feeding experiment that we’ve been embarked on for the last 20 or 30 years. There’s a physical activity component to it, as well, and we are certainly in general, as a population, less physically active at work and at play and at school than we previously were in other generations.

But most of the changes happened in the last 25 years, and the major component of that has been change in our food environment.

Gretchen Miller: Force feeding. That’s forceful words.

Dr Paul Kelly: Yes. When you look at, and I’m somewhat biased here I guess here in Canberra because we have three major industries. We have the public service, we have universities, and we have catering for feeding of said public servants and students. And so a lot of the economy is based on the café and restaurant culture, which is fantastic, and anyone that hasn’t been to Canberra recently, they should come because it’s a wonderful component of our lives.

The problem is that people just eat too much, and they eat too much good food, and the portion sizes are too big, and there’s way too much of a proportion of our diet high energy, low nutrient food. So when I say the force feeding experiment, that’s sort of, I think we’ve been encouraged to eat, and food is in general become less expensive as a proportion of our income for most of us. Not for all. And certainly, high energy, low nutrient food has become much, much cheaper for various reasons.

Gretchen Miller: In other words, sugar.

Dr Paul Kelly: Sugar is a big component of it. But it’s not just sugar. I think in general terms we eat too much, and we eat too little of the food that we should be eating.

Gretchen Miller: So what’s interesting about that is here in Canberra, it’s a relatively wealthy population I think, and the obesity epidemic is just as bad? Is it pretty much the same as around Australia? So that kind of puts a lie to the notion that only poor people eat badly.

Dr Paul Kelly: So a bit more of a nuanced argument than that, I think. There’s certainly, wherever obesity has been looked at, there is a social gradient. And so people who are at the lower end of the socioeconomic gradient tend to be fatter, tend to have all sorts of chronic illness issues, including mental health, as well. So that exists here in Canberra. There are poor people in Canberra, and they are more affected than others.

What I call the Canberra Paradox, though, is what you’ve just described, that we have the highest educational outcomes, very high employment rate, all of those things that we think should be associated with having a much better outcome in terms of obesity and other chronic disease issues, and we don’t. We have virtually the same as everywhere else.

So there’s something else going on there. It’s not just poverty, although that’s something that we have to keep in mind, and we have to keep an equity lens on whatever we’re doing. But it’s not just that. And it’s the commercial determinants, as well as the socioeconomic determinants. It’s other things that are going on that we need to think about there.

Gretchen Miller: The force feeding?

Dr Paul Kelly: The force feeding.

Gretchen Miller: So a question for you. In terms of obesity, why isn’t it the problem of the individual to solve?

Dr Paul Kelly: This comes up whenever I discuss about obesity, and it’s an interesting conundrum. So firstly, we are masters of what we eat, to a certain extent. All of us have agency in relation to our choices in what we eat and how much we eat, how often we eat. We all of us have our own genetic makeup, and some of us store fat, and others don’t. But those two things operate within a structure of society as it’s run, and when we are constantly bombarded with advertising around different types of food, which tend to be in the less healthy varieties, we have virtually constant access to as much food as we want. There are structural elements there that we need to think about.

And so whilst of course people can always make an individual choice, if there is no choice, and if you go to many places within Canberra and also around Australia, there is no healthy choice. Go to a shopping mall and try to find something healthy. They’re just not there. Go to a cinema. These are settings where there is no choice. If there is no choice, you can’t make a healthy choice, no matter how much you want to do that, how much you’re willing to do that. You can’t.

So my work has really been sort of addressing those elements and saying, “How do we make the healthy choice the easy choice? How do we make that availability there?” And in the case of children, maybe there shouldn’t be an unhealthy choice. And so the work we’ve done in schools, and we’ve scaled that up to over 90% of public schools and just under 90% of schools across the ACT, is about that. It’s actually limiting or actually excluding unhealthy choices in canteens, that is part of a program to educate our kids around what those healthy choices are, how to make them and what they mean for their own bodies.

Gretchen Miller: When you’re looking at obesity, which is one of the largest health problems that we have, how should the government get involved, apart from, say, in primary schools? What else can they do?

Dr Paul Kelly: So I think there’s a range of ways that government can get involved, and it requires a degree of political commitment, which is difficult sometimes. There are some things that can be done at the national level in relation to taxation, but that’s less of an opportunity at the state or local level. Certainly, regulations can be made at that level. Leadership is another thing, and policy making.

So for example, and this has happened most recently in Queensland in the last few weeks and it was originally part of our healthy weight initiative here in the ACT, is to look at government buildings and government workplaces and look at what options are there in terms of healthy eating. What options are there in terms of physical activity within those buildings, as well, is another one to think about it. Sit-stand desks, open fire escapes so that people can actually walk rather than catch the lift. So looking at those incidental exercise options. So there’s a leadership component there.

Incentivising industry is another way of thinking about it. So looking at where are the healthy options, the healthy choices that are coming up through industry itself, and looking at ways to incentivise those to allow them to have a foothold in the workplace. So one of the things we’ve tried to do here is around healthy catering policies. So some business will do badly out of that, so if you don’t have a healthy catering option, then you’re not gonna get that contract. Sorry. You need to change. So that’s a way of certainly moving things in the right direction.

Gretchen Miller: So the interesting thing about prevention, of course, and you’re doing with the Prevention Centre what’s called, it’s called the Compelling Case Project. I think it’s really interesting, of course, with prevention, if you succeed there’s no punchline to the story. There’s no dramatic conclusion to prevention, is there? So how do you go about telling that story, and how do you make a compelling case?

Dr Paul Kelly: So the Compelling Case Project is really looking, and it’s quite ground-breaking. A lot of this work that’s being done in TAPPC is actually internationally ground-breaking in its complexity. So this is an attempt to actually put together the major risk factors for chronic disease, many of which are inter-related and so not independent risk factors in themselves, but if you smoke and you have a poor diet and you’re obese, then that makes you even more at risk of chronic disease.

Dr Paul Kelly: Putting all that in to a model which somehow looks something like the Australian population right now, and then using some of the ideas that we’ve talked about today in relation to prevention and putting those into that model and seeing what happens. It’s partly theoretical, and it’s contestable, but that’s one of the beauties of this way of doing things, is you don’t have to come up with a great idea, and then do a randomised trial, and then 15 years later decide whether it worked or not. You can actually do these thought experiments and change them slightly pretty much instantaneously.

And so our idea of that is to actually have a model where we can go to policy makers and to politicians and the general public around Australia and say, “Look, these are the things that we have at the moment. Look what happens if we do nothing. Look what happens if we only do curative care and don’t do anything about prevention. And here’s some opportunities in prevention, where we could act like this now and look what it does into the future. And so thereby building the compelling case and to say, “Yeah, well, of course that’s what we should be doing. And yes, we should be investing more money in prevention. And yes, we should get past this whole concept of nanny statism and actually do something that will actually help not only this generation, but coming generations.”

So that’s where we’re aiming. It’s an ambitious task. Even the mathematical elements of it are quite complex. Getting agreement from a wide range of stakeholders has also been complicated, and for the first time, we’ve done quite a lot of these modelling in projects in the TAPPC up to now in the first five years. This one involves our health economics colleagues, as well, which is something we’ve added in to this to say “This is a good idea. It works. This is how much it costs, and the cost effectiveness of it”. So that’s an even more powerful argument to put to politicians to compel them to actually make those decisions.

Gretchen Miller: You’re with Prevention Works, which is the podcast of The Australian Prevention Partnership Centre, or TAPPC, as it’s known. Gretchen Miller with you, and we’re talking with Professor Paul Kelly. And we’ll talk in a minute about why Australians are so reluctant to be nanny stated. And we’ll also talk about Paul’s time in Malawi and how that influenced his work. But first, recreational drugs. Because one way the power of the prevention story can be told was with the success Paul had with pill testing at a Canberra music festival.

Dr Paul Kelly: It’s a new field for me. I haven’t done much in alcohol or drugs until recently in terms of policy work. And so I was given a task a couple of years ago now, I suppose, 18 months ago. A consortium of harm reduction advocates and scientists and emergency department physicians approached the ACT government to say, “We would like to take a different approach to monitoring and preventing harm from illegal drugs at music festivals”. Something that’s actually pretty much standard practice throughout Europe and other parts of the world, including and importantly New Zealand. But it’d never been officially sanctioned or tried here in Australia.

So we were given the task to look at what were the legal and medical impediments that might be there in terms of what was being proposed and to look very specifically at the science behind what was being proposed to see whether what they were claiming they could do, they could do. In the end, that was the easiest component of getting this up. The harder thing was getting everyone that needed to agree, to agree.

Gretchen Miller: And I’m thinking here of politicians and police.

Dr Paul Kelly: Yeah. So, extraordinarily, one of the main supporters that I had through this whole process was the Chief Police Officer here in the ACT, Justine Saunders. And hat off to her, because, as distinct from most of her other colleagues around Australia, she was prepared to take a chance on this and said, “No, if we continue to do what we have always done and continue to put our head in the sand, even the best ways that we have of decreasing supply and education for decreasing demand, we’re still gonna have kids that are putting themselves in harm’s way. And so let’s think about it in a different way.” And she did. And she came along that journey, and we had many discussions between myself and the Chief of Police about how this would work on the ground. What were the issues from the police force’s point of view?

So that was actually the easy part. And politically, it was risky, and hats off also to Meegan Fitzharris, the Minister for Health and Wellbeing here in the ACT, because she took a risk on that. There was very strong and vocal opposition from the Opposition in the ACT Legislative Assembly. But she took a risk, and she supported it.

We have two main music festivals here in the ACT. On one occasion, the landholder decided that that wasn’t a good idea. On another occasion, it was the person that wanted to run the festival itself. They were difficult to get across the line. Eventually, we did succeed in getting everyone that needed to agree to agree, and it went ahead. And the sky didn’t fall in.

Gretchen Miller: And what happened for two people at that festival?

Dr Paul Kelly: So we found a range of substances, over 100 people came to the tent, even despite for various reasons not having large amount of communications about pill testing being available. But word got out, and people came. And of those, actually a lot of the things that we did test were Panadol, sugar tablets, all sorts of weird stuff that had no psychoactive effect. A lot of it was MDMA or ecstasy, so that wasn’t a surprise. That’s the most common drug of choice at these type of events. But we did find two very dangerous drugs that we were able to alert the people that had been given those thinking that was something else. And they were not consumed.

Gretchen Miller: And if they had consumed those pills?

Dr Paul Kelly: Well, both of those particular drugs have been associated with overdose and even deaths quite recently at similar events around the country and internationally. So we saw that, just that, was enough to show its success. There’s certainly not a great jump to replicate this elsewhere, but hopefully as the local experience and evidence builds up again, people will be compelled to do so because the null effect of not doing anything, that’s not a null effect. That’s a definite choice, and kids are dying at these festivals. They are putting themselves in harm’s way. And so if we continue to do what we’ve always done, we will continue to get that result. And so deciding not to do pill testing is a decision, and people will have to live with that.

Gretchen Miller: The thing about Australians, and I don’t know if this is a national trait, but I think you probably could say it was, we love our universal healthcare, we love Medicare, but we don’t much like being told what to do. But another thing, which kind of complicates this story is that some of us are quite laid back about a lot of things, including our health, particularly Australian men, I think, who are quite notorious for not going to the doctor.

So what I’m interested in, is if you could talk about why getting government to get involved isn’t what’s called nanny stating. We’ve resisted it in so many ways. Seatbelts, cigarettes, now we accept and we probably don’t even think of these things as nanny state activities. They’re just sensible. What are the ingredients to countering the notion of the nanny state?

Dr Paul Kelly: So I’m fascinated by how people have changed over the last generation, which coincides with many of the chronic disease problems what we’re facing. But interestingly, not the one we faced a generation ago. When I first was at medical school, the major issue we had was smoking. And we’ve had extraordinary success in relation to cigarette use and decreasing cigarette use, to the point now in the ACT where almost two-thirds of the population, adult population of the ACT, have never smoked. And our rate of smoking is below 10%. So there are pockets where smoking still remains an issue, but essentially it’s almost a non-issue from a public health point of view. And we’ve seen that in terms of lung cancer and cardiovascular disease rates, particularly lung cancer decreasing rapidly over time.

Gretchen Miller: There was a very firm nanny state approach to that in a way, wasn’t there. There was public health messaging, there was banning. There was some really strong laws that came in, as well as some social deterrents, and a pricing deterrent, as well.

Dr Paul Kelly: Yeah, and I think the key there is that combination. The other thing about smoking is to consider that we knew smoking caused lung cancer in the 1940s. It took more than 40 years before we stopped having a Winfield Cup for the Rugby League and for other advertising and so forth to be restricted. So that’s why when people say to me why aren’t we doing more about obesity and why isn’t happening more quickly and aren’t you depressed by that, well, I’m not. Because these things take time. And I’m sure that eventually we’ll get to the point where we say, “Yeah, look, enough’s enough. We have to do something serious about this.”

In smoking, it took 40 years and lots and lots of evidence and lots of pushback from industry and difficult conversations about what government’s role should or shouldn’t be. But eventually, though, the evidence was so strong that it became accepted.

And when you think about it, as a smoker, you’re incredibly discriminated against. And I’ve never been a smoker, but I can imagine, I’m always surprised why people aren’t more pissed off about that and make more of a thing. It’s still 10% of the population. And so there’s been a range of elements that have happened. So you’ve mentioned pricing, so taxation has been used, regulation very strongly in relation to restriction of access. So if you’re under the age of 18 in any of the states of Australia or the territories, you can’t buy cigarettes, and that’s enforced in various ways. You can’t smoke in certain places, and those places have become more and more wide as time has gone on.

So restriction, regulation, taxation, the social norm has changed, and so people in Australia, and this different from other parts of the world, quite happily say “Don’t smoke in my presence” Or if someone asks can I smoke, you say “No”. And that’s acceptable. It’s not acceptable in parts of Europe, for example. That would be seen as extremely rude, and “What do you mean I can’t smoke?” So there’s nuances there and changes of culture. They’re a range of small things that have added up over time to a very strong effect.

But some of it has to be regulatory, and some of it has to be a decision of government. Why did we start calling this nanny statism? It fascinates me how many laws that we have on the statute books to protect health, which are seen as just standard stuff. Why wouldn’t you do that? And one of my arguments I say when people start really coming back at me at a nanny state is a slightly tongue-in-cheek one. So driving, you don’t want to make it compulsory that it’s on the left-hand side? So people can choose which side of the road they want to drive on? Is that really what you think this would be a reasonable thing? “No, no, that’s ridiculous”.

Gretchen Miller: Before we go, let’s go back a little bit in time to the 1990s, when you were not here in Canberra. You were far away running a hospital in Malawi. And you were a clinician, as well. I wonder if you were obliged to be. I wonder what it was like. Tell me about Malawi.

Dr Paul Kelly: So Malawi is in Central Africa. Population at the time I was there of around 10 million. One of the poorest countries in the world, and I was running a 200-bed hospital with usually one, sometimes two other doctors. When I say that to people, people can’t understand how that could possibly happen, but we had a range of other clinical supports, and many of the local Malawian nurses, for example, were extremely skilled and the midwives in particular. So lots of help there.

But lots of challenges. And in a very poor country, limited resources to deal with them. And it was during that time whilst I was working as a clinician doing operations and delivering babies and giving anaesthetics and whatever else needed to be done where I really kept seeing the same things every day, and the same people coming back with the same things every day. And I realised that prevention was absolutely crucial here, and we needed to do more of that.

Gretchen Miller: What were those things that could have been prevented that you were seeing? I bet it wasn’t obesity.

Dr Paul Kelly: It wasn’t obesity. In fact, I’m just trying to think whether I ever saw anyone with obesity. Probably not. That was at the height of the HIV/AIDS epidemic. I was there just prior to the introduction of highly active retroviral therapies, so we really had no treatment for the HIV virus itself. But many of the people I saw and become my interest at the time and my research interest for some years was in tuberculosis, so often coinfected HIV and tuberculosis together. But for tuberculosis, we had good medications. It was a case of finding people with that diagnosis and treating them early enough before they had other complications.

Gretchen Miller: So seeing these repeated illnesses coming through your door, when did you say right, preventative health, actually this is crazy? We can get rid of a lot of this.

Dr Paul Kelly: It was just before I went, actually. So I was working and I’d done a lot of clinical work in preparation to go to Malawi, and I actually saw a tiny little poster at the old Children’s Hospital at Camperdown in Sydney saying “Come to a discussion about the Masters of Public Health at Sydney University next Tuesday at 7:30” or something. So I went. And I thought, “That’s what I want to do. That makes a lot of sense to me.” And so I did some of the coursework before I left, and then followed on with, my PhD was on tuberculosis and HIV in Malawi.

So I came to that through a process, but it was really what I saw in Africa, that of course you need good primary healthcare, you need good clinical care, and you can’t have one or the other. You have to have both. But unless you do something about preventing the illness coming in the door, you will continue to be overwhelmed.

And so it was very much in your face with those acute issues and infectious issues, infectious disease issues in Malawi. But a similar case is there for chronic disease, and that’s why I’m so attracted to the TAPPC project because we really take all of those aspects together and try to think about what can we realistically be doing to prevent these new epidemics that we’re faced here in Australia.

Gretchen Miller: That’s a perfect place to finish, I think. Thanks so much, Dr Paul Kelly.

Dr Paul Kelly: Thanks so much, Gretchen. It’s been a pleasure talking to you.

Gretchen Miller: Professor Paul Kelly of Public Health at ANU and Chief Health Officer at ACT Health. This has been, of course, Prevention Works, the second series from The Australian Prevention Partnership Centre. So many more interviews for you to catch up on wherever you get your podcasts, and check out our website for transcripts, too.

I’m Gretchen Miller. See you next time.


Host: Gretchen Miller

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