Photography / Charles Buenconsejo
A better diagnosis
Where he once treated car-crash casualties, Middlemore Hospital intensive care specialist David Galler now sees wards full of people with preventable diseases. He says there’s a better way of doing things – but a lack of will to embrace it.
Finlay Macdonald: You see the reality behind those headlines virtually every day, so how would you describe Middlemore this winter?
David Galler: As time’s gone on, it seems the hospital is now full of people with complications of chronic disease. In theory, the disease is preventable and the complication is preventable. And at this time of year the hospital is bulging. And in fact, the hospital has been bulging for much of the year. It’s running over capacity almost every single day.
You used an analogy of intensive care doctors being a bit like panel beaters – that you can do more with a shiny Lexus than with a rusty Skoda. By which you mean it’s harder to treat someone who is already very unwell, right?
It’s interesting when I look back over my career in intensive care. When I started, intensive care wards tended to be populated by younger people who’d had road crash trauma, been in fights. But it’s been overtaken to a large extent by people who’ve got complications of chronic disease, long-standing health conditions. In south Auckland, there is what we call a “six card full house” – it’s usually obesity, diabetes, renal impairment, heart disease, hypertension and gout. And there are complications of one of those conditions, or a deterioration of a concurrent illness, usually an infection of some sort. And those things are exceptionally common, and the hospital is now full of people who, in theory, have preventable diseases.
The other analogy you’ve used for your intensive care work is gardening – that you try to cultivate the conditions for a patient to recover.
Whether or not people do well or not will relate to a whole lot of different factors. Some of those factors are about who they are, their genetic predisposition to certain things. But if someone is healthy and well, and they become unwell or are injured, there is a far greater chance that they will do better. If they’re not, there is a far greater chance they won’t do so well. That may lead to an increased level of mortality or morbidity, they suffer more, they may not recover to the same extent. So there are factors over which we don’t have much immediate control, which are the public health determinants of wellbeing in the community.
There’s a disconnect here, isn’t there? As medical science and technology becomes ever more sophisticated, you’re seeing more and more preventable disease.
That’s exactly right, I think that’s what we’re seeing. Our population in south Auckland is not a well-off population; at least 200,000 living in poverty, probably a quarter of those children. That’s a huge driver of demand for acute hospital services.
So you’re saying these are socio-economic casualties as much as medical casualties. When you talk about poverty in the New Zealand context, what are you describing?
People living in overcrowded, damp houses; people who live off very little money and scrape by, who can’t afford or don’t have the organisational skills, because they haven’t been brought up to have them, to know how to potentially work their way out of that. So there is a trap there. There are groups of people who do work their way out, largely because of community efforts, but it’s not systematic.
Do you think the debate about poverty in New Zealand gets bogged down in arguments about relative hardship – that compared to the Third World there is no real poverty here?
I just think that’s an obfuscation by people who don’t want to address the real issue. There was a report in 2012 by the Office of the Children’s Commissioner, led by Professor Jonathan Boston, that clearly defined poverty in New Zealand on the basis of well accepted international definitions. And there was a plan presented to the government to reduce it, and the government chose not to accept that gift. A strange thing to do, for an issue that is really intractable and difficult. To have a group of people who are experts in the field come to you with a solution to this problem – you would think you would grab it with open arms wouldn’t you?
Even at a purely monetary level, given the pressure to save health dollars, you’d think stemming demand would be logical.
I struggle with that too. There’s no question that the government must and needs to hold the line to some extent on acute health care services. But to not address the upstream issues defies logic.
You once said hospitals are a little like jails, in that they’re a sign of social failure. They’re still quite useful though, aren’t they?
There will always be accidents and illnesses that just happen. But when I look at the population that is causing our hospital to bulge at the seams, you’d have to say that a lot of that is potentially preventable.
It must be more than just a lack of common sense. What do you think is really missing in this debate?
Part of it I think is that there is no sense of purpose here. I like to think, when people ask me why we spend $16 billion on health services in New Zealand, is it just to keep people off the front page of the paper when they don’t get their hip done? Is it for governments to stay in power? Or does health serve a higher purpose?
And does it? Is it an end in itself or is it part of a bigger picture?
When you look at First Nations and Māori people, they recognise that health and wellness is a holistic thing… they recognise that health contributes to a higher purpose. And that’s individuals and families and communities reaching their potential. What does potential mean? I would say being self-reliant, being productive, being able to start their own businesses, being able to staff their own businesses. That kind of stuff.
Which sort of closes the circle, too, because it comes back to social and economic health, rather than just not being ill.
We can’t afford in a small country like ours, just from a cost point of view, to have this kind of fallout from the productive workforce, as well as the costs of treating those people who are so ill. Children who die of Sudden Infant Death Syndrome, are run over in driveways, or have rheumatic fever or chronic lung disease because they live in a shitty house and they get pneumonia, or they don’t do well at school for various reasons. We just can’t afford to lose those people.
If, as you say, we need a more holistic approach to reducing this need for acute services, that means big policies around housing regulation, food regulation, sugar taxes, those kinds of things. Can you envisage that happening?
Well, it’s not to say that there aren’t lots of examples around the country of fabulous things happening – small initiatives by schools, by communities, by different groups, who see all of this. They understand the interconnectedness. But it’s not systematic, it’s quite hard yakka, you know? We don’t have the kind of recognition and support at a national level for that, we have barriers to it.
To make a final analogy, you see the symptoms every day, so what you’re really saying is that we need a better diagnosis, is that fair?
I think we do, and I think it’s becoming more and more obvious that what we’re doing now is not making us happier, it’s not making us better… and it’s not the New Zealand way. My sense is that instead of becoming the best little country in the world, we’re heading to becoming just another little country in the world.
*Dr David Galler spoke in an individual capacity and not on behalf of any hospital or health organisation.