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| Journal of the New Zealand Medical Association,
02-April-2004, Vol 117 No 1191
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Key arguments for increasing New Zealand’s health
development assistance in the Pacific
Nick Wilson, Osman Mansoor, and George Thomson
OverviewNew Zealand is a relatively poor
contributor of financial aid to developing countries – with a rank of 15th
in the OECD. Given the poverty and poor health status within some Pacific Island
Countries (PICs), there is an ethical imperative to do more. This imperative is
strengthened by the need for the remediation of current and past harms to the
health of Pacific peoples (eg, from New Zealand tobacco exports). Development
aid can also lead to direct and indirect health (and other) benefits for New
Zealand. These benefits are most obvious for communicable disease control (eg,
for tuberculosis, measles, pandemic influenza, and vector-borne diseases). These
benefits will apply more broadly to any health intervention of relevance to the
Pacific Island community in New Zealand (eg, diabetes prevention programmes).
The reduction of poverty and population stabilisation in PICs may also enhance
regional stability. Such stability would benefit New Zealand in terms of trade,
reduced needs for peacekeeping, and a lowered risk of refugees arising from
internal conflicts.
IntroductionThe New Zealand Government has been
contributing around $NZ 250 million in overseas development aid each year, with
this being recently boosted by $NZ 20 million.1
This sum is only around $NZ 70 per person per year—which is equivalent to
just a few hours work per year for a person on the average wage. In 2001, New
Zealand ranked only 15th out of 22 OCED countries in terms of aid as a
proportion of GDP.2 This level was also less
than half the United Nation’s target of 0.7% of GDP and less than a
quarter of the level provided by Denmark. Nevertheless, New Zealand has also
been ranked fourth out of the world’s 21 richest countries on a
‘Commitment to Development Index’ (with this index considering
additional factors such as support for peacekeeping and trade
policies).3
The major recipients of New Zealand development assistance
are countries in the South Pacific (47% of the total assistance) and countries
in East and South East Asia. New Zealand is the fifth largest donor in the
Pacific region (after Japan, the European Union, Australia, and
France).4 New Zealand’s development
assistance has recently been reviewed5 and a
new semi-autonomous organisation ‘NZAID’ (New Zealand Agency for
International Development) has been established. The current major focus of
development assistance is on poverty elimination, which includes health
development.6
Various non-governmental organisations based in New Zealand
also contribute to overseas development (eg, VSA, Oxfam, etc). Yet the impact of
such organisations is generally small compared to official overseas development
assistance.7 This article takes a public health
perspective on the key arguments for increasing overall development assistance
to the Pacific, particularly for health development.
Reason 1—Ethical reasonsThere is a strong case on ethical
grounds for rich countries to assist developing countries in alleviating poverty
and disease.8 As noted in a recent
review,5 the South Pacific region includes
places with extreme poverty. In particular, the Solomon Islands, Papua New
Guinea, and Vanuatu suffer from serious health problems, reflected in low life
expectancy and high infant mortality. Infectious and vector-borne diseases are
important contributors to the poor health outcomes (including malaria,
diarrhoeal diseases and respiratory infections in many PICs). HIV/AIDS is
spreading in the region and is of particular concern in Papua New Guinea. There
are also problems with alcohol abuse, intentional and non-intentional injury,
and increasing rates of diabetes and cardiovascular disease. Premature deaths
from these conditions can result in families losing their principal income
earners, which in turn exacerbates poverty. Similarly, chronic illness impairs
workforce productivity and increases dependency levels.
Another ethical issue is remediation of current and past
harms imposed on PICs by activity allowed by New Zealand Government policy. For
example, one estimate is that New Zealand’s cigarette exports cause around
75 premature deaths per year in nine Pacific
countries.9 New Zealand also exports meat
products high in saturated fat (eg, as ‘mutton flaps’) thus
contributing to cardiovascular disease and diabetes in PICs (given the good
evidence that saturated fat consumption is associated with these
diseases).10
In the past, New Zealand has provided ‘development
funding’ to the construction of a cigarette factory in Samoa in the
1980s.11 This factory continues to supply
cigarettes to Samoa and surrounding countries. Some of New Zealand’s
training of health professionals from the Pacific may also have contributed to a
drain of nurses and doctors from Pacific Island Countries (PICs) to New Zealand
or Australia.
There is a precedent for New Zealand concern for the
consequences of its actions in the Pacific with a recent apology being by the
Prime Minister to Samoa over New Zealand’s ‘inept’ management
of pandemic influenza.12
Reason 2—Shared communicable disease control benefitsGlobalisation and extensive air
travel allow for the rapid spread of communicable diseases between countries,
and border controls have incomplete capacity to prevent their spread. In order
for New Zealand to achieve or maintain control of these diseases, control is
vital in neighbouring countries with frequent reciprocal travel. New Zealand
faces three types of communicable disease risk from PICs: importation of
diseases (and their subsequent spread in New Zealand); infection of New Zealand
travellers who then require treatment by New Zealand health services; and
infection in Pacific migrants who then both require treatment by health services
and who can spread disease in New Zealand.
There are a number of examples of communicable disease
spread from PICs to New Zealand—including
typhoid,13 Ross River
fever,14 and acute haemorrhagic
conjunctivitis.15 Dengue fever poses both risks
to travellers from New Zealand,16 and there is
also a potential risk of it becoming established in this
country.17 Migrants from PICs to New Zealand
also have relatively high rates of tuberculosis (30% of all cases in Auckland
were born in PICs).18 Infectious agents in
imported food from PICs have also caused health problems in New
Zealand.19 Indeed, the 1997 measles epidemic
may also have been started by an importation from the Pacific. Other diseases in
which there is a potential risk of spread (from PICs to New Zealand or vice
versa) include: HIV, pertussis, rubella, pandemic influenza, and SARS (severe
acute respiratory syndrome). Indeed, the global response to SARS particularly
highlights the importance of nation states cooperating on communicable disease
control issues.
Fortunately, many communicable disease control interventions
in developing countries are highly cost-effective. Tuberculosis control
strategies in developing countries are estimated to save a disability-adjusted
life year (DALY) for only $US 3–520 (and
$US 12 per year of life saved).21 There is
extensive international data on the cost-effectiveness of malaria control (eg,
$US 13 and $US 43 per year of life saved in
Guinea,21 and $US 69 per DALY in
Brazil).22 In Melanesian countries, malaria
poses a major and continuing threat and there is evidence from the Solomon
Islands that permethrin-impregnated bednets are an effective low-cost control
strategy.23
Immunisation programmes are also generally considered to be
extremely cost-effective in developing countries (eg, $US 12 – $17 per
DALY for the Expanded Program on
Immunization).20 A hepatitis B immunisation
programme (part-funded by the New Zealand Government) was found to be successful
in protecting infants from chronic infection in the Pacific—at an
estimated cost of around $US 190 per premature death
prevented.24 Even newer vaccines such as Hib
vaccine appears to be cost-saving in some
settings,25 and in the Pacific, Fiji has used
this vaccine to substantially reduce Hib disease
rates.26 Given this evidence, it is not
surprising that improving immunisation cover is an indicator for one of the
United Nations Millennium Development Goals (ie, Goal 4 to ‘reduce child
mortality’).27
Reason 3—Shared non-communicable disease control benefitsNew Zealand shares with PICs such
problems as high rates of rheumatic heart disease, obesity, diabetes, and
tobacco use among its citizens (particularly among Maori and Pacific
peoples).28 Indeed, the increasing prevalence
of adult obesity and type 2 diabetes are particularly major problems for both
New Zealand and PICs. As Auckland has the largest single concentration of
Pacific peoples in the world, many lessons learnt in the process of addressing
these health problems (in both Auckland and in PICs) can be shared to the
benefit of all. Examples might include the sharing of lessons in public health
legislative frameworks, tobacco control policies, culturally-appropriate
nutritional interventions, physical activity promotion programmes, and diabetes
control programmes (eg, as per a programme run in Otara,
Auckland).29
If future immigration from PICs occurs at high rates, then
improved control of chronic diseases in these countries might ultimately lower
health costs for New Zealand. —This may especially be the case for
low-lying island nations (eg, Tuvalu, Kiribati) that could be de-populated by
rising sea levels attributable to global climate change (particularly as
seawater invades below-ground freshwater supplies).
Reason 4 —Enhanced regional stabilityThere are several areas of
instability in the Pacific. Furthermore, some small states may also be at risk
of exploitation by terrorist organisations and crime syndicates (eg, for money
laundering, human smuggling, and drug
trafficking).30 New Zealand has been involved
in a number of successful stability-promoting initiatives, including
peace-keeping activities in both the Pacific and South East Asian region (eg,
Bougainville and East Timor), providing police training (eg, Solomon Islands),
and supporting constitutional reform (eg, Fiji). Such actions appear to be well
worthwhile, but can be supplemented with actions to reduce poverty and improve
health. For example, improving the health status of the workforce may contribute
to stronger economic development and therefore reduce the risk of state
instability. Family planning programmes can assist in lowering population
pressures in island nations that have limited natural resources. Family planning
is also a very cost-effective way to improve child and maternal health (at $US
20-30 per DALY20). Child health programmes may
also contribute to population control, since as child survival improves,
maternal fertility tends to decline.31
A more stable South Pacific would facilitate mutual economic
development (including more trade and tourism) and reduce New Zealand
requirements for expensive peacekeeping operations. It would also lower the
long-term risk of New Zealand having to accept refugees from local conflicts.
Similarly, enhanced stability may increase the resilience of PICs to the impacts
of climate change and, therefore, future numbers of environmental
refugees.
SummaryThere are both ethical and
self-interest reasons for New Zealand to enhance its health development
assistance to neighbouring Pacific Island Countries (PICs). Many of the relevant
health-related interventions are highly cost-effective and are likely to result
in health gains in both PICs and New Zealand.
Nick Wilson Senior Lecturer (public health) Wellington School of Medicine & Health Sciences Wellington
Osman Mansoor
Public Health Physician, Wellington George Thomson
Research Fellow Wellington School of Medicine & Health Sciences Wellington References:
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