Vaccination to create immunity against infectious diseases has been a key public health initiative since the mid-19th century. Children were the main focus.
Smallpox was the only disease preventable by vaccination before the early 20th century. A vaccine for diphtheria was available from 1922, for tuberculosis from 1949 and poliomyelitis (polio) from 1956. A wider range of vaccines, some combined for different diseases (such as the diphtheria–tetanus–whooping-cough vaccine), were available from the 1960s.
Though child vaccination was compulsory between 1863 and 1920 (with a brief period of non-compulsion in 1872) almost all parents ignored this law – in 1916 fewer than 1% of babies were vaccinated against smallpox.
Spanner in the works
Edgar Wilkins, the first director of school hygiene at the Department of Public Health, was firmly opposed to immunisation. His appointment was an odd choice, given that the School Medical Service was responsible for promoting immunisation. Child immunisation rates increased after Wilkins resigned in 1923. The second minister of public health, George Fowlds, was also a critic of immunisation.
Immunisation rates increased slowly. In the mid-1920s around 15% of schoolchildren were vaccinated. This increased to about 33% in the late 1920s. In the 1950s a target rate of 70% for the diphtheria vaccine proved hard to reach.
Severe polio epidemics of the 1940s and 1950s resulted in high immunisation rates once vaccines were available – 97% of children received the first dose and 93% the second dose of the oral vaccine in 1962. Rates dropped once polio was eliminated from New Zealand.
From the 1970s the decline of infectious disease as a cause of illness and death meant parents were less concerned about immunising children. Full immunisation rates were below 80% in many health districts in the mid-1980s – while this was historically high, it was below the 90% experts said was required for community immunity. In the early 21st century New Zealand’s full immunisation rates were lower than most other developed countries, and below a target rate of 95% of all two-year-old children.
In 2018 the national immunisation schedule covered the following diseases: rotavirus, diphtheria, tetanus, whooping cough, polio, hepatitis B, haemophilus influenza type B, pneumococcal disease, measles, mumps, rubella and human papillomavirus (girls only). Fully immunised boys would receive a total of 12 vaccinations, and girls 13. Protection against some of the diseases were combined in a single vaccine, which reduced the number of jabs. The schedule was reviewed every two years.
From its inception in 1907 Plunket emphasised infant nutrition. When the School Dental Service was established in 1919, and after the Department of Public Health assumed responsibility for the School Medical Service in 1921, close attention was also paid to child nutrition. From 1937 to 1967 providing free milk for schoolchildren was the department’s key nutritional initiative.
The appointment of a nutritional officer (Dr Muriel Bell) by the department in 1940 signalled a broader focus on the nutritional health of the whole population. Bell had researched the eating habits of workers and Māori communities for the Medical Research Council in the late 1930s.
Other initiatives included banning the sale of unpasteurised raw milk in 1953 and investigations into cholesterol and heart disease in the 1950s. Emphasis on increased consumption of fruit and vegetables, and less sugar, fat and meat, was ongoing.
Despite a long history of publicity about good nutrition, unhealthy diets were a major cause of chronic disease in the 21st century. Obesity in children and adults increased from the late 20th century. In response, the Ministry of Health funded healthy eating and physical-activity programmes.
Hygiene and morality
From the 1920s school children participated in the daily ‘toothbrush drill’, which involved brushing, rinsing and spitting in group formation, overseen by a teacher. In 1921 School Medical Officer Dr Elizabeth Gunn inspected Stratford District High School and discovered many of the boys masturbated on school grounds. She blamed the ‘listless, inattentive, and perverted’1 behaviour of the boys on the school’s failure to maintain the toothbrush drill.
Fluoride is added to some public water supplies to reduce dental decay. The Department of Health first conducted fluoride trials in Hastings in 1953. In 1978, 54% of New Zealand communities had fluoridated water; by 2016 it was 58%. Christchurch and New Plymouth were the only major cities without fluoridated water. A 2009 survey found that children living in fluoridated areas had 40% less severe tooth decay than children in areas without.
Local councils are responsible for decisions about the fluoridation of drinking water. In 2016 the Health (Fluoridation of Drinking Water) Amendment Bill was introduced which inserted the power for district health boards to make decisions and give directions about fluoridation of local government drinking water. In 2018 this Bill was still to come back to Parliament after the Select Committee process. Passage of this Bill would increase the powers of district health boards relative to local councils.
Some people have argued that fluoridation of water supplies breaches individual rights and limits choices. In 1980 the Human Rights Commission ruled that it did not contravene human rights. In the 2010s there were further legal challenges to the fluoridation of water supplies. Consumer advocacy group, New Health New Zealand Inc., claimed in 2014 that fluoridation of water breached the right to refuse medical treatment under the Bill of Rights Act. They argued that fluoridation was a form of medical treatment that should not be compulsory. They also challenged the right of the South Taranaki District Council to add fluoride to the water supplies of Patea and Waverley. After decisions in the High Court and the Court of Appeal, their challenges to fluoridation went to the Supreme Court in 2018 where a majority of judges, sometimes for different reasons, dismissed these claims.
Lifestyle and behaviour
In the early 1970s, as infectious diseases declined, attention turned to lifestyle issues that caused ill health and death.
While the Department of Health issued warnings about smoking and cancer in the 1950s, a focus on polio epidemics meant tobacco control did not start until the 1960s. Cigarette advertisements were banned on television and radio in 1963, and on billboards and cinema screens in 1973.
Though tobacco-control initiatives (such as price increases) were associated with a decline in smoking rates, the long development period of lung cancer meant it was still the leading cause of cancer deaths in the 21st century.
Hard to ignore
From 2008, 30% of the front and 90% of the back of cigarette packets had to be covered by graphic health warnings. The warnings included pictures of rotting body parts and diseased lungs and hearts. Packets also had to include the logo and phone number of Quitline, a service that helped people stop smoking. Research demonstrated that graphic warnings on packets were the most effective way of showing smokers how dangerous their habit was.
Campaigns against drink-driving started in the 1970s. However, the road toll remained high until the mid-1990s, when it declined rapidly. In the 21st century alcohol (along with speed) remained a major cause of road deaths.
Cancer screening programmes
National cervical screening started in 1990, and breast screening in 1998. Cervical screening occurred in response to the Cartwright Inquiry (1987–88), which investigated the treatment of women with cervical abnormalities at National Women’s Hospital in Auckland. While some have advocated for a free prostate cancer screening programme, screening of men without symptoms is not recommended by the Ministry of Health. A task force set up in 2012 to consider prostate screening concluded that while some men who would benefit from early diagnosis have limited opportunity to access appropriate health services, other men may suffer harms from over-diagnosis and overtreatment.