An article in the New Zealand Herald nearly a month ago painted a somewhat concerning picture of New Zealand’s health system, following a review of Covid-19 recovery plans by all 20 District Health Boards filed prior to the current delta variant outbreak⁽¹⁾.

At that time more than 15,700 people were waiting longer than four months (the maximum time someone should wait under official guidelines), for a first appointment with a specialist. Another 13,500 had been accepted for treatment but were waiting longer than the four months target.

Our health system has been catching up after many appointments and surgical procedures were put on hold during last year’s lockdowns. On the positive side, these figures showed a reduction of nearly 14,000 patients waiting for appointments and treatment, from when we emerged from level 2 lockdown last year. However, progress had been slower than expected, with some District Health Boards struggling to meet their proposed reduction in waiting list numbers. Reasons for this were increased demand, the complexity of procedures, industrial action, and workforce shortages. Many services were already under severe stress, before the emergence of Covid-19.

Compounding this situation, there is a shortage of General Practitioners (GP’s) in several areas, and GP’s nationwide are calling out for increased primary care funding resources and less pressure.  Having a patient every 15 minutes and a full waiting room, is hardly conducive to being able to provide much in the way of educating and motivating a patient to undergo lifestyle or dietary changes that could have a major benefit on their disease outcomes.

And all this, was the situation before the need for NZ to again go into a level 4 lockdown 10 days ago, due to emergence of the more transmissible delta strain of Covid-19 within our population.

The economic burden of chronic illnesses

A huge component of the NZ government’s $20 billion expenditure annually on health, goes into the treatment and management of chronic conditions such as diabetes mellitus, obesity, cardiovascular disease, depression and anxiety. More than 250,000 people in NZ have diabetes mellitus, predominantly type 2. Management of this and its long term secondary outcomes such as leg ulcers, cardiovascular disease, neurological problems such as retinopathy and blindness, and kidney failure, draws heavily on health system resources and invariably requires increasingly intense treatments. The contribution to the pathology of type 2 diabetes, and economic burden that physical inactivity and obesity alone place on health care resources, is also being increasingly recognized⁽²⁾. This situation is set to worsen further still, with the prevalence of childhood obesity also increasing at a phenomenal rate⁽³⁾. 

In all likelihood there will additionally be a future potential impact of so-called ‘Long Covid’ – chronic health ailments that can be long-lasting and very debilitating (thus expensive to manage) as a result of the secondary and residual effects of Covid-19 on some patients following recovery from the acute infection itself.  Some have projected these long term sequealae which include damage to organs such as the brain and heart, could produce a second public health crisis on the heels of the pandemic itself⁽⁴⁾.

Pharmac’s budget was increased to $1.1 billion in the last budget, through many more drugs remain on its wishlist and on those of many New Zealanders that are yet to be approved for funding. Given the impact of our aging population, the continued increase in drug costs and effects of the pandemic on their supply chains, our reliance on a drug-based treatment system for so many chronic conditions, cannot continue to grow as it has done in the recent past. The many inequities within our society in terms of health service access, also need further addressing.

What can medical herbalists and naturopaths do?

I’ve written about this before^(5,6), but in life repetition and relitigation is often necessary.

Limited understanding of natural medicines including herbal medicines by politicians and regulators, and lack of statutory regulation of natural health practitioners such as medical herbalists, is currently contributing to reduced accessibility to these medicines, resulting in adverse health and financial costs to society. Given the seriousness of the Covid-19 pandemic, and that it’s starting to look like we may be dealing with it for many years to come, this failure to optimize health outcomes for our population, should be urgently addressed.

Hospitalisation is costly, and in many locations in NZ hospital capacity is limited and already under stress. As an alternative to hospitalisation, home-based secondary prevention programmes for patients with many different types of chronic diseases, are being increasingly shown to provide improved patient as well as cost-benefit outcomes^{(7, 8, 9)}.  A recent meta-analysis of studies comparing outcomes in patients with chronic conditions who received “hospital-at-home” visits from a nurse or physician, versus those who received the usual in-hospital care, provides promising data. Those visited at home had a lower risk of long-term care admission than the hospital care group, and lower rates of depression and anxiety than those who remained in hospital^(9). There is no reason why other health professionals such as medical herbalists, naturopaths, nutritionists or counsellors could not also achieve useful (and cost-effective) outcomes if patient access to their services was better facilitated.

Some types of interventions

New Zealand Public health researchers have shown cost savings and favourable cost effectiveness ratios for various interventions modelled by the Burden of Disease Epidemiology, Equity and Cost-Effectiveness Programme (BODE³) Programme⁽¹⁰⁾.Not surprisingly,obesity and inactivity have been identified as major factors. They have recommended dietary changes and taxes on junk food and soft drinks, limits on junk food marketing to children, banning sugary drinks in schools, upgraded food labelling regulations, and improvements in walking and cycling infrastructure, as being likely to have the greatest and more lasting health impacts⁽¹¹⁾.

Herbal medicine treatments aimed at preventing some of the long term neurological and cardiovascular sequelae of poorly controlled diabetes and metabolic syndrome, or helping in the management of conditions such as anxiety disorders or depression, would also be worth evaluating from a cost versus benefit perspective. The cost to the taxpayer in terms such as number of Quality Adjusted Life Years (QALY) achieved through health sector interventions, a metric used also by Pharmac in determining drug-funding decisions, should also be properly researched for specific herbal treatments and practitioner interventions. 

Potential patient as well as pharmaco-economic benefits from adjunctive herbal treatments alongside conventional medical treatment, are now apparent for a large and growing number of common medical conditions. They include infectious disease, leg ulcers, wound healing, and even recovery after a heart failure or stroke.

Insomnia is a very common complaint in today’s world, and as Ive written about previously, there are many herbal medicines that can help⁽¹²⁾. A 2011 study by NZ economists calculated a total net benefit of treating someone with insomnia to be $482, consisting of avoidance of $627 in related health costs, less an average cost of treatment of $145. Applied to the at risk population of NZ at the time, annual savings of nearly $22 million were estimated through treatment using a range of different practitioner or other interventions⁽¹³⁾.

Herbs such as Japanese Honeysuckle (Lonicera japonica), gymnema, fenugreek, cinnamon, ginkgo and ginger, can produce useful actions in type 2 diabetes including helping to prevent some of the long term neurological and cardiovascular sequelae seen in poorly controlled diabetic patients. Hawthorn, Dan Shen (Salvia miltiorrhiza), Tienchi ginseng (Panax notoginseng), pomegranate and others, can help in the management of various cardiovascular conditions, though concomitant drug medication should be considered, and practitioner supervision is advisable.

New Zealand’s mental health statistics are amongst the worst in the world and rising. Greater resourcing of treatment options is required, and while more money was allocated in the last budget to mental health services, with rates of anxiety, depression and suicide showing no signs of abating anytime soon, a paradigm shift in thinking, would probably help more patients.

Herbal medicines have some relevant unique pharmacological actions and produce improvement in a great deal of mentally distressed people, with herbs such as St Johns Wort, withania (Ashwagandha) and kava being safer and often more accessible, than other interventions⁽¹⁴⁾. And again, a skilled medical herbalist or naturopathic practitioner undertaking a comprehensive interview and history taking, and providing lifestyle and other advice in addition to individualized herbal treatments, should help reduce the need for psychiatric input and institution and drug-based care.

Freeing up healthcare resources for other needs!

I have the utmost respect for virtually all health professions and practices, and am very grateful to be able to access specific services and treatments for different health conditions and concerns, when needed. This is the hallmark of a good public health system, which has been an expectation for several generations now, in countries such as New Zealand.

However, the government simply cannot afford to continue to spend ever-increasing percentages of our GDP on Health (this rose from 5.6% of our GDP in 2005 to 6.5% in 2020), and when issues such as viral pandemics or natural disasters trigger a sudden surge in demand for health care resources, there needs to be some spare capacity in the system. One of the best ways we can enable this, is to focus more on reducing the burden on our limited health care resources that chronic conditions such as diabetes, cardiovascular disease, and mental health conditions, are currently causing. Medical herbalists and naturopaths who have undergone 3 or 4 year training to obtain degree qualifications, and the plant-based interventions which have prophylactic or useful adjunctive properties that they prescribe, are a greatly under-utilised resource.

From an evidence-based perspective considering phytomedicinal treatment options alone, the cost versus efficacy ratio is already compelling to subsidise certain plant-based interventions as alternatives or adjuncts to conventional treatments, for many patients with chronic health conditions. Adding to the benefits of such herbal interventions alone, is the ability of properly trained natural health practitioners to undertake a comprehensive assessment of patients, form a good rapport with them, and provide dietary and lifestyle advice to help slow down disease progression and lessen the need for further and often expensive and limited, mainstream health care interventions. And as an increasing amount of evidence is now informing us, that can only be a good thing in a world that a certain clever virus, is changing so much.

References:

1. Jones, Nicholas, The New Zealand Herald, Health system failing to cope. August 2, 2021.
2. Colditz GA. Economic costs of obesity. Am J Clin Nutr. 1992 Feb;55(2 Suppl):503S-507S. doi: 10.1093/ajcn/55.2.503s. PMID: 1733119.
3. Nga VT, Dung VNT, Chu DT, Tien NLB, Van Thanh V, Ngoc VTN, Hoan LN, Phuong NT, Pham VH, Tao Y, Linh NP, Show PL, Do DL. School education and childhood obesity: A systemic review. Diabetes Metab Syndr. 2019 Jul-Aug;13(4):2495-2501. doi: 10.1016/j.dsx.2019.07.014. Epub 2019 Jul 8. PMID: 31405667.
4. Rando HM, Bennett TD, Byrd JB, et al. Challenges in defining Long COVID: Striking differences across literature, Electronic Health Records, and patient-reported information. Preprint. medRxiv. 2021;2021.03.20.21253896. Published 2021 Mar 26. doi:10.1101/2021.03.20.21253896
5. Rasmussen PL, Statutory regulation of medical herbalists and naturopaths: an essential step towards a more cost and outcome beneficial future healthcare system. www.herbblurb.com 26 April, 2019.
6. Rasmussen PL, Herbal Medicine can help reduce high demands on Hospitals. www.herbblurb.com 31 March, 2017.
7. McClure T, Haykowsky MJ, Schopflocher D, Hsu ZY, Clark AM. Home-based secondary prevention programs for patients with coronary artery disease: a meta-analysis of effects on anxiety. J Cardiopulm Rehabil Prev. 2013 Mar-Apr;33(2):59-67. doi: 10.1097/HCR.0b013e3182828f71. PMID: 23426558.
8. Clark AM, Haykowsky M, Kryworuchko J, MacClure T, Scott J, DesMeules M, Luo W, Liang Y, McAlister FA. A meta-analysis of randomized control trials of home-based secondary prevention programs for coronary artery disease. Eur J Cardiovasc Prev Rehabil. 2010 Jun;17(3):261-70. doi: 10.1097/HJR.0b013e32833090ef. PMID: 20560165.
9. Arsenault-Lapierre G, Henein M, Gaid D, Le Berre M, Gore G, Vedel I. Hospital-at-Home Interventions vs In-Hospital Stay for Patients With Chronic Disease Who Present to the Emergency Department: A Systematic Review and Meta-analysis. JAMA Netw Open. 2021;4(6):e2111568. Published 2021 Jun 1. doi:10.1001/jamanetworkopen.2021.11568.
10. Wilson N, Davies A, Brewer N, Nghiem N, Cobiac L, Blakely T. Can cost-effectiveness results be combined into a coherent league table? Case study from one high-income country. Popul Health Metr. 2019;17(1):10. Published 2019 Aug 5. doi:10.1186/s12963-019-0192-x
11. Wilson N et al, BODE3 Interactive League Table – Public Health Expert, University of Otago, New Zealand
12. Rasmussen PL, Overcoming insomnia: drug versus herbal solutions. www.herbblurb.com Oct 20, 2018.
13. Scott GW, Scott HM, O’Keeffe KM, Gander PH. Insomnia – treatment pathways, costs and quality of life. Cost Eff Resour Alloc. 2011;9:10. Published 2011 Jun 21. doi:10.1186/1478-7547-9-10
14. Rasmussen PL, New Zealand’s woeful mental health statistics for young people. www.herbblurb.com Aug 23, 2019.