Towards health equality


Dreaming the Future: A Fair Go and Health For AllIn June 2010 Martin Laverty, CEO of Catholic Health Australia, appeared before a senate committee to give evidence about COAG health reforms. He drew attention to a lacuna in the public discussion and policy planning. There was next to no reference to the social determinants of health. He said:

I would be misleading this inquiry if I suggested we were entirely happy with the announcements that COAG made. We are critical of what was not actually agreed to.

For example, income levels, as a measure of socioeconomic status, are a better predictor of cardiovascular death than cholesterol levels, blood pressure and smoking combined. A person's access to income is more important to the chances that they face of dying of a heart attack than whether or not they have high cholesterol, high blood pressure or whether they smoke.

The social determinants of health, those factors that include housing, income, educational level, family support, supports at times of personal crisis in a person's life, can have more bearing on a person's health outcomes than access to health systems.

No senator had any interest in taking up this challenge. There were more immediate issues to tackle — like hospital funding and the mooted structure of Medicare Locals.

There are five key influences on our health: genetics, social circumstances, lifestyle, accidents, and access to health care. There is not much we can do to alter our genetics. With better occupational health and safety at work, good design standards, and improved public infrastructure, we can reduce the risk of accident.

The World Health Organisation (WHO) and Sir Michael Marmot in the UK have done a power of work finding that social determinants have a big impact on health outcomes. Fran Baum from Flinders University has worked closely with Marmot and brought home to Australia many of his key findings.

If you are from a poor, dysfunctional family with little education and low job prospects, your health outcomes most probably will be much worse than those of the person from a well off functional family with good education and fine job prospects.

Following the Blair initiative from the UK, Kevin Rudd announced a social inclusion agenda aimed at ensuring that all persons can secure a job, access services, connect with family and friends, pursue personal interests, engage with local community, deal with personal crises and have their voice heard.

The Rudd Government started concerted work on addressing the social determinants of health for Indigenous Australians with the annual Closing the Gap report. The Gillard Government has continued to present parliament with an annual update on closing the gap. It is time for a similar approach to address the health needs of marginalised groups in the community generally.

Marmot found in the UK that health inequalities result from social inequalities. He has put forward the idea of proportionate universalism: 'Focusing solely on the most disadvantaged will not reduce health inequalities sufficiently. To reduce the steepness of the social gradient in health, actions must be universal, but with a scale and intensity that is proportionate to the level of disadvantage.'

In the Australian context, Fran Baum observes that 'while the Closing the Gap and the social inclusion initiatives tackle social determinants, they do this from the point of view of the most disadvantaged and don't tackle the issue of the health gradient'.

The Commonwealth has undertaken fresh initiatives to improve the lifestyle of Australians most likely to have poor health outcomes — especially smokers, heavy drinkers, the unexercised and the obese. But there is only so much government can achieve in attempting to modify people's behaviour without also improving their prospects in education, housing, work, income, and social connectedness.

Policies that target behavioural change in a vacuum do not work. There is little point in telling the unemployed, homeless person with minimal education and few social contacts: 'Don't smoke and don't eat fast food. It's not good for you.'

Steve Hambleton, President of the AMA points out, 'Generally, people on low incomes — including young families, elderly people and those who are unemployed — are often most at risk from poor nutritional choices.' The AMA has called on government to 'improve the quantity and quality of services to those in the poorest and most disadvantaged communities and make such services accessible to the resident populations'.

Most of the airplay on health reform is dedicated to better access to health care services. The research commissioned for the 2009 National Human Rights Consultation which I chaired found that such access is the issue of most importance to the majority of Australians — coming in ahead of pensions and superannuation issues, human rights, global warming and the quality of roads.

This becomes an issue of good money after bad unless there is also action on social determinants and lifestyle questions.

Though the majority of Australians think our human rights are adequately protected, over 70 per cent of those surveyed thought that persons suffering a mental illness, the aged, and persons with a disability needed better protection of their human rights.

Bishop Anthony Fisher, in a co-authored work on the health system in the UK with an already existing Human Rights Act, has advocated the extension of human rights protection to include an enforceable right to healthcare. He says:

A strong case can be made for clear legislative recognition of a right to healthcare, suitably delimited to genuine healthcare need, which could ground proceedings before some tribunal when it is the case that a person has been unjustly denied appropriate treatment ...

Because of the evidence of unjust discrimination against the elderly, and particularly the cognitively impaired elderly, there is a strong case for specific legislation to outlaw such discrimination in the allocation of healthcare resources.

It is not a matter of just providing more resources which improve the lot of all persons much like the rising tide raises all boats. At the same time as we lift the bar, we need to decrease the steep gradient between those with the best and those with the worst outcomes, whether the indicators are income, education, housing, employment or social connectedness.

In this land of the fair go, we need to flatten the gradient of adverse health outcomes, not just attend to those at the top or the bottom.

Further reading: 'We need to break down the silo mentality between health, welfare and education. This exists in church agencies as much as elsewhere in society. We must be committed to providing first rate health care to our patients, but also to creating a more equal society.' Full text from Frank Brennan's MercyCare Oration, of which the above is an edited extract.

Frank BrennanFr Frank Brennan SJ is professor of law at the Public Policy Institute, Australian Catholic University and Advocate in Residence at Catholic Health Australia, Catholic Social Services and the Society of St Vincent de Paul. Tomorrow at Parliament House he will launch Determining the Future: A Fair Go & Health For All, M. Laverty and L. Callaghan (eds), Victoria: Connor Court, 2011.

Topic tags: Frank Brennan, COAG, National Human Rights Consultation, Martin Laverty, Catholic Health Australia



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Existing comments

Wonderful idealism, Father, but how do you propose we change human nature. We cannot afford (or refuse to pay for) the health services we currently have. Where do you propose to raise the money necessary to provide this enormous improvement in education, employment and incomes. Human life has always been a rich source of study for theses promoting academic advancement. Bit of a pity that such studies have a bad habit of achieving nothing simply because human nature does not change to accomodate the findings and suggestions. And then of course we have the politicians to deal with!

john frawley | 24 August 2011  

It's only the land of the 'fair go' for those who are connected.

Greig WIlliams | 24 August 2011  

I look forward to the day Brennan agrees that birth control also feeds into health outcomes for many women and children and can play a role in 'better health outcomes' too.

A bridge too far for religious spokesmen?

Maybe, but that then leads to questioning of their real commitment to human rights and their 'fellow man' (pardon the phrase please but it does seem appropriately paternalistic to be attached to a 'male' and 'religious' world view on 'health').

Harold Wilson | 24 August 2011  

As a professor of general practice and public health physician, I am very familiar with the fact of the socio-economic differential in health outcomes.

Politically there is no imperative to change the inverse care law defined by Julian Tudor Hart as the least and worst care is offered to those who most need it.
Our healthcare funding system Medicare delivers more money to patients from the wealthier areas and the doctors who serve them usually in the private sector. When Tony Abbott introduced changes to the subsidies paid for out of pocket expenses for medical fees, his electoral constituents received more in the first year of the new scheme than the inhabitants of Tasmania. Tasmanians die fifteen months sooner than all other Australians apart from the inhabitants of the Northern Territory. Surely their need for medical care and the cost of that care is higher than the inhabitants of the wealthier northern suburbs of Sydney?

The Labor Party is not immune from criticism either. The funding of public hospitals and primary care in both public and private sectors in safe Labor electorates is not commensurate with the degree of ill health in these areas or equal to that offered in marginal electorates.

Similar things could be said for the education and public transport systems.
State and Federal governments continue to draw vast revenues from alcohol, tobacco and gambling taxes. These activities disproportionately harm and impoverish the poorest and most vulnerable members of our society.

Societies with a flatter distribution of wealth have better health outcomes. Work as John Paul II stated is health giving.
Like St Anthony of Padua is it not time to preach against the sins of greed and avarice? Along with gluttony and sloth they not only harm your chances of salvation but harm your fellow human beings.

Gerard Gill | 24 August 2011  

As usual, Father Brennan is frank and courageous when he points to distorted economics as the basic cause of the unfair provision of health services in Australia. It is even worse in the United States which is ranked 37th in the world for provision of health care despite massive expenditure.
The economic remedy is simple: apply appropriate tax rates and close loopholes to ensure that more money is provided by those who can well afford it.

Unfortunately, this is unlikely to happen. The rich, and the powerful corporations, are too influential with massive dollar donations at election times - together with their influence, if not ownership and control, of much of the mass media.
Greed and lust for power are overcoming democracy.

Bob Corcoran | 24 August 2011  

But surely our world needs more idealism John!

We could choose to adopt an equality strategy if this was something that was collectively agreed upon. There is always an 'opportunity cost', and there is plenty of evidence that society's with higher social welfare programs (e.g. sweden, holland, france), also have much 'healthier' populations and use a lower proportion of their GDP on healthcare.

Unfortunately however i don't often see collectivist ideas winning out to that of the dogged everywoman-for-herself attitude that abounds here.

On the issue of contraception, I don't suppose that the vatican sanctioning their use would make substantial difference to the lives of most Australian women. Even amongst Australian Catholics a significant (?majority) do not pay heed to the totality of Catholic dogma, and perhaps most pointedly on this issue. In saying that, i think the Church's position on marriage and sexuality is beautiful. A wholesome ideal.

Liz | 24 August 2011  

The mining tax in it's original form may have contributed to a little more sharing of the wealth to those who are disadvantaged.
It seems we cannot just rely on a few philanthropic Australians.

Mike Pauly | 24 August 2011  

"Because of the evidence of unjust discrimination against the elderly, and particularly the cognitively impaired elderly, there is a strong case for specific legislation to outlaw such discrimination in the allocation of healthcare resources"

And if we had legislation providing for voluntary euthanasia then possibly a lot of money could be better spent on those who need it, rather than wasted on those who would prefer to die easily and when they choose.

Russell | 24 August 2011  

We must look at our social structures. Generally in Western Society we take the model of the nuclear family as being the basic family structure. this model only came in after the Industrial Revolution. Earlier models look to an extended family and households that in richer families would include servants. Modern suburbia is a very artificial model for community. Support structures are so important. It is not surprising that so many marriages end up in divorce. Law and Order models that think that one can build up a healthy society with more police and more prisons is doomed to failure. Churches that can build up worshiping communities that attract new people and be good role models is the way to the future.

john ozanne | 24 August 2011  

You can tell our 'fair go' value when we can guess a person's income level by their teeth. Working-class root issues/pain/sore gums, broken, can't chew meat, infections left too long. Only dealt with by public health in a crisis. We must integrate dental with Medicare bulk-billing health in mind, body and governance. Elderly friends of mine who have laboured hard since they were 14yrs deserve better attention as do all citizens even if you can't afford a private dentist.

Julie | 25 August 2011  

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