Health and equality

The Mercy charism

I remember when I first addressed a public meeting here in Perth convened by the late Archbishop William Foley in 1985 to discuss the emotive issue of Aboriginal land rights. Some Catholic miners were not too impressed by the presence of a Jesuit who had come from the eastern states. One gentleman prefaced his question to me with the words, 'We are well used to wise men from the east coming here to Perth'. I made no pretence then to be a wise man, and I make no such assertion this time. But I must plead guilty to the charge of being from the east.

I know little about the way the Mercy charism has been lived out in this part of Australia inspired by the witness of Catherine McAuley and Ursula Frayne. But I presume it would find resonances with our experience in the eastern states. I was brought up in Brisbane. My mother's aunt was a Sister of Mercy who ran very fine schools for many decades, providing poor Catholics with the education which provided them with access to employment, power and influence. My father's first cousin was a Sister of Mercy who nursed and provided pastoral care for decades at the Mater Hospital. In recent years, I have performed the nuptials of a couple of my nieces at the All Hallows School chapel. I have visited the Mater Mother's Hospital to visit three generations of mothers in my family giving birth to their children. I recall over twenty years ago turning up to visit my sister Madeline who was giving birth to her fifth child. She was in one of the finest available rooms at the Mater. I knew she and her husband could not afford it. I asked how she came to be there. She told me that she had arrived at the front desk; sister had greeted her with the words: 'Welcome back Mrs O'Gorman. You must be looking forward to a good rest.'

The Mercy charism in health, education and welfare has been lived out in the lives of ordinary Australians for many generations. There is no substitute for sustained presence and public service. Last Week, I met with Sr Denise Coghlan RSM in Bangkok. She has spent twenty years in faithful service to the Cambodian people whom she first met in the wretched refugee camps on the Thai border and whom she accompanied back home to rebuild their nation. The Mercy charism has always thrived at the frontiers, as it did here in Perth in 1846 when Ursula Frayne arrived at the Swan River Colony saying, 'We stood in the wilds of Australia in the mid-summer night and we could truly say of it that we had nowhere to lay our heads'.

Three perennial challenges for Catholic health providers

Any of us involved in Catholic health care are challenged by the gospel calling given us in the story of the last judgment (Mt 25:31-46). At the end of it all, the King will reply, 'Truly I tell you, whatever you did for one of the least of these brothers and sisters of mine, you did for me.' And yet, each of us knows that for every person we help, there will be millions we will never touch. We are all ultimately dependent on God's mercy. As we try to do more, to serve more people, we need to find the balance: we always face the risk of being too worldly or too idealistic. We can't serve everyone. But are there groups we routinely exclude? We are called to be prophetic. But we must be realistic.

Many of you have told me how impressed you were to read the pre-retirement interview with Archbishop Barry Hickey in the West Australian on the feast of the Assumption. He expressed his regrets that he had not been more outspoken on social issues 'because of fears grants to the Church could have been cut if it was too critical of government policies'. He told the West Australian: 'In accepting government grants the Church's role as an advocate of the poor can be blunted. While I am proud of the broad range of social work in which the Church is involved, I think I should have been more vocal about social issues such as the plight of the homeless, Aboriginals, the disadvantaged and refugees.' This is the voice of a lifetime of experience and a lifetime of reflection on that experience in the light of the gospel injunctions.

Second, let's consider the story of Dives and Lazarus (Lk 16:19-26). 'There was once a rich man, who dressed in purple and the finest linen, and feasted in great magnificence every day. At his gate covered with sores, lay a poor man named Lazarus, who would have been glad to satisfy his hunger with the scraps from the rich man's table.' The challenge is for us wanting to provide excellent, respectful, compassionate service to our patients who can afford it while at the same time professing a preferential option for the poor.

Third, we must always take into account ethical questions. Consider the healing of the man with the withered hand (Lk 6:6-16). Jesus performs the cure in the face of opposition from the religious authorities and says: 'I ask you, is it lawful to do good on the sabbath rather than to do evil, to save life rather than to destroy it?'

I thought Jesus had it easy on one count. The autonomous man with the withered hand wanted Jesus the conscientious healer to do good rather than evil, to save life rather than destroy it. The legalism of the religious authorities could be readily disregarded because the patient's autonomy and the healer's conscience could be honoured by the performance of an agreed healing. But what of the case when the autonomous patient wants the conscientious doctor to perform an action which the doctor thinks wrong and death dealing? And what of the case when the autonomous patient wants the conscientious doctor to desist from doing what the doctor thinks is good and life giving?

The need for organisations in the health and community sectors to take account of the Social Determinants of Health

In June 2010, Martin Laverty the CEO of Catholic Health Australia was appearing before a Senate Committee to give evidence about the 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. [T]he 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. Laverty has now co-edited a book Determining the Future: A Fair Go & Health For All which we will launch at Parliament House in Canberra this Thursday.

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 as prime minister announced a social inclusion agenda aimed at ensuring that all persons can secure a job, access services, connect with family, friends, work personal interests and local community, deal with personal crisis 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. He says, '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.'

Meanwhile Tom Calma and Mick Gooda speaking for their indigenous brothers and sisters remind us, 'Aboriginal and Torres Strait Islander peoples have long asserted that their health is linked to their collective ability to control their lives and cultures and the recognition of their rights'. As indigenous leaders of the Close the Gap campaign they are convinced that 'a holistic and empowering approach that reduces the impact of negative cultural determinants (such as racism) and strengthens the support provided by culture, language and land is vital in any overall national effort to achieve health equality.' David Cooper from the Aboriginal Medical Services Alliance of the Northern Territory (AMSANT) is very critical of government's 'pathologising of traditional culture'. He concedes that Closing the Gap is 'the most expensive, extensive and far-reaching policy intervention in Indigenous affairs in recent times', but claims that 'it comes at the cost of Aboriginal community control being weakened or dismantled to facilitate government control'. For him, 'The pattern that has emerged in Closing the Gap policies is one of asserted Aboriginal failure or deficit being used to justify transferring Aboriginal control to government.' Recent research shows better health outcomes in some remote Aboriginal communities like Utopia in the Northern Territory even though there is less access to routine services than in major centres like Alice Springs.

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 just 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 was privileged to chair 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.'

NATSEM (the National Centre for Social and Economic Modelling at the University of Canberra) has now completed a report Health Lies in Wealth applying some of the findings of WHO and the Marmot methodology to Australia, studying health inequalities in Australians of Working Age. Up to 65 percent of those living in public rental accommodation have long term health problems compared with only 15 per cent of home-owners. More than 60 per cent of men in jobless households report having a long term health condition or disability, and more than 40 per cent of women. The most discriminating socio-economic factors for smoking are education, housing tenure and income. Fewer than 15 per cent of individuals with a tertiary education smoke. Education and housing tenure are consistently related to rates of obesity. Around 40 per cent of Australian men of working age are high risk alcohol drinkers. The likelihood of being a high risk drinker for younger adults who left high school early is up to twice as high as for those with a tertiary qualification.

The Commonwealth Government is committed to establishing Medicare Locals and Local Hospital Networks as part of the COAG health reform process. It will be a lost opportunity for comprehensive health reform if these institutions are permitted to focus only on improved access to health care facilities. We need to break down the silo mentality and have health professionals educated to a greater awareness of the inequalities confronting their patients and committed to greater equity in their local regions so that the scarce health dollar might deliver better real health outcomes for all, especially those whose health is most at risk. This way, the government's social inclusion agenda could impact usefully on the allocation of scarce health resources.

John Falzon, the CEO of St Vincent de Paul, insists that 'the personal is political'. He says, 'Health is not a commodity to be bought and sold. It is a complex of social relations. Like all social relations it is in a state of permanent flux. Everything is related to everything else and everything is constantly changing. Good health is a social good. Good health is hard to achieve in a context of disempowerment and a lack of self-determination.' His members are 'daily witnesses to the experience of people who are crushed and colonised by the undiluted messages that they are to blame for having been left out or pushed out of prosperity afforded by a strong economy and the freedoms afforded by a strong democracy.'

Rhonda Galbally , Acting CEO of the National Preventive Agency, sees a National Disability Insurance Scheme as the 'best buy' for health improvement because it will improve 'the capacity of many people with disability to exercise their rights to be treated as equal citizens'. It would allow them 'to participate in their communities, exercise their rights, undertake education and training, and find employment. It would change their lives.' Australian of the Year, psychiatrist Patrick McGorry calls for a 21st century approach to mental health which 'provides stigma-free comprehensive community based mental health care closely linked to the primary health care system.'

Jenny May, Chair of the National Rural Health Alliance Council, points out that people in the bush don't only have lower socio-economic status than their city cousins. They also encounter greater health risk factors including poorer roads and lesser access to preventive and acute health services.

Journalist Melissa Sweet says, 'The social determinants of health receive plenty of rhetorical attention, but there is far less investment in action to tackle them.' Decision makers need to redirect investment and human resources, breaking down the silo mentality and forging partnerships which can provide a pathway to improved health and wellbeing for all persons, and not just for those at either end of the gradient.

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 attending to those at the top or the bottom.

To do this we need to break down the silo mentality between health, welfare and education. This silo mentality exists in church agencies just as much as elsewhere in society. We must be committed to providing first rate health care to our patients. But we are also committed to creating a more equal society, improving:

• the social circumstances of all persons
  
• the lifestyle of all persons
  
• the frequency of accidents (and violence)
  
• access to health care

In the tradition of Catherine McAuley and Ursula Frayne, let's remember: 'Truly I tell you, whatever you do for one of the least of these brothers and sisters of mine, you do for me.'

'At our gate covered with sores, lies a poor man named Lazarus, who would be glad to satisfy his hunger with the scraps from our table.'

'I ask you, is it lawful to do good on the Sabbath rather than to do evil, to save life rather than to destroy it?'