This text is from Frank Brennan's graduation address to the Australian Catholic University Faculty of Health Sciences, at Sydney Exhibition and Convention Centre on Tuesday 5 April 2011.
Pro-Chancellor Mr Excell, Professor Martin, Ladies and Gentlemen: Thank you for the honour of being the last lecturer to whom the 2011 graduands from the faculty of Health Sciences have to listen, and without the need for any marking or assessment.
This last weekend, I had the pleasure of baptising a baby in the Cathedral at Cairns in far north Queensland. The baby's maternal grandfather was a local Aboriginal leader who welcomed us to country, as did Mr Ralph this afternoon. The grandfather had been the elected leader of the Yarrabah Aboriginal community when they were negotiating their land title with the Bjelke-Petersen government 30 years ago. I was privileged to be their legal adviser at the time. So I happily join with Mr Ralph in acknowledging the traditional owners of this place and thank him for his welcome to country.
The baby's paternal grandmother had flown from her home in Ireland and presented us with baptismal water from the Jordan River, a pilgrim's shell from the Camino de Compastella and a linen cloth replete with the Celtic cross. The baptism was a truly Australian event celebrating the Aboriginal and migrant heritage of the newborn embodying the history of this land.
Yesterday, I stopped over in Townsville to visit an Aboriginal friend who is doing life in the Townsville jail. Though Aborigines are a single-digit, small percentage of our population, they are the overwhelming majority in the Townsville Women's Prison. My friend was trained in the health sciences. I asked her what I should say to you today. She said, 'Look with two eyes. Look beyond. Look for things which are unspoken. They are the things that matter. When your spirit is broken you cannot communicate your pain. That's why my people are sick.'
Those of you graduating in the health sciences know the challenges confronting us in closing the gap on Aboriginal disadvantage. The current gap in Aboriginal life expectancy is estimated at 11.5 years for males and 9.7 years for females. Non-Indigenous life expectancy is expected to rise over coming years. So Indigenous male life expectancy will probably have to increase by almost 21 years by 2031 to close the gap. This is a challenge for all Australians especially those of you who are to be health professionals. Approximately 70 per cent of the gap in health outcomes is due to chronic diseases, which tend to have common lifestyle-related risk factors such as smoking, poor nutrition, obesity and low levels of physical activity.
There are five key influences on our health: genetics, social circumstances, lifestyle, accidents, and access to health care. Often we focus only on the 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. 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.
The Rudd Government started concerted work on addressing the social determinants of health for Indigenous Australians with the annual 'Closing the Gap' report. Is it not time for a similar approach to address the health needs of marginalised groups in the community generally?
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 go to McDonald's. It's not good for you.'
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.
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 WHO and 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 Gillard Government maintains a commitment to social inclusion. Sir Michael 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.'
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 want 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.
We need to break down the silo mentality. As health professionals, you need to be aware of the inequalities confronting your patients, being 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.
In last month's edition of the Australian Nursing Journal, the national president of the Australian Nursing Federation wrote a very one sided article on voluntary euthanasia espousing the case of the Dying with Dignity lobby group. She said:
Most Australians want the availability of both palliative care and VE (voluntary euthanasia). Experience in countries with legalised VE confirms that VE does not undermine palliative care but often enhances it in terms of services and funding ... I urge all nurses and midwives to actively participate in the VE debate as it intensifies and consider the issues at hand.
I agree with her that nurses and midwives and health professionals generally should be engaged in the debate, and I would hope that graduates from ACU would consider all sides of the debate espousing the time honoured medical principle 'Do no harm' and adopting the approach of Catholic social teaching seeing the issue from the perspective of the common good and the public interest, with a particular eye to the needs, dignity and entitlement of society's most vulnerable members. There is a lot of trendy political correctness around this issue at the moment. I would hope that today's graduates will be at the forefront of public discussion about how best to ensure a dignified death for all without placing at risk the poor and vulnerable who can least afford good long term palliative care. If euthanasia laws are instituted (and I hope they are not), we need to ensure that our most vulnerable citizens have a real choice freely to choose continued life despite their demands on the rest of us, and we need to choose life for the incompetent who have not previously freely chosen death.
Today's health science graduates will need to be well informed about issues affecting the health of future generations — issues such as climate change.
In his recent encyclical Caritas in Veritate Pope Benedict XVI said, 'The international community has an urgent duty to find institutional means of regulating the exploitation of non-renewable resources'. He insisted: 'The technologically advanced societies can and must lower their domestic energy consumption'. He put this challenge to us all: 'We must recognize our grave duty to hand the earth on to future generations in such a condition that they too can worthily inhabit it and continue to cultivate it. It is incumbent upon the competent authorities to make every effort to ensure that the economic and social costs of using up shared environmental resources are recognised with transparency and fully borne by those who incur them, not by other peoples or future generations: the protection of the environment, of resources and of the climate obliges all international leaders to act jointly'.
As graduates of a Catholic university, you are not expected to be experts in the science, economics and politics of climate change. But you are expected to be citizens who will bring your critical minds and open hearts to the issue at hand, once again from the perspective of the common good and the public interest and not just your own self interest, and with an eye to the needs, dignity and entitlements of the vulnerable including future generations who are not here to vote or speak for themselves. There is no doubting that climate change is real. There is no doubting that we human beings contribute to that climate change. There is no doubting that per capita we Australians contribute more adversely to that change than any other people on the planet. By unilaterally cutting our emissions, we will not arrest the threat of climate change. By unilaterally putting a price on carbon, we will not pave the way for the development of new less threatening energy sources. But we must do our bit to reduce emissions and to encourage the development of new technology. We might not agree on the politics or the economics for ensuring action by all big polluting nations, but we should agree on the need for them and us to change — and soon — for the well being of future generations and for the well being of the planet.
Today we join with your loved ones and those who have supported you most during your years of difficult study. We thank them for their support, patience and practical help, including those late night suppers which appeared mysteriously beside the computer and those early morning additional commitments they undertook getting the kids to school or at least getting you out the door. With the rapid changes in the health sciences and the increasing demands on our health services, we need you always to be educated, informed and conscientious health professionals. Considering just one further statistic — that the number of Australians aged over 85 will increase from 400,000 to 1.8 million during the working life of today's graduates (i.e. by 2050) — we need very clever strategic and moral thinkers in your midst. Having an eye just to the treatment of the patient in front of you will not be enough, even for that patient in front of you in the years ahead.
Thanks for your commitment to health care. May your professional lives be blessed and enriched by the satisfaction of contributing to the healing of the sick and of the planet. Remember to look with two eyes. Look beyond and look for things which are unspoken.
Fr Frank Brennan SJ is professor of law at the Public Policy Institute, Australian Catholic University and adjunct professor at the College of Law and the National Centre for Indigenous Studies, Australian National University.