Will Medicare Locals bring a new dawn or a dark night for Indigenous health?
How might Medicare Locals help address some of the wider determinants affecting the health of Aboriginal and Torres Strait Islander people?
In the article below, Indigenous health policy analyst James Lamerton offers the new organisations some practical advice, including on working with local education, justice and public housing agencies.
Some tips for tackling the wider determinants of Indigenous health
James Lamerton writes:
Like the Aboriginal community-controlled health movement (which works from a social determinants of health perspective, in spite of the restrictive and constricting Commonwealth funding formulae under which they operate), Medicare Locals look to be eminently well positioned to conceptualise their local health planning and assessment tasks through the lens of the Social Determinants of Health (SDoH).
But will they?
The noises coming from the Department of Health and Ageing indicate that Jupiter really is aligned with Mars this time, and it’s a propitious moment to push back the health horizon and come to grips with the fact that 80 percent of the causal factors associated with our health status lie outside the health system.
But can organisations emerging so recently from the rarefied air of the general practice environment be relied upon to so radically reinvent themselves – to so radically shift their worldview, and adopt a SDoH focus?
As they say in the classics, the jury’s out.
SDoH thinking is, after all, pretty radical stuff!
The folks over at the World Health Organization (like Dr Anders Nordstrom and Dr Margaret Chan) don’t pull any punches when they say that improving people’s daily living conditions by tackling the inequitable distribution of power, money and resources is what the SDoH are all about.
The WHO insists that governments across the globe should be addressing the inequalities and inequitable conditions in which the vast majority of the world’s people live out their lives and, while they’re at it, addressing the inequities in the way that society is structured and organised.
Wow! Can that be right? If it is, then that’s the most revolutionary and blood-curdling rhetoric we’ve heard since Rosa Luxemburg roamed the streets of Berlin.
Yet it just might be that these sorts of SDoH are several bridges too far for Medicare Locals and their socially and politically conservative core constituency (i.e. GPs).
Instead, I’m guessing we’re much more likely to hear that “we’ll have the socially acceptable Social Determinants of Health, thanks very much – and not too spicy please”.
What’s all the fuss about, anyway? What are these Social Determinants of Health? Well, they’re, like, everything!
They’re the political, social and structural conditions into which you’re born and in which you’ll die (possibly prematurely); in which you grow (or fail to); in which you work (or don’t) and play (or not) – and whether they constitute a positive or negative influence in your lifelong health and happiness depends on where you were standing when the gender, power, money and resources were handed out.
Interestingly, many people now prefer to talk of the ‘social gradient’, which is a parallel concept arguing that there are multiple intricate and intersecting patterns of association between socioeconomic, political and socio-structural factors and health outcomes. Simply put, the higher you’re positioned on the social heap, the better your health – generally speaking.
Importantly, however, the ‘social gradient’ concept allows those of a more pious post-modern bent to philosophically disengage from that hopelessly and laughably modernist notion of ‘determinism’ – whether religious, political or social – and to explore more nuanced and complex social fusions and discontinuities.
However, regardless of your philosophical disposition, the fact remains that Aboriginal people simultaneously hold both the short straw and the wooden spoon when it comes to social determinants and/or the social gradient.
In many parts of Australia, 75 percent of Aboriginal men with serious mental health conditions have their first interaction with a mental health professional in gaol. If you’re an Aboriginal or Torres Strait Islander person, you’re twice as likely to commit suicide as a non-Aboriginal person.
Do we need to talk about comparative incarceration rates? Homelessness? Housing? Access to healthy, affordable and culturally appropriate fresh food on a daily basis? Meaningful employment? Access to trauma-sensitive and culturally secure schooling?
Yet, rather than throw their hands up in desperation (or horror) at the prospect of completely restructuring our society, perhaps Medicare Locals can put their oars in the gentler water a little further downstream, and begin to engage with issues such as those outlined above.
• Get active with the local justice and corrections people, identify who’s the top dog in public housing in the Medicare Local footprint. What are the billing, collection and disconnection policies and procedures of the state-run or private utilities companies that operate within the Medicare Local boundaries?
• Investigate whether there is a consistent and uniform otitis media testing strategy for Aboriginal littlies in the Medicare Local patch.
• Develop a relationship with the local cops – and get a grip on the relationship between the police and the local Aboriginal community.
• Develop an “in” with the local/regional educational authorities so that there’s a coordinated response to Aboriginal kids in the system who might be seen as ‘at risk’.
• Develop an awareness of the state of the relationship between the Aboriginal community and emerging immigrant communities in its area.
• Develop the best and most effective partnerships for the Medicare Local to establish that could assist in reducing tensions between Aboriginal youth and the youth of other disadvantaged, disengaged and culturally diverse communities.
• Work to draw together any and all of the relevant agencies that might be involved in any and all of the above issues so that there’s a comprehensive, local social determinants of health partnership.
This is not an exhaustive list and, as can be seen, it will be unaccustomed and difficult work for Medicare Locals. But it’s part of the daily grind for the Aboriginal community controlled health movement, which is immersed up to its eyeballs in these issues.
So the key, it would appear, is for Medicare Locals to establish, formalise, normalise, maintain, celebrate and occasionally re-invent a partnership with the local Aboriginal Community Controlled Health Service that’s been wrestling with these – and many more – SDoH for nigh on 40 years.
This will be the pivotal developmental relationship for those Medicare Locals moving into the social determinants space.
The Commonwealth, also, must play its part. It must expand its thinking beyond programs that focus their performance indicators on narrow healthcare policy rather than on policies that are good for health, and it must live up to its responsibilities as provider, protector and guarantor of the rights of all its citizens.
All of these health equity and social determinants matters shouldn’t just be depicted as coming from a social justice and human rights perspective, either.
A 2012 report by Catholic Health Australia estimates that reducing the inequities in self-assessed health status could generate as much as $6-7 billion in extra earnings, and in the prevalence of long-term health conditions upwards of $8 billion.
We can’t, of course, expect Medicare Locals to resolve all the issues thrown up by the SDoH; after all, the reason they’re called ‘social determinants’ is because they relate to conditions prevailing in society.
As functioning members of society it is a given that we all have a responsibility to confront the most intractable and enduring of social determinants of health for Aboriginal people: racism.
• Previous post by James Lamerton: Some practical advice for Medicare Locals on engaging with the community controlled sector