Croakey’s North American correspondent, Dr Lesley Russell, writes:

“While an excellent discussion is underway on Croakey about the value of calorie labeling in tackling obesity, it has been shocking this week to confront front page news that the number of Americans who don’t have enough food is at an all-time high, largely as a consequence of the nation’s economic crisis.

Every year the Economic Research Service of the US Department of Agriculture compiles a report on Household Food Security.

The 2008 report released this week revealed that last year almost 50 million people in 17 million households (14.6% of all US households) were food insecure and families had difficulty putting enough food on the table at times during the year. This is an increase from 13 million households (11.1%) in 2007. The 2008 figures represent the highest level of food insecurity since national food security surveys were initiated in 1995.

Given that unemployment has risen from 7.2% at the end of 2008 to 10.2% today, this might now be an under-estimate of the number of people struggling to put enough food on the table.

The magnitude of the increase in food shortages, or in some cases outright hunger, has startled even anti-poverty advocates and those who have noticed the increasingly longer lines at food banks and soup kitchens.  It is especially concerning that so many children are going hungry.  In 2008 nearly 17 million children (4 million more than in 2007) lived in households where food was sometimes scarce, and children in more than half a million households faced “very low food security”.

The USDA did not actually use the word “hunger”, but President Obama did and in a statement yesterday, he called the report “unsettling.”  Others were even more forthright.  Mariana Chilton, a Drexel University public-health professor, said: “This is a catastrophe. This is not a blip. This recession will be in the bodies of our children.”

The fundamental cause of food insecurity and hunger in the US is poverty and a lack of resources to provide housing, food and health care.  The Obama Administration has taken action to help needy families through the American Recovery and Reinvestment Act of 2009, which provided a significant increase in nutrition assistance benefits for the 36.5 million people (half of whom are children) who participate in USDA’s Supplemental Nutrition Assistance Program (SNAP), formerly the Food Stamp Program.

The USDA also has a National School Lunch program which serves 31 million children a healthy meal each school day – for some children in need, this is their most important meal that day. Also, nearly half of all infants in the US participate in the Special Supplemental Nutrition Program for Women, Infants and Children, or WIC program, which ensures mothers and their children have access to nutritious food.”

• Dr Lesley Russell is the Menzies Foundation Fellow at the Menzies  Center for Health Policy, University of Sydney/ Australian National  University and a Research Associate at the US Studies Centre, University of Sydney.  She is currently a Visiting Fellow at the Center for American Progress in Washington DC.

Don’t be deceived by the title – the updates are coming fast and furious.

But let’s just keep some sense of perspective; at this stage, the numbers of deaths are miniscule (none in the US reported so far) compared to the toll that influenza causes year-in, year-out, not to mention the deaths caused by many other, less newsworthy killers – lack of clean water, malnutrition, poverty etc etc.

Who says what about the report will be interesting – if only for the insights these comments will yield about the health system and whose interests it serves. The observation that the public’s interests are often the poor cousin to other interests in the health industry is an old one but, unfortunately, still apt.

We in the media often reinforce this power imbalance by giving disproportionate space and weight to those representing professional, commercial and institutional interests.  It’s likely that the AMA, ANF, and hospital lobby (both public and private) will win a prominent run next week.

Whose responses should we be seeking to represent the public interest in the debate? Especially those sections of the community who get a particularly raw deal from our current health system, like Indigenous, and rural and remote Australians, and others who generally don’t wield much clout in society?

More importantly, whose voices should the Government be listening to as they develop their response to the report?

In a stroke of serendipitous timing, the Canadian Health Services Research Foundation has just released two relevant articles with self explanatory titles:

• PUBLIC ENGAGEMENT (PART I) – ENGAGING THE PUBLIC IN HEALTHCARE POLICY: WHY DO IT? AND WHAT ARE THE CHALLENGES?
• PUBLIC ENGAGEMENT (PART II) – HOW DO DELIBERATIVE PROCESSES ACHIEVE MEANINGFUL PUBLIC ENGAGEMENT?

Some timely reading for both journalists and policy makers who are likely to be swamped by the powerful voices of vested health industry interests in coming weeks.

His conclusion, as reported in Crikey yesterday, is that the system is generally fine – but it’s not fair.

“You do much better in Australia’s health care system if you’re wealthy, if you’re well educated, if you live in the city and if you’re not Indigenous,” the report says. “Otherwise, it seems, you receive a lesser standard of care.  If you have a chronic condition such as diabetes or heart disease, you’ll end up in hospital where someone better off will manage to stay home and get the care they need. And if a rich person and a poor person get cancer at the same time, the poor person will die sooner.”

One of the report’s most politically sensitive sections concerns the Australian Government’s subsidy of private health insurance. Ragg notes that the cost of the scheme is rising rapidly but that it has not taken the pressure of public hospitals and that health funds are spending less per member than they did 10 years ago.  Meanwhile, the total equity of Australian private health insurance funds has risen by about $3 billion since the Government started subsidising private health insurance.

“In effect, private health insurance and its application in Australia through the private health insurance rebate scheme does a reverse Robin Hood – it takes money from the poor and gives it to the rich,” says Ragg. “And it does little good for public hospitals.”

Let’s hope someone in the PM’s or Treasurer’s office is reading…

But what do others think of Ragg’s report?

Professor Ian Olver, CEO of Cancer Council Australia and a medical oncologist, writes:

Mark Ragg makes some good points about healthcare inequity in Australia. It’s important to add that poorer cancer treatment outcomes experienced by socially disadvantaged people can in many cases be linked to lost opportunities in preventative health, rather than access to treatment.

Around a third of fatal cancers in Australia are caused by smoking, obesity/overweight and alcohol consumption – partly because some of these cancers, such as lung cancer, are difficult to treat no matter how good the care.

And the cancer burden from these behaviours is borne disproportionately by socially disadvantaged groups. For example Indigenous Australians, who are twice as likely to die within five years of a cancer diagnosis as non-Indigenous Australians, smoke at 2 times the rate of others. So, while there’s evidence that Indigenous people have very poor access to cancer treatment services, there’s also data suggesting that the higher prevalence of smoking-caused cancers among Indigenous people contributes significantly to the unacceptable disparity in cancer survival.

Yet less than 2% of Australia’s health budget goes towards prevention – and far less to tailored programs for disadvantaged groups. This is despite the well-documented social and economic gains available from investing in targeted, evidence-based public health programs.

The Rudd Government’s Preventative Health Taskforce has made strong recommendations to reduce smoking, obesity and alcohol use – setting targets; integrating policy, programs and research; multi-sector approaches and so on. Now it’s up to the Government – which campaigned on building disease prevention into the intergovernmental healthcare agreements – to begin implementing the recommendations through COAG this year.

And with early detection another key to cancer survival, the Government should also expedite its piecemeal bowel cancer screening program – and support it with tailored communications that help ensure all population groups are screened for Australia’s most fatal cancer after lung cancer.
***

Sally Crossing, Chair, Cancer Voices NSW, writes:

Mark Ragg poses the question “Why do poorer and less educated people have worse cancer outcomes than wealthy well educated people?”

It may be because they fall through the cracks on the route to best practice treatment.  They may not get referrals to the multidisciplinary teams which give the best outcomes. They may give up trying to navigate the cancer world “silos” – perhaps this is where assertiveness of the better educated can help, though a cancer diagnosis is pretty destabilising for us all.   They may present too late due to cultural or poverty reasons.

Cancer is a disease which can be most successfully treated when diagnosed early and we still don’t really understand it – unlike heart disease treatment which resembles human plumbing.

Cultural reasons could include the “I’ve got cancer so I’m going to die” belief, a mantra not shared with any heart patients anymore.  And then there are situations where cancer is still not to be spoken of.  Or they may live a long way from good cancer care and be unable to access it…so many possible facets in an answer.

Whatever the truth, thanks for raising the issue.  One vital piece of info we needed to have was how great is the difference between poor/uneducated and wealthy/well educated, and how any people are involved and how many fall in between.  Then we’d have some real evidence for advocacy to address the inequities.

***

Professor Stephen Leeder, co-director of the Menzies Centre for Health Policy, writes:

Assuring fair and equal access to equal medical need remains a constant challenge in health. Centralisation of highly specialised services is technically essential for efficient use of health dollars but each time we do this people who live remotely have less access.  A system that is not tuned to cultural difference will provide less access to cultural minorities.

Let me tell you about another source of inequity and that we have encountered in our work with patients with chronic illness. It is that chronically ill people are told that they should do all they can to stay out of hospital.

Why! Because the hospital is not geared to treat them. So why not change the hospital? This is like going to a shoe store and being told they have no shoes that fit and so please change the size of your feet!

***

Anonymous writes:

Whenever I read such pieces, I am always reminded of the seminal paper by Julian Tudor Hart that was published in the Lancet in 1971 (J. Tudor Hart, The inverse care law. Lancet (1971), pp. 405–412 – also accessible at http://www.sochealth.co.uk/history/inversecare.htm).  Much of his characterisation of Britain’s NHS in the 1960s is relevant to Australia today.  Furthermore, he also provides quotes from several earlier sources which might be viewed as resonating uncannily with our current system some 40 years on eg:-

“We have learnt from 15 years’ experience of the Health Service that the higher income groups know how to make better use of the service; they tend to receive more specialist attention; occupy more of the beds in better equipped and staffed hospitals; receive more elective surgery have better maternal care, and are more likely to get psychiatric help and psychotherapy than low-income groups- particularly the unskilled.” Titmuss R M, Commitment to Welfare. London 1968 (Reference 2)

“The general practitioner in working-class areas discovered the well-tried business principle of small profits with a big turnover where the population was large and growing rapidly; it paid to treat a great many people for a small fee.  A waiting-room crammed with patients, each representing 2s. 6d. for a consultation … not only gave a satisfactory income but also reduced the inclination to practise clinical medicine with skilful care, to attend clinical meetings, or to seek refreshment from the scien­tific literature.”
James E F, Lancet (1961) I 1361 (Reference 5)

“Of 169 new general practitioners who entered practice in under-doctored areas between October, 1968, and October, 1969, 164 came from abroad.” DHSS Annual report for 1969, London 1970 (Reference 13)

****

Michael Moore, CEO, Public Health Association of Australia, writes:

Mark Ragg has stumbled on the social determinants of health.  There is no doubting that the cancer example he uses puts equity and fairness under the spotlight.  It is just downright unfair that the wealthier you are, the healthier you are.

Sir Michael Marmot, as Chair of the Commission on the Social Determinants of Health, has just released a report on behalf of the World Health Organization called Closing the gap in a generation.  Sound somewhat familiar?  In Australia the health inequities are bad enough but viewed from an international perspective they are downright appalling.

The Preventative Health Taskforce are also aware of this issue and gave as an example in their discussion paper Australia: the healthiest country by 2020 that “even within a city such as Melbourne, life expectancy can vary by up to five years within a matter of kilometres.

The problems of inequity in health outcomes have been recognised – the challenge is in finding ways to work to fairer health outcomes.

***

Jeff Richardson, Professor and Foundation Director, Centre for Health Economics, Monash University, writes:

Mark Ragg’s comments in Crikey are well made. Perhaps they are even too generous. It is true that Australians now live longer than almost anyone apart from the Japanese.

But whether this is attributable to the health system (as a system), as distinct from some very specific factors has never been demonstrated. Smoking, drinking and blood pressure are all down. Exercise is up. But at best this reflects the success of public health measures, not the remainder of the system which accounts for about 98.3 percent of expenditure. We do not know if it is the skill of doctors or the efficacy of anti-hypertensive drugs which have the greatest impact in the curative services.

There is absolutely nothing to suggest that it is improvements in the system (which remains largely static) which have caused the improvement. Policies at both the State and Commonwealth level are largely concerned with cost containment and tinkering on the margin with issues associated with health outcome.

The system remains as fragmented as it did 20 years ago when the need for integration was first recognized. In all probability, adverse events continue to kill very large numbers of Australians unnecessarily. The chief publicised policies here are about counting numbers (imperfectly) rather than removing the systemic causes of error and accelerating the inadequate rate of error learning.

Mark Ragg correctly identifies unfairness as a pervasive problem. This was documented for 1976 by myself and John Deeble and reinforced by sporadic research thereafter. Once again the response indicated no real interest in the problem beyond the cosmetic.

Indeed, rather than concern, over a five year period I was unable to obtain data from the Commonwealth Department of Health to analyse how the unfairness had changed through time. We should not, however be particularly surprised by this lack of interest.

Despite folk myth to the contrary Australia remains one of the least egalitarian and meanest countries in the developed world. Our rates of poverty amongst disadvantaged groups, the amount we transfer in social services, the amount we give to other countries, the amount we take from well off taxpayers all come at the bottom or close to the bottom of the OECD league table.

Australians seemed to be far more focussed upon downward envy and less concerned with the position of Aboriginals, rural minorities and other disadvantaged groups than people in more compassionate Western societies.

The unfairness of the distribution of doctors, services and the widespread support for queue jumping via private health insurance are all a reflection of this national character. But apologists will doubtless continue to use any available statistics to support their self congratulation and to avoid the need for a thorough inquiry into the operation of our antiquated and often dangerous delivery system.

“It was said of the Australian cricket team during several of the ill-fated Ashes series in the 1980s that repeatedly it ‘seized defeat from the jaws of victory’. In the lead up to the 1986/7 Ashes series, which Australia approached as clear favourites, Martin Johnson of The Independent wrote that the English team “had only three things wrong with them – can’t bat, can’t bowl, can’t field”. Yet England went on to win the series and retain the Ashes. If cricket is a strong metaphor of life as many devotees insist, then this wimpy Australian quality is far from novel.

Think of the Treaty of Versailles following World War I, where in the long shadows of the tragedy of trench warfare and the annihilation of the young men of Europe, to say nothing of the flu, heavy punitive terms were inflicted upon Germany. Of the many provisions in the Treaty, some of the most controversial required Germany and its allies to accept responsibility for causing the war, to disarm, make substantial territorial concessions and pay reparations (Germany will finish paying off her World War I reparations in 2020). It is generally agreed that it was this Treaty which helped the rise of the Nazi Party. As Barbara Tuchman explained in The March of Folly, history is replete with self-perpetuating repetitive and self destructive behaviour, ranging from the destruction of Troy (“How lovely a horse the Greeks have given us in their defeat!”) to Vietnam.

My grave concern is that, having seen the problems of global poverty, inequity and climate change, we will continue to put our foot on the accelerator, believing it to be the brake, time after time until we hit the wall. The omens are that we will not, in fact, change the world economic structure in the light of the current malfunctions, but feed it with handouts and marginal legislative changes and tickle it back into moderate functionality.

But, more broadly, the image of wall into which we may soon crash is taking shape –in the countless faces of people who survive on less than a dollar a day, in the disintegrating polar ice caps, in the wars for fossil fuel, and now in the illness of global financial structures. Baum and colleagues urge us to change direction – and the voice of the prophets has ever so called us to do. The question is this: do we have the strength of mind and political will to respond?

Baum and colleagues rightly, in my opinion, point to the critical importance of political leadership underpinned by support from civil society (aka the voting public). Mercifully and miraculously, we are now only weeks away from the disappearance of the ghastly Bush administration. We may not know what we don’t know, Mr Rumsfeld, but we know we don’t like you and your friends.

But I find myself wondering whether the US has changed permanently under Bush the Lesser (perhaps the Least), and how many degrees of freedom Obama has left at his disposal. But the potential power of political leadership cannot be underestimated. Take for example the amazing grace of our Prime Minister’s (and, credit where it is due, the Leader of the Opposition’s) apology to our Stolen Generations when the new Parliament opened on 13 February 2008. Political leaders can recalibrate debate, a necessary primary move in democracies for substantial change. Mr Gordon Brown’s current endorsement of poverty reduction programs is welcome and consistent with previous statements and commitments from him, although his own faltering future and lacklustre leadership do not empower his words as once they might.

What can we do about global health inequity? We need a plan. We need political sign-on and to work hard, lobbying and advocating to convince our political leaders to change direction. While money alone will not help, its absence makes action harder and so pressing Australia to contribute 0.7% of its GDP to aid (the Prime Minister is committed to an increase in aid to 0.5% of GDP) is a reasonable symbolic step. The average citizen believes we contribute much more than this already. They should be disabused. Our aid programs often manifest weirdness and incoherence and strong political leadership must make them far more strategic. We have made a mess of our assistance to Papua New Guinea and we cynically export crap food to the sinking Pacific nations and contribute to their high diabetes rates. We should stop. A few symbolic gestures – upping our aid, making it strategic, and stopping treating our near neighbours like trash cans for offal – would be an excellent beginning.

Is it simply too hard to do anything? Is individual action in the face of these problems nonsensical, or incoherent? Large amounts of foreign aid are lost to corruption and pathetic management practices. Wheat sits rotting in warehouses in desperate countries while people starve. Others argue that unless these poor people first become organized, then we will waste our aid on them. Hard though as my colleague and friend Jeff Sachs puts it in his crusade against poverty, to pull yourself up by your bootlaces if you have no boots.

Australian ethicist Peter Singer discusses this topic in One World. He hears all these arguments and then points out that each of us can still save a life by giving $200 to international aid agencies, such as UNICEF and Oxfam Australia. This allows for the cut for corruption, administration, and inefficiency. That much money will not hurt us to give. We can do this today: we can deal with the larger systemic causes of poverty tomorrow. Forego two restaurant dinners and presto, you have the cash to save a life.

Warm inner glows and moral discomfort about global health inequity are good ignition. But we need an engine for change, fuel and a spark plug or two. We must hammer away at the media, the public and our school children, use the web, show pictures, tell stories, push for a program of invigorated attention to global poverty, hook in with the environmental and sustainability movements, speak to big industry, and give more generously to effective foreign aid agencies from our pay packets. These are all things we might DO. Enough talk.”