All eyes may be on the US just now when it comes to discussions about health care reform, but perhaps it’s worth looking to the French as well.
Croakey’s roving health correspondent Simon Burrow reports on his recent experiences with the French health system:
Health workforce maldistribution and shortages, and the oncoming tsunami of medical graduates are generating widespread discussions about the future of health and medical training in the context of moves towards health reform.
Professor Bruce Robinson, dean of medicine at the University of Sydney, has recently suggested that one solution may be to broaden the range of services involved in providing postgraduate medical education. The University of Melbourne’s Emeritus Professor David Penington recently urged the Feds to incorporate university hospitals into health reform.
Now Professor Peter Brooks, who has been a strong advocate of workforce reform and innovation, says it’s time to take the debate a step further.
The health sector, strangely enough, has a long history of beating up on those it is meant to serve. Men, for example, have been widely castigated for being “poor patients”. What this means is that they haven’t always done what health services or health professionals think they should – ie turn up for appointments, seek help earlier rather than later and so on.
The Federal Government is due to release the country’s first national men’s health policy sometime soon. It’s likely that the policy will try to change some of the rhetoric around men’s health – instead of blaming men for not engaging, the policy may just turn the tables, and ask health services to take a hard look at themselves and what they could do to become more men-friendly.
The discussion about relationships between public health and the food industry continues…
Boyd Swinburn, Professor of Population Health, and Director of the WHO Collaborating Center for Obesity Prevention at Deakin University, writes:
“Stephen Leeder makes a well argued plea for people to quit blasting the food industry with moral indignation and to work with them to find solutions to the food over-supply and over-promotion which are important drivers of our current obesity epidemic.
As the previous Croakey post points out, the news about Indigenous smoking rates may be more encouraging than we’ve previously understood.
Dr Mark Ragg, a health and communications expert, believes the history of smoking among people with mental illness holds some lessons for those working to tackle Indigenous smoking, and also gives cause for optimisim.
He writes:
“David Thomas’ article is fascinating, as well as providing very good news. I’ve come recently to the issue of smoking in Indigenous populations after doing some work in smoking among people with mental illness, and have been struck by the similarities in approaches towards these two disadvantaged groups.
In both cases, there is a false belief that smoking is uniformly high and unchanging, leading to an almost nihilistic belief that nothing is possible. So if nothing is possible, nobody needs to act. And in both cases, smoking is excused by many health workers on grounds like ‘they have nothing better to do’ or ‘I don’t want to jeopardise our relationship by bringing up a difficult issue’.
There are certain things that clearly work to reduce smoking rates in populations – reducing the opportunities to promote smoking, reducing the opportunities for people to smoke, increasing the price and having health professionals give advice, support and medication such as nicotine replacement therapy when needed. Legislation, regulation, social marketing and specific health programs are all means to achieve these ends.
Certainly in people with mental health, and it seems in Indigenous populations, the problem has been that the basics have not been applied. People with mental illness have not had health professionals giving them advice and support. In fact, many people with mental illness are still told to smoke by their doctors.
But some progress is being made. In the US, psychiatrists have specific training programs in smoking cessation which are proving popular and effective, and similar approaches are being considered here.
In Australia, various health services are running smoking cessation programs for people with mental illness, and providing training for employees involved.
Croakey encourages bold predictions, so here’s one.
In 20 years time, policymakers and academics will look at smoking among people with mental illness, and among Indigenous people, and see that these high prevalences were a blip. A troubling time with severe health consequences, but a blip. Once these disadvantaged groups received the same resources and support as others, the problem began to recede.”
• Mark Ragg is director of the health and communications consultancy RaggAhmed and adjunct senior lecturer in the Sydney School of Public Health, University of Sydney.
We are so inundated by bad news about Indigenous health that it’s easy to be overwhelmed by doom and gloom. But when it comes to smoking – a major cause of sickness and premature death – the news may be more encouraging than we’ve previously thought.
Dr David Thomas, a senior research fellow at the Menzies School of Health Research in Darwin, reports:
“In March last year, the National Indigenous Health Equality Summit set a target of reducing Indigenous smoking prevalence by 2% every year. It sounds great: so much Indigenous suffering would be avoided and so many early deaths averted.
Tobacco control became a big ticket item in Rudd and Roxon’s plans to ‘Close the Gap’, with millions committed in last March’s Indigenous Tobacco Control Initiative and millions more to come as part of their COAG initiatives. But few would have really believed that the 2% target could be achieved: just aspirational slush like ‘no child will live in poverty’.
Back then, the hard truth was that Indigenous smoking prevalence had not changed whilst smoking was successfully falling in the rest of the population. This was based largely on three large national Indigenous surveys performed by the Australian Bureau of Statistics in 1994, 2002, and 2004. All other national survey data had tiny Indigenous samples, and so provided useless estimates. Each of the ABS surveys reported that about 50% of Indigenous adults smoked, about double the Australian prevalence of smoking.
What most readers have overlooked is that the reports of these surveys used different age cut-offs and different definitions of smoking (daily or all current smokers). This week in the International Journal for Equity in Health, I described the prevalence of current smoking amongst Indigenous adults aged 18 and over in each survey.
From 1994 to 2004 Indigenous smoking prevalence in non-remote Australia fell in parallel with the total Australian population (by 5.5% in men and 1.9% in women). In remote Australia, smoking prevalence also fell amongst men (by 3.5%) and appears to have peaked in women. These two different trends can be neatly explained by international research about the shape of smoking epidemics, with remote Indigenous Australia just at an earlier point in the predictable smoking epidemic curve than Indigenous peoples in non-remote Australia.
Also this week, the ABS released the first results of the fourth national Indigenous survey in this series. Detailed comparisons are not yet possible, but they too have reported a drop in national Indigenous smoking, from 51% in 2002 to 47% in 2008.
Even though both of this week’s reports have some limitations, we can reasonably confidently say that Indigenous smoking prevalence is not resiliently static, as once thought. The Indigenous smoking epidemic is not exceptional, and there is no need to entirely re-think and re-fashion tobacco control in this setting. We can adapt what has been successful in Australia and elsewhere.
Reducing Indigenous smoking is no longer a seemingly impossible task.
Indigenous smoking was slowly falling before a cent of the new money was spent. How fast it falls now the new money is starting to hit the ground will depend on how that money is spent.
We should feel emboldened by this week’s news. We should no longer call ‘encouraging’ any future reduction in Indigenous smoking; we should expect a dramatic reduction, maybe even the fabled 2% annual reduction dreamed up last March.”
The recent debate between nutritionist Dr Rosmary Stanton and PepsiCo executive Dr Derek Yach generated much discussion at Croakey. Many public health experts were sceptical about the intentions of companies like PepsiCo.
However, Stephen Leeder, Professor of Public Health at the University of Sydney, argues that the public health community needs to move beyond moral indignation to effective engagement with industry.
He writes:
“The recent Croakey conversation about obesity and the soft drink industry is imbued with strong moral concerns, as is the public health community more generally – many members march at the front of the platoon that seeks to secure equitable access to health care, even, indeed, equal health outcomes from care or equality of health status.
No great problem there: this moral concern has motivated deep inquiry into the social determinants of health and action to tackle maternal and child survival, extreme poverty, the humane care of people with AIDS and Indigenous health. It is in sympathy with international movements that promote human rights generally and those pertaining to health specifically.
While this moral concern has generated power in the grid of modern public health action – including the battles fought and partially won with tobacco companies – paradoxically it may inhibit progress in achieving better health for people who suffer because of the negative effects of global economic expansion, city building and food manufacture. Illnesses caused by these changes now dominate the lists of global mortality and morbidity.
Why may our moral indignation in public health be a problem? Before answering that question we need to hear a word from the philosopher John Rawls.
As Denver ethicist Jack Donnelly wrote recently in a monograph on concepts of human dignity, Rawls distinguishes notions of justice that derive from religious and philosophical doctrines such as Islam and Marxism from “political conceptions of justice”.
These, in Donnelly’s words, “address the political structure of society, defined (as far as possible) independent of any particular comprehensive doctrine. Adherents of different comprehensive doctrines may be able to reach an overlapping consensus on a political conception of justice.”
What Donnelly is getting is that while the foundational motivations and ideology of different people will vary, and sometimes radically so, it remains possible “to achieve an overlapping consensus [that is] partial rather than complete. It is political rather than moral or religious.”
Many of the solutions to our current health woes undoubtedly sit outside the health sector, and will involve stakeholders with sometimes very different values and objectives and different concepts of morality. Finding the points of ‘overlapping consensus’ is key for us to move forward towards health gain.
Recently in Sydney we listened to two points of view – from Derek Yach and Rosemary Stanton – about nutrition and how it might be altered in favour of a slimmer society. Derek works with PepsiCo and Rosemary definitely does not! Both are people of impeccable public health credentials and they deliberated about how we might enter an age where obesity and its dark consequences did not dominate our thinking.
It has generated lively debate but I do not see how we can make progress until such time as we accept that a solution to this problem will be based on a political conception of social justice, to use Donnelly’s term – at the school, local government, state and federal levels. It will be a political and pragmatic rather than ideological notion of justice that will motivate action.
Instead of allowing ourselves the indulgence of shouting from the moral high ground about the motivations of industry, perhaps we should seek a consensus around what a social conception of justice in regard to food means.
We need as public health people to get over our shock and horror at food companies being primarily motivated by profit. We need to move beyond saying, “Their good will is just PR!” A mutual understanding of each other’s values and goals is essential to merit a seat at the table, a table of policy and politics.
This applies to many public health policy problems. Recognising a problem, and even understanding it is different to choosing the most effective course of action, knowing how to speak in terms that industry will take seriously, being pragmatic and knowing how to go about getting things done when success more often than not requires people to negotiate the politics.
This viewpoint is reinforced by my previous experience. Two years ago I participated in a Canberra meeting hosted by Senator Guy Barnett about obesity. I chaired a small working group that included representatives from the food industry, academic nutrition, advertising, media and urban designers. Naturally we sparred about traffic light food labeling, advertising on children’s TV and other contentious topics, but we all stayed till the going home bell sounded. The conversation was prickly but OK.
Just before we went, one of the participants turned to me and said, “You know, professor, you have the wrong people at this forum. We’re middle managers. You need the CEOs. If they say something is going to change, it will.”
I was pondering the good sense of this suggestion – and others were nodding affirmatively, when my colleague added, “And you’re the wrong person to be chairing it. We should have the PM and a few of his ministers without their bureaucrats at the table. He could say to them all, ‘We have a problem and we are all going to contribute to its solution, so before you leave today I want to hear what you are going to do to help!’”
Besides revising our attachment to moral indignation, the other thing we need is a clear view of how long it has taken us to get into a situation where nearly half of all Australian adults and close to three in every 10 Australian children are overweight or obese, a mess that has disturbing similarities to global warming. Decades: so it will probably take decades to get out.
The history of public health progress is nearly always of incremental change with many people taking many different actions. Even the apocryphal wrenching removal of the Broad Street water pump handle has a richer context than we commonly recognize.
That is why public health is accurately perceived as a community movement and public health research workers as social scientists. There are times when aggressive advocacy and the force of the law are necessary. At other times they are not. Then, as Churchill put it, we need jaw-jaw and not war-war.
The rise and rise of obesity is complex. Recruiting the food industry – or a bit of it anyway – to our cause, while being true in our policy discussions with them to a “political conception of justice,” strikes me as a good move.
I am not at all convinced that confrontation and moral indignation do anything in this context other than make things worse. This does not mean that we should be silent if we find abuse and hypocrisy but rather in conversation we should define those interests that are common and where, if a consensus is struck – by the PM if not by us – we can inch forward.”
As the previous Croakey posts report, the NT Government is under fire for its policy of refusing dialysis treatment in Alice Springs to Central Australians who live outside the Territory’s borders.
But the spotlight should be put on the Federal Government, argues Professor Wendy Hoy, of the Centre for Chronic Disease, School of Medicine, University of Queensland.
She writes:
“This problem of provision of dialysis services across state/territory booundaries would be solved if the Federal Government assumed responsibility for all such services across Australia.
If the federal government also takes charge of primary care services, at least where current options are not satisfactory, the links between death rates and need for dialysis with efforts in prevention, timely screening and quality treatment of chronic diseases in their asymptomatic and their less advanced stages would become clear.
This would allow informed health services planning to minimise sickness, dialysis, premature death and costs.
The Federal government could contract back with local providers for those services, where current systems are effective, transparent and accountable, but everything would come under one umbrella and one system of ongoing evaluation of processes, outcomes and costs. Inclusion of hospital services under such an umbrella is an obvious option.”
Continuing the thread from the previous post, the Aboriginal Medical Services Alliance Northern Territory is warning that the NT Government’s policy of refusing dialysis treatment for patients from outside the Territory is causing enormous harm.
This is the statement:
AMSANT has written to the Northern Territory Health Minister with a potential solution to needless deaths among central Australian renal dialysis patients, AMSANT Chairperson Stephanie Bell said today.
“The current policy of refusing to treat Aboriginal patients in Alice Springs is contributing to early deaths for Aboriginal people,” Ms Bell said.
“Sending people from remote communities to Perth or Adelaide is creating enormous psycho-social impacts on individuals, their families and their communities.
“Some people are opting to refuse or withdraw from treatment so they can go back to their country to die: it is an intolerable situation.
“The patients concerned live on or close to their ancestral estates—and didn’t “ask” for those estates to be alienated from their kin and country by the arbitrary imposition of state and territory border lines.
“We have suggested to Minister Vatskalis that a short term solution is available—nocturnal dialysis—and that AMSANT would back the Territory Government in seeking proper recompense from the South and Western Australian governments, as well as Commonwealth support.
“The demand that they move many thousands of kilometres to distant capital cities is irrational and—in the long term—far more expensive than treatment closer to home in a regional centre such as Alice Springs.
“The tri-state committee dealing with these issues for 18 months and has done little more than sit on its hands.”
Ms Bell said that AMSANT realises that the Northern Territory is in an invidious position in being asked to take on patients that don’t “belong” to the Territory in a jurisdictional sense. She said the costs of introducing night dialysis at the Alice Springs Hospital, along with social and housing support, should be met by interstate governments.
“This is clearly a short to medium term solution, one that will be relieved to an extent with the new satellite facility opening in April next year,” said Ms Bell.
“Beyond that, of course, we must work towards peritoneal and haemodialysis being made available in the regions to reduce the load on facilities in Alice Springs.”
Croakey suspects that this is just one slice of a much bigger story about how Indigenous patients with kidney disease miss out on all sorts of potentially life-saving interventions – including measures that might help prevent the need for dialysis in the first place.
Copyright © 2008 Private Media Pty Ltd, Publishers of Crikey.com.au. All Rights Reserved.
Independent news, blogs and commentary on politics, media and business.
Editor: Jonathan Green.
Publishers: Eric Beecher, Diana Gribble.
Level 7, 22 William St, Melbourne, 3000. Ph: 1800 985 502 Fax: (03) 8623 9975
