One of the puzzling features of the debate about health in Australia is how much of it is focused on the delivery of health services and, in particular, gaps in the delivery of those services.
Discussion about the causes of illness are more muted and confined. So in my home state of Western Australia, waiting lists for elective surgery and the number of ambulances forced to bypass overloaded hospital emergency services are a government threatening issue, while the critical issue of factors leading to illness receives relatively little attention.
There is some debate about public health issues and the impact of social and economic factors on health but it seems to be largely a discussion among aficionados. Pronouncements on the significance of absolute incomes, of relative incomes and of the social gradient of health, all of which suggest that current economic and social policy might need to be challenged, never seem to result in wider discussions of related public policies.
I am not aware of any systematic interaction between health professionals, including public health professionals and epidemiologists, which engages economists and political scientists in challenging the status quo. I don't recall being told that results of the current hegemonic post-Thatcher ideas of general reliance on market forces and competition, which dominate the current thinking of all major political parties, might be making us sick.
In the current intellectual climate there is something almost heroic about trying to link health to a treaty. It flies in the face of the prevailing practical approach to both social policy generally, and reconciliation in particular, and might even invite ridicule outside the circles of those who choose to see things through the prism of their public health expertise. As a result, attempts to link health with ideas of a treaty could be dismissed as elitist.
Much of the community, I suspect, sees Indigenous ill health as largely self-inflicted anyway. Violence, substance abuse, malnutrition flowing from inadequate diet, excessive weight, smoking and lack of exercise all involve choices. They are all critical contributors to the dreadful health statistics.
I recall a researcher from the Menzies Research Centre in the Northern Territory observing that there was no medical solution to the epidemic of renal disease in central Australia. It could only be remedied through lifestyle change.
There is plenty of ammunition for the sceptics relating to apparent lifestyle choices. Yet the evidence is clear that the factors that produce such a cocktail of bad health factors have a substantial structural element. It is widely acknowledged that social and economic status significantly determines people's health status.
The World Health Organisation describes the correlation between poor health and low income and social status: People further down the social ladder usually run at least twice the risk of serious illness and premature death of those near the top. Between the top and bottom, health standards show a continuous social gradient. The social gradient in health reflects the material disadvantage and the effects of insecurity, anxiety and lack of social integration.
Moreover, inequality in the distribution of incomes in society has been shown to lead to poorer health for the society as a whole. Research suggests that countries with a more egalitarian distribution of income have better health outcomes, and that policies that aim to reduce health inequalities must first address inequities in income distribution.
In the Australian context, the gap between incomes of Indigenous and non-Indigenous people is alarming, and this issue of relative income needs to be addressed at the level of policy if the health issue is to be successfully addressed.
How you feel about yourself is another big part of the health story, which has been acknowledged by the current Federal Minister for Health. "Continuing anxiety, insecurity, low self-esteem, social isolation and lack of control over work and home life have powerful effects on health." The relationship between psychological and physical wellbeing is emphasised by Gregory Phillips in Addictions and Healing in Aboriginal Country .
This is an edited version of an address given by Fred Chaney to the Indigenous Health and Treaty Conference on September 11, 2004.
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