During the last 50 years the health of all Australians has improved markedly. Deaths from infectious disease have largely been brought under control, public health campaigns have produced some behavioural and life-style changes, and a reasonably fair and equitable health care system put in place. In international health terms, Australia now ranks highly, with life expectancy and mortality rates among the best in the world.
Despite this, stark health inequalities continue to persist in our society and one wonders how we can sit back complacently when we know that a male Aboriginal can expect to live more than 20 years less than his European counterpart; that Aboriginal infant mortality is at least 3 times the rate of other Australians; that residents on Sydney’s North Shore can expect to live 3-5 years longer than residents in the Far West of NSW; that death rates for a variety of causes increase progressively with increasing geographical remoteness; and, that significant socio-economic differentials in health and health behaviour continue to persist.
In addition, should we not be concerned that 19th century scourges like trachoma continue to afflict many rural Aboriginal communities, that a much higher proportion of Aboriginal children are overweight or obese, and that asthma and diabetes are considerably more prevalent among Aboriginals than other Australians?
But these are not the only disturbing health inequalities to mark 21st century Australia.
Our workplaces, for example, are not the safe places we often assume them to be. Today, approximately 2,700 Australians die as a result of injuries or diseases acquired in the course of their employment. This is more than are currently killed on Australian roads. In addition, a further 650,000 suffer from a non-fatal injury or illness acquired at work.
Our hospitals also often belie their true purpose and can be very dangerous places. Possibly as many as 9,000 Australians admitted for surgery die every year in hospital - some as a result of a hospital-acquired infection - others because of medical errors or delays. And the list goes on. Possibly 15 per cent of all children and 12 per cent of all adults are afflicted with asthma, 225,000 Australians have Hepatitis C, 20 per cent of all adults have a heart problem , 60 per cent of us suffer from an arthritic condition and 50 per cent of all adults have high blood cholesterol levels.
About one in five adults and one in eight children continue to smoke and there are disturbing income differentials in oral health. Such inequalities are striking, and in a wealthy country like Australia, totally unacceptable. Further, they question Australia’s commitment to an equal, free and healthy society.
So what is the solution? Do we shrug our shoulders and say that this health experience is pretty much on a par for all ageing developed countries and that some degree of health inequality will always be a characteristic of a society that allows freedom of choice? Do we argue that such inequalities are outside our control and can simply be attributed to biologic or genetic differences between individuals. Or do we acknowledge that such health disparities are unjust and avoidable and demean our status as a developed nation?
If we accept this, what should we do? Could we for example, consider an annual “Warrant of Fitness” for all Australians, such has been recently suggested by Britain’s National Health Service, whereby every citizen would be offered a personal “health plan” designed to get people to take more responsibility for their own health? Such health plans might set goals and standards on such things as fitness, weight loss, sexual activity, healthy nutrition, smoking and the consumption of alcohol and would be monitored by local GPs assisted perhaps by a special “health hotline” dedicated to providing specific health advice. Would such a plan work in Australia? Would it place undue pressure on already overworked GPs? Would it address many of our health inequalities, or would it simply cater to the affluent “worried well” rather than to those who are really in need of advice and intervention?
One of the basic problems that confronts us is that health inequality is very much a value-laden ethical issue, and depending upon one’s stance, not all health inequalities might be considered unjust or unfair. Some inequalities arise because particular individuals and groups suffer poor health as a result of societal and environmental forces outside their control: For example - overt discrimination, institutionalised neglect, limited access to education, low income and or exposure to environmental or work-based health risks.
By comparison, other health inequalities may arise as a result of personal choice - people choosing to engage in risky activities that they are largely free to adopt. Given this, perhaps we need to develop a coherent ethical health policy that defines which health inequalities are unjust and should be addressed.
Recently, the Swedish Government has gone down this road and produced a framework for addressing health inequalities that is largely based on the assumption that health contributes to the basic capabilities that allow people to live the lives they want, and that inequalities in rights, liberties, freedoms, opportunities, income and education are fair and acceptable only if they do not come at a cost to the worse off groups in our society.
What we really need is for Australian Governments to follow such a line and develop ethical health inequalities policies that clearly define inequalities that are unjust and unfair and advance policies for redressing such inequities.