Equality in health

Australia, like many other countries around the world, seriously binds itself to the obligations of treaties which spell out rights to which our citizens (and those of other countries) are entitled. For many, that is the end of the process, and the treaties, both for domestic politics and international law, are forgotten. However, the treaties usually have seriously under resourced secretariats assigned to them and primitive enforcement mechanisms. By these processes countries, including Australia, can be reminded of the basic standards to which we have committed ourselves and our governments. This piece is about one such recent reminder.

On June 3, 2010, the UN Special Rapporteur on the right to the highest attainable standard of health, Mr Anand Grover, released his final report on the implementation of this human right in Australia. The rationale of the existence and the visit of the Special Rapporteur may be gleaned from the fact that Article 12 of the International Covenant on Economic, Social and Cultural Rights (“the ICESCR”) includes the obligation that “The States Parties to the present Covenant recognize the right of everyone to the enjoyment of the highest attainable standard of physical and mental health”.

In a nutshell, the report found that the standard of living and quality of health care in Australia is excellent, except as experienced by Aboriginal and Torres Strait Islander people and those in detention.

The report calls for action by the Australian Government to minimise the impact of poverty and discrimination on the enjoyment of the right to health, particularly in the context of Indigenous health and health care of those in detention, including prisoners, asylum-seekers and refugees.

At the invitation of the government, the Special Rapporteur visited Australia from November 22 to December 4, 2009. During that time, the Special Rapporteur travelled extensively and met with the Minister for Health and Ageing, Nicola Roxon, MP; the Minister for Immigration and Citizenship, Senator Chris Evans; the Minister for Indigenous Health, Rural and Regional Health and Regional Service Delivery, Warren Snowdon, MP; and the Parliamentary Secretary for Disabilities and Children’s Services, Bill Shorten, MP. The Special Rapporteur also met with civil society organisations, academics and health professionals, and visited Indigenous communities and met with their representatives.

The report describes the health conditions and outcomes among Aboriginal and Torres Strait Islander people as “a disturbing picture”. Much of the information relied upon by the Special Rapporteur is from published sources in Australia and much of it is from Australian government sources. It is still salutary to have an outsider bring the information together in one place and to draw the observations that the information provokes.

Indigenous Australians are being affected disproportionately by ill-health, disability and death. The life expectancy for Indigenous Australians is 67.2 years for males and 72.9 years for females, compared with 78.7 and 82.6 years, respectively, for all males and females. Indigenous people are hospitalised at 14 times the rate of non-Indigenous people for renal dialysis, and at three times the rate for endocrine, nutritional and metabolic disease. Indigenous Australians are twice as likely as non-Indigenous Australians to report high or very high levels of psychological distress, and are hospitalised for mental or behaviour disorders at twice the expected rate of the general population. Injury and poisoning are large contributors to Indigenous morbidity, especially in younger people.

Unmistakably, the picture is of a striking gap between the everyday lives of mainstream and Indigenous Australians and the existence of stark inequalities. It is indeed disturbing, and worse, disturbingly familiar.

Australian governments have thrown a considerable sum of money and resources at Indigenous health. The average expenditure on health goods and services per person for Aboriginal and Torres Strait Islander people is 17 per cent higher than expenditure for non-Indigenous people and there is, after all, the Northern Territory Emergency Response.

However, through the keen eye of an outsider, recurring stumbling blocks in government responses are obvious: meaningful engagement and informed community participation; mechanisms for monitoring and ensuring accountability; striking the balance between upgrading mainstream services to adequately service the needs of Indigenous Australians and the diversion of resources to community-controlled services.

Equally the Special Rapporteur highlighted as a concern government policies and measures that temporarily address secondary problems but fail to address relevant long term causal factors.

For example, restricting alcohol supply and creating permit systems are measures which address excessive alcohol consumption but overlook the fundamental goal of promoting responsible alcohol use, which is better achieved through education, support, counselling and rehabilitation. As in most policy areas, the attempted quick fix of the symptom (secondary problem) always looks easier than the patience, the resources and the persistence needed to address the underlying causes.

The current health care needs of Indigenous Australians derive from their inadequate access to the primary determinants of health. As a matter of urgency, the report calls for the government to address the inadequacy of educational services for remote communities. To do so would progress the health outcomes of individuals, directly, through improvement of health-related knowledge and the ability to utilise that knowledge and, indirectly, through increasing employment prospects and income, thereby, facilitating access to health services.

In relation to persons in detention, both in prisons and immigration detention, the Special Rapporteur made the point that time spent in detention provides a unique opportunity for diagnosis and intervention, and should be better utilised for these purposes and to effect long-term behavioural change in those who are detained.

In brief, the standard of specialised health care in prisons is high, although delay and the capacity of services to manage chronic diseases are issues and preventative health services are inadequate.

The report endorses the view that Australian prisons have become “de facto mental institutions”. This assessment reflects the significant overrepresentation of individuals with mental illness within Australia’s prison system and the deficiency in the ability of current services to treat those prisoners. This service deficiency is the result of the failure to establish community-based treatment options at pace with population growth since the deinstitutionalisation of mental health care services.

Indigenous people are also overrepresented in Australian prisons and present with the coexistence of mental illness and substance abuse at a high rate. The Special Rapporteur strongly recommends that further steps be taken to reduce the rates and lengths of Indigenous incarceration through, for example, diversion programs, reconsideration of relevant criminal laws and assessment of sentencing policies.

The Department of Immigration and Citizenship (DIAC) aims “to ensure that the only change to an individual’s well-being as a result of being in [immigration] detention is to the restriction of freedom of movement”. Overall, the report found that the health services provided in immigration detention centres (IDCs) met the needs of the detainees, except to the extent of the prevalence of mental health issues among detainees and, particularly, those detained for lengthy periods.

Three other issues emerged for the provision of health services to detainees: the role of IDC security services in facilitating access to mental health and other health services; the availability of interpreters; and the utility of locating IDCs at excised offshore and remote places such as Christmas Island.

Security personnel facilitate access to services upon request by detainees, are responsible for identifying detainees at risk of suicide and self-harm (SASH) and can make decisions regarding the return of detainees to regular facilities once they have been placed in SASH rooms. The Special Rapporteur has called for more support and specialised training to enable security personnel to adequately fill these roles.

Health care service providers in IDCs face particular challenges in meeting the cultural needs of detainees, which are exacerbated by language barriers. Presently, telephone interpretation services are used for most translations. The Special Rapporteur identified the provision of on-site part-time interpreters for the main languages represented in IDCs as a not particularly onerous measure to improve access.

Although it ought to be acknowledged that Christmas Island is no more remote that certain parts of mainland Australia, its location poses significant challenges regarding service delivery. The report recommends that the government reconsider the appropriateness of detention facilities continuing on the island and assess the provision of mental health services to the population as a matter of priority.

Most recently, discussion about the state of health care in Australia and health reform has taken place in the context of political point scoring with the Australian electorate.

The Special Rapporteur’s report is a timely reminder that the enjoyment of the highest attainable standard of health is not appropriately conceived as an election promise. It is, in fact, a fundamental human right: one which Australia is obligated under international law (an obligation which we have freely and voluntarily undertaken) to ensure for all persons within the jurisdiction, whether they are a member of a minority population, disenfranchised, an asylum-seeker or an illegal immigrant.

The report draws together much of the available and valuable information in respect of the health status of Aboriginal and Torres Strait Islander people and persons in detention, and presents that information in the context of Australia’s human rights commitments.

In doing so, it is clear that the right to health is the equal entitlement of all persons but, in Australia, some persons enjoy the right more equally than others. This provides yet one more challenge for a newly sworn in Prime Minister, both in the short term of the lead up to this year’s election and, if she were to be re-elected, for the longer term.