JOHN MENADUE. How the politically urgent pushes the important health issues aside.

Australians have some of the best health outcomes in the world measured for example by high life expectancy and low death rates, although that is not the case with Indigenous Australians.  

But despite these good outcomes, we have a ‘health system’ which is always under pressure. The system performs well because of the very dedicated and professional people that work within it. An improved service is hindered because of the lack of integration particularly between hospital and non hospital care.

There are two big picture issues that I see as being at he core of our health system problems. I sense that there is a growing community and government understanding on these two issues.

The first important big issue is that we have a highly medicalised and specialised system based on treating sickness rather than keeping people well. One example of this medicalisation is that childbirth is treated as a sickness rather than a natural life event. We pay our GP’s on a fee for service basis to treat sickness ,not to keep people healthy. The financial incentives are all wrong.

The major improvements in health outcomes over the centuries have not been in medicine, but in prevention -early detection of chronic diseases and public health, eg clean water, sanitation, vaccinations. And in out time of course curbing junk food ,excess sugar and poor exercise. But we spend minimal money in these areas. About 98% of our health dollar in Australia is spent on medical services. There are major health risks that are not being adequately addressed in Australia. They are:

  • Tobacco causes over 15,000 deaths in Australia per annum. Smoking accounts for 9% of the total burden of disease. The total national cost of tobacco smoking is over $30 b per annum, about a quarter total health expenditures. It is the biggest avoidable health risk in Australia. The solution is not more medical services.
  • Neglect of early childhood development. The early years, even in utero, are critical for the future health of the individual. They are also important for the wider community. There are large individual and social dividends to be obtained by investing in early childhood. Underweight babies and neglected children are warning signs for the future. The risks in this area must be addressed in improved nurturing rather than in more medical services.
  • Obesity is another high-risk health problem for Australia. It is caused by excessive and bad diet, and a decline in exercise. It brings with it Type 2 diabetes, coronary heart disease, respiratory and other health problems. Nearly two thirds of Australian adults are over weight or obese. One in 5 Australian children are over overweight or obese. It is a health time bomb loudly ticking. The solution again – is not more medical services. Our cricketers and foot ballers line their pockets with advertising revenue from junk food and alcohol. Some inspiration for young athletes!
  • The major risk factor in poor health is poverty. Poverty is always the biggest cause of death. Poor people are sicker and die earlier. Poverty affects the health of people in many ways – poor nutrition, poor lifestyle, stress, poor nurturing, exclusion and addiction. The main reason why Indigenous Australians have poor health is because they are poor. Here again – the solution is not more medical services.

Effective response to these critical health risks – tobacco, neglect in early childhood, lifestyle, obesity and poverty – are not to be found primarily within the medical field. They are to be found in public health programs, eg educating people about lifestyle, exercise and diet; wellness centres. Addressing these high health risks also means looking beyond the health field itself. The key to improved Indigenous Australian health is self-esteem, training, jobs and housing which go far beyond both medical services and health.

The second big picture issue is that we have a highly institutionalised health system. By institutionalised, I particularly mean a highly hospital-centric system. Hospitals are our first resort. They should be our last resort. In the community we have the mindset that health equals hospitals. Politicians and media always focus on the shot term and urgent…beds and more beds. The public debate is invariably driven by issues concerning hospital beds and waiting lists. That is not where we need the debate and the resources. I estimate that over 40% of people need not be in hospital if there was appropriate care outside in the community and where possible, in the home. That is more consistent with personal autonomy and personal dignity. It is also better and cheaper for all concerned. The primary focus of care and good health must be in the community, not in hospitals. My experience of informed community attitudes is that the community has a very good sense of what is important. It is invariably mental health, indigenous health, dental health women and children subject to violence, and health care as far as possible in the community and in the home.

We need a seismic shift away from medicalisation and institutionalisation in health. We need to focus on the important big issues. But so often we get caught in the detail, the day-to-day issues. Public attention is focused on the medical and hospital – hospital beds and waiting lists, rather than on the important. We are focused on the urgent and short-term, rather than the important long-term issues.

The major solutions to our poor health are not to be found in the medical and hospital fields. Unless we seriously address these two major flaws in our health system, it will remain continually under pressure.

The political problem is that the costs and benefits of effective health ‘prevention’ programs don’t show up for years so the urgent always gets priority.

There are strong vested interests who would like to keep us medicalised and institutionalised when our priorities and resources should be elsewhere- in prevention and integrated care in the community and not in hospitals.

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3 Responses to JOHN MENADUE. How the politically urgent pushes the important health issues aside.

  1. Richard Barnes says:

    Thanks John.
    I work (as a doctor) in a big hospital, and I couldn’t agree more. We do some great things but we also do some incredibly expensive things with predictable small likelihood of benefit.
    Dental care and mental health care are in my opinion the two areas par excellence where we should re-direct our health expenditure.
    Of course, as you indicate, poverty reduction is even more important, but I guess that is outside the remit of health policy.

  2. tim woodruff says:

    Agree with everything said except for this sentence ‘Effective response to these critical health risks – tobacco, neglect in early childhood, lifestyle, obesity and poverty……………… are to be found in public health programs, eg educating people about lifestyle, exercise and diet; wellness centres.’
    I’m not aware of evidence that people require much education about the health risks of the issues listed. Instead, to all those issues I would focus on the last sentence in the paragraph ‘The key to improved Indigenous Australian health is self-esteem, training, jobs and housing which go far beyond both medical services and health.’ these are key to health and as said elsewhere, poverty is central to many but not all of these issues. Whether it be middle class workers in stressful jobs and/or relationships, or those on low incomes struggling hour to hour, day to day, week to week to make sensible decisions about long term health outcomes, the issues are the same: self-esteem, meaningful jobs, housing etc. It’s quite challenging to have self esteem if one is on Newstart, 40% below the poverty line.

  3. Rosemary Lynch says:

    With respect, John, health is not merely a function of medical diagnoses, but also, as Sir Adrian Marmot observed, a matter of poverty and environment, and subjection to government policy or lack of it, in relation to primary health. Off and on over a period from 1975 to 2015 I spent some time in remote Aboriginal communities around the country. None of them could be said to have had adequate, safe housing. Last year the NT had their remote housing disappeared, this year it is Qld. and W.A. that were not budgeted remote housing And this to our poorest communities, where population can be up to 20 per house, where houses exist; and where the sewage and electricity supplies may be unsafe. Tell me how you bring up a child safely to clean their teeth twice a day in a house with 20 people, when the risk of haemolytic strep and the risk of Rheumatic Heart Disease is apparently the highest in the world, and the only correlate is inadequate housing and inadequate primary health care. Then there are people like the Newman LNP Govt. which did not “get” infectious diseases, and so stopped treating pulmonary tuberculosis for PNG traders in the Torres Strait, and cut the Qld Sexual Health Clinics budget at a the beginning of a syphilis epidemic. Can the “neglect” be governmental, do you suppose?

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