TIM WOODRUFF. Health, Class Warfare, and Social Justice

Class warfare has been with us forever. It could be called a fight for social justice. Indeed, it would seem to be integral to the stepwise progress we have made over centuries as we have moved to a society which outlaws overt slavery, has a moderately progressive tax system, provides a wide range of public services, and has a variety of safety nets, all combining in the aim to be a civilised society.

A Return To Class Warfare?

The recent claim of the Coalition that Labor has returned to class warfare is ridiculous on two counts. In our society, class warfare has been, and will continue to be an ongoing battle simply because there will always be a power elite. Secondly both Labor and the Coalition have always been to varying degrees, on the side of the elite class.  The recent significant policy differences which have emerged have only been about the degree to which this class warfare has been pursued.

Health Outcomes

As I began to compose this article I considered my position as a white middle class well educated male Australian doctor flying across the Indian Ocean back from a holiday in England. I return to my patients with the knowledge that the health outcomes of many of them are determined firstly by the access to health resources our elites decide to give them and secondly by the degree to which they have control of their own lives as determined by those same elites. In my position I am fine. My well educated rich patients are as healthy as any can be, given whatever medical condition they have. But many of my patients are not, and it has little to do with my knowledge and skills and much to do with class warfare.

Australia has a world class health system, ranked second of eleven first world countries by the Harvard based health research institution, the Commonwealth Fund. On access to care it rates fourth but on equity it rates only seventh. We could be number one if only the rich elites accept the importance of equity and social justice and desist from the class warfare they have selfishly and self righteously waged forever.

Access To Health Care

Private patients have access to elective surgery within months of referral. Public patients may wait years. There has been no significant change in waiting times for elective surgery in the public sector for at least five years. In addition however, the real waiting time which must include the time to get to see a specialist to get on a waiting list remains unmeasured because governments have failed to require the collection of such data. Some of my patients can wait over a year just to get on a waiting list. Thus according to the Australian Institute of Health and Welfare (Page 29) information on the real waiting time is unavailable, despite this being an election issue in various states over five years ago. The elites don’t want to know. The class war continues. Social justice is ignored.

The two major political parties have continued to impose co-payments for prescription drugs despite the knowledge that 14% of sick Australians on below average incomes delay or don’t fill prescriptions because of cost (Commonwealth Fund 2014 Page 24). Such drugs are approved for subsidy on the Pharmaceutical Benefits Scheme because they improve health and/or save lives. Not being able to afford such drugs leads to worse health and probably premature death. To the elites the lives of Australians on below average incomes would appear to have less value than richer Australians. The class war continues. Social justice is ignored.

Access to dental care is grossly inequitable. According to the Australian Bureau of Statistics Patient Survey one quarter of those in the lowest socioeconomic quintile avoided dental care in 2016 because of costs. Only one in ten of those in the richest quintile limited their dental access to cost. Our dental ‘system’ is a shambles. Rich elites are fine. The class war continues. Social justice is ignored.

Socio-economic Status

More generally those in the lowest socio-economic quintile have a mortality rate 50% higher than those in the top quintile and importantly have much higher rates of obesity, smoking, illicit drug use, un or under-employment, exposure to domestic violence, and homelessness. These are the social factors which irrespective of access to health care, are key factors affecting health outcomes: the social determinants of health. A sense of control over one’s life is crucial to a healthy life. The rich have it. The poor struggle. Importantly however, there is a gradient. The more control, the better the health outcome (Whitehall study Marmot).

Relative income differences are central to such control. Since 1994 the two major political parties have maintained the unemployment benefit Newstart, at the same monetary level despite inflation, so that it is now 40% of the poverty level. Is it any wonder that the unemployed and their dependants struggle with poor health? Our highly targeted welfare system demeans and debases applicants and reduces their sense of control over their lives. The rich and powerful elites have no such issues. Indeed it is they who, through support for regressive tax policies and a demeaning welfare system,  maintain those needing welfare in such a debased state. The class war continues. Social justice is ignored.

A Progressive Tax System?

Like most first world countries we have a moderately progressive tax system. This has been introduced because of the recognition that the distribution of income in a relatively free market capitalist society would result in gross inequality, which would undermine any desire for a cohesive society. It would also leave the rich elites with no middle class to buy the goods and services they control. Improving the progressivity of our tax system, to achieve greater equality, has been the task of social reformers including unions for centuries. Rich elites have resisted as they pursue their class warfare and ignore social justice.

Regressive taxes such as the GST, the Medicare Levy, co-payments for pharmaceuticals and co-payments for other government provided services are weapons used to wind back the progressivity of our tax system. The impact of all of these taxes on those on low incomes is massive compared to such charges on the rich, whose disposable income is so much greater than low income earners. The cost of three prescription drugs is $120 a month. For an Aged Care worker on $35,000 that requires budgeting. For a politician on $350,000 it means little.

Now we see Labor advocating for removing some of the more inequitable tax policies such as capital gains and negative gearing which favour the rich, whilst the Coalition resists with the mantra that this is a return to class warfare. One cannot return to a place one is already at.

Worse still are the new tax changes proposed by the Coalition which do nothing for the very poor, give a couple of McDonalds a week to the low income employed, give a very modest boost to those around the average wage, and $7000 a year to the rich elites. Class warfare continues. Social justice is ignored. Indeed these policies indicate a strengthening of resolve by the rich elites to fight on to maintain their privileged position.

Jobs and Growth

The clarion call for the Coalition has been ‘jobs and growth’. It’s worth noting the opinion of the International Monetary Fund, an organisation well known previously for its strong support for destructive austerity policies in struggling economies. Finally at least in a discussion paper, they are looking harder at consequences.

‘If the income share of the top 20 per cent increase by 1 percentage point, GDP growth is actually 0.08 percent lower in the following five years, suggesting that the benefits do not trickle down. Instead, a similar increase in the income share of the bottom 20 percent (the poor) is associated with 0.38 point higher growth

The Lucky Elites

It is curious to note that the Prime Minister is well aware that he is privileged by luck as he indicated in Parliament on October 15, 2015

“The fact is that Lucy and I have been very fortunate in our lives……….. I do not believe that my wealth or, frankly, most people’s wealth is entirely a function of hard work. Of course, hard work is important, but there are taxi drivers who work harder than I ever have and they do not have much money……… Some of us are fortunate in the intellect we inherit from our parents. There is a lot of luck in life, and that is why all of us should say, when we see somebody less fortunate than ourselves, there but for the grace of God goes me”.

Luck may be intelligence, parentage, race, gender, physical appearance, or simply personality. The appreciation of luck is obvious from the above statement. The failure of that appreciation to result in policies which reduce the effects of such luck in life and health outcomes can only reflect a belief that having been lucky, he and his kind are now more deserving of privilege, high income, and better health outcomes than unlucky people.

Health For All

Health for all is a concept sometimes used by those fighting for social justice in relation to health.  This concept would appear to be anathema for the sometimes very hardworking, but nevertheless lucky and privileged ruling class. We have moved over centuries to a recognition by many and perhaps most people in our society, that there is an intrinsic value to every human life and that that value is the same irrespective of the outward trappings of class, gender, race, and intellect. In this ongoing class war the warriors for social justice, for equity and for equality of opportunity will continue to make gains despite setbacks. Health for all remains a dream, but those who aspire to live in a society which respects that intrinsic value of every human life will continue to pursue the challenge despite the fierce resistance of the privileged.

Tim Woodruff is President of the Doctors Reform Society.

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5 Responses to TIM WOODRUFF. Health, Class Warfare, and Social Justice

  1. Richard Barnes says:

    A great piece Tim, which deserves a wider audience.

    Personally, I think you go too easy on the elites, ie the top 1% who run the show; who make and interpret our laws; who decide that a ‘Denticare’ scheme would be unacceptable; who inadequately fund public healthcare, particularly primary care and mental health care, but transfer billions to the wasteful private health system.

    As Tim outlines, ‘health’ is influenced more by broader socioeconomic factors than by actual healthcare provision. And here again it is the elite 1% who are, to use JK Galbrith’s famous line, “engaged in one of man’s oldest exercises in moral philosophy; that is, the search for a superior moral justification for selfishness”, shamelessly feathering their own nests yet running the Centrelink Robodebt scheme.
    Since the end of the ascendancy of Keynesianism and the Welfare State, the percentage of income going to the top 1% in Australia has risen from 4.8% to 10% (Piketty); and the wealth commanded by the top 1% is now 23% of the nation’s total (Credit Suisse 2017 Global Wealth report).

    In supposedly egalitarian Australia, we ignore this to our shame and to our peril.

  2. Rosemary O'Grady says:

    The real ‘luck’ in contemporary society comes from having income at one’s disposal which is not ‘earnt’. You can’t ‘work’ your way out of poverty in today’s world, not even in rich countries. One could say: especially in rich countries. Financial enterprise is geared to take advantage of every margin. The ‘rich’ / beneficiaries of egalitarianism are those who ‘strike it rich’ (mines, lotteries, windfalls), or inherit (are given their wealth/ possibly resulting from innovation & patent). This is not a wholly-exhaustive account but you get the drift.
    The obligations of secure, democratic governments to structure equality into a system which, by its very financial and fiscal nature does the opposite, is an inheritance of the social theories of the Industrial Age in which obscene wealth was countered by morally decent entrepreneurs/owners who shouldered the burden of spreading some of the benefits of wealth – voluntarily, not mandatory, and it is remarkable that it happened at all – considering the unbrooked temptations of wealth and power. The obligations of today’s electorates are to hold firm our ‘representatives’ to those values we learned to believe were ‘democratic’- not aspirational (which is nonspeak for Competition) but Fair, which is plainspeak for sharing the wealth of the nation. Which begs the question: what happened to the Wealth Fund? and why are so many ‘children living in Poverty?’

  3. Ian Webster says:

    Dear Tim,

    A great piece on practical social justice.

  4. This is a most significant article and I will do all that I can to ensure it’s read widely. The depth of discussion in Australia on all key social justice issues is so seriously hampered by a kind of blindness about both race and class. And perhaps also a lack of vocabulary and even practice at this kind of essential discussion. This matters because as Tim Woodruff’s article so amply demonstrates, this refusal to see/understand/shift vision radically affects policy and, more seriously still, it is recklessly harming and limiting real people’s real lives.
    Thank you to Tim Woodruff for writing it and P & I for being a place where such thoughtful writing is welcomed.

  5. Anthony Pun says:

    Dr Woodruff’s article reminds us the need to incorporate social justice in our “capitalist democracy” by using health access and equity as an example.

    If we do not prepare ourselves to counter the moves of the “elite” to slowly and surely removal bits and pieces of Medicare and supplemented with ”regressive” taxes mention by Dr Woodruff, we will end up with a not so universal health care like the US.

    In the 1980s, I visited a hospital in LA (California) in the 1980s whilst giving a paper in the US. I did asked a question about their procedures for receiving a patient from an ambulance at the Trauma Centre (Accident & Emergency department).

    I was told me that the first person to see the patient was the accountant (not the Doctor) and if the patient do not have a blue book (insurance) the ambulance driver was told to take the patient to a downtown Trauma Centre.

    We are not fighting a class war between the nobility and the peasants; Australia as an egalitarian society has never embraced such caste system. However, if the gap between the rich and the poor widens, then it creates an “elite class” and an “under-class” of citizens and in this new era, the respect for intrinsic value of every human life will be lost,

    Hence, in the defence and maintenance of social justice, we must all stand up to fight to resist the changes propagated by the elite in order to preserve our civil society and its humanitarian principles.

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