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Surviving the bush: health and rural communities

Address by Chris Sidoti, Human Rights Commissioner to the Australian Healthcare Association National Congress, Melbourne, 10 November 1999

I would like to thank the Victorian Healthcare Association for inviting me to speak today. I hope that the Congress has been stimulating and has provided all of you with both an understanding of the problems facing healthcare in Australia, and some sense of optimism for what can be achieved to improve the health outcomes for all Australians.

In a sense I am an outsider at this Congress. I have no health or medical background. I do not work in health policy. I am not even from Victoria. However, I hope that I can bring you another, rather less spoken about, perspective on healthcare in Australia, in particular in rural and remote Australia - the right to health in country Australia.

Many of you will be aware that the Human Rights and Equal Opportunity Commission over the last 18 months has been conducting a Bush Talks program in rural and remote Australia. As part of this program I have travelled to over 50 communities in all States and Territories from large regional cities like Cairns and Bunbury to small towns like Bourke and Euroa, to remote communities like Papunya, Boulia and Yuendumu, listening to the human rights concerns of people in the bush. They told us loud and clear - health care, education, jobs, access to services, a future to hope in and live for. Tonight I will also meet with the community in Bairnsdale here in Victoria as part of Bush Talks.

Health is also an area that has received some well-deserved attention across all sectors in recent weeks. At the Regional Australia Summit two weeks ago, for example, health was one of the main topics raised as a concern for regeneration of country Australia. A commitment to rural and remote health was included in the Communique from that summit.

Human rights

Today I thought I would spend a little time explaining our international obligations with regards to the human right to health. What are they and how shall we interpret these obligations?

Human rights belong to every person by virtue of birth. They are not only for majority groups or for minority groups but for everyone equally and without discrimination.

Human rights are also not granted to us by others or by the government. They are ours to be enjoyed simply by reason of our common humanity and innate dignity as human beings. For that reason we cannot agree to give them up and they cannot be taken away from us.

Most people are aware of their civil and political rights, for example the right to freedom of expression and the right to vote. These are of course fundamental human rights. But matters relating to people's social, economic and material well-being are equally matters of human rights. These include the right to an adequate standard of living. The enjoyment of this right requires, at a minimum, adequate food and nutrition, clothing, housing and necessary care and support such as health and medical services. Human rights also include the right to work, to social security and to education. They impose an obligation on government to give assistance and support to families in need.

These rights are often overlooked by governments because they raise issues of public welfare and public spending. In a climate of fiscal restraint governments are reluctant to face issues which require more spending. And in a climate of economic rationalism governments reject many spending options that, in purely economic terms, are not cost effective. However, Australian Governments have made solemn promises to the Australian people that oblige them to uphold these rights and ensure that the basic needs of every person are satisfied.

One of the most important human rights treaties is the International Covenant on Economic, Social and Cultural Rights. Australia is a party to this treaty.

It is perhaps not as well known as the International Covenant on Civil and Political Rights, but it is no less important. These two sets of rights are not mutually exclusive. They are most definitely linked. For example, a society that promotes and respects individual rights is more likely to be well placed to enjoy economic growth and good standards of living. At the same time, where there is economic inequality and poverty, where health is neglected and education denied, civil and political rights often suffer.

Many will argue that these rights - social, economic and cultural - are difficult to measure or attain, as circumstances differ so substantially from country to country. Economic inequality has not been solved anywhere to date. Unlike the right to vote, it can appear impossible for governments to guarantee the right to work. Consistently high unemployment, especially in rural Australia, despite good intentions of governments at every level, has taught us that there is no quick solution to extending these rights to everyone.

However, the International Covenant on Economic, Social and Cultural Rights is a means of getting governments to measure their achievements or failures, and to commit to progressively attaining realisable goals. Unlike the Covenant on Civil and Political Rights, it commits each state party to achieving the rights progressively, but this does not mean that they are not achievable. And importantly, governments must guarantee that these rights are protected and enjoyed without discrimination of any kind.

The right to health

Article 12 of the International Covenant on Economic, Social and Cultural Rights calls on nations to recognise the right of everyone to the enjoyment of the highest attainable standard of physical and mental health. The right to health, it is often argued in human rights law, is awkward because it suggests that people have a right to something that cannot be guaranteed, namely perfect health. It is argued that the terms 'right to healthcare' or 'right to health protection' are more realistic. However, at the international level the term right to health is most commonly used because it covers a broader understanding of health, including healthcare and environmental health. In practice it is a shorthand expression for a specific range of rights in treaty texts.

For example, the treaty monitoring body of the ICESCR addresses the following broad range of topics within its framework of the right to health: national policies on health, issues relating to healthcare, underlying preconditions for health such as accessibility of clean drinking water, and the accessibility of health services for various vulnerable groups. When assessing healthcare services of nations, the Committee assesses the availability, accessibility, affordability and quality of healthcare services. With respect to accessibility in particular, the Committee has expressed its concern about the accessibility of healthcare facilities in remote and rural areas.1 It is clear to that body that nations which have signed the treaty not only have an obligation to formulate national policy on health but also to ensure that healthcare services are in existence and are accessible to all people within their responsibilities.

Unlike civil and political rights, very few examples exist at the United Nations and at the regional and national levels where courts have reviewed the right to health. There are no specific complaint procedures in force to make health rights and other economic, social and cultural rights justiciable. However there are some indications that this may develop in the future.2

There is also a trend among scholars and activists towards delineating a certain core in the right to health - a set of elements that states have to guarantee immediately irrespective of their available resources. For example the primary health care strategy of the World Health Organisation has devised a list of basic health services which make up a core content of the right to health.3 A set of core elements can provide a benchmark for nations, or for vulnerable groups within nations, to assess the government's progress on fulfilling its obligations.

Bush Talks

If in Australia we were to create a core set of elements of the right to health, of even the most fundamental kind, I suspect that we would reveal great inequality in many areas of healthcare. Having travelled to many parts of rural and remote Australia I have no doubt that we are failing to protect and promote economic, social and cultural rights in the bush as we should. In many respects the bush comes off second best to the city and this most certainly is not equal treatment.

People in the bush should not be excluded from the enjoyment of human rights simply because they make up less of the population or live outside metropolitan centres. As one person in the country said to me during Bush Talks 'we pay the same taxes; so we should get the same services'.

The talks confirmed for us what many people in the bush already know, and I am sure that many of you here today know- many communities in rural Australia are under siege. These communities have declining populations, declining incomes, declining services and a declining quality of life. The infrastructure and community of many rural, regional and remote towns have been slowly pared away. It was described to me by a woman in Port Augusta as the 'dying town syndrome', a downward spiral of de-servicing, de-resourcing and de-populating. People are moving out of the towns where they can no longer make a living or find a job.

The smaller the population, or the more geographically isolated, the more difficult it is to get access to a necessary range of services, whether government or non-government services. These are not luxury service that people are asking for. Remote and isolated communities are still waiting for the basic means of survival and well-being.

As one submission to Bush Talks put it

Governments must acknowledge the fact that people live in rural communities and need to be recognised as being a part of society rather than part of an economy.4

To a certain extent, those who live in a rural area, and especially a remote area, expect to have reduced access to a full range of services. I did not find that people's wishes were extreme or unreasonable. There is an element of choice in deciding where to live.

Still, it is false to argue that people should up and leave a farm or a town where they were born or in the case of indigenous people where their traditional land and people are, just to get the basic essentials for life. Regardless of where you live, all Australians should have access to basic health facilities, good education, decent housing and access to a reliable supply of safe water.

Health problems in the bush

Let me turn to what is known and what I was told about health in the bush.

Certainly, the poor state of rural health has been the focus of some media attention for several years. Governments have also begun to hear this cry, for sound political reasons: the bush is punishing political parties. Just look at the Queensland state election last June or NSW in March or Victoria last month. People in rural areas are forming networks and organisations to lobby the government for much needed improvements. In the last Federal budget, although there were comparatively few policies and programs addressing fundamental economic and social problems in the bush, there were a few good initiatives for rural health, for example the announcement of a new fly-in fly-out female GP service and the continuation of some excellent programs such as the Bush Crisis Line run by the Council of Remote Area Nurses of Australia. However, there is still along way to go before it all appears as mere tokenism to people in rural areas.

Despite research, conferences, meetings, national strategies, in a number of areas the health of rural and remote Australians continues to fall well below that of people in the cities.

Death rates from all causes are higher in rural and remote areas than in capital cities. Rural Indigenous people die on average 15 to 20 years earlier than their fellow Australians. Rural Australians are more likely to suffer coronary heart disease, asthma and diabetes than city dwellers. Deaths of males from road accidents are twice the rate in remote areas than in capital cities.5 And suicide, especially of young males, seems endemic in many communities.

Not surprisingly, while the level of health need increases, the level of health care drops dramatically as we move from capital city to regional city to a rural or remote area. Yet instead of increasing services, it seems that many are being pared away.

In Geraldton WA Bush Talks was told that the hospital had recently closed 29 beds, reducing the total to 60 beds. The average number of patients is 60 but the peak to date has been 73.

In Biloela Qld 'a few years ago the hospital had two full-time doctors'. When we visited there last year the only doctors practising at the hospital are GPs in private practice who were said to limit themselves to four appointments daily at the hospital.

In one town in south western NSW I was told about a woman who collapsed in a supermarket. When the ambulance was called the paramedic decided she had to be taken to hospital and so asked bystanders whether someone could drive the ambulance while he travelled in the back to look after the patient.

The shortage of GPs in the bush is well-known, and I will not detail it here as you are all aware of the problems involved. It is pleasing to see that the federal government and several state governments are establishing more programs to encourage GPs to take up and stay in rural practices. This is, however, only one part of the problem. There were some towns we visited in which not one GP would bulk bill, in some instances not even for health care card holders.

One man from Mudgee told us how all the medical centres in town had refused to bulk bill and how his wife had been turned away for a regular prescription of heart medicine because she could not pay for the consultation, even though she offered to pay on next pension day. And the pattern is inconsistent. Travelling across north west NSW I found that all doctors in Bourke, Brewarrina and Walgett bulk bill but not a single doctor among the 12 in nearby Moree, by far the largest town in the region.

Almost everywhere we went, lack of services for mental health was raised as a most pressing issue - counselling, psychiatric, hostel, in-patient services, especially services suitable for young people, and especially suicide prevention programs.

As one person from North Queensland put it,

Mental health services are abysmal in the bush, almost non-existent, as is detox for alcoholism which is rife, marriage counselling, respite, palliative care, legal services, etc. These are of course all related.6

In Geraldton I was told there is no specialist in child and adolescent mental health. In Central West Queensland "there is no-one to provide counselling services and a lot of young people are struggling with mental health problems". In Rockhampton Qld there is no permanent child psychiatrist. Even in Wagga Wagga NSW, that State's largest inland city, there is no resident psychiatrist. Psychiatrists have to be flown in on circuit to see patients by appointment. If it is that bad in the regional cities I can only imagine how appalling it must be in remote areas.

Suicide rates are especially high for young rural males. For the 15 to 24 age group of males, the suicide rate is more than double that of their metropolitan counterparts.7 And it has increased by around 350 per cent over the last 30 years.

The suicide rate is especially serious among young gay and lesbian people. An excellent national study indicates that the suicide attempt rate is four times that of heterosexual young people and occurs at a much earlier age - 15 years is the average age.8

Whatever indicator you choose, the situation of Aboriginal people is even worse that that of any other Australians. For Aboriginal Australians:

And Indigenous people in remote areas have it hardest of all.

The lack of accessible dialysis for kidney disease among Indigenous people is deplorable. Wongai residents of the Ngaanyatjara Lands and other people in the Central Desert region of WA must go to Kalgoorlie or Perth for dialysis and this means that they have to be separated from their traditional lands and community support.

In the Northern Territory, dialysis has only been available in Darwin and Alice Springs until a third unit opened recently on Tiwi Island. People in need of dialysis are forced to move from as far away as Tennant Creek and the Barkly.

Being separated from family, community and traditional lands can be devastating for rural Aboriginal people. One person described it as follows:

People can't bear to be away from their land and family and some have chosen to return home. It really breaks a Wongai's heart when he has to go away. But without dialysis, patients will die.10

And many choose to die rather than leaving family, community and land. And when they do go, they see it as a life sentence, for they can never come back except to die. Support in the towns for those on dialysis is almost non-existent. Many live in the river beds or, if they are given accommodation, their families who accompany or visit them are not.

Indigenous people also raised with us the common ignorance of Indigenous cultures among health professionals which means inappropriate and often inadequate treatment. In Cairns Qld Bush Talks was told that it was often difficult for Indigenous patients from outlying areas to understand the medical terminology and language of doctors at the Cairns hospital. The information could be about critical issues such as medications and treatment.

Services for elderly and frail are also particularly in demand in rural and remote areas. Small towns have lost or are losing their young people - leaving towns to age dramatically. The health needs of older people mean that it is increasingly difficult for them to maintain an independent lifestyle. In Burnie Tasmania Bush Talks was told that there is a six month wait for nursing home care.

Problems of distance obviously greatly affect the health and well-being of communities. For people on low incomes, those who do not have family and friends to support them, people with disabilities, young people, parents with young children, travelling long distances to see a medical practitioner, go to hospital or visit the dentist can be near to impossible. Although there is a federally-funded and State-administered travel and accommodation assistance scheme, this was criticised as inadequate by some of the rural people we spoke to. Because of restrictions on eligibility, Bush Talks was told in Bathurst of cancer sufferers 'taking the risk' rather than find the money to go for treatment and in Geraldton of a spinal injury patient having to pay her own airfare because she was only in a full body cast and not a wheel chair. Cross border issues under a federal system are leading to people being seriously inconvenienced and money being wasted.

I want to emphasise, though, that many of the problems which people told us about were not 'luxury' items or complaints about not having a wide range of choices. People are talking about access to basic standard health care - a doctor, a dentist, someone to talk to if contemplating suicide. Without access to these services in a rural community lives are at risk and quality of life is seriously threatened.

Of course, the problems were very different according to which region we visited - some towns have plenty of access to GPs but no services for the mentally ill. Others have a doctor but no hospital. There are also differences in the state of rural health depending on whether you live in a remote area or in a rural town, what the economic situation is like in that area, whether or not you are Indigenous. As you all know, the 'bush' is by no means homogenous. However, overall, the range of problems and shortages in rural health is somewhat overwhelming.

Positive way forward

I do not want to leave you with a completely negative picture of rural and remote area health. Those of you who work in health care are more than aware of the many positive initiatives which are occurring in the country. You would also be the first to point out that many rural communities are not caught in a downward spiral, but are thriving and growing at a rapid pace.

However, a few points made to me by rural communities again and again over the past months have some direct relevance for how we might begin to plan to regenerate declining rural areas, including health care.

The first is that communities need to be involved at all levels of planning for their own futures. This may seem obvious, but too often rural communities feel that they have been left out of the loop in decisions which directly affect them. There is certainly a lot of energy in rural and remote Australia which could be harnessed for change.

In Bush Talks we came across many communities which were willing to organise the meetings, were concerned about their communities and wanted to be involved in finding solutions.

They told us about many good initiatives undertaken by their communities to try to address some of the problems of isolation or declining services. People expressed interest in other communities and what they did, and how they too could do the same, whether it be in health, the local school, youth culture and support or employment opportunities.

Some good healthcare models - sound community based models- have been around for a number of years. For example the Nganampa Health Service in South Australia is a positive model of decentralised health services which is community controlled although regionally based, allowing for some economies of scale whilst remaining of a size which can respond to community needs. We need to revisit these models and work to encourage similar initiatives in areas where none exist.

On a smaller scale, one local institution in a small community can, perhaps with regional or national collaboration, generate a project with far reaching effects. Kyogle High School in NSW, for example, have conducted a mental health project under the National Suicide Prevention Strategy where young people are provided with training in leadership skills, wilderness skills and music, art and small business management including management of local youth centre. The project has assisted local residents to provide short-term crisis accommodation and develop local TAFE courses for young people.

I found that in many communities there is a willingness to work co-operatively and learn from other rural and remote communities, contrary to the stereotype of parochialism in rural areas. They want to see their regions develop, they want a confidence-building, integrated approach to planning and development and they want to be involved - to make the key decisions about their health and their future.

Helen Sheil, from the Centre for Rural Communities spoke recently at the Regional Australia Summit about the capacity of rural communities themselves to provide the 'missing link' in the chain of decision making in regard to the future well being of regional Australia. She provided an interesting quote from David Suzuki on human survival

Just as the key to species survival in the natural world is its ability to adapt to local habitats, so the key to human survival will probably be the local community.11

There is no doubt that the local community is an essential starting point.

However, the second point it is important to make is that, although small rural communities can be resilient and energetic, governments cannot absolve themselves of responsibility for them. Regions need participation, transparency and flexibility in decisions about priorities and plans for change but they also need outside assistance and resources to turn plans into realities. Rural communities pay taxes - they are entitled to as much support as urban communities.

We need to move beyond the principle of 'do-it-yourself', which has the danger of being an excuse to abandon those most in need.

People in rural and remote Australia know that this responsibility is about more than national economic policies. Of course, rural communities are the first to welcome an injection of resources and the development of employment opportunities. But these are not the end of the story, nor always the panacea for the ills of a community. We must insist that all the human rights of people in rural and remote communities - their economic, social and cultural rights as much as their civil and political rights - are respected, protected and promoted.

Endnotes

1 Brigit Toebes, 'Towards an Improved Understanding of the International Human Right to Health', Human Rights Quarterly, Vol 21, Issue 3, August 1999, p.667.
2 Brigit Toebes, ibid, pp.671-674.
3 WHO, 'Primary Health care: Report of the National Conference on Primary Health Care', Alma Ata Conference, USSR, 6-12 September 1978, cited in Brigit Toebes, ibid., p.676.
4 Submission to Bush Talks from the Highway Safety Action Group of NSW Inc., Molong NSW.
5 National Rural Health Alliance, Proceedings of the National Rural Public Health Forum 12-15 October 1997, NRHA, Canberra, June 1998, p.1.
6 Submission to Bush Talks from E Stafford, Kuranda Qld.
7 NRHA, ibid, p.3.
8 Jonathon Nicholas and John Howard, 'Better dead than gay?', Youth Studies Australia, Vol.17, No.4, December 1998.
9 Submission to Bush Talks from Central Australian Aboriginal Congress, Alice Springs NT.
10 Bush Talks meeting, Kalgoorlie WA, August 1998.
11 Helen Sheil, Transformation: despair to optimism, Regional Australian Summit, Canberra, 27-29 October 1999.

Last updated 1 December 2001