Wednesday, July 2, 2014

Limits to growth, deepening inequality and Australia

This is a postscript to my recent post "The future health of the emerging Australian underclass" but it can be read on its own.

Why am I so sure there is already an underclass? This is in part because, between 1988 and 2008, I worked as a locum general (medical) practitioner (a GP) for more than 30 different GPs in about 20 different practices in over 12 towns and small cities, as well as running my own practice for several years. In all this summed to about ten years. I did this not only to get medical experience but because my ambition was always international health; locums at different times allowed me the chance to study and travel more, especially to India for the charity I co-founded in 1989.

As a result, I estimate I saw, as a GP, well over 10,000 different people (though only in Tasmania, Australia's poorest state). Perhaps I saw 25,000.. Whatever the number, it is far more than the average GP would see in his or her working life. Few Australian GPs look after more than 2,000 people. It is this experience which informs my conclusion that there is a culturally distinct underclass at least in parts of Australia, especially in rural areas and poor suburbs. (I also worked extensively for the after hours medical service in both Launceston and Hobart, in both cities 90% of my patients were poor; I did many house calls in poor suburbs.) One day I hope to write in more detail about this; the patterns of names, cultures and behaviours, repeated in neighbouring towns. Remember, much of general practice is social medicine, by which I mean that the social context of the patient is very important in determining risk factors, behaviour and health outcomes.

Primarily, here, my intent is to link this underclass to inequality and to limits to growth. It is, I hope, self evident that today there are many examples of individual who have succeeded in life, even from poor backgrounds. However, my view is that societies can influence the setting, the "milieu" from which many more from this group can do well, and to influence the average, in terms of life expectancy, education,  and living standards. Some from this class also contribute to a participatory democracy; if more could then that would be good.

This task is of course difficult but until recently there has been broad agreement in Australia that foundational elements such as reasonable education and a reasonable health system are components, though their existence cannot completely overcome the cultural barriers and constraints.

I agree that too many handouts to this group, with no obligation, is harmful, but what I think is in danger of happening in Australia is that the settings to nurture the "determinants of prosperity" are now being reversed, accompanied by slowly growing cultural tolerance for the failings of the underclass by the non-underclass.

Think of it this way. Imagine you are in rural Russia in 1850, with a Tsar, a court, and a peasantry. I am not an expert on history, but it is clear that the chances for peasants in that environment to "succeed" or even to have a long life are limited. From the perspective of the court, the circumstances of the peasants don't matter much, as long as the peasants have food and prospects to not revolt (and/or as long as the secret police are powerful enough to quell any rebellion.) The determinant of health and well-being for the peasants (and even worse, the serfs who preceded them) were dismal.

We are not Russia in 1850, which shows progress can be made. The question is, can we make even more progress, or will we regress towards Russia in the past? (or Ireland in 1840?)

From my perspective, as someone who values and works for a fairer (though never equal), prosperous and enduring world, the lives of the peasants would matter, and so too do the conditions for the current underclass (including beyond our shores, eg Tamils in camps in southern India). I believe that the policies of current Australian government, via enforcers such as Andrews, Abbott, Dutton and Abetz are worsening their prospects, eroding the "social determinants of health" which has a long history, but is perhaps jargon to most people not working in public health.

I have long argued that global society is now getting poorer (per person especially), due mainly to higher energy costs and other manifestations of "limits to growth" (in part offset by more energy efficiency and invention, but not sufficiently). This is evident at many scales, not just globally, but regionally (eg food banks and soup kitchens in Europe) and also, increasingly, here. Global policy settings have long ignored, denied and suppressed limit to growth, and they largely continue to; hence it will get worse.

A shrinking "cake" with more claimants means either everyone eats less, thus sharing it, or that the poor claimants eat even less, enabling the better off (eg me) to not be very affected, materially, at least for the time being. It would be far better to have global policies to expand the cake, but this is not happening at the rate needed, in fact, the cake is shrinking. 

Taxing the poor in Australia for seeing a GP, forcing them to "learn or earn" (how can that work for rural people who have to travel?) and exploiting them via work for the dole is going to make it worse, as does cutting foreign aid and our increasingly blatant flouting of the refugee convention. (How morally different is handing over Tamil asylum seekers to the Sri Lankan government to returning fleeing Jews to the Nazis?)

I would rather pay more tax, see mining companies like Glencore and technology companies like Google and Apple also pay more tax, and spend that money raised on education, and other ways to change the culture of the underclass, including through deep listening and respect. To do that is a multi-generational process; I used to feel part of it; I do not mean to sound glib, it is not easy.

As for employment: in theory, with the internet, many more rural (or even urban Western suburban) jobs are possible, if there was the culture and skills to make this possible. There also needs to be affordable energy to do this.

The current Liberal National party policies (the Labor Party was not much better, especially internationally) are not thoughtful enough, they will lead to widening inequality, materially, in health and in attitudes. Already the problems of the poor in (say) Kenya or Sri Lanka seem impossible to fix, and in Australia they are becoming very difficult. As Limits to Growth tighten, my prediction is that we will see strengthening disregard for the poor in Australia. When I graduated in medicine in 1986 I was debt-free. Working in rural Tasmania was a way I could re-pay the non-obligatory debt I felt to the Australian people. If I was to graduate in 2016 with a debt of over $100k (still cheap by US standards) I would be far less likely to work in a poor area, and I would be far less likely to care for the common good.

It is well-known that life expectancy in the US is lower than here, despite its enormous health expenditure. The current Australian government policies are leading us in that direction. I know this blog is a tiny offering (as is our charity and even my entire career) even so, I feel obliged to try.

Thanks for reading (if you get this far!)  By the way, I have two edited books in press, including Climate Change and Global Health  and Healthy People, Places and Planet: Reflections based on Tony McMichael’s four decades of contribution to epidemiological understanding (ANU E-Press) (co-editors Jane Dixon and Tony Capon). We expect it to be available in early 2015. It will be entirely free, on line. Many of its chapters will be accessible to the general public, though some are quite technical. There is no link yet for the book. Some chapters in both books are relevant to these general issues.