It's getting too hot and scary for me

I went to a New Year's eve party for about 40 mins last night. Friends of friends. The house turned out to be over the top ostentatious (at least for my taste) .. the hostess worked as a lawyer. Making conversation, I asked "what kind of law do you do?" She said "tax" .. I said, "you mean tax avoidance". She disagreed and didn't actually appear to take immediate and strong offence and I have absolutely no proof or even evidence that her morals are any different to mine (the house was owned by her father) .. but I just had to leave.. I felt contaminated staying there. My friend took me home, later returning to the party, apologising that I had suddenly felt unwell (which I had)..

I reacted in the context of knowing so many companies in Australia (quite lawfully) pay no tax, including the coal conglomerate Adani. 

As Richard Denniss writes:

"For years, Australians have been berated by big business, and their boosters in parliament, about the punitive and stifling impact of the 30 per cent corporate tax rate. For years, we have been subject to a flood of econo-babble about the need to "incentivise investment" by cutting the "uncompetitive" corporate tax rate. And, for years, we have been lied to. Either that or the people making such claims were entirely, and wilfully, ignorant of the facts".

I feel the same revulsion when I think of Dubai etc, eg the exploitation of "guest" workers, more like slaves, many of whom have been involved in the construction of grandiose but potentially lethal high-rise death traps, coated with flammable material . I try not to fly Emirates.

We have a culture that pays Russian roulette with the environment. The evidence is now terrifying to those who look: escaping methane blasting holes in the tundra,  above zero temperatures at the North Pole in mid-winter and 72 deg F in New York City on Christmas Eve. Fish are appearing in puddles in Miami, migrating through the porous limestone with the seawater. As the seas rise top officials in Florida Miami try to censor the words "climate change".

Perhaps my reaction was intensified as I have been working very intensively in the last few days on a Wellcome Trust grant proposal to do with reducing poverty in South Asia and Sub-Saharan Africa, and with enhancing planetary health. 

I have been in opulent places before, but have never felt as strongly repulsed. But I feel the same way when I think of Joe Hockey (and his partner's) fortune .. I think such inequality is truly wrong (I also think this about Kathy Jackson and her partner, even though I used to admire her.)

There is a profoundly disturbing disconnect between haves and have nots. As the "haves" get more out of touch, do they think they can move to another planet when this one becomes too hot and strange?Spring in December in NYC is beautiful and alluring, but so was inspecting the receding sea bed before the tsunami. Perhaps dangerous climate change starts at 1 degree, not two. And two degrees could occur by 2036.

Happy New Year!

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.

The future health of the emerging Australian underclass

Perhaps unconsciously and because they perceive the world in a different way, the Tony Abbott-led Australian Federal government policies resulting from the budget and more generally will deepen the poverty and thus the ill-health of the poorest in Australia (including people living in shipping containers), leading (if these trajectories continue) to grossly increased health inequality; this will be accompanied by widened public acceptance of this situation. Already, and increasingly, affluent populations believe and will increasingly believe that the poor have “caused” their own illth and thus also the poor should pay for their treatment. But already this is increasingly difficult, by 2030 it will be impossible.

As the population of the emerging Australian underclass grows and their health deteriorates the future public purse may well be spared, as the rest of the population accept that it will be cheaper (and morally acceptable) to allow the poor to die quickly rather than struggle heroically to keep them alive a bit longer. We already see people with under-treated mental health, in future we will see gross under-treated physical health. People with mental health are currently threatened by a loss of their disability pension in exchange for cheaper payments.

Australia's current Minister of Health, Peter Dutton, boycotted Kevin Rudd’s apology to the stolen generation, on the grounds that it would do nothing tangible for Indigenous health. The GP co-payment will particularly harm Indigenous people, especially in more remote parts of Australia.

TONY JONES: Okay, well, we've got a few people with their hands up. Keep your hands up, but first of all we've got a web question that's come in from Andrew James Brown on this subject. "To Peter Dutton: Why did you choose not to attend the apology to the stolen generations?"

PETER DUTTON: "Well, for pretty much the same reasons. I support any legislation whatsoever that would go through our parliament that I thought would provide a tangible outcome for, particularly, Aboriginal children. I..."

Dutton has little if any understanding of the psychological underpinnings of health. This may be excusable in a drug squad policeman but is disgraceful for a minister of health. (He's not much chop as minister for sport, either.)

The government persistently defends the co-payment for general practice visits by the poor as similar to a pharmaceutical benefit co-payment. This also reveals a bias to a biomedical “curative” view of health.

So too is the illusion that the GP co-payment will produce a treasure chest of miracle drugs sometime after 2035.

As part of its strategy for punishing the poor the Federal Government also proposes to compel people to “learn or earn”, under threat of losing their already meagre benefits. But how can someone who lives 90 mins away from a centre afford to travel to “learn”.. who will pay for that? Many people who are functionally illiterate cannot effectively learn these skills over the internet. (Ninety minutes is close for many people in remote Australia).

Instead of all punishing and taxing the poor proportionately more, I would rather people like me paid more tax, also companies like Glencore, Google and Apple, and that there were genuine policies to promote fairness.

***
The author is professor of public health at the University of Canberra. In the past I worked for almost 10 years full-time equivalent as a general practitioner (1988-2008) mainly in very poor rural areas of Tasmania, where I learned all too much about the relationship between poverty, social exclusion, and ill-health, whether from ischaemic heart disease, type II diabetes, smoking, depression, domestic violence, unemployment, drug addiction and other forms of attempted escape from social exclusion.

There is a postscript for this.