In the fourth edition of his crowd-funded Wonky Health column, Dr Tim Senior examines evidence from around the world about the health needs of disadvantaged peoples, reporting that poorer people tend to develop more complex medical problems and at a younger age than richer people.
While this is a critical area of policy that needs addressing, he cautions:
“… the solutions may not be the ones we think they are. If we’re making policy, we’re employed with a computer on the desk in front of us, and another one waiting for us at home. We have a high degree of choice in our lives and usually aren’t confronted with as many mental health, drug and alcohol problems and chronic pain as those we need to be thinking about.
In other words, the solutions we come up with are those that would work for us. These may be not just the wrong solutions, but solving the wrong problems.”
***
By Tim Senior
If you’re worried about the aging population, and what that means for our health system, then you need to be worried sooner about inequality. Here’s why.
It’s generally recognised that as people get older, they have more medical conditions, and together these are more complex to manage. They require more services and more professional help.
Our health services (not to mention social services) will have to work out ways of providing this. And as a society we will have to work out how to fund it.
In the field that I work in, Aboriginal and Torres Strait Islander health, we recognise that on average people have more medical conditions at a younger age. Often Aboriginal and Torres Strait Islander people become eligible for services for older people from the age of 55, where it is 75 for non-Indigenous people.
The reason for this is not that they are Aboriginal. It is not due to genetics. It is due to the fact that Aboriginal and Torres Strait Islander people are over-represented in those sections of our communities who have been excluded from the main workings of our society and do not have access to social goods.
There are specific historical and cultural aspects to our society’s exclusion of Aboriginal and Torres Strait Islander people, but just the fact of exclusion has an effect.
A team of health researchers in Glasgow have done a lot of work in this area. They show that while multimorbidity is more common in those older then 65, more than half of those with more than one medical condition are younger than this. What’s more, they show that the poorest group in society has 2 or more medical conditions 10 to 15 years earlier than the richest group.
So while we are grappling with the complex services required for the elderly, those in underserved communities will need these services 10-15 years earlier. A rough guess might suggest that time is now!
Certainly, evidence from this research group and from Aboriginal Medical Services in Australia shows that the effect on primary health care is that longer consultations are required dealing with more problems at each visit. More professionals are involved for each patient.
But it’s not enough just to think that not having money is just the same as having money without the designer goods. For example, offering everyone health checks (leaving aside the fact they don’t work) is a nice middle class solution that attracts middle class people to health services they can already access. It doesn’t attract those who might really benefit from preventive care.
Three recent papers put some interesting meat on this. First of all, the same group of researchers showed that not only did the presence of multimorbidity come in at a younger age for the socioeconomically deprived, but the types of conditions they suffered from were different.
There was much more anxiety, depression and drug and alcohol problems in deprived communities, which is perhaps unsurprising. There were also higher rates of chronic pain – think on that! – as well as dyspepsia, coronary heart disease and diabetes.
You can imagine from this the sort of services that will be required in these areas. Drug and alcohol and pain clinics aren’t very sexy, though, and rarely get people out on sponsored fun-runs. They are also treatment areas that don’t provide simple solutions.
It’s easy to think people should just make more sensible choices about their lifestyle. Another recent paper looks at preventive advice and activities in lower-income compared to higher-income individuals.
The survey was done in Canada so some of the findings may have not translate directly to Australia, though personal experience would not suggest it is hugely different here. They found that preventive health advice, such as smoking cessation, dietary changes, and exercise were offered equally by health professionals regardless of income.
However, they found that people on low-incomes were less likely to stop smoking, and less likely to have a cholesterol or glucose test. The reasons for this were more often due to extrinsic factors beyond the person’s control in lower income individuals, such as cost or availability. Higher income individuals were more likely to say it was due to personal choice.
The third study comes from America and looks at the use of e-health activities. They found that the biggest predictor of whether someone used e-health or not was their socio-economic status.
Older men and those on low incomes or lower levels of education were less likely to use the internet to look for health information, or to find or communicate with a doctor, let alone use computers to track their own information. Again, this is America, but there is evidence of a digital divide in Australia, and I’d be surprised if these findings were completely different here.
Policy implications
What does this mean for the development of policy?
First of all, it means that the multimorbidity and need for complex services that we are expecting as the population ages is already here for the worst-off sections of our society.
Second, it means that the solutions may not be the ones we think they are. If we’re making policy, we’re employed with a computer on the desk in front of us, and another one waiting for us at home. We have a high degree of choice in our lives and usually aren’t confronted with as many mental health, drug and alcohol problems and chronic pain as those we need to be thinking about.
In other words, the solutions we come up with are those that would work for us. These may be not just the wrong solutions, but solving the wrong problems.
Fortunately there is some more evidence for an age-old remedy that works – engage! This paper looks at health reform in Australia and suggests that if we want equitable health care in Australia – and I would firmly suggest we do – then we need to think about equitable governance. This is policy-speak for involving those who need the service in the planning and running of the service.
Clearly, Aboriginal Community Controlled Health Services show a way of doing this in Australia. They have demonstrated excellent outcomes in populations that are often described as difficult, high risk and hard to reach. That’s only true when you ignore their needs!
The paradox here, of course, is that while the health sector worries about an aging population, the Aboriginal health sector is seeing too many people die before they reach retirement age.
There really is no time to lose for any of us.
• Tim Senior and Croakey thank and acknowledge all those who contributed to the crowd-funding campaign to support Wonky Health – more details here.
• This link compiles Wonky Health columns.
Great piece – what this highlights for me is the importance of consumer and community consultation in the development of health promotion, preventive health and primary care policies and programs, where this consultation specifically involves people from culturally and economically marginalised groups. No matter how well intentioned, a group of middle class public servants, academics and clinicians are never going to be able to solve these problems on their own.
Government cut backs in funding to aboriginal medical services (AMSs) have already begun. However the proposed $7 co-payment and the soon to be introduced inability to bulk bill indigenous patients for management of an acute illness along with a chronic disease plan at the one consultation starting in November will lead to widening of the gap in survival between indigenous and non-indigenous people.
I work in an AMS in the remote north of Australia. Our clients only present to the clinic when they feel ill. I don’t see ‘worried well’ Aboriginal and Torres Strait Islander (ATSI) people. Many ATSI people don’t understand the concept of subclinical illness. When I first started working with ATSI people I managed indigenous people like I had my non-indigenous clients in the outer suburbs of Melbourne. I would attend to their acute problem or the most important problem on their list of complaints and ask that they see me again for management of non-acute and less urgent problems. The non-indigenous clients in Melbourne would return for follow-up and be interested in returning for preventative activities such implementing measures to address chronic disease, immunisations and smears. This is not the case with ATSI clients. Most ATSI clients never return until they are symptomatic again. I have therefore found that when they attend I have to address every complaint on their list, perform a complete health check and ensure preventative activities are completed to ensure better health in the future. This means consultations regularly take over an hour. Thus apart from managing the scabies or impetigo they present with, I commence management of the previously undiagnosed diabetes, treatment for the asymptomatic STI or renal disease, and counselling and or medication for suicidal depression and other psychiatric illness. These problems left undiagnosed and untreated not only increases death rates in our ATSI clients but increases the public health risk to others who contract these asymptomatic infections.
Those of you who don’t work with these clients possibly don’t understand the barriers to their more regular attendance. This includes ATSI patient ignorance of the importance of addressing asymptomatic illness before complications develop. Other barriers include embarrassment and many clients not having developed trusting relationships with doctors who often only stay in these communities for a short period of time. Some clients have no transport to get to the clinic (we have insufficient very poorly paid drivers who attempt to find clients and bring them in to be seen), some clients are not contactable (no phone or no service where they live remotely) or combinations of these impediments. Some of the very remote small communities are only visited by doctors every few weeks in the ‘dry’ season. It is crucial that all patient problems are addressed during these visits. However, now the government wants to introduce another barrier – the $7 co-payment. AMS’s already have difficulty recruiting doctors as better remuneration exists in the hospital system (where only acute problems are addressed). Taking another loss of income will surely be the death of AMS’s whom I believe are vitally important to fund appropriately if we are to have any chance of ‘closing the gap’.
Dr Andrew Beveridge
SMO, Ord Valley Aboriginal Health Service