The Canadian Medical Association has a new president, Dr Anna Reid, who says that addressing health inequities will be one of her priorities. An emergency room physician, she regularly sees the impact of social and economic disadvantage upon the health of her patients.
Meanwhile, public discussions about health in Australia often remain very narrowly focused, addressing issues such as individuals’ lifestyles and behaviours. We don’t hear enough about how broader societal forces shape the health of individuals and communities.
In the article below, Dr John Falzon, Chief Executive Officer of the St Vincent de Paul Society National Council of Australia, explores what kind of society promotes good health, and argues that punitive policies, such as compulsory income management, are a sign of an unhealthy society.
For those readers who use Twitter, he also announces the launch of a new hashtag #goodsociety, which may be of interest to readers who are interested in broadening the debate about health and wellbeing.
What’s a good society got to do with health?
John Falzon writes:
When I was four years old I went into hospital to get my tonsils out. It was in the East End of London, not far from where the Olympic Games have been held.
From my stay in the hospital I retain a strong memory of sneaking off with the other kids from the children’s ward at night and going down some stairs into an underground cellar or tunnel.
Perhaps my family is right and I imagined it all or perhaps it was a powerful dream that accompanied the upheaval of being separated from my parents and placed in a scary environment. Anyway, I never fail to amuse my kids when I recount the story and insist on its veracity.
I want, in this reflection, to go back underneath the hospital. I want, this time, to be the one with the torch and I would like to take my readers down those stairs to see what lies beneath.
What, in other words, underpins the structure of a health system? What is accumulated in the hidden cellars and where do the tunnels go? What other edifices do they connect to?
In Black Skins White Masks, Frantz Fanon, a psychiatrist and arguably the 20th Century’s greatest theorist of the confluence of colonisation and the crushing of the spirit, wrote:
“Oh my Body, make of me a human who always questions.”
This is a beautiful prayer. It does not take the attitude of questioning for granted. It invites us to go down those stairs to check out what lies beneath or to sneak outside to see for ourselves what lies above! It throws away many of the givens, the assumptions that we are taught, sometimes very subtly, to accept and to even support.
Why on earth, for example, should we assume that good health is unrelated to just about everything else that happens in our lives? How can we possibly assume that class, for instance, has nothing to do with the state of health we are likely to enjoy or, to put it another way, that the degree of power we have over our lives is unrelated to our health?
If we want a map for the cellars and tunnels underneath the hospital, we have the entire social determinants of health framework at our disposal. This is an enormously useful resource to help us to ask the best questions.
As the World Health Organisation defines it:
“The social determinants of health are the conditions in which people are born, grow, live, work and age, including the health system. These circumstances are shaped by the distribution of money, power and resources at global, national and local levels. The social determinants of health are mostly responsible for health inequities – the unfair and avoidable differences in health status seen within and between countries.”
So why not put the question another way? What kind of society would help us to achieve good health outcomes? For a start we would have to stipulate that it would be the kind of society that didn’t just focus on outcomes but on the means as well!
The offence of compulsory income management
To give a current example from the Australian social policy scene there is no way we could justify the use of punitive and paternalistic policies such as compulsory income management on the basis that this is good for someone because they are a member of the First Peoples of Australia or because they are outside the labour market.
Scratch the surface of this offensive assumption and you come face to face with the most objectionable racism, classism and sexism; a veritable smorgasbord of attitudes that fundamentally construct people as being dangerous to themselves and to the rest of society; a set of attitudes that are begotten by the failure (inability? refusal?) to ask questions.
When we fail to go down the stairs to what lies beneath we are led to a position that is swift to pathologise or even criminalise. The hospital, in this case, is only a stone’s throw away from the prison. People are blamed for their own exclusion. The history behind their exclusion and the structure of their exclusion are both ignored. We are left with the false notion of an individual who drops from the sky and goes forth to wreck their own lives!
Compulsory income management is causing humiliation and shame for people whose only crime is to be on the wrong side of growing inequality.
Manifesto for a #goodsociety
A good society is one in which the people who are treated as the most marginal enter the public space and teach the rest of us about what really matters.
A good society can only be created when we learn to accept that, as per the Feminist insight that had its origins in the 1969 essay by Carol Hanisch, “the personal is political”, allowing us to see the connections and intersections between what happens in our personal stories and what is happening in the social, cultural, economic and legislative spheres.
A good society will value, and be unafraid of, diversity.
A good society will create structures to ensure that resources and opportunities are distributed rather than commodified; so that the many rather than the few can profit from them.
A good society will encourage and value creativity.
A good society will not encourage collective amnesia. We will remember where we have come from. We will not pretend that colonisation has not happened. A good society will engage, painfully and honestly, with a way of facing this fundamental contradiction and learning from it and from allowing it to become the historical space in which justice is collectively struggled for, and won!
A good society will not humiliate people.
A good society will ensure that the resources and opportunities available to all include the right to engage in sports and recreation and the arts.
A good society will deliver the rights to: appropriate housing, adequate income, education, health care and working conditions that are dignified, safe and never demeaning.
A good society will be a place in which it feels normal to care about people.
A good society will be profoundly, rather than just formally, democratic. It will be created by, and constantly changed by, the collective participation of the people.
Is it so hard to see how a good society is the best means of achieving good health? Is it not obvious that those societies that are highly unequal, disempowering, degrading, violent and dehumanising are terribly good at destroying health?
So this is exactly where we must start; not with the ideal but with the reality in which we are living. We can only create a good society by beginning with a relentless analysis of the disempowerment and inequality at the heart of a social and economic structure that is bad for our collective health.
We should see real signs of hope precisely in the current upheavals across the globe where ordinary people are intruding into the public space and articulating their critique of inequality.
In Europe we are seeing this public critique of the retrenchment of social security accompanying a massive growth in unemployment. In Australia we are seeing an outpouring of grief over the extension of the Intervention as a form of colonising control over the lives of the First Peoples and, in accordance with the logic of internal colonisation, the lives of non-indigenous peoples as well on the basis of gender and class. We are also seeing the deep shame felt by many over the demonisation of people who seek refuge in Australia and the continued detention of asylum seekers, including nearly 600 children who are locked up as if they had committed a terrible crime.
New passions are springing up within society. They point to the glaring contradictions. They also offer the promise that another kind of society is possible, and can be created collectively under the guiding stars of struggle and hope.
• On Twitter: @JohnFalzon