AMA Speech - AMSA Global Health Conference

FRIDAY 28 AUGUST 2015

PERTH

AMA PRESIDENT PROFESSOR BRIAN OWLER

**Check Against Delivery

“Global Health, Local Solutions”

I would like to acknowledge the traditional owners of the land on which we are meeting, and pay my respects to elders past and present.

It is a privilege to once again to have the opportunity to speak to such a large gathering of medical students.

Global health

The great thing about the modern medical student is what appears to be a universal focus on the ‘big picture’.

You study hard to be a doctor to care for the patient in front of you. At the same time, you are concerned about the patients who have no doctor readily available – people in different, often difficult, circumstances in all corners of the world.

You have your eyes set on a medical career at home, but you want to help to improve the health of people less fortunate in other countries, in other communities, in poorer conditions.

It is a noble calling, and I applaud you for it.

Global health, and the attitudes of medical students to global health, reflect how different we are as a society compared to even 20 years ago.

We are more aware of global issues. We are more interconnected - not just because of the internet, but all forms of media.

So it makes sense that, compared to my generation of medical students, you are more connected and aware of issues that affect people all over the world.

We have also recognised that diseases and other factors don’t recognise international borders or sovereignty. This requires co-ordinated responses – locally and internationally. And this is where many of you see yourselves playing a role in the coming years and decades.

Governments have a role, but so do organisations like the AMA.

I want to talk about some examples of the AMA’s advocacy in relation to global health.

The AMA has been warning of the health issues associated with climate change for years.

In fact, the AMA was one of the first health professional bodies in Australia to recognise, and draw public attention to, the relationship between health and climate change, and the responsibilities that health care providers have in this area.

The scientific evidence that climate change is occurring now, as a result of human activity, is unquestionable.

The health impacts are obvious. We have warned of health consequences of changing patterns of disease, extreme weather events, the issues of drought, and famine, and many more.

The Federal AMA has recently updated its Position Statement on Climate Change and Health, with input from AMSA. We will be releasing this Statement in coming weeks.

This is an area of great importance to you and to the AMA. If we do not get policies in place now, we will be doing the next generation a great disservice. It would be intergenerational theft of the worst kind.

The AMA has been strong on the issues of non-communicable diseases.

The big three – smoking, alcohol and obesity – are all areas where the AMA has been advocating and lobbying for change. A great example is plain packaging for tobacco - an initiative of the previous Government, but something the AMA has supported and more recently staunchly defended.

It is a great example of how what we do here at home affects the rest of the world. The tobacco companies know this, too. That is why they have been in the courts trying to change the legislation. Australia has led the way, and other countries are following.

The AMA has been talking about possible negatives from the Trans-Pacific Partnership (TPP) free trade agreement.

We have done much around obesity and alcohol, particularly in terms of marketing and of alcohol to young people, and alcohol-related violence.

We have been vocal about Australia’s human rights obligations in relation to asylum seekers and refugees.

We have an obligation to ensure that they have access to health care at a minimum. We have called for an independent panel of doctors to inspect detention centres and report to Parliament.

Along with AMSA, we have protested strongly about the Border Force Act and its draconian measures against doctors who speak out about the health care of asylum seekers.

The AMA joined the WMA in condemning human rights abuses around the world, and protesting attacks on doctors and other health personnel in world trouble spots.

Today I want to focus on two issues – the Ebola outbreak as an example of what can be achieved, and the importance of continuing to focus on social determinants, and what that means in terms of Indigenous Australians.

Last year, I watched not only with sadness, but also with frustration, as the West African Ebola outbreak unfolded each night on CNN.

The increase in deaths, but also in despair and panic, and the collapse of societies, as Ebola gathered pace, was evident. I remember one scene of an ambulance outside an Ebola treatment centre. There were two adult passengers inside. Neither was wearing pants because the diarrhoea was so severe.

People yelled at them to get out and walk into the centre. No-one would go near them for fear of the disease. One slowly got out and lay on the concrete. Too weak to go on - they were dying. A small boy walked into the scene. Scarred, confused, and weak, he lay down next to then man on the concrete. They died.

The international community, including the World Health Organisation, was slow to move. The NGOs on the ground could see what was happening. The WHO declared it a health event of international importance.

Some nations began to assist West Africa. Australia's focus was on our borders. What would we do to stop someone bringing Ebola to Australia?

Initially, the Australian Government pledged $1 million in financial aid.

It was clear to me, and to many of the experts, that the answer to Australia's safety was not money, and it was not screening at borders. It was controlling the outbreak at its source. It had to be people on the ground in West Africa with support.

Not only was that the right thing to do, it was a moral and ethical necessity.

For months last year, the AMA worked hard to convince the Federal Government of the need for Australia to join the international effort to combat the Ebola outbreak in West Africa. I coped a lot of criticism for being outspoken - for being ‘political’.

The AMA took this position, not because there was something in it for the medical profession, but because it was the right thing to do.

I was criticised for putting Australians in harm’s way. There was criticism about people coming back to Australia and causing a local outbreak. Our advice was that this would be an extremely small possibility.

The Government said it would not send people into a risky situation. But this was never about sending people. It was about supporting volunteer doctors and nurses to do this work.

I knew that doctors, if their circumstances allowed, would volunteer and go to do this dangerous work – and volunteer they did, because that is the nature of the people in this profession.

As doctors, we cannot just stand by while people – wherever they are – die needlessly.

The stand taken by doctors and the AMA on Ebola is but an extension of the commitment made by doctors to their patients that they will do all that they can to ensure the best possible health outcomes.

Too often, this underlying truth gets lost in the political hurly-burly over Medicare rebates and the so-called turf disputes.

When the Australian Government announced the decision to contract Aspen Medical to be part of international efforts to build a field hospital and treat patients in Sierra Leone, the AMA was the first to applaud the move.

The Government-funded Aspen operation meant they could do that with greater safety and security.

Following the announcement, Aspen Medical was more than happy to meet with me about standards of training, equipment, and care and evacuation arrangements should health workers become infected with the Ebola virus.

As a result of the contract between the Federal Government and Aspen Medical, Sierra Leone now has a legacy health facility that has been created for the people of Sierra Leone.

The international response, though belated, was crucial in slowing the epidemic to the point where it is now close to a standstill. The teams of Australian health workers that were deployed in Sierra Leone have played their part in achieving this great outcome.

As for the AMA, I am proud of the role we played in facilitating this outcome. It was an honour as AMA President to meet the first group of volunteers on their first day of training in Canberra. And yes, I was relieved when I was told everyone was home safely.

But I was most proud when Aspen presented its experience in West Africa at AMA National Conference this year.

They showed their first survivor, a young girl of 13 years who lost most of her family. But she was alive because of the work of Australian volunteers and I like to think that the AMA had some small role in that outcome as well.

Local solutions

As global health involves us looking at how other nations look after the health of their people, we must also examine how we in Australia look at the health of Australians – all Australians.

I want to spend some time now talking about the health of Indigenous Australians, with a particular focus on the social determinants of health.

The social determinants of health are major issues for Australia as a nation in its attempts to ‘close the gap’ for disadvantage of Indigenous people in relation to a range of outcomes, including health.

The issues are much more complex than whether someone has a roof over the head, whether they have access to clean water and nutritious food.

What I want to talk about, from the Australian perspective, are two themes.

First, there are deeper issues that underlay the social determinants of health. This comes from a sense of physical, social, and emotional wellbeing, the origins of which have deep spiritual roots for Australia’s Indigenous people.

The second is that the term ‘social determinants of health’ is somewhat misleading. We must not forget that health is a determinant of social and other outcomes.

Australian Indigenous peoples represent about three per cent of the Australian population.

Indigenous Australians experience poor health outcomes. We have a gap between Indigenous and non-Indigenous Australians in terms of health, but also in many other aspects of life. Life expectancy of Indigenous Australians is 10.6 years less for men, and 9.5 years for women. This gap in life expectancy is a serious blight on our nation, and remains unacceptable.

The AMA sees that addressing this issue is a core responsibility of the AMA and the medical profession.

While the gap in life expectancy and other indicators remains unacceptable, there have been some gains in Indigenous health. For example, mortality rates for Indigenous Australians declined by 9 per cent between 2001 and 2012.

So, what are the main contributors to the gap in life expectancy? 

Chronic diseases are the main contributors to the mortality ‘gap’ between Indigenous and non-Indigenous Australians. But there are other reasons too. The Indigenous child mortality rate remains well above that of the non-Indigenous population.

Suicide is the third leading cause of death among Indigenous males, at six per cent. The rate of suicide is about two times higher, compared to non-Indigenous Australians.

Suicide also occurs at a younger age. This is not consistent with Aboriginal culture, in which suicide was thought to be rare.

As a nation, Australia is conscious of the need to improve the health of Indigenous Australians.

This acknowledgement of Indigenous disadvantage and the national commitment to improving outcomes, including health, are encapsulated by the Closing the Gap campaign.

Despite good intention and considerable investment by successive Governments, the disparity in outcomes remains.

Each year, the Prime Minister, in the first week that Federal Parliament sits, delivers a report on Closing the Gap. The lack of progress was expressed in this year’s Closing the Gap statement by the Prime Minister: ‘It is profoundly disappointing that most Closing the Gap targets are not on track to be met’.

Closing the Gap is an incredibly difficult task, and it is fair to say that Australia and Australians have learnt much about how to Close the Gap over a number of decades.

There have been gains and we need to ensure that Australians, and our Governments, don’t fatigue in this task. It will take time, but most of all continual commitment.

One of the key tasks is to ensure that health remains a priority.

We have to guide our politicians and their policies; to shape the national narrative and debate. This is what the AMA does.

Prime Minister Tony Abbott has spent significant amounts of time with Indigenous people. In Government, he has ‘run the country’ for a week from remote Indigenous communities. This week, he has been running the country from the Torres Strait.

Upon election, Prime Minister Abbott took over the responsibilities for many Indigenous policy areas. Numerous programs were coalesced into the Indigenous Advancement Strategy (IAS). The IAS outlines a number of priority areas - getting children to school, adults to work, and making communities safer.

But what is missing from the core of the IAS is a focus on health.

Health, in a modern sense, underpins many of these outcomes. Education and economics alone are not sufficient. Health is the cornerstone on which education and economics are built.

If you can’t go to school because you or your family are sick, truancy officers won’t work. If you can’t hear because of otitis media, you won’t learn. If you miss training opportunities because of depression or ill health, you won’t progress to employment. You can’t hold down a job if you keep having sick days.

We need to ensure that the Government sees spending on health as an investment. Investing in health must underpin our future policies to Close the Gap, and to address what is, for Australia, a prominent blight on our nation.

It will only be through continued strong commitment to targeted health programs and support for local delivery of health services to Indigenous people that we will Close the Gap.

We must also acknowledge that there were many mistakes, not only in Closing the Gap, but also in how modern Australia has treated Indigenous Australians.

These issues have had to be confronted in order to advance efforts to Close the Gap.

For example, from 1910 to 1970, it is estimated that 100,000 Indigenous children were taken from their families and raised in institutions or fostered to non-Indigenous families.

The ‘Stolen Generation’, as they are termed, was disastrous in its outcome, however well-intentioned it may have been - separating families, but also alienating individuals from their own culture and families.

We have learnt, unfortunately by mistake, but also through partnership with Indigenous Australians that, when it comes to health, there is much more to improving Indigenous health than building houses and sending people to school.

The concept of health for Indigenous Australians is very different from that of Western culture.

There is no word for health in many Aboriginal languages. Rather, health is more of a concept of social and emotional wellbeing than of physical health.

The attachment to land is an important part of Indigenous culture. For each Indigenous ‘nation’, certain places hold spiritual importance.

From the land stemmed the basis of Aboriginal ‘dreamtime’, the spiritual conceptualisation of the universe and the basis of human existence for Aboriginal peoples. One might say that their landscape was their religion.

Recognition of the longstanding connection to the land came through a series of legislative changes. We all know the image of PM Gough Whitlam poured sand into the hands of Vincent Lingiari, an Elder of the Gurindji people in 1975.

The Aboriginal Land Rights Act was passed by the Fraser Government in 1976, and established land rights for traditional Aboriginal landowners in the Northern Territory.

In 1992, the doctrine of terra nullius was overruled by the High Court of Australia in Mabo v Queensland. The Native Title Act was legislated the following year by the Keating Government.

Not only did this provide the legal acknowledgement that Indigenous Australians sought, it also provided a source of revenue through regional land councils.

More has been done since, but these are important issues to address that underlay social and emotional wellbeing and, therefore, the health of Indigenous people.

In 2008, Prime Minister Kevin Rudd issued a formal apology to Indigenous people for the stolen generation. It had enormous symbolism for Indigenous Australians.

The next important step is to recognise Australia’s first people in our Constitution.

Constitutional recognition is a vital step towards making Aboriginal and Torres Strait Islander people feel historically and integrally part of the modern Australian nation.

Recognising Indigenous people in the Constitution will improve their self-esteem, their wellbeing, and their physical and mental health.

The AMA is a proud supporter of the Recognise campaign, and is a Foundation Signatory of the campaign.

My point to you is this. When it comes to social determinants of health and global health, we have to broaden our thinking.

We have to address the injustices of recent history. We have to acknowledge connections to land. We have to acknowledge and incorporate Indigenous concepts into Western thinking, whether it be in medicine or education.

As the medical profession, if we want to improve the health of Indigenous Australians, if we want to Close the Gap, we have to contribute to the national debate around these broader social issues as well.

Governments and other groups that influence policy cannot do this work themselves. It must be a partnership with Indigenous Australians.

The AMA does this in a number of ways. We have close relationships with NACCHO and Aboriginal Community Controlled Health Services, the Close the Gap Steering Committee, and by attending events like the Closing the Gap Statement and the Garma Festival.

The Indigenous Health Task Force, which I chair, is another way that the AMA works in partnership with Indigenous people to improve the health of Indigenous Australians.

Through the Task Force, the AMA regularly publishes the AMA Indigenous Report Card. Not only do we highlight the problems, but the AMA works on solutions and to highlight the successes as well.

Last year, we highlighted the importance of a healthy early start to life.

This year, the AMA Report Card will focus the issues of Indigenous incarceration rates, which have continued to escalate.

Law and order policies and health policies are often interlinked. Incarceration leads to a multitude of poorer physical and emotional health outcomes.

The AMA is working with the Law Council of Australia on this issue - look out for the AMA Indigenous Report Card later this year.

So, as you work hard to gain your medical degree and aspire to improve the health of people here and overseas, spare a thought for maybe doing some work in Indigenous communities.

Global health begins at home.

I wish you well with the AMSA Global Health Conference. Congratulations to the organisers. I hope that you all continue your commitment and interest in global health throughout your career. Remember that involvement with the AMA is one way that you can make a difference.

28 August 2015

CONTACT:       John Flannery                     02 6270 5477 / 0419 494 761

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