CURRENT POLITICS

Beyond Medicare—Towards Wellness

By Humphrey McQueen

Seeing Red, 2003, slightly updated)

The current campaigns to defend and extend Medicare offer the opportunity to diagnose the commodification of life, both by merchandisers and by corporatised medicine. Whether health care is treated as a human right or as a commodity will always be the outcome of social action. Human rights are brought into existence through imagination and struggle. They can be maintained only with those two “tools for conviviality”.

Whole of life

Such an approach looks beyond primary care to the ways in which wellness is affected by education, employment, housing, working conditions and nutrition, as the following examples will illustrate. Their cross-currents establish the setting for a wider debate,

Let’s begin with the case of an eight-year old girl with chronic tonsillitis. The infections caused her to miss school, and generally learn below par. Disruptions to her education would have gone on for another eighteen months if she had had to wait for a public bed. That delay for a simple surgery could have had consequences for her lifelong prospects of employment. She was lucky to have a grandparent to give her the $1500 to have her tonsils out privately. Her situation can be multiplied a thousand fold. Her happy outcome should never have had to rely on chance or privilege.

Education and health are bound to mental and physical development from the womb. The rights of the unborn child include nutrition for the mother long before she becomes pregnant and then throughout her pregnancy, as Fiona Stanley argues elsewhere on this site.

For school leavers, getting a job can be a tonic. As the Nursing Manager for Mental Health based in Broken Hill explained in regard to rising rates of rural suicide: “Employment not only provides income but develops time structure, enlarges social experiences, engagement in collective purposes and provides identity and activity—all of which enhance one’s mental health.”

Of course, a job is no guarantee of wellness. The deaths of several miners along the North-West Coast of Tasmania led the State to commission a survey of 1000 miners, their families, managers and public servants. ( See Kathryn Heiler’s The Struggle for Time, 2002.) In 2001, the average weekly hours for full-time workers in Australia was 41. In metalliferous mining, the average was 52. In Tasmania, the norm was between 42 and 60 hours a week, but exceptions reached 72.

Overtime was compulsory. Fatigue became chronic—in effect, a medical condition. Repetitive tasks made the exhaustion worse. Half of those on night shifts reported nodding off regularly on the job. A third had trouble staying awake on the drive home. The menace increased when miners worked more days in a row than they had off. That roster deprived them of the time they needed to recover. About one in ten seemed never to be fully rested. Four out of five miners reported ill effects on their family life. The long hours and exhaustion also deprived communities of the involvement of husbands and fathers in school, sporting or social associations.

Similar pressures operate within the health care system itself. In 1999, the amount of unpaid overtime and working through meal breaks equaled 750 full-time nurses a week. In specialist units, nurses did 70-80 hours a week, often over seven days. Some went for three months without a weekend off. Their health and the care of their patients suffered. As one observed: “You hardly ever go home and think I’ve done everything.” Another recognised that: “Experienced nurses are really stressed and burnt out. You just don’t even want to ask them a question or for help so you’re on your own as soon as you get to a ward.” Another pointed out that, in the past, the managers would say: “Look we’re short, we need more staff.” That response had been replaced by: “You’ll cope. We know you can do it.” The under-staffing became so chronic in Victoria that nurses battled for and won mandatory nurse-to-patient ratios. The working conditions for hospital staff must no longer be injurious to their health and to the safety of patients. They defended the ratio in their recnt strikes.

Healthy diets have been made more difficult to achieve because of exhaustion at work. Fast foods laden with fats, salt and sugar are one more result of an intensification of the labour process. Nutrition policy has to deal with those who get too little of any foods, the large numbers who get too little of what is good for us, and those who consume too much of eerything. Obesity is one consequence of marketeering by food manufacturers just as anorexia is encouraged by fashion merchandisers. Nutritionists have come to recognize that poor diet is more than a problem for individuals, more even than an epidemic of ill-effects such as diabetes. Director of the International Health and Development Unit at Monash University, Mark Wahlqvist, believes that ill-nourished populations provide the hosts in which viruses can jump species or mutate into killers.

All these case studies remind us that health cannot be bought from medical professionals. Nonetheless, most of us need running repairs. Hence, we need to consider the principles behind the funding of Medicare and turn the searchlight on the pharmaceutical industry. Problems in curative medicine encourage us to look beyond budgets and funding mechanisms to a quite different approach to achieving wellness. An examination of community, social and preventive strategies will bring us closer to the efforts needed to create a socialist way of living.

Funding Medicare

History

The latest round of changes for insuring against the costs of treatment has raised the question of how the hell we were landed with the current system. In 1953, the Menzies government adopted a system of privately funded care, in accordance with the demands of the Australian Medical Association (AMA). In the mid-1960s, the curative regime, even by its own lights, was chaotic. The Doctors Reform Society appeared to promote the public good, as it still does through its policy statements and a quarterly magazine, New Doctor. (www.drs@org.au) In opposition, Whitlam was adapting a universal contribution system, which his government introduced as Medibank between 1973 and 1975.

Flat tax

Whitlam sold his model by repeating an example from the voluntary insurance scheme that had staggered out of the 1950s. Under that system, the better-off got tax deductions for both their medical cover and their expenses. Whitlam pointed out that his Commonwealth drivers paid twice as much for their health care as he did, precisely because he earned five times as much as they did. His Medibank model was more equitable than the voluntary system. That improvement was no excuse for his retreat from progressive taxation.

Medibank installed flat-rate taxation into welfare. The funding of Medicare continues to undermine redistributive justice. Socialists support tax regimes that redistribute income and wealth towards those in need. The contribution base for Medicare needs to be made equitable by the introduction of progressive scales to replace the regressive Whitlam hang-over.

To make matters worse, the principle of flat-rate tax has seeped from Medibank-Medicare into the thinking of otherwise progressive people. In recent years, the Medicare levy has been trotted out as a model for funding all manner of government initiatives, from the gun buyback and Timor Tax to environmental reclamation and now to fund the National Disability Insurance Scheme which aims to end government provision of services. The Medicare flat-rate therefore has to be fought to redeem the concept of redistributive welfare.

Universalism

In an unequal society such as ours, universal entitlements may seem inequitable. Why should the rich get anything for free? Because in a society riven by class, gender and ethnic injustices, universalism is more likely to produce greater equity in the delivery of services. Universalism also removes the stigma of being classifieded as “undeserving”. The current two-tier system of private and public care penalises the already disadvantaged. Opting out by the top earners leaves the rest of us more vulnerable. Where everyone has to use the same hospital, the rich and powerful have some incentive to use their skills and connections to make sure that it works better for everyone.

Of course, universal entitlement is not a guarantee of quality care or of equity. Rather, it provides a platform from which those outcomes can be defended. The front line of that effort today is to make sure that the Howard-Abbott attacks are “Dead On Arrival”.

The clearest example of the benefits of universal provision in public health is drinking (potable) water. Its provision from the end of the nineteenth century was the single most effective medical procedure for reducing death rates. Its absence is the most potent factor in infant mortality in the Third World. If everyone relies on the public system for their drinking water, the rich and powerful will see to it that all the water is kept pure. If they can opt out by buying bottled water, then the political effort needed to maintain clean, fresh supplies will be endangered. The sell-off of water systems to globalised corporations has endangered potable supply. Adelaide was lucky to have no worse than the Great Pong of 1999. The retention of water supply in the state domain is a public health issue.

Drugs

Visits to the GP often end with the writing of prescription. Australian investigative journalist Ray Moynihan pictures the medical profession and the pharmaceutical oligopolies twisted together like the snake around the staff on the traditional symbol for medicine. In a recent issue for the British Medical Journal (30 May 2003), he documents inducements to GPs to behave as drug-peddlars. Many professional journals are financed by advertisements from these firms.

Because waiting-room pressures make it harder for GPs to keep up with research, they are relying more on drug peddlers from the pharmaceutical giants. Their gifts to doctors range from a wall clock to all-expenses-paid trips to the Seoul Olympics or to $10,000 conferences. The companies also pay GPs $500-1000 for adding their name to a reference group. In the US, one corporation, TAP, had to pay $US885 million in fines for bribing doctors to prescribe its products and for getting them to charge patients for free samples. In reaction, US medical students are sporting T-shirts with the slogan: “Just say no to drug reps”.

Quarantining pharmaceuticals from the so-called free trade negotiations with the US imperialists will not stop the conglomerates extracting monopoly profits here. Fortune magazine (27 October 2003) reported that ten percent of US medical costs are fraud. All the major pharmaceutical corporations have been forced to confess to corrupt practices. Bayer, GlaxoSmithKline and Pfizer have admitted to fraudulent labeling and been fined hundreds of millions of dollars.

How can we insure against the curative system becoming an open-slather for the pharmaceutical conglomerates? For a start, the Commonwealth Serum Laboratories should be returned to government hands after their sell-out by the Keating Liberals. Self-regulation of the industry and the stuffing of regulatory authorities with industry mates must also stop.

What alternative?

The flat-tax levy and drug frauds mean that, even if bulk-billing were 100 per cent, certain inequities in service delivery would remain. In addition, the poor have more health problems but fewer doctors. They wait for up to four weeks to see a GP. When they do get an appointment, their consultation times are shorter. According to the chief of General Practice in the Hunter Valley Region: “If you’ve got a doctor shortage, your community can’t even access Medicare dollars. Medicare hands over money to leafy suburbs because Medicare is built around who’s got the most doctors.” The strain on one part of the curative system shows up elsewhere. The mal-distribution of GPs has put pressure on hospital emergency departments. The solution has to be sought in a different model.

Community and industry-based health centres

In 1972, the radical alternative to the Medibank model was for a community approach. That vision had been proposed by the Federal Caucus Health Committee, comprising five doctors. Whitlam cast their recommendations aside as not grandiose enough.

The meat workers union had led the way by establishing a clinic and research centre in the Melbourne suburb of Footscray in 1964, as described in A Few Rough Reds (2003). The community model was further developed in Prahran (Victoria) from the late 1960s, at the initiative of the local council and with support from the Medical Faculty of Monash University. That center integrated GPs with community services such as Meals-on-Wheels.

Women, Aboriginal and ethnic groups retain their own health centers. Those for women have been invaluable for ensuring access to abortion, especially in non-metropolitan areas.

Workplaces remain a top priority for an expansion of community health centers. Their medical staff can recognise and treat conditions specific to each industry. Local health workers took the initiative in preventive campaigns, targeting legal drugs such as tobacco and alcohol. Schools should become part of the network, monitoring tuck-shop menus and physical activity levels, testing for sight, hearing and dental carries.

Prevention needs more than professionals. Industrial safety begins with regulations about equipment, protective gear, repetitive strains and clean air. Those rules then have to be enforced. The right of union officials to enter sites without notice is crucial. Otherwise, government inspectors phone the boss to say they’ll be around tomorrow. The law must protect shop-stewards who blow the whistle. Only workplace militants can enforce standards.

Manslaughter provisions are the next step for reducing work-place fatalities. Nonetheless, sub-contractors should not be left to carry the responsibility for injuries. The blame must be sheeted home to the firms, in transport or construction, that impose conditions that can be met only by stretching the law. As well as penalising a speeding delivery driver, the labour movement must make the law pursue the guilty up and down the supply chain.

An industry-based health care would also recognise the impact of overwork on well-being, physical and emotional. As detailed above, those with jobs are working longer. In 1974, only one male employee out of eighteen put in more than eleven hours a day. By 1997, the proportion was one in eight. Safety in the workplace is built around limiting hours and restricting the intensification of effort. Those objectives require rest breaks and provision of appropriate meals.

Socialising medicine

Australians are proud of our volunteer blood donors. The Blood Bank is a living reply to “user pays”. Along with surf-life saving clubs, it is another instance of the social responsibilities upon which a socialist society will be constructed. In The Gift Relationship (1964), the British socialist R. M. Titmuss demonstrated why a voluntary approach to blood transfusions will be safer than one where people are paid to donate.

Australians are horrified by even the thought of a market in body parts. Yet capitalism reifies all human capacities when it exchanges labour power for money-wages. Under its ethical order, the sale of one’s blood, or of a kidney, is not only logical, but necessary for the commodification of life.

By contrast, the struggles around Medicare are inscribing “Preventive, Social, Universal and Community” as watchwords for wellness. They highlight the “social” in socialism.