HEALTH PROFESSIONALS AS PUBLIC ADVOCATES PRESENTATION TO PUBLIC HEALTH NURSES’ SEMINAR Manukau SuperClinic 26th March 2014 Alan Johnson – Social Policy Analyst The Salvation Army Social Policy & Parliamentary Unit Being a Kiwi And most New Zealanders, whatever their cultural backgrounds, are good hearted, practical, commonsensical and tolerant. Those qualities are part of the national cultural capital that has in the past saved the country from the worst excesses of chauvinism and racism seen in other parts of the world. They are as sound a basis as any for optimism about the country’s future. The Penguin History of New Zealand (2003) Michael King (1947-2004) Historian & author The source of our ideas New Zealand was the last major landmass on earth to be settled by humans Louis John Steel & Charles F Goldie (1898) The Arrival of the Maori in New Zealand All our ancestors have come somewhere else and have brought with them cultures and histories which shaped their lives and those of their descendants The source of our ideas Most often it was poverty which pushed people to migrate and opportunity which drew them to New Zealand The source of our ideas But clearly it has been western ideas and particularly the cultural values of British settlers which have been most influential on our social and political ideas (to date) The source of our ideas Poverty and population control were clear motivations for the migrations from the 1850’s to 1890’s from industrial revolution era Britain and post famine Ireland Fear of unemployment, hunger and the workhouse were clear motivations for those migrating The source of our ideas Given the extent of British migration – especially from 1870-99, Victorian morality had a huge impact on Pakeha New Zealanders’ ideas of society. This morality was prudish, elitist, industrious and self improving – it was also hypocritical ignoring child labour and widespread prostitution Queen Victoria (1817-1901) New Zealand’s head of state 1840-1901 This gave rise in part to a strong work ethic and to THE clear idea of the deserving an un-derserving poor The deserving poor v the un-deserving poor The deserving v undeserving thread has been present in New Zealand’s social policy for over 100 years The Old Age Pension was introduced in 1898 although it was administered by magistrates who determined the moral character of the applicant – the pension was not available to “Asiatics’ aliens or alcoholics and was paid at half rate to Maori who did manage to get it The recent re-definition of working age benefits is based on this notion of deserving (disabled and chronically ill) and the undeserving (unemployed, solo parents and casually ill) Pragmatism v philosophy New Zealanders however weren’t keen on thinking too hard A visiting French political philosopher commented in 1905 “Their outlook, not too carefully reasoned, and no doubtful scornful of scientific thought, makes them incapable of self distrust. Like almost all men of action they have a contempt for theories: yet they are often captured by the first theory that turns up, if it is demonstrated to them with an appearance of logic sufficient to impose upon them. In most cases they do not seem to see difficulties, and they propose simple solutions for the most complex problems with astonishing audacity.” Democracy in New Zealand (1905) Andre Siegfried (1875-1959) French political analyst Pragmatism v philosophy There are numerous recent examples where political pragmatism rather than theory and philosophy has driven social policy 1975 – dismantling of contributory superannuation in favour of a tax funded one despite long-term affordability problems 1991 – benefit cuts on the basis of creating a gap between benefits and wages to incentivise people to work 1993 – introduction of Accommodation Supplement with no thought of supply side policies to provide needed housing 1999 – re-introduction of income related rents for state houses with no thought of horizon equity problems created 2005 – introduction of Working for Families without thought on how to lift 200,000 children out of poverty Why is this important? FRAMING Why is it important? FRAMING A frame is a conceptual structure which we use to gain an understanding of ideas and to reason with A frame involved participants – things that stuff happens to & events – the stuff which happens Frames most used metaphors – which use one concept or idea (often a simpler one) to gain an understanding of a more complex concept or idea WHAT WE SEE DEPENDS ON THE LENS WE SEE IT THROUGH Why is it important? Think about the various metaphors being used in this framing of British welfare policy So what is important? Two common causes of death – especially of young people 700 600 Number of deaths 500 400 300 200 100 0 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 December years So what is important? Both causes of death are somewhat preventable One has halved in number over the past 20 years that other has remained constant One is the subject of cost-benefit analysis, engineering solutions and ongoing regulatory intervention and social marketing campaigns the other relies on goodwill and sympathy One has its statistics updated on a daily basis the other has statistics two years out of date One is reported in the newspapers the other is ignored So what is important? Two common causes of death – especially of young people 700 600 SUICIDES ? Number of deaths 500 400 ROAD DEATHS 300 200 100 0 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 December years So what is important? 2014 STATE OF THE NATION REPORT An annual social progress report which utilises publicly available data to present an accessible story of the social progress of New Zealand’s most vulnerable people 5 topic areas 22 indicators 23 databases 11 agencies – 9 public Reframing views on inequality 0.7 x Maori ECE enrolment v non-Maori 2.7x Maori NCEA L1 failure v non-Maori 3.9 x Maori 14-16 apprehension for violent crimes v non-Maori 1.2 x Maori 14-16 prosecution rate v non-Maori 5.7 x Maori imprisonment rate v non-Maori 1.2 x Maori re-imprisonment rate v non-Maori 2.4 x Maori unemployment rate v non-Maori 1.6 x Maori male suicide rate v non-Maori male rate Reframing views on inequality Lower spending on healthcare Lower spending on home heating Poorer nutrition HIGHER PUBLIC HEALTH COSTS SHORTER LIFE EXPECTANCY Less disposable income High cost relative to income Higher risk of communicable disease Overcrowding Crowded bedrooms = less sleep POOR HOUSING Higher risk of respiratory illnesses Poor physical conditions Increased morbidity Increased absences from school Frequent moves EDUCATIONAL FAILURE Shifting schools often SOCIAL ISOLATION Reframing views on inequality INEQUALITY AND POVERTY ARE NOT RANDOM – they are structured in at least three ways 1 Sub-groups and especially ethnic sub-groups are concentrated amongst the poor – this may be the result of some historic injustice such as enslavement or colonisation 2 It is inter-generational in that social mobility is the exception and not the rule 3 It is compounding in the one disadvantage is manifest several times over creating a lifetime of disadvantage Health professionals as public advocates A TRUSTED & PRIVILEDGED POSITION The opinions and experiences of health professionals are likely to be respected by the wider New Zealand public in part because groups such as doctors and nurses are already valued for their work and in part because their experiences are quite unique and well outside those of most people – in other words health professionals are trusted and have access to quite privileged information. A CRITICAL ROLE AS PUBLIC WITNESSES This means that health professionals especially those working in the public health system have a critical role as public witnesses of the social conditions of the most vulnerable New Zealanders – this role is at least twofold Health professionals as public advocates SYSTEMATIC COLLECTION OF EXPERIENCES Firstly there is the job of identifying and discussing these social conditions obviously in ways which do not breach confidentiality or privacy but which are systematic and comprehensive. This requires more than anecdote or casual observation but a rigorous and considered approach to gathering patients’ stories and experiences RE-FRAMING TO CHALLENGE MYTHS The second role of health professionals is in the opportunity to re-frame these stories and experiences and by doing so challenge the myths and prejudices which many Kiwi’s often apply thoughtlessly to the poor and vulnerable. Health professionals as public advocates REFLECTION ON PERSONAL VIEWS This re-framing requires health professionals as individuals and as collegial bodies to deliberately reflect on how their own views of the causes and position of their patients have been framed by the prevailing ‘common sense’ view of deserving and un-deserving – of the included and excluded. ACCEPT THAT MOST PEOPLE STILL HAVE AGENCY Such a reflection probably should still accept that most patients have some level of agency and they that can and do make poor decisions. Health professionals as public advocates TAKE ACCOUNT OF THE CONTEXT However this reflection should also take account of context and consequences – that is that disadvantage and vulnerabilities are often multi-faceted and connected both backward into personal and family histories and forward into extending costs and problems.