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.