Event
Date
by Ian W Webster
Presented at a MCH Conference - Reinvigorating Australia: Public/private balance in health and education, 27 October 2004.
I will argue that governments are re-inventing their relationships with community (or they ought to be) and this is profoundly important for health and well-being of the community.
One thinker, Anthony Giddens has said: On each side of the political spectrum today we see a fear of social disintegration and a call for a revival of community[i]
This is as an important window of opportunity for community health.
Community medicine
My perspective will be that of community medicine. The emphasis will be on social and existence issues in health homelessness, mental health and substance use problems.
Assessing health by two combined parameters loss of years of life and impaired quality of life the modern epidemics have to do to with behaviour and social risks. The importance of these issues can be seen in the health problems of young people.
In young people this measure - known as the burden of disease - is overwhelmingly due to mental health and substance use problems (see figures below).
When I started community medicine at UNSW, a colleague from public health at Sydney University said to me, community medicine is the department of lost causes, and so it seemed at the time. These lost causes have now become good causes as the imperatives of mental health and well-being and substance use have started to overwhelm our people, institutions and services.
The case for partnerships
Governments of both the right and left espouse community participation as a means of representing their constituencies. Concepts such as social capital, social justice, social participation, social entrepreneurship, social coalition[ii], equity and communitarianism are frames through which social policies are now being viewed. These directions are reflected in the rhetoric of government as whole of government approaches in Australia, the third way and joined up communities in the United Kingdom and related concepts of 3600 accountability.[iii] These grand ideas should inform the way the health system is organised and planned for the future.
Grand plans
In the early 80s the Federal government aimed for national health goals and targets.[iv] States too, defined targets, goals and outcomes for heath programmes. These were managed approaches, as if health is the task for engineers. Tweak the knobs on the grand dial and health would then be distributed.
Implicit in this thinking is the view of the population is an amorphous blob capable of having its health managed from the top down, with outcomes flashed on the computer screen.
Many communities
The community is not so constructed. It is many communities, communities interacting with each other and within themselves, each with their own patterns of health. Inner city communities are different from outer urban communities; in turn they are different from rural communities.
There are the marked differences between Aboriginal and non-Aboriginal communities, and there are differences between migrant groups.
There are masked differences. For example, in the South West of Sydney population health is about average for New South Wales, but the massed data belie the poor health of the Australian-born residents locked into poverty in that area. Their predicament is diluted by the health of migrant populations. Neither do these averages reflect the serious health problems from drug abuse in the young people of Cabramatta and some other impoverished suburbs.[v]
Those citizens recorded as having been treated for mental illness by a state mental health system have massive levels of morbidity and mortality. This has been shown by some excellent work in Western Australia (see figure below).[vi] People with mental illness are exposed to higher risks to their health and the access and delivery of health care to them is poor.
By attending to the health needs of particular communities, overall population health in the aggregate can be improved. That is not to gainsay the importance of mass campaigns such as immunisation; as they too depend on reaching into communities for their effectiveness. This then relies on community development approaches as well. For example, national campaigns about alcohol and drugs must also be constructed around local circumstances, issues and capacity if they are to be effective.
Young people
Thinking about community in this way shifts the focus to causes - and from there to young people and their development as the key local approach to improving health of populations. This shift comes from the belief that communities can be nurturing and protective environments, essential prerequisites for community health. Of course they can be dysfunctional and harmful environments and create marked disparities in health and disease.
Up to this time, young people have been undervalued in public advocacy, indeed they are feared in the popular mind as is so often portrayed in the media. And services for young people - especially health and related services have been especially deficient.
Causes
Our knowledge of the relationship between communities and health comes from data of morbidity and mortality in populations associated with national poverty, social class, occupational health, Indigenous peoples, fractured inner city communities, homeless populations, marginalised groups and the historical trends which track changes in community health with economic and social development.[vii]
Then there are data to show the opposite that communities with material resources, social and psychological support, shared values, reinforcing psychological and social networks, supportive family structures, teachers, physicians and health care, artists, and, some sense of purpose for living, have better health and well-being than those that do not.[viii]
We believe as an article of faith that by re-creating these attributes in communities, population health will be improved.[ix]
Social and existential issues
Looking back at the last three decades, Western governments are increasingly taking up social-health issues. Concerns for public health have moved beyond the basic issues of adequate nutrition, shelter, health services, access to health care and protection against infection, to issues bound up with social and community issues, structures and relationships.
In Australia, state, territory and Commonwealth Government programmes reflect these shifts. For example there have been the following national initiatives in the last five years -
Running through these initiatives are common themes of community partnerships, of young people and their futures and connectedness. The National Anti-Crime Strategy said,
Only in recent years has much scientifically persuasive evidence emerged that interventions early in life can have long term impacts on crime and other social problems such as substance abuse. [x] and,
At a broader level, protective factors can be enhanced by strengthening the capacity of a community to intervene positively in the lives of children, and by building facilities or social structures that support involvement and attachment, that help maintain a civil society rather than an oppositional culture. [xi]
And the Mental Health Promotion and Prevention National Action Plan said, for children aged 5-11 years
..effective prevention of mental health problems can be achieved through: positive parenting, mental health promoting school programmes that enhance life skills and resilience, foster a supportive school environment, support a school culture which links the community and school communities, that promote optimistic thinking, and which promote self efficacy and reduce aggressive behaviours. [xii]
This array of national strategies operates through almost identical processes, although planned and managed independently of each other. Six of these strategies are represented in the figure below.
Mental Hlt National Mental Health Plan; NDS National Drug Strategy; Suicide National Suicide Prevention Strategy; Homeless Youth Homeless Strategy; Crime Prev National Crime Prevention Strategy; Alcohol - National Alcohol Strategy
Despite their separate origins the programmes have much in common. They speak of whole of community, early intervention, importance of young people, community capacity, partnerships, lessening harms and the needs of special of groups.
Future for Government and Non-government Relationships
These ideas are expressed in a number of parallel approaches referred to above joined up communities, whole of government, dissemination of best practice in community organisations and outcome based funding. At the same time there are demands for more open and transparent governance in both non-government and government organisations.
Such broad canvasses involving government administrations carry important implications for the non-government sector. For in responding to these complex demands a quite different set of arrangements and structures is needed than the responses of the past to crises in acute and emergency health care and in welfare relief.
The new concerns are with social provision, place and chains of care. All areas in which family, work, community environment and community responses are most important and significant. These are areas in which government is impotent.
Bilateral partnerships
In the current situation non-government organisations come with cap in hand as supplicants to government for funds. They accept contracts which require them to perform to objectives defined by the funding body. In the new phase of open governance and with emphasis on partnership and building capacity in the community service area, new arrangements are needed.
Accountability should be a true partnership with shared accountability within and between government and non-government sectors. In other words, whenever funding agreements are reached there should be reciprocal obligations between the organisations in receipt of funds and funding bodies. Funders, generally governments, should have contracted or agreed commitments to the sector and the organisations funded in which they, for example, will see there is appropriate support from government services and infrastructure.
This would be a new style of relationship different from the client supplicant relationship of community organisations to government to one in which there are mutual obligations and bilateral accountabilities.
Summary:
There are political and social movements which promote development at the community level. Many of these initiatives pivot around young people and their futures and can be regarded as true prevention and public health. My hope is that these approaches can better engage with socially excluded groups in the interest of public health. The challenge in health is deal with the fall-out from contemporary life such as in the prevalent problems of mental health and well-being and alcohol and drug problems, all of which will require strong cooperation across sectors of interest, governance and professionalism.
[i]Giddens A Beyond the Left and Right. Cambridge: Polity Press, p. 124.
[ii]Howard J, Transcript of the Prime Ministers Speech, National Press Club, Canberra, 8 December 1999.http://www.pm.gov.au/news/speeches/1999/pressclubr0612.htm
[iii]Turner D, 3600 Accountability Exploring Community Partnerships, their contribution to developing joined up government approach and to community empowerment; concentrating upon the issues of accountability within this emerging strategic and funding relationship. Draft Discussion Paper prepared for Enterprise and Career Education Foundation, October 2001.
[iv]Better Health Commission Looking Forward to Better Health Australian Government Publishing Service, Canberra, 1986.
[v] Jalaludin B, Chey T, Mohsin M and Bauman A. Health in South Western Sydney, Epidemiological Profile, 2000Epidemiology Unit, South Western Sydney Area Health Service, Liverpool, BC, NSW.
[vi] Lawrence D, Holman CDJ, Jablensky AV (2001) Preventable Physical Illness in People with Mental Illness. Perth: University of Western Australia.
[vii]For richer, for poorer, in sickness and in health Royal Australasian College of Physicians, Sydney, 1999.
[viii] Berkman Lisa F, Glass T, Brisette I and Seeman TE From social integration to health: Durkheim in the new millennium Social Science and Medicine 51 (2000) 843-857.
[ix]For richer, for poorer, in sickness and in health Royal Australasian College of Physicians, Sydney, 1999.
[x] Pathways to Prevention: Developmental and early intervention approaches to crime in Australia. National Crime Prevention, Attorney Generals Department: Canberra, 1999; page 4.
[xi]ibid. Page 30.
[xii] Ibid., page 14.