Surviving the bush: health
and rural communities
Address by Chris Sidoti, Human
Rights Commissioner to the Australian Healthcare Association National
Congress, Melbourne, 10 November 1999
I would like to thank
the Victorian Healthcare Association for inviting me to speak today. I
hope that the Congress has been stimulating and has provided all of you
with both an understanding of the problems facing healthcare in Australia,
and some sense of optimism for what can be achieved to improve the health
outcomes for all Australians.
In a sense I am an
outsider at this Congress. I have no health or medical background. I do
not work in health policy. I am not even from Victoria. However, I hope
that I can bring you another, rather less spoken about, perspective on
healthcare in Australia, in particular in rural and remote Australia -
the right to health in country Australia.
Many of you will
be aware that the Human Rights and Equal Opportunity Commission over the
last 18 months has been conducting a Bush Talks program in rural and remote
Australia. As part of this program I have travelled to over 50 communities
in all States and Territories from large regional cities like Cairns and
Bunbury to small towns like Bourke and Euroa, to remote communities like
Papunya, Boulia and Yuendumu, listening to the human rights concerns of
people in the bush. They told us loud and clear - health care, education,
jobs, access to services, a future to hope in and live for. Tonight I
will also meet with the community in Bairnsdale here in Victoria as part
of Bush Talks.
Health is also an
area that has received some well-deserved attention across all sectors
in recent weeks. At the Regional Australia Summit two weeks ago, for example,
health was one of the main topics raised as a concern for regeneration
of country Australia. A commitment to rural and remote health was included
in the Communique from that summit.
Today I thought I
would spend a little time explaining our international obligations with
regards to the human right to health. What are they and how shall we interpret
Human rights belong
to every person by virtue of birth. They are not only for majority groups
or for minority groups but for everyone equally and without discrimination.
Human rights are
also not granted to us by others or by the government. They are ours to
be enjoyed simply by reason of our common humanity and innate dignity
as human beings. For that reason we cannot agree to give them up and they
cannot be taken away from us.
Most people are aware
of their civil and political rights, for example the right to freedom
of expression and the right to vote. These are of course fundamental human
rights. But matters relating to people's social, economic and material
well-being are equally matters of human rights. These include the right
to an adequate standard of living. The enjoyment of this right requires,
at a minimum, adequate food and nutrition, clothing, housing and necessary
care and support such as health and medical services. Human rights also
include the right to work, to social security and to education. They impose
an obligation on government to give assistance and support to families
These rights are
often overlooked by governments because they raise issues of public welfare
and public spending. In a climate of fiscal restraint governments are
reluctant to face issues which require more spending. And in a climate
of economic rationalism governments reject many spending options that,
in purely economic terms, are not cost effective. However, Australian
Governments have made solemn promises to the Australian people that oblige
them to uphold these rights and ensure that the basic needs of every person
One of the most important
human rights treaties is the International Covenant on Economic, Social
and Cultural Rights. Australia is a party to this treaty.
It is perhaps not
as well known as the International Covenant on Civil and Political
Rights, but it is no less important. These two sets of rights are
not mutually exclusive. They are most definitely linked. For example,
a society that promotes and respects individual rights is more likely
to be well placed to enjoy economic growth and good standards of living.
At the same time, where there is economic inequality and poverty, where
health is neglected and education denied, civil and political rights often
Many will argue that
these rights - social, economic and cultural - are difficult to measure
or attain, as circumstances differ so substantially from country to country.
Economic inequality has not been solved anywhere to date. Unlike the right
to vote, it can appear impossible for governments to guarantee the right
to work. Consistently high unemployment, especially in rural Australia,
despite good intentions of governments at every level, has taught us that
there is no quick solution to extending these rights to everyone.
However, the International
Covenant on Economic, Social and Cultural Rights is a means of getting
governments to measure their achievements or failures, and to commit to
progressively attaining realisable goals. Unlike the Covenant on Civil
and Political Rights, it commits each state party to achieving the
rights progressively, but this does not mean that they are not achievable.
And importantly, governments must guarantee that these rights are protected
and enjoyed without discrimination of any kind.
The right to health
Article 12 of the
International Covenant on Economic, Social and Cultural Rights
calls on nations to recognise the right of everyone to the enjoyment of
the highest attainable standard of physical and mental health. The right
to health, it is often argued in human rights law, is awkward because
it suggests that people have a right to something that cannot be guaranteed,
namely perfect health. It is argued that the terms 'right to healthcare'
or 'right to health protection' are more realistic. However, at the international
level the term right to health is most commonly used because it covers
a broader understanding of health, including healthcare and environmental
health. In practice it is a shorthand expression for a specific range
of rights in treaty texts.
For example, the
treaty monitoring body of the ICESCR addresses the following broad range
of topics within its framework of the right to health: national policies
on health, issues relating to healthcare, underlying preconditions for
health such as accessibility of clean drinking water, and the accessibility
of health services for various vulnerable groups. When assessing healthcare
services of nations, the Committee assesses the availability, accessibility,
affordability and quality of healthcare services. With respect to accessibility
in particular, the Committee has expressed its concern about the accessibility
of healthcare facilities in remote and rural areas.1 It is
clear to that body that nations which have signed the treaty not only
have an obligation to formulate national policy on health but also to
ensure that healthcare services are in existence and are accessible to
all people within their responsibilities.
Unlike civil and
political rights, very few examples exist at the United Nations and at
the regional and national levels where courts have reviewed the right
to health. There are no specific complaint procedures in force to make
health rights and other economic, social and cultural rights justiciable.
However there are some indications that this may develop in the future.2
There is also a trend
among scholars and activists towards delineating a certain core in the
right to health - a set of elements that states have to guarantee immediately
irrespective of their available resources. For example the primary health
care strategy of the World Health Organisation has devised a list of basic
health services which make up a core content of the right to health.3
A set of core elements can provide a benchmark for nations, or for vulnerable
groups within nations, to assess the government's progress on fulfilling
If in Australia we
were to create a core set of elements of the right to health, of even
the most fundamental kind, I suspect that we would reveal great inequality
in many areas of healthcare. Having travelled to many parts of rural and
remote Australia I have no doubt that we are failing to protect and promote
economic, social and cultural rights in the bush as we should. In many
respects the bush comes off second best to the city and this most certainly
is not equal treatment.
People in the bush
should not be excluded from the enjoyment of human rights simply because
they make up less of the population or live outside metropolitan centres.
As one person in the country said to me during Bush Talks 'we pay
the same taxes; so we should get the same services'.
The talks confirmed
for us what many people in the bush already know, and I am sure that many
of you here today know- many communities in rural Australia are under
siege. These communities have declining populations, declining incomes,
declining services and a declining quality of life. The infrastructure
and community of many rural, regional and remote towns have been slowly
pared away. It was described to me by a woman in Port Augusta as the 'dying
town syndrome', a downward spiral of de-servicing, de-resourcing and de-populating.
People are moving out of the towns where they can no longer make a living
or find a job.
The smaller the population,
or the more geographically isolated, the more difficult it is to get access
to a necessary range of services, whether government or non-government
services. These are not luxury service that people are asking for. Remote
and isolated communities are still waiting for the basic means of survival
As one submission
to Bush Talks put it
must acknowledge the fact that people live in rural communities and need
to be recognised as being a part of society rather than part of an economy.4
To a certain extent,
those who live in a rural area, and especially a remote area, expect to
have reduced access to a full range of services. I did not find that people's
wishes were extreme or unreasonable. There is an element of choice in
deciding where to live.
Still, it is false
to argue that people should up and leave a farm or a town where they were
born or in the case of indigenous people where their traditional land
and people are, just to get the basic essentials for life. Regardless
of where you live, all Australians should have access to basic health
facilities, good education, decent housing and access to a reliable supply
of safe water.
in the bush
Let me turn to what
is known and what I was told about health in the bush.
Certainly, the poor
state of rural health has been the focus of some media attention for several
years. Governments have also begun to hear this cry, for sound political
reasons: the bush is punishing political parties. Just look at the Queensland
state election last June or NSW in March or Victoria last month. People
in rural areas are forming networks and organisations to lobby the government
for much needed improvements. In the last Federal budget, although there
were comparatively few policies and programs addressing fundamental economic
and social problems in the bush, there were a few good initiatives for
rural health, for example the announcement of a new fly-in fly-out female
GP service and the continuation of some excellent programs such as the
Bush Crisis Line run by the Council of Remote Area Nurses of Australia.
However, there is still along way to go before it all appears as mere
tokenism to people in rural areas.
conferences, meetings, national strategies, in a number of areas the health
of rural and remote Australians continues to fall well below that of people
in the cities.
Death rates from
all causes are higher in rural and remote areas than in capital cities.
Rural Indigenous people die on average 15 to 20 years earlier than their
fellow Australians. Rural Australians are more likely to suffer coronary
heart disease, asthma and diabetes than city dwellers. Deaths of males
from road accidents are twice the rate in remote areas than in capital
cities.5 And suicide, especially of young males, seems endemic
in many communities.
while the level of health need increases, the level of health care drops
dramatically as we move from capital city to regional city to a rural
or remote area. Yet instead of increasing services, it seems that many
are being pared away.
In Geraldton WA Bush
Talks was told that the hospital had recently closed 29 beds, reducing
the total to 60 beds. The average number of patients is 60 but the peak
to date has been 73.
In Biloela Qld 'a
few years ago the hospital had two full-time doctors'. When we visited
there last year the only doctors practising at the hospital are GPs in
private practice who were said to limit themselves to four appointments
daily at the hospital.
In one town in south
western NSW I was told about a woman who collapsed in a supermarket. When
the ambulance was called the paramedic decided she had to be taken to
hospital and so asked bystanders whether someone could drive the ambulance
while he travelled in the back to look after the patient.
The shortage of GPs
in the bush is well-known, and I will not detail it here as you are all
aware of the problems involved. It is pleasing to see that the federal
government and several state governments are establishing more programs
to encourage GPs to take up and stay in rural practices. This is, however,
only one part of the problem. There were some towns we visited in which
not one GP would bulk bill, in some instances not even for health
care card holders.
One man from Mudgee
told us how all the medical centres in town had refused to bulk bill and
how his wife had been turned away for a regular prescription of heart
medicine because she could not pay for the consultation, even though she
offered to pay on next pension day. And the pattern is inconsistent. Travelling
across north west NSW I found that all doctors in Bourke, Brewarrina and
Walgett bulk bill but not a single doctor among the 12 in nearby Moree,
by far the largest town in the region.
we went, lack of services for mental health was raised as a most pressing
issue - counselling, psychiatric, hostel, in-patient services, especially
services suitable for young people, and especially suicide prevention
As one person from
North Queensland put it,
services are abysmal in the bush, almost non-existent, as is detox for
alcoholism which is rife, marriage counselling, respite, palliative care,
legal services, etc. These are of course all related.6
In Geraldton I was
told there is no specialist in child and adolescent mental health. In
Central West Queensland "there is no-one to provide counselling services
and a lot of young people are struggling with mental health problems".
In Rockhampton Qld there is no permanent child psychiatrist. Even in Wagga
Wagga NSW, that State's largest inland city, there is no resident psychiatrist.
Psychiatrists have to be flown in on circuit to see patients by appointment.
If it is that bad in the regional cities I can only imagine how appalling
it must be in remote areas.
Suicide rates are
especially high for young rural males. For the 15 to 24 age group of males,
the suicide rate is more than double that of their metropolitan counterparts.7
And it has increased by around 350 per cent over the last 30 years.
The suicide rate
is especially serious among young gay and lesbian people. An excellent
national study indicates that the suicide attempt rate is four times that
of heterosexual young people and occurs at a much earlier age - 15 years
is the average age.8
you choose, the situation of Aboriginal people is even worse that that
of any other Australians. For Aboriginal Australians:
- Life expectancy
is 20 years less than for non-Aboriginal Australians.
- Aboriginal boys
born today have only a 45 per cent chance of living to age 65 (85 per
cent for non-Aboriginal boys); Aboriginal girls have a 54 per cent chance
of living to age 65 (89 per cent for non-Aboriginal girls).
- Over the last
forty years, the Aboriginal infant mortality rate has declined (though
it is still over three times the national average); over the same period,
adult mortality in the Aboriginal population has increased.9
And Indigenous people
in remote areas have it hardest of all.
The lack of accessible
dialysis for kidney disease among Indigenous people is deplorable. Wongai
residents of the Ngaanyatjara Lands and other people in the Central Desert
region of WA must go to Kalgoorlie or Perth for dialysis and this means
that they have to be separated from their traditional lands and community
In the Northern Territory,
dialysis has only been available in Darwin and Alice Springs until a third
unit opened recently on Tiwi Island. People in need of dialysis are forced
to move from as far away as Tennant Creek and the Barkly.
Being separated from
family, community and traditional lands can be devastating for rural Aboriginal
people. One person described it as follows:
bear to be away from their land and family and some have chosen to return
home. It really breaks a Wongai's heart when he has to go away. But without
dialysis, patients will die.10
And many choose to
die rather than leaving family, community and land. And when they do go,
they see it as a life sentence, for they can never come back except to
die. Support in the towns for those on dialysis is almost non-existent.
Many live in the river beds or, if they are given accommodation, their
families who accompany or visit them are not.
also raised with us the common ignorance of Indigenous cultures among
health professionals which means inappropriate and often inadequate treatment.
In Cairns Qld Bush Talks was told that it was often difficult for
Indigenous patients from outlying areas to understand the medical terminology
and language of doctors at the Cairns hospital. The information could
be about critical issues such as medications and treatment.
Services for elderly
and frail are also particularly in demand in rural and remote areas. Small
towns have lost or are losing their young people - leaving towns to age
dramatically. The health needs of older people mean that it is increasingly
difficult for them to maintain an independent lifestyle. In Burnie Tasmania
Bush Talks was told that there is a six month wait for nursing
Problems of distance
obviously greatly affect the health and well-being of communities. For
people on low incomes, those who do not have family and friends to support
them, people with disabilities, young people, parents with young children,
travelling long distances to see a medical practitioner, go to hospital
or visit the dentist can be near to impossible. Although there is a federally-funded
and State-administered travel and accommodation assistance scheme, this
was criticised as inadequate by some of the rural people we spoke to.
Because of restrictions on eligibility, Bush Talks was told in
Bathurst of cancer sufferers 'taking the risk' rather than find the money
to go for treatment and in Geraldton of a spinal injury patient having
to pay her own airfare because she was only in a full body cast and not
a wheel chair. Cross border issues under a federal system are leading
to people being seriously inconvenienced and money being wasted.
I want to emphasise,
though, that many of the problems which people told us about were not
'luxury' items or complaints about not having a wide range of choices.
People are talking about access to basic standard health care - a doctor,
a dentist, someone to talk to if contemplating suicide. Without access
to these services in a rural community lives are at risk and quality of
life is seriously threatened.
Of course, the problems
were very different according to which region we visited - some towns
have plenty of access to GPs but no services for the mentally ill. Others
have a doctor but no hospital. There are also differences in the state
of rural health depending on whether you live in a remote area or in a
rural town, what the economic situation is like in that area, whether
or not you are Indigenous. As you all know, the 'bush' is by no means
homogenous. However, overall, the range of problems and shortages in rural
health is somewhat overwhelming.
Positive way forward
I do not want to
leave you with a completely negative picture of rural and remote area
health. Those of you who work in health care are more than aware of the
many positive initiatives which are occurring in the country. You would
also be the first to point out that many rural communities are not caught
in a downward spiral, but are thriving and growing at a rapid pace.
However, a few points
made to me by rural communities again and again over the past months have
some direct relevance for how we might begin to plan to regenerate declining
rural areas, including health care.
The first is that
communities need to be involved at all levels of planning for their own
futures. This may seem obvious, but too often rural communities feel that
they have been left out of the loop in decisions which directly affect
them. There is certainly a lot of energy in rural and remote Australia
which could be harnessed for change.
In Bush Talks
we came across many communities which were willing to organise the meetings,
were concerned about their communities and wanted to be involved in finding
They told us about
many good initiatives undertaken by their communities to try to address
some of the problems of isolation or declining services. People expressed
interest in other communities and what they did, and how they too could
do the same, whether it be in health, the local school, youth culture
and support or employment opportunities.
Some good healthcare
models - sound community based models- have been around for a number of
years. For example the Nganampa Health Service in South Australia is a
positive model of decentralised health services which is community controlled
although regionally based, allowing for some economies of scale whilst
remaining of a size which can respond to community needs. We need to revisit
these models and work to encourage similar initiatives in areas where
On a smaller scale,
one local institution in a small community can, perhaps with regional
or national collaboration, generate a project with far reaching effects.
Kyogle High School in NSW, for example, have conducted a mental health
project under the National Suicide Prevention Strategy where young people
are provided with training in leadership skills, wilderness skills and
music, art and small business management including management of local
youth centre. The project has assisted local residents to provide short-term
crisis accommodation and develop local TAFE courses for young people.
I found that in many
communities there is a willingness to work co-operatively and learn from
other rural and remote communities, contrary to the stereotype of parochialism
in rural areas. They want to see their regions develop, they want a confidence-building,
integrated approach to planning and development and they want to be involved
- to make the key decisions about their health and their future.
Helen Sheil, from
the Centre for Rural Communities spoke recently at the Regional Australia
Summit about the capacity of rural communities themselves to provide the
'missing link' in the chain of decision making in regard to the future
well being of regional Australia. She provided an interesting quote from
David Suzuki on human survival
the key to species survival in the natural world is its ability to adapt
to local habitats, so the key to human survival will probably be the local
There is no doubt
that the local community is an essential starting point.
However, the second
point it is important to make is that, although small rural communities
can be resilient and energetic, governments cannot absolve themselves
of responsibility for them. Regions need participation, transparency and
flexibility in decisions about priorities and plans for change but they
also need outside assistance and resources to turn plans into realities.
Rural communities pay taxes - they are entitled to as much support as
We need to move beyond
the principle of 'do-it-yourself', which has the danger of being an excuse
to abandon those most in need.
People in rural and
remote Australia know that this responsibility is about more than national
economic policies. Of course, rural communities are the first to welcome
an injection of resources and the development of employment opportunities.
But these are not the end of the story, nor always the panacea for the
ills of a community. We must insist that all the human rights of people
in rural and remote communities - their economic, social and cultural
rights as much as their civil and political rights - are respected, protected
Toebes, 'Towards an Improved Understanding of the International Human
Right to Health', Human Rights Quarterly, Vol 21, Issue 3, August
2 Brigit Toebes, ibid, pp.671-674.
3 WHO, 'Primary Health care: Report of the National Conference
on Primary Health Care', Alma Ata Conference, USSR, 6-12 September 1978,
cited in Brigit Toebes, ibid., p.676.
4 Submission to Bush Talks from the Highway Safety Action
Group of NSW Inc., Molong NSW.
5 National Rural Health Alliance, Proceedings of the National
Rural Public Health Forum 12-15 October 1997, NRHA, Canberra, June 1998,
6 Submission to Bush Talks from E Stafford, Kuranda
7 NRHA, ibid, p.3.
8 Jonathon Nicholas and John Howard, 'Better dead than gay?',
Youth Studies Australia, Vol.17, No.4, December 1998.
9 Submission to Bush Talks from Central Australian Aboriginal
Congress, Alice Springs NT.
10Bush Talks meeting, Kalgoorlie WA, August 1998.
11 Helen Sheil, Transformation: despair to optimism,
Regional Australian Summit, Canberra, 27-29 October 1999.
updated 1 December 2001