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Rural health: A human right for rural people

Address by Chris Sidoti, Human Rights Commissioner to the 7th National Conference of the Association of Australian Rural Nurses, Adelaide, March 1999

Over the past year I have travelled to about 30 communities in all States and Territories from large regional cities like Cairns and Bunbury to small towns like Bourke and Peterborough, to remote communities like Papunya and Yuendumu. Wherever I have gone I've heard of the hard work and commitment of rural nurses in their local communities. Rural nurses are part of the backbone of many rural and remote communities, not only in health areas, but as a constant and central point of contact for the community, especially in times when resources in many rural towns are dwindling and populations are decreasing.

My travels in regional, rural and remote Australia have been part of the Human Rights Commission's Bush Talks program. We set out at the beginning of 1998 to learn about the human rights concerns of people outside the capital cities. They told us loud and clear - -health care, education, jobs, access to services, a future to hope in and live for. I would like to speak to you today about the first of these concerns - health as a human right for people in rural towns and remote areas.

I realise in some ways I am speaking as a newcomer to the experts. You all know well the problems faced by many rural communities across Australia. But I thought today I would place this in a different context - a human rights context.

Human rights

When I speak with people I find that most know innately what fundamental human rights are - people know when something is unfair or discriminatory, they know when they have a right to equal treatment and a right to a decent standard of living. When I speak about human rights to people, they rarely say - what are they? They tell me how important they think they are or where they are being neglected.

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, the right to social security and the right to education. They impose an obligation on government to give assistance and support to families in need.

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 are satisfied.

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 suffer.

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.

Bush Talks

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 recently 'we pay the same taxes; so we should get the same services'.

During our Bush Talks consultations we met with a wide range of country people. The main issues they raised are discussed in our report - Bush Talks, released a fortnight ago. I have brought a few copies today. The notes from most of our meetings are also available on the Commission's website.

The talks confirmed for us what many of you in the bush already know - many communities in rural Australia are under siege. They 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 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 and well-being.

As one submission to Bush Talks put it

Governments 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.1

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.

Health problems 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. And little wonder. Despite research, 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. In coronary heart disease, asthma, diabetes, rural Australians are more likely to suffer than city dwellers. Deaths of males from road accidents are 100 per cent higher in remote areas than in capital cities.2 And suicide, especially of young males, seems endemic in many communities.

Not surprisingly, 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'. Now 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 a woman 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. There is an estimated shortage of 445 doctors in the country compared with an oversupply of 2,400 doctors in all metropolitan regions, except Darwin.3 In many towns we visited, we heard of long waits for appointments with GPs, towns without a GP for lengthy periods and towns in which not one GP would bulk bill, in some instances not even for health care card holders.

I heard many times about doctors refusing to bulk bill. 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 last week 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. Perhaps it is time the ACCC had a look at whether there are any collusive restrictive trade practices at work here.

Almost everywhere we went, lack of services for mental health was raised as a really pressing issue - counselling, psychiatric, hostel, in-patient, especially services suitable for young people, and especially suicide prevention programs.

As one person from North Queensland put it,

Mental health 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.4

In Geraldton WA 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 - something you know all about.

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.5 And it has increased by around 350 per cent over the last 30 years.

One person in Albany linked suicide to the declining economic situation in some rural communities.

Economic downturn with the resulting sense of hopelessness and despair is a major factor contributing to the high rate of rural suicides. A lot of people who get put on the economic scrapheap through no fault of their own feel an enormous sense of worthlessness.6

Whatever indicator you choose, the situation of Aboriginal people is even worse that that of any other Australians. For Aboriginal Australians:

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 support.

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:

People can't 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.8

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.

Indigenous people 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 home care.

Problems of distance obviously greatly affect the health and well-being of the 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 you are 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.

Good news

Before you all despair, I want to make the point that it is not all bad news. In our Bush Talks consultations we came across plenty of good stories - stories of communities banding together and thinking creatively of solutions, instances of individuals with a remarkable sense of responsibility and drive, who were looking around for solutions and some government programs which are beginning to make a difference for the community.

I was continually impressed by how people working together could make a difference, especially when they have a little outside support and some more flexible, less bureaucratic government responses. I thought I would share a few of the initiatives we heard about with you today.

In Yeoval NSW the Yeoval District Hospital was about to be closed due to funding shortages, a familiar problem to many of you I am sure. The community got together to try to work out ways of saving it and formed a co-operative. The State Government agreed to make the funds available and the Co-operative Development League in NSW guaranteed bank loans to get the project going, funded a feasibility study and prepared a business plan. Almost $100,000 was raised through local charities and the co-operative's 250 shareholders. The co-operative also lobbied the Federal Government which agreed to provide more than $300,000 under its Aged and Community Care Program - provided that accommodation and care for older people were part of the hospital priorities. The Co-operative now provides a range of health and aged care services at one site, a doctor's surgery, hospital, physiotherapy, ambulance, X-ray unit, nursing home, hostel and self-care units, as well as community services such as Meals on Wheels and a volunteer driver service.

Another approach to two familiar problems was taken by the Remote and Rural Training Unit in Dubbo. The problems were the departure of young people from country towns and the inability of these towns to attract and retain health care workers. The unit decided to conduct a week long health care career options program for twenty Year 10 students from high schools in surrounding towns. It hopes this will encourage local young people to train in health care work and to remain in their own communities.

I was pleased to learn of a project in South Australia, Bridging the Gap, focussing on the mental health of Aboriginal children and adolescents in the Far North Region communities of Copley, Maree and Oodnadatta. Because of a number of concerns about the impact of trauma of deaths, suicide and at risk behaviour of young Aboriginal people, this project aims to identify the needs of young people and promote the social and mental health of communities to develop their resourcefulness and resilience in dealing with social distress.

In Manangatang Victoria local farmers agist, manage and shear 1,300 sheep owned by the District Hospital, free of charge, handing part of their wool cheque back to the hospital. Their aim is to raise funds to maintain the six-bed hospital, 10 bed nursing home, sports clubs, school and voluntary ambulance service.

In nursing as well, there are some worthwhile initiatives. It is good to see that rural nursing has received some attention from the federal government, especially nurse training. The Department of Health and Aged Care has established an Australian and rural nursing scholarship scheme, administered by the Royal College of Nursing to help rural and remote nurses to continue professional training which they can use in their rural or remote area.

I have also heard of some community initiatives for rural nurses. For example in Mortlake, Victoria, when the town lost its hospital and two GPs, a nurses-run centre was established in the old hospital wards. The centre is run Monday to Friday 8am to 5.30pm and a nurse is on call after hours. This means that the nurses had to retrain at an advanced level. Although not equal to services available in urban areas, it is a practical means of dealing with a very real problem of declining services.

Rural nurses have quite different experiences and functions from nurses in the cities because, through isolation and lack of resources, they have had to be resourceful and cope with crises in a flexible way. Nurses are well-placed to inspire their communities to think creatively about their health problems.

I know that there has been a lot of talk about Multi Purpose Services - it seems to me that rural nurses already are that! They combine many different functions in one dynamic individual.

There are obviously many pressures facing rural nurses as a result, for example, how to get further training, how to avoid a lawsuit but treat sick people at the same time and what to do when the hospital closes down. I'm sure these are the issues which you may address at the conference. I am pleased to see that this conference will help rural nurses to share some of their knowledge and concerns, and take them back to their communities.

Getting the information out

The initiatives I have mentioned are perhaps known to some of you. But I suspect that many of the communities we visited are not aware of some of the successful community initiatives in health which are being implemented in other rural communities. The Commission has planned a project to get this information out there - to share it with rural communities.

The project will identify some of the successful community initiatives and the factors contributing to their success and publicise these initiatives to the wider community so that others can be inspired to address their own concerns. We aim to place the delivery of health services within a human rights framework.

We are particularly interested in hearing about good initiatives in key areas of need: remote area health services, young people, substance abuse and emotional well-being, aged care, mental health services. I encourage you to let us know about these good projects, so that we can spread the word and give some hope back to rural communities.

Conclusion

Openness to creative ideas and determination to survive may be the best resources a local community has.

Professor John Humphreys at the 1998 Worner Research Lecture in Bendigo Victoria spoke some inspiring words on rural and remote area health.

Whereas history looks backward to reflect on what has happened and why, vision is forward looking about what is possible and how. How optimistic we are may well depend on the perspective from which we perceive the world and what we believe is possible even in the face of seemingly insurmountable odds. Often it is easy to succumb to resignation and pessimism. However, I recommend that we model our future approach on examples of pioneers who battled in the face of daunting impediments and whose achievements and legacies grew from small initiatives.9

Health is a human right. We can create a society where all Australians, regardless of where they live, have adequate access to appropriate and responsive health care services and thereby lead longer and more active and happy lives. All it takes is commitment on the part of government, business and the community. And that is the challenge.

Endnotes

1 Submission from the Highway Safety Action Group of NSW Inc., Molong NSW.
2 Proceedings from the National Rural Public Health Forum 12-15 October 1997.
3 Commonwealth Health Department figures published in Consuming Interest, Nov 1998.
4 Submission from E Stafford, Kuranda Qld.
5 National Rural Public Health Forum Conference, 12-15 October 1997.
6 Albany WA, August 1998.
7 Submission from Central Australian Aboriginal Congress, Alice Springs NT.
8 Kalgoorlie WA, August 1998.
9 Professor John Humphries, Worner Research Lecture, 10 September 1998, LaTrobe University, Bendigo.

Last updated 1 December 2001