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:

• 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.⁷

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