Depoliticising Indigenous Health via Consensus and Statistics

‘Politics’ has become a dirty word in Australia. To ‘politicise’ an issue is regarded as obfuscation. Good governments ‘govern’ and make ‘policies’. And good oppositions should work with governments to produce policies not debate endlessly, or so we’re told – usually by sitting governments.

While a lot of the ‘politics’ has devolved into oppositional tactics, political debate is essential for democracy.

At a minimum political debate should reveal the reasons and justifications for a particular policy. However, false consensus and the use of statistics are increasingly used to depoliticise debate of important issues. A recent example is Indigenous health.

Dangerous Consensus

indexIndigenous health is an area where “every opposition wants the government to succeed”. However, perhaps it is this consensus that has resulted in continual failure.

The 7th Closing the Gap report was presented in Parliament earlier this month. Prime Minister Tony Abbott gave a sobering speech, noting that most targets were not on track “despite the concerted effort of successive governments since the first report”.

Opposition Leader Bill Shorten, however, called on the Government to reverse the budget cuts to social services that disproportionately affect Indigenous populations and compound existing inequalities. Coalition MPs were unhappy with this suggestion. Some walked out and others said Shorten was playing political games on an important occasion.

The focus on consensus – that everyone wants to Close the Gap – has reduced Indigenous health and education to a national human interest story. It is bracketed from the realm of politics and serves either to inspire or a cathartic release. Sociologist Pierre Bourdieu writes that “human interest stories create a political vacuum. They depoliticize and reduce what goes on in the world to the level of anecdote and scandal”.

In breaking with the ritual bipartisanship, where Opposition and Government solemnly agree that “more should be done but it is all so very difficult”, Bill Shorten re-politicised Indigenous health, if only briefly.

While liberal political philosophy values consensus established via publicly justifiable reasons, when consensus is assumed, publicly justifiable reasons become redundant. The presumption of consensus between the two major parties on indigenous health (and anti-terror legislation and asylum seeker policy) lowers the expectation of rigorous political arguments for or against certain positions.

Shorten broke with the consensus game and exposed the gap between Abbott’s rhetoric of “concerted efforts” and the first budget he delivered. Budgets are not simply economic documents, but reflect political and moral decisions about the lives that are valued.

Politics of Life Expectancy

Not unrelated, last month Treasure Joe Hockey attracted ridicule with his comment in a 3AW interview ‘that somewhere in the world today, it’s highly probable, that a child is being born that is going to live to a 150’.

Close-the-Gap

Hockey’s comment received some support from Professor Peter Smith who points to advances in medicine and public health as reasons to expect a continued increase in human life expectancy.

Professor John Quiggin however suggested that these claims are highly dubious and ignore the fact that the extension of life expectancy in the 20th Century ‘came from a reduction in death rates for the young.’

Will Cairns also pointed to the success of reducing death rates. Writing in the Medical Journal of Australia that

our numbers plummet as we approach 100 years of age because all of these interventions [public health, disease treatment, nutrition] make no difference to the reality that we eventually wear out and die. Apart from the odd unverified outlier, only one person has ever been confirmed as living for more than 120 years.

Hiding Politics in the Statistics

Like the assumption of a consensus, Hockey’s use of life expectancy statistics to justify changes to the health system hides the political nature of these decisions.

Altering the financing of the health system through strategies such as co-payment schemes may appear reasonable. We are told Australia’s population is ageing and more people need to use the health system. However, what these statistics hide is the disparities of life expectancy in Australia.

While a child may be born today to live to 150 120, the latest ‘Closing the Gap‘ report reveals that Indigenous Australians born today can expect to live more than a decade less than non-Indigenous Australians.

The reality of significant gaps in life expectancy should be the cause for alarm and inspire the creation of a more equitable health system. Yet often population statistics hide the details. As Professor Mick Dobson notes, ‘Statistics of shortened life expectancy are our mothers and fathers, uncles and aunties who live diminished lives. We die silently under these statistics.’

Statistics: measuring and managing people

Vital statistics have been used to govern populations since the 17th century. But it’s important not slide over the word “statistics” too quickly as its literal meaning is hidden through repeated use.

Statistics is not simply about numbers but “state craft“. By knowing birth and death rates, and the incidence of disease it is possible to establish probabilities of epidemics, movement of people, and to order the State in a rational manner.

Vital statistics also enable the segmentation and division of populations. We see this all the time in professional sports. The explosion of statistics about batting averages, field goal percentage, or a players historical probability of kicking a goal from a certain angle against a certain team all help coaching staff to know who is performing and who is not.

Divisions in the details

Despite appearances, the use of statistics as political tool for governing a population is not neutral. Historian and philosopher Michel Foucault notes the way vital statistics introduce a power over life or biopolitics. The increased knowledge about nutrition, physiology and sexuality in the 19th century lead to the creation of norms from statistical averages that allowed political strategies to regulate human life. Close-the-Gap-005

Statistical analyses are used in public health to show the distribution of disease and enable interventions in populations. But as Foucault notes, these techniques also allow the identification of lives that are healthy and should be fostered and which lives are not performing and can be neglected.

A danger with the celebration of a statistically increasing life expectancy, is that it masks the very real health inequalities faced by many Australians. This is seen in a number of areas:

  • allow for certain health issues to be prioritised (e.g. ageing population), while others marginalised (e.g. health inequalities)
  • enable the allocation of funding towards some research (e.g. Medical Research Future Fund), while moving it away from other areas (e.g. preventive health)
  • suggest a particular financing models for the health system (e.g. co-payment), yet discount others (e.g. progressive taxation).

These are not simply economic decisions, but political and ethical decisions about which lives count. For too long the supposed neutrality of statistics and the assumption of consensus have allowed the political reality of Indigenous health inequalities to be hidden. To close the gap we need to recognise the historical and political processes that have made it and maintain it.

Morally Indigestible Listicles: Food, Experts, and the Burden of Choice

Never Eat

The Sydney Morning Herald (via the Telegraph, London) has published another “no-nonsense-straight-shooting-science-based” listicle of the foods YOU SHOULD NEVER EAT AGAIN! These lists seem to appear at least once every week on some form of news website.

This current list is prefaced with references to recent British Medical Journal studies that turned upside down “everything we thought we knew about eating and drinking healthily”. Instead of saturated fats being “the killer”, it turns out carbohydrates are!

Put down that bacon & egg roll and get yourself a KFC Double-Down sandwich!

Surprisingly the article doesn’t question why these new claims have a stronger knowledge base than previous claims or how we can be sure that in a week there won’t be another “nutritional revolution” that will turn this all on its head and finger protein as Grandpa’s real killer.

Leaving aside the science-base of these claims – not to imply this is unimportant – what is most disturbing about these articles (and this article in particular) is the emphasis on individual food choices as the determining factor of health. “Expert” claims that “every bacon sandwich you eat knocks half an hour off your life” reinforce ideas that my heart disease or your diabetes are reducible to that sandwich or chocolate bar eaten six years ago.

When these factoids are spoken by folks in white coats during times of austerity cuts to health services there is a real danger of compounding already existing public health policy problems by pretending that structural influences can be addressed via a nice social marketing campaign or a Jamie Oliver TV show that teaches people how to cook, garden and “never eat those foods again”.

In the UK (where this article originated) David Cameron recently flagged that sick benefits may be cut from people who are obese and do not lose weight. The rationale for this idea is that obese people can lose weight simply by making “correct” and “healthy” food choices. However, according to Cameron, they aren’t making these choices because life is too good on benefits. Hence, cut the benefits and healthy food choices will be made.

While these listicle articles may be dismissed as “not too serious” or “a bit of fun”, they depend on and reinforce a moralistic and biopolitical perspective on the relation between food, choice and health. This perspective is often used to justify budget cuts to health services due to the expectation that health is simply a matter of individuals making the right choices.

In an article for Public Health Ethics, my colleague Donald B. Thompson and I argue that this perspective is morally and scientifically unjustified. Below is the introduction. If you’d like read the whole thing but the pay wall gets in the way send me an email.

Continue reading →

The Nightmares of Tony Abbott

In promising a new approach to government Tony Abbott has reverted to the well-thumbed pages of the politics of fear playbook that dominated domestic and international political rhetoric between 2001 – 2008.

In a speech to the nation he repeated his four step plan for terrorism – ‘a knife, a flag, a camera phone and a victim‘ – but also drew bizarre links between ISIS and people who “cheat” the welfare system.

It’s clear to me, that for too long, we have given those who might be a threat to our country the benefit of the doubt.

There’s been the benefit of the doubt at our borders, the benefit of the doubt for residency, the benefit of the doubt for citizenship and the benefit of the doubt at Centrelink.

And in the courts, there has been bail, when clearly there should have been jail.

We are a free and fair nation. But that doesn’t mean we should let bad people play us for mugs, and all too often they have: Well, that’s going to stop.

In connecting immigration, welfare, and the judicial system to ISIS – or as he prefers “the Islamist death cult” – the Prime Minister bundles complex and disparate institutions and policies under one banner of “national security under threat”. In using this politics of fear that equates the people on welfare or bail with ISIS, Abbott hopes to swiftly pass new legislation that purports to secure us from these fears and neuter any opposition.

The rise of the Islamist death cult in the Middle East has seen the emergence of new threats where any extremist can grab a knife, a flag, a camera phone and a victim and carry out a terror attack.

As a nation we are responding to this threat. Abroad, Australia is working with allies to disrupt and degrade the Islamist death cult. At home, we have provided our security services with more powers, more resources and stronger laws.

We are currently considering additional legislation on data retention that’s before the Parliament – and this will make it easier to keep you safe and we want to get this legislation passed as quickly as we can.

But this is an old trick and a trick that further reveals that Tony Abbott (and most senior Australian politicians) are bereft of ideas. There is no vision other than more freedoms and less threats.

As the BBC documentary ‘Power of Nightmares‘ shows, politicians in Western liberal democracies following September 11, 2001 no longer offered visions for a grand future. They, and we, have grown cynical of dreams where “the only fear is fear itself”. Instead, the focus is on nightmares. Whoever can portray the greatest fears, yet also assurance of deliverance, is king.

This tactic arguably receded with the elections of Rudd in 2007 and Obama in 2008. Both had optimistic visions. Rudd had his “2020 Summit” and Obama his “Yes We Can”. However, with financial crises, widening gaps in economic equality within nations and between them, as well as the return of Islamic terrorism with ISIS, these optimistic slogans rang hollow and arguably reinforced cynicism. Today, there is a return to a politics of fear.

With his leadership in question Tony Abbott is resorting to a tactic he knows well from his time in the Howard Government. He may not be able to answer who he is or what he stands for in positive terms, but he is able to conduct an orchestra of threats and fears – Labor, ISIS, debt, welfare fraud, radicalisation of youth, ‘inter-generational theft’, and lenient bail laws. In orchestrating these fears, he is able to give us this assurance: “As a country, we won’t let evil people exploit our freedom.”

Abbott is hopeful that this new tough line of government will save his leadership. Perhaps it will. But maybe this time we will recognise the old negative tune and demand something new – something more courageous and imaginative than borders and laws to protect “us” from a fictional “them”. Perhaps we will recognise the folly of jumping at nightmares and spectres that we help create and sustain.

See Tony Abbott’s full message here: https://www.pm.gov.au/media/2015-02-15/message-prime-minister-0

Tony Abbott’s ‘how to guide’ on modern terrorism

1) A knife. Stainless steel, but plastic will do in a pinch.
2) A flag. Black is scariest. Maybe that New Zealand one.
3) A camera phone. At least 6 pixel sensor resolution – grainy but not too grainy.
4) A victim. NB doesn’t have to be a human, could be something abstract, like freedom or Australian values e.g. mate-ship

See from 2:17

Bioethics, obesity and the harm principle

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Fat people should pay more to fly, because they weigh more and hence use more fuel.
Fat people can’t make good food choices so they should be coerced and stigmatized into making the right choice.
These and other spurious ideas are permitted to float around opinion pages of leading newspapers and journals because a) we think we have a fat people problem; b) shocking, blunt and simplistic solutions to complex problems are key ingredients to “click-bait”; and c) if we can reduce complex problems to economic calculations then we can pretend moralistic interventions into peoples lives are “neutral” because, hey it’s the raw numbers talking.
Anyway, in the below paper published this week I argue against Peter Singer and Dan Callahan’s attempts to justify direct interventions into the lives of fat people based on a simplistic use of the harm principle and a deep ignorance of empirical and public health research on obesity. Or as H.L. Mencken quipped, “For every human problem, there is a solution that is simple, neat, and wrong.”
If you can’t get beyond the paywall send me an email or message.

The Harm of Bioethics: A Critique of Singer and Callahan on Obesity

Abstract

Debate concerning the social impact of obesity has been ongoing since at least the 1980s. Bioethicists, however, have been relatively silent. If obesity is addressed it tends to be in the context of resource allocation or clinical procedures such as bariatric surgery. However, prominent bioethicists Peter Singer and Dan Callahan have recently entered the obesity debate to argue that obesity is not simply a clinical or personal issue but an ethical issue with social and political consequences.

This article critically examines two problematic aspects of Singer and Callahan’s respective approaches. First, there is an uncritical assumption that individuals are autonomous agents responsible for health-related effects associated with food choices. In their view, individuals are obese because they choose certain foods or refrain from physical activity. However, this view alone does not justify intervention. Both Singer and Callahan recognize that individuals are free to make foolish choices so long as they do not harm others. It is at this point that the second problematic aspect arises. To interfere legitimately in the liberty of individuals, they invoke the harm principle. I contend, however, that in making this move both Singer and Callahan rely on superficial readings of public health research to amplify the harm caused by obese individuals and ignore pertinent epidemiological research on the social determinants of obesity. I argue that the mobilization of the harm principle and corresponding focus on individual behaviours without careful consideration of the empirical research is itself a form of harm that needs to be taken seriously.

Keywords: obesity; Peter Singer; Dan Callahan; harm principle; public health

Mayes, C. (2015), The Harm of Bioethics: A Critique of Singer and Callahan on Obesity. Bioethics, 29: 217–221. doi: 10.1111/bioe.12089

Shall I Appear on Television?

I bought Pierre Bourdieu’s little book ‘On Television and Journalism’ for $1 from a bargain bin. This alone illustrates the disconnect between the market and things of value – a concern of Bourdieu’s in relation to what is considered “news”. However, maybe it was in the bargain bin because it was written in 1996. What could a pre-internet, pre-9/11, pre-social media book have to say of relevance about television and journalism?

Perhaps nothing. I haven’t read it. But the below excerpt suggests that many of the contemporary practices of gathering and disseminating “expert opinion” in news media would not surprise Bourdieu.

If the media today had existed in full force at the time, [Mallarmé] he would have wondered: “Shall I appear on TV? How can I reconcile the exigency of ‘purity’ inherent in scientific and intellectual work, which necessarily leads to esotericism, with the democratic interest in making these achievements available to the greatest number?”

Earlier, I pointed out two effects of television. On the one hand, it lowers the “entry fee” in a certain number of fields – philosophical, juridical, and so on. It can designate a sociologists, writer, or philosopher people who haven’t paid their dues from the viewpoint of the internal definition of the profession. On the other hand, television has the capacity to reach the greatest number of individuals. What I find difficult to justify is the fact that the extension of the audience is used to legitimate the lowering of the standards of entry into the field. People may object to this as elitism, a simple defense of the besieged citadel of big science and highculture, or even, an attempt to close out ordinary people…In fact, I am defending the conditions necessary for the production and diffusion of the highest human creations. To escape the twin traps of elitism or demagogy we must work to maintain, even to raise the requirements for the right of entry – the entry fee – into the fields of production. I have said that this is what I want for sociology, a field that suffers from the fact that the entry fee is too low – and we must reinforce the duty to get out, to share what we have found, while at the same time improving the conditions and the means for doing so.

Pierre Bourdieu, On Television and Journalism, Pluto Press, 1996, p.65

It appears one of Bourdieu’s main frustrations is with Bernard-Henri Lévy, of whom “no sociologist worthy of the name talks about” (p. 54).