Gavin Mooney on the difference between compassionate acts and a compassionate society

photo courtesy of the Age and Getty

This piece first appeared in Crikey.

Floods aside just how compassionate is Australia
by Gavin Mooney, Health Economist and co convener WA Social Justice Network

The recent devastating floods have brought out all sorts of emotions. We have seen expressions of great compassion and generosity. And these are emotions that we seem genuinely to treasure when we see them, whether these be in our fellow citizens or in our leaders. In all the heart-wrenching devastation of lives and property, it is heart-warming to see so many showing their compassion for those who have lost so very much.

The question of compassion is one in which as a health economist I have a particular interest. I have recently sought to make a case that strong, compassionate communities are good for people’s health.
I also argued a few years ago, for example, that countries that were more compassionate treated drug addiction and drug addicts better and, while it was difficult to "prove", some leading drug experts expressed the view that I was on to something.

One of the difficulties here is how to quantify compassion. Can we find a measure that will allow us to see how compassionate we are as a society compared say to the Swedes or the Americans or the Brits?

Earlier I used just public expenditure as a proportion of total national income and Australia didn’t come out of that well. Across 33 OECD countries, for example in 2008, we came fifth from the bottom on 27.1%. On this indicator, the countries that came out well -- perhaps predictably -- were the Scandinavians with Denmark at the top with 48.2%.

Another possible measure is public social expenditure and here we do rather badly again.
These are somewhat crude but not silly measures of social compassion. In this context, public expenditure matters. It is difficult to see how we can build a caring society if we rely too heavily on the market. That may be OK for Tim Tams and TVs but for addressing poverty, inequality, Aboriginal disadvantage, mental illness and flood protection, we need public monies.

But I have just come across a paper that has some really worrying stats on Australian compassion. Well not strictly compassion but what is called "generosity" but it is pretty much the same thing. It examines what it calls "the generosity of social insurance".

What it does is rather neat. It argues that we can use certain public-sector programs to get an estimate of how generous (or in my language compassionate) a country’s welfare state is.

So, for example, we can take unemployment insurance. One measure of that program’s generosity is what proportion of income that replaces. Added to that is the "coverage ratio" i.e. the proportion of the population covered. Multiplying these together gives an index of "generosity" for that program. Clearly the higher the index, the greater the generosity.

The paper then does the same for sick pay and for state pensions. It adds the three indices together and comes up with an overall generosity index.

Not perfect but an interesting exercise.

Now the scary bit. Australia comes bottom of 18 OECD countries! Oh dear, we are the least generous of them all. Even the US, which is often seen as being the land of free enterprise, individualistic and unwilling to provide decent health care for its people (especially its poor), comes out quite a bit above us. According to this index, in comparison, countries such as Sweden and Norway are dripping with compassion.

I think we are a compassionate people -- if we are given the chance and all sorts of private acts in the past few days and weeks show that. But we need our governments to recognise that. We need leaders prepared to lead. Many -- most? -- of us who are well off would be willing to pay more taxes to help the less fortunate.

We do want a compassionate society. We do believe in the fair go.

Julia: stop messing about. Recognise that we Aussies really do have a decent streak in us -- we have just shown it. We want a caring community. We cannot get it -- and you will not get it -- if you continue to pander to our baser selfish interests and instincts.

Tax us more. Build a caring public sector. We want to be the custodians of a decent society. We want to be led to that compassionate society. It will also make us a healthier society. Let’s get on with it.

Crisis in WA hospitals

This op ed piece by Professor Gavin Mooney appeared in the West Australian on Friday September 24th in response to ongoing problems in the WA health care system, highlighted by a recent crises involving ambulance ramping at the city's major public hospitals.

Ambulance ramping

By Gavin Mooney

The accounts of the ramping of ambulances at the major Perth hospitals last week are worrying and one feels very much for the patients involved and their families. Something clearly is going wrong and, while last week was particularly bad, these events do occur with some regularity.

 But let’s stop and think this through a bit more. There will never be a health care system in WA or anywhere else that can meet all demands and needs for health care. No society can ever achieve that. If we tried to, it would be so expensive and we would end up with very poor educational, transport and justice systems. Or we would have to cut back markedly on private consumption as we paid more and more in taxes. Or, if we went further down the private road, we’d be spending enormous amounts on private health insurance.

Taking public and private together, as a country or as a state, do we spend enough on health care? Well in comparison with other countries we seem to be getting it about right – although out of the total we do spend rather a high proportion on hospitals.

But then of course we need hospitals!  My questions however are these.

First have we got the right mix of types of hospitals? And second have we got the right mix of types of health services? The Reid Review of 2004 which is the most recent assessment of the WA health service indicated that 80% of patients in our big teaching hospitals did not need to be there. That is a staggering figure, especially as these are very expensive places to be. 

There is a ‘law’ in health policy that says ‘a built bed is a filled bed’ meaning that if we create more beds they automatically get used. That 80% figure clearly suggests an oversupply of beds in our big hospitals. Many patients could be treated just as well but at less cost in other hospitals. Rather than building the Fiona Stanley Hospital what we should be doing is expanding other, cheaper hospitals. 

But maybe we need to increase services outside of hospitals – GP and community services, preventive services. It is of note that in the “Citizens’ Juries” (of randomly selected citizens brought together and given good information) in this state that I have facilitated, when asked about their priorities, not one has wanted more hospital beds. Indeed to pay for the priorities that they as citizens want – prevention, mental illness, greater equity, community care - some juries have suggested closing hospital beds!

The push for more and more beds is simply not working. I have been in the west for 10 years and over that period we have pumped more and more money into these teaching hospitals and we still have the ramping of last week. These hospitals are ‘sick’ but the ‘treatment’ over the last decade is not working. We need more ‘investigations’ so that we can up with a better ‘diagnosis’. 

What to do? Well the first thing - and I have asked for this repeatedly – is to conduct a detailed investigation into our teaching hospitals. Where is the money going? What is driving costs? Can the services be provided as well but at less cost i.e. more efficiently? That sort of detailed study was not done by Reid and it has not been done since. We cannot make sense of any of this until that study is done.

The second thing is to put in place more policies to keep people in the community – bolster prevention and invest in programs to keep people out of hospital. Most people want to live as long as they can in their own homes. Let’s respect that. And it is cheaper. 

And third let’s find out what the people of WA want from our health services – and they are our health services, not the doctors’, not the politicians’, not the Health Department’s. They are ours, the citizens’. Let’s have a series of these “Citizens’ Juries”, say ten across the state, so that critically informed citizens can have a genuine say in the future of the WA health service.

Early last month I did one of these Citizens’ Juries in the ACT at the request of the Minister of Health in the ACT, with fascinating results for their services.

Dr Hames, Mr Snowball, I make this plea. In response to ambulance ramping, instead of pouring more and more money into these expensive hospitals, let’s have an investigation into how the vast sums of money they are currently getting current are being used. And rather than assume that supplying more and more beds is the answer, let’s work on reducing demand.  And finally will you please fund a program of Citizens’ Juries across the state so that you can learn what we as citizens want from our WA health services?

Professor Gavin Mooney, Health Economist and Co-convenor, WA Social Justice Network 

Democracy and the big miners

A PS to the RSPT

By Gavin Mooney

The ‘debate’ around the super profits tax has been illuminating. For me it has said so much about the mentality of the top executives in the mining sector - and of politicians. Early on there were the suggestions that Kevin Rudd was a communist (Clive Palmer), that it amounted to nationalisation (Andrew Forrest) and the tax was straight from the pages of Das Kapital (Julie Bishop)

In the wake of their success in bringing down both Rudd and the tax, their arrogance and their indifference to democracy is now out there in full flow. According to Forrest it wasn’t the miners who brought down Rudd – Twiggy’s pal – it was Ken Henry. Atlas chief David Flanagan divulges to The Australian that he would talk to his wife each night about the implications of the tax ‘and the legacy it would leave for their two children’. He went on: ‘I actually could see a scenario where the RSPT could destroy the fabric of the Australian economy… I mean, totally f…ing smash it to bits.’

Forrest asked ‘who voted for Ken Henry?’ Thank God for Forrest to alert us to the dangers of an unelected Ken Henry. And thank God for those who brought down the tax and saved us from these commies who were otherwise set to ‘destroy the social fabric’ of Australia.

These mining giants also have global aspirations. They are keen to use their power to save not just Australia. They want to save the world from nasty governments elsewhere as well! In a speech to mining executives in London last week, Tom Albanese, the Rio Tinto CEO, according to Peter Wilson in The Australian, ’issued a none-too-subtle warning about the events in Canberra to other governments attracted to the idea of “resource nationalism” and hiking taxes on mining profits’. Albanese is reported to have stated: ‘Policy makers around the world’ (and presumably that includes democratically elected governments – like ours) ‘can learn a lesson when considering a new tax to plug a revenue gap, or play local politics’. We are fortunate however that as Wilson reported Albanese ‘held back from openly crowing about the fall of Mr Rudd’.

The Fin Review joined in. ‘In a shot across the bows of Brazil, South Africa and Chile’, writes Andrew Cleary, ‘Rio Tinto’s chief executive Tom Albanese, has warned countries considering a super tax on resources to “learn a lesson” from the Australian government’s experience in dealing with the industry’s opposition’.

I would encourage readers to write to The Australian and the Fin Review to express their thanks to the big miners for saving – today - the social fabric of Australia yesterday and – tomorrow - the world. Good chance your letters will be published.

Against this background what chance any reasoned debate about the impact of the mining industry on global warming? Ah, but the Flanagan kids’ future is secure in the knowledge that their dad and the other big miners are there to look after the future of all of us.

And just a final thought: why do we need an election?

Corporate control of Health care

The Corporatization of Health By Gavin Mooney

As a health economist one ceases to be shocked by the quite disgusting behaviour of the pharmaceutical industry. It happen so often. But every now and then Big Pharma manages to find yet more offensive ways of trying to corrupt research, clinicians and the WHO.

At the same time I note how willing some in health services – doctors and others – are to take the Big Pharma shilling and without any recognition often of the conflicts of interests involved. A couple of examples from my own experience. Nearly 20 years ago, a leading Australian clinician was keen to do a study with me which would have involved bringing a colleague out from the UK. He said he’d get the money for the airfare from a drug company. I indicated that if there were any drug company money involved then I would not be. He was amazed at this response and said: ”I can’t remember when I last paid for an airfare.”

More recently I suggested to a very senior university administrator that the university should not accept drug company money when evaluating drugs since there was good evidence that such funding resulted in bias in favour of the company’s drug. “Studies sponsored by pharmaceutical companies were more likely to have outcomes favouring the sponsor than were studies with other sponsors” (1). The university administrator’s response? “But if we say no Gavin, the company will just go down the road to another university!”

There are countless such stories and on a much bigger scale. One is the recent case of WHO and the swine flu pandemic. The Guardian of June 4 (2) reported: “An investigation by the British Medical Journal and the Bureau of Investigative Journalism … shows that WHO guidance [on stockpiling drugs in the event of a flu pandemic] issued in 2004 was authored by three scientists who had previously received payment for other work from Roche …and GlaxoSmitKline (GSK)” the companies which make the drugs which were to be stockpiled. The guidance led to drug companies making billions of dollars from the stockpiling.

According to the Guardian, one of the main authors (Professor Fred Hayden) was being paid by Roche for lectures and consultancy work at the very time he was writing the guidance! And he had previously received payment from GSK.

What I find most worrying in all of this is that there are so many stories of the nastiness of drug companies in funding unethical practices, arranging ghost written articles for clinicians to sign on to (yes that is true! (3), etc. ... and nothing changes. Nothing.

Can this sort of corruption be stopped? Well there seems not much point in trying to stop individual clinical researchers and individual universities accepting payment and kickbacks from the drug companies. It’s been tried. It does not work. Policing it is just impossible and the climate and culture of clinical research would need a revolution. It will not happen.

The place to tackle this is in the incentive structures that the industry faces. So state ownership of companies is one option. Those who worry that investment in new drugs would dry up need to note that currently only 14% of the industry’s budgets goes on developing drugs (4). Another attractive option is one that the economist Joseph Stiglitz (5) has come up. He suggests that there be a massive multi-billion dollar prize set up by governments which would be won on the basis of drug inventions which did the most to improve health – instead of profits. I would suggest that rather than have governments pay for the prize as Stiglitz proposes, that this is funded by taxing the drug companies’ marketing budgets.

The majority of health problems in this world are in very poor countries where there are very limited monies available from governments and from people to pay for drugs. So the chances currently of Big Pharma seeking to develop drugs for developing countries is remote – the prospect of making profits is just not there. So the R&D on malaria drugs for example is inevitably tiny. And the extent to which the world gets on top of malaria is … tiny.

Currently the world’s poor struggle to pay for their drugs. When they succeed they often push themselves deeper into poverty. When they fail, they die.

There has to be a better way but it starts with outrage that this profit driven enterprise that could do so much good gets away with doing so little - except making big profits.

References

1. Lexchin J, Bero L, Djulbegovic B and Clark O, Pharmaceutical industry sponsorship and research outcome and quality: systematic review British Medical Journal 2003;326:1167-1170

2. Report condemns swine flu experts' ties to big pharma http://www.guardian.co.uk/business/2010/jun/04/swine-flu-experts-big-pharmaceutical

3. Medical editors push for ghostwriting crackdown http://www.nytimes.com/2009/09/18/business/18ghost.html

4. Angell M (2004) The Truth about the Drug Companies. New York: Random House.

5. J Stiglitz Scrooge and intellectual property rights http://www.bmj.com/cgi/content/full

Neo liberalism in post apartheid South Africa

Image from Zed Books

" Despite the government having replaced the predations of apartheid with one of the most inclusive and progressive constitutions on earth, neoliberal capitalism has stalled the rights of ordinary people in South Africa"
Raj Patel, The Value of Nothing, p 135

Gavin Mooney is currently teaching in South Africa. This piece follows an earlier piece on the anniversary of the Sharpeville Massacre written by Colin Penter that can be found on his blog.

Neo liberalism in post apartheid South Africa By Gavin Mooney

The 50th anniversary last week of the Sharpeville massacre left a bitter taste in the mouth. For my generation- I was 17 at the time- it was a truly horrendous barbaric event and it was seen as such by many across the globe. Sixty nine people killed, mown down in cold blood standing up for their rights. Horrific- and 50 years on I can still vividly remember how tangible was the outrage.

Here in South Africa at present for a few weeks, what does the memory of Sharpeville convey? Perhaps more than anything a great sadness arising not so much from the massacre itself but from events in the years since.

Enormous hope was kindled by the release of Mandela and the ensuing democratic elections of 1994. The hope continued as, in the initial years of black rule, some attempts were made to bring about elements of social justice in this country. There was an economic policy called GEAR which at least had R for redistribution in it. But then the neolibs re-established themselves and Mbeki set out to show he was just as capable of running an economy along neoliberal lines as any white man. And he did.

As a result poverty remains horrendous in this country; and inequality is now worse than in 1994. Let me repeat that. The inequality today is worse than it was in the apartheid years. South Africa now competes to be the most unequal society on the planet.

Yet the world still sees South Africa as free, as democratic, with a (genuinely) wonderful constitution. This 'wonderful' constitution in this 'liberal democracy' has failed to deliver either freedom or justice to the people.

Sad how the world could condemn the evils of apartheid- and rightly so- but passes by on the other side when the perpetrators of oppression are driven by neoliberalism and not race. Is it any more obscene? Has the world become just too bored with all the poverty and inequality to care any longer? Have individualism and materialism become so dominant globally that compassion and concern for the vulnerable and oppressed are now passe?.

To me the real sadness today is that no one would seem to care enough to listen if South Africans were to protest and bring about another Sharpeville. Why would the poor of South Africa risk provoking another massacre when they know that no one cares any longer? Then the 'enemy' was clearly identifiable as white supremacy; today when neo-liberal ideology is 'the enemy'...?

Alternatives to market approaches

Looking for alternatives to neo-liberalism

by Gavin Mooney

One of the issues that must become foremost in any challenging of the market is to imagine alternatives. I am doing this in economics and health policy. My starting point is that health care systems need to be seen as social institutions. Here I spell out some of my thinking. Is there I wonder, merit in running with this idea in a wider context?

There is a need to consider the broad, social role of health care systems as institutions, as part of the fabric of society. Such a focus means trying to devise ways to involve the community as a community in values to underpin these social institutions.

With respect to health care, there is a need for a dual level approach, a personal one nested within a community one. The first is at the level of individual desire for our own health. The other, community level, is concerned with setting the social principles on which health care systems are to be based. At this second community level the individual now is a citizen rather than a patient.

Two potentially important caveats here. First the citizenry will need some education so that they operate on an informed basis. Second there is a risk, that needs to be addressed, that the rights of minority groups will not be adequately recognised by the majority.

What is required to pursue the above proposal is to determine how different levels of preferences might be elicited. Three levels of preferences or interest functions are proposed.

In the context of multiple interests functions it is useful to think of Frankfurt's** first and second order preferences and to develop a third order as well. The first approximates to some notion of desire; the second to what individuals want when they have time to reflect, perhaps embracing the issue of what sorts of individuals they want to be. These may be different not only in being reflective, but also in terms of the object of the preferences. This is inter alia because reflection comes at a cost; time is needed for reflecting (There seems little point in reflecting over long on whether to buy a chocolate bar but we might want to dwell more on preferences about our chocolate dependency.)

Third order preferences are "communitarian". This philosophy recognises that individuals are not free floating atoms. Their identities are embedded in some community/ies. Being active in a community is good in itself and not just instrumental. Institutions such as health care, but also education, are valued not only for producing some narrowly defined outcomes such as health gain and educational human capital gain. They can be valued for other outcomes, in health (e.g.information) or processes (e.g.caring), or as institutions per se which contribute to the decency of a society (e.g such as a tax based universal health care system). These issues are related to what sort of society citizens want.

To advance these third level preferences I have proposed the idea of "communitarian"claims." John Broome proposed the idea that a claim to a good meant that there was a duty owed to a person that she or he have the good.

I have previously suggested moving Broome's concept of claims to make it more relevant to the discussion here in the following way. It is proposed that "communitarian claims" be a sub-set of claims more generally where this sub-set is the responsibility of the community to meet or address. Thus, the duty in the case of communitarian claims is a duty owed by the community.

These are labelled "communitarian claims" reflecting the fact that it is the community who have the task of deciding what constitute claims, the duty to allocate claims and to decide on the relative strengths of different claims. There is value in being part of the process of arbitrating over claims. The more embedded individuals are in a community, the stronger will be communitarian claims in that community.

The strength of a claim is not a function of an individual's ability to manage to feel harmed. Harms and the strength of these harms are for the society to judge not the individual.(In the market, income is the determinant of claims and individual satisfaction is what is to be maximised). Strictly, with respect to claims, the bad feelings arising for the person harmed are only relevant in so far as the society deems them to be relevant. They are a matter for "community conscience".

The actual consumption of the resources however remains determined by how an individual values the options with which he or she is then faced.

Finally it is apparent that there may be problems in advancing the concept of claims and retaining the ability to measure and quantify within whatever set of principles emerges.

I am unsure if the obsession with quantification is a product of the market or not-it is certainly more prevalent in today's neo- liberal societies. On this issue Amartya Sen the Noble laureate in economics argues that measurement can be taken too far and he seeks to guard against 'over completeness'. As Sen sees it:

"Waiting for toto" may not be a cunning strategy in a practical exercise".

He suggests that:

"the nature of interpersonal comparisons of wellbeing.. as a discipline may admit incompleteness as a regular part of the ... exercise.. An approach that can rank the wellbeing of every person against that of every other in a straightforward way.. may well be at odds with the nature of these ideas"

So I don't worry too much about such problems. Maybe others will. More importantly for this blog I wonder if others can see merit in using the idea of communitarian claims in sectors outside of heath care.

* Broome, J (1991) Weighing Goods, Blackwell
**Frankfurt, H (1971) Freedom of the will and the concept of a person, Journal of Philosophy, 68:5-20
*** Mooney, G (2009) Challenging Health Economics, Oxford University Press
**** Sen A (1992) Inequality Re-examined, Clarendon