TAKING HEART FROM INDIAN PROGRESS

India, with its population of 1.2 billion, is planning to build 150 new medical schools in the next five years and at least 250 more in the following five years.  “India,” as Venkat Narayan, a lean, lively and vocal Indian academic who had flown in that morning from Emory School of Public Health in Atlanta to Delhi, put it, “is a place of magnificent chaos, where poverty and wealth co-exist, almost with no self-consciousness, a place where it is very difficult to get things done because of stifling bureaucracy but a place where you can get things done because of the permissive chaos!”  No-one minds a cow slowly crossing the road or minicab drivers lining up and having a pee on the verge even in prosperous neighbourhoods.

“When I was a medical student at Bangalore in 1980, there were two medical colleges and two colleges of engineering.  Now there are nine medical schools and 86 schools of engineering!” Venkat told me, with an energetic laugh. He admits that equity gets rough treatment in India.

I was visiting Delhi as a member of a review panel that has visited India eleven times in the past decade and reports to the prime minister, the minister for health and the ministry to offer informed comment on progress with the National Rural Health Program.  The panel is headed by Jeffrey Sachs, an economist who leads the Earth Institute at Columbia University. He is a valiant warrior for global awareness of poverty.  He has ‘skin in the game’ as his Institute has auspiced the formation of over 40 experimental development villages in Africa where education, health and agriculture capacity building is under way but self-limited to a sustainable budget.  

Sachs has strongly supported a rural health initiative in India to enlist social health workers, respected women in the villages who, with only days of training and no salary, assist young pregnant women to access facilities for safe delivery and neonatal care. There are now 800,000 of these women working effectively in rural India. Mobile phones and bicycles are their basic equipment.  Maternal mortality rates have continued to fall.  Infant mortality rates have been declining in India as a whole (more so in the cities, less so in rural areas) at 6% per annum. 

The rural health program is achieving other goals: there have been no reported cases of polio in India for two years.  Five years ago I recall learning how the polio vaccination team, concentrated around Kolkata, numbered an astonishing 400,000.

And now India, as we have done in Australia, is actively pursuing a program of managed decentralisation of health services.  Expenditure is slowly, slowly rising from 1% to 2% GDP.  Health districts, generally much larger than ours and working on budgets of about $40 per capita per annum, are forming.  It is interesting to see the complex tensions between federal, state and district, so familiar to us in Australia, played out at a mind boggling scale and stupendous complexity.  India gives democracy as a conversation among all citizens powerful and astonishing meaning.

Health statistics are sparse and hard to interpret.  What stats there are point upwards.  As I drove through urban slum areas all my thoughts about chronic disease prevention and primary health care were pounded by rough surf of the social realities of that vast country.  But India is moving and progress is occurring.  No shortage of work for doctors there!

THE APOLOGY – FIVE YEARS ON*

On February 13^th five years ago, the then Prime Minister, Kevin Rudd, and the leader of the opposition, Brendan Nelson, together presented an apology on behalf of the Australian people to our Indigenous brothers and sister.  The apology was offered on behalf also of the parliaments that passed the legislations that led to the forced removal of Aboriginal children from their parents.  http://www.dfat.gov.au/indigenous/apology-to-stolen-generations/rudd_speech.html .  Mr. Rudd explained the reason for the apology.

Let the parliament reflect for a moment on the following facts: that, between 1910 and 1970, between 10 and 30 per cent of Indigenous children were forcibly taken from their mothers and fathers; that, as a result, up to 50,000 children were forcibly taken from their families; that this was the product of the deliberate, calculated policies of the state as reflected in the explicit powers given to them under statute; that this policy was taken to such extremes by some in administrative authority that the forced extractions of children of so-called ‘mixed lineage’ were seen as part of a broader policy of dealing with ‘the problem of the Aboriginal population’.

Mr. Rudd then went on to say:

We need a new beginning—a new beginning which contains real measures of policy success or policy failure; a new beginning, a new partnership, on closing the gap with sufficient flexibility not to insist on a one-size-fits-all approach for each of the hundreds of remote and regional Indigenous communities across the country but instead allowing flexible, tailored, local approaches to achieve commonly-agreed national objectives that lie at the core of our proposed new partnership; a new beginning that draws intelligently on the experiences of new policy settings across the nation.

Let us resolve over the next five years to have every Indigenous four-year-old in a remote Aboriginal community enrolled in and attending a proper early childhood education centre or opportunity and engaged in proper preliteracy and prenumeracy programs.

After Mr. Rudd and Dr Brendan Nelson had completed their speeches they greeted members of the Stolen Generation in the distinguished visitors’ gallery in Parliament House.  The official report of the day http://www.fahcsia.gov.au/our-responsibilities/indigenous-australians/programs-services/recognition-respect/apology-to-australias-indigenous-peoples describes how ‘Aunty Lorraine Peeters [then] presented the Australian Parliament with the gift of a glass coolamon [created by Indigenous artist Bai Bai Napangarti].

Peeters

The coolamon contained a message thanking the Parliament for the apology on behalf of all those affected by removal from their families. In the message Aunty Lorraine explained that the coolamon was a traditional vessel for carrying children, and "a symbol of the hope we place in the new relationship you wish to forge with our people".’ 
‘‘The idea of the empty coolamon was poignant;’ said Brenda Croft, senior curator of Aboriginal and Torres Strait Islander Art at the National Gallery of Australia at the time. “It reinforced the idea of children being taken away from their communities,’’ she says. ‘‘It’s the indigenous form of the cradle. It was no accident.’’  The coolamon, together with the apology documents, are displayed in Parliament House.

How are we doing?  The Australian Bureau of Statistics offers encouragement. Infant mortality is improving.

INFANT MORTALITY RATES:  Aboriginal and Torres Strait Islander and non-Indigenous people 2001–2010

Source: ABS Deaths collection.

It remains the case, though, that we have an incomplete picture of life expectancy of our Indigenous people.  If it mattered to us we would probably do better at measuring it.  At present it is like sending soldiers into battle and not knowing how many are shot dead.  But

‘For those jurisdictions with reasonable information about Indigenous deaths, the median age at death in 2010 for Indigenous males ranged from 50.8 years for those living in the NT to 58.3 years for those living in NSW. These levels were around 20 years less than those for non-Indigenous males, which ranged from 64.9 to 79.6 years. The median age at death for Indigenous females in 2010 ranged from 55.4 years for those living in the NT to 67.1 years for those living in NSW. These levels were also around 20 years less than those for non-Indigenous females, which ranged between 75.2 and 84.9 years.’ http://www.healthinfonet.ecu.edu.au/health-facts/overviews/mortality

We get the parliament we elect:  that’s democracy.  Neither Mr. Rudd nor Dr Nelson lasted long and our parliament has descended from the mountain top to once again concentrate on the things that really matter to us and to them.  But it is a wonder, a treasured memory, that day, five years ago, when the cant, self-comforting delusion and bluster were stripped off the reality of the way in which we had treated Aboriginal Australians, and we said sorry.  Maybe other great days will dawn.  Maybe the coolamon is not empty after all.

*This article has been published in Australian Doctor