Has preventative health care become code for paternalism?

‘The Taskforce says that prevention is everyone’s business – and we call on the state, territory and local governments, on non-government and peak organisations, health professionals and practitioners, communities, families and on individuals to contribute towards making Australia the healthiest country by 2020.’ (Extract from ‘Taking Preventative Action’, the federal government’s response to the Report of the National Preventative Health Taskforce).

I find the sentiments in the quoted passage objectionable for two reasons. First, preventative health care is not ‘everyone’s business’. Individual adults have primary responsibility for their own preventative health care because no-one is better able to exercise that responsibility than they are. Individuals who are persuaded that preventative health care is a collective responsibility could be expected to look increasingly to the various levels of government, non-government organisations, health professionals and practitioners, communities and families – everyone except themselves - to accept responsibility for what they eat, drink and inhale.

Second, the goal of making Australia the healthiest country by 2020 is being put forward as though it is self-evidently desirable collective good that should be pursued by any and every means available to everyone. The goal is not self-evidently desirable. Individual health is not a collective good. And the end does not justify the means that are being proposed to pursue it.

If you delve behind the spin about making Australia the healthiest country my 2020, the underlying goal seems to be to raise average life expectancy in Australia to the highest level in the world by reducing the incidence of chronic disease. What does this entail? It would be hard to object to the goal of enabling individual Australians to reduce their risk of chronic disease. The problem is that the government’s strategy is more about achieving national goals than providing better opportunities for individuals - more about behaviour modification than about ‘enabling’ individuals to reduce their health risks.

The government claims that analysis of ‘the drivers of preventable chronic disease demonstrates that a small number of modifiable risk factors are responsible for the greatest share of the burden’. The behavioural risk factors led by obesity, tobacco and alcohol apparently account for nearly one-third of Australia’s total burden of disease and injury. The chronic conditions for which some of these factors are implicated include heart disease, stroke, kidney disease, arthritis, osteoporosis, lung cancer, colorectal cancer, depression and oral health problems.

Since these risk factors stem from individual lifestyles it is obviously desirable for individuals to be aware of them. There may be a role for governments in provision of this information. Perhaps governments should also be involved in helping people in various ways to live more healthy lifestyles. It is questionable how far governments should go down this path, but it is difficult to object to modest efforts by governments to improve opportunities for people to live healthier lifestyles.

However, rather than helping people to help themselves the federal government has chosen the path of Skinnerian behaviour modification. It has chosen to drive changes in behaviour through what it describes as the ‘world’s strongest tobacco crackdown’. (This is one instance when I hope the government doesn’t actually mean what it says – some people in Bhutan have apparently been jailed recently for possession of more than small amounts of tobacco products.) The government’s strategy also involves ‘changing the culture of binge drinking’ and ‘tackling obesity’, but in this post I will focus on smoking.

Some of the tactics being used in the tobacco crackdown involve information and persuasion but there is also an element of punishment involved. The tobacco excise has been increased to over $10 for a packet of 30 cigarettes and legislation is proposed to require cigarettes to be sold in plain packaging. It seems to me that this amounts to persecution of smokers and their families. It will reduce the amount of household budgets available to be spent on other products and encourage some to avoid excise by obtaining tobacco from illegal sources.

As a former smoker, I am probably more strongly against smoking than most people who have never smoked. I encourage other people to quit smoking and discourage young people from taking up the habit. But having given up smoking several times, I know how hard this can be. Governments have no basis on which to judge that people are not in their right mind if they consider that the pleasures they might obtain from additional years of life are not worth the pain of giving up smoking.

In my view this question of whether smokers are capable of judging what is in their own best interests is at the crux of the matter. The politicians and bureaucrats who seek to modify the behaviour of smokers may see themselves as enhancing the capability of these people to have lives that they ‘have reason to value’, in accordance with well-being criteria proposed by Amartya Sen. If so, their attitudes highlight a major problem with Sen’s approach. Governments have no business deciding what kinds of lives individuals have reason to value.

Is Australia's mateship ethic being lost in the big cities?

This question was raised by Shona in a guest post about volunteering in the eastern suburbs of Sydney. I don’t feel qualified to provide an authoritative answer, but that feeling does not always prevent me from providing comments on other matters outside my area of expertise. Perhaps someone will tell me if my comments are wide of the mark.


Mateship was identified by Russel Ward as an important component of the ‘Australian identity’ – the ideas about themselves that Australians tend to identify with - in his book, ‘The Australian Legend’, first published in 1958. Ward suggested that this mateship ethic stemmed mainly from the loneliness of life in the Australian inland. In his later book, ‘Australia’, Ward explained mateship in these terms:

‘In reaction to their loneliness, to the sundering distances and to the harshness of nature, men tended to help and trust each other. This is not to claim of course that Australians are in fact notably more altruistic than other people, but merely that they tend to value collective aid and mutual aid more highly than do, for example, Americans; just as they value less highly rugged individualism’ (1967: 9).

I am not entirely comfortable with those comparisons with America. I agree that Australians probably do tend to place less value on rugged individualism than do Americans. For example, surveys show that the percentage of Australians who consider it to be important to encourage children to develop qualities of both independence and determination is lower than in the US. However, Ward himself claimed that ‘fierce independence’ was a component of Australian identity. Ward also observed in ‘Australia’ that in the third quarter of the 19th century Australian political sentiment was ‘strongly individualistic and not markedly either collectivist or nationalist’ (p 79).

Has the propensity of Australians to form voluntary associations for mutual benefit been any greater than that of Americans? I doubt it. Remember the observations of Alexis de Tocqueville in ‘Democracy in America’ (published in 1835) :

‘Americans of all ages, all conditions, and all dispositions constantly form associations. They have not only commercial and manufacturing companies, in which all take part, but associations of a thousand other kinds, religious, moral, serious, futile, general or restricted, enormous or diminutive. The Americans make associations to give entertainments, to found seminaries, to build inns, to construct churches, to diffuse books, to send missionaries to the antipodes; in this manner they found hospitals, prisons, and schools’ (II, 2, V).

Ward seems to be on firmer ground in suggesting that the early dominance of large-scale grazing properties in the Australia farm sector (in contrast to the dominance of smaller-holder agriculture in the US frontier until about 1870) led to a situation where much of the work was done by people – shearers, drovers etc. – who did not perceive their interests to be closely aligned with those of property owners (p. 60). This can be linked to the subsequent development of trade unions, major strikes, the rise of the Australian Labor Party and the advance of state collectivism – which tended to displace voluntary associations for mutual benefit.

It is worth noting at this point that mateship has a downside as well as an upside. The downside of mateship is that it can mean ‘looking after your mates’ at the expense of other people. For a long time this aspect of mateship supported racial discrimination, compulsory unionism and abuse of trade union power, high trade barriers protecting some industries at the expense of others, discrimination against women and various forms of corruption. Some aspects of this negative form of mateship are still evident in the activities of some interest groups, as well as some politicians, unionists, businessmen and public servants in the big cities as well as the rest of the country.

At last I think I am now ready to focus on the positive side of the mateship ethic and the specific question of whether it has been lost in the big cities. Volunteering is more common among those living in parts of the states outside the capital cities (38% of those surveyed by the ABS in 2006 versus 32% for the capital cities). When I look more closely, however, the difference is most marked in Victoria and New South Wales and non-existent in Queensland - the state with the highest average rate of volunteering (38%). In both Sydney and Melbourne, 30%, of those surveyed were engaged in volunteering, but in the rest of the two states the proportion was 41% in Victoria and 37% in New South Wales.

There are strong reasons based on self-interest to expect rates of volunteering to be higher in small rural communities than in major capital cities. In a small rural communities people are exposed to greater risk of natural disasters such as bush fires and floods and depend to a larger extent on voluntary help from each other to avoid harm to their families when disaster threatens. In most small communities people who had a reputation for free-riding (sponging on their mates) would probably not be denied help in the event of disaster, but few people would be prepared to take that chance.

Would people in Sydney and Melbourne show a strong spirit of mateship if these cities were threatened by a major disaster? I’m not sure. When a substantial part of Queensland was flooded earlier this year, it was obvious that many people in the rural areas showed great acts of kindness to each other. As the flood waters approached Brisbane I wondered whether this community spirit would be replaced by an attitude of just helping family and close friends. Such concerns were unwarranted. After the flooding many people in Brisbane volunteered spontaneously to help strangers to clean up their properties. This suggests to me that the best aspects of the mateship ethic is still alive and well in Brisbane. I can’t be as confident that people would help each other to the same extent in the event of a disaster in Sydney or Melbourne – but I hope I am being too pessimistic.

Postscript:
I rarely write a postscript so soon after writing an article. However, after checking the World Values Survey data on qualities that parents consider important in children I found that the situation has turned around between 2000 and 2006/7 surveys. In the later survey 64% of Australians identified independence as a desirable child quality versus 54% in the US. The percentages identifying determination/perseverence as desirable were 50% among Australians and 40% among Americans. That suggests to me that Australians might now place a higher value on rugged individualism than US citizens.

A comparison of active membership of voluntary organizations in the US and Australia does not suggest that volunteering is more important in one than the other. Americans are about twice as likely as Australians to be active members of a church, but Australians are about twice as likely as Americans to be active members of a sporting organization. (That lines up with the view that sport is the national religion of Australia). Active membership of 'Arts, music and educational' organizations and charitable organizations is much the same in both countries.

Why are people reluctant to volunteer at playgroups in the eastern suburbs of Sydney?

This post - the 300th on this blog - is a guest post by Shona. This is the fourth post in a series on volunteering. Earlier contributions can be found here, here and here. Shona has provided the following additional comments:

My thoughts continue down the path of not why do people volunteer, but rather, why don’t people volunteer.

I loved your reference to Australian mateship ethic, described by Russel Ward, in your comments on my first contribution. Having recently studied arduously for my citizenship test, I too am familiar with the ideas about the harsh environment bringing people together. Perhaps our playgroup is suffering from the opposite of this. We live in the affluent eastern suburbs of Sydney – a beautiful but densely populated area, hardly a harsh environment to live. As you know more about Ward’s work perhaps you could discuss this aspect further. Has the mateship ethic been lost in the large conurbations?

The dynamics of playgroups are unique in many ways so I’m not sure the theories relevant elsewhere apply. People with young children moving into the area look up the local playgroup and head there straight away – even more so than people who have lived here for years before starting families. People moving into the area see it as the best way to make friends and connect.

Playgroups are a unique form of volunteer community groups – any action of one person has an immediate effect, one that can be benefitted from by that person immediately, but also shared by the free riders. Still, this is perhaps more tangible than other volunteering efforts such as environmental or social work, where someone’s actions don’t necessarily result in direct benefits to the individual. That to my mind is altruistic action and I commend it – if only I had more time! That is when the dynamics of volunteering that you write about are more relevant.

I’ve noticed two breeds of volunteers – obviously I am going to place myself in the more favourable of the two groups. One which selflessly carries out work with little fuss, without taking the task or themselves too seriously (I could go on but I won’t). And the other, where they take the role far too seriously and make it almost political or personal. I had a conversation with a friend at playgroup a few years ago. She had been heavily involved in the local surf club and as a result, was put off from volunteering for any other community organization. When I asked her why, she said that it became all too political. (I have some other great examples, but I don’t want to bore you or embarrass anyone concerned). It only takes one bad experience or story of another’s experience to put someone off.

Back to my original point – I still cannot understand why people don’t volunteer, whether this is for the session they attend, in whatever form, or to a more long-term role. I agree, the timescales of a bigger role may put people off. Maybe some people do such a great job, they think it is a hard job or a hard act to follow (I say that in regard to two day leaders that have just finished an eight month stint and not myself!). I’d be interested to discuss any other barriers. One friend also suggested that people won’t commit (even for a month) if they are thinking of moving out of the area. Given this is an expensive area to live, this could be the reasoning for many attendees. However, at least two of our volunteers last year were both here on a temporary basis (not knowing how long for) and both have moved back overseas.

How well can volunteering be explained by a naive economic model?

I should begin by defining what I mean by a naïve economic model. The naïve model I have in mind is a conventional neoclassical model, with a few bells and whistles added. The bells and whistles are necessary because so called ‘rational economic man’ who is the basis of conventional neoclassical economics doesn’t practice altruism. There are probably still some economists who claim that everything everyone does is for a selfish reason, but I am not one of them. While I recognize that a lot of people do a lot of noble things for their own satisfaction, I see no reason to doubt people when they claim to be motivated by altruism.


So, in terms of the naïve model I have in mind, the objective functions that individuals follow in making choices take some account of the well-being of other people (i.e. I am assuming interdependent utilities). That means that individuals might volunteer to do something even if they perceive that this involves some cost to their own well-being. The extent that they do this would depend on the net cost in terms of loss of individual well-being and the extent that their actions affect the collective benefit they seek to obtain by volunteering. The main potential source of net loss of individual well-being would be the value to the individual of opportunities foregone from use of time in volunteering, which would be offset to the extent that the individual obtains satisfaction from volunteering, or from recognition of her efforts. The effect of individual actions on the collective benefit being sought would depend on the size of the group seeking the collective benefit. In a large groups the actions of each individual tend make a small contribution to the objective being sought, so there would be a greater incentive to free-ride on the efforts of others.

The naïve model suggests to me that people would tend to volunteer to a greater extent when they had fewer opportunities for paid employment. It therefore suggests that volunteering would tend to decline if workforce participation increased. It also suggests that volunteering would be a substitute for other forms of charitable giving – people with time on their hands would tend to volunteer their time and people in well-paying jobs that give them little leisure would be more inclined to put their hands in their pockets to make financial donations. It also suggests that people would tend to volunteer to a greater extent in small, well-defined communities (e.g. country towns) where their efforts are more likely to be recognized that in major urban centres where individuals are more likely to get lost in the crowd.

How well does this naïve model explain volunteering in Australia? Not particularly well. The first point I noticed when I looked at the relevant section of the Productivity Commission’s recent report on ‘Contribution of the Not-for-profit sector’, is that there has been a consistent upward trend in rates of volunteering across all age groups over the last decade, although this has been offset to some extent by a decline in the average number of hours volunteered. This has occurred at a time when labour force participation has continued to increase.

As might be expected, ABS data show that volunteering rates are higher among women than among men. The difference is confined mainly to the 35-44 year age group – when most female volunteering could be expected to be associated with school canteens etc. People with young children are the group most likely to volunteer regularly, but they spend fewer hours per week volunteering than do people with older children and older people without children.

Again, as expected, the rate of volunteering is higher outside capital cities than within capital cities. But the difference is not huge. The rate for regular participation in voluntary work was 19% in capital cities and 23% outside capital cities in 2006.

The naïve model would not predict that employed people would be more likely to volunteer than unemployed people. For women, although those in full-time employment had the lowest rates of regular volunteering, those who were employed part-time had higher rates of regular volunteering than those classified as unemployed. For men, rates of volunteering for those in full-time and part-time employment were the same and higher than for those who were unemployed.

The most surprising departure from the naïve model relates to donations of money as a substitute for donation of time. I know such substitution does occur, but it doesn’t show up at an aggregate level in the ABS survey data. Volunteers are much more likely to have donated money or contributed financial assistance to someone outside the family in the last 12 months than non-volunteers.

In order to explain non-volunteering we seem to need a model of behaviour that recognizes that volunteers and non-volunteers have different personal characteristics. It seems that non-volunteers tend to have relatively weak links to the community in general. The evidence suggests that they are much less likely to have attended a community event recently. They are also less likely to agree with the proposition that most people can be trusted.

Other posts on volunteering:
This is the third in a series of post on volunteering. In the first post, Shona discussed her experience in a volunteer role in a community playgroup. In the second post I discussed some research on the determinants of volunteering.