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Institutional racism in Australian healthcare: a plea for decency

Barbara R Henry, Shane Houston and Gavin H Mooney

5 April 2004 - There is no dispute that Aboriginal health in Australia is both poor and very much worse than that of non-Aboriginal people, and their life expectancy at birth is about 21 years less for men and 19 years less for women. Among Aboriginal and Torres Strait Islander males, 6.8% die in infancy, compared with 1% for the rest of the population. For females the figures are 6.7% and 0.8%. A large array of diseases are much more prevalent among Aborigines.1

This is not news. The question is how to improve this situation. The argument presented in this article rests on two core and related ideas:

• that our health services are “institutionally racist” and
• that such racism stems from Australia being, or at least having become, an uncaring society.

The way forward that we propose is recognising and addressing institutional racism. This would provide a framework for improving Aboriginal health. We believe, however, that acceptance of the need to address such racism can only come about through building a more compassionate and decent society.

To suggest that healthcare in Australia is institutionally racist may be confronting for some, but we argue not only that it is institutionally racist, but, more importantly, that such racism represents one of the greatest barriers to improving the health of Aboriginal and Torres Strait Islander people. We will also indicate what might be done to overcome this institutional racism and improve Aboriginal health.

Defining institutional racism

Institutional racism “refers to the ways in which racist beliefs or values have been built into the operations of social institutions in such a way as to discriminate against, control and oppress various minority groups”.2 It has been claimed that “Institutional racism is embedded in Australian institutions”.3 Often, institutional racism is covert or even unrecognised by the agents involved in it.

In recent years, interest in both the concept and practice of institutional racism has increased. In the United Kingdom, it was sparked by the Stephen Lawrence Inquiry,4 published in 1999. This examined the events which followed the completely unprovoked murder in 1993 of Stephen Lawrence, a young black man, which was “unequivocally motivated by racism”. It found that the investigation was marred by a combination of professional incompetence, institutional racism and a failure of leadership by senior officers. It claimed that “officers approached the murder of a black man less energetically than if the victim had been white and the murderers black”.

In the context of racial and ethnic disparities, Camara Jones,5 an Assistant Professor at Harvard University School of Public Health, has called for “a growing national conversation on racism”, one key aspect of which is “institutionalized racism”. This she sees as being “often evident as inaction in the face of need”. An increasing focus on institutional racism in Aotearoa (New Zealand) was prompted by a visit there by Camara Jones in 1999.6

In Australia, institutional racism has been an almost constant feature of our history, from the British designation of the continent as terra nullius, through the 1897 Convention on Federation (where the question of whether Aboriginal people should be counted as “people” in the national census was covered in just 195 words7), to the stolen generations and the failure of the federal government to issue an apology.

Clash of cultures

We believe that any healthcare system is a social institution built on the cultural stance of the population it serves. It follows that cultural values should provide the value base for health services.

Between Aboriginal and non-Aboriginal Australians, there is not only a difference in culture, but a clash of cultures. We think some white people are at least dimly aware of this. However, the extent of their understanding of the difference between a culture based on individualism, where the individual ranks above the community in importance, and a communitarian culture, in which each individual is less important than the whole, is limited.

One of us, S H,7 a Gungulu man, has written: “Aboriginal Peoples have built a communitarian solidarity that includes an awareness and affirmation of the [cultural] difference [of Aboriginal people]. Such communitarian solidarity is a form of civic friendship between peoples that is distinguishable from other forms of friendship because it unites people who are members of the same particularistic cultural community ­ persons who share a common worldview and use the same primary moral vocabulary.” Yet that value base is inadequately recognised in the planning of healthcare services in this country.

Where societies or social entities have a greater awareness of and concern for mutuality, reciprocity and sharing, trust in institutions will be fostered and racism will diminish. Many Australians have embraced the individualism of neoliberalism. Uniting as a community around little other than the successes of its sporting teams, today’s white Australia lacks these “communitarian” traits.

While communitarianism need not always be a force for good (the Nazi vision of the “master race” is a case in point), it can be and has been a beneficial force in Aboriginal culture. Here it is best seen in terms of what the distinguished public servant Coombs12 describes as “the Aboriginal ethic of accountability to others”. This, he writes, “is required by their commitment that autonomy, at a personal and group level, will be exercised so as to ensure that what is done contributes to the care and nurture of others with whom they are related; so that personal behaviour remains socially grounded”.

In current health policy there is little attempt to recognise the differences in culture between black and white. The holism of Aboriginal health involves not just a “wholeness”, but a series of mutual obligations. Aboriginal Medical Services attempt to provide culturally “secure” services (ie, services based on Aboriginal preferences where differences in culture do not create additional barriers to use). Their poor funding levels, however, severely restrict them in this. Mainstream services make almost no effort to understand or provide culturally secure services. To deliver such services might increase primary healthcare costs for Aboriginal people by more than 50%.9,13 This is because, for example, questioning with respect to history has to be indirect, and preceded by time spent in building trust and confidence between the doctor and patient. This process, to be done well, can be time consuming. Also, advocacy on behalf of the client with other agencies, such as those providing housing, is often expected by Aboriginal clients as part of a GP’s role.

The prospects for creating a cohesive Australian community, advancing social capital, furthering equity and reducing racism are not bright. For example, the Human Rights and Equal Opportunities Commission conducted a series of consultations across Australia which showed racism to be widespread and institutionally based, especially with respect to Aboriginal people.14 We believe that the current Australian federal government puts at risk our social capital in its pursuit of divisive policies. This applies not only to Aboriginal people, but also to other minority groups, defined racially or otherwise. For example, extending upfront fees for universities gives the affluent greater access compared with the poor; and ignoring the principle of universality (which did not rate a mention in the Prime Minister’s media release as one of his three pillars of Medicare15) on Medicareplus creates yet more of a two-tier healthcare system. The government’s policies on immigration have been severely criticised by many, including Father Frank Brennan, the Jesuit priest and lawyer, who concludes his book on the subject with an appeal to re-create social capital in Australia: “Many of us would like to return collectively to being a warm-hearted, decent international citizen.”16

We believe that Aboriginal people have lost their trust in the institutions of government, including healthcare services. Lack of respect by white Australians for Aboriginal values, the discounting of these values by those who have sought, patronisingly and paternalistically, to “do good” to Aboriginal people (according to a “good” defined by white fellas), leads to further erosion of trust. The lack of trust by Aboriginal people in white people and white institutions is obvious. More tellingly, we believe there is a lack of trust by Aboriginal people in themselves as a people ­ a lack of confidence in their culture. It is this last, a legacy of colonisation and its aftermath, that has wreaked the greatest havoc of all.

We also believe that there is a lack of political will and of leadership to deal with inequalities generally in Australian healthcare. The most glaring example in recent times lies in the government’s schemes to promote private health insurance. The cost of increasing spending on primary healthcare for Aboriginal people to a level which would take into account such considerations as greater health problems, cultural-access barriers and equity (ie, increasing it to five times the per-capita level for non-Aboriginal people17) might be measured by the benefit forgone if the government were to halve the rebate (from 30% to 15%) for private health insurance.18

Progressing from institutional racism

Currently, cultural differences and ignorance create racism, and indifference nurtures it. Cultural differences must be celebrated, rather than denigrated. Former Prime Minister Paul Keating’s Redfern Speech on reconciliation pointed the way forward: “I think what we need to do is open our hearts a bit. All of us. Perhaps when we recognise what we have in common we will see the things which must be done . . . If we open one door others will follow.”19

That was 12 years ago. Today, the converse is true. As we have closed one door, others have followed. So many doors on social justice are closing in this society. We closed the door on a Norwegian freighter carrying abandoned refugees. We close the door on children in detention centres, on poor youngsters trying to get a university place. We close the door on opportunities for Aboriginal people and on the richness of an ancient culture which is potentially there for all Australians to learn from and take pride in.

What scope is there for building compassion? Not much, it might seem, in this neoliberal society and this globalising world. Yet, as the social commentator Richard Titmuss remarked 30 years ago about the UK National Health Service, altruism and compassionate acts are infectious not only to other people, but to other events and circumstances.20 Compassion is good for us.

What to do?

Firstly, white Australia must learn to understand Aboriginal culture, particularly with respect to its fundamental philosophy of “communitarian solidarity”. Only then can social institutions, such as healthcare services for Aboriginal people, be built on a genuine understanding followed by accommodation of the hopes and aspirations of Aboriginal people. More directly, only then can Aboriginal people have the chance to have health services delivered to them that are, by right, as accessible (in the broadest sense) as they are to white Australians.

Secondly, those white people who were described (above) as patronising and paternalistic would cease to be so when, in their “doing good”, good was defined by Aboriginal preferences.

Thirdly, Aboriginal communitarian preferences must drive Aboriginal health services, their funding and their performance indicators. Unless the governance of Aboriginal organisations is based on Aboriginal cultural values, these services will not function effectively or efficiently.

Fourthly, public compassion must be built into the Australian social fabric. The “fair go”, if it ever existed, has gone, but Australia needs a leadership that will articulate that fair go. The philosopher Martha Nussbaum argues against “impoverished models of humanity” with “numbers and dots taking the place of women and men”.21 She continues: “. . . when one’s deliberation fails to endow human beings with their full and complex humanity, it becomes very much easier to contemplate doing terrible things towards them . . . if you really vividly experience a concrete human life, imagine what it is like to live that life, and at the same time permit yourself the full range of emotional responses to that concrete life, you will . . . be unable to do certain things to that person. Vividness leads to tenderness, imagination to compassion.”21

Finally, our call is for a more compassionate society. Attitudes to asylum seekers, to Aboriginal people, to people who are in any way disadvantaged, are linked. Social attitudes need to be more compassionate to all who are disadvantaged, and not just to Aboriginal people.

Conclusion

Aboriginal people merit so much more from white Australia. First and foremost, they deserve white Australia’s trust ­ trust that Aboriginal people know better than white Australians what is good for Aboriginal people. They deserve (and not just in their music and dancing) recognition of their culture. Two things are necessary ­ first, Australian society needs to listen and hear the calls of the disadvantaged (and there are so many in Australia today, especially Aboriginal people); then, those who have compassionate voices need to use them. Many people working in healthcare and in universities have social consciences and believe in social justice. They need not only to give voice to the voiceless, but to give themselves voice as decent, white Australians.

In this Australia ­ this divided, divisive, racist, socially unjust society that we have built ­ we now need institutions and policies that will unbuild it. We need to acknowledge that the “fair go” is struggling to survive, if not already dead. Fairness and compassion need to be once again the guiding principles of our leaders and our democracy. Only then can we build a society where decency can become the fundamental in addressing Aboriginal health.

There will be no sudden breakthrough; there is no magic pill. Decency, however, is a good place to start.

Competing interests

None identified.

References:
1. Australian Institute of Health and Welfare. The health and welfare of Australia’s Aboriginal and Torres Strait Islander peoples. Canberra: AIHW, 2003.
2. McConnachie K, Hollingsworth D, Pettman J. Race and racism in Australia. Sydney: Social Science Press, 1988.
3. Bolt RJ. It’s just how you’ve been brought up! An Aboriginal perspective on the relationship between the law, racism and mental health [honours thesis]. Sydney: University of Sydney, 2001.
4. The Stephen Lawrence Inquiry. London: Stationery Office, 1999.
5. Jones C. Invited commentary: “Race”, racism and the practice of epidemiology. Am J Epidemiol 2001; 154: 299-304. <PubMed>
6. Jones C. Maori-Pakeha health disparities. Can treaty settlements reverse the impacts of racism? Available at: www.fulbright.org.nz/voices/axford/jonesc.html (accessed Apr 2004).
7. Houston S. The past, the present, the future of Aboriginal health policy [doctoral thesis]. Perth: Curtin University, 2004.
8. Australian Institute of Health and Welfare. Expenditures on health services for Aboriginal and Torres Strait Islander people 1998–1999. Canberra: AIHW, 2001.
9. Wilkes E, Houston S, Mooney G. Cultural security: some cost estimates from Derbarl Yerrigan health service. New Doctor 2002; 77: 13-15.
10. McGuire T, Houston S, Rohwedder E, Montague G. Identifying Aboriginal person care in hospital and Medicare documentation. Perth: Health Department of Western Australia, 1998.
11. Wakerman J, Tragenza J, Warchivker I. Review of health services in the Kutjungka Region of WA. Perth: Office of Aboriginal Health, Health Department of Western Australia, 1999.
12. Coombs HC. Aboriginal autonomy. Cambridge: Cambridge University Press, 1994: 222.
13. Mooney G, Collard K, Taylor T. Costing cultural security. SPHERe Discussion Paper. Perth: Division of Health Sciences, Curtin University, 2003.
14. Human Rights and Equal Opportunities Commission. I want respect and equality. A summary of consultations with Civil Society on Racism in Australia. Available at: www.humanrights.gov.au/racial_discrimination/consultations/consultations.html (accessed Mar 2004).
15. Howard JW. Medicareplus: protecting and strengthening medicare. Available at: www.pm.gov.au/news/media_releases/media_Release574.html (accessed Mar 2004).
16. Brennan F. Tampering with asylum. Brisbane: University of Queensland Press, 2003: 216.
17. Mooney G. Inequity in Australian health care: how do we progress from here? Aust N Z J Public Health 2003; 27: 267-270. <PubMed>
18. Henry B, Mooney G. Improving Aboriginal health: more than just chucking more money at it. SPHERe Discussion Paper. Perth: Division of Health Sciences, Curtin University, 2003.
19. Keating P. Redfern Speech (Year of the World’s Indigenous People) ­ 10 December 1992. Available at: www.keating.org.au/main.cfm (accessed Feb 2004).
20. Titmuss RM. The gift relationship. London: Allen and Unwin, 1971.
21. Nussbaum M. Love’s knowledge. Oxford: Oxford University Press, 1990: 101, 209.

Source: The Medical Journal of Australia

Institutional Racism in Australian healthcare and disparities in health care for Afro/Americans in the United States

The Health Report, ABC Radio

Presenter: Norman Swan
Producer: Brigitte Seega

31 May 2004 - In Australia we have great disparities in the health system when it comes to health care for Aboriginal people compared to the white population. The authors of an article recently published in the Medical Journal of Australia call this institutional racism and one of the authors, Professor Gavin Mooney from Curtin University in Perth, explains why.

And Professor Arline Geronimus from the University of Michigan talks about the situation for Afro/Americans in the United States.

Program Transcript
Talking of high risk, in Australia no group of people are at more risk of everything than Aboriginal people and Torres Strait Islanders. They also significantly under-utilise the health care system for the level of sickness they have. According to a recent paper in the Medical Journal of Australia, a tangible example is that in one remote Aboriginal community the Medicare and pharmaceutical spend is $80 per person per year, compared to Double Bay in Sydney, where apparently it’s $900 per person per year.

A major reason for this disparity, claim the authors of this papers, is what they call institutional racism. One of the researchers was Gavin Mooney, Professor of Health Economics at Curtin University in Perth.

Gavin Mooney: Institutional racism refers to how racist beliefs or values get built into how social institutions operate and end up discriminating against Aboriginal people.

Let me give you some examples. Aboriginal Medical Services were created for Aboriginal people so they could have care which is culturally more appropriate. These services attempt to deliver holistic health care, in essence, treating people as whole people and not ‘body parts’.

Yet Danila Dilba, the Aboriginal Medical Service in Darwin, has 26 different funding streams and consequently 26 separate accounts and 26 different demands for accountability. With so many different funding boxes there’s no recognition of the Aboriginal concern for holism. And there’s no sense of trust in allowing the Aboriginal management to decide how best the funds can be spent.

The lack of recognition of the cultural phenomenon of holism is the sort of institutional racism we’re pointing to.

Another example is Derbarl Yerrigan, the Aboriginal Medical Service in Perth. This service was cut when it overspent by about 10%, around $800,000. And that arose because it opened a new branch on the outskirts of Perth, in Midland, which attracted so many new Aboriginal clients, that it bust the budget. Despite that success, management accountants were sent in, new financial arrangements were imposed and to save money, Derbarl Yerrigan had to close its Midland branch. That in itself might be described as institutional racism. Why we say this is very clearly institutionally racist is that, at the same time as that was going on, the teaching hospitals in Perth were overspending to the tune of $100-million, that is 120 times as big an overspend, but no closures occurred, no management accountants were sent in, no new financial arrangements imposed, and the teaching hospitals were bailed out. All hell would have broken loose if that had been a black organisation. In terms of accountability, one law for white organisations and another for black.

The way in which Aboriginal people are treated in hospital can be institutionally racist. For example, in Western Australia in the late 1990s, Aboriginal people aged in their 50s were receiving only low cost nursing care, whereas a similar white group were receiving higher cost technological care for what were similar problems. The only difference between these two groups of patients was that one was white, the other black. That is again institutional racism.

There’s not just a difference between cultures, it’s a clash, and reflects the fact that the nature of white Australia today is very much based on the individualism of neo-liberalism. Aboriginal culture is traditionally and remains, much more community focused and there is a desire for mutuality, reciprocity, sharing. We would argue that health services are first and foremost social institutions built on the cultural stance of the population that they serve, or at least this is what they should aim for. Mainstream health services in Australia are driven by individualistic western values and not the community values of Aboriginal people.

Aboriginal people have lost their trust in the institutions of government, including specifically Australian health services. Lack of respect by white Australians for Aboriginal values and the discounting of these values by those white people who have sought patronisingly and paternalistically to do good to them, according to a good defined by whitefellas, leads to further erosion of trust.

The old missions were a case in point. Today the same phenomenon continues in not the disbanding as such of ATSIC, but the failure to consult Aboriginal people in determining its replacement. The lack of trust by Aboriginal people in white institutions is obvious. What is more telling still, is the lack of trust by Aboriginal people in themselves as a people and a lack of confidence in their culture. This last, a legacy of colonisation and its aftermath, has wreaked the greatest havoc of all.

Some progress was made in the 1980s. There was hope in Paul Keating’s Redfern speech on reconciliation when he said, ‘I think what we need to do is to open our hearts a bit. All of us. If we open one door, others will follow.’

But what to do today? Well first of all, white Australia needs to understand that Aboriginal culture is different, particularly with respect to having the notion of community centre stage. Recognising that will allow health services to be designed to be culturally more acceptable to Aboriginal people and have services delivered to them that by right are just as accessible as they are to white Australia. Aboriginal Medical Services need to be funded adequately, at least twice as much as currently, partly to provide this better access and partly because of the greater burden of illness they have to deal with, compared to the average white general practice. They also need to be able to have Aboriginally appropriate governance structures and Aboriginally designed performance indicators to be met out of one bucket of money and not up to 26. Good, tight governance and good, tight financial management and good, solid public health principles are much more likely when Aboriginal people have a say in how they want services delivered.

In the mainstream, there needs to be an acceptance that Aboriginal people see hospitals and other mainstream services as being run by white authority according to ‘white’ rules. Aboriginal patients approach such services with fear and foreboding or worse, are prevented from approaching them because of fear and foreboding. Aboriginal people are different and need to be treated differently but fairly, according to their culture.

More fundamentally, public compassion must be built into the Australian social fabric and the ‘fair go’ resurrected. The nation desperately needs compassionate leadership. Currently Australian politics is run on the basis of what the philosopher Martha Nussbaum in another context has called ‘impoverished models of humanity’ with ‘numbers and dots taking the place of women and men’.

We have built a divided, divisive, racist, socially unjust society. We now need institutions and policies that will unbuild that.

We need to build a compassionate society. It is in this compassion that the key lies to getting society to listen to the wishes of Aboriginal people and Aboriginal patients.

There is no magic pill in Aboriginal health but we suggest that decency is a good place to start.

Norman Swan: And the paper by Barbara Henry, Shane Houston and Gavin Mooney can be found on the Medical Journal of Australia’s website.

Norman Swan: We’re not alone though in having these disparities in health. The United States has them in spaces and someone who studies the effects in detail is Arline Geronimus, Professor of Health Behaviour and Health Education at the University of Michigan School of Public Health. And she has an interesting concept for it.

Arline Geronimus: In the United States there’s tremendous differences in length of life and length of healthy life between Americans on average and African Americans who reside in high poverty urban areas. People in those areas for instance, have less chance of surviving to age 45 than Americans nationwide have of surviving to age 65, and they’re also likely to have multiple functional disabilities.

Norman Swan: Now sitting in Australia, when you hear about African Americans, you come up with the rather prejudiced view, it’s drugs and urban violence, that’s the reason why they’re dying early. But your research suggests significantly otherwise.

Arline Geronimus: Right. That’s certainly the popular perception here in America too, but it’s not confirmed by the facts. The main causes of death at early ages in the African American urban community are cardiovascular disease, cancer, other chronic diseases, and in fact those rates have been rising over time, at the same time that some of them are tabloid notions of homicide deaths or violence or drug induced deaths have been going down.

Norman Swan: There’s a huge now black middle class; how does that pattern play out?

Arline Geronimus: On all measures African Americans at the same say income level are doing worse than white Americans. But within the African American community there are clear gradients in terms of mortality, that is life expectancy, where middle-class African Americans do better than poor African Americans. In terms of chronic disease and functional limitations however, there’s very little difference, suggesting that even middle-class African Americans bear a burden of disease that they’re able with their resources, to avert early mortality from, but they’re not able to avert entirely the burden of disease. And in fact, what it implies is that the extra years of life that middle class blacks have, are years of unhealthy life, whereas for whites as their gradient goes up and their life expectancy increases, they have a greater number of years of healthy life.

Norman Swan: What’s the explanation for that? There could be various explanations. One is that if you’re born African American, life’s dealt you a bad genetic hand. Or is it a first generation problem, that these people are people who’ve pulled themselves out of poverty into middle class. What do you think is causing this flat line, where in whites if you improve your social circumstances, you seem to be better off physically?

Arline Geronimus: It’s a few things. One you touched on before, which is I do think you do harbour into later ages of your lifespan any disadvantages you had in youth. But I think above and beyond that, there’s a real struggle to be socially mobile if you’re an African American in a race conscious society that privileges white Americans. So those who become socially mobile are people who’ve had to endure persistent high effort coping who then see in a race conscious society, that they still don’t reap the same rewards that their white peers do. There’s lots of evidence that for the same level of education and the same job, even in the same firm, that African Americans are paid less than white Americans, you’re part of a collective community of African Americans, you probably have relatives, friends and kin who are struggling or are very disadvantaged, and you care about them, and that takes a toll too.

Norman Swan: And you call this process weathering.

Arline Geronimus: Yes, for several reasons. On a physiological level I think it’s about the wear and tear on body systems of persistent high effort coping, and I also think metaphorically weathering’s an interesting way to think about it because we’re talking about people who have weathered the storms. Urban African Americans are working hard every day and in some ways part of the ill health they suffer even when they become middle class, is the physiological price they’ve paid for that constant struggle, the constant fighting, the constant working, and working not only in paid employment, they have tremendous caretaking obligations. You have in black communities, tremendous caretaking needs of people of all ages, and you have a depleted pool of caretakers because people are dying or becoming disabled at the ages that we again usually think of as the prime supportive and productive ages.

Norman Swan: Does it tell you anything about spending money more effectively, which is the struggle in Australia?

Arline Geronimus: I think it suggests to some extent a 180-degree turn. I think it suggests that first of all, putting money into medical care is important, but it’s not going to make a big dent in this. It suggested even traditional health promotion programs are likely not to be very effective. It suggests almost a different set of guidelines for how to think about social policies, to think about them in terms of how they affect different populations economically of course and in terms of their environment and environmental hazards in their residential environment and work environments, but it also means thinking about the ways in which social policies exacerbate the need to do this high effort coping, to what extent do they fragment already overburdened local social networks, to what extent do they cause psycho-social stress by being implicitly, sometimes explicitly racist, but other times inadvertently racist. To what extent are they affecting the psycho-social conditions of life as well as the material conditions. And bearing in mind always that it is local networks who are taking care of these huge caretaking needs, and so policies need to be particularly as sensitive to not disrupting those networks and if there are ways to support them doing that.

Norman Swan: Arline Geronimus is Professor of Health Behaviour and Health Education at the University of Michigan School of Public Health.

References:

• Geronimus A.T. et al. Inequality In Life Expectancy, Functional Status, And Active Life Expectancy Across Selected Black And White Populations In The United States. Demography, May 2001;Vol.38;2:227-251
• Geronimus A.T. et al. Excess Mortality Among Blacks And Whites In The United States. The New England Journal of Medicine,( November 21, 1996);335:1552-1558
• Arline T. Geronimus. Understanding and Eliminating Racial Inequalities in Women’s Health in the United States: The Role of the Weathering Conceptual Framework. JAMWA;56;4:133137
• Arline T. Geronimus. To Mitigate, Resist, or Undo: Addressing Structural Influences on the Health of Urban Populations. American Journal of Public Health, June 2000;90;6:867-872

I’m Norman Swan and you’ve been listening to The Health Report.

Guests on this program:
Dr Arline Geronimus
Professor of Health Behaviour and Health Education University of Michigan, School of Public Health U.S.A.
Dr Gavin Mooney
Professor of Health Economics Curtin University Perth Western Australia

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