The ABC Boyer Lecture series this year is being delivered by Sir Michael Marmot, the World Medical Association President and Professor of Epidemiology and Public Health at University College London .The main thrust of his lecture series has been about inequalities, poverty and social conditions – the social determinants – that have a major impact on health in the community.
Reading the Boyer Lectures, I was reminded of my experience in chairing the Generational Health Review in SA in 2003. We held a discussion with indigenous women about indigenous health problems in SA. Towards the end of the discussion, a woman who was known affectionately and with respect as ‘aunty’ and who came from a well-known indigenous family in SA, said
“Thank you, Mr. Menadue, for what you are trying to do to help indigenous people , but when I speak to young men in my mob about the importance of health, they say to me “Aunty, with our prospects in life, what is the point of being healthy?”
I have never forgotten.
In his lecture, Sir Michael said:
‘In my view, the reason why aborigines have worse health than the non-indigenous population is because of inequality.’ … ‘Isn’t health a matter of personal responsibility? If people fail to heed advice about smoking and healthy lifestyle, they have no one to blame but themselves. I invite you to go into a deprived community in Sydney or Melbourne, let alone the fringes of a benighted country town and start lecturing people about healthy eating. To put it politely, you would be given short shrift. It is not ignorance of the health consequences that lead to unhealthy behaviour. Making ends meet, avoiding violence and other crime all take priority. People are not responsible for the social forces in their life. Get the social conditions right… and then of course people can be expected to take responsibility for their own health.’
There is a stark message here that we have got our priorities in health wrong, We have developed health services focusing on treating people when they get sick, a highly medicalised approach, rather than keeping them healthy from the beginning. We have our financial incentives all wrong. We reward doctors for treating sick people on a fee-for-service basis rather than paying them by salary or contract, to keep people healthy.
We have a hospital-centric system when the objective should be to keep people out of hospital wherever and wherever possible. Hospitals are dangerous and expensive places. They should be a last rather than a first resort.
Many ministers in the ‘health’ field would be better described as ministers for hospitals. This is particularly true of many state ‘health’ ministers. These ministers focus almost exclusively on hospitals and the media does exactly the same. Ministers love iconic hospitals. They are great opportunities for public announcements about an expansion or laying a new foundation stone.
The fact is we have too many hospitals and too many hospital beds. But we refuse to accept that fact. Hospitals are like the family refrigerator, they will always be full.
An objective of good ‘health’ policy would be to reduce the focus on hospitals and beds by building healthcare in the community and the home.
Unfortunately, acute and urgent care in hospitals, displaces the important and money and effort is focused on hospitals and beds . This is a particular problem in Australia because of divided responsibilities in health – the states run the hospitals and the federal government provides most of the money for community care. Until we address the dysfunction that arises because of different funding streams, we will continue to have major problems. Our emergency departments in state public hospitals are under great pressure in part because of the collapse of federally funded general practice in unsociable hours.
In addition to the over-focus on hospitals, ministers focus on health services rather than health. Many of the most important factors influencing health outcomes are outside the health portfolio. These include
- Advertising of junk foods and alcohol, particularly to young people.
- Poor employment prospects and high unemployment which directly affect health outcomes. Poverty and poor health go together.
- Poor education and poor parenting reduces the prospects of children for an improved life, including good health.
- Poor transport particularly affects country people and affects their health outcomes.
- Poor housing affects health.
- In urban areas particularly, there is a lack of open space and opportunities for exercise.
There are numerous ways in which health is affected significantly by what happens in portfolios beyond that of the Minister for Health. There is little consideration of ‘joined up government’ to address many health issues.
The real and basic problems that cause bad health are largely ignored. The social determinants of health have a major impact on health. The evidence is clear. Professor Fran Baum in The Conversation (September 1, 2016) drew attention to the social consequences of inequality. She said :
‘Men living in the Sydney suburb Fairfield East for instance, are twice as likely to die between ages 0 and 74 as those in the far richer Sydney suburb of Woollahra. The infant death rate in Fairfield is four per 1,000 live births, compared with 2.4 in Woollahra. Across Australia, low income people lose about six years of life compared to their better off compatriots. If policy makers want to reduce health inequities, one of the best ways is to create environments that promote better health. This is known as addressing the social determinants of health. ‘
Sharon Field also in The Conversation on 1 September 2016 points to the way that class and wealth affect health in the community. She shows that poor people have much worse health outcomes than rich people. See table below.
Long term health conditions by socio-economic status. Comparing the lowest quintile of SES status with the highest quintile.
|Condition||Lowest SES quintile – %||Highest SES quintile – %|
|Mental and behavioural problems||21.5||15.0|
|Chronic obstructive pulmonary disease||4.1||1.5|
|Heart, stroke, vascular||7.2||4.2|
We need to focus on several priorities that we choose to ignore.
First, the key to good health outcomes is focusing on the social determinants of health, such as poverty and inequality, that have such a dramatic affect on health outcomes.
Second, public health and prevention must have priority.
Third, health services are best delivered in the community and not through hospitals.
Fourth, many of the factors that dramatically affect health outcomes depend on action outside the health portfolio. Unfortunately, most ‘health ‘ ministers are really ministers for hospitals or health services – and not ministers for health.
Poverty and inequality are the major factors causing poor health across the Australian community and particularly in indigenous mental and rural health. We apply band aids in our highly medicalised model of care. We deal with the symptoms , not the cause.
Unless we focus on these issues, we will continue to be left with the question raised with me by indigenous people and others who say “With our prospects in life, what is the point of being healthy”. That is what the social determinants of health are all about.