The Social Determinants of Health are the conditions in which we work, live, and play. We, as a society, choose these conditions and/or choose not to change them. They play at least as important a role in health outcomes as access to care.

Climate change

Most people don’t disagree that climate change is happening, and humans are a major contributor. The harmful effects on health in the next 30 years are likely to be major. There will be changes in the distribution of various known infectious diseases as well as the potential for the evolution of newer diseases in the ecological disruption as we head to a hotter planet.

We already see the destructive effect of changing weather patterns at home and across the world. Australians are dying in these disasters and will continue to do. Unexpected heat is killing people across continents.

The worldwide disruptions to life in areas affected by rising sea levels, weather changes, and climate-related “natural” disasters will have implications for Australia as we see large population upheavals across the world and increasingly desperate battles for basic resources such as food and water, let alone a stable house in a stable community.

We are making very slow progress in reducing the amount of greenhouse gases we emit in Australia. Most of the improvement towards achieving our Paris Agreement commitments have been achieved through a reduction in land clearing from a peak in 2005, the baseline for the Paris targets.

However, we export fossil fuels whose carbon (our carbon) goes into the atmosphere, and we ignore that figure in our policies. Twice as much CO2 is emitted by burning these fossil fuels as we emit in Australia. We intend to increase those exports.

These are the policies of the current government, and the Coalition plans even more local emissions as it plans to use more domestic gas.

Disaster will be the legacy we leave our grandchildren.

Education

There are clear links between education and health outcomes. Often it is indirect e.g. through earning capacity, but often it is much more direct as poorly educated people struggle to understand illness, prevention, and access to the health system.

The widely heralded Gonski recommendations of the Rudd era are yet to be fully implemented. Labor is finally making some changes to the huge disparity in schooling opportunities at the primary and secondary level. Universities are no longer places dedicated to learning. Learning is seen as a means to an end i.e. more money for the universities. Access has been made a little easier by Labor, but the new model of education as business permeates the sector is getting worse rather than better. The best and smartest rise above it. Others are left with wasted years.

Social services

The Australian Council of Social Services reported in 2016 that in the decade to 2014, 13.3% of Australians and 17.4% of children lived below the poverty line. Pre-COVID, in the year 2019-20, the figures were 13.4% and 16.6%. This was, and is, despite the various assistance packages in place.

JobSeeker used to be 90% of the pension in 1990. It is now 69%. JobSeeker has been increased by Labor, but remains below the poverty line. For the Coalition, the justification is that the unemployed will not look for work if they are living at the poverty line. There is evidence from studies on basic income guarantees that even when given incomes slightly above the poverty line, the majority chase either jobs or education to get a better job. Labor ignores the fact that poverty is directly correlated with health outcomes.

The link between income and health outcomes is not simply related to access to care. Groundbreaking research by Marmot in the 1960s looked at Whitehall public servants. He found a direct and continuous link between health outcomes for a range of diseases and position in the public service. The rich did well. The middle earners did reasonably well. The lowest paid (not in poverty) did worse. Similar work since has confirmed the link. Position combined with income suggests that a sense of control over one’s life is crucial to health outcomes irrespective of access.

Housing and rental affordability

Housing is a health issue. Health is worse among the homeless. It is worse in the poorly housed. Poor quality and siting of housing exposes people to environmental health risks, including pollution, noise, flooding, fire, and infectious diseases. This is a major issue for those on low and even middle incomes. It is multifactorial and both major parties have suggested policies, and Labor is implementing some policies which may help. Not considered at all is the possibility of a National Housing Commission which could build houses. There is nothing new in such a suggestion. In 1965 the authoritarian president of Singapore, Lee Kuan Yew, set up a Housing Commission and over five years housed 30% of the population in apartments. By 1989, 80% were housed in government units. The UK did similarly after the war. It’s a suggestion former ACTU secretary Bill Kelty made on this site recently. Instead, we leave ourselves at the mercy of private profit-driven developers. It does not appear to have been considered by the major parties.

Taxation

“For one very rich man, there must be at least 500 poor, and the affluence of the rich supposes the indigence of the poor.” – The Wealth of Nations

So said Adam Smith, a darling of capitalism. Conservatives and liberals who take time to think do know that luck is so important in determining wealth and therefore health outcomes. Hard work is often, but not always, necessary. But few are prepared to redress the wealth imbalance as is clearly evidenced by our tax system which does a very modest job of redistribution. The reality of income and wealth inequality in our capitalist economy continues. Most know what should be done. Labor lost the 2019 election after proposing modest changes and has run from those changes ever since.

Our gradually less entrenched two-party parliament will continue to fail to adequately address these issues. We can only hope that neither party is in total control after the election.