The government report released last week, optimistically titled Australia the Healthiest Country by 2020, offering the National Preventative Health Strategy managed to avoid any acknowledgement of the toxic effects of inequality. The report recognises that economic inequities go with health differences but fail to recognise that the inequalities are themselves causal.
Last week I attended a session in Sydney with Richard Wilkinson, co-author of a range of reports that show that social inequality within nations is toxic. Wilkinson’s latest book, The Spirit Level, follows a decade plus of work, on health and other social statistics which is widely accepted but not by governments.
This is the core interesting message in Wilkinson and Pickett’s latest book and their websit www.TheEqualityTrust.com. Remedies need to address people’s perceptions of lack of control over their lives and wellbeing to address poor social and health outcomes.
The Health Sociology Review special issue on the Social Determinants of Child Health and Wellbeing states:
With the growing evidence of the impact of social inequalities on health, policy makers in all countries are showing an increased interest in understanding them and in seeking ways to create more equitable societies.
The importance of this trend is charted in two editions of Social Determinants of Health by Michael Marmot and Richard Wilkinson (1999, 2006), the establishment of the Commission on the Social Determinants of Health (CSDH) by the World Health Organisation (WHO), (followed by a big list of other reports).
Their website states:
We have shown (see The Evidence) that greater equality improves health and life expectancy and dramatically reduces the frequency of a wide range of social problems including violence, mental illness, drug addiction and obesity. Many people worry about what has gone wrong with modern societies without recognising how many of the problems originate in the effects of low social status and status competition which are exacerbated by greater inequality.
Conventional approaches that focus on changing individual behaviours through education or punitive costs are not likely to be effective. Those most likely to listen to social marketing messages about self harm are those who feel some control over their lives. This is shown by high smoking and obesity rates which correlate with low incomes.
Higher taxes and costs will drive some low income people to cut their spending but those with least sense of self control will go without food instead.
Yet this brand new National Preventative Health Strategy report reflects none of these findings, apart from some brief mentions and acknowledgements towards the end. Early on it sounds promising, to quote:
We need this Strategy because Australia has a national commitment to fairness. Currently, good and bad health is unevenly distributed — there is a social gradient, which means that those Australians with less money, less education and insecure working conditions are much more likely to get sick and die earlier. This inequity is extremely acute for Indigenous Australians.
This Strategy is important. It seeks to do. It is evidence-based, or where the evidence is yet to be developed, it is evidence-building…
Where is their evidence base? Why does the report fail to acknowledge that the patterns of ill health in most unequal affluent societies are remarkably similar, which raises questions on the social bases for many of these conditions?
What struck me some months ago was how closely the Wilkinson data gaps match the equally intransigent gaps identified between Indigenous and non-Indigenous health in Australia.
This apparent coincidence suggests that poverty per se is not the primary reason for these types of health outcome problems but a unexamined mix of lack of appropriate services and the perceptions of social status and lack of agency of populations. We have ample evidence that services that work in Aboriginal communities must engage and involve the local community in their planning and management, be culturally appropriate, preferably involve local staffing and be there long term so good relationships and trust can be developed.
Yet none of this was reflected in the preventative health report. As this is the sector of health services most dependant on relationships, trust and cultural appropriateness, the absence of the social factors is serious. The model that underpins the report seems to be primarily based on the sin factor: people eat, drink and abuse their bodies because they are individually irresponsible, ill informed or maybe unable to find services.
Therefore the solutions are targeted to changing individual or maybe group behaviours, and fail to acknowledge the social causes and social solutions to many of the problems identified.
There are serious echoes of standard conservative/neo liberal ideologies in the way the report identifies the problems and solutions. Yet the evidence is out there, so why is it not acknowledged? The social determinants of health powerfully show us new ways forward to better health, but this report doesn’t reflect them. Why not?