Health equity is a political and community choice
While the causes of non-communicable diseases are different to that of infectious diseases, they too are largely preventable. Diet and physical activity are important contributors, but these are in turn strongly influenced by the design of towns and cities, by education and employment opportunities, and by the nature and extent of community facilities (Giles-Corti et al., 2016). Indeed there is extensive evidence to support the proposition that the social ecology of the places we live – the conditions of ‘upstream’ health-determining natural, built, social and economic environments (Department of Human Services, 2001) – play an important role in determining how healthy we are (Marmot, 2005). Significant among this evidence is the observed gradient in health status: at the population level, health and life expectancy strongly correlate with income and social status (Preston, 2007).
With a recent paper estimating that almost a quarter of global deaths and a similar percentage of global disability adjusted life years are attributable to social determinants (Prüss-Ustün et al., 2016) there is huge potential to improve public health, particularly that of the most disadvantaged populations, by improving the conditions in which we live, work, play and age. So why so little action on social determinants and on health equity? Fran Baum, in a recent presentation to the 15th World Congress in Public Health, provided some useful perspectives, and identified a number of reasons for the inadequate level of ‘upstream’ action.
An underlying reason appears to be the widely-held neoliberal and individualist ideologies that underpin much current political and social decision-making. Rather than facilitating action on the social determinants of health (SDH), such ideologies afford greater tolerance for, and community investment in what has been termed ‘public health behaviourism’ (Watt, 2007, Basu, 2004). This is the individualistic approach of patient-centred medicine and the focus on ‘downstream’ health education and behaviour change as ways of preventing illness.
Despite the powerful influence of upstream determinants on our health and wellbeing, public health behaviourism and medicalization have resulted in an imbalance in the health budgets of many nations, with inordinate investment focused towards ‘downstream’ health care, rather than towards prevention. To make matters worse, in some first world countries increased inequity has seen much of this investment reaching the ‘worried well’, producing only marginal improvements in overall population heath (Corderoy, 2017). While investment in prevention – especially upstream preventative activities – is likely to be more cost-effective and to have greater long-lasting benefits, it is also slower-acting, and the benefits are often not measureable in the same way or within politically palatable timeframes as are investments, in for example, hospitals. Within this context, medical groups are also powerful advocates for their field. They are able to attract funding that would be more efficiently and effectively used to improve the determinants of health. As Professor Prabhjot Singh of Columbia University stated,
Consider diabetes. A few major pharmaceutical companies compete for a finite group of diabetics by offering new formulations, marginal improvements in blood-sugar control, competitive pricing, and strategic partnerships with insurers and health-care providers. These incumbents are primarily concerned with defending their market position. Their activities do not extend to helping the hundreds of millions of obese people at risk of diabetes ... (Singh, 2014)
Further, current news cycles are often geared towards and re-inforce individualism and neo-liberalism. These are ideologies that do not support strong systems thinking that facilitates action on SDH. In such a climate, downstream actions on health appear as quick fixes that are often more compelling, politically palatable and newsworthy than upstream action. Compare for example the ongoing debate about mandatory bicycle helmet laws versus the population benefits of making cycling more attractive (Holm et al., 2012, Carey, 2017, Teschke et al., 2015).
Neoliberal ideologies are also fertile ground for corporations whose business it is to sell unhealthy products. Ilona Kickbusch states that many health outcomes ‘are determined by the influence of corporate activities … namely the availability, cultural desirability, and affordability of unhealthy products’ (Kickbusch et al., 2016). But within a culture in which the rights of the individual seem sovereign, in conjunction with arguing a need to maximize shareholder profits, corporations often use libertarian rhetoric to avoid accountability, while simultaneously placing an unrealistic level of responsibility on consumers to ‘make the right choices’.
There is no simple way to respond to inadequate action on the SDH. Michael Marmot states that health equity 'is a policy choice that could be achieved through the tax and benefit system’ (Marmot and Bell, 2012). But economic approaches need to be socially and politically acceptable. Responding to the SDH requires the community to be systems-literate and amenable to a more nuanced, equitable and ethical approach to policy reform.
Geoff Browne @CubisticNevad is undertaking a PhD in local government's use of evidence in their health planning and how it organises its efforts against a social determinant of health framework. He is an academic at the niversity of elbourne's School of Population and Global Health and a lecturer and tutor in the Melbourne School of Design and ACU's School of Allied Health. Prior to this Geoff worked for seven years as a senior policy analyst and professional wildfire fighter with the Victorian Environment Department and Environment Commissioner. He was a chief author of the 2008 State of the Environment report and the 2013 State Waste Policy. Geoff also has experience in local government and private practice as a sustainability consultant. It was while working for state government that Geoff beca interested in the role of evidence in decision making, and the importance of community wellbeing for sustainability.
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