Dr Pieter Peach, a Melbourne clinician and a Croakey correspondent with an interest in next generation web technologies and their potential impact on health, would like to tap the creative intellect of the Croakey readership.
He would you like you to brainstorm around the topic of the digital revolution and how it might measurably impact on social determinants of health.
So belt up, and read on….
Social Determinants of Health and the Digital Economy
Pieter Peach writes:
You’ve just sat down for your early morning flight to Canberra. You’ve put in your earplugs, and then removed them discretely as the Minister for Broadband, Communications and the Digital Economy sits down in the seat next to you.
You strike up a conversation, and for light chatter you get to the topic of economic opportunities in the progressive digitisation of our lives as Australians.
As you know less about telecommunications than you do about your day job, you end up talking about health.
You skip the hospital and doctor focused discussion around eHealth, and you mention potential economic opportunities in quantifying the impact of social determinants of health, and the potential solutions to modify these risk factors.
He says to you, “That’s all very interesting, but give me examples, and tell me what the federal government could do to help facilitate economic opportunities around this.”
You pause, looking thoughtfully out the window as Black Mountain approaches.
You say…
• Please contribute your creative suggestions as a comment on this blog, or contribute them here.
(I will present some of your ideas to a upcoming panel meeting with the Minister exploring eHealth opportunities in the digital economy.)
***
PostScript from Croakey: On a related theme, the Mental Health Association NSW 2011 conference will examine “how the internet is helping improve our mental health”.
The conference blurb says:
We will cover how the internet is being utilised by organisations and what’s available online for consumers and mental health professionals. We’ll put the spotlight on a variety of online initiatives including awareness campaigns, e-communities and forums, treatment modules, web based information and how personal experiences are shared on the internet.
Key questions of the conference:
- How are consumers using the internet to seek help and share their experiences?
- How effective is the information and services available?
- How is the internet improving or changing services?
- Are organisations utilising social media effectively to engage others?
- Can the internet replace face-to-face help from mental health professionals?
Few things I can think of straight away
1. Smart Cards that store electronic records/xrays etc in an encrypted format, but can be read by hospitals/GP clinics etc. Allow people to store their own ehealth records rather than have a centralised database.
2. Roving health case managers/Nurse Practitioners/midwives who have the ability to consult at persons homes. Connected to hospitals/head office/early childhood centre via wireless internet/mobile phone.
3. Health hotlines/web portals that allow people to give their symptoms/complaints and receive advice from qualified people 24/7.
4. Web Portals that allow people to manage their own chronic issues…Can put in appointments for doctors/specialists/dieticians etc and the portal keeps track of activity and sends reminders via email/mobile phone if an appointment hasn’t be made in a while.
5. Social media compaigns for public health. i.e use of twitter/facebook to reach the young and transmit healthy eating/exercise/sexual health/safe drug and alcohol messages.
6. Medicare summary emailed to everyone every year around tax time detailing GP visits/dentist visits/eye tests/hearing checks/innoculations etc and based on the age of the person, recommendations for appointments for the year ahead.
Here in South Australia we have been looking at exactly this question, with a Health In All Policies social health focus on a generally rather technical area. We have a paper recently out in the online Journal of Community Informatics (“Digital Technology Access and Use among Socially and Economically Disadvantaged Groups in South Australia”) reporting empirical qualitative research, which details some ways the digital revolution can impact social determinants. However, we also found that people’s resources and capabilities lead to digital exclusion: http://ci-journal.net/index.php/ciej/issue/current (note they are tidying up a glitsch in the layout). In turn, we have also written on how this may exclude them from potential e-Health benefits.
Professor Kerin O’Dea (University of SA) asked me to post this comment on her behalf:
I think the greatest opportunities for gain for Indigenous people will be in education – and particularly in remote communities if they can have access to fast broadband. Poor education outcomes are holding back generations of young people in remote communities – and probably also in rural areas.
‘You skip the hospital and doctor focused discussion around eHealth, and you mention potential economic opportunities in quantifying the impact of social determinants of health, and the potential solutions to modify these risk factors.
He says to you, “That’s all very interesting, but give me examples, and tell me what the federal government could do to help facilitate economic opportunities around this.”’
How did the ‘economic’ get into the social determinants of health (sdh)? The quote above from your question confuses me. A major part of the SDH hierarchy of causes is the entrenched inequalities that remove from those on lower rungs, or off the ladder, is their lack of a sense of agency, of control over those factors that affect their life chances or individual/group decisions. It is not the primarily the financial/materialist deficiencies themselves that determine unequal results but the ways these are read as making personal or structural change unlikely. So social perceptions are big in the differences in status ‘lifestyle’ diseases as decisions to avoid risk require a sense that it is possible to have some control.
How E health will affect this mal-distribution of power, influence and self efficacy is quite hard to suss out. On one level, the ability of individuals to use online services and access better advice in isolated areas would be good for those who trust the health services that use the material or have personal access capacities. However, digital divide factors may make this access even more biased.
Therefore I would be onto the Minister to make sure that there was an actual push to finance extra resources for those with less access eg NACCHO Aboriginal based services, with heaps of support and training. It would also need to integrate the necessary cultural components and equipment experiences that would allow the users of the service to use and trust the services.
If low trust of authority, expertise and government is part of the mix of the inequitable spread of social determinants of health, then the gaps may widen with e health. This puts a an extra load on a system because being media savvy probably goes with a reasonable sense of control and trust in systems.
as long as the system relies on individuals to find information and use it, the so called underclasses will not benefit. Economic models of markets and information assume rationality and not feeling dominate. Feeling powerless makes health harder to sustain. And power in this area is likely to be mal-distributed although, in theory, it should be more accessible.
Funding therefore for training and intermediaries/advocates will be important for any beneficial impacts will happen. it means that control over service access needs to be given to bottom up groups eg Indigenous run groups, and time taken to familiarise them with the access options. Most community, social service, local groups etc which represent low income problematic groups are the least likely to be technology savvy, unfortunately.
eva cox
Like Eva Cox I too wonder how ‘economic‘ got in here – and I am an economist! And I share her worry that eHealth will add to inequalities. Lareen Newman’s research shows that is likely to be the case.
So what would I be telling the Minister? Well basically: “watch it, mate!”. What the literature on the social determinants of health tells us indirectly and implicitly is that individuals sitting alone (and isolated?) in front of their computers or whatever cannot at the same time be chatting to their neighbours or taking part in their local community garden. And that aint good for their health.
In this so-called technological age it is all too easy to forget that health care is not just about ‘caring for’ but also as Miles Little has put it ‘caring about’. EHealth might be able to help with the former but the latter? I doubt it. I have a very caring GP. I know that because from time to time I go and see him. The human contact with him matters. Of course there are circumstances where eHealth is useful but let’s not get too carried away with it. That e can never stand for empathetic.
But as the concern here is the social determinants of health, I would take a different tack with the Minister and suggest that the best thing that can be done with web technology is to promote both recognition of the social determinants of health and solutions for social determinants of ill-health. So please Minister would you employ some web technology eHealth wizards? They might then use their expertise to examine and then disseminate on the web relevant information on government policies (current but certainly planned) which affect poverty, inequality, housing, education, etc. Other non eHealth wizards might then look to see what might be done to address some of the problems the eHealth wizards came up with.
Minister: ‘OK then tell me, where might such eHealth wizards start?’
A few suggestions:
1. Various aspects of the Henry Tax Review and their likely impact on poverty and inequality – and health.
2. The move from the RST (Resource Super Profits Tax) to the MRRT (Minerals Resource Rent Tax) – and again the impact on poverty and inequality – and health.
3. A rise in interest rates and the impact on poverty, inequality and housing – and health.
4. The impact on health of a carbon tax.
Minister, we might need a lot of eHealth wizards.
Eva, Gavin, thanks for the thoughtful responses. It a broad topic so I’m trying to boil it down to fundamentals. By “economic opportunities” I meant several things.
1. There are problems. Costs to the individuals and costs to the taxpayer. These are a function of both quality of decision-making and availability of alternatives.
2. There are solutions. Some solutions exist as there is a margin between what it costs the customer, and what it costs the innovator to provide that value. Some solutions don’t exist because, despite the technology being available, it doesn’t *yet* make economic sense.
We’ve all witnessed how technological/social innovation is rapidly changing the cost side of the equation for many of the problem/solution opportunities in, for example, media. Also, where educational content is/was expensive to provide, we see examples where the traditionally costly content creation and distribution costs have fallen rapidly to near zero (wikipedia). The inequity does though, remain in physical access to the internet and literacy/motivation to engage, as Eva mentioned.
I’m trying to understand which opportunities related to health outcome problems have a solution which is becoming cheaper to the point of becoming a viable market opportunity, and where these opportunities are likely to arise. What government can do to reasonably facilitate their evolution through removal of unreasonable barriers is something is worth considering.
The customer for some solutions would be the government/taxpayer who is providing ever increasingly expensive healthcare for increasingly smaller marginal gains. We have an interest in keeping people (appropriately) out of our healthcare system and enjoying their life. If we understand how the “digital economy” is evolving we can understand the significance to various players in the system and how we can get to work on hard problems with new, evolving tools.
For other solutions, the customer would be the individual recognising value and paying for this themselves in exchange for a better perceived quality and quantity of life.
I’ve been lucky enough to speak to innovators who have found opportunities where evolving technology has made new business models a reality. Provision of health messages via SMS in India where 15 milllion new mobile phones come online each month is one such example. See http://www.mdhil.com/aboutus/. Another is opportunities around anti-corruption services http://bit.ly/5XPfvj
One point is this. It is likely that the highest potential marginal utility gains to be made in the coming evolution of digital technology may well be amongst the resource-deprived fraction of the Australian population, and although a “gap” measured by speed of internet or net worth may widen, a “gap” measured in quality adjusted life years might not. Where government has made little gains in solving major health inequities in the past as a solution provider, maybe they can succeed as a customer in an ecosystem where low cost, high distribution businesses are beginning to make a significant impact.
Scott – thanks, the medicare summary seems to be one that has come up a couple of times. Also, technology as an enabler of behaviour change, (reminders etc) will be an interesting challenge.
Lareen – thanks, will have a look at the paper.
Prof O’dea – agree that education may one of the high yield opportunities
First, we need a campaign to raise public and political awareness and understanding of the social determinants of health, and to create some will to tackle them. This campaign could explain why they matter and what can be done about them.
The digital revolution could be harnessed to help create the revolution that is required in thinking, in resource allocation, in policy etc. Otherwise we will just be spending more and more on hospitals, judging by the AIHW stats released this week. And, as Pieter suggests, for less and less health return.