The impact of cruel and punitive welfare policies, women’s health inequities, food insecurity, and poverty were among the wide-ranging topics discussed when a Stretton Health Equity team at the University of Adelaide took charge of Croakey’s rotated X/Twitter account, @WePublicHealth during the first week in March.
The tag-team: Professor Fran Baum, Dr Connie Musolino, Dr Julia Anaf, Kim Anastasiou, Dr Joanne Flavel and Dr Toby Freeman.
They covered a seminar on poverty presented by Professor Martin McKee CBE from the London School of Hygiene, and the report below also covers McKee’s calls for the public health community to do a better job at communicating about the upstream determinants of health and at speaking truth to power.
The Stretton team noted that “when we think of poverty, people in Gaza are the poorest in the world right now”.
“They’ve lost their families, friends, food, houses, livelihoods, hospitals, schools, universities.They are facing starvation and more bombing. Total health catastrophe.”
They also cited this Oxfam International report, ‘Richest one percent bag nearly twice as much wealth as the rest of the world put together over the past two years’.
“What do you think – should we put a cap on people’s wealth?” they asked.
“Elon Musk, CEO of Tesla SpaceX, owner of X, is the richest person in the world with a net worth of $215 billion. Perhaps after $100m, then a global tax on wealth of 90 percent tax could be invested in health?”
Punching Above Their Weight
Professor Martin McKee is founding director of the European Centre on Health of Societies in Transition, a WHO Collaborating Centre. He is research director of the European Observatory on Health Systems and Policies, and a Commissioner, and Chair of the Scientific Advisory Board, of the Pan European Commission on Health and Sustainable Development, reporting to WHO EURO. To find out more about his work: https://www.lshtm.ac.uk/aboutus/people/mckee.martin.
The Punching Above their Weight (PAW) network examines why some countries do much better or much worse in terms of life expectancy than would be predicted by their economic status.
Most research in this area has focused on the health sector performance, whereas the PAW network examines more closely the political, social, environmental and economic context and processes that drive good or poor performance in promoting population health and health equity.
Workers are more and more on precarious contracts and workplaces, lacking control over their own lives, not able to predict and plan their futures – detrimental to health and well-being.
The deterioration of mental health when you lose your job during a period of austerity in an economic crisis is worse than when a country is not in austerity because there are less social safety nets.
Politics and public health
Listen to the podcast here. [The summary below is provided by Croakey].
In the podcast, McKee discusses the impact of the global financial crisis, the introduction of austerity and in some countries – such as the United States and United Kingdom – a widening of gaps.
He also discusses the impact of commercial determinants of health, and the need to act on the political determinants of health, and to shift the narrative away from individuals being responsible for their health, and for public health to look at its own communications.
“We’ve often retreated into silos and looked downstream rather than upstream, that’s natural because people do specialise in their own areas,” he said, but “we need to see the big picture, so we can communicate it to others”.
“We really do need to speak truth to power. We need to be able to challenge people who are talking complete nonsense. For example, the Murdoch empire is an example of very powerful interests promoting a narrative that undermines health.”
McKee highlights the tension when public health work professionals work within government, and says there is a very strong duty on those in academia and civil society to convey the needed messages publicly.
He says: The worst thing to do is to remain silent. History shows people in public health have not spoken out when they should have done so. We have a real responsibility to the public, whose taxes are often funding us, to be the conscience of the nation. Recognising that politicians have short term goals. But we need to help them and hold them to account.
We also need to communicate much better, with the public, we need to find language that works. In the pandemic, some communicated very well, and some people didn’t.
Young people are our hope but the system often grinds them down. We need to be encouraging them.
Re the future, he says “I’m remarkably pessimistic because we have some existential risks that we’ve failed to address”, and he cites the climate crisis and related environmental changes, and failures in global governance.
“We do not have a sufficient degree of leadership going forward,” he says.
If Trump is elected at the US election, “we could very easily be in enormous global difficulty”, especially given his previous actions while President in undermining climate action.
We have some very dangerous times ahead, and “the worry is whether the global architecture is sufficiently resilient to face up to this”.
McKee also says that that whenever peoples’ health deteriorates when they are left behind, they are fertile ground for non-democratic populist politicians.
Other news shared
In Australia, the @AntiPovertyN_SA and other advocates have lost trust in successive governments who acknowledge with words the struggles of living in poverty but continue to fail to make systematic change backed by evidence and community support; for example, raise all social security income!
Food security matters
Kim Anastasiou covered poverty, equity and food.
The right to food is “realised when every man, woman and child, alone or in community with others, has the physical and economic access at all times to adequate food or means for its procurement.” – General Comment No.3, UN Doc.E/1991/23, Annex III, paragraph 1.
Unfortunately, we’re still a long way off achieving this goal. Barriers to accessing ‘adequate’ food (which I would argue needs to mean quantity and quality – including impacts on health and the environment) are rife, both in Australia and beyond.
This has caused major road-blocks to policy change across the world. Ultimately, if we want to re-orient the food system to support EVERYONE, we need to seriously re-think who holds the power, and who stands to gain from the current policies in our food system.
So what can we do to re-orient the food system to support health and sustainability FOR ALL?
The Healthy, Regenerative and Equitable Food Systems Strategy for Victoria provides some important pointers.
Previous research has emphasised the importance of representative governance – for example, including women and youth on advisory committees. Clear boundaries to protect against undue vested interests is also needed.
UPF sales result in the growth of corporate wealth, and allows large transnational corporations to grow their influence and policy power. This includes lobbying for public-private partnerships and self-regulation over state-led food systems governance.
Further highlighted in this article, ‘Corporate interest groups and their implications for global food governance: mapping and analysing the global corporate influence network of the transnational ultra-processed food industry’.
One industry that has repeatedly targeted low-income earners is the ultra processed food (UPF) industry. We know that low-SES groups are more likely to have diets high in UPFs.
Food insecurity occurs when there is inadequate access to healthy and affordable food It can include limited dietary variety, inability to eat cultural or nutritious foods, skipping meals/ running low on food, anxiety about food sufficiency and being unable to maintain food norms
There are six pillars of food security: 1. Availability 2. Accessibility 3. Utility 4. Stability 5. Agency (ability to exercise control over personal circumstances and governance) 6. Sustainability
While support systems are vital, service delivery has issues, with “evidence of controlling, demeaning and depriving practices in the interactions between the participants and the services and staff at national welfare providers and food charities.”
Addressing food insecurity at the source, such as by improving income, housing and reducing the cost of healthy and sustainable foods is critical.
Australian research on food security has highlighted the need to use humans rights language and mechanisms to improve commitments to food security. Although this approach may be more successful if embedded into the 2030 sustainable development agenda
Watch this space for further research on policy interventions to improve food security and look out for some food security updates from the Stretton Health Equity team in the near future…
Women’s health
Dr Joanne Flavel examined how social determinants of health impact on economic inclusion and health equity for women.
It isn’t all bad news! Female labour force participation has steadily increased. There is more to be done, with caring work being undervalued (lower paid) and women having higher rates of casual employment than men. Women also have higher rates of underemployment than men
More positives! Girls have higher year 12 attainment rates and a higher percentage achieving above national minimum standards in year 7 and at age 15. Education is vital with links to health.
International Women’s Day is a time to celebrate what women have achieved, reflect on what is holding back on progress, and identify action that can be taken to do better. Collecting more data that is not binary would help. A limitation of much of the statistics above is binary sex.
The Workplace Gender Equality Agency reported an increase in access to paid parental leave in 2022-23, and an increase in women in management positions. More needs to be done to overcome barriers but also to lift women out of poverty, with the ACOSS raise the rate campaign important.
Improving economic inclusion and improving social inclusion via reduced inequities in social determinants of health, such as income, employment, housing, would accelerate progress on health equity.
Increases in income share of top one percent, top 10 percent and increases in wealth of top one percent, top 10 percent much faster than growth for those with less. Women are underrepresented in the top one percent, top 10 percent. Per Capita has done research finding higher housing insecurity for women.
Important to acknowledge intersectionality of diverse genders, disability, rurality, Indigeneity, socioeconomic status compounding economic exclusion and societal stigma and discrimination, inequities in social determinants of health, and barriers in access to healthcare contributing to inequities.
Women are higher proportion of single parents and carers and this impacts on incomes. ACOSS estimated poverty rates, finding overall poverty rate of 13.4 percent in 2019-20 but higher poverty rates for households relying on parenting payment (72%), carer payment (39%), Jobseeker (60%).
Cruel, punitive welfare systems cost lives
Dr Toby Freeman referred to Professor Martin McKee’s discussion of the link between unemployment and suicide.
This is of particular interest as we are just embarking on a new Medical Research Future Fund (MRFF) funded project examining work, unemployment and suicide, in collaboration with the @RobsInstitute @sacoss @AusUnemployment @R_Wanganeen @AntiPovertyN_SA and @SuicidePrevAU.
I want to home in on one excellent element of Professor McKee’s lecture. But first, a trigger warning, this is a discussion of suicide. Lifeline Australia is available on 13 11 14 if this raises any concerns for yourself or someone you know.
In Spain, the co-variance of rates of suicide with rates of unemployment over time is clear – when unemployment went up, rates of suicide went up. When rates of unemployment went down, rates of suicide went down.
In Sweden, there is no discernable relationship between unemployment and suicide. Unemployment has fluctuated considerably, while over the same time periods suicide rates show a consistent downward trajectory.
In another excellent study from the US, Flavin and Radcliff compared the effect of welfare payments on suicide rates across states. They found the higher the welfare payments in that state, the lower the suicide rate.
The study found that a $US45 per capita increase in welfare reduces the suicide rate by 10 percent, which if it applied to Australia would translate to over 300 fewer deaths by suicide each year.
So it is possible to design a welfare system that decouples unemployment from suicide, and the data from Skinner et al 2023 indicates that Australia has failed to do this.
Advocates such as @AusUnemployment and @AntiPovertyN_SA have long pointed out that it is not just the amount of the welfare payment that matters, but other characteristics of the welfare system and practices that influence the wellbeing of people who are unemployed.
Australia’s approach to mutual obligations, our political and media discourses, and punitive approach to welfare all contribute to a cruel welfare system that undermines the wellbeing of people who are unemployed.
Robodebt was an appallingly clear example of this cruelty, where poor quality automated data matching practices were used as an excuse to send debt recovery notices of highly variable veracity to people who had at some point received welfare payments.
There has been a recent Royal Commission into Robodebt that made a number of recommendations relevant here: “acting with sensitivity to financial and other forms of stress experienced by the customer cohort and taking all practicable steps to avoid the possibility that interactions with the government might exacerbate those stresses or introduce new ones”.
And “avoiding language and conduct which reinforces feelings of stigma and shame associated with the receipt of government support when it is needed”.
It is also positive that ParentsNext has been axed. As the Guardian reported “A key complaint was that parents who failed to meet their obligations would have their payments temporarily suspended, which caused significant stress and anxiety”
The Work for the Dole scheme is also receiving criticism, with the Brotherhood of St Laurence ceasing participation: “”As unemployment payments are already well below the poverty line, this pushes people into even greater hardship.”
It is clear that Australia’s welfare system needs reform, both to raise the rate of payments, and to design a more supportive, less stigmatising and victim blaming system to safeguard the wellbeing of people who are unemployed and to reduce rates of suicide.
In our MRFF project, we aim to generate policy and practice recommendations for government, employers, and community suicide networks on suicide related to work and unemployment, and to develop a training package for frontline workers to intervene with people at risk.
And, finally, some congratulations
See Croakey’s archive of articles from guests at @WePublicHealth this year
