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  1. 1


    Yes – and congratulations!
    But where do we find an outlet for systems-based, evidence-driven (and note that I have a very wide conceptualisation of evidence!) and community-oriented critiques of the current stale status quo which would support politicians appropriately?
    Both the peer-reviewed public health as well as health promotion academic journals are either too mainstream or too marginal, and an outlet like ‘Arena’ is decidedly too fringe/esoteric. Isn’t it time to be more sophisticated?

  2. 2


    This must be one of the most sensible articles about health I’ve read. I think some of the reasons the Government hasn’t done what the UK has done in terms of setting up a review of the WHO SDH ‘Closing the Gap in a Generation’ report is that firstly, they probably haven’t been alerted to the significance of the report, secondly, they probably wouldn’t have much of a clue as to how they should go about translating its recommendations for action, and thirdly Australia doesn’t have a Michael Marmot.

    However, given these short commings, the evidence is becomming clearer that as a nation, to effectively address chronic diseases like CVD. obesity and diabetes, we need to go beyond sctraching the surface and advising the obvious – that people should be more physcally active and eat healthy diets. We need to address the deeper underlying socioeconomic, cultural and political landscape that creates the conditions and barriers preventing people being physically active and having access to healthy foods.

    I share Baum’s concern about the functiion of the proposed multi-million dollar Preventative Health Agency. I fear it might turn out to be a ‘surface scratcher’, dealing only with social marketing messages around lifestyle and paying lip service to the underlying social determinants of lifestyle. However, rather than adding yet another Federal ‘Commission’ as Baum suggests, broadening the scope of the proposed Preventative Health Agency to do the things suggested by Baum might meet the requirements. These would include a ‘health in all polices’ and ‘equity based health impact assessment’ of all levels of government policy and planning as well as linkages to critical areas of social policy like the social inclusion agenda. This would give the Agency a social determinants of health focus rather than what appears to be its raison d’etre – a lifestyles social marketing one.

    Our health system needs to put as much effort into health creation and development as it does into health protection. We know a lot about illness prevention and treatment – which is good, but not a lot about health creation and sustainability – which is not so good. We need a proper balance in the system between the two and there is no better time politically to do it than now. We have a chance to get the health system right but only if we focus on the right things and that must include equity and social justice as starting points.

  3. 3

    Doctor Whom

    C’mon – change our system?

    Sheesh “prevention” in Oz is built on a solid foundation of printing pamphlets, posters and TV campaigns with little coloured ribbons or wrist bands, while employing tertiary educated well paid professionals to tut tut, sneer and do some finger waving at the great unwashed.

  4. 4

    Tim Woodruff

    It is almost time to hear the Rudd Government’s ‘grand plan’ for addressing the problems of our health system. This is after a ‘root and branch’ analysis of the system, an analysis which left out the rather large branch of the private health insurance and private hospital industries.

    As pointed out by Fran Baum, social determinants get a mention in speeches from the Minister analysing the issues which confront the system, in the Commission’s report, and in the Preventive Health Taskforce report. Neither of the reports however, suggest any way of addressing the social determinants. It is unlikely that the Government will either.

    Along with all the reasons mentioned above to explain the Government’s reluctance to do so, I think there is another reason. It is that politicians don’t really believe in a socially inclusive society. Instead, the best intentioned of them are busy targeting gross inequity and ignoring Government supported structures which produce inequity. In the health system both major parties support the Howard Government’s PHI rebate and the Extended Medicare Safety Net. There is another major structural barrier to equity however. It is the fee for service Medicare rebate system with unlimited copayments. It sets the scene for geographical and financial inequity which no number of targeted programs will ever overcome. Thirty percent of sick Australians report doing without health care because of cost according to repeated surveys by the Commonwealth Fund. What is needed is regional needs based funding empoyering local communities to make decisions about how such funds are spent. This requires data on health needs and current health spending. It would set the scene for addressing those social determinants which are able to be at least partially addressed at the local level.

    But successive government responses of targeted programs and safety nets attempt to address gross inequity. They are not aimed at equity. They are charity. No one is against charity and it makes the givers feel good. Rather than being socally inclusive however, such charity is socially exclusive. Witness the doctors’ surgery “Oh, you’re on a health care card are you, ok , we can reduce the fee for you”. Not really empowering. It also avoids the real issues of structural adjustments.

    The same applies to our socially exclusive education system.

    But the really threatening issue is that of income inequality. We are in the wrong half of rich countries in terms of income inequality ie we are more unequal than the majority. Income inequality correlates with multiple measures of health and well being. But to address it the politicians would have to adjust the tax system to more heavily tax the rich. Are they even interested in discussing it? Perhaps the PHI rebate debate is the first sign of that but I doubt it. The Henry tax review had equity as one of its terms of reference, but how far was he interested in taking it? We will eventually find out.
    Most Australians however, might be quite happy to see a more equitable tax system and better income redistribution if it were sold as leading to a more healthy and safe society. I suspect the politicians, even the few who are aware of the evidence on social determinants, are not really interested in dispensing anything more than charity unless and until the evidence is in their faces and enough of the public are asking the right questions for it to be a possible political winner.

    tim woodruff
    doctors reform society

  5. 5

    Ben Harris-Roxas

    Well said Fran. It seems that COAG initiates new activity these days. How do we get this on their agenda?

    Others might be interested in earlier posts:

    If Australia took any notice of the Marmot Review…

    Will today’s health ministers meeting tackle health inequalities?


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