Wonky Health: It’s just not fair!!

In the second edition of Wonky Health, Dr Tim Senior explains why Health Minister Peter Dutton should be telling his Cabinet colleagues that they are making his job much harder – Budget policies that promote inequality are also likely to be harmful for the community’s health.

Whether politicians are as clever as children, who grasp the basic concept of fairness from about age three, is another matter…

Listen! That strange clanking noise you can hear around the budget is the changing of gear.

Instead of debates about how many promises were broken, or debates about whether there really is a budget emergency, the real discussion now is about fairness.

In a country whose unofficial motto might be “A fair go,” much of the unpopularity of the budget is because people think it is unfair. Last week Joe Hockey tried to defend the budget on the grounds of fairness.

So, if the federal budget has achieved one thing, it has got us all talking about fairness. We are all 70s class warriors and socialists now, it seems – charities, welfare agencies, the Australian Medical Association and even ex-liberal leaders John Hewson and John Howard are talking about fairness.

But, really. Be honest now. Does it really matter whether the budget is fair or not? We can moan, it might offend us, those at the bottom will struggle.

We might get away with a lack of fairness if we could just hide away and ignore those people who are affected. We could just get on with our own lives.

But what if it wasn’t just individual policies that had an effect on health care? It’s fairly easy to see how a Medicare co-payment might affect health, or making people live without any income for up to 6 months will make people sick.

But could the overall shape of the budget – where the richest incomes fall by 0.2% and the poorest by 2.2% – affect Australia’s health?

Let me introduce you to Richard Wilkinson and Kate Pickett. They are UK epidemiologists who have spent a lot of time asking just this sort of question. Their book The Spirit Level is a highly readable introduction to their findings (and the graphs and updates are available from Equality Trust website.)

They looked at developed countries and ranked them by the gap between richest and poorest – a measure of inequality – then looked at a range of health and social issues to see if they were correlated. They then did the same looking at states in the US.

They found that there was a clear correlation between health and social outcomes and inequality. Societies that were more unequal had worse health problems than more equal societies. Countries with larger differences between the richest and the poorest, had worse physical health and worse mental health.

I hope you are all chanting at me now “correlation doesn’t equal causation.” These findings don’t show that inequality causes poor health. It doesn’t prove that taking action to reduce economic inequality will improve people’s health.

Subsequent efforts to show that inequality causes ill health have had mixed results – which is what you’d expect for such a complex concept. It would be very difficult, though, to claim the opposite – that doing what this budget appears to do in worsening inequality will improve anyone’s health.

On the other hand, there is some evidence that people who move from an unequal to a more equal society do better than those who move in the opposite direction.

Economic inequality is also tied up with inequality in status, culture and ethnicity, and there is evidence that these play into the health outcomes too – for example, in Japan it has been pointed out that social status might be more important than income, which is why it is an outlier on some of the statistics.

Here in Australia, the obvious example is of Aboriginal and Torres Strait Islander peoples’ health, where colonisation and dispossession result in social exclusion, all of which have health consequences, and also contribute to inequality of opportunity.

Many of the Budget’s policies show a lack of understanding about what it is like to struggle to pay rent, fuel or medical bills.  There is a lack of empathy and imagination; it seems as if those now making policy have some idea that poverty just means less opportunity to buy expensive designer goods.

Poverty changes peoples’ decision making. People make decisions for the now, not the future when they don’t see a future. This is the reason people smoke (“It’s my only pleasure, doc”) or don’t take on debt to study.

We can wish it wasn’t so all we want, but fundamentally, if we really believe in the right of individuals to make decisions for themselves, we may have to understand this.

As Joe Hockey said, “Our duty is to help Australians to get to the starting line,” as he stamped on the toes of those already struggling to reach it.

While it might be interesting to debate the research findings on whether inequality causes poor health (and I do find it interesting!), there are policy decisions being made now.

Doing nothing while waiting for an answer to questions about the precise relationship between inequality and poor health outcomes is not doing nothing – it’s maintaining the status quo.

Putting policies in place that preserve income for the richest and remove income for the poorest will have consequences.

Restricting access to quality education to those who can afford to pay top dollar for it has an effect on social mobility and inequality. It’s fairly simple to predict from what we know that the effect won’t be to improve anyone’s health.

Meanwhile, Oxfam show that the richest person in Australia owns more than the bottom 10% of the population.

One of the striking findings in the Spirit Level was that everyone’s health is harmed by inequality – it’s not just those at the bottom, though clearly, they lose out most. The health of everyone is worse.

So, if you want more people to reach the age of 70 so they can retire;

If you want more children to survive their first year;

If you want fewer people to suffer with depression;

Then you’d be at least careful about making Australia more unequal with these budget measures.

Of course, you might not be interested in these health outcomes – especially if you’re not the health minister.

A budget sets out the sort of country we want to be, and the government may think that inequality is the necessary engine that drives economic growth. But the evidence for this is very frail.

It looks more likely that inequality acts as a drag on economic growth – like a tax, if you will. You also create a society that has higher rates of homicides and robberies. Children score lower on reading and maths tests. Even levels of trust are lower in more unequal countries.

We are entitled to ask “Is that the sort of country we are aiming for?” Seen in this light, health outcomes are a marker of a society not functioning at its best, rather than a collection of diseases people suffer from.

If I were the health minister, I’d be going round to all my Cabinet colleagues telling them that their budget is making my job harder.

The redistribution of wealth from those at the bottom to those at the top, the limiting of educational opportunity and the reduction in social mobility will harm people’s health in multiple ways, both because of specific budget policies, but also because of the reverse Robin Hood.

We all need to talk about inequality. It won’t make you into a 70s Class Warrior. It will, however, put you in line with everyone from Jesus to John Rawls.

It may be hard to explain to Cabinet ministers. But most children grasp the concept of fairness from the age of three.

Perhaps we need to treat our politicians like kids. “Now, listen…”

• Tim Senior and Croakey thank and acknowledge all those who contributed to the crowd-funding campaign to support Wonky Health – more details here.