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BORROW an idea from Michael Marmot, the guru of social determinants of health, and drive with me the 10 km from leafy, middle-class Baulkham Hills in western Sydney, where the median weekly income is $800 a week, to Mt Druitt, where it is $450.
As we travel each kilometre we would tick off 4 months of diminished life expectancy for women and 5 months for men. A similar gradient would be apparent in all aspects of life in the suburbs through which we drove — in literacy, social support services, readily available primary care and transport.
Heroic persons provide health, education, policing, social services and more in these disadvantaged areas, often with fewer resources per capita than those available to their colleagues in more affluent suburbs. And thank goodness they do.
But they would be the first to acknowledge the power of the social and economic environment in setting the agenda for the fortunes of the people they serve.
Public health, by tradition, has concerned itself with the social factors that support or distort health. Interest in clean air and water, an adequate supply of fresh and safe food, shelter and freedom from physical threat have been among its historical qualities.
Now that the environmental factors are more subtle from a health perspective — business, commerce, transport, planning, education, etc — what will be the public health response?
Experts from the Centre for Food Policy in London have written an essay in the BMJ proposing that public health needs a new way of doing business. They term this approach ecological public health.
Ecological public health, they write, “…focuses on interactions, with one strand focusing on the biological world — in concerns about increasing strains on biodiversity or antimicrobial resistance, for example. Another strand centres on material issues such as links between industrial pollution, energy use and toxicity, and the impact on human species and nature. The advantage of ecological thinking is that it theorises complexity, a key feature facing modern conceptions of health”.
They distinguish ecological public health from four other models — sanitary; biomedical (including immunisation); behavioural (built around health promotion); and one that emphasises economic development as the key to better health.
Elements of all four models are visible today and when correctly applied help solve public health problems. They can be effective parts of a broader ecological public health initiative.
The BMJ authors’ argument is that: “Telling families who live in poverty that they should make healthy choices ignores the conditions that prevent them doing so and is insulting and even futile. We now all live in total commercial environments in which many drivers are dominated by sponsors.”
How do we put wheels on the ecological public health cart?
By first accepting that to improve the health of our public we need conversations with all those who determine our ecology. Most obviously this means ministries of health, both state and federal.
It also implies that other government ministries that deal with education, trade, planning, transport and environment are important.
South Australia has shown leadership in achieving valuable conversations through the “Health in all Policies” initiative. Those crafting all new state policies are asked to carry out thought, or desktop, “experiments” assessing the health impact of what the new policy proposes to do and to converse with colleagues in health.
Occasionally a direct approach to industry may be appropriate, although the difficulty of partnering with it, with its fully justified primary concern being the bottom line, is large. Nevertheless, sometimes it works, especially when an industry has a strong social concern.
Problems such as those that we confront with our Indigenous citizens and that we see also in less privileged communities everywhere can be analysed using an ecological paradigm.
The multifaceted approaches that in combination have paralleled the decline in smoking from 72% in men in 1945 to 17% now and the interventions that account for our 80% decline in heart disease deaths since 1970 provide clues as to what we can do. An ecology of preventive action has achieved these wonderful outcomes.
Who knows, if we add an ecological arm to our public health efforts, the drive from Baulkham Hills to Mt Druitt may become less of a health hazard.
Professor Stephen Leeder is the director of the Menzies Centre for Health Policy and professor of public health and community medicine at the University of Sydney.
Posted 24 September 2012
Yes. There is a wealth of evidence to suggest that social determinants of health are more important to health status than medical care and even personal health behaviours.