AMA President Dr Steve Hambleton, the Social Determinants of Health Alliance public forum, 13 August 2013

I acknowledge the traditional owners of the land on which we meet today, and pay my respects to their elders, both past and present.

Thanks to Catholic Health Australia for organising this forum and inviting me to speak.

It is a pleasure to share a platform with The Hon Rob Knowles, Martin Laverty, Tessa Boyd-Caine from ACOSS, and young Ammy from The Smith Family.

Social determinants

Some of you might wonder why the head of the AMA is here to talk about the social determinants of health.

What is the link between doctors, medicine and the social determinants?  It is simple.  Doctors don’t just treat people who are sick or injured or advise people how to stay healthy.

If people are ill, we want to know what made them ill.  What are the factors that contributed to their sickness or poor health?  How can we address these problems?

The social determinants are the social and environmental conditions in which people live and work every day of their lives.  These conditions affect our lives in many ways, including our health.

The physical environment affects our health – air quality, temperature, the weather, the vegetation, and the water, among other things.

Our housing affects our health.  For many people it is a lack of housing, or the poor quality of housing.

Employment affects our health.  Being out of work, especially for long periods, can have a serious impact on both physical and mental health of a person, and the people around them.

Education is a major factor in maintaining good health.  Knowledge and health literacy and a hunger for learning – all-important factors in staying healthy.

This is why the social determinants are so important to doctors.

I might add that one of the world’s foremost authorities on the social determinants of health is a medical doctor.

Sir Michael Marmot is a former President of the British Medical Association – my counterpart – and between 2005 and 2008 he was Chair of the World Health Organisation Commission on the Social Determinants of Health.

Sir Michael visited Sydney for the World Medical Association Conference in 2011.  I had the privilege of spending time with Sir Michael at the WMA Conference in Thailand this year. 

Sir Michael is a pioneer in the social determinants arena and a tireless advocate internationally.

In fact, it was his World Health Organisation Commission that, in 2008, released a major report calling on governments to take action to reduce health inequities by addressing the social determinants of health.

The report outlined three principles for action.

The first was improving the conditions of daily life – the circumstances in which people are born, grow, live, work, and age.

The second principle was tackling the structural drivers of those conditions – the inequitable distribution of power, money and resources.

The third principle was measuring the problem, evaluating action, expanding the knowledge base, developing the workforce, and raising public awareness about the social determinants of health.

The Australian Government has not yet responded to this report.

These core principles are a sound basis for taking action on the social determinants of health.

As we are in the midst of an election campaign, I call on the major parties to commit to implementing these principles as part of their health policy.

It is five years since the report, but never too late to act.

While Sir Michael has been spreading the word around the world, the AMA has been doing its bit here in Australia to elevate the social determinants of health in the minds of the public, the health sector and governments.

We have for many years encouraged governments to consider all the social determinants of health when developing health policy.

Indigenous peoples and other disadvantaged groups

This is particularly important when considering policies for Indigenous peoples and other disadvantaged groups.

Many doctors – including AMA members – provide vital health services in remote Indigenous communities.  They see first hand the impacts of the social determinants of health among this population.

Many of these communities have or may have had poor housing, a lack of clean water, Third World sanitation, a lack of teachers, or no jobs.  The cumulative effect of these hardships takes its toll on human health - both immediately and over time.

The same patterns appear in areas of poverty and disadvantage.  People’s social and economic circumstances are intertwined with their health status.

Their knowledge of good health practices and their ability – through their circumstances - to attain and maintain an acceptable health status throughout their lives can be determined by many other factors.

Disadvantage is one, and disadvantage has many forms.  It can be absolute – for example, not having access to quality education or housing.  Or it can be relative – for example, poorer education, and insecure employment.

Each of life's many transitions - such as leaving school or getting a first job - can affect health by moving people onto a more advantaged or less advantaged path.

People who have been disadvantaged in the past are at greater risk in every subsequent transition of their life.

Disadvantages tend to congregate among the same people, and their effects tend to accumulate through life and be passed on from generation to generation.

Social and psychological circumstances can cause long-term stress and be damaging to health, and may lead to premature death.  Continuing anxiety, insecurity, social isolation, and lack of control over work and home life are examples of such stressors.

As well as contributing to poor mental health, the inappropriate and regular activation of the body's stress response negatively affects the cardiovascular and immune systems.

While of some concern in the short term, in the long term these feelings of stress make people more vulnerable to conditions such as infections, obesity, diabetes, hypertension, stroke and depression.

In industrialised countries, these conditions are more common in people who live in the lower levels of the social hierarchy.

It is now well understood that the foundations of adult health are laid before birth and in early childhood.  Slow growth and poor early experience increase the lifetime risk of poor emotional health and reduce physical, cognitive and emotional functioning into adulthood.

Poor experiences during pregnancy such as nutritional deficiencies, maternal smoking, alcohol and drug use, and inadequate prenatal care can lead to poor foetal development and consequent low birth weight babies, which are risk factors for poor health later in life.

Poverty - absolute and relative - has a major impact on health and premature death.  Poverty denies people access to full participation in the life of the community.

In the international context, those who are homeless have the highest rates of premature death.

Social exclusion also results from racism, discrimination, stigmatisation and unemployment.

The greater the length of time that people live in disadvantaged circumstances the greater the risk for ill health, particularly cardiovascular disease.

Generally, those with the lowest health status also have low educational and literacy levels.

Poor education means a person is less likely to attain secure and well-paid employment and this can lead to poverty and other predictors of ill health.

Employment and job security

As a general rule, having a job is better for health than being unemployed.  However, stress at work also increases the risk of disease.

Jobs that are demanding and where employees have little control or decision making in their employment are the most detrimental to health.  Improved work conditions will lead to a healthier workforce that will, in turn, improve productivity and decrease absenteeism.

Occupation is often used as a measure of socio-economic status.  Those in 'blue collar' occupations have poorer health status across almost all indicators compared with those in professional or managerial occupations.  People who are unemployed, and the families of those who are unemployed, experience a much greater risk of premature death. 

These risks are higher in regions where there is widespread unemployment and when the risks relate to the psychological and financial effects. 

For example, being in debt can have health implications.

The health effects begin when people first feel their jobs are under threat, prior to becoming unemployed.  Job insecurity or very unsatisfactory employment is harmful, with increasing effects on mental health, heart disease, and the risk factors for heart disease.

Adequate income affects the ability to have safe housing and to afford sufficient and quality food and health care.

As income continues to rise above a threshold level, there is no longer a correlation between increased income and increased health.  The health benefits of increased socio-economic status become smaller as socio-economic status increases.

In the past 20 or so years, income inequality has been increasing in Australia.

As an example, between 1994-95 and 1998-99, there was a 20 per cent increase in the taxable income of Australians.  However, the poorest postcodes achieved an increase of only 16 per cent, whereas the wealthiest postcodes achieved an average increase of 25 per cent.

This trend also exists internationally with income inequality increasing in nearly all countries since the 1980s.  Income inequality is higher in the United States of America than in Nordic countries such as Sweden.

Social support and social relations give people emotional and practical resources as well as a sense of mutual respect where people feel loved and valued.

All these aspects have a protective effect on health and provide a buffer against health problems.  Without them, people are likely to experience less wellbeing, more depression, and higher levels of disability from chronic diseases.

Social cohesion

At the societal level, social cohesion helps to protect people and their health.

Societies that have high levels of income inequality tend to have less social cohesion and more violent crime.

Alcohol dependence and illicit drug use are sometimes symptoms of social breakdown and can sometimes also contribute to further escalation of health inequities.

People can turn to alcohol and other drugs as a way of avoiding their harsh social and economic realities.  Unfortunately, apart from a temporary release, these substances only intensify the factors that lead to the use in the first place.

These substances are a large drain on people's incomes, reduce participation in society, and are a large cause of ill health and premature death.

Food quality and exercise

Food quality is an important issue in parts of Australia and internationally.  Quality food poverty can exist side by side with an abundance of food.  Ready access to good quality food makes a greater difference to what people eat than nutritional education.

Generally, people on low incomes – including young families, elderly people and those who are unemployed - are often most at risk from poor nutritional choices.

In Australia, there is a particular issue with food quality for isolated Aboriginal and Torres Strait Islander communities.  Fresh fruit and vegetables often must be carried many hundreds of kilometres, often in un-refrigerated trucks, and much of the nutrient value of the food can perish on the journey.

Once it arrives at the local store, it may or may not be able to be stored in conditions to maintain the nutrient value, and it is much higher in cost than what would be paid in urban areas.

There may not be the appropriate kitchen and cooking facilities to be able to store and then prepare nutritious well-balanced meals.  Under-nutrition can lead to susceptibility to disease in addition to specific disorders.

Equally, the over consumption of energy-dense and nutrient-poor food products and beverages is a major contributor to the epidemic levels of obesity in Australia today.

Cycling, walking, and use of public transport promote health through exercise, reducing accidents and air pollution, and increasing social contact.

People without private transport and people in places with poor or no public transport are less able to participate fully in the life of the community and experience its health benefits.

Racism and other biases

Other significant factors that affect equity in health outcomes are racism and other biases, whether at an individual level or institutionalised.

In A Public Health Perspective on Cannabis and Other Illegal Drugs, the Canadian Medical Association highlights the profound impact a criminal record has on heath status.

A criminal record can severely limit employment prospects, leading to poor health.  Prisoners also require equity in access to health services given their burden of disease.

People with a criminal record are less likely to be employed, or more likely to employed in lower skilled or temporary work.

Institutional racism and other biases against minority groups can occur are at many levels, and negatively affect health.

Health

There may be fewer doctors in lower socio-economic areas, meaning there is less chance for referral to more appropriate health services or medical procedures

Often, inequities are made invisible under the guise of treatment decisions.  For example:

• the risk of poor outcomes due to multiple other health problems;
• lack of transport or other means to keep appointments;
• lack of access to challenging treatments such as transplant; and
• lack of carer support to make choices.

People from higher socio-economic groups are often more comfortable standing up for their rights, and often more able to educate themselves on their condition and challenge or ask doctors for specific treatments.

While medical doctors may not be experts or authorities (other than Sir Michael, of course) on these social factors, and how to fix them, we see them and confront them daily.

We can see what these factors do to the health of our patients.  We can see the effect they may have on their families.

The social and economic costs of inaction on these social determinants are compelling.  In Australia – as elsewhere - health expenditure is growing at a faster rate than gross domestic product.

The context of an ageing population, burgeoning chronic disease burden, and rising health care costs pose fundamental challenges to our health system and the sustainability of health care expenditure.

If Australia is to meet these challenges, we need to rethink our approach to health, and redesign our policies and systems to tackle the root causes of ill health.  Tackling the social determinants of health is a public policy imperative.

Future policy

But when it comes to moving upstream from illness and tackling the root cause of health inequities, governments have been slow to act.

The AMA wants our governments to make health equity and health impact explicit goals of all public policy in every portfolio.

The theme of better population health must be embedded in policies within education, housing, employment, transport and the environment.

Unless the policy responses in these and other areas are aligned, they have the potential to widen disparities in health.

This is hard for governments.  It is not about the next three years – it’s about the next generation and deserves bipartisan support.

A cross-portfolio focus on the social determinants of health meets the challenge that I laid down at the National Press Club last month for governments and lobby groups.

We must plan for the future.  We must redesign our programs to meet the emerging challenge of the increasing levels of non-communicable disease to ensure we deliver an enduring and affordable health system into the next decades for the following generations of Australians.

The AMA has been doing its bit, and we will continue to do so.

We have a strong policy on climate change and health.

We have made submissions to inquiries on air quality.

We have concerns about possible health effects from coal seam gas mining.

We support government action to stop people smoking – plain packaging and higher tobacco excise are good policies.

We stand against the irresponsible use of alcohol, and have called for tighter controls on the marketing of alcohol to young people.

We have policy on the health of people in detention, including in prison.

We have called for an independent panel to monitor the health of asylum seekers.

And we have a long and proud history of working to improve Aboriginal and Torres Strait Islander health outcomes.

Health is about much more than hospitals and medical practices.  It is also about the promotion of wellness.

Just as the AMA is a champion in public health, we aspire to be a champion on the social determinants of health.

The AMA strongly supports the work of the Alliance.  We will continue to promote education and spark action on the social determinants of health.

I hope that today’s forum puts the spotlight on this very important – but often neglected – part of the national health conversation.

13 August 2013

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