Australia: the healthiest country by 2020
National Preventative Health Strategy – the roadmap for action

v - Reduce inequity through targeting disadvantage

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Major health inequities exist not only between Indigenous Australians and the general population, but between rich and poor and between rural and city dwellers. Even within a city such as Melbourne, life expectancy can vary by up to six years within a matter of kilometres.

The WHO's Commission on the Social Determinants of health (CSDH) makes three overarching recommendations to 'tackle the corrosive effects of inequality of life chances':

• Improve daily living conditions, including the circumstances in which people are born, live, work and age
• Tackle the inequitable distribution of power, money and resources – the structural drivers of those conditions – globally, nationally and locally
• Measure and understand the problem and assess the impact of action

The Commission has called on all nations, including Australia, to develop and implement public policies, private sector responsibility and social action that puts health equity as a central societal goal.

Social determinants of health

'Australian governments have an obligation to build community support and capacity to enjoy good health, particularly among those who are most vulnerable and have least capacity to make choices and changes in their lifestyle or living conditions that might improve and protect their health: the very young, the old, the poor and disenfranchised' (Quote from submission)

Choosing to eat healthy food, being physically active, limiting alcohol consumption and not smoking requires people to be empowered to make these choices. It means that the healthy choice must be physically, financially and socially the easier and more desirable choice than the less healthy option. This is not always the case, particularly with decreasing social position.

What, and how much, people eat, drink and smoke and how they expend energy are responses to a number of factors – political, economic, environmental and cultural. A significant proportion of the global population now eats large volumes of energy-dense nutrient-poor foods, does not expend enough energy, smokes and consumes harmful quantities of alcohol. The harmful health consequences of these behaviours, and the inequity in their social distribution, are the result of both market failure and failure by government to protect the health of all its citizens. Greater accountability (by both parties) is needed.
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The health gap

In some countries around the world there are differences in life expectancy among population groups of nearly 30 years. Australia, one of the wealthier countries in the OECD,[70] has a highly concerning gap in life expectancy between Indigenous males, compared to the non Indigenous males. While there have been some improvements in Indigenous death rates, in particular a narrowing of the gap between Indigenous infants and other Australian infants, the overall gap between Indigenous and non-Indigenous death rates is widening.[2]

Tobacco use, alcohol consumption, poor nutrition and inadequate physical activity are associated with a plethora of non-communicable diseases, including cardiovascular diseases, obesity, diabetes, cancers and acute respiratory conditions. Health inequities exist between the top and bottom SES quintile of the Australian adult population for a number of these health issues and their associated behavioural risk factors (Figure 1.9). Overweight and obesity and regular tobacco use are significantly greater among the lowest socioeconomic quintile compared to adults in the highest quintile.

Figure 1.9:
Proportion of people aged 18 years and over reporting selected health risk factors and long-term conditions, by socioeconomic status, 2004–05

Source AIHW. Australia's Health 2008.[2]

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The social gradient

Solely focusing on the difference in health experience at opposite ends of the social spectrum masks the graded relationship between social position and health. In Australia, as in most other countries, as one moves down the socioeconomic ladder the risk of shorter lives and higher levels of disease risk factors increases.[2, 71] A recent analysis of mortality rates, and notably avoidable mortality rates, illustrates how death rates decrease progressively with increasing SES (Figure 1.10).

Figure 1.10:
Age and sex-adjusted mortality rates, Australia, aged less than 75 years, 2002[72]

Source: Korda R et al Differential impacts of health care in Australia: trend analysis of socio economic inequalities in avoidable mortality. International Journal of Epidemiology 2007.

Overweight and obesity have become increasingly more prevalent among socially disadvantaged groups, particularly in urban areas, with the exception of very poor countries.[73] In Australia, like most other risk factors for ill health, excess body weight tends to be more prevalent among people further down the social and economic scale.[74] Analysis of the AusDiab 1999–2000 data shows a clear social gradient in the prevalence of obesity among adult women (Figure 1.11). A policy and programmatic focus on only the most disadvantaged, in this instance women with primary level education, would miss the equally significant health burden from obesity among women along the remainder of the education spectrum.

Figure 1.11:
Prevalence of obesity among women, by level of education(5)

Source: AusDiab 1999–2000

Understanding health inequity in terms of the social gradient in health allows us to embrace not only conditions of absolute poverty and exclusion but social conditions that affect everyone. In doing so, policies and programs will have greater potential to reach a wider population, thereby improving the health of more people.
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Social determinants of obesity, tobacco use and alcohol consumption

Social inequities in daily living conditions, lead to inequities in health outcomes. Of particular relevance to obesity, tobacco and alcohol consumption is the nature of, and inequity in:

• The physical and social experiences in early life
• Access to and quality of education
• The nature of urbanisation – how cities are planned and designed –along with the liveability of rural locations
• Transport options
• Distribution mechanisms and associated consumer price of food, alcohol
  and tobacco
• Exposure to marketing of energy-dense nutrient-poor foods, alcohol and tobacco
• The financial, psychosocial and physical conditions of working life
• The degree of social protection provided

Culture is a major social determinant of health. For Indigenous people, health status is not just a matter of position in the social gradient, as for the general population. Irrespective of SES or geographical location, Aboriginality itself is associated with poor health.[75] Specific recognition of culture, as a major social determinant of Indigenous health, is important when designing preventative health programs to contribute to 'Close the Gap' targets (see below).

Structural determinants: power, money and resources

Promoting health equity through healthy weight and reducing smoking and excessive alcohol use also means tackling some of the fundamental political, economic and cultural issues (the structural determinants) that affect people's living conditions, their daily practices and behaviour-related risks.

This means dealing with matters of governance; national economic priorities; trade arrangements; market deregulation and foreign direct investment; fiscal policy; and the degree to which policies, systems and processes are inclusive – each issue very much related to the CSDH recommendation of tackling the unequal distribution of power, money and resources. Addressing these structural determinants of health inequity not only helps individuals and communities but also national government and other key public sector institutions. For example, good global governance and regulatory frameworks create support for national governments to introduce policies that tackle corporate pressures such as irresponsible marketing.[76]

In light of the strong relationship between health and social disadvantage and the clustering of risk in the most vulnerable populations, the Taskforce welcomes the Australian Government's Social Inclusion Agenda and similar initiatives introduced at the state level (such as South Australia's Social Inclusion initiative).

The Taskforce shares the Australian Government's vision of an inclusive society as one in which all Australians feel valued and have the opportunity to participate fully in social and economic life. Health is one of the key resources that can enable participation. Conversely, social exclusion can itself be a contributor and determinant of poor health.

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