On Bernard Keane, Public Health and the Neglect of Social Determinants

Richard Eckersley, director, Australia 21 Ltd (formerly at the National Centre for Epidemiology and Population Health, ANU).

A colleague once caught me helping myself to some cakes left over from a staff party. Getting your fix of fats and sugars, she quipped. Yep, I replied, I was rebelling against public health fascism. I had in mind the growing number, and sometimes authoritarian tone, of health messages telling us how we should live. Hell, even sitting down (for too long) harms health these days.

So [Crikey Canberra correspondent] Bernard Keane’s attack on the ‘preventive health industry’ is understandable and partly right, but for the wrong reasons. It’s not that the health messages are unwarranted: There are real concerns about trends in both physical and mental health, especially among young people (http://blogs.crikey.com.au/croakey/2011/04/22/challenging-accepted-wisdoms-about-young-peoples-health-and-wellbeing/).

But there is a public or preventive health ‘industry’ in the sense of a professional body that applies a specialised, and restricted, view of how to improve people’s health. You can, as Keane does, talk of ‘social elites anxious to impose control on what they disapprove of’, but it is not particularly helpful.

The ‘industry’ emphasises modifying individual risk factors and lifestyles, particularly tobacco use, poor diet and lack of physical activity, and harmful alcohol use (http://blogs.crikey.com.au/croakey/2011/04/06/challenging-mainstream-thinking-about-health-and-medicine/). It largely overlooks the broader perspective of the social determinants of health (broadly defined to include social, cultural, economic and environmental factors). In doing this, it downplays the political or ideological significance of sickness and ill-health.

As we learn more about health, the bar of healthy living keeps getting raised - at the same time as the weight of unhealthy cultural expectations, or pressures, keeps increasing. Something has to give, and one result is the frustration and resentment expressed in Keane’s articles.

In promoting individual behavioural change, the orthodox public health approach misses the crucial point that social conditions act on population health in ways that cannot be reduced to individual choices. As British epidemiologist Geoffrey Rose observed, there is a relation between the mean of a characteristic in a population (for example, blood pressure or depressive symptoms) and the prevalence of the related disorder. ‘(T)he deviants are simply the tail of the population’s own distribution; they belong to each other…’ Or, as he also said, ‘The visible part of the iceberg (prevalence) is a function of its total mass (the population average)’.

This relationship shows that disease and disorder are the result of social conditions, not just individual lifestyles. Rose also argued that causes of cases can differ from causes of incidence: that is, explanations of why an individual becomes ill can differ from the explanations of why rates of illness in a population rise or fall. Efforts to improve health must match, or be appropriate to, the scale or level at which we seek improvement.

The two approaches – individual and social - are not completely separate and distinct; they represent the ends of a spectrum of interventions. Public health programs, while they are directed at individual behaviour, aim to produce changes in the population as a whole. They range from public education to substantial legislative and regulatory changes to promote healthier living. And it can be argued that social conditions are addressed elsewhere in government: through taxation, welfare, consumer safety and environmental protection, for example.

However, individual and population perspectives are conceptually different in important respects, and the effects of social conditions on population health need to be better understood and acknowledged as a basis for improving public policy and national goals and priorities.

It is very difficult for us to make healthy choices when the social conditions encourage unhealthy preferences. It puts us under considerable stress. As Keane demonstrates, we can respond angrily to attempts by governments and others to interfere in our private lives and to tell us how to live (which is ironic given a vast media-marketing complex spends billions of dollars doing just that, with little opposition).

Industry research on the recommendations of Australia’s National Preventative Health Taskforce (which include tax increases and advertising bans) found more than half of Australians reacted negatively, including agreeing that its report was a political document ‘intent on overturning much of the way we choose to live’.

Richard Wilkinson, co-author of the influential 2009 book, The Spirit Level: Why Equality is Better for Everyone, once told me that people can't keep to good intentions about healthy eating, giving up smoking and taking exercise unless they feel on top of life. ‘When we feel unappreciated, stressed and (with) no way out, we are more likely to eat for comfort and resort to alcohol, drugs, tobacco, and to become more sedentary.’

Wilkinson and others focus on the harm to health of inequality. I’ve emphasised the role of culture, arguing that modern Western culture, with its growing psychological stresses and pressures and its focus on consumption, pleasure and other external trappings of ‘the good life’, is a health hazard.

   

I’ve sometimes illustrated the importance of the social determinants of health by telling ‘the parable of the drowned’, modelled loosely on Hurricane Katrina’s devastation of New Orleans in 2005. Let’s assume most of those who perished drowned. On this basis, the response (reflecting the individual focus of public health campaigns) might be to issue life jackets, or to teach everyone to swim.

Going further, we find that most of the losses occurred in low-lying parts of the city, so the response might be not to build there. We then learn people lived there because they were poor and could not afford to live anywhere else, so poverty needs to be addressed. Then there were problems with the construction of the city’s storm and flood levees and the filling in of coastal wetlands that used to buffer storm surges, raising more questions about governance and city development.

But none of these explanations acknowledges the fundamental cause of the deaths as the hurricane’s severity, and the role of climate change in increasing the probability of such extreme weather events. This implicates industrial civilization. The parable makes clear that understanding and addressing health problems at the level of individual causes of death and disease are very different from understanding and addressing the social causes of a population’s health. As with climate change, so it is with social change.

This wider social perspective tends falls between stools. Public health pays too much attention to the individual; political commentators and analysts have too much regard for political theatre and policy detail. Both perspectives are too restricted. Both need to consider in greater depth the ways in which our world view - the whole framework of our way of life - works against better health and higher wellbeing.

Citation/original source

Eckersley, R. 2012. On Bernard Keane, Public Health and the Neglect of Social Determinants, Croakey, 16 December.

http://blogs.crikey.com.au/croakey/2012/12/16/richard-eckersley-responds-to-bernard-keanes-attack-on-preventative-health-wowsers/

Further reading (available at www.richardeckersley.com.au ):

Eckersley R. 2012. Whatever Happened to Western Civilization? The Cultural Crisis, 20 Years Later. The Futurist, Nov-Dec, pp. 16-22.

Eckersley, R. 2012. The science and politics of population health: giving health a greater role in public policy. Canberra: Australia 21 Ltd.

You can't stop the music

Both personally and as Chairman of Australia21, I am disappointed to hear that there is to be a spill of full-time positions at the Australian National University’s wonderful School of Music, so that the 32 full-time staff have to apply for positions in a reduced establishment of 20.

Disappointed because I think we as a society should be moving in the other direction – more engagement with music as high art – and I have begun considering how to frame an Australia21 project that could examine the social wellbeing benefits of the Venezuelan program known as El Sistema (“the system”) and how the lessons from that might be applied in an Australian context.

El Sistema is a publicly financed music education program in Venezuela, founded in 1975 by economist and musician José Antonio Abreu under the name of Social Action for Music.

El Sistema is a state foundation which watches over Venezuela's 102 youth orchestras, 55 children’s orchestras and 270 music centres, and the instrumental training programmes which make them possible. While the organisation has 31 symphony orchestras, its greatest achievement is the 310,000 to 370,000 children who attend its music schools around the country where it is estimated that 70 to 90 percent of them come from poor socio-economic backgrounds.  The program is known for rescuing young people in extremely impoverished circumstances from the environment of drug abuse and crime into which they would likely otherwise be drawn.

Interestingly, it has always been located under the wing of social services ministries, not the Ministry of Culture, a fact which has helped it to survive several changes of government, and political persuasions of government, over a period of more than 30 years.  We are talking about classical music as a positive force for personal development and a benefit to society, not simply as recreation, important as the enjoyment aspect is.  As Abreu himself puts it:

Music has to be recognized as an ... agent of social development in the highest sense, because it transmits the highest values -- solidarity, harmony, mutual compassion. And it has the ability to unite an entire community and to express sublime feelings.

A detailed account of El Sistema’s achievements and history, including its spread to the United States and the United Kingdom, may be found in the relevant Wikipedia entry.  A video of Abreu talking about El Sistema on the TED website on the occasion of being awarded the TED Prize may be accessed here, and a June 2010 TED Blog post on the graduation in Boston of 10 young musicians from the the El Sistema USA program at New England Conservatory may be accessed here. These young musicians were to spread out to seven centres across the United States and establish “nucleos” – programs and centres that will “teach children to play music, believe in themselves, and reach for their dreams”.

I would like to see Australia as one of the next to take up El Sistema, but sadly, we seem to be moving in the opposite direction. To mix the metaphors, we seem to see music as the icing on the cake, not as core business.  But for people “doing it tough”, and especially their children, music offers great benefits and opportunities.

Regreening Australia

Australia21 is seeking funding for a new project to re-assess the potential and feasibility of a large-scale reforestation and environmental rehabilitation program.

In 1989, CSIRO published Richard Eckersley’s report, “Regreening Australia: The environmental, economic and social benefits of reforestation”, a preliminary investigation into a large national program to “regreen Australia” through massive reforestation and revegetation over a period of 10-20 years. (The full report is available on his website www.Richardeckersley.com.au.)

The main justification for the program was to combat land degradation, regarded as Australia’s most serious environmental problem. However, the report outlined other potential benefits, including mitigating and adapting to climate change; protecting biodiversity; increasing the sustainability and productivity of Australian agriculture; boosting timber resources; building environmental management expertise and innovation; creating many useful jobs; and lifting national morale.

The report attracted a great deal of public, political and professional interest, but was never implemented on the scale envisaged and necessary to realise the benefits. Over 20 years on, there are grounds for re-assessing the report’s recommendations, especially that climate change has become a more widely recognised, serious and urgent problem; the scientific case for reforestation as a means of countering climate change has become stronger; and, in the event of deepening global financial crises, job generation will become an important part of maintaining economic and social stability.

If you would like to know more about this project or you would like to contribute in some way, please contact Richard Eckersley at richard@richardeckersley.com.au.

Fiddling while the earth burns

The following opinion piece by Australia 21 Director Richard Eckersley was published in The Age, Friday 27 August 2010. Access the original here.

Fiddling while the earth burns

No more 'politics as usual' should mean having enough courage to tackle the sickness of mindless consumption.

Nearly every decade from the 1970s has been declared a decade of reckoning, the time when we must deal decisively with looming national and global environmental crises. And as each decade passes, we postpone the deadline another 10 years. With the failure of the Copenhagen conference on climate change last year, the 2010s are now the critical decade of action.

This means the environmental ''emergency'' will have lasted half a century, or two generations. It is not just climate change that we must address, but also land and water degradation, food security, peak oil, population and biodiversity loss. And it is not that nothing worthwhile has been achieved; it is that our responses have failed to match the growing magnitude of the problems.

We have to accept that we cannot meet these challenges with ''politics as usual'' approaches, which seek to offend no one, yield to vested interests, and require no ''sacrifices'' in our way of life.

Beyond the election commentary about political executions, spin, negativity, leaks, botched or boring campaigns, risk aversion and lack of policy substance, we need also to acknowledge the systemic failure of our politics to deal with our problems. This deep current is largely ignored, while politicians, commentators and analysts focus on the swirling surface eddies.

The failure to act on climate change hurt Labor. But its shelved carbon pollution reduction scheme was a lemon anyway, an inadequate response. Also, it is unclear whether the key to voter disillusion was concern about climate change or the reneging on a core ''moral'' commitment. Both dimensions are important: climate change is a real threat to our future, but it is also an emblem of the wider challenge to our quality of life.

Mental health is another example of systemic political failure. Yes, mental health made the campaign agenda, but the whole focus of debate was on services. There was no consideration of why we face a crisis in mental health.

This is a Western problem, not just an Australian one. New US research suggests a fivefold increase since the 1930s in the proportion of college students experiencing psychological problems, and that more than half of young Americans today suffer a clinical mental disorder by the age of 21. If such findings are true, how are we to respond?

From a deep-current perspective, all these issues - environmental, social and economic - have their source in a world view that sees the central purpose of our society as pursuing ever more material enrichment in order to allow us to consume more. Not only does this put pressure on resources and lead to the financial excesses that produced the global financial crisis, it ultimately lies behind the crisis in mental health.

Evidence suggests rising mental illness, especially in the young, is the result of the cultural emphasis on materialism and individualism, manifest in changes in the family, work, the media, religion, education and diet. One specific factor is a shift towards defining ourselves in terms of our extrinsic achievements, in the external trappings of the successful life, including wealth, status, recognition and appearances.

The shift emphasises goals that distract us from what is most important to our well-being: the quality of our relationships with each other and our world, which contribute to a sense of intrinsic worth and existential certainty. As Goethe warned, things that matter most must never be at the mercy of things that matter least.

Fixing this situation goes beyond politics; it requires leadership at all levels of society. But politics has a role to play. Politicians and the electorates they serve must have the courage to enact sweeping policy changes that shift the course of the deep current, not just stir up the surface eddies.

It means recognising that economic growth measures progress very imperfectly, that the content of growth is more important than its rate, and that we need to direct economic activity away from consumption for short-term personal gratification towards long-term investment in the social transformation necessary to address all the challenges of our century and ensure our future.

And that will mean radical reforms, such as limiting or banning political donations by corporations and other vested interests, making polluters pay for greenhouse gas emissions through effective carbon pricing, abolishing tax deductibility for advertising to ease the pressures on us to spend and spend, and creating jobs where they are socially needed and useful, not where confected demand dictates.

Neither politicians nor citizens fully grasp the size of the gulf between political priorities and social realities. In an Australian National University poll late last year (when Labor's stocks were high), 70 per cent of Australians said they were satisfied with ''the way the country is heading'' (a political question), but only 24 per cent thought quality of life in Australia was getting better (a social question).

It makes for a volatile situation, revealed these days in how quickly our political leaders disappoint us. The results of the election, with the shift in power to independents and the Greens, might shake loose the rusted shackles of the political status quo and make deep change possible. The Prime Minister has acknowledged that the Australian people want something different from ''business as usual''. Can we achieve something different enough, in both process and policy?

Richard Eckersley is a director of Australia21, an independent, non-profit research company, and a visiting fellow at the Australian National University

Richard Eckersley on the mental health crisis

The following article by Australia 21 Director and Fellow Richard Eckersley was published in The Canberra Times, 24 June 2010.  See the article as published here.

Cash grab hurting wellbeing

Cultural changes towards extrinsic goals – like financial success – are adding to pressures on young people, Richard Eckersley writes.

The resignation of the Federal Government’s top mental health adviser, John Mendoza, is just the latest episode in the unfolding mental health crisis in Australia. Professor Mendoza, the chair of the National Advisory Council on Mental Health, quit last week saying he was deeply disappointed at the Government’s lack of vision and commitment to mental health.

The crisis goes deeper than even many psychiatrists and psychologists, let alone governments and the public, realise. Addressing it requires more than increasing funding for mental health services. Our understanding of the causes of the situation remains a contentious matter among researchers, but there is growing evidence that they lie deep in the psychological impacts of the changing culture of Australia and other Western societies.

Most mental illness begins in adolescence and early adulthood and concerns about mental health care for young people are a prominent feature of the current debate, championed by the 2010 Australian of the Year, Professor Pat McGorry.

Earlier this year, American psychologist Jean Twenge and her colleagues published the findings of a remarkable study, in which they compared the results of the oddly named but widely used psychological test, the Minnesota Multiphasic Personality Inventory, or MMPI, going back to the 1930s.

The researchers found a steady decline in the mental health of college students between 1938 and 2007 and high-school students between 1951 and 2002. Five times as many college students now score high enough to indicate psychological problems as they did in 1938. The increases translate into a greater likelihood of characteristics such as moodiness, restlessness, dissatisfaction and instability; unrealistically positive self-appraisal, overactivity and low self-control; feeling isolated and misunderstood; sensitivity and sentimentality; and being narcissistic, self-centred and antisocial.

The findings are not conclusive. Critics point out that people might just be becoming more willing to endorse items indicating psychological problems (although Twenge says the MMPI allows researchers to test for this bias, which they did; the trends remain).

Another new study, conducted by British psychologist Stephan Collishaw and colleagues, found that English adolescents experienced considerably higher rates of emotional problems in 2006 than they did in 1986, especially girls. The greatest changes were for worry, irritability, fatigue, sleep disturbance, panic and feeling worn out or under strain; the more severe the reported symptoms, the larger the increase over the two decades.

A few months ago, I looked up the most recent results of national surveys conducted by the American College Health Association. The survey shows that large proportions of students report strong negative emotions for both the previous twelve months and the previous two weeks. For example, 47 per cent in the last twelve months (and 17 per cent in the last two weeks) had felt things were hopeless; 87 per cent (54 per cent) had felt overwhelmed by all they had to do; 82 per cent (50 per cent) had felt exhausted; 31 per cent (10 per cent) had felt so depressed that it was difficult to function; 49 per cent (19 per cent) had felt overwhelming anxiety; and 39 per cent (12 per cent) had felt overwhelming anger.

Although I have been steeped in data like these for over 20 years, I find the figures shocking, even hard to believe. I’ve asked colleagues here and in the United States and Britain what the findings mean. I think it is fair to say that we don’t know for sure. They are certainly not the whole story of young people’s lives.

Had they been asked, 80-90 per cent of the students would have said they were happy and satisfied with their lives; most would be leading seemingly normal lives: attending lectures, completing assignments, working, partying and dating. At the same time, I think these findings tell us something about being young today, including specific social problems such as youth violence and binge-drinking.

The disturbing picture is likely to be broadly true of Australians (we lack comparable data over time to assess trends here). What explains it? There are many possibilities, including changes in family life such as more family conflict and breakdown, increasing work-life pressures and changes in parenting. The growth of the media and communications technologies, the weakening influence of religion, more junk food and other changes in diet, and even chemical pollution might be involved.

Twenge and her colleagues considered – and rejected – the possibility that economic factors were responsible. Instead they favoured a cultural explanation – in particular, a shift from intrinsic to extrinsic values and goals. An intrinsic orientation means doing things for their own sake – because we want to do them. It is ‘self –transcending’ and is good for our wellbeing.

An extrinsic orientation means doing things in the hope or expectation of other rewards - status, money, appearance, recognition. It is ‘self-enhancing’ in the sense of being concerned with self-image. It is not good for our wellbeing. A focus on the external trappings of success and ‘the good life’ encourages unrealistic and misguided expectations and increases the pressure to perform and achieve, leading to stress, frustration, resentment and dissatisfaction.

One American student says in an Associated Press article on Twenge’s findings that she feels pressure to be financially successful, even when she doesn't want to be. ‘The unrealistic feelings that are ingrained in us from a young age — that we need to have massive amounts of money to be considered a success — not only lead us to a higher likelihood of feeling inadequate, anxious or depressed, but also make us think that the only value in getting an education is to make a lot of money, which is the wrong way to look at it.’

The results of regular surveys over more than forty years of how American college students rate the importance of various life goals confirm her observation. The biggest change has occurred in the two goals of ‘developing a meaningful philosophy of life’ and ‘being very well off financially’. Meaning declined sharply in importance during the 1970s and 1980s, while money rose to become the highest rated goal.

Youth problems today are more the result of existential and relational deprivation than material and economic deprivation. Our individualistic, consumer culture relentlessly and ruthlessly promotes extrinsic values and norms, making it harder for us to develop a grounded sense of who we are and what we want in life, and distracting us from what matters most to our wellbeing: our relationships with other people.

Australian novelist Ruth Park, in describing growing up in New Zealand during the Depression, says of young people then: ‘Whatever hardship came our way was all on the outside. Inside we knew, without doubt, that Life was aware of us and somehow had us in its care’. It strikes me as a good description of intrinsic worth and existential certainty and confidence.

Richard Eckersley is a director of Australia 21, an independent, non-profit research company and a visiting fellow at the Australian National University.

Richard Eckersley on indigenous wellbeing

On 15 March Australia 21 director Richard Eckersley gave a seminar, entitled “Indigenous wellbeing and the problems of Western benchmarks and contexts: 'closing the gap', but what gap and how?”, in a current series on Indigenous wellbeing at the Australian Institute of Aboriginal and Torres Strait Islander Studies. 

The Federal Government's report Closing the Gap notes that Indigenous Australians are at a marked disadvantage compared to non-indigenous Australians and the gap has not decreased over the past decade or more.

“Closing the Gap” is a great national challenge, but also a great national opportunity to achieve lasting change and ensure that future generations of Indigenous Australians have all the opportunities enjoyed by other Australians to live full, healthy lives and achieve their potential.'

Richard argues that the goal of “closing the gap” in indigenous health, education and employment may seem laudable from a practical, political standpoint, but at a more abstract, philosophical level, it misses important questions about the benchmarks used and the cultural contexts of health and wellbeing, including whether Australian society as a whole can learn from Indigenous cultural perspectives. Western nations like Australia don't perform as well as the dominant indicators of human development suggest; they are not the best of role models. This matters, especially when some commentators believe the consequence of “closing the gap”, whether intended or not, will be to have Indigenous Australians live like the rest of us.

The back cover of Karl-Erik Sveiby & Tex Skuthorpe's 2006 book Treading Lightly says it takes us on “a unique journey into traditional Aboriginal life and culture, and offers a powerful and original model for building sustainable organisations, communities and ecologies.” The blurb might seem to suggest the book is about the external features of sustainability, the outward manifestations of lifestyle. But it is really about the internalities, especially notions of the self and its relationships to others and to the environment.

The book is, in this sense, a parable or allegory for our times. The moral is not that we could or should adopt an indigenous lifestyle, but that we need to recognise that other, quite different, and even better, ways of making sense of the world and our lives are possible. And not only that: we need to examine our present situation at this most fundamental level if we are to have any chance of achieving a high, equitable and durable quality of life.

One important gap to close is that between the scale of our responses and the magnitude of the challenges, between policy relevance and response effectiveness. The transformation of our society requires transformation of the self and what we believe it to be. Indigenous spirituality and philosophy might help us do this (without suggesting that non-indigenous Australia could, or should, appropriate them or graft them on to Western modes of thinking and doing things).

Perhaps we cannot, or need not, confront head-on the orthodoxy of “closing the gap” in Indigenous health and wellbeing. But in this policy area, as in so many others, we need to look more closely at the wider social, economic and cultural context or framework within which policy is formulated. In his 2004 book Well & Good Richard says: “In ordinary times, it is perhaps normal for different planes of perception and understanding of the human condition to remain relatively separate and distinct, with little 'friction', or influence, occurring between them. In transitional epochs, when what it is to be human is undergoing profound evaluation and radical alteration, these planes of perception need to come together in a single, interwoven, public conversation. Ours is such a time.”

The seminars are available in PDF format here.

Robyn Archer on resilience

One of the highlights of Australia 21’s National Conference on Resilience was an entertaining and thought provoking address by our after-dinner speaker Robyn Archer AO, who in 2009 was appointed the Creative Director for the Centenary of Canberra in 2013.

She spoke about the application of resilience thinking in her field of expertise, the arts – what resilience means in the life of an individual artist, how to ensure the resilience of the arts, and what the arts and the creativity of society contribute to the resilience of the society itself.

Robyn’s address may be accessed here.

The health and wellbeing of young Australians

Australia 21 Director and Fellow Richard Eckersley’s report, Never better — or getting worse? The health and wellbeing of young Australians — was launched at a public lecture given by Richard at the Australian National University in September 2008. The report served several purposes: to review the evidence over the past twenty years since his first report on youth, Casualties of change, was published by the Commission for the Future; to analyse the many ambiguities and contradictions in this evidence; to highlight the growing importance of non-fatal, chronic illness, especially mental disorders; and to challenge the dominant view that young people are healthier than ever before.

The report attracted good media coverage and professional attention, including invitations to Richard to address several state and national conferences of state and independent schools. Over the past year, Richard has also extended this work to explore population health and wellbeing more broadly.

He has published papers in the journal, Social Indicators Research, and an OECD newsletter, Measuring the progress of societies, that contest the orthodoxy that Western liberal democracies represent the leading edge of human progress and development, as suggested by commonly used indicators. He argues that life expectancy is not a valid measure of overall health; happiness may not be comparable across cultures and does not, in any case, cover all the attributes of healthy people or societies; and other common measures such as income, education, governance and human rights, being mainly structural and institutional, do not adequately reflect the cultural and moral qualities that shape the more intimate aspects of life, and so are central to health and wellbeing.

Richard also contributed an item on this topic to Australia 21’s Next Big Question project (for details of this project see The Next Big Question).

Another application of this work was an essay in the Australia 21 publication, Brighter prospects: enhancing the resilience of Australia, in which Richard proposed that the health of a population was a critical dimension of the resilience of a society, being not only a consequence but also a cause of national and global developments. If people are getting ‘sicker and sadder’, this not only weakens the confidence and resolve they need to face and overcome threats and adversities, it can also increase the risk that they will respond inappropriately — even in ways that make the situation worse.