A new group advocating for action on the social determinants of health has been established in Tasmania.
In the article below, Miriam Herzfeld, Facilitator of the Tasmanian Social Determinants of Health Advocacy Network, and Gavin Mooney, a health economist and a member of the new network, argue that all members of the community can contribute to the creation of a healthier society.
They also pose a challenge: will we see similar groups set up in other jurisdictions?
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An invitation to Tasmanians who’d like a healthier State
Miriam Herzfeld and Gavin Mooney write:
In Hobart, a new body was recently born – the Tasmanian Social Determinants of Health Advocacy Network (SDHAN). The purpose of the Network is to get Tasmanians working together to leverage action on the social determinants of health so as to improve health and wellbeing outcomes for all Tasmanians.
The vision of the Network is:
All Tasmanians have the opportunity to live a long, healthy life regardless of their income, education, employment, gender, sexuality, capabilities, cultural background, who they are or where they live.
Membership of the Network is open to all Tasmanians who share in this vision. Membership is free of charge.
The starting point of the SDHAN is to get the whole of Tasmania and all of Tasmanians to address the questions: How do we get health at the centre of our lives? How can we build a healthier Tasmania?
The answer to these questions are probably going to be driven by people’s line of work, their qualifications and their working life experiences. So if a Tasmanian is a nurse, public health worker, an allied health professional, a medical researcher, a health promoter or a general practitioner, he or she probably would say, ‘yes of course health is my core business – I do it every day – I help people get better, I’m researching a treatment for cancer, I educate the community about preventing diabetes’ (or whatever the case may be)’.
The real push of the SDHAN is to get recognition that this really needs a whole of community effort.
Thus if someone is an architect or a plumber in the building industry; a lawyer or a policewoman or a court attendant in the justice system; or a teacher or a school janitor or university cleaner in the education system; or a merchant banker or a bank clerk in the financial sector; or a retired or unemployed person with time on their hands, then each of these in their different ways can contribute to the health not only of themselves but also the health of the broader community.
The SDHAN emphasises the need for action at a state level but also in local communities, indeed especially the latter. The seeming cliché that health is everyone’s business is in principle and practice the driving force behind the Network.
Through the Network what we are trying to do is get all of these different people to realise that working at a community level we can all make a contribution.
The building industry: we know that people who live in inadequate housing are more likely to suffer from respiratory conditions. The Network seeks greater recognition among those in the building industry that good housing is good for health.
The justice system: we know that mental health issues can contribute to crime and violence. Acknowledging that can bring greater understanding to the way in which the justice system operates and treats offenders.
The education system: the more educated live longer and healthier lives. Is it not the role of those in the education sector to use this as a stimulus to try that bit harder to guide and support students to do the best they can? But the Network also wants to see more recognition of the importance of literacy and numeracy in day-to-day life. Lack of literacy can be a serious barrier to health.
The financial sector: many bankers (and others in society) are wealthy and as a result healthy. The Network seeks to persuade the better off that they have a role to support those who are less fortunate.
For those familiar with the literature on the SDH, there is nothing really new here. But in Tasmania our Network wants action and we want that action to be genuinely social. The social determinants of health can work. The evidence is there. Our Network wants to make a practical difference, hence the ‘advocacy ‘ in our title.
Tasmania is a relatively poor state. Poverty breeds ill-health. But it is also a small state where we tend to think that we know everyone and everyone knows us! Not true of course but more true than most other parts of Australia. And that is an advantage in trying to build on the SDH.
As a coherent and cohesive state on most fronts, we can all start doing more to share in the responsibility for maintaining the health and wellbeing of our communities.
Our health services, excellent though they are, struggle to cope with the demands made on them. The message for our Network is: ‘Let’s not leave it all to the formal health service. What can the Tasmanian community do to make health our core business?’
There are two other arguments that the Network is using to build support. One is that the gap between the rich and the poor is widening and we know that inequalities are bad for health. Such inequalities are a global phenomenon from which Tasmanians are not sheltered. We know people on lower incomes generally have worse health outcomes. If we don’t act to close this gap, we will see increasing inequities in health outcomes. This will have enormous ramifications across Tasmanian society.
Secondly, the financial resources in health care are under stress. There needs to be action to keep people well. That is best done by investing in changing the social conditions of health and wellbeing – in education, jobs, work conditions, food, transport and all those social factors that contribute to health. This clearly makes health everyone’s business.
The Federal Health Minister, Tanya Plibersek, has given our hard-pressed health care services a lifeline by way of a bail out package. Tasmanians are grateful. It seems that quite a lot of this money will go to promoting health outside hospitals.
Part of the role of the new SDHA Network will be to advocate for a sizeable chunk of this money to go on the social determinants. In that way the Network believes we can promote not only better health but also take some of the strain off the health services.
But we wonder. Are other states or territories setting up such networks?  This ideally needs to be an Australia-wide initiative. So let’s make it that! What Tasmania does today ….
The SDHA Network may be setting itself up for failure by asking the wrong question. ‘What can the Tasmanian community do to make health our core business?’ carries with it certain assumptions. The truth of the matter is that there is nothing like a consensus — among Australians or other population groups — that ‘health’ should be ‘core business’ or even a central or guiding or paramount concern. It may come as a surprise to many public health advocates that ‘health’, in the biophysical sense, is not everyone’s over-riding concern. Not everyone actually believes that the pursuit of healthy individuals and communities is any more important than anything else — many people are actually of the view that it’s the ‘b!oody do-gooders’ who are making their lives miserable by trying to make them think about and worry about health all the time.
Qualitative research on men’s health indicates that men rarely place health at the top of their priority list, and, when they do, it’s a very different concept of health. Many men are quite candid in acknowledging that they’d rather live a shorter and more indulgent life than a longer one full of restrictions, limitations, and ‘do withouts.’ It is important to realise that many people are quite prepared to risk having ‘worse health outcomes’ if it means they can keep living the way they want to live.
It is also a mistake to continue to equate economic prosperity with better health: the factors, the causes, and ‘the causes of the causes’ which give risk to communicable diseases differ from those responsible for non-communicable diseases: social determinants of health work in different and more complex ways in relation to NCDs.
Yes, by all means try to involve other disciplines and walks of life, but will they fall all over themselves getting excited about their role in promoting ‘health’? There are so many major, yet relatively simple, health-enhancing things that we have so far failed to do in settings such as schools and workplaces, and there are intense debates going on about what constitutes the most health-enhancing approaches to urban planning and residential development.
There will always be tensions, too, between behavioural and SDH approaches: two approaches that bridge these are regulation (where unhealthy choices are reduced or eliminated) and ‘nudges’ (where there are still choices, but the default option is the healthy option). I remain unconvinced, however, that we will solve Australia’s, or even Tasmania’s, health problems by eliminating social and economic inequalities.
Well said Margo.
Margo writes: “The truth of the matter is that there is nothing like a consensus — among Australians or other population groups — that ‘health’ should be ‘core business’ or even a central or guiding or paramount concern. It may come as a surprise to many public health advocates that ‘health’, in the biophysical sense, is not everyone’s over-riding concern.”
Thanks Margo as you have neatly summarised the key reasons why we have formed this network. We want to try to begin to build that consensus and we want to make health not an overriding concern but more of a concern. We also think that the fact that over 80 people came to the launch and we have 100 members within 13 days of the launch suggests maybe here in Tasmania there are many who want to try to make health more of a core concern. We think it is worth a try and we already have clear evidence that many fellow Tasmanians agree.
We also agree when you conclude: “I remain unconvinced, however, that we will solve Australia’s, or even Tasmania’s, health problems by eliminating social and economic inequalities.” The Network is aiming (as our piece indicates) much more broadly than simply “social and economic inequalities” although we think these are important. We certainly don’t have plans to ‘eliminate’ them!
I was asked, via a tweet, to explain whether my comments about men’s health apply only to a certain demographic, ie lower SES/disadvantaged men. The reason I don’t tweet is that I can’t face the challenge of condensing a response like this!:
Male health attitudes, beliefs and behavior are not so much about demographics as they are about finding a comfortable ‘masculinity’ – i.e., it’s not education, occupation, or status that matters as much as beliefs about what it means to be a man. Much of men’s resistance to health promotion messages is grounded in beliefs about how masculinity should be enacted. Conformity to dominant masculine norms has been found to be one of the most significant factors in men’s likelihood of engaging in certain preventive health behaviours, in their attitudes and behaviours in relation to health risks, and in the way that men explain why they adopt certain ‘healthy’ practices. It is not just low SES men who avoid going to the doctor, who avoid ‘rabbit food’, and who ‘don’t want to be the sort of person who makes food decisions based on nutrition labels’ (actual quote). Men right across the socio-economic spectrum have been found to be resistant to health promotion messages (which are not usually pitched at them, anyway), as they don’t like being told what to do and they especially don’t like being told that they should prioritise something as feminine as ‘health’.
Qualitative research has shown that, in many cases, the onset of a serious illness or disability can prompt a reassessment of what is ‘permissible’ within the parameters of masculinity. In the absence of overt symptoms of disease, however, expecting ‘health’ – consistently regarded by men as a female concern – to become a priority, represents an immediate obstacle for strategies which assume, or are designed to encourage, men to be proactive about, or to care about, their health. It’s not impossible to market ‘health’ to men — the success of gender-sensitive commercial marketing speaks volumes for the ability to target men through carefully-chosen language, presentation, content and imagery. I am sure it is not beyond our ability to promote a concept of masculinity in which looking after yourself and staying in control are key components. One of the clear messages from the ‘lay epidemiology’ of men’s health, however, is that men want to be healthy – they just don’t want to have to make a big deal out of it. (The benefit of ‘nudges’ and other similarly subtle appeals is exactly that.) So I’d just be sensitive to fact that, for a range of reasons, not everyone responds positively to the argument that ‘health’ must be treated as a priority.
There is now steadily increasing evidence that improving health outcomes is not as simple as giving people access to opportunities for healthier options (such as fresh food) – there are numerous conditions that need to exist to make those opportunities both practical and socially acceptable. It may be a matter of finding the proverbial ‘win-win’ so that people (individuals, organisations and sectors) will ‘get it’ in terms of how better health can translate into meaningful benefits. A key issue will be how to proceed in relation to different aspects of ‘health’, including whether ‘motivation’ comes first or whether ‘change’ comes first.