When the spectre of COVID-19 first arose, our immediate reaction was to prevent the pandemic taking hold in Australia. It was not to wait and treat the consequences. Our national and state and territory governments deserve great kudos for this—and for the respect they showed for expert public health advice.
Our response to COVID-19 is a powerful reminder that prevention is, indeed, better than cure. It shows that investing in preventing the cause of a disease is much cheaper (but it still costs), is fairer and is more sustainable. The highly imminent, contagious threat of COVID-19 has resulted in rapid, creative and consensual thinking and action. As a result, more has changed in Australian health and welfare since the virus emerged than has changed in the last three decades.
However, the causes of an astounding nine out of ten deaths in Australia are not infections.1 They are chronic illnesses such as cancer, diabetes, heart disease, respiratory disease and mental ill-health. Nearly 40 per cent of our disease burden and premature deaths could be prevented by reducing proximal risk factors such as tobacco use, overweight and obesity, and harmful use of alcohol,2 which, as we will see later, are driven by ‘Big’ industries. These chronic illnesses have a much greater impact on already-disadvantaged groups, such as Indigenous Australians, people living with mental health problems, and those with lower incomes and education.
We propose two mutually reinforcing perspectives alongside key structural reforms to substantially improve our health and wellbeing.
The first proposal is to ramp up prevention of the major proximal causes of premature death and the vast array of other health and social problems as mentioned above (obesity, tobacco, alcohol, gambling). We then propose four essential structural reforms needed to finance and implement the expanded prevention workforce and concomitant technologies needed to carry out long-term, equitable, widespread and highly effective prevention programs.
The second approach is to metaphorically ‘go upstream’ to prevent the causes of the causes3 (of poor physical and mental health4). These include poor housing, poor urban design, poor education, unemployment and hazardous employment. Layering these is their intricate link with inequality, socioeconomic disadvantage and poverty, structural racism, intergenerational trauma, and decades of policies that have entrenched, rather than relieved, social exclusion.
Investing in prevention: Investing in the proximal causes of disease
One in two Australians have one of the chronic diseases mentioned above.5 Let us take one of them: type 2 diabetes. It is at epidemic proportions, with an estimated 1.5 million Australian adults in 2017-18 living with diabetes, including an estimated 500,000 whose type 2 diabetes is yet to be diagnosed. The number has doubled since 2001 and the prevalence is more than twice in the lowest socioeconomic group (7 per cent) compared to the highest socioeconomic group (3 per cent).6 More than 100,000 Australians have been diagnosed with it in the past year, and well over 4000 have lost a leg due to a diabetes-related amputation.7 Imagine how we would react if landmines were the cause?
It will be impossible to treat our way out of these chronic diseases. Australia has to prioritise spending on prevention and public health. Our investment has been declining, with just 1.5 per cent of total recurrent health expenditure allocated to prevention in 20158—a reduction from a high of 2.2 per cent in 2007-08. This is significantly less expenditure than in other comparable countries.9
We will now examine some key structural reforms needed to finance and implement effective prevention programs.
Developing local ‘markets for prevention’
We can start by completely rethinking who can invest in prevention and why it would benefit them. A vast range of local and national social enterprises focused on prevention, inclusion and sustainability can be established using new forms of social financing. These include blended forms of financing such as social procurement financing, an example of which is the Victorian Government’s Partnerships Addressing Disadvantage, where investors can receive ‘success payments’ as delivery agencies or service providers.10 Other finance formulations include social impact investment, indirect equity (for example, selling share sale proceeds), debt financing, direct equity (crowdfunding), credit support, grants, and concessional tax finance.11
These forms of blended financing can bring in a far broader range of local investors to support locally driven prevention initiatives to complement national and state investments. Local investors could include banks, local employers, industry superannuation funds, infrastructure companies, developers, chambers of commerce, local philanthropists, life insurance and health insurance companies, and renewable energy providers.
These health-promoting social enterprises can become social franchises as they go to scale across Australia financed both by local and national investors. Recent research shows that social enterprises’ net employment effect (per social enterprise entrant) is larger than that for commercial firms.12
Establishing a preventive health benefits scheme
We have the Pharmaceutical Benefits Scheme (PBS) and the Pharmaceutical Benefits Advisory Committee (PBAC), which recommends new medicines for listing on the PBS. Similarly, we have the Medicare Benefits Scheme (MBS) and the Medical Services Advisory Committee (MSAC), which advises the Australian minister for health on the strength of evidence relating to the safety, clinical effectiveness and cost-effectiveness of medical services and technologies proposed for public funding.13
Why not a preventive health benefits scheme?
It would be supported by an independent, non-statutory advisory committee to advise on the most effective and cost-effective large-scale national prevention approaches. Just as Australia did in 1998 with MSAC, we could become one of the first countries in the world to adopt a national evidence-based approach to the public funding of preventive health services.
The role of such a scheme would be, just as it is with the PBS and MBS, to meet service needs in prevention so that both optimal health outcomes and economic objectives are achieved. There is now much better data available about the ‘best buys’ in prevention, and better information on how they should be evaluated economically; data also shows that they provide much greater cost-effectiveness than downstream low-value healthcare practices.14
Progressive taxation: Taxation as a contribution, not a penalty
Inequality damages health and corrodes societies. Increasing income inequality results in declining child wellbeing, higher levels of mental illness, greater drug use, higher infant mortality rates, higher teenage birthrates and greater adult obesity levels.15 As the celebrated economist Thomas Piketty points out, a progressive tax on net wealth is one of the most effective ways of stemming inequality.16 And large corporations must pay their way. Many of them currently pay little or no tax—and they pay proportionally much less than small and medium-sized enterprises (SMEs).17
In addition, taxation on harmful products such as tobacco, alcohol, sugar-sweetened beverages and gambling should be based on public health principles and be hypothecated or dedicated to promoting and protecting our health by reducing the harm from these products.
An Australian national centre for disease prevention and control
Many, including the Australian Medical Association (AMA), have been calling for the establishment of an Australian national centre for disease control (CDC) with a national focus on chronic diseases and current and emerging communicable disease threats, and engaging in global health surveillance, health security, epidemiology and research.18 As mentioned, the management of COVID-19 has been done expertly and we need to ensure the lessons and approaches become part of our national public health ‘DNA’. Australia is the only country in the OECD that does not have an established national authority delivering scientific research and leadership in disease control and prevention.
Drivers of chronic illnesses in Australia: Investing in minimising the enormous damage of some very unhealthy industries
The UN Sustainable Development Goals (SDGs) agenda argues that ‘private business activity, investment and innovation are major drivers of productivity, inclusive economic growth and job creation’.19 While this is true, philosopher Michael Sandel argues that ‘market values have crowded out nonmarket norms in almost every aspect of life’ and we have drifted from ‘having a market economy to being a market society’.20 The most powerful manifestations of this phenomenon are perhaps in the many industries that produce and promote harmful products: tobacco, ultra-processed food and drinks, alcohol, arms, fossil fuel and some pharmaceuticals.
The so-called free markets don’t work freely or effectively. Rules are needed. Supranational corporations (SNCs) such as Big Tobacco, Big Food and Big Alcohol have enormous power and influence and are growing through mergers and acquisitions across the globe.21 Of the world’s 100 largest economies, 71 are now corporations, up from 51 in 2001. One of them, Walmart, makes more money than Australia!22
These SNCs, headquartered outside Australia, should not be ruling health policy in our country through their lobbyists. The Australian Government Register of Lobbyists shows an estimated 20 direct and 14 indirect lobbyists for tobacco, 43 direct and 23 indirect for alcohol, 33 direct and 13 indirect for junk food, and 31 direct and 16 indirect for gambling.23 They are there to cajole, schmooze and, when necessary, threaten elected members of parliament on all sides, and their civil servants. Their business is not health or wellbeing: it is simply bottom-line profit for their shareholders, whatever it might take.
Because we have no effective regulation (and self-regulation is as ineffective as no regulation) of ultra-processed food and drinks industries, Australia’s levels of obesity and diabetes continue to worsen to quite staggering levels, and life expectancy increases can be expected to start to flatten.24 Setting ground rules through effective regulation, as we have done for tobacco, will without doubt be the cheapest and most cost-effective method of improving Australia’s health—all the more compelling a reason to act, given the current and projected constraints arising from COVID-19.
There is an urgent need to respect both science and common sense to improve our health. Two very simple and highly cost-effective examples are:
• reducing the exposure of Australia’s children to advertising and promotion, be it for junk food, sugar-laden drinks, gambling or alcohol. This is especially the case in sport, where Australian sporting role models have become ambassadors of junk food, drinks, booze and gambling—just as they were thirty years ago for tobacco.25
• negotiating much fairer deals with the pharmaceutical industry over the price we pay for prescription drugs. This would save Australians more than $500 million each year.
Investing in the causes of the causes: Addressing the social determinants of health
Health inequalities within Australia are avoidable. There is no biological reason why Aboriginal and Torres Strait Islanders live on average seven to nine years less than other Australians.26 Minister for Health Greg Hunt recently commented: ‘We haven’t closed the gap yet … The nation is not whole until we have achieved genuine parity.’27 People with mental illness, too, suffer dramatic and widening gaps in their life expectancy compared to the general population in Australia.28
The major determinants of health are systemic and societal, therefore so must be many of the remedies. Some of these are discussed at length in other chapters.
It is well understood that good housing, education and employment opportunities all afford good health. Likewise, it is easy to comprehend that poverty, in the form of material deprivation, poor nutrition, unsanitary conditions and poor access to health care, leads to higher mortality and morbidity. However, when we layer this with structural racism, intergenerational trauma and decades of policies that entrench social exclusion, the problem becomes more complex.
We need to ensure financial security; COVID-19 has illustrated the importance of adequate income protection and sufficient unemployment benefits.
Complex problems require multifaceted, interdisciplinary and dynamic solutions. In this chapter we can only address a few of the causes of the causes—but if we value a sustainable, equitable and inclusive Australia, one place to start is with our cities and towns. We need to build safe, sustainable, good-quality housing. We must afford deprived neighbourhoods transportation options that allow access to quality education and stable employment, and in doing so improve safety.
The number of homeless people in Finland has declined from a high of 18,000 thirty years ago to approximately 7000 today: Finland opted to give housing to the homeless from the start, enacted on a nationwide basis by supporting housing units for tenants with their own leases, and phasing out the existing network of homeless shelters. The program pays for itself due to the fact that medical and emergency services are no longer needed to assist and respond to homeless people.29
In country towns and large cities we can apply tactical urbanism, which is all about action led by the city, town and/or citizens to neighbourhood building using short-term, low-cost, scalable interventions to catalyse long-term change.30 We can protect and expand green space, which is invaluable for mental and physical wellbeing and can directly reduce mortality rates.31
We can indulge in ‘hedonistic sustainability’, a term coined by Danish architect Bjarke Ingels; it occurs when we ‘stop thinking about buildings as structures and start thinking about them as ecosystems’.32 An example in Copenhagen is the new Copenhill waste-to-energy facility. It is the most efficient plant in the world and provides power and heating to 150,000 households. It also happens to be an architectural wonder.
What becomes more complex when addressing the ‘causes of the causes’ are issues such as systemic racism, discrimination and intergenerational trauma, which continue to feed cycles of disadvantage. The 1989 National Aboriginal Health Strategy stated that health status is linked to control over the physical environment, to dignity, to community self-esteem and to justice.33 Thirty years on from this statement, many steps still need to be taken. The Uluru Statement from the Heart, discussed elsewhere in this book, is a profound pathway for good health.34 While it is not a standalone solution to generations of inequality, hurt and suffering, it is an important step towards addressing immense inequalities and their downstream effects on health.
Illicit drug use and incarceration are two examples of social exclusion among many where our current policies worsen health. Illicit drug use is a societal issue where ongoing discrimination, stigmatisation and harsh policing reinforce cycles of disadvantage. We need to urgently reframe the lens through which we view this issue from the one we have inherited from perhaps the greatest policy failure in modern times—Nixon’s so-called war on drugs, which unfortunately Australia readily embraced—to one based on public health principles.
A similar view can be taken with crime and incarceration. The Netherlands has an unusual problem: not enough inmates to fill its prisons. Since 2014, twenty-three prisons in that country have been shut and the incarceration rate has been cut dramatically, as have the number of prison sentences and jail terms for young offenders imposed.35 One of the key aspects of this success is a program of care in the community for people with psychiatric problems.
Similarly, Norway strikingly demonstrates how effective policy and restorative justice can reduce recidivism, stigma and cycles of social disadvantage. The recidivism rate in Norway is 20 per cent, compared to 76 per cent in the United States. Norwegian prison governor Arne Wilson—also a clinical psychologist—explains that ‘the punishment is that you lose your freedom … Here [in Norway] we pay attention to you as human beings.’36
The chasm of social and economic disadvantage and inequality continues to widen at an awe-inspiring rate. In the United States between 2009 and 2012, the wealthiest 1 per cent captured 95 per cent of the post-financial-crisis growth while the bottom 90 per cent became poorer.37 Given that inequality and social exclusion lead to poor health outcomes, surely it is time to use the evidence and address the inherent social roots of ill-health.
Australia has great opportunities to enhance our health and wellbeing at the same time as increasing inclusion and decreasing inequity. We need to invest in prevention, and we need to do it urgently. We can learn not only from our own experience with COVID and the way we have respected scientific evidence, but also from so many of our other wonderful public health successes, such as tobacco control, gun control and reductions in road trauma. And we can learn from other countries and cities across the globe. If we invest wisely in public infrastructure—be it health, housing, education, energy, transport or welfare—we will get a healthier and more sustainable, equitable and inclusive Australia.38 The evidence is there: it is up to us to create dynamic, multidimensional and robust solutions that address the causes of poor health.