There is no doubt that the Australian Labor Party Government has made a strong commitment to preventing disease, as shown by the Council of Australian Governments’ (COAG) National Partnership Agreement on Preventive Health (NPAPH),1 the commissioning of the National Preventative Health Taskforce (NPHT)2 and the Commonwealth Government's response to that Taskforce report.3 Each of these initiatives stresses the importance of preventing chronic disease by encouraging people to adopt appropriate lifestyles. These lifestyles involve not smoking, drinking in moderation, eating a healthy diet and taking enough exercise. Similar messages were evident in the lifestyle push of the 1980s when the ‘Life be in it’ campaign promoted Norm as a model of a coach potato who did not heed the lifestyle advice. The face of the lifestyle campaign this time around is Eric, an obese-looking balloon man, and his family who urge people to swap an unhealthy lifestyle habit for a more healthy one (see Figure 1).
There is an inherent logic to the intention of social marketing campaigns, such as those featuring Norm and Eric. The idea of people wanting to live longer and healthier and so responding to lifestyle messages and adopting smoke-free, moderate alcohol, low-fat and sugar, and active lifestyles has a ring of truth to it. The problem, however, is that there is a paucity of evidence to suggest that telling people to change their lifestyle to be more healthy works. In the 1980s it was perhaps forgivable to assume that such a strategy to change lifestyles might work. But in the 21st century there is a far stronger accumulation of evidence to indicate that mass social marketing of lifestyle messages is not effective. This is more so the case if the aim of policy is to reduce health inequities. The large lifestyle campaigns of the 1970s and 1980s have been shown to have had little, if any, impact on population health,4,5 and if anything act to increase inequities.6,7 The programs that did work were those that were implemented alongside a program of policy and structural change (such as changing the food supply), the Finnish North Karelia experiment being an example.8 In the past decade the power of the social determinants of health in shaping overall population health and the distribution of health within populations has received considerable attention, most prominently in the work of the Commission on the Social Determinants of Health.9 Why haven't we learned from this evidence?
A crucial reason for the failure to learn from the evidence is that, politically, action on the social determinants of health is generally less palatable than instituting a lifestyle advice program. The focus on the behaviour of individuals is entirely consistent with political systems that use neo-liberal political philosophies that draw heavily on discourses of individualism.10 This point is graphically illustrated by taking the current Eric campaign and juxtaposing the social determinants of health equity frame on the notion of swapping, and considering what structures need to change in order to create the conditions for health (see Table 1). This exercise immediately demonstrates that the changes needed to bring about improved health primarily require changes to the structures in which people live. It also indicates that people living lives characterised by the conditions on the left-hand side of the table may quite understandably adopt unhealthy lifestyles as a way of coping with the stress of these conditions, as Graham11 showed was the case with working class women and smoking in the UK. Wenzel has pointed out that unhealthy behaviours in the short term “are mainly relaxation, pleasure, fun, i.e. wellbeing for a short period of time”.12 Of course taking the social determinants approach makes it immediately clear that the strategies required to improve health will rely overwhelmingly on actions taken outside the health sector and, in effect, making all ministers health ministers. The Government's response to the National Preventive Health Taskforce3 notes that the South Australian government's experiment with the European Union's idea of ‘Health in all Polices’13 should be monitored. It is a shame that a bolder approach wasn't taken and a campaign launched for all Departments to look at how they could assess practices within their portfolio areas that could be swapped for those that lead to healthier and more equitable outcomes.
Two areas of Government policy do embrace a social determinants approach much more whole-heartedly than the Government's preventative health agenda. The first is the ‘Closing the Gap’ programs.14 These programs are concerned with improving the early childhood experience, education and employment status of Aboriginal and Torres Strait Islander people and are grounded in a strong awareness of the impact of social determinants of health. The other area is the social inclusion strategy15,16 which is concerned with improving the situation of the 5% most disadvantaged people and considers their housing, employment and education needs. It is likely that these program areas reflect an understanding of the social determinants of health simply because it is so much harder to ignore or brush aside than when considering the whole population. Hunter et al. coined the term ‘lifestyle drift’ to describe the tendency they observed in English health policy “whereby governments start with a commitment to dealing with the wider social determinants of health but end up instigating narrow lifestyle interventions on individual behaviours, even where action at a governmental level may offer the greater chance of success.”17
The Gillard Labor government has committed $872.1 million over six years (from 2009/10) to establish the Australian National Preventive Health Agency.18 The challenge for this Agency will be to ground its work in the accumulating evidence on the social determinants of health and avoid the lifestyle drift that Hunter et al. warn of.17 Practical ways they could do this would be, firstly, to learn from the agenda of the ‘Closing the Gap’ campaign and the social inclusion agenda and apply these lessons to approaches for the whole population. Secondly, a systematic analysis of the previous work on the social determinants of health, especially the CSDH and its work on inter-sectoral action,19 the UK Marmot Review,20 the implementation of HiAP in Europe21 and in South Australia13 should be conducted to draw specific lessons for Australia. If this were done and the lessons used to inform all government portfolio areas then Eric would find making the healthy choices much easier when unhealthy social and economic structures are swapped for healthy ones.