Thank you for publishing the editorial “From Norm to Eric: avoiding lifestyle drift in Australian health policy” by Professor Baum, based on her 2011 keynote address to the Australian Health Promotion Association which has given much food for thought to those of us unable to attend.1 I agree with Professor Baum that it was perhaps ‘forgivable’ in the 1980s to rely so heavily on social marketing campaigns focusing on individual behaviours to deliver health impact but now we do know better. Knowing is not doing, however.
For example, I cannot yet share Professor Baum's inherent optimism about the likely positive long-term impact of ‘Closing the Gap’ when so little political and fiduciary control has been wrested back from non-Aboriginal bureaucrats and, instead, genuinely and whole-heartedly afforded to Aboriginal communities and their Aboriginal leaders. This persistent racism and distrust of Aboriginal governance will compromise ‘Closing the Gap’. In particular, ‘red tape’, staffing constraints and a reporting burden that would never be tolerated by mainstream health services impede the community-controlled Aboriginal health sector where health promotion of the scope demanded by Professor Baum is meant to flourish.2,3
I agree strongly with Professor Baum that the Australian National Preventative Health Agency also must avoid the lifestyle drift. Perhaps it can examine whether we produce too many professionals far better-versed in individual lifestyle counselling, coaching and marketing strategies because of the research directions of their university rather than the demands of their future jobs. Nowhere do we see a course-based degree in public health or health promotion which puts front and centre the necessary macro-economic, micro-economic, social and business foundations necessary if these graduates are to add intelligently to policy formulation alongside quantitative ‘hard heads’ in treasury and other central agencies to ensure upstream social and economic levers are deployed to address the social and economic determinants of health as raised by Professor Baum. How do we judge employment compacts, public-private partnerships or tax incentive financing as upstream levers? Is it time for a director of health promotion to add value to their staff mix by appointing a macroeconomics graduate with expertise in tax policy or a lawyer with expertise in industry regulation? In addition, I suspect that most government-funded health promotion units are dominated by graduates wedded to the design and implementation of individual lifestyle interventions not only because of their training but also because of the continuing realities of their own funding base. ‘Lifestyle drift’ is so much easier to fund – and launch! Is it time to relinquish the individual lifestyle programs that perseverate the inequity so poignantly described by Professor Baum in order to release funds for a school-based breakfast service in disadvantaged postcodes run by our colleagues in the Department of Education?
As Professor Baum insists, we should also consider the accumulating Australian evidence for social and economic determinants of health. I conclude by commending another article in the Journal– in my view, one of the best to be published in 2010. Dobson and her colleagues demonstrated that death rates among the Australian Longitudinal Women's Health Cohort are significantly higher for those women living in rural Australia than their urban counterparts.4 As also shown with crystal clarity in their article, this inequity was not explained by differences in individual risk factors such as cholesterol, physical activity or weight. Rather, this mortality difference arises from fundamental environmental, social and collective conditions that are experienced by rural women. For starters, a far higher proportion of country women would see their spouses, children, extended family and friends out of work because of the poorer economic prospects in country Australia. Whether temporary, long-term or permanent, unemployment hurts. Unemployment in and of itself diminishes health and well-being of the entire social unit as readily as any virulent contagion wreaks physical disease or cortisol raises blood pressure. Rates of suicide are also far higher in rural Australia. It is not hard to imagine that a high proportion of rural women in Dobson et al.'s cohort would have lost a husband, a brother or a son from deliberate self-homicide. To make matters worse still, women in rural Australia have poorer access to primary health care services – and this injustice is entirely out of their control. Closure of regional railway lines and withdrawal of daily regional air flights diminish community vitality and confidence. These exacerbated by large-scale but unplanned shifts in what we sell, buy, grow and make as a country. Each and every day these background conditions take their toll. No wonder that individual lifestyle factors cannot explain the differential death rates.
Professor Baum reminds us that health is not as much about your cholesterol level as the slick social marketing campaigns might have you think! It's about where you live and what happens around you, what macro-economic policies are pursued by your government and whether anyone who cares is also responsible for the training, distribution and work priorities of the health workforce at your service.