Adelaide Thinkers in Residence public lecture
The Shift To The Health Society
With Professor Ilona Kickbusch
Tuesday
13 November 2007: Adelaide Town Hall
Co-presented by Adelaide Thinkers in Residence and The Bob Hawke Prime Ministerial Centre at UniSA
PRO VICE-CHANCELLOR McDERMOTT:
Good evening, everybody. My name is Robyn McDermott. I’m Pro Vice-Chancellor
of Health Sciences of Uni SA. Before we continue on this evening, I would
ask you just to check your mobile phones, that they’re turned off, please,
or to silent, thank you. It’s great to be here for the latest event in this
successful Adelaide Thinkers in Residence public lecture program. Tonight
we’re here to hear Professor Ilona Kickbusch. First, I’d like to acknowledge
the Kaurna people, whose land we’re on, and we’re joined tonight by many
distinguished guests. I would like to recognise, in particular, Minister
John Hill, representing Premier Mike Rann; Mr Michael Pengilly, representing
Mr Martin Hamilton-Smith, Leader of the Opposition; the Honourable Carmel
Zollo, Minister for Road Safety; the Honourable Ian Hunter, Member of the
Legislative Council; the Honour Lea Stevens, Member for Little Para; Dr
Basil Hetzel, Chair of the Hawke Centre and Mrs Hetzel; Professor Lowitja
O’Donaghue, Patron o the Hawke Centre; Professor Fran Baum, Head of the
Department of Public Health, Flinders University; and, of course, our
speaker Professor Ilona Kickbusch.
We’ve had a tremendous response from our health professionals, as well as
from the three universities in this venture. I’d also like to welcome the
many interested members of the public who are here tonight. I’d like to
acknowledge, in addition, the partners and sponsors for Ilona’s residency
who we need to thank for tonight, the whole event. The partners are
Department of Premier and Cabinet; Department of Health; Flinders
University; the Motor Accident Commission; Children’s, Youth and Women’s
Health Service; University of Adelaide; Central Northern Adelaide Health
Service; Department of Education and Children’s Services; University of
South Australia; WorkCover; Track SA; the City of Marion; the City of
Onkaparinga; the Southern Adelaide Health Service; and Healthy Cities,
Noarlunga. Thanks for your generous support.
This free lecture is co-presented by the Adelaide Thinkers in Residence and
Uni SA’s Bob Hawke Prime Ministerial Centre. I thank the Director of the
Adelaide Thinkers in Residence, Brenda Kerr, and the Director of the Hawke
Centre, Elizabeth Ho, for arranging this evening’s program. As your Chair
for this evening, I am delighted to be here to take part in this important
discussion, the shift to the healthy society. Uni SA is delighted to have
the Bob Hawke Prime Ministerial Centre involved in this lecture series as a
co-presenter and a key organiser. The centre promotes active citizenship
through its public learning program, and plays an active role linking the
university to the community. Unfortunately, the Premier is unable to attend
tonight, but is being represented by the Honourable John Hill MP, Minister
for Health and I now call on John to commence.
THE HON J HILL:
Good evening, ladies and gentlemen. Thanks very much for that, Robyn. Can I
also acknowledge the traditional owners of the land that we meet on tonight,
the Kaurna people; to my Parliamentary colleagues – Michael Pengilly; Carmel
Zollo, Ian Hunter, Lea Stevens, Basil Hetzel and Mrs Hetzel, Lowitja
O’Donaghue - it’s great to see the patron of the Hawke Centre here with us
tonight – Professor Fran Baum, the Head of the Department of Public Health
at Flinders and, of course, our special guest tonight, our Thinker in
Residence, Professor Ilona Kickbusch. I’m also very pleased to see such a
great response to this event tonight from health professionals, both in the
Health Department and from our universities. I know both those groups are
very well represented here this evening. Ladies and gentlemen, it’s a great
pleasure for me to be here on behalf of the Premier, Mike Rann, who does
send his best wishes.
As you would all know, it was the Premier’s initiative to establish this
unique residential program which brings some of the greatest minds on the
planet to Adelaide. I’m not suggesting that any of our thinkers are
extra-terrestrial, but I’ll let you make your own judgment after you’ve
heard Ilona speak. Ladies and gentlemen, the Adelaide Thinkers in Residence
program reflects the State Government’s commitment to improve the health,
well being and prosperity of all South Australians, and to foster a
sustainable, culturally rich, and forward-thinking society. During the
course of the Thinkers program, we have been inspired, enlightened and
challenged by a succession of outstanding Thinkers in Residence who have
each left their mark on Adelaide.
Professor Ilona Kickbusch follows this outstanding tradition of excellence
and innovation. She has an international profile, and is a leading figure in
public health, health promotion and global health. Professor Kickbusch has
had a distinguished career with the World Health Organisation where she
initiated a range of innovative, worldwide programs such as Healthy Cities,
which has been operating in the Noarlunga area for many years now, and
health promoting schools. As Director of Communication at the World Health
Organisation headquarters in Geneva, she oversaw the planning for World
Health Days and the World Health Reports. As Minister for Health and the
Southern Suburbs, I have followed her residency with great interest, and it
has been a privilege to hear her views on the economic and social impacts of
health, and the implications for our future.
During her residency, Professor Kickbusch has established many partnerships
– partnerships with the Department of the Premier and Cabinet; the
Department of Health; Flinders University; the Motor Accident Commission;
Children’s, Youth and Women’s Service; the University of Adelaide; the
Central Northern Adelaide Health Service; the Department of Education and
Children’s Services; the University of South Australia; WorkCover; Track SA;
the City of Marion; the City of Onkaparinga; the Southern Adelaide Health
Service; Health Cities, Noarlunga. She’s been a very, very busy Thinker in
Residence and I know she’ll tell you about some of the young people she’s
met as well. We have to do health in a different way, ladies in gentlemen.
We’re now at a stage in our development as a society where 30 per cent of
our State budget, just about 30 per cent, goes into the public health
expenditure in our State for the public hospitals and all of the
infrastructure associated with it. The cost of providing those health
services to our State economy is growing at the rate of about 8 to 10 per
cent a year, yet our income base – our revenue base – is only growing at
about 4½ per cent a year. So we can calculate that by about the year 2035,
our entire State budget will have to go into health in order to maintain the
same level of services that we currently provide to our community. Clearly,
that is not sustainable.
We have to change the way we do health. We have to have a much greater focus
on prevention, and a must greater focus on primary health care. I don’t know
if you know this but something like 450,000 South Australians over the age
of 20 – that’s roughly 40 per cent of our adult population – has at least
one preventable chronic disease. 450,000 people contribute something like
two-thirds of the costs of running our public hospital system with those
preventable chronic diseases. It’s all to do with diet, exercise, drugs,
smoking, alcohol, social connection, and all of those other things. Most of
those things are not within the bailiwick of the Health Department.
The Health Department looks after people when they’ve developed all those
illnesses. We’ve got to do health in a different way. Ilona Kickbusch is
going to be part of the solution to that conundrum we face. So, ladies and
gentlemen, can you please welcome, as I introduced to you, Adelaide’s 13th
Thinker in Residence, Professor Ilona Kickbusch.
PROFESSOR KICKBUSCH:
Good evening, ladies and gentlemen. It’s, indeed, a great pleasure to be
here even though I am appropriately nervous being the 13th Thinker speaking
on the 13th, and a couple of things have already gone wrong today, so let’s
see what happens in the course of this evening. So we’re at a turning point,
as Minister Hill indicated, in health policy. The way I’ve tried to frame
this is to say that we are actually entering a health society – a society
where health plays a much more important and much more central role than has
been the case in the past. In order to address the health issues that we
face, we need, on the one hand, a change in mindset – that is to say how we
think about health, how we define health, how we understand health – but we
also need a new understanding of how we govern health.
So having been asked to come here as a Thinker in Residence with the title
of Healthy Societies that, of course, is an enormous remit and there would
have been an enormous number of issues for me to take up and to take
further. And I made a number of decisions along the way that I’ll share with
you in order to be able to focus. The starting point, of course, was an
extraordinary one because there are very few societies and political systems
that have actually set themselves overall goals such as the State of South
Australia has. And that, of course, is an excellent way to start thinking
about healthy societies, to take South Australia’s strategic plan and to
take the entirety of these goals and to say: how does health contribute to
reaching a whole range of the other goals in the plan and, at the same time,
how do other goals in the plan allow us to reach a healthy society?
And the brief was, in a sense, to say: okay, if we start from such a high
level and also a high level of health to a certain extent within the
society, what can we do to make the State of South Australia a global leader
for health in the 21st century?
Now, if that sounds a bit grandiose, “a global leader health in the 21st
century”, I want to remind you that 20 years ago Adelaide actually hosted a
very important WHO conference and the result of this conference were the
Adelaide recommendations on healthy public policy issued in 1998 and
throughout the world people in health promotion and in health policy
actually quote Adelaide in a number of ways when they refer to these
Adelaide recommendations on healthy public policy. So coming here as a
thinker on healthy society, in a way, it was coming full circle and, in a
way, it was coming home and that everyone knows innovation usually takes
about 20 years until it is fully diffused and digested. I guess, that is
exactly where we are at right now.
So if we have the goal, South Australia as a healthy society, what are the
requirements that we need for that? And, again, the starting point is three
key elements. One is to use interconnected forms of government, those
processes that have already started under the title, also, of whole of
government approaches, joint up government – use those for health and
strengthen them for health, so a process within government. At the same
time, a lot of health is created beyond government and, therefore, we need
processes within society which help create new partnerships for health and
make other actors in society accountable for health. But all this doesn’t
work if we don’t include people. Citizens participation in health is
absolutely critical and many of the partners here have implemented this
during my residency and some of them, like Noarlunga Healthy Cities, has
been working to exactly this principle also for nearly 20 years.
So this triangle of within government, beyond government and including
citizens is critical and that, of course, is reflected in all the partners
of my residency that you’ve already heard about and that, accordingly, I
won’t name again. So if the starting point, South Australia’s strategic plan
objectives, the overall goal is, amongst others, to secure a good quality of
life for South Australians of all ages and all backgrounds. And that is why
we then said: okay, let’s take this plan and let’s apply a health lens to
all the targes in the strategic plan and to see how that dynamics of health
works. That was one side of the picture. The other side of the picture was
to say: well, it’s all very well measuring individual targets, shouldn’t we
perhaps introduce a measure of well being that captures this whole
development?
Usually societies only measure their progress according to GNP, probably it
needs some other new outcome measures for well being to be able to document
how the quality of life for citizens in South Australia is really moving
ahead. So we were able to introduce a process of policy learning and I say
with great join actually, that in the months between my two residencies a
couple of hundred people throughout government worked on this process of the
health lens. We selected 14 goals and targets from South Australia’s plan.
Detailed case studies have been done for seven of these targets of people
from various departments working together on these case studies and together
these case studies will be presented next week at a Health In All Policies
Conference where we will develop, with very senior people from across
government even including the Treasury, to see in what way one can establish
mechanisms of working within government and new mechanisms of financing
co-operative work on health that we call Health In All Policies.
So while that health lens is going on, I do want to suggest that it would be
important in South Australia to introduce a broad measure of well being. A
measure of quality of life that South Australia could put next to the gross
domestic product. There are a number of such measures around, a very
interesting one has recently been developed by the National Institute of
Health in the United States. So I think and I would like to recommend a
state well being account, a different kind of measurement of progress to
actually see how good life is in South Australia for each and every citizen
and to be able to assess the differences in quality of life between
different types of citizens in South Australia.
And you can see here is another one of such surveys. There is such a thing
as the World Happiness Survey and you can see the three most important
predictors of happiness which are health, wealth and education. And you can
see the leading countries and you can see roughly where Australia ranks. At
this stage, there are no separate data for South Australia so Australia is
number 26 on this scale. Still doing relatively well if you think there is
about 190 countries in the world so there is nothing to be ashamed of. But
it might be a quite interesting challenge for South Australia to move up
that list and since you can see also that it is relatively small countries
that actually manage a high happiness index, then probably South Australia,
as a relatively small State, could easily do very well if one moved in that
direction.
So if one says health is not just health, we need to understand health as
well being. WHO says physical, mental and social well being – many here in
South Australia have added cultural and spiritual well being to this
equation, particularly in relation to the Aboriginal cultures. And we need
to think of health around the determinants. As the Minister has said, the
health policy, the health system as it is structured now usually deals with
illness. We need to find a way to deal with health and its determinants and
we need to find a way to deal with the interface of these determinants. And
that is why in some of the previous work I’ve been involved in with the
World Health Organisation, we said health is created in the context of every
day life where people live, love, work and play. And now in the 21st
century, as you’ll see, we probably need to add: where we shop, where we
Google, where we travel and all those new kinds of things that we do.
And where our health is defined in a society that is full of virtual
messages, that is a consumer society that sends us a whole range of very
disconnected and often contradictory messages at the same time. And it’s
within this context that as soon as we look at the determinants, we need to
think equity. There is nothing that is of greater impact on people’s health
that what in health we call the social gradient. It’s not just a difference
of who is rich and who is poor, but every stage of society as you move
through it – if you move sort of down the ladder, you have less life
expectancy. Some colleagues in England took the map of the London
Underground from west to east and they calculated that with each train
station going east, you lost one year of life. That’s the social gradient.
Now, here in Australia in one area you don’t have a social gradient, you
have an extreme inequality that obviously in whatever issue we discuss has
to be considered and has to be made visible. And that is the difference in
health and life expectancy of the Aboriginal peoples of this country and,
therefore, I fully concur with the recommendation that has been made by
others before me that for a range of government policies, health policies
and other policies there should be clear Aboriginal health impact
statements. What does that mean for the health of the Aboriginal population?
If we think health in the 21st century we need to think it together with
wealth. And I thought it might be nice to express that in Chinese for those
of you that can read Mandarin.
The health and wealth interface is well known in many societies for many
generations but it seems in the 21st century we are just re-discovering
that. We are just re-discovering, as our society become knowledge and
service societies, that our wealth increasingly is driven by human capital.
We can’t afford people not being healthy and Minister Hill expressed that
partially, if the present trends were to continue, our health systems will
not be sustainable any more. But also given our demographic development, we
need people who live longer to be healthy longer in order to contribute
productively to society and to live an independent life. So the two issues
of quality of life and health as a value and the needs of society also come
together in a very productive way.
But one step further is also important. It is not only that determinants
create health, increasingly health itself is a major driving force in our
society. For example, in most OECD countries 10 percent of all the jobs and
more are in the health sector. Most OECD countries tend to 15 percent of the
GNP is spent in health. In most countries the health economy, the wellness
economy, the prevention economy is growing so that some of our colleagues in
the United States even say that the growth of this economy is going to be as
big as that of the medical care system. So some of the data show us that in
five to 10 years we will, in this mix of the preventative economy – healthy
foods, all those kinds of development and the health sector, the medical
sector, disease management, health information probably have an economy that
takes up, not only as expenditure but as growth, about 20 percent of our
economies.
And that is something to calculate – to look at and, therefore, with the
support of the Minister of Health, a feasibility study is being done for
South Australia, how this health economy is developing here and what it
would mean and what its impact would be. The other “Think!”, of course, if
we talk health productivity growth is that in a 21st century society we need
to think sustainability. And increasingly many colleagues in the health
arena make the point that ensuring the health of the next generation is as
big an issue as climate change, that we must not think sustainability only
in terms of the environment, that we must also think sustainability in terms
of public health. And the colleagues, for example, those producing an
important report, the Forsyth Project Report, on tacking obesity shows that
just as in the environmental arena where our technological progress is
significantly damaging the environment, they say what we are experiencing is
something similar, a mismatch between out genes and our environment meaning
that the pace of the technological revolution is outstripping our human
evolution and this is a slightly humorous way of expressing that.
That means we’ve got to think health, not only in terms of the health data
here today and now, but we have to say: do all the systems that we have
established actually meet the needs of the future generations, are we
guaranteeing the health of the next generation? And increasingly we are
getting a message in epidemiology that we might be in danger of having, for
the first time in 150 years of public health history, the danger that the
present day young generation could be the first to have a lower health and
life expectancy than their parents. And that, indeed, is a major challenge
and that is why I decided, from all the many problems I could have focussed
on around healthy societies, that I should focus on the next generation. And
I have called this Generation H, Generation Health, South Australia.
If you look at the data you would say: you know, why worry? If you take the
average life span in Australia it’s about 80 years. Even more important, the
healthy life span is about 72, 73 years so that is the picture of today. But
if you go a step further and you look at the obesity data world wide, you
can see that while Australia is high up there in terms of life expectancy,
it is also high up there in terms of the rates of obesity world wide. And
the figures that you probably can’t read where the red arrow is, that is
about 21.7 percent of the population in Australia that are obese. The
country that has the highest rate of obesity is the United States but, as
you might see, the second in line there is Mexico so that gives you an
indication also the emerging economies are going down that route.
So that means that this picture and if you think of other data that obesity
in children grows at a rate of one percent per year in Australia and in
South Australia, then you can see what the challenge can be. So if we
approach this issue we have to approach it from a health in all policies
perspective from what many now call the Obesegenic Environment. That is, as
I said before, this mismatch between how we are and what our environment
asks us to be. And the changes of work, the changes in our leisure time, the
changes in transportation – all of those come together to actually impinge
on our health in a variety of ways. Here the data reflect the overweight and
obesity epidemic but you could play it through, for example, for mental
health issues where the life/work balance is becoming an increasingly
difficult issue for people to cope with.
That means we have to start looking at terms in a new way. With 150 years of
public health and a whole range of infectious diseases, we’ve come to
understand the notion of infection and pollution. I suggest we apply that in
a slightly different way. You can see a map here that I’d like to term
Infection. That is a map of fast food outlets. Research in the United States
by the centres of disease control has shown the poorer a neighbourhood, the
more fast food outlets and the less healthy choices. So if you take this
kind of understanding of infection, you clearly can’t just speak about
individual responsibility for health. People do not have the healthy choice.
There is a different kind of push and pull effect around the issue.
Pollution – what you see up there are games on the internet for very small
children by producers of sweet things.
And the more restrictions there are on television, the more these kind of
adver-games, they are called, are accessible on the internet for children as
young as two. That I would term a form of pollution that we have to deal
with. These are new kinds of sanitation issues we have in modern society.
Obesegenic environments – what are the settings of every day life -
Supermarkets. Where do young people meet – shopping malls. So our strategies
need to reach out to different kind of places so that the health messages
are there and relate to the people where they spend their every day life.
But increasingly also, these issues – the obesegenic environment means
mediascapes and images and obesegenic environment doesn’t only mean obesity,
it means a whole lot of messages in relation to body image and weight. And
we can see there is a pressure on young girls and young boys to have a
certain body image, to be as those figures are in the media and we see that
there is an increasing amount of eating disorders. They have doubled in
South Australia in the last six years and an increasing dissatisfaction of
young people with their bodies. In this kind of environment you cannot learn
to be healthy and you need counter action that is very, very critical and
important.
So of we are to approach Generation H, South Australia, health must become a
critical goal of all government and one of the recommendations I’m making in
my report is to consider a Children’s Health Act. A Children’s Health and
Well Being Act that actually starts out from the rights of the child to a
healthy environment and a healthy future and that brings together many of
these issues of promoting children’s health and of protecting children’s
health in the many ways that we need to do in our societies. And there is a
range of actions here that need to be considered. I have taken those that
relate to healthy weight such as breast feeding, reducing fat, sugar and
salt in foods, cycling and walking possibilities, good nutrition in schools,
new types of protection measures against marketing, but also all the other
kinds of measures that we are concerned with relating to child pornography
and other issues that have come to pass in our modern societies.
And if you look at this picture it tells you why we need health in all
policies. Don’t worry that you can’t read what’s in the boxes, that is not
necessary. It just shows you if you want to address healthy weight in a
society, these are all the areas where you need to act. You need to act in
transport, you need to act in health, you need to act in education, you need
to act within the libraries, you need to act in the home with food, in work
places, so this gives you a picture of the interface of the kind of healthy
public policy that you need. And, therefore, we need to think health in all
policies and you might wonder why Mr Hawke is up there. Not just because we
are talking at a Hawke lecture, but the definition of health in all
policies, as I put forward here – healthy public policies characterised by
an explicit concern for health and equity in all areas of policy and by an
accountability for health impact - that is the definition from the Adelaide
recommendations.
And that conference was opened by the Australian Prime Minister, then Mr
Hawke who actually with that expressed the importance he attached to health
and well being at that point in time. And that would my wish beyond South
Australia, whoever is the Prime Minister of Australia after this election,
that he would also take health in all policies as seriously as Mr Hawke did
at that point in time. The book you see next to it is the modern version of
healthy public policy, Health in All Policies as Developed during the
Finnish Presidency of the European Union and, based on that work, the
European Commission has now agreed to do a health impact assessment of all
its policies. So this is the kind of direction that we are thinking of
moving into.
So the main aim of healthy public policy is to create a supportive
environment to enable people to lead healthy lives. And I have worked on a
rather detailed proposal that time would not be sufficient to share with you
here on how that can be done across government, but I’ve just indicated some
elements here, of course, ranging from top level policy commitment through a
Premier’s directive to the creation, in that directive, of the need to have
impact statements and a health lens applied regularly in planning. To have
high level co-operation between the various sectors and to have a Minister
supporting Minister Hill in the areas of generation H and issues of well
being. And, of course, then to have joint budgets, a new form of budgeting
procedure that would be absolutely critical for this kind of enterprise.
Now, that’s within government. If we think partnerships throughout South
Australian society and beyond government, you can see in the little sheet
that we gave you on Generation H that there are other things that we need to
do. A platform that actually works with the large
multi-national companies that are here in South Australia, that they should
implement their best practice which they have been forced to do in a number
of other countries, that they need to implement that here in South
Australia. A local alliance following a model also that’s available from
Europe, the EPOD model – a local alliance on Generation H to address healthy
weight. A coalition that is going to be formed on eating disorders and body
image to be sure that that other dimension is taken care of and, most
importantly, the voice of young people themselves, a Generation H youth
forum to express how young people see their own health and well being and
how they would like it taken forward.
A critical area, of course, is the school and here in South Australia you
are starting at a very high level in terms of health in schools with the
DECS well being framework, but I believe even here still more can be done
and I’m suggesting that a number of elements around health actually be
introduced into the new South Australian Education Act that is presently
being prepared so that health becomes a very integral part to the
responsibility of the education sector. Other partnerships – just one I want
to mention. We’ve worked very closely with the Motor Accident Commission and
TRAXA and have redefined transport and accident issues into issues around
mobility, equity and health because accidents are no accident. If you look
at accidents, there is a big social gradient there and, again, it’s the
disadvantaged in society that have a much higher accident rate than others.
And, again, if you look at mobility and not just transport, you can see how
important issues of mobility, for example, are for the Aboriginal population
and how frequently it’s the lack of mobility that keeps them out of health
services, that doesn’t give them access to education and that doesn’t give
them access to work. And we’ve developed a small model around the driver’s
licence to actually show how one can group a health in all policy strategy
around something as concrete as a driver’s licence and around that you start
to have access to society and part of your identity is also expressed
because for me, as an European, it was also strange to learn that actually a
driver’s licence is your identity card. And needing to drive in order to
have an identity seemed to me, at least, a very strange concept. But then if
that is the case, then we need to make that accessible to people so that
they do have an identity within society, so I think there are issues here
that are absolutely critical.
Think more health in the health sector. The Minister has already indicated
some of the issues and areas. Again, we are starting at quite a high level
but, I think, still a number of things can be moved forward to strengthen
health in all policies within the health sector to strengthen the dimension
of empowerment in disease management and to move towards an integration of
services that is absolutely critical. And within that context then, to be
able to have in the Health Ministry a supporting Minister particularly for
these kinds of health issues that need to be taken forward. And that is one
thing that I truly would recommend that one find a more integrated way of
dealing with issues ranging from the policy approaches to the high risk
approaches into the treatment approaches.
And there we need to look at communities and we need to look at families
because once you go into a family, particularly a disadvantaged family, they
will need all three dimensions of this. There will be someone in acute care,
there will be somebody managing a disease and there will be children who
need to learn how to live a healthy life. And if we cut people up and if we
cut our services up in the way as we have done so far, that is not good.
And, therefore, using examples of community participation that exists,
building on the new possibilities and potentials of the GP plus strategy, I
think, are absolutely critical in order to move forward and help create
healthy communities and healthy societies. And then, of course, we need to
think healthy public policy at the Local Government level. And, again, there
is a clear strategy from the Department of Health to give local authorities
a greater role in health but they need to learn that role.
Competencies need to be developed in order to move that forward and we are
working and tomorrow is our next meeting on this, on a southern centre for
collaborative action on health in order to create that competency and those
skills at the local level to move forward. And the role of Local Government
is critical for another reason. Very frequently, again, we look at health
only in physical terms and we are more and more aware – and some excellent
research from Flinders University also shows that – how important social
capital is for health. And this is one of the areas where truly Local
Governments need to be much more pro-active to help generate local capital
at the local level, to bring people together, to enable people to support
each other as citizens, as friends and as a community.
That takes me to the last point in the circle, remember within governments,
beyond government the role of the citizen. If we take the role of the
citizen in health seriously, again, we can see that some have more baggage
to carry than others for some health is easier to achieve than for others.
And again, as you know, particularly the Aboriginal peoples have great
difficulty in going over all these hurdles that you can see on this picture.
Now, again, one could have dealt with many things but South Australia has so
much experience in community participation that it definitely didn’t need me
to tell them anything about it. So I have focussed my work around the issues
of health literacy and equity focussing on the fact that policies – healthy
public policies must increase people’s control over their health and its
determinants, but that it needs competencies to do that.
And I’m very glad to say that two weeks ago, as one of the results of my
residency, the South Australian Health Literacy Alliance was created with 36
partners from throughout the state and they have set themselves a number of
goals some of which include to assess the levels of health literacy in the
state, to make health literacy a key bench mark in GP plus and for
hospitals. Actually the Queen Elizabeth Hospital will embark on such a
health literacy self assessment and we hope that the new hospital that is
planned will take health literacy criteria into account. I’m suggesting to
create a patient university using the resources of the schools of health
sciences and the medical schools in this state to actually also teach
patients and citizens about health, not just their students, and there’s
excellent models for that – and to prioritise the navigation support for
Aboriginal peoples in the health service.
Many of them are left literally alone when they are ill and we cannot accept
that as a democratic society and we must help them navigate the system as
best as we can. The final point which I have mentioned earlier is the
emerging health market. There are great opportunities, I believe, for South
Australia to actually use the notion of health which is now a global notion
to take ideas into the world and to invite people to South Australia, be it
ideas of bio innovation or be it the healthy tourism that South Australia
Tourism is looking at, but particularly also education. Remember I told you
that about 10 percent of each OECD country – 10 percent of the employed
population works in health. Think of the emerging economies. Thinks of their
growth in health services and think of the fact that China, that India, that
Korea, that all these countries need to train health professionals.
There’s a tremendous opportunity here for South Australia, not only to train
professionals but also to help build schools of training in those countries
to develop partnerships, to move forward in innovative ways that, I think,
can really open up new vistas and, at the same time, bring new people to
South Australia. So the very last point is all this needs research. South
Australia has excellent universities. What needs to be supported, I believe,
a little bit more is the inter-disciplinary research capacity and, I think,
that is particularly possible through the health lens research – really
building a new type of health research program around South Australia’s
strategic plan. I’ve suggested a cohort study to go with Generation Health,
South Australia and, as I’ve already mentioned, I’ve suggested a health
literacy survey.
So those are some of the elements when we think health. To think health as
well being, to think health in all policies and establish mechanisms, to
think health beyond government and create partnerships and have health as a
goal of other organisations, to include citizens and to include, in
particularly, the voice of young people in the health conversation and to
include the traditional owners of this land, the Aboriginal people, in that
conversation at every point in time. So if South Australia were to move
along this direction, I think, it could extend significant global leadership
which is why I chose a map that has Australia in the middle and, I guess,
South Australia in the middle of the middle then. And there are suggestions
that there should be a regular Premiers’ health summit in this state sharing
the experience of South Australia in health in all policies and with
Generation H.
So the opportunities in South Australia to think together in the state and
to think together globally are, I think, quite extraordinary. The resources
here for thinking and for action are wonderful and I have experienced that
and this is why, frequently, you will have heard me say, “we”, and not, “I”,
because we’ve had so many meetings and hundreds of people in the state have
been thinking with me around this and, therefore, we will not only have the
usual Thinker’s Report, but we’re going to do a CD ROM in order to be able
to bring all this material together and to make sure none of the wonderful
thoughts that were put forward will get lost. And so, I guess, my key
message as a Thinker that I can leave behind – the most productive thing
that one can do is think together. Thank you very much.
PRO VICE-CHANCELLOR McDERMOTT:
Thank you, Ilona, that was great. Lots to think about. We have time for some questions. There are two microphones, one at the front and one towards the back. If you could come up, please, identify yourselves and we might start at the back.
MISSION AUSTRALIA:
I work with Mission Australia which is a community service provider particularly in learning and education. And I’m just wondering, in your opinion and your vision, what sort of level of importance will service delivery from community organisation and NGOs play out and I was pleased to hear you say that South Australia has a strong participation rate in communities. I’m just wondering about your vision or what your hopes would be with NGOs providing services and the importance and the impact that it may have on them in the future to do with health in, not so much clinical ways and traditional pharmaceutical or medical ways, but in service delivery and community services such as homelessness, education and young people?
PROFESSOR KICKBUSCH:
Well, citizen’s participation, as you indicate, takes many forms. It takes
the form of a wide range of civil society organisations, non-governmental
organisations and it’s a whole realm of things, like, in some of the
meetings we’ve had the Red Cross involved and their volunteer work. We’ve
seen in a number of European societies that actually volunteerism is
increasing significantly as the demographic shift happens because many
people do want to give back to society. So in many areas, particularly in
generating social capital, helping older people, I think our societies will
increasing be dependent on non-governmental organisations and citizens who
contribute in a variety of ways.
But it is also true in the preventative area, not only in sort of services
for people who are disadvantaged or are immobile or need special help. It is
also important in the preventative area, let us say play groups for
children, sport associations are absolutely central. Some of the things you
have, you know, around food in this state, the foodies and those kind of
teaching and learning is critical. But also in the disease area. As we have
increasing numbers, as the Minister said, of people living with chronic
disease, the issue of disease management and managing that, not only
individually, but I’m thinking of the cancer survivor groups that we have.
I’m thinking of, you know, the heart disease rehabilitation groups.
So increasingly those kinds of groups of people coming together to help each
other and actually increasing their own health and coping strategies through
that, that mutual aid principle, is very important. So within that beyond
government, civil society is absolutely critical and one, you know, could
give a whole second lecture on that contribution. And I’ve actually been
very lucky to work with the International Federation of the Red Cross and
the Red Crescent to develop their health strategy because they are seeing
increasingly their role is starting to be in the health promotion and
prevention area and not only in the classic areas of service delivery. So we
are seeing that kind of shift as well.
MR NORDENE:
Chris Nordene. I noticed that you didn’t make any reference to the
pharmaceutical industry and I would like your comments on one aspect of it.
The pharmaceutical industry, of course, is here to treat disease. What I’ve
noticed is that, with time, there is a tendency for what starts off being a
treatment for disease to start being used as a preventative so that we are
being diverted from prevention by simple methods like exercise and diet into
using expensive pharmaceutical products for preventative purposes. I think
that’s an extremely expensive way of going about prevention and I think it’s
a rather sinister development so I’d like you to comment on. And the other
point I’d like a comment on is how do we manage to achieve a single message
on health to the public?
My experience from patients and friends and public is that they get
different messages. They get one message on television, another from the
newspaper and another from radio and, in the end, they really don’t know
whether, for instance, milk is good or bad for you – that’s just one
example. So I do think it’s very important, if we’re going to influence
health in the way you suggest, that the message getting to the public has
got to be consistent and very, very clear and not ambiguous or confusing.
PROFESSOR KICKBUSCH:
Well, thank you for taking up those two points. The first one is a very,
very critical one and that is that we’re seeing a movement into what is
called different things on the one hand, the whole area of what people now
call lifestyle drugs and which is looked sort of as a preventative taking of
drugs to prevent disease. And that is a very, very big market and it is a
market that, as you rightly say, is competing with healthy behaviours. And
you can even see it, you know, in the field of diabetes, you can partly see
it in the field of depression where actually one of the best “treatments”
for light depression is physical activity rather than taking pills over a
long period of time. So I believe there’s a number of issues here that,
first of all, looks at the way these pharmaceutical products are marketed;
point one.
But point two also, I think, there is an increasing work that needs to be
done in the context, for example, of such initiatives as GP plus, that if
there were better possibilities for the GP to actually do a different kind
of “referral”, that is to say: yes, you know, here is the life style adviser
or here is a group you can go to or, you know, in some cases they actually
write prescriptions for exercise in order to keep to the same model of, you
know, that one is used to in terms of a medical culture, so you don’t write
a drug, you write that. But these in between things – I think it was today
or yesterday in the paper in Australia one million Australian dollars are
spent daily on diet – what you call diet products.
And one is finding that, increasingly, these are bought by young girls. They
are very much in the forefront of the drug stores and pharmacies. They are
marketed incredibly heavily and it’s particularly these in between products,
as I call them, that are starting to be very, very dangerous. So you have
that spread from a sort of quasi, you know, medicine to a real medicine and
then we’re in the situation also that probably one needs in general to look
at the prescription practice and that there needs to be a better
understanding of health, for example, in the training of general
practitioners and medical professionals. What are the options – the life
style options to the medical options and, particularly, what’s the evidence
base because, of course, that’s the basis on which a doctor needs to act.
And I think for many of these things we now have a very good evidence base
that one can build on so – and, therefore, I would hope that a lot of the
electronic information systems that doctors are increasingly using would
start to take those kind of options into account more than they do at
present. The second relates to the work we have done on health literacy. I
don’t think in a pluralist society and a consumer society you’ll be able to
send just one message on health where everyone says the same thing. But what
we are seeing is that, increasingly, people aim to seek out accredited
information. They look for a navigation – at least we see that in those
countries where a lot of health information is taken from the internet, that
people go to legitimate sites.
That they don’t just take any health information like, you know, they go to
the CDC site or the NHS site because that gives you reliable health
information. But the noise – because health is big business, you know: this
yoghurt is healthy or, you know, this is healthy. And then you have a media
that does not always reflect research results appropriately like, recently,
you know, there were these headlines that, you know, you – it’s actually
healthier to be over weight. And, I mean, that was irresponsible reporting
because if you looked closely at the study that was reported, it clearly
had, I think, seven dimensions of disease and it was, in three of these
areas of the seven, that slightly over weight people did better but in at
least four others, they did worse. So you can see how that kind of reporting
really makes people very disoriented. So if we, at least, had more
responsible headline reporting on health, we’d be doing much better. We’ve
got enough problem with the marketing of health already.
MEDICAL STUDENT:
Hello. Thank you very much for your talk. It is really good to see that integrated approach to health. I’m a medical student and we’re just starting at the building blocks of one kidney and one leg and gradually getting our way up to this level. I’ve just got a question in that we heard you talk about impact statements and policies on health and a Children’s Health Act which is fantastic but - just with the election looming I’m reminded of the ’96 non-core promises – governments change, Acts can be over written, bureaucracies are very effective at dissolving the impact of policies and failing to operationalise them. Why don’t we go further and go for a Right to Health or enshrine Health is a Right?
PROFESSOR KICKBUSCH:
Well, some constitutions do that and I think it would be a good start to
enshrine as a right of children, so if a Children’s Health Act did enshrine
health as a right of children, I think, we would’ve done – taken a
significant step further. So that’s why I suggested that this could be a
first step. Of course, in many of our societies, even though, you know, not
everyone likes the word “welfare state” any more, as I gathered, but we are
states – in many of the OECD countries with one big exception, that
actually, you know, does give universal access to health care. And I think
what we need to make much more clear is there is a right to universal access
to health information and health literacy and that the right to health care
also includes a right to prevention and health promotion.
And that those kind of rights then will lead to new types of regulations,
for example, as we, you know, approached tobacco advertising, as we
approached a number of public health issues historically over the years and,
you know, we can hardly understand that when it was suggested to have sewers
under the City of London that there was significant political opposition
saying that, you know, healthy water was an individual responsibility. So I
think, you know, those kind of issues repeat themselves historically again
and again and that is why citizens action on health is so important. And
that is why a health literacy that understands what politicians are
promising or not promising is so critical.
And my wish would be that citizens do not only demand health services which
is their right, but that citizens would actually demand more prevention and
health promotion which, I believe, is their right as well.
REGISTERED NURSE:
Hi, my name is Sandy. I’m a registered nurse, I work at a school, but I’m also a research student who’s working on advanced directives. And my question to you is: when do we reintroduce the concept of death in our healthy continuum?
PROFESSOR KICKBUSCH:
That’s an issue that’s increasingly discussed and some people actually use
the words, “a healthy death”. We see that happening in a number of new
approaches to palliative care. We see it happening in people saying how they
want to die - the issue of living wills is becoming more and more important.
We’re seeing people wanting to go home to have a death in their own
environment so I believe in a society that’s increasing aging we will need
to deal with this issue, let me just call it, a healthy death increasingly
and people will want that. And to some extent we will also have to face the
very difficult ethical issue if people want to choose when and how they die.
I think that issue is increasingly going to come up. We don’t yet know how
to resolve it because there are many, many other ethical issues.
In Switzerland they have a very, very big discussion around that and – but I
think it’s a discussion that, as a society, we will have to start dealing
with. And I hope that governments and citizen’s groups think about it and
deal with it while there is not yet a kind of, you know, crises in the air
because something has gone wrong, but that that it is done in a good and
preparatory way. It’s also, of course, linked to the fact that because of
the medical advances, we are still trying to learn, you know, how far should
we be kept alive and how far do we want to be kept alive. And that is also
something we do need to deal with in society. So thank you for raising that
because it’s increasingly a very important issue.
MR CALLESE:
Thank you. My name is Ross Callese and I really enjoyed your talk, it was lovely. I’m actually seeking a word of reflectiveness and comfort. I run a very major program in an emergency department at Flinders and our problem is that we wouldn’t disagree at all with many of the things you’re saying and we, in fact, try and have a way to put them into place, but our real problem is that we’re utterly overwhelmed by a demand. And you must have struck lots of clinicians who are in that situation and I wonder how you think that through. I mean, how do we try and incorporate the kind of ideas you’re talking about into a service which is just overwhelming in terms of acute clinical demand. I imagine you’ve thought about that and I’m just interested to know what you think.
PROFESSOR KICKBUSCH:
Well, even though my brief wasn’t health services but obviously you can’t
avoid it. I do think what is a big challenge here in South Australia – and I
know the Minister and everyone else is dealing with that and very aware of
it – which is, you know, very different from how, at least, many of the
European societies I work in – health is organised. That there are better
entry points that are then – they’re not the emergency care services of the
hospitals so it does need, you know, more health centres in the community.
It needs more 24/7 health centres. It needs more integrated care,
particularly for disadvantaged populations. It needs some of the things that
will be attempted with the GP plus.
And it needs also a higher health literacy within the population who are
frequently at loss, what I call, navigating the health system and who then
frequently, you know, either don’t have the possibility or the ability to
access other points in the system and then access the emergency departments.
So it’s a much larger health services reform agenda that you are facing, but
it’s also not only that, it’s definitely also linked to the social gradient.
It’s also linked to your specific geography in this state and, I think,
those are really big issues that need to be tackled. So I believe, you know,
that – and that is one of the reasons, I might add, why this concept was
developed of sort of a senior and a junior health minister as they’re called
in Europe to say, you know, the services agenda that looms is still so large
and so important and needs to be resolved in new ways that one needs that
additional high level support for the health agenda so that the two can be
driven forward.
They’re not in opposition, they are not, you know: hey, I’m the health
minister and you’re not, or something like that. But it’s really to say
health is such an important factor in our health society both the services
side and the prevention side, that it needs a stronger voice and that that
voice needs to be balanced within government and in cabinet. But your
challenge is truly a health services reform that is being worked on here in
South Australia and, partly, a hospital reform but, you know, that’s a big
new issue and may be you’ll get a Thinker in about reforming health
services. But definitely health services is part of a healthy society,
they’re not excluded.
MR ROWLES:
My name is John Rowles. I was involved with another conference in Adelaide in 1987 which was concerned with climate change. It strikes me there are a great number of overlaps between causation in terms of health and climate change. It also strikes me that one of the things that we’re going to have to do in both areas is to change a lot of people’s behaviour and that behaviour change programs are notoriously difficult and expensive. I’d like to suggest that may be there would be some advantage in what, we might call, action learning programs where one would embark on behaviour change – exercises in which people’s attitudes to the behaviour in relation to health and their behaviour in relation to response to climate change were conducted simultaneously.
PROFESSOR KICKBUSCH:
We’re actually seeing that as part of, what I call, the new health market.
In Europe we call it ethical consumption. And we’re seeing that it links,
for example, using local produce, packaging issues, eating, you know, fresh
foods because it’s local, looking at the kinds of ingredients, looking at
the amount of, you know, food miles and things like that. So in that area, I
think particularly around food, there is a great opportunity to link sort of
health concern and environmental concern. And it’s definitely starting to be
a – I would really say a movement in some of the European countries and
we’ve just had one interesting example, a series of so-called
bio-supermarkets was opened in Germany and turned out to be a tremendous
success taking into account all those issues in the things they were
offering their clients.
And recently, there was a take over attempt by one of the large food
retailers, you know, one of these normal, cheap food things – a German kind
of – well, I won’t name any names. And the fact was that the clients
revolted and they said: you know, we will not accept this, we do not want to
be part of, you know, that other thing, we want to be able to – and be
insured that this, you know, is ethically managed, that, you know, they’re
fair trade coffee and, you know, the whole range of things and healthy and
local produce. So I think, in general, in this whole area what you’ve
indicated that the role of the consumer and clients and the customer is a
consumer society is unbelievably important. And I do think that the
potential here is still very, very big and that we as consumers – and I, you
know, include myself on a number of occasions – are just not astute enough
and, in some cases, just not radical enough in what we buy and what we want
and what we expect.
And companies are responding. I mean, Coca Cola has had to change its
product range significantly in the United States because there’s no growth
in soft drinks any more. So we, as consumers in the kind of society that we
live, can extend pressure both in terms of fair trade for the developing
countries, for environmental issues and for health issues, so thank you very
much for that, sir, for that point.
PRO VICE-CHANCELLOR McDERMOTT:
Thank you, Ilona. I’m sorry, we have to – you’ll have to speak to Ilona privately, I’m afraid we have to leave. I’d like to thank Ilona, thank you Minister Hill, thank you for the Adelaide Thinkers in Residence Program. There’ll be a transcript of this talk available in a few days on the website in the leaflet on your seat. And so please join me in thanking Ilona.
While the views presented by speakers within the Hawke Centre public program are their own and are not necessarily those of either the University of South Australia or The Hawke Centre, they are presented in the interest of open debate and discussion in the community and reflect our themes of: strengthening our democracy – valuing our cultural diversity – and building our future.