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Adelaide Thinkers in Residence public lecture

The Shift To The Health Society

With Professor Ilona Kickbusch

Ilona KickbuschTuesday 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.

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