To the Editor: It is a worthy aspiration for Australia to become the world’s healthiest country, but it will take revolutionary leadership to prevent and manage the effects of obesity that will reverse the previous gains in reducing heart disease.1 In addition, we have to overcome the adverse impact on the health of young people caused by fundamental changes in Australia, highlighted by Eckersley.2 He also identifies medical practitioners as a potential obstacle in that we are overfocused, with government approval, “on an individual, biomedical, disease-centred approach to health at the expense of a more social, preventative model”. He also calls for an increase from the current investment in prevention and public health programs, 1% of health expenditure — but that will only occur if his more radical suggestion is adopted: that governments change their focus from wealth to health creation.

It was Japan that embraced this concept, with a health creation policy developed in 1978. It led to a law ensuring that at least 5% of their compulsory health insurance expenditure is allocated to preventive activities. If we are going to achieve Ring and O’Brien’s vision, we are going to have to do more than adopt Japan’s healthy diet.

Other keys to their success are: good antenatal care; reinforcement of high breastfeeding rates by provision of small incentive payments; routine home visits to women during pregnancy and during the postpartum period by maternal and child health care workers; and all parents having their own maternal child health record.

While these and other measures have probably contributed to Japan having the lowest infant mortality in the world, these interventions are also likely to have influenced their longevity by preventing the Barker hypothesis from being applied. This hypothesis, or developmental origins theory, was derived from observations of infants who are small at birth being at higher risk of increased blood pressure and other adverse cardiovascular endpoints later in life.3

It is interventions during the early years that have evidence of high returns on investment — whereas attempts to influence adult behaviour are difficult, and can fail.4,5

In reply: Our paper demonstrates the considerable potential for improving Australia’s already competitive international mortality ranking by focusing on several selected conditions and inequalities in their distribution among Australians.1 Hart recognises the aspirational nature of the paper and proposes several challenges and opportunities to improve the health of the mothers, babies and young children of Australia.

We agree. As shown by our evidence, Australia’s performance on mortality in infancy and early childhood is less than stellar. We acknowledge that our ranking on some childhood risk factors, such as obesity (which can confer lifelong health disadvantage and may affect future mortality), may well be similar or even worse. A critique of these was beyond the scope of our paper, as we confined our analysis to measures of past mortality.

There is ample evidence of effective interventions for infants, children, adolescents, adults and older people, and for various population groups. The interventions include preventive or clinical services — as the Journal’s own repository of guidelines shows.2 We contend that rather than being alternatives, childhood and adulthood interventions are complementary (as are biomedical and social interventions), and we have to advance simultaneously on many fronts.

Australia has accelerated to be among the world’s leaders on mortality and life expectancy, but, as Hart presages, this will not remain the case merely through a continuation of current trends. It may take a revolution, but we can at least be clear about how we compare in these areas and what we need to achieve.