Climate change will widen health inequities; action on the social determinants of health is essential
In a conversation recently, a former senior public servant suggested to me that the social determinants of health are too theoretical. It is true that there are a number of theoretical perspectives associated with social determinants. A key one, from Nobel Laureate Amartya Sen,1 highlights the importance of having the freedoms and capabilities to lead a flourishing life. According to theory, these are shaped by the conditions in which people are born, live, work and age, which are unequally distributed.2
There is, however, nothing theoretical about the manifestation of social inequities and their impact on peoples’ health. Every day, people living in Australia embody stark inequities in income, working conditions, lived environment, and access to quality health and social care. For example, before the coronavirus disease 2019 (COVID‐19) pandemic, Australians in the top 20% income bracket received six times more money than the lowest 20%.3 Three million Australians were estimated to be living below the poverty line in 2017, including 18% of all children.3 Before the pandemic, more than a million people were in rental stress, and waiting lists for social housing were into the hundreds of thousands.4 Within the first few months of 2020, 880 000 Australians lost their jobs, with women, young people, and those in precarious employment disproportionally affected.3 Workers in casual employment accounted for 63% of job losses between February and May 2020.3 Since the COVID‐19 pandemic began, Australia’s 31 billionaires have increased their wealth by $85 billion.5
People embody these inequities,6 which makes them sick and contributes to high levels of premature death. In 2017, 17% of Victorians reported high psychological distress. In 2020, that rose to 44% and to 60% among those who lost their jobs.7 Across Australia, people living in the lowest socio‐economic quintile had mortality rates twice as high as those in the highest quintile, and these inequities widened between 2011 and 2016.8 Despite narrowing, the gap in life expectancy between Indigenous and non‐Indigenous Australians remains high.9
The relevance of the social determinants to climate change
What do social determinants have to do with climate change and planetary health? The fires, hail, floods and droughts that Australia has endured in recent years10 affect everyone, but not everyone experiences them equally.11 Affluent people can afford to live in insulated buildings with air conditioning and air purifiers, or add flood proofing and extra drainage. Meanwhile, people who are poor, older individuals, people with disabilities, and those who are socially marginalised are the least able to adapt to the changing climate, unable to escape the fires and heat, and live in dwellings and environments that amplify its effects.11 As has happened in other countries experiencing similar impacts from climate change, having lost homes and livelihoods, and fearful for the future, some people may leave their communities and perhaps the country.12 This will exacerbate inequities, with those who have more financial and social capital having more options — wealthy Australians are already buying land in Tasmania to escape the worst ravages of climate change.13 For people living in caravan parks in Lismore, New South Wales, having insurance is a stretch.13 Moving is not an option.
This climate change‐exacerbated social inequity adds to existing inequities in disease burdens and premature mortality — this is climate change interacting with the social determinants of health inequities.11
The consumptogenic system
Planetary health inequity is a concept that recognises the impact of climate change on social and health inequities. It also recognises the importance for health equity of considering planetary systems — if we do not have a functioning Earth system, we have social disruption and risk to human survival. Planetary health inequity therefore embodies the common drivers of climate change and health inequity. These common drivers comprise major structural forces. Power asymmetries between actors, institutions and ideas, a neoliberal fetishism of market forces and individualism, hyperglobalisation, and the associated norms and values that permeate institutions and communities affect policy decisions that structure society and differentially affect daily living conditions and, ultimately, health.14,15,16,17,18
These structural social determinants of health inequity overlap substantially with the drivers of climate change and can be described collectively as the global “consumptogenic system”. The consumptogenic system is characterised by institutions, policies, business practices, and social norms that embed and entrench principles of extractive capitalism and colonialism.19 Such a system encourages and rewards excessive production and hyperconsumerism of fossil fuel‐reliant goods and services that are unhealthy and inequitably valued and distributed.20 If left on the current trajectory, the consumptogenic system will amplify potentially irreversible consequences for environmental degradation, inequalities and poor health.
Governments have the chance to advance planetary health equity goals by addressing the consumptogenic system and inequitable distribution of resources that create negative health outcomes and climate change. The issue is not that it is too theoretical, the issue is the often lack of political will to address inequality, adopt a social model of health, and tackle climate change.
In the May 2022 federal election, the Australian electorate demanded change. Encouragingly, the new Labor government promised to do better by the people and, although not in the language of the social determinants, their proposed action plan21 will go some of the way to advance planetary health equity goals. But it must go further. Achieving the transformative goal of planetary health equity requires a “social vaccine”22 (Box), the targets of which are the conditions underpinning four basic requirements for health and equity to flourish: a life with security, opportunities that are fair, a planet that is habitable by humans and supports biodiversity, and governance that is just.
Achieving these conditions requires the ambition, design and implementation of policies that ensure a fair social foundation and economic environment operating within the ecological ceiling.23 In Australia, as elsewhere, we have long needed policy that helps with adaptation to the damage already done by climate change. Good social and planning policy that ensures access to safe, stable and affordable housing, decent working conditions for all, income support levels that enable living with dignity, and inclusive infrastructure development is good climate adaptation policy. They are also good health equity policies.
Adaptation is essential. So too is mitigation. The Climate Change Bill 2022 commits Australia to a greenhouse gas emissions reduction target of a 43% reduction from 2005 levels by 2030. This target should be considered only a starting point. A roadmap to net zero and an empowered secure Climate Change Authority is essential. Adequate climate change mitigation and planetary health equity will not be achieved unless there is ambitious and immediate action that disrupts the consumptogenic system. The targets should be the institutions, actors, structures and discourses that embed, facilitate and normalise the global dominance of a consumptogenic system addicted to growth regardless of the environmental, social and health costs. At the very least, any new fossil fuel project must be assessed for potential damage to species and environments through its impacts on climate change. Fundamentally, however, disruption of this system requires Australia and the rest of the world to stop extracting, burning and investing in oil, coal, gas and other fossil fuels, with government vetoing all new fossil fuel developments.
The absence of an overarching framework guiding the actions of all Australian Government departments in a mission towards planetary health equity is problematic. This lack of authorising environment enables at best an ineffective siloed, scattergun approach; at worst policy silence. Implementing a national strategy that brings together climate change, inequality and health, such as the proposed Climate and Health Alliance’s Healthy, Regenerative and Just framework, is essential.24
An engaged strong civil society is key to the delivery of a social vaccine. Implementing a progressive policy framework will confront stubborn resistance and challenge the power of dominant vested interests. Public‐interest coalitions can support governments to act, as well as hold them to account.25 Climate change and health alliances are essential — doctors and other health professionals have knowledge, opportunity and political leverage that can help ensure actions are taken.24
This article has laid out ways of advancing planetary health equity goals. To help achieve these, the health community must advocate for and engage in intersectoral policy discussions relating to the social determinants and the structural consumptogenic system. Acting immediately on these issues is critically important if we are to avert a planetary health inequity crisis.
Box – A “social vaccine” for planetary health equity
- Embed policy norms of social equity, environmental sustainability, and wellbeing
- Apply these policy norms and implement multisectoral policies that ensure a fair social foundation and economic environment operating within the ecological ceiling
- Implement a guiding national strategy on climate, equity and health
- Reset the governance of planetary health equity ensuring that no vested interests are at the policy development table and that there is protected space for civil society
Provenance: Commissioned; externally peer reviewed.
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