This article by DEA Committee Member David King was published in Medical Observer 30th April 2013 and appears under a Creative Commons licence.
THE social determinants of health have long predicted poorer morbidity and mortality for the marginalised and those on lower incomes.
Extensive analysis by Wilkinson and Pickett has demonstrated poorer health outcomes in developed countries with greater inequality – that is, the gap between the lowest and highest income earners. These trends were independent of the absolute wealth and GDP of countries. Even the top income groups in the more unequal countries had poorer health and more insecurity than their counterparts in the more equal countries.
There are likely to be similar connections between inequality and adverse environmental impacts. Poorer people around the world can’t afford newer technologies, so depend on clearing forests for food and fuel, and using older, more polluting cars. Poorer countries tend to have higher birth rates and lax environmental regulations and safeguards. The poor often carry the blame for environmental impact, but the top end of income range has an infinitely larger environmental footprint per capita.
In the US, the richest 1% are estimated to use up to 10,000 times more carbon than the average citizen. One long-haul flight from Australia to Europe consumes up to two tonnes of CO2 per passenger, more than some African villagers produce in a decade. Much of the carbon footprint from imported goods has been outsourced to dirtier production in developing countries.
As inequality within countries rises, people spend a higher proportion of income on material goods than on services, as the appearance of ‘keeping up with the Joneses’ is greater in more competitive societies. This is despite research showing consumption beyond basic needs fails to significantly improve reported happiness. Countries with more income equality tend to spend more on services such as public transport, which can benefit health and the environment.
Health impacts of climate change, including food insecurity and infectious diseases, are increasingly experienced by the least developed countries. They have insufficient resilience to cope with the unexpected. This is clearly an issue of global justice, given they contributed little to historical carbon emissions.
One of the proposed UN Sustainable Development Goals aims to “reduce inequality while moving towards sustainable consumption and production”. The environmental constraints imposed by climate change and finite natural resources bring an added dimension to the effort to reduce poverty and inequality. Twentieth century tools such as trickle-down economics, deregulation, resource-based growth and inept global governance are no longer suitable.
One solution is ‘Contraction and Convergence’, developed by the Global Commons Institute. This calls for industrialised countries to reduce their emissions while developing countries increase theirs to allow for development and poverty reduction.
This approach initially seems idealistic and unrealistic, as humans don’t easily give up their positions of privilege, nor want to ‘do without’. As doctors we know ‘crash diets’ rarely work for sustainable weight loss. Yet long-term behaviour change is more successful if unhealthy behaviour is replaced with a healthier behaviour, rather than creating a vacuum that usually ends with relapse. The analogy between the obesity epidemic and growing environmental crisis is apt. Both are due to overconsumption and require systemic solutions.
Medical professionals have a role in moving the debate about sustainability from a polarised political or narrow economic debate to encompass health and wellbeing. Social determinants and the biophysical environment contribute greatly to this. We know that cooperation and competition can coexist. We can enumerate how reducing the extent of inequality will be good for health and the environment. Sometimes less can be more.
For more information www.dea.org.au
Dr David King
Senior lecturer in General Practice, University of Queensland