Even if you are lucky enough to live in a wealthy country, one of the biggest influences on your health and life expectancy will be your socioeconomic status.
Most people in wealthy countries now reach old age, which is wonderful, but with this there is a rise in chronic disease. The health consequences of poverty and lack of social supports also drive the need for care.
No amount of social restrictions will fix healthcare if we don’t address these issues.
The health system is designed to treat sickness. Public health is supposed to help people stay well. Over the past two years, public health has intruded on our lives with rules ranging from border closures to the harmful and pointless one-hour limit on time we could spend outside doing exercise in Melbourne for months of 2020. All in the name of protecting a “system” that is supposed to be serving the needs of the community.
Hospitals are designed to treat acute illness but they function as the stop-gap for a lack of community care. Social supports, including stable public housing, income support and carers, are the key underpinnings to health, because if you can’t meet your basic needs, it’s almost impossible to be “healthy”. If there is a crisis in one of these, for example a carer for someone with dementia becomes unwell, the person with dementia can end up admitted to hospital because there is nowhere else for them to go.
Before 2020 the idea of widespread social restrictions to protect the health system did not exist. At the start of the pandemic, the idea was they would be short-term, an opportunity to increase skills and capacity. This did not work. Along with viral infections, we are dealing with consequences of delayed care and a lack of focus on chronic disease.
A public health mandate is an extension of the idea of health as personal responsibility, except it is being enforced by a state that doesn’t believe people know enough to make good choices. It turns citizens into enforcers: that supermarket worker who has to stand at the front of the store asking people to put a mask on, or the 18-year-old at the cinema checking everyone’s vaccine certificates.
The people calling for mandates to be reinstated are saying that if only everyone did as they should, if only everyone controlled themselves, we would all be OK.
The real and very uncomfortable truth is that, even in a country as rich as Australia, if you want excellent health, the most important thing to do is to be born to wealthy parents.
In a report from the Australian Institute of Health and Welfare, for people living in the lowest socioeconomic areas, the age-standardised death rate was 1.5 times the rate for people living in the highest socioeconomic areas (623 and 414 deaths for every 100,000 respectively). Unsurprisingly, people living in lower socioeconomic areas also have poorer health and higher rates of chronic disease and disability. I just wish people were as outraged about this as they are about masks on public transport.
It’s easy to make public health policies that benefit those who are already the healthiest because of their wealth, it’s much harder to make public health policies that will address the social determinants of health and address inequality. But this needs to be at the forefront of system design and health policy if we are going to fix the problem of an overburdened health system.
The health system is a complex interplay of primary care, acute hospitals, subacute hospitals and community services. The federal government mostly funds primary care and the hospitals are funded mostly by the states. The health system also intersects with federally funded aged care and the national disability insurance scheme. If someone with a disability has been admitted to hospital, and needs funding approval for services and equipment, they can be in hospital for months.
As someone who works full time in a public hospital, I can say that, while under severe strain, our healthcare system is not broken. If you are hit by a car and turn up to our emergency department, you will get excellent care. You might just get stuck in ED for a long time because there are so many people who can’t go home.
There are many people – those who often need healthcare the most – who the system consistently lets down, like all the people with severe mental health problems who end up in an ED needing admission because there was no way to get help until they were in crisis.
The Covid pandemic is causing trauma but it is also shining a light on the changes we need to make in healthcare. If we only focus on the narrow idea of restrictions, we miss the opportunity for the post-traumatic growth that is needed to create a health system that meets what all people need, not just those who are wealthy.
Covid will not go away, nor will ageing, chronic disease and inequality. We need to take the chance to look at gaps in healthcare. We need to think about how we better serve communities by engaging in co-design and rebuilding trust in public health. We need to acknowledge that lack of social supports leads to long hospital admissions and collaborate to remove barriers.
The pandemic means can no longer ignore the problems that have been building for as long as I have worked in healthcare and, paradoxically for me, this gives me hope for the future of our health system.
Kate Gregorevic is a geriatrician working at a hospital in Melbourne.
