Determinants of health—Are we arguing for the right things for better rural health and well-being?

At the National Rural Health Conference in Hobart this year, Dr Bo Reményi presented a heartfelt keynote presentation on rheumatic heart disease and asked a good question: “why are we fixing social health problems with surgical solutions?” Especially when rheumatic heart disease is a disease that can be prevented with community-lead solutions, sanitation, housing and culturally appropriate health education.1

Fran's words remind us that when we see people in the (ill) health system with their chronically sick bodies, with their risk factors (the smokers, the drinkers and illicit drug takers, the physically inactive and the overweight or obese), or suffering affects from physical and psychological trauma and abuse, this is the tip of the iceberg; the things that we can see. Unfortunately, the way we respond to these issues is typically with an individualistic biomedical and/or behaviour change approach.3, 4 And yes, there are times when biomedical and surgical interventions or behaviour change methods are necessary and appropriate, for example, to “fix” heart valve problems irreparably damaged by rheumatic fever. But the question remains, would these kinds of intervention be necessary at all if the social issues, essentially of poverty, had been addressed in the first place? Of course, basic logic tells us the answer is no (or at the very least, a lot less likely).

It is those things that are hidden beneath the surface of that iceberg that has led a person to the health professionals' door. These hidden factors include the social stratifiers of social status or class, education attainment, occupation, gender, race/ethnicity and income that position a person across their lifespan in a social context that enables them to flourish, have choices and control over their lives, or not, as the case maybe. These stratifiers are in turn influenced by society's social and cultural attitudes and shape other structural determinant policies be they macroeconomic, social (labour market, housing and land) or public (education, health and social protection) policies.5

With all that complexity, it is easy to understand why our policy machine would try to “cause a major effect on a complex issue by addressing a single factor.”6 An argument often advanced is that these determinants are outside of the health sector's purview and that we should be focusing only on those factors that the health sector has responsibility for, namely health services and the workforce to deliver those services, medications and diagnostic investigations.

Arguably, one of the prominent single factors dominating rural health discourse is the issue of access to health care, particularly, access to health services and health workforce. This makes sense when access to health care accounts for (depending on which data source you ascribe to) anything from 10% to 45% of a person's health. It sounds logical to argue for more health professionals and an equitably distributed workforce in the bush. Particularly when there is a clear need to recruit and retain and highly skilled and workforce capable of dealing with the challenges and gaining personal sense of achievement and professional pride from “going rural.” But how often are other dimensions to access considered?7 For example, the need for a high level of health literacy to be able to understand and navigate the health system? Improving health literacy comes from improving education and starts in the early years of life. How often is the cost (time, money and stress) of accessing care taken into account when it is deemed reasonable for people in remote areas to travel long distances to access it, or the impact that a culturally unsafe environment can have on accessing care in the first place taken into account when advocating for access to more workforce?

In this issue of the journal, there are a whole range of papers presenting ideas about ageing in rural Australia. Whilst there is a need for the appropriate health services to help keep older people well, how we create rural places and services that meet the needs of older people that enable a sense of wellness, connection and inclusiveness, control, purpose and meaning, directly influenced by the structural determinants of health cannot be ignored. We need this kind of holistic thinking if we are to create communities where older people are enabled to live and age well in a rural place.

So my question to you is as follows: if we are really serious about improving health outcomes in rural and remote Australia, are we going to see a great improvement in health outcomes if we are focusing on one single issue for example access to health service or workforce?

I ask you—should we be arguing for things that will bring about individual and community wellbeing that go beyond batting for more health workforce? For example, should we be arguing for every rural child to get the best start in life? For rural places that are vibrant liveable places to live, work, play and age? For more strategies that create opportunities to bring communities together, maybe through the lens of arts and health? For rural places that ensure children, young people and adults have best chance they can to maximise their capabilities and have control over their lives? For employment, good work and incomes that enable dignified lives? Should we be pushing for all people in rural areas having a healthy standard of living for everyone regardless of where they live?8

So are we arguing for the right things?