How a wellbeing economy approach could promote health equality for future generations

Gretchen: Hello, welcome to Prevention Works, the podcast of The Australian Prevention Partnership Centre, coming to you today from Gadigal and Ngunnawal land. I’m Gretchen Miller. On the show we’ve often talked in a lateral way about the ripple effect taking positive action in one area of preventive health has in other areas, for example, ensuring access to healthy food options impacts positively on heart health, obesity, and diabetes. Ensuring there’s public transport options reduces the impact of airborne pollution, encourages community wellbeing, and exercise, all of which have direct health benefits in reducing obesity and increasing heart health and mental health, and influencing public health as socioeconomic and commercial factors, and the resulting feedback loop can be economic, like improved productivity and social, as in education outcomes. A good example of a broad range of co-benefits can be seen with reducing alcohol use, that has positive benefits on non-healthcare costs incurred by, for example, road crashes, police, criminal courts, prisons, child protection, and out-of-home community services. But while the language of co-benefit has long been used in the environmental movement and our own discipline has talked about health across all policies for some time. Research that simultaneously measures health and other options is relatively new in the prevention of chronic disease. So in this episode we’re going to talk about co-benefits as our main theme with our guest, Dr Katherine Trebeck, who describes herself as a freelance advocate for a more humane economy. She has worked between Scotland and Canberra for a while now but is back in Australia for three roles, as Strategic Advisor to the Public Policy Thinktank Centre for Policy Development, as Economic Strategy Advisor to the not-for-profit advisory group, The Next Economy, and she is Thinker in Residence at the Planetary Health Hothouse at ANU. Her book is co-authored with Jeremy Williams, The Economics of Arrival: Ideas for a Grown-Up Economy, published by Bristol University Press.

Katherine, I’m so thrilled to talk with you. You write across so many vitally intersecting areas, so shall we start with a broad overview. If a health policy maker picked up your book right now they might not find public health front and centre, can you explain how public health is a part of the net of ideas that you cast?

Katherine Trebeck: I love that phrase, net of ideas that I’ve cast. I will think of that the next time I’m writing. I would hope, actually though, that while it’s not maybe explicitly front and centre that a public health practitioner would really recognise a lot of the ideas that they would be familiar with, a lot of the patterns in terms of social outcomes and inequalities and how that impacts people’s lives that they would be familiar with some of the evidence that’s presented in the book around community breakdown, and also some of the discussion of human needs, I think a lot of that would resonate with public health practitioners, not least because a lot of the work that’s spoken about in the book is inspired by colleagues in the public health sector and is really taking a lot of the evidence that they bear witness to and that they foreground so very, very powerfully, and asking the question, okay, what has the economy got to do with this, why is the economy that we’ve got not serving enough people, and then dwelling on that question and really taking a good hard look at the way our economic system operates and who is winning and who is losing out of that. So I think, I would hope that colleagues in the public health community would see it as almost a translation of their work into the economic sphere and using their inspiration to hold a mirror up to the way the economy operates today.

Gretchen: What sort of arenas might you find there that relate to public health?

Katherine Trebeck: So the big one of course is distribution of wealth and resources and power and how that has an impact on individuals, on communities, and on the planet, and then that then circles back to having an impact on communities, so we’re seeing also that the impact of environmental breakdown has very, very real health consequences, and so the discussion of the way resources and power and control and agency is distributed, and maldistributed is probably a better word to use, and how that then feeds into a very profound health inequality. So I’ve just returned to Australia from living in Glasgow for 17 years and this is a part of a very, very wealthy country in financial terms where just a few kilometres up the road from where I was living people had a life expectancy of around 54, and that’s extraordinary. I mean that’s below the life expectancy of many countries that people in Scotland itself would recognise as low-income developing countries, and yet here we are in one of the most developed countries in financial terms where people are not living to pension age, and that demands that you ask very hard questions of business as usual, it demands that you say to the current way of doing things this isn’t good enough, and so I think that that’s a story there through those statistics and the reality of people’s lives that shows the very, very literally life-and-death questions of the way the economy is operating.

Gretchen: You talked about public health and economics and quality of life and wellbeing as all being kin concepts, kin ways of thinking, I wonder if you could expand on the idea of kin there?

Katherine: Kin I use as a term, almost sort of an affiliation but also a cousin, there’s a relationship, there’s a familiarity when I use that term kin, and mutually reinforcing, it’s almost a bit about ideas that are linking arms with each other and showing a bigger picture, it’s almost that part of joining up those dots, and I think that, in a way, is the approach that the book and that the work I’ve done before and since the book is trying to do, is trying to really see the interconnections between a lot of issues that are often dealt with in isolation, really understand how related and affiliated also some of the solutions are. One of the things that I find really, I would say sad but I guess the positive side of it is an opportunity, is how there are so many ideas to make the world a better place, and often they’re held up as alternatives, and actually, I think, what we need to do is recognise when they’re put together they can all be mutually reinforcing and linked together and add up to something very, very powerful, and that’s a question of how change happens and movement building as well, but I think the positive side is just seeing that there are lots of great examples of changes that need to be made but not only have positive ripple effects, but also can enable subsequent changes to happen again, so you get this almost virtuous cycle of shifts and improvement that then create the enabling context for further shifts and improvements. I mean that’s the best-case scenario. Of course, we see it operating in reverse, often, as well.

Gretchen: It seems to me that although the system we work in is incredibly flawed, as my teenager is constantly pointing out to me, that there are the seeds for connection across areas that have become siloed from one another. I’m not sure that they always were, how did all these areas become so siloed from one another?

Katherine: Sure, Gretchen, I mean I think there’s a lot of reasons and my suggestions will probably only be part of the picture, I think others working in government and working with government will have other suggestions about the origin of the siloed thinking, but for me I think there’s a couple of reasons around just how you can manage what you can manage, and so, so often to think systemically and think long term is overwhelming, and so how do you start to have a go at that, so even if the original intention is to enable joined up work and holistic undertakings, you have to start somewhere, and then that just leads into a very issue-by-issue, event-by-event, crisis-to-crisis approach, and so I guess I have a bit of sympathy with how that’s happened. I mean the acute needs in those crises are very real, so we have to respond to them in the here and now, we have to help people and planet survive and cope with the fallout of the current system and so that then takes us or takes the action into a conversation around immediate response, often that’s measure, the success, apparently, is measured in how much we’re spending on an issue, as opposed to stopping that issue arising in the first place, so you see government budgets, for example, heralding X number of billion dollars being spent on an issue when actually that’s a downstream reactive response to the damage being done in the first place. I think there’s also something around the idea of expertise, particularly probably also comes from the way universities operate, they’re very much about demarcation between departments and very specialist areas and people dive very, very deep to build a body of work and to build a deep expertise and there’s absolutely an importance of that, but that reductionist approach then often comes at the cost of making those interlinks between various issues and getting those experts to almost play together and jam together a little bit, and star to see the links and the connections between their issues. And I mean I’m really heartened by Donella Meadows who is one of the obviously great systems thinkers and one of her, particularly when I’m feeling imposter syndrome, which is every day and feeling gosh, I’m not an expert in anything, but actually, Donella says it won’t be experts who will change the system, because that’s not what they’re trained to do, that’s not how they’re set up to work, they dive deep into an issue, and actually folks who will be helping change the system, are those who can work across and link up those areas of expertise, link up the lessons, bring the opportunity and different perspectives from those different areas of expertise to bear on the wider, bigger, deeper questions, so I try to not give myself too much of a harder time when I’m feeling not an expert in anything and remember Donella’s term, ‘It’s time to dance with the system’, is her beautiful phrase.

Gretchen: So I’ve got two questions, I want to note one before we get to it though, and that is how health practitioners can bring this kind of thinking into their work, okay, but first of all I’d like to ask why the language of co-benefit is useful? And I know it’s not a term that you use a lot, but it carries with it a whole range of ways of thinking and ways of speaking about these interconnections, I think, so perhaps you’d like to answer both those questions in one.

Katherine Trebeck: Co-benefits is a really beautiful concept, actually, I mean it’s not the sexiest of terms is it, it’s fairly technical, but in a way it’s just about positive ripple effects, isn’t it, and really being more ambitious for interventions, and so I think if we approach a challenge in a way that’s saying let’s not just put a band-aid and solve and fix, let’s try to do something bigger and better, let’s try to make sure that when we intervene or try to bring about a solution that we’re thinking bigger, we’re looking for more opportunities, we’re looking for the potential of wider benefits and these beautiful, positive ripple effects, and I think that’s almost a very freeing way of looking, it enables people to look up and cast their eyes around, or hopefully literally, actually, say is there something more we can be doing here. I think it’s almost an antidote to downstream reactive thinking, it’s an antidote to that very, very narrow idea of cost-benefit analysis, and I think it also implicitly helps people take the time to look at root causes and to look more upstream, and I think it also is about understanding the sort of sequence of positive impacts. And I’m speaking very abstractly here, I realise, but if you can get something right in one scenario so often that enables another scenario, so to give an example, there’s a lot of discussion at the moment about the four-day work week, there’s been massive trials that have just been reported on and seem to be very, very successful.

Gretchen: Not here in Australia, so much.

Katherine: Yeah, there are a couple of the participants in this global trial were Australian companies, and yeah, there’s been a senate enquiry has just recommended that we do trial it here in Australia, but yes, it’s very much not as far on this discussion as it is in the UK and Europe, just as a little footnote, I think the four-day week frame is a bit of a red herring, because actually what we should be talking about is how we share and distribute paid work more fairly, and for some people that might be term time working, it might be working shorter hours over five days, for example, but for whatever reason it almost needs to become a meme, the four-day week, but let’s use it as a catch-all term for a wider, a different approach to work where we work fewer hours individually, and also then enable other people to work more hours if they need that. But if you think about that, particularly people are going to be more able to step into that space if they’re rethinking their own work-life balance, if they’re ready to get more involved in community activities, if they’re going to rethink their transport and how they get to work, for example, and so I think there is something about, if we’re wanting to bring about large-scale, systemic change is really understanding what’s the sequence of different policies and what are the enabling conditions for the next policy, and to bring it back to your original question that’s where I think this framing of co-benefits is really helpful, and it brings another lens to this idea of investment. So often governments think well what’s the return we’re going to get on investment, and I think thinking about co-benefits also opens up this idea for justifying a particular positive investment or a solution or a change.

Gretchen: I’m thinking about I can imagine as a health researcher you might be going oh my god, how can I possibly work more complexity into my research, but the fact is if you’re writing an article that you can draw these ideas into your work by referencing other people’s work, and maybe not just health researchers’ work, but economists’ work, for example, so that work is being done, you just have to make those connections and draw those citations into your journal article, for example, or your article for the conversation, it’s not like you have to do it from first principles, right, you just have to be thinking laterally and drawing that thinking into your work, and I’m thinking about that as a recently completed PhD working across disciplines, actually how beautiful and elegant and fun that is.

Katherine: Do you know, I think there’s a really important point you’re making there, and it’s almost to give people reassurance that they don’t need to be everything, they need to just celebrate what it is they bring to the party, and work out who’s bringing other things to the party and how that goes together well and how that actually creates something better than just the sum of the parts, and I think there’s something really empowering in what you’re describing there, because the change, if we’re really honest with ourselves, the changes that are required in our economies are enormous, they’re across all different layers of how we do the economy from the very, very local, right up to the supranational, they require a whole lot of different shifts, whether it’s how we do changes in taxes, what sort of business models are out there, how we do energy, how we produce and consume, design of products, a whole, I mean it’s overwhelming, a whole plethora of shifts are needed, and what the point you’re making there, I think, has got such resonance for wanting to be part of that movement because it’s saying you don’t need to do everything, others are picking up different pieces of that jigsaw puzzle and bringing them along as well.

Gretchen: And in the practical sense that can mean okay, first of all you start with citations from other disciplines, but second of all you can then start bringing those disciplines into your working groups, right. What’s interesting here is that we keep coming back to the economy, and by economy that usually means dollars and cents, so to speak. I think there are other kinds of economies, but one, I think we’re referencing economy because it’s just such a dominating force in the zeitgeist, everything is about what things cost in monetary terms, but one of the things you’ve asserted is governments are putting the economy ahead of things like, well science, for example, and I wondered if you could elaborate on that.

Katherine: Yeah, there’s actually a real irony because economics, the discipline of economics used to have real science envy, particularly physics envy, and used to really want to be seen as a hard science, and actually, economics is often, it’s more like a social science, it’s how people behave and treat each other and interact, but they were very envious of some of the nice graphs, for example, that physics had, and so they tried to come up with these sort of apparently iron-clad laws of supply and demand and so on, and now, I have to say, I think there’s a very real irony in a really sad and really dangerous way that often proponents of certain approaches to the economy seem to be ignoring the very, very strong real science around environmental breakdown. I mean I don’t think you can get stronger and clearer than the recent IPCC report into the extent of climate change and the urgency of massive shifts that need to be undertaken by societies, but there’s also a beautiful way of remembering what the economy is about, I mean its original meaning was household management, and if we take the idea of household as our planetary home, then that brings us to thinking about the economy of, well, how do we take care of our planetary home and how do we make sure that everyone on it is taken care of, and that’s, I guess, implicitly the way I think about the economy, it’s how do we divvy up resources, how do we create those resources, how do we share and cherish those resources, but you’re right, it does seem to have, a more narrow conception of the economy does seem to really trump other decisions, other goals, often, and I think that’s at a really fundamental sense a real danger, because it means we’re treating the economy as a goal in its own right, rather than a mechanism to deliver, what I’d describe as, higher-order goals, things like everyone having enough, everyone having a good fulfilling life where they have dignity and purpose and fun and good relations, and everyone being happy and healthy on a healthy planet.

Gretchen: And all of those things then playing into public health, of course…

Katherine: Indeed.

Gretchen: Because dignity and fun and health and wellbeing are all about solid mental health and fitness and bodily health.

Katherine: Yeah, they’re preconditions of good health, aren’t they? And I think what’s interesting too is that for health researchers, often there’s a compulsion to bring things back to okay, and this will be good for the economy, we’ll keep people out of hospital and that will be good for the economy, have we gone too far in centring the economy in our pleading for better health for the population?

Katherine: Yes, yeah, I think we have and I see it, it’s not just health, I see it in calls for gender justice being framed as this is good for the economy, more women, more gender equality will boost the economy. You hear groups like the World Bank saying poverty is a drag on economic growth, therefore, we need to address poverty. You hear the IMF saying inequality is bad for the economy, and it just, to me they’re just all examples of how society, we’ve got things the wrong way around, why aren’t we asking what can the economy do for poverty reduction, what can the economy do for gender justice, what can the economy do for health, we don’t ask that enough. Instead, I mean we’ve completely flipped the means and the ends, and I think it’s a really fundamental problem in how we think about issues in places like Australia and the UK where I’ve just been based, we’ve really got our means and ends tangled up the wrong way around, and so we’re demanding almost the business case for poverty reduction or the business case for gender equality, the business case for health, rather than saying actually, that’s the end in and of itself, how can everything else come in behind it and support it, and help deliver the outcomes that we’re really, ultimately really striving for?

Gretchen: Well, stepping away from the economy then with this next question and just looking at two really significant spheres, I suppose, in human futures, let’s take climate change. The fact is that if we address climate change in a variety of ways we’ll also improve our own human health, measurably our mental health, rates o cancer, deaths from extreme heat, less cardiovascular disease, and less respiratory disease. I mean I still think about the fires that preceded the COVID-19 outbreak and how the smoke hung in the air across the major cities of Australia, let alone the regions, it seems self-evident, how should health researchers factor these other sectors of crisis into their work, should they be drawing climate into their research, should they be referencing it, should they be normalising it?

Katherine: I think people are starting to make those connections. I think you’re right, that we’re not really doing that loudly enough and boldly enough and regularly enough, but I think you’re right, the evidence is there so it’s not a shortage of understanding and proof. It’s more making the, joining up those two issues and showing how they’re deeply connected, and the implications as well, because I mean, you say let’s step away from the economy, we can’t, because there’s also fiscal, very real fiscal impacts, so in last year’s October budget there was a huge amount of money earmarked to help the Health System, with a capital H and capital S, hospitals and so on, deal with the health impacts of climate change. So already governments are cottoning onto this and having to earmark more money to respond to this. In Melbourne, they’ve just appointed heat officers, so these are public officials whose job it is to help individuals who are vulnerable to extreme heat find shelter and so on. So there would be salaries attached to that, there’ll be the resources attached to that, I mean very needed, but a very, very downstream, response, to the extent that one, we’ve got individuals who are so vulnerable in the first place, they’re unable to take care, they don’t have the resources to take care of themselves in times of extreme heat, but also we’re pushing our planet so far beyond her boundaries that we’re seeing these periods of extreme heat. So it’s another example there of how so often government spending and a lot of charitable response is channelled into downstream, reaction, repair, after-the-fact, response, and it comes back to one of your original questions around siloed thinking, and so the acute need is profound, I don’t want to at all denigrate those efforts, this is helping people and planet survive and cope with a very inhumane situation that’s doing a lot of damage to people and planet, but if we keep doing that things are just going to get worse and worse and worse and we’ll be having to spend more and more money on that and it’s almost like we’re missing this opportunity to get things right first time around, and that’s where I think health practitioners can, because of the credibility and the inherent kudos in their work and their esteem amongst the general public and amongst politicians and policy makers, I think they’ve got a very, very powerful voice that I think, perhaps, they could be using more loudly to bring to bear on these debates around social policy and economic change, and to give an example, in Scotland where I’ve just been living it was a former chief medical officer, a chap called Professor Harry Burns, who brought incredible graphs, incredible evidence, and incredible testimony from his role as a former surgeon and his role as CMO to really push the conversation in Scotland around the social determinants of health, he was very, very influential over the then first minister and that really pushed the discussion around having to rethink the way we do the economy, so it’s a great example about the way that public health practitioners can be heroes of sparking a conversation about much needed economic system change.

Gretchen: Thank you, super interesting, and there’s much to unpack, I wish we could talk all day, but getting back to co-benefits I’m kind of interested to dive into the detail a little further and, for example, take exercise, mental health, and their connections with improved liveability and say, public transport, and talk about how these arenas actually all have co-benefits for us as humans living in a living environment, so co-benefits for the environment as well.

Katherine: Yeah, so I’ll answer it with an example that’s very top of my mind, so about 12 years or so ago I was part of a project developing an alternative measure of progress for Scotland, very, very small little project, I was working for Oxfam at the time, tiny budget, lots of flaws, lots of things we’ll do differently, but it was all about asking communities what really mattered to them, very, very deliberative conversations, and particularly making sure people who are most marginalised in current policy making that their voices were at the forefront, and I say that now because I think it’s a really important lesson for Australia when we’re talking about measuring what matters, how do we know what matters if we’re not speaking to people, but one of the partners in that project were folks from a group called Glasgow Centre for Population Health, it’s an incredible team of public health practitioners…

Gretchen: Remembering of course this is a place where the life expectancy is 54…

Katherine: Yeah, in parts of Glasgow, and this Centre has done amazing work around understanding what’s going on there and the evidence around that, and bringing that to the public mind very powerfully. So we did these conversations with people across Scotland and we’re sort of grappling with those tensions between sort of subjective measures and objective measures, and just how they feed onto each other quite a bit, and so this is coming to start to answer your question about these interconnections and ripple effects, because issues around safety, it’s often the perception of safety that can matter most, because crime rates were going down. In Glasgow, there’d been a lot of amazing work around knife crime reduction we can talk about because it’s a really interesting story there, and yet, if people were scared to go out, if they were anxious about crime, then they’ll stay home, that’s then going to affect their mental health, it’s going to affect their physical health, it’s going to undermine their social connections, and then that will have a ripple effect and it will become self-fulfilling, and so that’s just to me, that’s I guess the negative example of these interconnections, but it also shows that if you can open up one corner of that, perhaps by helping people have more social connections, then they’ll be ready and willing to go out more and then that will have the ripple effect, the co-benefit on their mental and physical health as well.

Gretchen: Such a profound example. What’s the relation to that kind of work with the notion that you’ve brought about called Downscaling the Doughnut, and I wondered how that idea has developed for you since you did the work with Oxfam?

Katherine: Okay, so there’s a bit of a backstory to the Downscaling the Doughnut project. So I was working for many, many years with Oxfam and I worked at the time very closely with a woman called Kate Raworth, who was at the time writing just a discussion paper, and she came up with this idea of the doughnut, which of course since has become, almost gone viral as a way of thinking about the economy and social progress, and so if folks haven’t heard of the idea of doughnut economics, what she did is she took this evidence around planetary boundaries, and these were almost the physical boundaries of our finite planet that earth-system scientists were drawing up and putting evidence to, led by people at the time, the Stockholm Resilience Centre, and so they mapped this out almost as a circle, the planet circle, to denote these different nine planetary boundaries, and so Kate looked at that and she said okay, in Oxfam, we’re a social justice organisation, we recognise that environmental breakdown is pushing back some of the progress on development that’s been achieved in the last few decades, we see the impact of environmental destruction on people’s livelihoods, but those planetary boundaries have no people in them, there’s no humans there, so she literally took a pencil and drew and inner circle within that outer scale, so it yielded this doughnut shape, so hopefully folks are listening to this, they’ve got in their mind the shape of a doughnut, and she said what we need is an economy that operates inside the doughnut because that’s where its safe in the sense it’s not breaching those planetary boundaries, so we’re not pushing the planet beyond what she can handle, but it’s also just in the sense that we’re lifting humans above various aspects of social foundation, which she at the time crowd-sourced from the SDG, the Sustainable Development Goal process. So you get this sort of very, this visual, this beautiful visual, she describes it as a compass for humanity, and she was writing this discussion paper and then actually she left Oxfam to write the book, Doughnut Economics, it’s become a best seller, but working with her at the time, once you start looking at the world, once you’ve had this seed of the idea, this different image put in your mind, you look at everything with doughnut lenses, and so when Kate left she actually left me with, passed over to me a project to say okay, there’s this big, bold sort of general idea of a doughnut in a conceptual sense, what does that mean for different countries, how do we downscale it? So I worked with colleagues to think about right, where is Scotland sitting inside the doughnut, where’s Wales, where’s South Africa, where’s the UK, where is Brazil, the Brazil one wasn’t published but all the others, all the other downscaling efforts will be on Oxfam’s website, and so essentially saying okay, what’s, for example, Scotland’s fair share of contributing to those breaching of planetary boundaries, how much beyond it’s fair per capita emissions, for example, and carbon dioxide is it emitting, is it overfishing its oceans, is it contributing more to land-use change than UN agencies would say it’s a safe process, but also what are Scottish people say are the relevant planetary boundaries, so what do you need to live well in Scotland? So things like what are participatory measures of having enough to live on in order to be able to participate in Scottish society, and then how is Scotland fairing on that front as well, do people have enough food, do they have enough energy to do their homework, do they have enough decent transport? And they would have been different in Scotland than they would have been in South Africa, so it’s quite a numbers-focused report around just understanding the state of play, but a really good, important beginning, it’s a first part, a first step to understanding right, here’s where we are, if we want to get inside the doughnut here is where we need to work on.

Gretchen: So it’s about justice and equity, isn’t it, by the sounds of things, and measuring those up in…?

Katherine: Yeah, in a range of areas.

Gretchen: …across a range of different communities and cultures. So I wanted to ask you then look, what’s wrong with growth, and more specifically what’s wrong with growth in relation to population health? Because in a way we’ve come to see growth as a healthy notion, right?

Katherine: Yes, because if a young baby is not growing everyone will panic, and if a young plant that you’ve just planted is not growing you’ll be thinking what’s going on here, what’s wrong. The problem is that growth as I’ve just illustrated there almost with different examples of the different sorts of growth and in different contexts where it’s good, growth is an abstract term. Growth is not in and of itself good or bad, the question is just not asked enough of what sort of growth, where, for whom, and how. So there are parts of Australia that will need more. The problem is there’s a narrow pursuit of growth and then of course it’s measured by gross domestic product with all its flaws that we could talk about, I mean very, very well-known flaws, even within the heart of government and economists will admit GDP is a very flawed measure of progress, the problem is that the pursuit of growth in and of itself without asking those questions, and as we were talking about earlier without seeing it as a means rather than the ends in and of itself, means we take all sorts of problematic choices, so it can bring about, well, selling off government assets, turning a beautiful park into a car park, but actually what might have been better for public health, to keep that park full of trees and places to play and run around and have community activities, and yet selling it into a carpark will increase economic growth.

Gretchen: So the thing is there, so the implication is the more money we have the healthier we will be, and in fact, that does play out, it’s true, if you’re wealthy, when you don’t have enough money your health suffers, when you do have enough money you’ve got far more access to services, but I wonder if you could work in then the leapfrog idea, and in relation to health, in fact?

Katherine: Yeah, so the point is if you don’t have enough you need more, particularly wealth and resources, and that applies to the individual level but also to the country level as well, but the evidence is that beyond once the individuals, but also for countries, once that growth has been used to address the basic needs, then the benefits of growth in terms of social progress start to tail off. So you can see, just to give one example, a country like Costa Rica and a country like South Korea have very, very similar levels of attainment in something called the social progress index, and the social progress index measures a whole wide range of various dimensions of social progress, literacy rates, gender equality life expectancy, infant mortality, education levels, all sorts of things that I’d say there that they’re the ends we’re really wanting, and so South Korea and Costa Rica, pretty similar in terms of their level on the social progress index. But South Korea has per capita got about 40,000 more GDP in US dollars than Costa Rica, so they’ve got all this extra GDP economic growth for almost no social progress benefit, and yet, we know also that that will have come with quite a serious environmental footprint as well, because we know there still is a pretty tight correlation between GDP and environmental footprint in all sorts of dimensions, where there’s beginning to start to decouple in some countries to some degree around emissions and carbon but not on the whole wide range of environmental areas, so that’s important to note.

So the idea of leapfrogging, this is to come back to your question is to one, really recognise that there are places in the world, there are places in Australia that need more, so let’s help them get that, and let’s help them use it and work with them and hear what they need more of and make sure it’s on their terms, but the key thing is that growth needs to be used well, it needs to be invested in collective institutions like health systems and educations, it needs to be directed to those who need it most so it’s pro-poor, if you like, and there’s a lot of places where that growth hasn’t been used to invest in those institutions, that make such a difference to people’s health and wellbeing and their ultimate life outcomes, their quality of life. So to give one example, in somewhere like Nigeria they’ve had huge growth in the last few decades in GDP terms, and yet poverty has gone up because that growth has gone to those who already had it, and that’s actually been the story of growth almost in many, many countries, including Australia where, and particularly places like the US where economic growth that has been attained has been captured by those at the top for various reasons that we could go into and talk for a long time about, but it hasn’t been directed to those who need it most, who are seeing their living standards flatline, so it’s not trickling down, this idea of growth trickling down has been debunked, and so leapfrogging, I’m getting there, I promise, the idea of leapfrogging is saying, we know from the story of the UK so profoundly where I’ve just been living, the economic development model they’ve had over the last few decades and longer has come at a huge cost to individuals, it hasn’t delivered for enough individuals, life expectancy of 54, case in point, and it’s come with a huge footprint on the planet, so there must be a better journey, so one, there’s a cautionary tale to be told, don’t follow in our footsteps, but also, instead of following those footsteps could countries, for example, Sri Lanka, Bangladesh, leapfrog to a place where they have enough, but without having to go through this extractive economic model that has caused so much damage to people and planet, that places like the UK, and to a greater extent Australia, have been through, and so what that’s going to require is learning the lessons, but also really celebrating and taking note of inherent knowledge and ideas that come from countries themselves.

There’s no GDP correlation with good ideas of course, so you’d have, for example, in many countries in Latin America this idea of buen vivir, good life, and it’s not about bigger, it’s about good life, and to the extent it’s been writing into the constitutions and national development plans of countries like Ecuador and Bolivia, but what they’ll need to build good lives in the 21^st century is yeah, technology and yes, finance as well to invest in the renewable energy infrastructure and so on, so countries like ours should be helping them make that transition, so can they leapfrog and cut to the chase, rather than having to walk that same pre-sorted, dirty, polluting, damaging to people journey.

Gretchen: People don’t need to walk in exactly the footsteps to gain the benefit of the learnings.

Katherine: I mean there’s a beautiful phrase, I think we quote it in the book, from Frantz Fanon who says ‘Catch up, I don’t want to catch up with the rich, global north, I want to do something better.’ But of course, being able to do that will require countries like ours make ecological room, and I think that’s why this is the belly in the best in this conversation, places like Australia and the UKM and the US and Canada and so on, because they’re still currently using more than their ecological fair share, and so if we care about global justice we have to take a good look at our own use of resources and materials and ecological space.

Gretchen: I’d like to bring in now your book, The Economics of Arrival, and the title suggests, and you argue, that we have in fact arrived, and I wonder what that means then for the way we think about an economy, particularly in relation to public health and chronic disease, what does arrival mean?

Katherine: Yeah, and it’s almost this forbidden question is yeah, are we able to say, or has the journey of growth got a destination, and this is what we’re trying, my co-author Jeremy Williams and I are trying to do is float this possibility of having this conversation. Well maybe in countries that have got plenty of economic wealth, have got a lot of resources, maybe they’re not very good at sharing them yet, so it’s not saying everything is sorted, but it’s opening up the possibility and the permission almost to say well, have we got enough collectively? Okay, yeah, if we look around in Australia I think hard to deny, very, very wealthy country, are we there?

Gretchen: Are we there yet?

Katherine: And surely we can ask that question, and then there’s a very crucial second part to that question is now we can make ourselves at home, and of course, so for example, if you’re going on a car journey to the coast, are we there yet, are we there yet, you get there, you have arrived, but then there’s another task, isn’t there, it’s to make sure everyone’s got a bed to stay at your holiday cottage, for example, to make sure everyone’s got enough for lunch, to maybe do a few repairs around the holiday cottage. Still it’s about improvement, it’s about taking care of each other, it’s about cherishing what you’ve got, and it’s almost, it just feels like this is a conversation we need to allow ourselves to have, it’s not by any means saying if we’ve arrived everything is sorted, because I think arrival is more about resources, do we have enough, and then the making ourselves at home has to be about making sure that we’re sharing those resources much better than we currently do. And so that brings into play questions around how do we distribute resources, so not just about using taxes and welfare to redistribute but asking the question, and there’s this beautiful term, a beautiful concept, the term is a bit clunky, of pre-distribution, so could we design market outcomes where they distribute resources more fairly from the beginning?

So here you’d start to see things like more worker cooperatives, which we know give more power to workers so they have more control over their daily work, more sense of autonomy, more sense of purpose, more sense of dignity, which we know will have also a positive effect on their health as well. And the health example is also pertinent in another way because so often we spend so much on treatment, and we celebrate a big hospital budget as a good thing, and fair enough at the moment the way things are, because acute need is real, but in a way the more we’re spending on in-hospital care, I mean is often a sign of failure, it’s a sign that people haven’t been healthy and supported to live healthy lives where they feel in control and they’re not stressed and anxious where they have a sense of purpose and dignity, and I often wonder wouldn’t it be amazing if we had going into say, a local mayoral election for a town where you could have the mayor saying under my watch we’ll have 1000 fewer acute nurses and 1000 fewer police because people in this town will be healthy and they’ll feel safe. So we still need hospitals but maybe so much effort on tending to avoidable health problems could be averted if we designed our cities, our communities, and through that our economy in a different way.

Gretchen: So that’s that notion of pre-distribution again.

Katherine: Yeah, getting it right first time around, and that’s the essence of the idea in arrival, it’s since becoming known as this idea of the wellbeing economy, where you have the economy designed for human and ecological wellbeing, this idea of getting things right first time around and what sort of economy do we need to deliver that sort of scenario where people have good jobs, where they have enough to live on, where they’ve got good safe homes, where they’re healthy in their homes, all those sorts of beautiful contextual factors, the economy has a very real role in that, as does wealth, but it’s about having enough to do other things, that’s a really crucial aspect.

Gretchen: Yes, and I really love the idea of making yourself at home in the world that we have, and just saying have you got enough to eat, have you had lunch yet. Look, I’m really interested in your background, and I think these are related questions because you mentioned the wellbeing economy, you started life working in social justice and poverty and you came to focus on the economy from there, both of these things obviously remain incredibly intertwined for you, and you’ve set up an alliance called the Wellbeing Economy Alliance, and the Wellbeing Economy Governments or WEGo, and I wonder what these two bodies are designed to do?

Katherine: Yeah, so WEAll, the Wellbeing Economy Alliance, is a multi-stakeholder collaboration of all sorts of different people around the world, lots of Australians and Australian organisations are part of it as well, but it’s essentially anyone who recognises that if collectively we’re going to have a chance at dealing with some of the challenges facing our world we’re going to have to transform the economy, and also, people who want to work with others to bring about that change. So that collaboration is absolutely essential to WEAll, and almost the Wellbeing Economy Alliance abbreviates to WEAll, which is almost the theory of change, by working together through collaboration we can bring about amazing change, and it supports that work, it amplifies the pioneers, it translates a lot of the messages from practice up to policy makers, it helps bolster the connections between all that amazing work that’s being done, whether that’s academics building the evidence base, whether practitioners building that understanding of what’s possible and what needs to happen, whether it’s activists, whether it’s intrapreneurs within government making changes in the corridors of power, whether it’s businesses who are setting up enterprises, where commercial viability, again, is a means rather than the ends in itself, and so that’s WEAll, and then related to that at the same time I sort of instigated something called WEGo, as you mentioned, the Wellbeing Economy Governments partnership, and WEGo is several countries who recognise that in the 21^st century we shouldn’t be measuring success purely through a country’s gross domestic product and comparing one country’s GDP to another, how big is your GDP is the ticket to all sorts of global geopolitical groups, G7, the G20, and so on, even where the headquarters of the IMF is often based on how big a country’s GDPO is. So many global rules and accounting systems established that reinforce GDP, but yet, these governments in their different ways are saying we understand it’s about more than that, we want to put the goals of collective wellbeing, and collective wellbeing is really important, it’s not just on the scale of one to ten how happy are you, it’s about much more quality of life questions. We want to put that into economic policy making, but then they say none of us have all the answers, so we want to learn from each other. So it was established at the end of 2018 officially at an OECD Wellbeing Forum, with Scotland, New Zealand, and Iceland, and I’ll be really honest with you, Gretchen, it was really fragile and very small at the beginning. The following year though, Nicola Sturgeon, who was then leader of the Scottish government, First Minister, she did her TED Talk on WEGo, and I thought that’s going to give it a bit more space, a bit more momentum, and I saw inside the Scottish civil service how her TED Talk bought space for people within there who wanted to push these agendas, so well look, the TED Talk, we can do this more, and then COVID hit, and I also then thought oh, it’s going to be kicked into long grass, they’ll just be focusing on the emergency of COVID, and to my delight, I love being wrong, I was very wrong here, what happened actually was that it really came into its own, because instead of having their policy labs, because you had senior civil servants meeting with each other in these policy labs, instead of waiting till they could all get together face to face, they of course, as everyone did, moved online. So they moved online for these policy labs, they had them more regularly, they were a shared discussion of how do we put wellbeing at the heart of the COVID response, and more governments joined. So Wales and Finland and Canada have since joined. So it’s a really, and those six countries, Canada not quite officially yet but for all intents and purposes they’re there, we just need one more government and then we can call it the WE7, the Wellbeing Economy Seven, it’s a nice challenge to the G7.

Gretchen: Could it be Australia?

Katherine: Well, I’m talking to some people in the Treasury and every so often talking about WEGo, and I think it would be amazing for Australia to be part of that, to show leadership, but also to feel that strength in numbers that these questions aren’t only being asked in Australia, they’re being asked and grappled with and experimented on by governments all around the world, and Costa Rica is another government that I mentioned earlier that’s been part of those conversations, so again it’s not just the high income countries in a GDP sense, there’s lots of other governments that are working on these questions and want to share their experience.

Gretchen: Well it’s very exciting that you are the one that brought all that to bear.

Katherine: I co-founded WEAll, it wasn’t me my own.

Gretchen: You’ve mentioned already systems thinking, and we talked last year with Steve Allender, the Professor of Public Health and founding director of the Global Obesity Centre about systems thinking, and I wondered if you could describe your approach to systems thinking as part of the solution?

Katherine: So I don’t think of myself officially as a systems thinker because I don’t claim to be an expert or particularly, yeah, qualified, it’s more that I find it, the ideas of looking upstream and staying curious to those connections and attentive to the connections, and the root causes of an issue I find very, very compelling. I mean it’s as simple as channelling, as I so often say to folks and to audiences, channel your inner three-year-old and ask but why, but why, why, and why, until we can get to the root causes, really go upstream. So it’s about really challenging to go beyond just symptom by symptom and problem by problem, crisis to crisis, it’s about thinking about people’s needs. It’s also about questioning people’s agendas as well, because then you start to unpick some power dynamics and where people are coming from and don’t take everything at face value, is the economy a means or is it seen as an end in itself as we were talking about earlier, all of that plays into being a good systems thinker, but I think it’s very, very hard to just, not see some of the patterns in our world today, like more and more people sleeping rough, more and more young people who are lonely and committing self-harm, more people who are scared for their future, more environmental crises, more people who can’t afford to put a roof over their head, rich country, and see those paradoxes and not think there is something deeply broken here, it’s not just tweaks of the system we need to do now, we need to go beyond that to really stop playing whack-a-mole and look at the machine that’s driving some of these challenges.

Gretchen: So in terms of those challenges I wonder what they are for creating a more multisectoral collaborative decision-making process to improve health outcomes in Australia. I mean I’m thinking about the Health Minister, many of the policy changes needed to improve health outcomes occur outside his portfolio, so how do health policy makers address the profound challenges that you outline?

Katherine: Yeah, it’s a great question, and I think firstly it comes from naming the fact that some of the impacts are outside the immediate Health System, with a capital H and capital S, and outside the health portfolio, and once you’ve named that then that gives you permission to have conversations and dialogue with colleagues in other departments, and have a look at what service delivery is happening, who is getting those services, how is it undertaken, and it also gives permission to maybe say well, could we share budgets, for example, so things like joint budgets or diagonal budgets or pooled budgets, whatever you want to call them, that’s the sort of thing we need to be doing, and there’s a good example of this starting in Victoria, led by the Victorian Treasury, there’s something called the Early Intervention Investment Framework, so it’s still intervention, so it’s not upstream prevention, so it’s not upstream enough, but it’s starting to say if we can support people from their challenges getting worse there’s going to be pretty real fiscal savings and we can reinvest to do more of it. So it’s a really cracking project, I think cutting edge, of some of the sort of policy changes and different ways of working that we need to see in more government departments.

Gretchen: Before we finish, you’ve just arrived back in Australia, in Canberra, what are you hoping to do now you’re back on home ground?

Katherine: Gretchen, I want to be useful, I’m very conscious I’ve been away for a long ti8me and so how useful I can be I’m not quite sure, but I think I just want to work with others who are wanting to ask these similar questions and have similar conversations and who are wanting to push the envelope of the conversations happening in Australia around the need for and the possibility of economic system change. So I’m working with two Australian organisations at the moment, the Centre for Policy Development and The Next Economy as part of their different programs of work that ultimately, I’m trying to just stay a little bit humble at the moment and to not sort of swing in and say I’m back, I’m here, but really just listen to what’s happening and learn what works already going on and just take my time to figure out where I can add value and where the time overseas might be useful for different efforts that are already happening here.

Gretchen: Bringing all of that experience across, that international experience will be so valuable and hopefully Australia will get drawn into some of those international projects as well. I just want to thank you for a fantastic discussion, we really could talk all day, I think this will be an extended interview for Prevention Works, it’s going to be very hard to edit. Thank you so much, Katherine, for your time today.

Katherine: Such a pleasure, it’s been really fun chatting to you, and thanks so much for your interest and all your questions, and such a fun conversation.

Gretchen: Dr Katherine Trebeck. You can find links to Katherine’s work on The Australian Prevention Partnership Centre’s website. Do leave us a review and let your friends and colleagues know about us. I’m Gretchen Miller, this is Prevention Works, we’ll catch you next time.

[End of recording – 56:15]