How can we use the law to help improve our health?

When a lot of Australians think about public health law, they think about the “nanny state”. However, we have laws to thank for a lot of the policies we take for granted today, such as gun control, pool fencing regulation, seat belt use and bike helmet legislation. In this episode of Prevention Works, host Gretchen Miller talks to Janani Shanthosh, Research Fellow in Health Economics and Law at the George Institute for Global Health, and PhD candidate with the Prevention Centre, about how we can use the law to improve our health in the future.

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Episode: How can we use the law to help improve our health? 

Jan Shanthosh: In the Australian public, people are very surprised to hear law framed as a public health tool. There’s a certain cultural aversion to the law and it’s rarely seen as something that can produce a social good.

Gretchen Miller: Hi, this is Prevention Works, a series of conversations all about the prevention of chronic disease. I’m Gretchen Miller and I’m thoroughly enjoying meeting some of Australia’s top researchers to talk about their work with The Australian Prevention Partnership Centre. The Prevention Centre brings together researchers and policy makers who are working to find new ways to prevent Australia’s greatest health challenge, lifestyle related chronic disease.

Jan Shanthosh: I’m Janani Shanthosh. I’m a Research Fellow in health economics and law at the George Institute for Global Health and a PHD candidate with The Australian Prevention Partnership Centre.

Gretchen Miller: Janani is working to look at shortfalls in existing public health law. Surveying where it’s working and where it isn’t. And in this episode, we’re talking about the way the law can and does intersect with population health as well individuals’ health; how it’s brought about changes we all now accept as given, and how we can better use the law to improve our health in the future.

Out on the street we tend to think of the law as a bit of a blunt instrument. You know, law tends to mean doing something wrong and going to court and it’s combative. But, of course, the law is a much finer implement than that and I’m wondering how the use of L – A – W law brought about some of the behaviours we take for granted.

Jan Shanthosh: Actually, in Australia we’ve had a strong and a fruitful history of implementing effective public health laws – Australia’s gun control system, minimum ages of purchase for alcohol and tobacco, pool fencing, child restraint laws – that have saved lives, prevented injury and are responsible for our standard of living here in Australia.

Gretchen Miller: You’ve written that there’s a failure of policy to address national health. These are quite strong words. What’s falling between the cracks?

Jan Shanthosh: I think the first thing to note is we don’t have a culture of evaluating public policy. On a very simple level we know that public policy and public health law is failing us in Australia because despite our relative wealth we do have an epidemic of chronic disease, and part of the reason for that is that we have policies that often come about very quickly without the ideal evidence base behind them. Sometimes this is because of industry and lobbying influence, not being able to implement policies that we know work, that are World Health Organization ‘best buy’ interventions like controls on the availability of alcohol. And at other times policy makers and researchers aren’t sort of co-producing research questions to answer and very expeditiously produce evidence about how public health laws are working, if they’re not working, why they’re not working, what the unintended consequences are. And so, that’s what I really mean by saying that public policy is failing us.

Gretchen Miller: But what is interesting is that quite a number of the public health laws that you’ve mentioned have become quite successful. I guess they’re the ones that we get to hear about. There are others that are less so.

Jan Shanthosh: Because they’re measurable.

Gretchen Miller: They’re easily measurable.

Jan Shanthosh: Like smoking rates. But I suppose, with public health law program, a point we’d like to make is that there are so many other areas where it’s completely ambiguous as to how laws are working or if they’re working.

Gretchen Miller: So, you’ve done some real-world research on local governments and alcohol, but before we go there let’s quickly look at the background at some alcohol laws we’ve seen implemented in say the last 30 years.

Jan Shanthosh: Sure, the interesting thing with alcohol is that alcohol has been around forever and a day, but the world’s changed, societies have changed. So, with alcohol, in Australia for example, we’ve had legal interventions like a minimum age of purchase. We have a licensing system, an ever-revolving licensing system. So, random breath testing and mobile RBT’s are very well known in Australia for deterring people from drinking and driving. That’s one of our most well-known interventions, I think, in Australia. Another less well-known intervention is states like Victoria banning powdered alcohol pre-emptively. So, that’s what I mean when I say that industries are evolving to provide new products all the time and subsequently our laws need to, as living systems, need to respond to that to protect public health.

Gretchen Miller: Some of the legal challenges to public health problems are actually the community, it comes from that level. Tell me a little bit about the community of Shoalhaven.

Jan Shanthosh: Yeah, so it’s a south-eastern coastal local government area in New South Wales. Within Shoalhaven there is the community of East Nowra and that’s a community that we came across in one of our studies where having faced some of the highest rates of domestic violence in the state, harmful alcohol use, child neglect and abuse, fetal alcohol spectrum disorders. So, the community of Easy Nowra in Shoalhaven already had a high density of liquor outlets in that community. And so, they got together – social services, police departments, recovering addicts and other individuals in the community got together – and decided they didn’t want a new liquor outlet. Which was one that was proposed, it was a 1500 square meter liquor outlet reportedly cost around three million dollars to build. And so, fearing for a compromise in the health and wellbeing and safety of that community they got together and opposed that liquor outlet, working with their local government, Shoalhaven City Council, to reject the Dan Murphy’s proposal.

Gretchen Miller: This is really interesting because you’ve got a community effectively in strife, was already vulnerable from the effects of both poverty and alcohol, and I imagine some of the stakeholders wouldn’t have been on very friendly terms, you know. The community itself with police and social services aren’t always on each other’s sides and yet they work together. How did they do that?

Jan Shanthosh: I think when it comes to the health of communities, particularly our children and young people, you and I and most Australians are willing to work together with other stakeholders to achieve that purpose, and that’s exactly what we saw in this community that really cared for the health and wellbeing of all citizen and didn’t want their current standard of living to become worse. Ultimately unsuccessful of course.

Gretchen Miller: The outcome wasn’t good and they didn’t win because, by law, the courts can’t take into account social impacts, only whether there’s commercial competition.

Jan Shanthosh: It is difficult for public health arguments to be successful and that is because there isn’t explicit room made for in legislation to consider health impacts on communities. There are limited provisions for social impact, but much of the frustration of addiction clinicians and other health professionals, that is very ambiguous as to what social impacts means considering it’s very rarely a successful argument.

Gretchen Miller: But, the evidence is stark isn’t it? That there’s a direct correlation between the proximity of a bottle shop and people’s health. And if we were to illustrate that on a map what would it look like?

Jan Shanthosh: Sure, I mean it’s important to make the point that every community is different but there is a growing amount of evidence that shows higher density communities, and when I say high density I mean liquor outlets and alcohol venues, there is poorer health. And so, one of the studies that has come out, that was produced by The Australian Prevention Partnership Centre and an academic called Hannah Badland, showed that people who do not have a liquor outlet within 800 meters of their home say their health is better than those that do. So, studies like that and it’s an increasing area of interest with alcohol policy experts. Growing evidence suggests that where there is a higher alcohol availability people’s health is poorer. And yet in low socioeconomic areas are more likely to have higher rates of liquor outlets despite the disproportionate rate of chronic disease that they often experience.

Gretchen Miller: So, this is where public health law could really make a change?

Jan Shanthosh: We definitely think so and there’s a plethora of examples within Australia and outside of Australia. Limits on alcohol availability have been advocated for at the highest levels at the United Nations by the World Health Organization time and time again as a best buy, effective and cost-effective intervention.

Gretchen Miller: You’re with Prevention Works, a podcast of The Australian Prevention Partnership Centre with Jan Shanthosh, Research Fellow at the George Institute for Global Health. And stay with us as we discuss the progression of the way Australians react to the imposition of laws that are good for public health. We can be rather resistant to begin with.

Jan Shanthosh: I have to say that we’ve seen research come out looking at a spike in aversion to public health law and ‘nanny state’ arguments come up as soon as public health law is implemented. Years down the track, surveys have shown that people are very accepting of those laws. Particularly where they see health and social outcomes improved. Another thing to remember is that every time we implement public health laws – a sugar tax or greater restrictions on alcohol availability – industries will respond quite often negatively to restrictions on their ability to do business and profit making. And we see the same sorts of ‘nanny state’ arguments come out and also arguments about encouraging competition and employment. You mentioned bike helmets, that’s a really interesting one. Bike helmet legislation came in between 1990 and 1992 and since then many advocates have argued that bike helmets have saved people from obtaining brain injuries.

Adults have become a role model for children. Professor Rebecca Ivers, who is the director of injury at The George, makes the argument that children will only wear helmets if they see adults wearing helmets. On the flip side, anti-helmet legislation advocates make the argument that in Europe, in some countries in Europe, they don’t have these restrictions.

Gretchen Miller: And then there are more people riding?

Jan Shanthosh: Sure, sure. I guess importantly in Australia, we don’t know when the more people would ride if helmet legislation were to be repealed. It’s been an argument made, but there hasn’t been any convincing evidence that bike helmet legislation reduced the amount of people that would get on their bike. And another thing to consider is that when people are asked what the barriers are to getting on their bike as a mode of transport and leisure, helmet use falls way below infrastructure for cycling. So, that’s a huge difference between some European cities and Australia where we don’t have a very advanced sophisticated cycling network and we’re all a little bit scared to get on the road, particularly on the busy roads. And so, it’s important to put all these factors in perspective when we think about arguments for and against bike helmet legislation.

Gretchen Miller: Let’s talk a little bit about the way laws can be different according to communities. Tell me about what happened in the Northern Territory with the mandatory treatment laws and it sounds like those laws should have quite effective and quite good. The idea being that if you keep getting apprehended for drunken behaviour you get three months treatment and then, you know, you’re sort of rehabilitated and you’re back on the street. What went wrong with that law and what’s happened to it?

Jan Shanthosh: Well, as communities have said time and time again, culture needs to be infused with any kind of health care when it comes to Aboriginal and Torres Strait Islander people.

Gretchen Miller: So, you need to take culture into account?

Jan Shanthosh: Absolutely and cultural acceptability as well. It’s quite important that health care is led by Aboriginal and Torres Strait Islander peoples. So, I mean, the Mandatory Treatment Act allowed for legally sanctioned deprivation of liberty, taking away a person’s choice to be rehabilitated. So, I think the problem with that- and a lot of doctors and the medical community, health professionals, came out rejecting the Mandatory Treatment Act because of this, because it was providing treatment under situations where vulnerable individuals were being detained and it’s important to recognize that many would argue it would never accept those kinds of provisions in Sydney, in other metropolitan areas. But it was implemented in a community that had little say over it, the way that it was implemented as well. Subsequently, it didn’t work and it was repealed and I think a lot of the frustration from communities, particularly Aboriginal and Torres Strait Islander communities, is that we have this sort of haphazard chopping and changing of Aboriginal Policy. Often recommendations by the community aren’t taken into account and then you have laws like the MTA, the Mandatory Treatment Act, that are implemented and subsequently repealed. The community is no better off than it was before.

Gretchen Miller: So, not only the community but in fact people with experience, the service providers, also rejected this law. So, it was really all the expert voices and the community voices didn’t want it and in the end it failed.

Jan Shanthosh: That’s exactly right.

Gretchen Miller: So, to bring law into public health in a less ad hoc and a more effective way, what do you feel needs to happen?

Jan Shanthosh: I think there’s a number of things that need to happen. I think we need genuine investments into public health law research. It needs to be somebody’s core business to be evaluating public health laws so we know if they work, where they work, what the unintended consequences are. And so, that evidence can then go and inform laws to make them better and more robust and future-proof, if you like.

I think another thing that needs to happen is that people trained in the law and legal research need to be working with public health people. Public health research is best done when it’s multidisciplinary. I think my PhD and a lot of other public health law research happening in our program has shown that those that are legally trained and public health professionals can work together very effectively, produce meaningful results that have the potential to improve the health of Australians.

I think another thing that needs to happen is that policy makers and researchers need to work together to co-produce research questions and co-produce evidence. So, what I mean by that is that policy and law is not made in isolation to evidence. Part of the reason that there sometimes isn’t a sufficient evidence base for lawmaking is that public health researchers work, sometimes, in isolation from policy making. So, what we need to do is both be generating public health law research – quality, rigorous public health law research – and foster a culture of policy makers engaging with that evidence. So, using language that policy makers understand and part of that will be finding methods that allow us to expeditiously produce evidence and inform law reform, which can be a very tight window. So, it’s a difficult but an ambitious goal, but I think very possible.

Gretchen Miller: That takes time, that research. So, what can be done concurrently, as well, to get some of those essential laws into our public health system?

Jan Shanthosh: Sure, I think on a very basic level, what’s important to Australian society is important to governments. So when Australians decide and communities decide that public health law is important, particularly effective acceptable public health law, it will become important to policy makers. We will see investments in public health law research and we will see a greater engagement with high quality rigorous public health law research.

Gretchen Miller: Jan Shanthosh, thanks so much for introducing us to your work. All the best for getting that PHD finished and I look forward to hearing what happens next.

Jan Shanthosh: Thank you so much for having me.

Gretchen Miller: Jan Shanthoshspeaking with me, Gretchen Miller, for Prevention Works, a podcast of The Australian Prevention Partnership Centre. And if you’d like to hear more head to our website preventioncentre.org.au

Do like us on iTunes, leave us a review and let your friends and colleagues know about Prevention Works. See you next time.

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Host: Gretchen Miller
Music: The Zeppelin by Blue Dot Sessions

creative commons license for music