Super size me: is a big Australia good for our health?

The Rudd government has stated that it intends to increase the population of Australia. It is estimated by Treasury that the number of Australian citizens will reach 35 million by 2049. The federal government has identified that, to meet the challenge of the increasing population, major cities will have to increase their urban density. For this reason, the federal government has recently hinted that it is considering taking the initiative, and might extend its responsibilities to include housing development, land release and infrastructure — functions currently controlled by state and local governments.1

Prime Minister Rudd has been quoted as saying “I actually believe in a big Australia. I make no apology for that. I actually think it’s good news that our population is growing”.2 The previous leader of the opposition also welcomed a larger Australian population.2 But not everyone is as positive about the high rates of immigration, and the Secretary to the Treasury, Ken Henry, has questioned whether Australia has the necessary infrastructure in place to meet the influx.3

As there is bipartisan agreement on the advantages of increased migration to Australia, it is time for a debate on how “super sizing” will affect the health system.

The reason federal politicians support the migration drive is that it is believed to make good economic sense. A recent report praised Australia’s overall population growth of 1.9% in 2008, and credited it as being the reason why Australia fared so much better than other developed countries during the global financial crisis.4 In simple economic terms, more people means more customers, which results in more jobs.

While it might be favoured by economists, there is debate about whether a population-charged increase in gross domestic product (GDP) actually results in a better standard of living for Australians. Although Australia’s GDP has grown by 23% over the past 7 financial years, the GDP per capita has grown by less than half of that. So although economists, businesspeople and politicians extol the effects of population growth on GDP, it is debatable whether Australians really are better off, as this is only possible if the GDP is growing faster than the rate of population increase.3

It has been projected that total health expenditure (in 2002–03 financial year dollars) will increase from $71.4 billion in 2002–03 to $162.3 billion in 2032–33. This increase in annual growth would be 0.5% above the overall predicted economic growth rate. It was recently noted that governments will either need to accept this increase in annual GDP expenditure being allocated to health care (resulting in less money being available for other portfolios such as education and defence), or they will need to introduce cost-saving initiatives to curb the blow-out in the health budget.5

In the short term, a boom in Australia’s population might hold economic advantages, but in the long term, we as citizens will have to pay for this expansion. This will probably be in the form of higher taxes to put the necessary health, energy, food and transport infrastructure in place to accommodate a bigger Australia.

Australia’s major cities will have to accommodate the influx of immigrants.

Increasing urbanisation is associated with higher rates of obesity, asthma and depression, unless it is accompanied by appropriate town planning that provides adequate pedestrian amenities, limits pollution, ensures public safety, encourages social cohesiveness and allows access to fresh food.6

The aetiology of schizophrenia and related disorders is affected by environmental factors. The risk of developing schizophrenia has been found to increase linearly with increasing urbanisation of environments in which children live. It has also been found that some immigrant ethnic groups have a higher risk of developing schizophrenia than native-born individuals.7

A recent study that investigated the effect of living in an area close to a green space analysed self-reported indicators of physical and mental health. It found that the annual prevalence rate of some disease clusters was lower among those who had more green space available to them. Examples of disorders with lower prevalences were heart disease, diabetes, chronic neck and back pain, asthma and migraine. There was a very strong correlation between lack of green space and depression and anxiety disorders. The relation between health status and having green space close to home was particularly strong among children and people in lower income groups.8

The impact of “urban sprawl” (poorly planned growth of low-density housing on the edge of a city, lacking the requisite public transport and other infrastructure that encourages car use and discourages physical activity) in Sydney was investigated in another study. It found significant correlations between urban sprawl and the likelihood of being overweight or obese and having inadequate physical activity.9

The importance of town planning and development and the health of communities has been substantiated by another Australian study. The study found that the “walkability” of a neighbourhood (an index which measures factors that are thought to encourage walking, such as dwelling density, street connections and land-use mix) was negatively associated with television viewing time in women. It is known that physical inactivity is a major risk factor for type 2 diabetes, cardiovascular disease and some types of cancer.10

The need for reform to ensure that capital cities are able to meet the challenges of population growth and demographic change was acknowledged at the Council of Australian Governments meeting held at the end of 2009.11 It will require close collaboration between federal and state governments to ensure that the necessary infrastructure changes are provided for, so Australian cities expand in a way that minimises the adverse health consequences associated with increasing urbanisation. These infrastructure changes would need to be made in several areas, including public transport, waste management and other aspects of town planning. Although the migration drive is being instigated federally, it is the state governments that have to deal with the practicalities of Australia’s growing population. These two tiers of government will have to start paying more than lip service to how the needs of future new Australians will be met.

Even if the population begins to grow more rapidly as a result of immigration, the proportion of people over the age of 65 years will continue to rise. This is due to sustained low fertility combined with increased life expectancy. By 2056, one in four Australians will be over the age of 65 years.12

It has been acknowledged that one of the major health care challenges facing Australia is the ageing population and the resultant increased burden of chronic illness.6 The health services of a super-sized Australia will therefore have to deal with a greater burden of chronic diseases.

The Garling inquiry concluded in 2008 that the New South Wales health system is in a state of crisis.13 This finding also applies to the rest of the states, with the possible exception of Victoria.14

An independent analysis by the Australian Medical Association has concluded that Australian public hospitals are dysfunctional, operating at full or above-full capacity, and urgently in need of increased capital funding. An important finding was that major metropolitan teaching hospitals operate on a bed occupancy rate of 95% or above. The report noted that hospital overcrowding was the most serious cause of reduced patient safety.15

It is clear that, even at Australia’s current population of only about 20 million people, the public health system is struggling to cope with demand. Changes will be required to deal with a vastly increased, yet still ageing, population and the attendant multiple comorbidities, many attributable to increased urbanisation.

Practical measures might include disinvestment (reallocating health resources from existing practices, procedures, technologies, and pharmaceuticals that do not deliver much health gain for their cost); investing in prevention; increasing the health workforce; and emphasising community health. Other measures might include increasing the role of practice nurses and expanding the role of pharmacists.

The increasing pressure on health services as a result of increased immigration might provide further motivation for a move to a single level of funding, with the federal government taking over responsibility for hospitals from the states. At the very least, this might end the “blame game” and cost-shifting that currently blights the system.

In his 2004 documentary Super size me, Morgan Spurlock suffered severe adverse health consequences after a 30-day period of eating super-sized meals at McDonald’s.16 Prime Minister Rudd’s vision of a super-sized Australia, while it might have some short-term economic benefits, will put further strain on the health system.

The plan to dramatically increase the population of Australia has to be debated and critically evaluated, and a population policy must be developed. In particular, health care professionals must engage with the federal government to ensure that it commits to and delivers on comprehensive national health and hospital reform, matching its appetite for unfettered, economically expedient migration to this country.

If this is not done, we — the citizens of a “big Australia” — will all, like Spurlock, suffer the damaging health consequences of super sizing.