3.1 Contemporary health inequalities

Significant health inequalities exist both between and within countries, with social inequalities responsible for a major part of these inequities (World Health Organisation Commission on the Social Determinants of Health 2008, 1). It should not surprise, then, that health disparities occur on a gradient from the ‘have-leasts to the have-mosts’ (Burris Reference Burris2011, 1652). As the landmark World Health Organisation Commission on the Social Determinants of Health (2008, 1) explained, the poor health of the poor is:

Social Determinants of Health (SDH) research has produced compelling data on the links between social inequalities and the distribution of poor health since the 1990s (Marmot et al Reference Marmot, Smith, Stansfeld, Patel, North, Head, White, Brunner and Feeney1991; Marmot et al Reference Marmot, Goldblatt, Allen, Boyce, McNeish, Grady, Strelitz, Geddes, Friel, Porritt, Reinertsen, Bell and Allen2010; Wilkinson and Marmot Reference Wilkinson and Marmot1999; Wilkinson and Marmot Reference Wilkinson and Marmot2003). As noted, these inequalities should be a significant concern because of intrinsic harm, the way they limit opportunity and participation, and because these effects are frequently intergenerational (Aizer and Currie Reference Aizer and Currie2014). Yet, health inequalities also indicate other inequalities and social injustices, with health providing a measure of social and economic progress. As Fabienne Peter (Reference Peter2001, 159) notes, ‘[T]he more unequal a society, the worse its achievements in… health’. Sridhar Venkatapuram (Reference Venkatapuram2011, 21) provides a broad account of why we should be concerned about health inequalities:

This underscores the fact that our concern for health should not be reduced to how well health services function (Thomson Reference Thomson2022), but rather we need to attend to ‘the conditions in which people are born, grow, live, work, and age, and the inequities in power, money, and resources’ (Marmot et al Reference Marmot, Allen, Goldblatt, Herd and Morrison2020). Notwithstanding decades of empirical evidence, and the practical and theoretical frameworks this has generated, Amartya Sen has nevertheless been able to correctly note that ‘given what can be achieved through intelligence and humane intervention, it is amazing how inactive and smug most societies are about the prevalence of the unshared burden of disability’ and ill-health (Sen Reference Sen2010, 261).

In terms of this unshared burden, while at times income and poverty have been a disproportionate focus (Ingleby Reference Ingleby2012), the importance of factors such as gender, race, disability, and their intersection are now more often recognised. So, increasing attention is being paid to why, for example, some minoritised ethnic groups suffer from disadvantage in each of the social determinants, leading to a racial patterning of health inequalities (Marmot et al Reference Marmot, Allen, Goldblatt, Herd and Morrison2020, 7). While structural racism has been identified as a ‘fundamental cause’ of racialised health inequalities (Williams et al Reference Williams, Lawrence and Davis2019, 107) – and racism identified as a public health crisis (Paine et al Reference Paine, De La Rocha, Eyssallenne, Andrews, Loo, Jones, Collins and Morse2021) – it has remained a relatively minor concern in research and practice. This may, however, change in the wake of COVID-19 and its impact on wider understandings of how ‘ethnoracialised differences in health outcomes have become the new normal across the world’ (Yaya et al Reference Yaya, Yeboah, Charles, Otu and Labonte2020). In illustrating the ‘colour of health’ so starkly, the pandemic has drawn attention to structural racism – and structural gendered racism (Pirtle and Wright Reference Pirtle and Wright2021) – and the intersection with the social determinants framework (Marmot et al Reference Marmot, Allen, Goldblatt, Herd and Morrison2020). This, in turn, has highlighted the historic origins of the institutional discrimination and resource inequalities that drive contemporary racialised health inequalities.

3.2 Historic origins of today’s health inequalities

Gendered and racialised health inequalities have their structural causes in long-standing patterns of inequality that intersect. In terms of racialised health inequalities, this can be linked to practices of colonialism and its ongoing legacies in ‘racially codified economic and social inequality’ (Wilkins Reference Wilkins, Winterdyk and Jones2019, 8). Thus, social stratification is intimately linked to racial and ethnic diversity and, in particular, to practices of large-scale immigration, oppression of Indigenous groups by settlers and slavery (Ingleby Reference Ingleby2012). In terms of the SDH framework, Zinzi Bailey, Justin Feldman and Mary Bassett (2021, 769) argue that the multiple domains where structural racism affects health can all be characterised by three central features: that is, the ‘harms are historically grounded, involve multiple institutions, and rely on racist cultural tropes’.

Complimenting a social determinants approach, a number of fields of knowledge have emerged to attempt to provide the biological mechanisms that link past harms with current health inequalities. Of note is the field of social epigenetics (Lewis and Thomson Reference Lewis and Thomson2019; Thomson Reference Thomson2023), with its focus on the impact of environmental or social factors – such as pollution, neglect, abuse, racism, malnutrition, income and educational attainment – on the epigenome (McKevitt et al Reference McKevitt, Pinel and Prainsack2019). Here, epidemiological and laboratory studies are interpreted as evidence that experiences of discrimination, disadvantage and trauma can become part of our genetic ‘memory’ (Meloni and Testa Reference Meloni and Testa2014). In this, the research domain traces the contours of the social determinants of health, with social epigenetic studies linking inequalities in key determinants with a greater burden of ill-health and higher mortality rates. These studies address the epigenetic impacts of historic and contemporary social inequalities that can have their origin in colonial practices and abuses. In this, they challenge any bright line drawn between past, current and future generations.

In illustrating the complex temporalities and aetiology of health inequalities, Jonathan Wells’ work linking inequalities in contemporary cardiovascular risk and the legacies of colonialism provides an important example (Wells Reference Wells2020). Wells has coined the term ‘metabolic ghetto’ to describe the cardiovascular effects at population level, and across generations, of experiences of sustained malnutrition (Wells Reference Wells2007). Wells focuses on the effects of nutritional deficits experienced under conditions of colonial rule. As he writes: ‘When one population systematically exploits another population, the resulting loss of maternal capital can expose a population of foetuses to a disadvantaged niche,… a metabolic ghetto’ (Wells Reference Wells2020, 11). Drawing on anthropometric data, Wells argues that undernourished mothers in colonial contexts consistently give birth to low-birth-weight babies. This is epigenetically mediated, and it is argued that it ensures offspring do not exceed ‘maternal capital’ and are adapted to low-nutrient environments. Such responses are ‘likely to boost survival in early life under harsh conditions, but at the cost of contributing to the persistence of small size and low metabolic capacity across generations’ (Wells Reference Wells2020, 12). Low-birth-weight infants typically experience poorer health outcomes. These intergenerational effects are not ameliorated by sudden improvements in nutritional availability. Indeed, increases in body weight from higher levels of nutrition (particularly of the cheaper, low-quality and higher-fat foods available to poorer populations) mean that ‘metabolic capacity’ (what the vital organs can deal with) can be overcome by ‘metabolic load’ (the demands of large tissue masses, a high-calorie diet, and limited exercise) (Wells Reference Wells2020, 2). In this, Wells brings together epigenetic, behavioural and physiological plasticity. These compounding and intergenerational effects offer an explanation of contemporary health inequalities and how they are shaped by interrelated historic and contemporary inequalities (Wells Reference Wells2020, 13).

3.3 Future health inequalities in a changing climate

Recognition of the relationship between health inequalities and social inequalities has directed attention to the interconnection of human and environmental health, whereby contemporary and future health are not only shaped by past and current social inequalities but are also increasingly shaped by human destruction of our ecosystems. Human and environmental health are intimately linked – with environmental determinants of health interacting closely with a variety of social inequalities (World Health Organization 2020). The connections between climate change and health impacts are increasingly clear. The Intergovernmental Panel on Climate Change (IPCC) 2023 Synthesis Report noted that climate change has already adversely affected the physical and mental health of people globally (IPCC 2023, 16). It explained that ‘climate change impacts on health are mediated through natural and human systems, including economic and social conditions and disruptions’ (IPCC 2023, 16). In terms of natural systems, this ranges from human morbidity and mortality resulting from extreme heat events to the increase in water- and food-borne diseases. Increasing temperatures, trauma from extreme events and loss of livelihoods and culture are driving increased mental health challenges. With human systems, air pollution has increased, with urban heating and infrastructure being disrupted. These impacts and disruptions strain already inadequate health services.

The IPCC Report points to profound inequalities that will worsen the impacts of climate change for some populations. As the Report details, the most susceptible are those in regions that face ‘considerable development constraints’ and those in ‘locations with poverty, governance challenges and limited access to basic services and resources, violent conflict and high levels of climate-sensitive livelihoods’ (IPCC 2023, 17). The Report also notes that ‘vulnerability at different spatial levels is exacerbated by inequity and marginalization linked to gender, ethnicity, low income or combinations thereof’ (IPCC 2023, 17). As discussed in the preceding section, these inequalities are in many regards historic in their origins. As the crisis escalates, this will compound and deepen inequalities that have been experienced by some populations for generations.

Climate change is acknowledged as an existential threat, yet it sits amongst other environmental crises that have collectively provoked a concern for planetary health. Addressing planetary health, the Rockefeller Foundation–Lancet Commission (Whitmee et al Reference Whitmee, Haines, Beyrer, Boltz, Capon, de Souza Dias, Ezeh, Frumkin, Gong, Head, Horton, Mace, Marten, Myers, Nishtar, Osofsky, Pattanayak, Pongsiri, Romanelli, Soucat, Vega and Yach2015, 1973) concluded that economic and development gains have been pursued at the cost of the health of future generations:

This is an important statement on the relationship between planetary and human health, with climate and environmental damage positioned as the key threat to future human health. However, in suggesting equally enjoyed global health gains that are now equally threatened by unsustainable use of resources leading to climate change and environmental depletion, the Commission repeats the narrow understanding of inequality that we seek to challenge. Climate change and many of the environmental harms listed by the Commission are both unequal in their origin – the product of disproportionate extraction and consumption by high-income countries – and unequally experienced by the ‘have-leasts’ and the ‘have-mosts’ (Burris Reference Burris2011, 1652). Many parts of the global South are facing more extreme impacts with less capacity to respond to climate and environmental harms. Within wealthier countries, climate change disproportionately affects poor people, the elderly, people with disabilities, women, Indigenous peoples and minoritised racial groups. The growing incidence of extreme climate events, including heatwaves, flooding and fires, more often affects poor people, who are less able to protect their property, livelihoods and lives. More routine and increasing climate impacts such as higher temperatures often affect poor neighbourhoods in cities, where housing is inadequate and heat management such as tree cover is absent. Such urban segregation is, of course, often historic in both cause and experience.

Overcoming structural inequalities at the local and global levels is clearly necessary to achieve the interlinked goals of climate and health justice (Williams and MacNaughton Reference Williams and MacNaughton2021). Addressing the rights of people living now by tackling key environmental drivers of ill-health, such as pollution, improves the prospects of healthy environments for future generations. In this way, tackling inequalities now has cross-temporal impacts on future rights holders. But sustainable responses to resource use must align with efforts to provide adequate nutrition, healthy neighbourhoods, accessible health services and other essential components of good human health rather than expect the poor to sacrifice these goods long overused by wealthy nations and groups. A focus on health inequalities, past, present and future, illustrates our argument that supporting the rights of future generations cannot occur without confronting the complex historical and contemporary inequalities that are embedded in the lives and bodies of humans. It also requires us to acknowledge that our health is entirely dependent on the health of the non-human world. This requires, as Donna Haraway (Reference Haraway2016) has argued, that in seeking solutions for the future, we ‘stay with the trouble’ of living together on our damaged planet.

4.1 Revisiting the Capabilities Approach

Amartya Sen, Martha Nussbaum, and others have developed the Capabilities Approach in four decades of work (Nussbaum and Sen Reference Nussbaum and Sen1993; Nussbaum Reference Nussbaum2000; Sen Reference Sen and McMurrin1980, Reference Sen1992, Reference Sen1999, Reference Sen2010). The approach focuses on what is required to foster individual opportunity or freedom and – through this – human well-being and flourishing. For advocates of the Capabilities Approach, the central question in assessing a society for its basic decency or justice is, ‘What is each person able to do and to be?’ (Nussbaum Reference Nussbaum2011, 18). As such, social justice is conceptualised in terms of people’s capabilities or opportunities. This can be expressed as their ‘effective opportunities to undertake the actions and activities that they want to engage in, and be whom they want to be’ (Robeyns Reference Robeyns2005, 95).

The driving concern for this approach is the social and institutional structures within which individuals are embedded and the extent to which this either enables or limits opportunities and therefore flourishing (Dreze and Sen Reference Dreze and Sen2002, 6). Centring this embedded individual as the object of ethical concern reflects the approach’s genesis as a counter-theory to models of welfare or development that rely on aggregated measures of well-being or on proxy measurements such as gross domestic product (Sen Reference Sen2010, 48). As Sen states, the Capabilities Approach ‘proposes a serious departure from concentrating on the means of living to the actual opportunities of living’ (Reference Sen2010, 233). In focusing on opportunities or capabilities, an important element of the approach is the attention paid to factors that influence the ability of individuals to convert resources into functionings; that is, to achieve what they want to ‘do and to be’ (Nussbaum Reference Nussbaum2011, 18). These conversion factors address the social, institutional, structural and environmental conditions that prevent or enable an individual’s capacities to become effective opportunities and freedoms. These range from law, social and environmental factors ‘to the most specific resources and skills needed to exercise freedoms’ (Hart and Brando Reference Hart and Brando2018, 298).

The Capabilities Approach has been subject to criticism within liberal philosophy (Pogge Reference Pogge, Brighouse and Robeyns2010) and by theorists on the left (Dean Reference Dean2009), including those who raise important feminist critiques (Okin Reference Okin2003; Phillips Reference Phillips2001). Concerns include its focus on opportunity and freedom over equality of outcome (Kanbur Reference Kanbur, Chiappero-Martinetti, Osmani and Qizilbash2020; Phillips Reference Phillips2001). The place of the individual within the approach has also generated criticism. It is argued that the central place of the individual contributes to the failure to acknowledge structural inequalities within the capitalist economic and political systems (Phillips Reference Phillips2001). It is also argued that the individualism of the approach elides relationships of care as well as the values of solidarity and community (Dean Reference Dean2009). Others, however, have questioned whether these criticisms correctly identify the nature of the individual articulated by Sen, Nussbaum and others or recognise the approach’s primary focus on structural barriers to human flourishing and social justice (Thomson Reference Thomson2021). As Ingrid Robeyns (Reference Robeyns2005, 95) notes, in challenging proxy measures of human well-being, Sen’s is an ‘ethically or normatively individualist approach, but it is neither ontologically nor methodologically individualistic’; and thus that a commitment to the individual as the object of ethical concern ‘is not incompatible with an account of personhood that recognises the connections between people, their social relations and their social embedment’. Elsewhere, the Capabilities Approach has been endorsed by some who see its radical liberal promise as consistent with more structural approaches, including in relation to human rights (Balakrishnan et al., Reference Balakrishnan, Elson and Heintz2011; Fredman Reference Fredman2008).

Mindful of these debates, we engage with the approach by acknowledging its flexibility as a normative language and its long history of practical application, including within the UN (Deneulin Reference Deneulin, Cornia and Stewart2014). We also acknowledge that the approach is inherently future-focused (Poli Reference Poli2015). It is directed at creating the conditions that enable future decision-making and agency, a central concern of discourses and practices directed at future generations. It is also significant that health has been central in its genesis and development, and we focus on the capability to be healthy. In doing so, we extend current formulations of this capability to more explicitly and fully acknowledge the importance of the non-human world and planetary health. We use the approach as an example to argue that embodying generations in this way is essential to secure health equity and – through this – a more just present and future. Engaging with the Capabilities Approach in this way provides an important example of how our ethical models must be ecologically reorientated as we respond to threats to planetary health.

4.2 Capabilities and health

With our focus on health, it is important to map the multidimensional relationship between health and the Capabilities Approach. In terms of the approach’s principal architects, Nussbaum has sought to articulate a set of central capabilities for any democratic order. Her ten central human capabilities start with life, bodily health and bodily integrity (Nussbaum Reference Nussbaum2011). For Sen (Reference Sen, Agarwal, Humphries and Robeyns2005, 377), while he has refused to articulate a fixed list – or ‘grand mausoleum’ – of capabilities, he has repeatedly included health in his articulation of intrinsically valuable or basic capabilities. This has been built upon in work that has identified health as both a meta-capability and a subset of all capabilities (Venkatapuram Reference Venkatapuram2011). Here, health is identified as central to people’s ability to realise their capabilities; it enables people to do and to be what they have reason to value, pursuing life projects and goals.

Yet in the development of the approach, capabilities have also been identified as essential for health. Thus, the approach has been central to social determinants of health research and its theoretical development. Michael Marmot’s foundational work on health inequalities draws on the approach to argue that the control individuals can exercise over their environments is a key determinant of health outcomes (Marmot Reference Marmot2004). Greater control is provided by increasing the capabilities people have; that is, the opportunities they may choose from in determining their life course. The approach has provided a normative framework to understand and address health and other inequalities. Thus, Sridhar Venkatapuram identifies capabilities as central to achieving health justice, arguing that every human being has a moral entitlement to a capability to be healthy commensurate with equal human dignity in the contemporary world (Venkatapuram Reference Venkatapuram2011, 19). This entitlement is to the social bases of this capability. Identifying four factors that determine health – individual biology, individual behaviour, the physical environment and social conditions – the moral claim translates to social interventions into these factors in order to create a capability to be healthy that enables equal human dignity (Venkatapuram Reference Venkatapuram2011, 19).

4.3 The capabilities of future generations

A number of scholars have addressed the potential role of the Capabilities Approach in securing the rights of future generations. Rutger Claassen (Reference Claassen, Bos and Düwell2016b), for example, sees the approach applying intergenerationally through sustainable use of the earth’s resources by engaging a principled response to ecological impact. Alternatively, Nicky van Dijk (Reference van Dijk, Linehan and Lawrence2021) has argued that the Capabilities Approach is helpful in thinking about the well-being of future people in terms of their opportunities rather than in terms of their resources, income, desires or happiness. In proposing a draft set of capabilities, she considers the views of current people as a proxy for future generations but acknowledges that any approach – whether current or future-focused – must take account of human diversity, agency and indeterminacy.

While this work is important in orienting the Capabilities Approach towards future-oriented policy-making, it needs to go further in situating its human subjects within their ecological context. We argue that an eco-social reframing of capabilities is essential to acknowledge the indivisibility of human and planetary health as well as the non-instrumental rights and interests of non-human entities and ecosystems. Here, it is important to note that the Capabilities Approach can be understood as ‘protoecological’ in conception (Thompson and Bendik-Keymer Reference Thompson and Bendik-Keymer2012, 17). Nussbaum, for example, identifies the capability for having relationships with ‘plants, animals, and the world of nature’ as one of the ten central human capabilities to which citizens have as an entitlement (Nussbaum Reference Nussbaum2011). In a similar vein, Venkatapuram’s capabilities-driven model identifies the physical environment as one of the four underpinnings of health and health justice. The physical environment is therefore essential for the realisation of other capabilities. Articulating nature and the physical environment in this way is an important shift in acknowledging that our flourishing depends on the non-human world. It can, however, be seen as instrumental and limiting. This is also seen in the recent United Nations General Assembly (2022) resolution on the right to a clean, healthy and sustainable environment. While it may serve to ‘green’ human rights, it may also extend the anthropocentric notion that the environment must be protected for our benefit or survival, not for its own sake.

Bringing concern for the environment together with the rights of future generations, similar instrumental arguments are made elsewhere in the capabilities scholarship. Fabian Scholtes (Reference Scholtes2010), for example, addresses how the irreversible loss of environmental resources will limit the agency and well-being of future generations. Actions taken now will determine how resources are used, foreclosing the ways in which future generations might use these resources in ways they may value. This ‘environmental domination’ conflicts with the approach’s central goal of enabling people to lead the kinds of lives they have reason to value. Breena Holland develops this within Nussbaum’s framework, arguing that climate change will undermine the ‘ecological conditions for justice’. These are met when each person has a threshold level of each of the capabilities necessary for a good life and when ecological systems are such that they provide the resources to support these capabilities (Holland Reference Holland2008). Mirroring arguments regarding health, Holland (Reference Holland2008) identifies this capability as a meta-capability.

Such approaches conceive of the environment’s value in relation to human capabilities. It is a familiar ‘ecosystems services’ (Duraiappah Reference Duraiappah2005) or ‘ecological capital’ (United Nations 1987) model. While we acknowledge the significant shift in situating humans within the environment, the Capabilities Approach, as with other embodied theories, should account for posthuman and other theories that recognise the intrinsic worth of the non-human as well as ecosystems and our relational position within these. Nussbaum (Reference Nussbaum2006, Reference Nussbaum2023) is a firm proponent of the rights of non-human species. As with humans, it is individual animals that are the bearers of capabilities. Nevertheless, this means that care for ecosystems is again derivative, depending on whether or how such systems are necessary to promote the good of (human or animal) individuals that rely on them. While the individualism of the Capabilities Approach is intended to put the individual – rather than gross domestic product or other proxies for human development – at the centre of ethical concern, it has limitations in considering the inherent value of ecosystems and other aspects of the non-human world (Bendik-Keymer Reference Bendik-Keymer, Chiappero-Martinetti, Osmani and Qizilbash2020). In response, David Schlosberg (Reference Schlosberg2007, 148) argues for a systems approach that recognises the dynamic interdependence of life forms. He argues for conceptualising ecosystems as ‘living entities with their own integrity’. Following this, addressing health and ecological justice through a capabilities lens demands recognition of the potential of an ecosystem ‘to maintain its integrity, and to flourish’ (Schlosberg Reference Schlosberg2007, 148). This eco-social re-imagining of the Capabilities Approach demonstrates how it is both necessary and possible to rethink our ethical and legal frameworks in considering our responsibilities to future others as environmental degradation and the climate crisis deepen. We explore our arguments further in the next section, where we critically consider Australia’s introduction of its first well-being framework.

4.4 Responding to Measuring What Matters: The Capabilities Approach, health and future-oriented policy and law

A central motivation for the Capabilities Approach was as a challenge to measures of well-being that rely on a state’s aggregated production or wealth (Sen Reference Sen2010, 48). Such measures ignore the profound inequalities that can persist, or indeed deepen, as a nation’s production or wealth increases. In this, the Capabilities Approach has provoked the development of alternative measures, starting with the UN Human Development Index in 1990. More complex systems of measurement have since been adopted nationally and supranationally, with a focus on frameworks that have a closer bearing on people’s lives. The Organisation for Economic Co-operation and Development’s (OECD) Better Life Initiative is an example of how these frameworks have evolved, with a focus on four central dimensions: natural, social, human and economic capital (OECD 2020). This framework has been recognised as a leading example of where the resources or dimensions of future well-being are identified ( Sangha et al., Reference Sangha, Dinku, Costanza and Poelina2024, 15). In Australia, the Federal Treasurer recently published Measuring What Matters (Commonwealth of Australia 2023) based on the OECD framework and similar models that go beyond economic indicators to include broader well-being measures such as environmental and social outcomes. Through a process of public consultation, five well-being themes were adopted as Australia’s first well-being framework: health, security, sustainability, cohesion and prosperity. Inclusion, equity and fairness were identified as relevant across all five themes (Commonwealth of Australia 2023).

The government acknowledged that the new framework is a starting point, with the framework process identified as iterative. Importantly, while it has been initially conceived as a measurement tool, it is stated that ‘the Government will also consider ways to better link policy decisions with consideration of wellbeing metrics and the broad set of considerations captured in this Framework’ (p. 5). More generally, the Government has set out the aspiration that it ‘will underpin the broader efforts of business, community groups and others, to deliver better outcomes and opportunities for Australians’ (p. 5). As such, it is imagined that the content of the framework will be revised and that it will move from a measurement tool to a statement of values to guide decision-making.

While Measuring What Matters is an important and welcome advance in embedding well-being into an integrated framework across government policy in Australia, our discussion generates ways in which planned future iterations may be improved, both through a clearer articulation of the rights of future generations and through renewed attention to the Capabilities Approach. Turning to our first concern, the initial framework already has, at times, an implicit future orientation. For example, in discussing early childhood, it recognises that appropriate interventions shape children’s whole lives and that the effects can extend for generations (p. 90). Securing environmental rights also acknowledges future generations, as decisions must attend to the future impacts of decisions made now. More directly, the framework recognises that Australia must ‘anticipate, manage and adapt’ to climate ‘risks’ (p. 53). Nevertheless, we would argue that the next iteration of the framework needs to explicitly acknowledge the rights of future generations. This has recently been seen elsewhere in Australia where a Private Member’s Bill introduced by Federal Senator David Pocock attempts to create a duty of care owed to young people to prevent future climate harms (Pocock Reference Pocock2023).

As already noted, Measuring What Matters has its genealogical roots in the Capabilities Approach through the move to human-centred measurement frameworks that the approach provoked. Nevertheless, we argue for a renewed consideration of the approach in future iterations to strengthen the framework’s potential impact. We see this in returning to our central focus on environment and health. The framework explicitly identifies the connection between the environment and health in its sustainability theme (p. 45):

This statement provides an important potential foundation for the approach we advocate; that is, that future-oriented law-making should be made within an eco-social framework that promotes health equity. This, we have argued, can help to address past harms, tackle present-day inequalities and help to promote a future that is more equitable. This has a particular resonance for Australia’s colonial past and the enduring harms it has created. This has provoked some to articulate Indigenous capabilities (Yap and Yu Reference Yap and Yu2016), which we see as consonant with the eco-social model we have promoted. Further, Sangha, Dinku, Costanza and Poelina (Reference Sangha, Dinku, Costanza and Poelina2023) argue for recognition of Indigenous capabilities within Australian measurement frameworks. More specifically, they argue for Indigenous capabilities that reflect the centrality of nature – and specifically Country (Indigenous clan lands) – for well-being and health (p. 15):

They argue that such capabilities would contribute to addressing the stark health – and other – inequalities that exist between Indigenous and non-Indigenous Australians. These are the products of an ongoing legacy of colonial dispossession, genocidal policies and entrenched inequalities. The Australian Government has recognised that colonisation continues to have a devastating impact on Indigenous communities, culture and health (Australian Institute of Health and Welfare 2022):

Health inequities experienced by First Nations people have been a focus for government policy intervention since the first National Aboriginal Health Strategy in 1989. Nevertheless, this and other interventions such as the landmark Closing the Gap initiative – a national programme introduced in 2009 to address significant health and other inequalities experienced by First Nations people (Australian Government 2009) – are seen to have achieved little (Davis Reference Davis2015; Bond and Singh Reference Bond and Singh2020). After more than thirty years of policy attention, Indigenous Australians continue to die nearly nine years earlier than non-Indigenous Australians. Other key indicators are ‘flatlining or going backwards’ (Schultz Reference Schultz2020, 11). As Parter and colleagues stress (Reference Parter, Murray, Mohamed, Rambaldini, Calma, Wilson, Hartz, Gwynn and Skinner2021), ‘What has been missing from these policy commitments is the genuine enactment of the knowledges that are held by Indigenous Australians relating to their cultural ways of being, knowing and doing’.

Attention to Indigenous capabilities – that is, valuing and enabling Indigenous ways to ‘do and to be’ (Nussbaum Reference Nussbaum2011, 18) – is essential. We see these capabilities as deeply significant in foregrounding human embeddedness in the natural world. Indigenous capabilities in relation to Country are directly related to well-being and health. They also impact other determinants of health such as education and employment (Schultz Reference Schultz2020, 12–13). While this can help to address colonial dispossession and the injustices that have continued since that time, it is important to note that a focus on Country has the potential to deliver environmental benefits for all Australians, current and future. This is important, as Australia continues its steady decline in country rankings that measure action taken towards the Sustainable Development Goals, from 18th in 2015 to 40th in 2023 (Sustainable Development Report 2023).

Looking more globally, Indigenous care of Indigenous lands is a significant factor for worldwide conservation and therefore planetary health (Garnett et al Reference Garnett, Burgess, Fa, Fernandez-Llamazares, Molnar, Robinson, Watson, Zander, Austin, Brondizio, Collier, Duncan, Ellis, Geyle, Jackson, Jonas, Malmer, McGowan, Sivongxay and Leiper2018). Indigenous approaches challenge instrumental understandings of nature and ecosystems – as seen with the OECD’s ‘natural capital’ model that inflects Measuring What Matters – to acknowledging the inherent value of the non-human. This is echoed in Schlosberg’s (Reference Schlosberg2007, 148) development of the Capabilities Approach to frame ecosystems as ‘living entities with their own integrity’. This argument for bringing eco-social Indigenous capabilities into Australia’s first well-being framework responds to the many calls for greater attention to be paid to Indigenous knowledges regarding our ecological situatedness, as well as our relationship to time, both past and future (Watson Reference Watson2014; Yunkaporta Reference Yunkaporta2019; Redvers et al Reference Redvers, Poelina, Schultz, Kobei, Githaiga, Perdrisat, Prince and Blondin2020; Moreton-Robinson Reference Moreton-Robinson, Hokowhitu, Moreton-Robinson, Tuhiwai-Smith, Andersen and Larkin2020).

Measuring What Matters provides an example of how the Capabilities Approach can impact governmental action through the development of human-centred measurement frameworks. We have, however, highlighted the need to more explicitly develop the framework’s future orientation and have argued for a renewed engagement with the Capabilities Approach as the framework is developed. Importantly, in mobilising this Australian example and engaging Indigenous capabilities that we understand as eco-social, we illustrate how attention to the complex temporalities of health inequalities can provide a lens through which to address past harms and current inequalities while the rights of future generations are protected and promoted.