Introduction
Australian government inquiries and their respective reports are a feature of Australia’s approach to evaluating and making recommendations to improve the performance of emergency management systems. Contemporary knowledge of the impacts of disasters and their causal factors has evolved beyond the event-based focus of traditional emergency management practices to a risk-based approach that encourages broader understanding and identification of risks associated with disasters. This approach has been further refined by the World Health Organization (WHO) with the development and implementation of the Health Emergency Disaster Risk Management (HEDRM) framework.Reference Murray 1 Nevertheless, while people’s health is recognized as a key factor in determining the risks and outcomes of disaster events for individuals and communities, inquiries conducted in response to such events lack a deeper investigation into the health status of the communities affected. Common ground lies in understanding how determinants of health are related to the risk factors of disasters. A focus on both social determinants and on people’s health would bolster action aimed at reducing exposures and vulnerabilities, enabling communities to apply their strengths, resources, and assets; and targeting health outcomes—a key objective of disaster risk management. Actions to improve public health builds community resilience, such resilience enables people and communities to “resist, absorb, accommodate, adapt to, transform and recover from the effects of a hazard in a timely and efficient manner, including the preservation and restoration of its essential basic structures and functions.”Reference Murray, Abrahams and Adballah 2 Consideration of the social determinants of health and how they relate to the disaster risk experiences by populations or individuals’ vulnerability to disaster is a novel and potentially complementary method of understanding disaster risk and resilience.
The overarching objective of this paper is to critically assess the integration of social determinants of health within Australian governmental disaster inquiry recommendations from 2007 to 2020. The aim of this research was to examine whether Australian disaster inquiries made recommendations to act on improving social determinants of health. These research findings extend beyond observation to actively contribute to policy and practice by proposing recommendations for improvement.
The social determinants of health are defined as “the conditions in which people are born, grow, live, work and age, including the health system.”Reference Wilkinson and Marmot 3 They include the principles of action and action objectives as described in Table 1. 4
Social determinants of health principles of action and action objectives [Reference Murray1]
The extent to which these determinants are addressed can lead to a diverse and dynamic range of health outcomes. When these determinants are not addressed well or without a focus on reducing inequities, there are consequences of poor health, wide inequities and disparities. Conversely, effective and equitable promotion and support for social determinants of health can also yield higher standards of health and well-being for all. The differences in health status observed between populations are a complex web of factors that are influenced by these determinants such as the uneven distribution of wealth, power, policy and program priorities, and inequitable access to health services within and across populations. At the same time, health status is a risk factor for other social determinants, including poverty and levels of educational attainment across genders.Reference Fothergill 5 , Reference Fothergill and Peek 6 The practical implications of integrating social determinants of health into disaster management are profound. Such an approach would enable more targeted actions aimed at reducing exposures and vulnerabilities, thereby strengthening communities’ capacities to apply their inherent strengths, resources, and assets. By addressing the root causes of vulnerability, this research aims to inform policy and practice in a way that leads to more effective and equitable disaster preparedness, response, and recovery, fostering healthier and more resilient societies.
Method
An evaluation of all Australian Government disaster inquiry recommendations between 2007 and 2020 was undertaken to determine what, if any recommendations support action on the social determinants of health utilizing the “overarching recommendations” as described by Commission on Social Determinants of Health, 2005-2008. 4 The Social Determinants of Health are widely recognized as a framework for identification of causal drivers of health and well-being. 4 As such they were selected as the reference standard for recommendation assessment:
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• Improve daily living conditions: This principle focuses on the immediate circumstances of people’s lives, including housing, food security, education, and safe environments.
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• Tackle the inequitable distribution of power, money, and resources: This addresses the structural drivers of health inequities, such as macroeconomic policies, urbanization policies, and governance structures that perpetuate disparities.
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• Measure and understand the problem and assess the impact of action: This emphasizes the need for robust data, a skilled workforce trained in social determinants of health, and public awareness campaigns to effectively monitor and evaluate interventions. 4
Each recommendation from each inquiry was individually assessed to identify whether it explicitly referenced the overarching recommendation or if the recommendation intent included action objectives as described in Table 1. This dual approach allowed for the identification of both direct and indirect alignment with social determinants of health principles, providing a nuanced understanding of their integration within inquiry outcomes. The analyzed disaster inquiry recommendations included:
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• Operation Recovery Task Force 7 (7 recommendations)
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• 2009 Victorian bushfires Royal CommissionReference Teague, Pascoe and McLeod 8 (67 recommendations)
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• 2010-11 Flood Warnings & ResponseReference Comrie 9 (93 recommendations)
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• A Shared Responsibility. The Report of the Perth Hills Bushfire February 2011Reference Keelty 10 (55 recommendations)
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• 2012 Queensland floods commission of inquiryReference QFCo 11 (189 recommendations)
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• 2013 Tasmanian Bushfires InquiryReference Hyde 12 (103 recommendations)
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• Hazelwood Mine Fire InquiryReference Inquiry 13 (18 recommendations)
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• Royal Commission into National Natural Disaster Arrangements 14 (80 recommendations)
Results
Between 2007 and 2020, 8 disaster inquiries were conducted with a total of 612 recommendations across the inquiries.
Of the 8 reports, only 120 of 612 recommendations (19.6%) showed alignment with the social determinants of health principles of action. A more detailed breakdown of this alignment across the 3 overarching principles is as follows:
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• Improve daily living conditions: 48 recommendations (7.8%) demonstrated action in this area.
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• Tackle the inequitable distribution of power, money, and resources: This principle saw the highest number of aligned recommendations, with 59 (9.6%).
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• Measure and understand the problem and assess the impact of action: Only 13 recommendations (2.1%) aligned with this principle, indicating a significant gap in the focus on evaluation and understanding of social determinants of health impacts.
A summary of recommendations per inquiry that aligned with the social determinants of health overarching principles is shown in Table 2.
Summary report of inquiry recommendations that aligned with the social determinants of health overarching recommendations
Discussion
The finding that only 19.6% of recommendations from Australian disaster inquiries between 2007 and 2020 aligned with social determinants of health principles is indicative of a significant underrepresentation of these critical factors. This low proportion suggests a systemic oversight as the profound influence of social factors on disaster vulnerability, impact, and recovery would suggest a substantially higher integration of social determinants of health considerations into inquiry outcomes. This limited alignment reflects a persistent disconnect between the evolving understanding of disaster risk and the traditional focus of governmental inquiries. Historically, disaster practice in Australia has concentrated on event-based emergency management and response operations. This emphasis has often led inquiries to focus predominantly on operational failures, such as communication breakdowns, governance structures, and immediate response. Consequently, the terms of reference for these inquiries, and the expertise brought to bear, may not have explicitly mandated or deeply explored the underlying social and systemic factors that predispose certain populations to greater harm. When inquiries are primarily tasked with examining operational aspects, their recommendations naturally gravitate toward improving those operations, rather than addressing the deeper social inequities that amplify disaster impacts.
The consequence of this low integration is that disaster responses and recovery efforts, while potentially efficient in logistical terms, may remain less effective in addressing the root causes of vulnerability. This perpetuates cycles of inequity, leading to disproportionate impacts on marginalized groups and potentially hindering long-term community resilience. Such approaches represent a critical missed opportunity for policy intervention that could build more equitable and robust communities capable of withstanding future events.
Measure and Understand the Problem and Assess the Impact of Action
The inquiries varied in their scope, focus, and intent, and the extent to which community expectations have or have not been met, or calls for government accountability from both the public and the media, are factors in the commissioning of inquiries. There is limited understanding of how these inquiries promote, preserve, and improve the health status of communities that have experienced disaster impacts. Health, as defined by WHO, is the “complete state of physical, mental and social well-being.” 15 This definition identifies that health is not simply the absence of disease but the composition of multiple inputs to create a complete state of well-being. This construct has been further developed as reflected in the definition of the social determinants of health as “the conditions in which people are born, grow, live, work and age, including the health system.”Reference Marmot 16 It is postulated that the differences in health status observed between populations are a result of uneven distribution of wealth, power, and/or policy that influence these determinants. Flage and Aven anticipated emerging global societal risks that have eventuated, including pandemics and infectious diseases; chronic diseases in the developed world; greater economic inequality; breakdown of critical infrastructure; rapid shifts in demographic patterns; and unsustainable world population growth.Reference Flage and Aven 17 The findings of this study are consistent with that policy and research focus on understanding causal factors of risk related to vulnerabilities and strengths. Further, these show the potential of social determinants of health as a useful framework to inform the terms of reference and conduct of disaster inquiries and other forms of evaluation.
A critical examination of Australia’s approach to conducting governmental disaster inquiries reveals a notable absence of a single, consistent, overarching regulatory framework or standardized methodology specifically designed to evaluate the impacts of disasters. While broader frameworks exist, such as the Australian Disaster Preparedness Framework 18 and the National Strategy for Disaster Resilience, 19 these primarily guide national strategies for preparedness and risk reduction rather than dictating the specific conduct and scope of inquiries themselves. For significant events, Royal Commissions, such as the Royal Commission into National Natural Disaster Arrangements, are established under specific legislative acts like the Royal Commissions Act 1902, with their own bespoke Letters Patent and terms of reference. 20 However, these mechanisms for major incidents do not constitute a standardized methodology applicable to all disaster inquiries or a methodology for integrating a public health lens. Notably, Australia does possess methodologies for assessing social impacts in other governmental contexts. For instance, the Social Impact Assessment Guidelines, used for state-significant projects in New South Wales and Queensland, provide a robust framework for identifying, predicting, and evaluating the social impacts of major developments and for developing appropriate responses.Reference Parsons, Everingham and Kemp 21 –Reference Holm, Ritchie, Snyman and Sunderland 23 These guidelines demonstrate that the capacity and expertise for systematic social impact analysis exist within Australian governmental processes. Given that such methodologies are not explicitly or consistently applied to disaster inquiries themselves represents a significant opportunity. Adapting or developing similar, mandatory guidelines specifically for disaster inquiries, informed by public health principles, would provide valuable input that is currently lacking. This would enable inquiries to move beyond a purely operational focus to address the underlying social conditions that dictate disaster vulnerability and recovery.
While the focus of this study was based on Australian inquiries, international research to explore the linkage between the social determinants of health and disaster risks and impacts has also been undertaken. Biedrzycki and Koltun reviewed three case studies (Hurricane Katrina, BP oil spill, and H1N1) in relation to how impact was related to elements of the social determinants of health. Examples of economic status relative to health care behavior, where poverty was associated with low vaccination status; unemployment rates associated with the BP oil spill were associated with increased domestic violence; and minority populations associated with chronic illness and increased susceptibility to infection, all demonstrated the connection between social determinants and outcomes in disaster settings.Reference Paul and Raisa 24
Tackle the Inequitable Distribution of Power, Money, and Resources
This study found that the highest number of recommendations across inquiries aligned with the overarching recommendation of “Tackle the inequitable distribution of power, money, and resources.” A systematic review conducted by Nomura et al explored the intersection of disaster vulnerability and social determinants of health and proposed action upon identified themes to improve community resilience.Reference Norris and Stevens 25 Such action aligns with Nomura’s research showing that the effects of disasters disproportionally affect groups with higher levels of vulnerability within communities.Reference Marmot, Friel, Bell, Houweling, Taylor and CoSDo 26
Effective risk communication with communities was a feature of recommendations assessed in this study. This appeared to be associated with recommendations related to communication between government agencies and communities, their roles in engaging communities in disaster risk management (in particular, preparedness and response actions), and evaluating the roles, functions, and decision-making powers of government leadership and agencies. These recommendations also support previous findings that maintaining trust and mitigating fracturing of communities during and after disasters is achieved by timely, factual communication from leadership.Reference Chandra, Williams and Plough 27 , Reference Vernberg, Hambrick, Cho and Hendrickson 28 These findings are consistent with Norris and Stevens, who describe communication as a key element of communities’ adaptive capacities to risks posed by disasters.Reference Norris and Stevens 25
Marginalized populations due to income levels, gender, age, disability, ethnicity, religion, or sexual orientation are at greater risk from the impact of a disaster.Reference Marmot, Friel, Bell, Houweling, Taylor and CoSDo 26 , Reference Christoplos, Mitchell and Liljelund 29 Twigg reported that marginalized and disadvantaged groups suffer the worst from disasters.Reference Twigg 30 Those who are already at social or economic disadvantage are less able to undertake risk reduction measures, are at greater risk of experiencing disproportionate effects, and face greater challenges to recover. Such vulnerability, associated with underlying social and economic status, is described as the “the human dimension of disasters,” resulting from physical, social, economic, and environmental factors, which are also drivers of poor health.Reference Marmot 16 , Reference Twigg 30 This finding is consistent with Rodriguez-Llanes et al’s research, which identified lack of social support, female gender, prior traumas, resource loss, human loss, and poor physical or mental health as likely indicators of psychological resilience to disasters.Reference Rodriguez-Llanes, Vos and Guha-Sapir 31
Improve Daily Living Conditions
Poverty has been found to be a key driver and consequence of disasters, and those suffering poverty will remain so or worse following a disaster.Reference Hallegatte, Vogt-Schilb, Bangalore and Rozenberg 32 The unequal distribution of wealth and the increased vulnerability to adverse impacts of disasters have been identified by Naser-Hall, who advocates for poverty reduction pre-impact to mitigate disaster effect.Reference Naser-Hall 33 Research conducted by Winsemius et al. also reported that people experiencing poverty are disproportionally exposed to natural disasters caused by floods and droughts.Reference Winsemius, Jongman and Veldkamp 34 Lindsay provided an analysis of the determinants of disaster vulnerability, finding that “income and social status are the pivotal factors in determining disaster vulnerability,” and recommends “Britton and Walkers typology of vulnerability.”Reference Lindsay 35 Plough et al. make the connection between those communities that experience disparities during non-emergency times and the need to build resilience, which in turn can strengthen a community’s ability to rally from disasters.Reference Plough, Fielding and Chandra 36 Some of these impacts may be buffered by local community support and social connectedness, which have been previously explored by Lacoviello et al in reference to the impacts of disaster. Their findings showed that supportive social networks increase an individual’s resilience, and, importantly, enhancement of them pre-disaster impact had a positive effect on mitigating psychological trauma post-event. Findings of land scarcity as possible drivers suggest the need for developmental policies and land use planning that protect those experiencing poverty.Reference Iacoviello and Charney 37 Frameworks that enhance attention on the causes of socioeconomic inequities and challenges may be of use for consideration in future disaster inquiries.
Significant barriers in accessing basic needs by older persons have also been reported, which can exacerbate challenges faced by older persons in preparing and responding to disaster. Research investigating the impacts of Hurricane Katrina on this age group found differences in risks in disasters compared to the community they reside in. Identified challenges included physical and psychological health barriers and the inability to evacuate without assistance in preparation, transportation, and pet care.Reference Campbell 38 –Reference Rosenkoetter, Covan and Cobb 40 Further to this, specific social determinants of health related to financial status, mental health, and their relationship to disaster impacts have also been investigated. Norris et al. found that populations with low socioeconomic status are at greater risk of mental health consequences following a disaster, due to feelings of lack of self-worth and income stress.Reference Norris and Stevens 25
Findings made by Arnold related to resilience concluded that individual characteristics of mental health and higher intelligence contribute to developmental competence.Reference Arnold 41 , Reference Arnold 42 Sameroff, however, has noted that the effects of such competencies do not overcome the effects of high environmental risk.Reference Sameroff and Rosenblum 43 Such findings are of value in that risk factors identified hold commonality between health and disaster risk management and present a rationale for consideration of health determinants when recommending actions to improve disaster resilience. This complements research conducted by Lindsay, who recommends aligning disaster risk management with social determinants of health planning and a population health approach.Reference Lindsay 35 Such intent is consistent with the emphasis in the Sendai Framework for Disaster Risk Reduction on preventing the creation of new risks and reducing existing risks by addressing underlying risk drivers of all types of disasters. 44
This study observed variance in the investigation process between inquiries and the areas of expertise of commissioners and other investigators, an absence of clear frameworks for consistent evaluation across inquiries, including the criteria for establishing an inquiry, and inconsistent identification of the social determinants of health and recommendations related to health status across inquiries. Public health practice, as an evidence-based means of inquiry and action, can provide guidance to systematically investigate the underlying causes and impacts of disasters. Eburn’s review of lessons learnt and recommendation implementation related to Australian disaster inquiries and commissions found inconsistency between reviews, a lack of clarity on whether recommendations had been implemented, and if they had, to what effect they created change.Reference Eburn 45 Utilization of public health practice and the social determinants of health frameworks may assist in determining priority action to improve disaster risk management if applied through future inquiry processes. There are opportunities to further integrate social determinants of health in disaster risk management and to engage key actors and professions in emergency management systems in Australia, and those responsible for commissioning and conducting evaluations, including disaster inquiries, in applying public health practice.
The effectiveness of disaster inquiry recommendations is fundamentally contingent upon their implementation and evaluation. As highlighted by the 2009 Victorian Bushfires Royal Commission, a recurring challenge in Australia is that “the recommendations of previous inquiries have not always been implemented.” 46 This historical pattern of non-implementation is a critical barrier to achieving concrete improvements in disaster management and community resilience. When recommendations, particularly those that implicitly or explicitly touch upon social determinants of health, are not acted upon, the underlying social inequities that drive disaster vulnerability persist or worsen. This creates a detrimental feedback loop: disasters expose existing vulnerabilities, inquiries may identify and recommend addressing these, but if those recommendations are not implemented, the vulnerabilities remain. Consequently, communities, especially marginalized groups, continue to experience disproportionate impacts in subsequent disaster events. This perpetuates a cycle of harm and hinders the development of long-term resilience.
For recommendations to translate into tangible, positive change, their importance and intended impact must be clearly articulated, and robust mechanisms for tracking and enforcing their implementation must be established. Without a clear mandate and a robust system for monitoring and accountability, even well-intentioned recommendations are likely to remain aspirational rather than transformative.
There are substantial opportunities to further integrate social determinants of health into disaster risk management and to engage key actors and professions in emergency management systems in Australia. Public health practice, with its foundation in evidence-based inquiry and action, offers a powerful framework to systematically investigate the underlying causes and impacts of disasters. By applying public health principles, inquiries can move beyond superficial observations to uncover the deeper societal factors that contribute to vulnerability and influence recovery trajectories.
The utilization of social determinants of health frameworks can significantly assist in determining priority actions to improve disaster risk management. This is particularly relevant given the emphasis in the Sendai Framework for Disaster Risk Reduction on preventing the creation of new risks and reducing existing risks by addressing underlying risk drivers. 44 Integrating social determinants of health into the terms of reference for disaster inquiries could enable a deeper understanding of the multifaceted drivers of community risk, encompassing not only hazards but also exposures, vulnerabilities, and capacities. By systematically incorporating public health expertise and social determinants of health perspectives, Australian disaster inquiries can transition from merely identifying problems to fostering comprehensive, health-equity-focused solutions that contribute to the creation of healthier, more resilient societies.
Recommendations
Based on the analysis of current practices and identified gaps, recommendations are proposed to enhance the integration of social determinants of health into Australian governmental disaster inquiries. This aims to ensure that future inquiries contribute more effectively to building resilient and equitable communities.
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• Establish a clear regulatory mandate requiring all governmental disaster inquiries to explicitly include the assessment of social determinants of health as a core component of their terms of reference. This would ensure that inquiries systematically address underlying social vulnerabilities, moving beyond a sole focus on traditional emergency management operations.
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• Develop a national framework for robustly tracking the implementation and impact of disaster inquiry recommendations, with a particular emphasis on those related to social determinants of health. This framework could involve regular public reporting, designated oversight bodies, and clear performance indicators.
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• Develop and implement a national guideline or handbook for conducting disaster inquiries that incorporates a standardized methodology for assessing impacts and informing recommendations. This methodology could draw valuable lessons and adapt frameworks from existing Social Impact Assessment guidelines used for other governmental projects.
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• Mandate the inclusion of public health experts, particularly those with specialized knowledge in social determinants of health and health equity, on disaster inquiry panels and investigative teams.
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• Invest in comprehensive training programs for inquiry commissioners, investigative staff, and relevant government officials on social determinants of health concepts, their direct relevance to disaster risk, and practical methodologies for assessing social impacts.
Limitations
This study was limited to Australian disaster inquiries and reviewed the recommendations only. No evaluation of implementation (or not) of the recommendations has been assessed, or to what extent implementation has contributed to better health and well-being.
This study analyzed recommendations against the social determinants of health overarching recommendations as described by the Commission on Social Determinants of Health, 2005-2008. Further analysis of the underlying action objectives of these principles may provide more detailed insights into specific determinants such as gender, age, disability, ethnicity, and access to services.
Variance in terminology definitions, for example, the term “resilience” is used with different meanings in different contexts. Application of standardized evaluation to inform the development of recommendations and the overall design and conduct of Australian disaster inquiries was not evident.
Conclusion
This study investigated the extent to which social determinants of health were evidenced within the recommendations of selected Australian disaster inquiries. Despite the recognition of specific social determinants of health, such as poverty and gender diversity, as risk factors for disasters, comprehensive review and incorporation of wider social determinants of health is yet to be fully integrated in the understanding and actions to reduce disaster risk. The analysis revealed that only 19.6% of recommendations demonstrated alignment with social determinants of health principles, highlighting a significant systemic gap in current Australian disaster inquiry practices.
A key area where this understanding of social determinants of health can be applied is in government inquiries into disasters. The social determinants of health offer a consistent public health-informed approach to guide future inquiries, ensuring identification of recommendations that support action on social drivers of risk and reinforce a focus on improving health outcomes for all, particularly marginalized groups who experience disproportionate impacts of disasters. The integration of a common and consistent approach to inquiries that utilize agreed definitions, measures, and indicators is important to achieve robust investigation, analysis, findings, and recommendations for synergistic action.
Competing interests
None.
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