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Social inequality is toxic to our health

The government report released last week, optimistically titled Australia the Healthiest Country by 2020, offering the National Preventative Health Strategy managed to avoid any acknowledgement of the toxic effects of inequality. The report recognises that economic inequities go with health differences but fail to recognise that the inequalities are themselves causal.

Last week I attended a session in Sydney with Richard Wilkinson, co-author of a range of reports that show that social inequality within nations is toxic. Wilkinson’s latest book, The Spirit Level, follows a decade plus of work, on health and other social statistics which is widely accepted but not by governments.

This is the core interesting message in Wilkinson and Pickett’s latest book and their websit www.TheEqualityTrust.com. Remedies need to address people’s perceptions of lack of control over their lives and wellbeing to address poor social and health outcomes.

The Health Sociology Review special issue on the Social Determinants of Child Health and Wellbeing states:

With the growing evidence of the impact of social inequalities on health, policy makers in all countries are showing an increased interest in understanding them and in seeking ways to create more equitable societies.

The importance of this trend is charted in two editions of Social Determinants of Health by Michael Marmot and Richard Wilkinson (1999, 2006), the establishment of the Commission on the Social Determinants of Health (CSDH) by the World Health Organisation (WHO), (followed by a big list of other reports).

Their website states:

We have shown (see The Evidence) that greater equality improves health and life expectancy and dramatically reduces the frequency of a wide range of social problems including violence, mental illness, drug addiction and obesity. Many people worry about what has gone wrong with modern societies without recognising how many of the problems originate in the effects of low social status and status competition which are exacerbated by greater inequality.

Conventional approaches that focus on changing individual behaviours through education or punitive costs are not likely to be effective. Those most likely to listen to social marketing messages about self harm are those who feel some control over their lives. This is shown by high smoking and obesity rates which correlate with low incomes.

Higher taxes and costs will drive some low income people to cut their spending but those with least sense of self control will go without food instead.

Yet this brand new National Preventative Health Strategy report reflects none of these findings, apart from some brief mentions and acknowledgements towards the end. Early on it sounds promising, to quote:

We need this Strategy because Australia has a national commitment to fairness. Currently, good and bad health is unevenly distributed — there is a social gradient, which means that those Australians with less money, less education and insecure working conditions are much more likely to get sick and die earlier. This inequity is extremely acute for Indigenous Australians.

This Strategy is important. It seeks to do. It is evidence-based, or where the evidence is yet to be developed, it is evidence-building…

Where is their evidence base? Why does the report fail to acknowledge that the patterns of ill health in most unequal affluent societies are remarkably similar, which raises questions on the social bases for many of these conditions?

What struck me some months ago was how closely the Wilkinson data gaps match the equally intransigent gaps identified between Indigenous and non-Indigenous health in Australia.

This apparent coincidence suggests that poverty per se is not the primary reason for these types of health outcome problems but a unexamined mix of lack of appropriate services and the perceptions of social status and lack of agency of populations. We have ample evidence that services that work in Aboriginal communities must engage and involve the local community in their planning and management, be culturally appropriate, preferably involve local staffing and be there long term so good relationships and trust can be developed.

Yet none of this was reflected in the preventative health report. As this is the sector of health services most dependant on relationships, trust and cultural appropriateness, the absence of the social factors is serious. The model that underpins the report seems to be primarily based on the sin factor: people eat, drink and abuse their bodies because they are individually irresponsible, ill informed or maybe unable to find services.

Therefore the solutions are targeted to changing individual or maybe group behaviours, and fail to acknowledge the social causes and social solutions to many of the problems identified.

There are serious echoes of standard conservative/neo liberal ideologies in the way the report identifies the problems and solutions. Yet the evidence is out there, so why is it not acknowledged? The social determinants of health powerfully show us new ways forward to better health, but this report doesn’t reflect them. Why not?

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  • 1
    Simon Chapman
    Posted Tuesday, 8 September 2009 at 1:44 pm | Permalink

    Eva, sorry, but this is so much cant. I was on the taskforce’s tobacco committe and have had a good read of the obesity & alcohol c’tee reports. The main recommendations all have the relevant industries going nuts. What should that tell you? They are the ones now promoting the small beer community programs promoting “empowerment” etc. Philip Morris even had a program called “I’ve got the power”.The tired old canard that price rises on cigs will see food being plucked from kids mouths is absolutely devoid of evidence — the sort that you say we lack. Where is the evidence base, you ask? The tobacco report has 224 references, the obesity report 141 and the alcohol one 43 pages (they were not numbered). Try reading some of them.

    So where’s your evidence? Cigs are $20/pack in Ireland, $23 in Norway, and $17 in UK. You can get them for $11 here. I don’t recall reading that Irish smokers’ kids are starving or Norwegian kids are looking into empty Xmas stockings. The track record of the terribly unfashionable “standard conservative/neo-liberal ideologies” have delivered Australia one of the best health national profiles in the world, with the notable exception of the Indigenous population. You have to go back to 1962 to see Australia’s rate/100,000 of lung cancer so low; to the 1950s to see the rates we now have with COPD and heart disease. Our road toll is among the world’s lowest.
    What, precisely, would your model see as “the way forward” to (say) reducing the cervical cancer rate faster than “standard conservative/neo-liberal ideologies” have reduced it, or SIDS, or stroke, vaccine preventable diseases or any number of major diseases which are at all time lows?

    The quit rate in low SES smokers is almost identical to that in high SES smokers. The higher smoking prevalence in the former is all about more having been ever smokers (ie far few ever start in high SES groups). So what are we trying to do (and succeeding)? Denormalising by laws, regulations, awareness campaigns and price — all the things that actually work.

    There is huge focus in public health on policies and programs that optimally reach and influence low SES groups. We all want more equitable societies, but when I go into work each Monday morning I join a lot of people who aren’t just sitting around waiting for the revolution, but are contributing to research, advocacy, policy reform and control of rapacious industries who profit from over-consumption.

  • 2
    Gavin Mooney
    Posted Tuesday, 8 September 2009 at 1:58 pm | Permalink

    Thank you Eva Cox - this is so refreshing - and so spot on! The report really is about hitting the poor SODs (Smoking Obese Drinkers). And yes, Eva Cox is right to ask why the Preventative Task Force did not use the evidence out there on the Social Determinants of Health. But she also provides the answer “There are serious echoes of standard conservative/ neo liberal ideolologies”.

    The report on this front is victim blaming. It trots out old neo classical cliches about human behaviour. Yes, higher prices will reduce demand - sometimes; and sometimes the elasticity of demand is such that higher prices make little difference except that demand falls for other commodities such as food (or the SODs’ kids’ food).

    Sure the industries involved are squealing because they will suffer some loss of profits. We don’t hear the squeals of the SODs first because they are not so well funded to make their squeals heard and second because we good middle class people do not want to hear their squeals.

    The literature on the social determinants of health tells us that respecting people’s autonomy is good for their health which is a part of the reason why the NT intervention has some negative impacts on Aboriginal health. It is also why these tax measures from the Preventative Task Force may have some negative impacts on the health of the poor SODs. Racism and classism are both part of the neo liberal thinking that dominates much of public policy in this country. Ah if “these people” were only like us… Assimilation by any other name.

    Two ways forward. Yes use tax to alter consumption of ‘bad’ products but recognise that consumption is a function of demand and supply and not just demand. So tax the perpetrators and especially tax their marketing. Yes prices will go up but not as much and if I were a SOD I’d be happier to know that there was recognition on the part of government that something needed to be done to get at the perpetrators who were feeding my bad habits.

    But more fundamentally ask the poor SODs what they want done. Just as in Aboriginal health there are many Aboriginal people who not only recognise that there are problems; they also have some pretty good ideas what to do about them. So let’s give the poor SODs some good information about various options to help them to kick these nasty habits and get them involved in choosing.

  • 3
    Eva Cox
    Posted Tuesday, 8 September 2009 at 4:43 pm | Permalink

    Simon, just because big tobacco doesn’t like it, it doesn’t mean it’s good. I am not saying don’t run the programs you are supporting but i am saying these will not be as effective among outsider communities that have no sense of control over their lives, as they are amoingst those that have. As long as ‘professionals’ and politicians make decisions for them and essentially blame them for their often very accurate perception that they do not have any agency in their own lives, the gaps will continue. Yes there will be some improvements but the epidemiologists in immaculate statistics show intransigent inequalities are toxic as they destroy trust and credibility. If you failed to add this finding to the report you should be seriously worried. I know the revolution isn’t immanent and am sure I want it anyhow, as revolutions don’t work! But thinking outside the square does and can lead to good changes and we need to push boundaries should be pushed -so let’s do it, not attack each other and remember that ‘your enemies’ enemy is not necessarily your friend’.

    eva

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