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34754 results in Cambridge Textbooks

Page 1623 of 1738

  • 1 - Healthier progress: historical perspectives on the social and economic determinants of health

  • from Part A - Historical, global and cultural perspectives
    • By John Powles, University Lecturer in Public Health Medicine
  • Edited by Richard Eckersley, Australian National University, Canberra, Jane Dixon, Australian National University, Canberra, Bob Douglas, Australian National University, Canberra
  • Book:
    The Social Origins of Health and Well-being
    Published online:
    14 September 2019
    Print publication:
    12 December 2001, pp 3-24

  • Summary

    Introduction

    The World Bank's seminal report investing in health', published in 1993, has already established itself as one of the most influential public health documents of the late 20th century In seeking to draw lessons from the past, it noted that ‘three factors have been important in the dramatic and unprecedented mortality declines of the past hundred years … These factors are income growth, improvements in medical technology, and public health programs combined with the spread of knowledge about health’ (World Bank 1993, p 34)- When, as here, the past is used as a guide to the present, much rests on the truth of the interpretation offered. The purpose of this chapter is to examine underlying determinants of mortality change in adults in high income countries such as Australia, and, in the light of this, firstly, to suggest a re-formulation of the explanatory factors used in the 1993 World Development Report and finally to reflect briefly on some implications of this discussion for the social origins of health inequalities.

    The chapter starts with an exploration of the complexities of the relationship between economic development and health improvement, noting both the health-favouring and health-damaging potentials of increased incomes. The underlying theme is that gains in health have often depended on complex institutional adaptations to the effects of economic development - with the measures found necessary to overcome the increased transmissibility of infection associated with rapid urbanisation in the 19th century providing the classic example. At the beginning of the 21st century, important adverse health effects of economic development remain to be solved.

    Consideration then moves to the upward shift through the 20th century in the life expectancy attainable at given levels of real income. This points to the fundamental importance of increases in practical knowledge, which have enhanced capacities for health protection and improvement. The paths by which increases in knowledge may act to improve health are shown to be diverse and complex. Medicine therefore needs to be understood as an institution in which the whole of society participates and not merely as a vehicle for the professional deployment of 'medical technology'.

    The argument pushes towards a rather abstract model in which health improvement is seen to depend on the interacting effects of increases in knowledge and economic and institutional development.

  • 12 - Work and health: the impact of structural workforce changes and the work environment

  • from Part C - Social organisation and health
  • Edited by Richard Eckersley, Australian National University, Canberra, Jane Dixon, Australian National University, Canberra, Bob Douglas, Australian National University, Canberra
  • Book:
    The Social Origins of Health and Well-being
    Published online:
    14 September 2019
    Print publication:
    12 December 2001, pp 178-188

  • Summary

    The centrality of work to health and well-being is unarguable. In industrialised societies, work consumes the greatest active time in adult life, is the most reliable source of continuous access to adequate income, and provides access to a host of key psychosocial dimensions such as identity, self-esteem and social networks. In Australia and New Zealand, as in other developed countries, the relationship between socioeconomic status (SES) and health has been identified: lower socioeconomic status is consistently associated with poorer health outcomes (National Advisory Committee on Health and Disability 1998; Turrell and Mathers 2000). Given that occupation is a key dimension of SES, at least part of the impact of SES on health is likely to be a reflection of differences in working conditions (Marmot, Siegrist et al. 1999). Moreover, the absence of employment is clearly detrimental to both physical and mental health (Bartley, Ferrie et al. 1999). The significant relationship between work and health overall, well beyond traditional occupational health concerns, is therefore widely accepted.

    Worldwide, working life is undergoing major changes. Modern established market economies are increasingly characterised by demands for vastly greater labour market flexibility. They have been marked by rising participation by women, as well as increases in long-term unemployment, in temporary employment and in irregular employment contracts. New Zealand and Australia are similar in this regard: rapid and dramatic changes have occurred over recent years in the organisation of labour, of work and of the work environment. The question is what is the impact on health of the sorts of radical changes in working life that are taking place in modern economies? The present paper takes up this issue. Specifically, the aims of the paper are to:

  • • provide an overview of what we know about the changes that have taken place in working life in New Zealand and Australia;

  • • consider the mechanisms by which such changes may exert their influence on health; and

  • • highlight some key areas where gaps in knowledge are critically undermining our ability to identify important adverse health outcomes due to working life and targets for their prevention.

    • Changes in structure and conditions of employment

    It has been observed that the Australian and New Zealand labour markets share many similar characteristics: participation rates, gender distribution, wage structures and unemployment rates are all comparable (Brosnan and Walsh 1998).

  • 9 - Income, income inequality and health in New Zealand

  • from Part B - Explaining health inequalities
  • Edited by Richard Eckersley, Australian National University, Canberra, Jane Dixon, Australian National University, Canberra, Bob Douglas, Australian National University, Canberra
  • Book:
    The Social Origins of Health and Well-being
    Published online:
    14 September 2019
    Print publication:
    12 December 2001, pp 129-148

  • Summary

    Inequalities in health have to be seen against a background of economic inequality.

    (Atkinson 1999, p 283).

    Introduction

    Compared to other OECD countries, New Zealand moved particularly rapidly in deregulating its economy in the 1980s, undertaking far-reaching social and economic reforms, and having the fastest growth in income inequality (Statistics New Zealand 1999). Income inequality rose most notably in New Zealand in the late 1980s during a major economic recession, but it did not fall during the subsequent economic expansion in the mid-1990s (O'Dea 2000). Thus the increase in income inequality appears to have been driven by structural changes to New Zealand society, which persisted after the economic recession.

    There is some agreement among researchers about the reasons for about half the increase in income inequality; the reasons for the remaining increase in inequality are less easily identified. Changes in the 1980s to the taxation system appear to have been regressive, although removing tax loopholes and increasing company tax may have partially offset this effect. The rise in unemployment from the late 1980s contributed, but the most significant factor appears to have been the increase in income inequality among the employed as shown by the widening income differentials by occupation, education and hours of work.

    At a household level, there has also been a reduction in the number of households where a bread-winner supports another adult and children, resulting in an increase in work-rich households, where both adults work and work-poor households where no adults are in paid employment (Callister 1998). There has also been a change in household composition, with the growth of sole parent households and older households without children. During the late eighties’ recession, more people relied on government benefits as a source of income (Stephens and Waldegrave 1996). In 1991, the Government reduced welfare benefits, which also had some impact, though small, on income inequality (Statistics New Zealand 1999).

    In consequence of these changes, income inequality has increased in New Zealand over the past two decades. Middle-income families have fallen in number relative to both lower-income and higher-income families. Over the period 1986 to 1996, household disposable incomes actually fell in real terms in most deciles, but increased substantially in the top two deciles. Low-income households lost proportionately less of their income than those in the middle-income range (Statistics New Zealand 1999), but were often more vulnerable to begin with.

  • 8 - Migrants, money and margarine: possible explanations for Australia-New Zealand mortality differences

  • from Part B - Explaining health inequalities
  • Edited by Richard Eckersley, Australian National University, Canberra, Jane Dixon, Australian National University, Canberra, Bob Douglas, Australian National University, Canberra
  • Book:
    The Social Origins of Health and Well-being
    Published online:
    14 September 2019
    Print publication:
    12 December 2001, pp 114-128

  • Summary

    Introduction

    In the past, international comparisons have been treated as a useful starting point for studies of the social determinants of health, but that is all In fact, they have rather more to offer. For a start, national populations provide a natural unit of observation to tackle some of the biggest and most important questions in public health. These are questions such as:

  • • Why are mortality rates falling so consistently in most parts of the world, in virtually all age groups?

  • • What distinguishes the exceptions to this general pattern?

  • • Who or what deserves credit for the improvements (and the blame for the exceptional declines in life expectancy)?

    • Comparisons between countries also serve a unique bench-marking function, indicating what could, plausibly, be achieved if the performance of comparable countries was emulated.

    Ecological studies have often been a source of hypotheses about the causes of disease, exploiting the fact that variations in behaviour and environment between countries tend to be greater than variations within countries. These hypotheses have typically involved risk factors for disease measured at the level of individuals. However, the causes of disease that are 'social’ are, by definition, characteristics of groups rather than individuals and in some instances, are characteristics of whole countries. (Examples include taxation policies and occupational health legislation.) Here, international comparisons provide the only means of studying directly the association between social circumstances and health outcomes. The same approach may be taken to analyse interventions that are implemented nation-wide, such as the introduction of co-payments in health care (Schoen 2000) or the relation between distributive income policies and health inequalities (Kunst 1997).

    Australia and New Zealand are obvious candidates for comparison: despite extreme variations in geography, the societies have much in common. Donald Home suggested that ‘in one sense no country except New Zealand can be compared with Australia: these are the only two “Western” nations that are strategically part of Asia’ (Home 1966). They share a history of British colonial settlement, and have inherited language, culture and public institutions from a common stock. However, there are also important differences between the two in population make-up, natural resources and political arrangements. As the connections with Britain have loosened, the contrasts between Australia and New Zealand have become more marked.

  • 7 - Mediation of the effects of social and economic status on health and mortality: the roles of behaviour and constitution

  • from Part B - Explaining health inequalities
  • Edited by Richard Eckersley, Australian National University, Canberra, Jane Dixon, Australian National University, Canberra, Bob Douglas, Australian National University, Canberra
  • Book:
    The Social Origins of Health and Well-being
    Published online:
    14 September 2019
    Print publication:
    12 December 2001, pp 105-113

  • Summary

    Disease and mortality characterised by socioeconomic differentials

    There is a wide range of diseases and causes of mortality that are differentially distributed by socioeconomic status. This is not surprising since most disease and premature mortality are due to environmental influences, and exposures differ according to social and economic position. The major causes of illness and premature death are usually grouped as:

  • • infections and diseases of the perinatal period;

  • • noncommunicable disease, particularly cardiovascular disease and cancer (especially lung and breast); and

  • • injuries, including suicide and homicide (Murray and Lopez 1997a, 1997b).

    • In contemporary developed countries, the major causes of premature mortality are related to noncommunicable disease and injury, and these conditions have the greatest effect on socioeconomic differentials in health status. Conditions selected for particular attention in this review are important causes of premature mortality and morbidity in Australia and other developed countries:

  • • coronary heart disease (CHD), still a major cause of death and disability;

  • • lung and breast cancer (the major causes of cancer death in males and females respectively); and

  • • suicide, now equal to deaths from motor vehicle accidents.

    • In general, socioeconomic differentials in health and mortality are a consequence of the differing occurrence and outcome of the mass diseases and conditions afflicting society. In Australia and other Western industrialised society near the end of the 20th century, higher mortality and morbidity in groups of lower socioeconomic status (SES) is principally accounted for (Taylor et al. 1992, Lawson and Black 1993, McMichael 1985) by:

  • • cardiovascular disease, especially CHD;

  • • cancer, especially lung cancer; and

  • • injuries, especially traffic accidents, suicide and occupational injuries.

    • These conditions are not unchartered territory, and explanations for socioeconomic differentials in their occurrence must encompass what is known of their biology and epidemiology, and their changes over time.

    Requirements for explanations of SES differentials and health

    Explanations for SES differentials in health and mortality must encompass a number of complex circumstances:

  • • Variation in the major diseases and conditions accounting for socioeconomic differentials in health over time and between populations. During the first half of the 20th century, SES differentials in health and mortality were mostly due to under-nutrition and infection (especially in infants and children), and this is still the case in many developing countries, but by the late-20th century, SES differentials were due mainly to differences in noncommunicable disease and injury in adults.

  • 14 - Health inequalities: the seeds are sown in childhood, what about the remedies?

  • from Part D - Developmental and biological perspectives
  • Edited by Richard Eckersley, Australian National University, Canberra, Jane Dixon, Australian National University, Canberra, Bob Douglas, Australian National University, Canberra
  • Book:
    The Social Origins of Health and Well-being
    Published online:
    14 September 2019
    Print publication:
    12 December 2001, pp 207-215

  • Summary

    There is growing evidence from fields as diverse as education, criminology, child health, public health and mental health that early childhood is a more critical period in the life cycle than has been previously recognised. For example, the recent Acheson report (1998) concluded that:

    While remediable risk factors affecting health occur throughout the life course, childhood is a critical and vulnerable stage where poor socioeconomic circumstances have lasting effects. Follow up through life of successive samples of births has pointed to the crucial influence of early life on subsequent mental and physical health and development. The fact that the adverse outcomes, for example, mental illness, short stature, obesity, delinquency and unemployment, cover a wide range, carries an important message. It suggests that policies which reduce such early adverse influences may result in multiple benefits, not only throughout the life course of that child but to the next generation.

    Socioeconomic gradients in outcomes vary between countries

    In each of these areas, there are data to suggest that there are gradients in a variety of health and education outcomes across the socioeconomic spectrum. Countries with social policies that invest more in social assistance for workless and low-paid parents have lower child poverty rates, which in turn are associated with shallower gradient slopes and better mean outcomes for the whole population (UNICEF 2000; Keating and Hertzman 1999; McCain and Mustard 1999). The Scandinavian countries, for example, have lower rates of both relative and absolute child poverty at least in part because of taxes and transfers. These countries achieve higher overall literacy standards and shallower socioeconomic gradients than many other OECD countries, despite having relatively high rates of single parent families, which, in most other industrialised countries, is highly correlated with child poverty. The extent to which this outcome is a consequence of more generous parental leave provisions and high quality child care for young children is worth pondering. Mean outcomes and gradient slopes in Cuba are also much more impressive than those in many South American countries.

    Poverty, inequality or both?

    While there is no doubt that poverty on the scale experienced in many third world countries is a major determinant of poor health status within their populations, in industrialised countries there is considerable evidence that health is related to relative rather than absolute income.

  • 17 - How social factors affect health: neuroendocrine interactions

  • from Part D - Developmental and biological perspectives
  • Edited by Richard Eckersley, Australian National University, Canberra, Jane Dixon, Australian National University, Canberra, Bob Douglas, Australian National University, Canberra
  • Book:
    The Social Origins of Health and Well-being
    Published online:
    14 September 2019
    Print publication:
    12 December 2001, pp 231-244

  • Summary

    Introduction

    Hierarchy is associated with health- Resolving what it is about hierarchy that influences health has important implications for health and social policy. Large gradients in health status and life expectancy by income level, education and occupation were repeatedly observed in various parts of the developed world in the 20th century (Antonovsky 1967; Cassel 1976; Marmot and McDowell 1986; van der Meer and Mackenbach 1998). Income, education, and occupation indicators are interrelated and, individually and in various combinations, have been used to measure socioeconomic status (SES). That associations between SES and morbidity and mortality are found for each indicator suggests some underlying primary causal process, correlated with relative social position, which expresses itself through pathways of health and disease.

    Much research has targeted a better understanding of health disparities. Disease incidence, mental illness, morbidity and mortality have been shown to vary between groups rated, in terms of SES, as more or less ‘advantaged’ or ‘disadvantaged.’ Multiple studies have generated strikingly similar conclusions about the reduced life expectancy, greater frequency of chronic disease, and greater prevalence of behavioural and affective disorders for disadvantaged versus advantaged groups (Bennett 1995; Fiscella and Franks 1997; Lantz et al. 1998; Shouls et al. 1996).

    That low'SES groups are characterised by obesity, poor diet and physical inactivity, and are deprived of adequate medical care and exposed to environmental pollutants, crowding, sub-standard housing, violence, and infection does not fully explain the relationship between SEvS and health. Risk factors (eg, poor diet, physical inactivity, or obesity) and risk conditions (eg, social, or living, conditions) differ by level of SES in their distribution and relationship to health. An underlying causal determinant of the relationship between SES and health appears to operate across the entire range of SES. It has become clear that the impact of SES on health is not a threshold effect due to poverty, but is a graded effect across the social hierarchy (hence the term ‘social gradient’) (Adler et al. 1994).

    The Whitehall study (which takes advantage of the ranked grades of employment in the British civil service) is probably the most telling of the studies examining the social gradient in health outcome. Compared to the top administrators, the relative risk of mortality over 10 years was 1.6 for the professional-executive grades, 2.2 for the clerical grades, and 2.7 for the unskilled workers (Marmot et al. 1984).

  • 20 - Developmental prevention in a disadvantaged community

  • from Part E - Implications for policy, interventions and health research
  • Edited by Richard Eckersley, Australian National University, Canberra, Jane Dixon, Australian National University, Canberra, Bob Douglas, Australian National University, Canberra
  • Book:
    The Social Origins of Health and Well-being
    Published online:
    14 September 2019
    Print publication:
    12 December 2001, pp 269-279

  • Summary

    The need for a focus on disadvantaged communities

    Crime and violence have been near the top of the political agenda in Australia for the past quarter-century. The main response has been punishment - more police and more prisons. Slammed doors and a one-way ticket to ‘somewhere else’ characterise this time-hallowed and universally popular reaction to malignancy and turpitude.

    In the past decade, a number of related problems with a more obvious ‘health’ flavour have risen in the charts. These problems, which include illicit drug abuse (manifested particularly in deaths from ‘overdoses’) and child behaviour problems, have not dislodged punishment from its pre-eminent position - indeed, in some respects, they have entrenched its use - but they have had the singular virtue of at least opening the door to a public health policy response.

    Drug abuse well illustrates this point. Harm minimisation was, after a brief struggle, accepted in 1985 in Australia (but not the United States) as the overriding principle informing national drug strategy (Homel and Bull 1996). For this reason, it has been harder for governments faced with the drug problem simply to diagnose moral failing and prescribe law enforcement and punishment, notwithstanding recent trends. Harm minimisation requires some focus on prevention and at least a nodding acquaintance with risk and protective factors, something that until recently has been notably lacking from the crime arena (Developmental Crime Prevention Consortium 1999). More generally, the emerging evidence that much the same risk and protective factors underlie juvenile crime, child behaviour problems, mental and physical health, injury and drug use (Davison et al. 2000; Durlak 1998; Marshall and Watt, 1999) strongly suggests that there should be ‘joined up solutions’ to such ‘joined up problems.'

    The rise to prominence of crime and health problems in a period of great economic prosperity perhaps illustrates ‘modernity's paradox’ (Keating and Hertzman 1999, p i) - improving economic indicators combined with deteriorating indicators of health and well-being, particularly for children and youth. Although evidence for deteriorating outcomes in Australia is patchy (Zubrick et al. 1999), available data do indicate that the health and well-being of children and young people in Australia and in other developed countries at the end of the 20th century is worse than it was in the 1950s and 60s (Eckersley 1998b; Rutter and Smith 1995a).

  • 5 - A general model of the social origins of health and well-being

  • from Part B - Explaining health inequalities
    • By Jake M. Najman, Professor of Sociology, School of Social Science and Director of the Queensland
  • Edited by Richard Eckersley, Australian National University, Canberra, Jane Dixon, Australian National University, Canberra, Bob Douglas, Australian National University, Canberra
  • Book:
    The Social Origins of Health and Well-being
    Published online:
    14 September 2019
    Print publication:
    12 December 2001, pp 73-82

  • Summary

    Whether we compare groups within a society, across national borders or over time, the findings are similar: health varies and reflects different social, economic and political realities. Not only are the social origins of health substantial and persistent, but they offer the greatest prospect for improvements in population health. Of course, health needs differ according to social and physical location, and health problems are variably responsive to prevailing social, cultural and political forces. Different social and physical environments variably lead to particular health outcomes. While we know a great deal about the impact of the social and physical environment on health, much remains to be learnt, especially about the policies and programs that could improve the health of the population.

    A review of some key findings provides the basis upon which assertions about the social origins of health rely.

    Major socio-economic inequalities in mortality are observed in every country that collects relevant data. These inequalities are noted for most major causes of death, across almost all age groups, and persist over time. They are observed in the weight of children at birth (lower socio-economic status groups have lower birth weights) and in the mental and emotional health of children as early as five years of age (Najman et al. 2000). As early in life as it is possible to gather reliable and valid data, children from lower socio-economic status groups have lower IQ scores and higher rates of developmental problems (Najman et al. 2000). There is compelling evidence that, for many, these health and developmental inequalities start before birth and lead via a number of pathways to poorer adult health (Najman et al. 2002). The magnitude (and occasionally direction) of these socio-economically determined health inequalities may change as social conditions change. For example, the mortality gap between upper and lower socio-economic groups seems to be increasing in countries that manifest increasing economic inequalities (Marmot 1999).

    There are major health inequalities associated with religious affiliation. Whether religious affiliation is measured by membership of a particular group (eg, Mormons, Seventh Day Adventists) or by the degree to which a person participates in religious activities (frequent attenders versus occasional attenders), the evidence indicates that the more religious have a substantial health advantage (McEvoy and Land 1981; Lyon et al. 1994; Grundmann 1992).

  • 16 - Health inequalities: is the foundation for these laid before the time of birth?

  • from Part D - Developmental and biological perspectives
  • Edited by Richard Eckersley, Australian National University, Canberra, Jane Dixon, Australian National University, Canberra, Bob Douglas, Australian National University, Canberra
  • Book:
    The Social Origins of Health and Well-being
    Published online:
    14 September 2019
    Print publication:
    12 December 2001, pp 225-230

  • Summary

    Introduction

    Barker's original idea of the ‘foetal origins’ of cardiovascular disease (CVD) and chronic lung disease in adulthood relates to foetal under-nutrition in a malnourished mother. There is evidence suggesting that when the foetus receives an inadequate supply of nutrients, its growth is slowed and blood flow is redistributed preferentially towards the brain. It is hypothesised that these adaptions result in reduced weight at birth, and structural or metabolic adaptations that predispose the foetus to disease in adult life (Barker 1991).

    Lower socio-economic status (SES) is associated with lower birth weight (Pattenden et al. 1999), and it has been suggested that the harmful effects of low SES on adult health may be mediated via a pathway involving foetal under-nutrition and low birth weight (Barker and Martin 1992). The implication is that preventive efforts aimed at reducing diseases of adults need to embrace measures to alleviate social inequalities in women of reproductive age

    In this paper, we discuss the findings of our own research that suggest the link between social status and adult disease can be explained largely by differences in foetal development.

    Health effects of low birth weight

    There are now a very large number of studies that have shown that babies who are small at birth have a higher risk of adult cardiovascular disease (Leon et al. 1998) and diabetes (Hales 1997). The following data (table 16.1) from the Nurses Health Study in the United States (Rich-Edwards et al. 1997) demonstrate just how strong an effect this might be.

    Risk factors for these diseases such as higher blood pressure and impaired glucose tolerance are also found more commonly among children and adults who were small at birth.

    The association between low birth weight and SES

    Could this apparent effect of low birth weight explain the known associations of SES with CVD and diabetes, and possibly with other diseases? The available evidence does show that low birth weight is more common in lower SES families.

    For example, we have found that 30% of the occurrence of low birth weight (defined as less than 2500g) in a sample of British children can be attributed to the effects of social inequality. These subjects were 921 children recruited into two large infant nutrition studies (Lucas et al. 1999; Lucas and Morley personal communication) and randomised to bottle-feeding or to the breast-feeding ‘control’ arm.

  • 10 - Equity in access to health care

  • from Part B - Explaining health inequalities
  • Edited by Richard Eckersley, Australian National University, Canberra, Jane Dixon, Australian National University, Canberra, Bob Douglas, Australian National University, Canberra
  • Book:
    The Social Origins of Health and Well-being
    Published online:
    14 September 2019
    Print publication:
    12 December 2001, pp 149-156

  • Summary

    There is now extensive literature documenting significant inequality in health status associated with a person's different place in Australian society. The starkest differences are revealed in comparing the health status of indigenous Australians to nonindigenous Australians. However, a series of publications from the Australian Institute of Health and Welfare (AIHW), the National Health Strategy and academic authors has demonstrated the existence of health inequalities in Australia on a range of dimensions. There is some theoretical debate about the causal factors associated with the inequalities. A major contributor to recent work in this area is Wilkinson (1996a) who argues that it is not social disadvantage, per se, which is associated with poor health but rather the extent of social inequality (but see Saunders 1996 and Judge et al. 1998 for critiques of Wilkinson's argument).

    The role of the health system in promoting health and curing ill health is self-evident, but, as with health status, the health care system may involve significant inequality. The US work by Anderson, Aday and colleagues at the University of Chicago has pioneered one aspect of this area, namely analyses of differential use of health services. The model used by Anderson and colleagues has evolved over time (Andersen 1995), and the emerging model involves environmental factors (including the functioning of the health care system); population characteristics (including predisposing characteristics, enabling resources, and need); and health behaviour (including personal health services and use of health services). These factors lead to outcomes (in perceived health status, clinically measured health status and consumer satisfaction).

    Different models of the impact of the health system on health status will obviously lead to different conclusions about the mutability of the health system's role in addressing differential health status. The Chicago work made some initial assumptions about the mutability of various factors, and in this context, it is important to recognise that social structure was seen as relatively immutable.

    This paper focuses on the extent to which barriers to access to health services might be inequitable. Ensuring access and facilitating health service utilisation is not, of course, the only way the health system might respond to health inequalities. Changing the focus of health promotion programs might also lead to reduction in inequity (Duckett 1998).

  • 6 - Income inequality and health: in search of fundamental causes

  • from Part B - Explaining health inequalities
  • Edited by Richard Eckersley, Australian National University, Canberra, Jane Dixon, Australian National University, Canberra, Bob Douglas, Australian National University, Canberra
  • Book:
    The Social Origins of Health and Well-being
    Published online:
    14 September 2019
    Print publication:
    12 December 2001, pp 83-104

  • Summary

    Introduction

    Despite the long-held myth of equality and egalitarianism, Australia is a socially and economically divided society: it was from the early days of white settlement (Connell 1977), it has been since (Western 1983; Baxter et al. 1991), it still is today (Fincher and Nieuwenhuysen 1998), and all indications are that it will continue to be so in the future (Megalogenis 2000). In fact, the socio-economic divisions within this country are predicted to widen (Kelly 2000; Steketee and Haslem 2000). Income inequality is a key indicator of this divide. Between 1982 and 1993/94, earnings and private income inequality increased in Australia, and while most of this increase was offset by government-initiated changes to the taxation and welfare systems (Harding 1997), Australia still has marked inequities in its distribution of income. One perspective on the extent of income inequality in Australia is illustrated in figure 6.1. These data indicate the share of total weekly income received by the poorest and richest 20% of families between 1994 and 1998. For each period, families in the bottom quintile of the income distribution received less than 4% of the total income going to Australian families, whereas those in the top quintile received just under 50%. This represents more than a 12-fold difference in share of the nation's income. The extent of Australia's income inequality has also been made apparent in recent international assessments that have shown that Australia is not far behind ‘high’ inequality countries such as the United States and Britain in terms of its level of income disparity (Smeeding and Gottschalk 1999).

    The movement towards a more divided society is of concern, not only because of its inherent injustices and offence to moral sensibility, but also in light of studies showing that income inequality is bad for health. Since the mid-1980s, a growing body of epidemiological and public health research has demonstrated that morbidity and mortality risk is greatest in areas with high levels of income inequality. At present, our knowledge and understanding of how income distribution affects health is limited, although a number of explanations have been proposed. These include differential investment in human, physical and social infrastructure; psychosocial processes related to perceptions of one's position in the socio-economic hierarchy; and social cohesion.

  • 19 - Does our limited analysis of the dimensions of poverty limit the way we seek solutions?

  • from Part E - Implications for policy, interventions and health research
  • Edited by Richard Eckersley, Australian National University, Canberra, Jane Dixon, Australian National University, Canberra, Bob Douglas, Australian National University, Canberra
  • Book:
    The Social Origins of Health and Well-being
    Published online:
    14 September 2019
    Print publication:
    12 December 2001, pp 259-268

  • Summary

    Introduction

    Poverty is rarely about one thing - it is about having no money, no voice, no infrastructure and no opportunities. Voices of the Poor (World Bank 2000).

    Poverty and other forms of social disadvantage are multidimensional in their manifestations, multifactoral in their causes, and complex in the pathways through which they operate on health and well-being. However, there is a danger that the high level of interest in the public health community in the statistical relationship between unequal income distribution and health may lead to an oversimplification of both the nature of poverty and the action required to address health inequality. Also, a preoccupation with describing associations and developing models for explaining causal pathways leaves public health workers open to criticism of developing a research industry that has few tangible benefits for those whose health is most vulnerable.

    This paper raises issues that need to be considered as complex notions of poverty and social disadvantage are transferred from (often complex) sociological to (often relatively simple) public health frameworks. For instance:

  • • Are measures of income and income distribution simply proxies for a more complex and systemic web of disadvantage?

  • • Is poverty better understood as a set of issues affecting an individual, family network or community rather than as a single entity in itself?

  • • Does the current emphasis on relative poverty blind us to the absolute paucity of resources and life chances experienced by some Australians?

  • • Is our limited analysis of the dimensions of poverty preventing a more sophisticated approach to solutions?

  • • And most importantly, if, as some argue, the prime cause of health inequalities in developed countries is the very unequal income distribution, and the remedies for this lie so clearly outside the mandate of the health system, are health workers released from any responsibility to act?

    • Additionally, we reflect on the limitations of the income inequality argument that are emerging in the literature, and examine the ways in which an analysis that is based on simple, strong statistical associations between income inequality and health may be limiting effective action to reduce health inequalities. It is not our purpose to throw the baby out with the bath water. We do not dispute the observed relationship between income inequality and health but seek to reflect on the limitations of this approach in understanding the origins of health inequality and in taking action to redress these inequalities.

  • 15 - Family, early development and the life course: common risk and protective factors in pathways to prevention

  • from Part D - Developmental and biological perspectives
  • Edited by Richard Eckersley, Australian National University, Canberra, Jane Dixon, Australian National University, Canberra, Bob Douglas, Australian National University, Canberra
  • Book:
    The Social Origins of Health and Well-being
    Published online:
    14 September 2019
    Print publication:
    12 December 2001, pp 216-224

  • Summary

    Developmental outcomes and pathways

    The current and generally accepted model of development views children's development as the result of the ongoing interaction and transactions between the children and the environment they grow up in. Those interactions have effects on both the child and the environment, and include transactions between the child's family, the neighbourhood and the wider community. All are variously affected as well by the policies and the structures of the government and the broader society in which they exist (Bronfenbrenner 1979; Shonkoff and Phillips 2000).

    Throughout their development, children follow various pathways to particular physical, social, emotional and cognitive developmental outcomes. There is no single straight pathway from early to later development but a number of ‘straight and devious’ pathways to various developmental outcomes (Robins and Rutter 1990). Children may reach the same outcome or 'point’ in different areas of development by a number of different pathways, but the research evidence suggests that certain adverse outcomes in adolescence and adulthood such as criminal behaviour and substance abuse are continuations of anti-social behaviour and mental health problems in childhood (Farrington 1994; Nagin and Tremblay 1999; National Crime Prevention 1999; Robins and Rutter 1990; Werner 1987).

    At various points along the pathway, there are a number of points of change or transitions which involve major re-orientations in how a child relates to his or her environment (Shonkoff and Phillips, 2000). These are important because they tend to be periods when individuals and/or others around them are looking for information and are likely to be more open to some assistance or intervention. Transitions may occur as particular aspects of the child's development (for example, when children are acquiring language or trying to increase their independence from their parents, either as toddlers or as adolescents) and they may also be a result of changes imposed by the child's environment or stage of life. Such life-stage transitions include entering child-care or school, changing from primary to secondary school, and getting a job and leaving home. In addition, certain life events such as moving to a new area, changing schools, and changes in family structure as a result of divorce, the birth of a sibling or the death of a family member also bring with them changes in various aspects of a child's life.

  • 11 - Human settlements: health and the physical environment

  • from Part C - Social organisation and health
  • Edited by Richard Eckersley, Australian National University, Canberra, Jane Dixon, Australian National University, Canberra, Bob Douglas, Australian National University, Canberra
  • Book:
    The Social Origins of Health and Well-being
    Published online:
    14 September 2019
    Print publication:
    12 December 2001, pp 159-177

  • Summary

    Introduction

    The healthy cities movement is not new; it began in the late 19th century in response to industrial city slums. The problems of polluted water, filthy streets and fetid air, together with the lack of any natural parkland gave rise to modern town planning. The role of health professionals in this movement was very significant. This chapter will gather some perspective from the history of settlements before showing how we are facing a set of issues just as critical as those that faced the first industrial cities. It will try to show what those problems are and how some settlements are facing them. The role of health professionals in gaining acceptance of the required integrative approach will be stressed, as will the need for a sense of hope in these debates.

    The physical environment of our cities presents a range of problems that concern health professionals: indoor air pollution, toxic chemicals in the workplace, industrial pollution, toxic site remediation, and so on. The focus of this chapter is on the physical environment as it relates to the transport and land use issues associated with the automobile. As with all physical environmental issues, we must consider their social and economic context.

    Healthy cities in history

    The health profession was a major factor in changing the nature of cities in the 19th century. The rapid growth of industrial cities meant that often, simple needs like separating water from waste (well known in every indigenous culture) were unmet. John Snow's ‘discovery’ that a sewage-contaminated well was causing cholera in London was said to have led to a burst of public health awareness in the late 1840s. Sewers were built, and public health approaches were adopted from that period but these improvements were outpaced by the growth of the cities and their polluting industries.

    By the 1890s, the worst depression ever known had led to terrible poverty and crime throughout industrial cities. The air was full of the smoke and smells of the ‘dark satanic mills'. People crowded into tenements, and all the services were overwhelmed. Garbage filled the streets, and epidemics raged through the slums.

    The social, economic and environmental problems of the cities dominated political and academic agendas. In response, the resulting ‘hygiene’ movement spread through the developed world's cities.

  • 4 - Culture, health and well-being

  • from Part A - Historical, global and cultural perspectives
  • Edited by Richard Eckersley, Australian National University, Canberra, Jane Dixon, Australian National University, Canberra, Bob Douglas, Australian National University, Canberra
  • Book:
    The Social Origins of Health and Well-being
    Published online:
    14 September 2019
    Print publication:
    12 December 2001, pp 51-70

  • Summary

    Introduction

    In the 1970s, I spent two years travelling overseas - through Africa, Western and Eastern Europe, the Soviet Union and Asia. The most difficult cultural adjustment I had to make was on my return to Australia. My initial celebration of the material abundance and comfort of the Western way of life soon gave way to a growing apprehension about its emotional harshness and spiritual desiccation. In a way I hadn't anticipated, the experience allowed me to view my native culture from the outside, and in ways I hadn't appreciated before, I realised ours was a tough culture.

    In his book, Biology and the Riddle of Life, the biologist Charles Birch says science inevitably leads to mechanical analyses. Is there nothing more to be said, he asks:

    I think there is. It is to propose that there are two points of view - the inside and the outside, the subjective and the objective, from within and from without… There is an enormous gap between what science describes and what we experience … (T)he solution to the riddle of life is only possible through the proper connection of the outer with the inner experience (1999, p 58, italics in original).

    This chapter is concerned with this connection as it relates to the social determinants of health, and as it is expressed in the relationships between cultural and socio-economic factors. 'Culture’ is a difficult concept because it is defined and used differently between different disciplines, and even within the same discipline. Culture can be taken to include all aspects of society, to describe an entire way of life of a people. However, it is often distinguished from social structure, with a key research goal being a better understanding of how the two interact (Swidler 1986). Larazus (1991, pp 349-83), in his study of emotion and adaptation, distinguishes between ‘culture’ and ‘social structure’ in this way: ‘culture’ provides a set of internalised meanings that we carry into our interactions with the social and physical environment; 'social structure’ refers to the detailed patterns of social relationships and transactions among people with different roles and status within a social system.

    However, Hays (1994) challenges the separation of culture and social structure. Culture, she argues, is a social structure, both internal and external, subjective and objective, ideal and material.

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