A baby girl born in Japan this year can expect to live twice as long as a girl born in Zimbabwe. Americans have one third more income than the Japanese, and yet they die nearly five years earlier. In all countries at all levels of income, health and illness follow a social gradient: the lower your socio-economic position, the worse your health. Is there a common thread tying together all these differences in health between countries and within countries?
Typically, health has been considered a function of genetics, health care or lack thereof, and our own personal lifestyle and habits. However, increasingly it has become apparent that while these factors are important, the circumstances in which people live, work and age are intimately related to risk of illness and length of life. Variations in the conditions of early childhood and schooling, the nature of employment and working conditions, the built environment, how much control you have over your life and the opportunities you have for full social engagement and participation are crucial for health, well-being and longevity.
“Significant differences can arise in children’s health depending on
where they live in Victoria”
Professor Elizabeth Waters
These can be described as the social factors or determinants of health. Professor Rob Moodie (MB BS 1976) from the Nossal Institute of Global Health has worked on HIV prevention in India. “It is not enough to focus on the immediate health issues of increasing use of condoms and clean needles. The best results come when these measures are combined with empowering communities and giving them more control over their income and their lives.”
The World Health Organization’s (WHO) 2008 report focuses on what can be done to reduce health inequities in all countries, concentrating on the social determinants of health and reducing social injustice. The report calls for closing the health gap in a generation as “social injustice is killing people on a grand scale”. Three principles of action are recommended: improve daily living conditions, tackle the inequitable distribution of power, money and resources, and measure and understand the problem and assess the impact of action. Across the University of Melbourne community, epidemiologists, health researchers, economists, it engineers, architects and early childhood development specialists, individually and in teams, are working on projects in this area.
Professor Elizabeth Waters, the Jack Brockhoff Chair of Child Public Health*, says that significant differences can arise in children’s health depending on where they live in Victoria. Children in rural areas are five times more likely to need hospitalisation for dental care than children from metropolitan areas while children from poorer areas have obesity rates of up to a third higher than those from wealthier areas. Also one in five children in low income families experience serious emotional and behavioural problems, compared with one in seven from higher income families.
To address some of these issues, the University’s McCaughey Centre**, in partnership with the Moreland Community Health Service, is conducting a child health promotion and obesity prevention research and intervention study called Fun ’n Healthy in Moreland! It involves 23 primary schools in a culturally and economically diverse inner urban area of Melbourne. Intervention strategies are driven and customised by each school and the schools are supported in the implementation of a range of whole-of-school initiatives designed to address healthy eating, increased physical activity and self
esteem. One of the principals recently reported that, “Being involved with Fun ’n Healthy in Moreland! has been invaluable for our school. When we started our involvement we had an idea of where we wanted to go, but the support and guidance we have received has been the driving force behind us actually making changes and making a positive difference to the children in our school.”
Investigating the impact of social standing and status on health, Associate Professor Tony LaMontagne from the Mc-Caughey Centre has conducted research into the impact of working conditions on mental health. He found an increasing proportion of depression in people with job strain, a form of stress common in people with low-skill, demanding jobs who have little control or autonomy at work. This finding is consistent with other studies that have found a clear relationship
between inequalities in social participation and autonomy (how much control you have over your life) playing a big part in producing the social gradient of health.
Putting theory into practice in rural India
In a remote regional area of India, University of Melbourne alumnus Dr Santa Pasricha (MB BS(Hons) 2001 MPubHlth 2002), spent a year researching anaemia, a condition which affects more than 80 per cent of children in rural India, leading to impaired physical and mental development.
“I decided to leave my formal training aside for a year and see if I could conduct a community study to find out more about this hugely prevalent and little understood
problem,” says Dr Pasricha.
Inequalities in social participation have a huge role to play in Indigenous health too. “While Indigenous infant and child mortality rates have fallen significantly and Aboriginal life expectancy has risen, there is still a significant and unacceptable disparity in life expectancy and health outcome”, says Professor Ian Anderson, Chair of Indigenous Health. “There is a gap which sees an Indigenous person bear five times the burden of diabetes, four and a half times the burden of cardiovascular disease, and more than four times the burden of intentional injuries such as suicide or harm from violence. Closing the gap will require opening access so that Indigenous Australia can participate fully in the Australian economy. Universities will need to improve the way in which Indigenous students are recruited and supported, and to boost the quality of the learning experience for all students of Indigenous health.”
Professor Anderson is also Director of the Onemda VicHealth Koori Health Unit at the University, which is conducting a number of research projects including a holistic approach to reducing smoking among pregnant Aboriginal women in Victoria, and working with the Rumbalara Football and Netball club in Shepparton to develop the health, education and personal development needs of their members.
Professor Sir Michael Marmot, Chair of the WHO Commission on Social Determinants of Health described a framework for explaining the inequalities within and between countries. He uses the example of a low grade civil servant in the uk and a Kenyan slum dweller. The better material conditions and basic services in the uk explain why the civil servant has better health than the Kenyan slum dweller. In both cases, however, low social position means decreased opportunity, empowerment, and security, leading to poorer health than those higher up the social hierarchy. He argues that social conditions in every country put limits on people’s autonomy and their ability to participate fully in society, and hence lead a life they have reason to value. The greater the limitation,
the worse the health.
However, while all societies have hierarchies because individuals are unequal in a variety of ways, not all societies have the same gradient in health. There is evidence that countries with large income gaps (where the richest fifth are more than seven times richer than the poorest fifth, for example the usa, Portugal, uk and Australia) have higher levels of mental illness, obesity, prison population and teenage pregnancies than countries with low income gaps (for example Japan, Finland and Norway). Over 25 per cent of the adult population in the (unequal) USA have suffered from some type of mental illness in the past year but less than 10 per cent have been affected in (more equal) Japan.
Simple networking technology changes lives for young cancer patients
Image: Information Systems building.
University of Melbourne researchers and academics have developed a purpose-built social network application that allows young patients communicate with each other, share experiences and give each other support as well as invite other friends to join their friendship network.
As an example of place affecting health, researchers from the University’s Melbourne School of Population Health studied the food purchasing and exercise patterns of almost 5000 people around Melbourne. Findings indicate residents of lower socio-economic areas weigh more, walk less, buy more fast food and eat less fruit than people in more advantaged areas. Principal researcher Professor Anne Kavanagh, of the University’s Key Centre for Women’s Health in Society, says these differences cannot just be put down to individual differences in income and education. “It seems that whether you live in a richer or poorer neighbourhood could be a more important factor than your actual individual income,” she says.
“That’s why simple strategies such as improving and lengthening walking paths, increasing the number of pedestrian crossings and reducing the density of fast food outlets could make a difference,” she says. If the health gap is to be closed in a generation, as Sir Michael Marmot hopes, projects that focus on social opportunity and equity as much as access to quality healthcare may well be the key to making it happen.
The Nossal Institute for Global Health is committed to making a difference to global health practice, learning and research, and has a combined focus on development assistance, research and teaching. Learn more at www.ni.unimelb.edu.au
To learn more about the faculty of Medicine, Dentistry and Health Sciences and the Dean’s Lecture’s series go to www.mdhs.unimelb.edu.au/ and click ‘events’.
The WHO report can also be found by visiting www.who.int/whr/en/index.html
* The Jack Brockhoff Child Health and Wellbeing Program was established with the 2008 Jack Brockhoff Centenary Gift. The program will provide a fitting legacy to Sir Jack Brockhoff, who through his generosity in establishing The Jack Brockhoff Foundation, has provided significant benefit to the people of Victoria.
** The McCaughey Centre was established in 2006 with the support of the Victorian Health Promotion Foundation (VicHealth) and the Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne. It is named in honour of two outstanding Victorians, Davis and Jean McCaughey. Their commitment to “knowledge for common good” is at the heart of all of the work of the McCaughey Centre. Jean McCaughey is the Centre’s Patron.
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