Health inequalities: plus ça change, plus c’est la même chose

‘The poorest Australians are twice as likely to die before age 75 as the richest, and the gap is widening. People living in socially disadvantaged areas and outside major cities are much more likely to die prematurely, our new research shows. The study […] reveals this gap has widened significantly in recent years, largely because premature death rates among the least advantaged Australians have stopped improving.’

So begins an article in The Conversation on May 26th that briefly describes a published, peer-reviewed study that compared deaths between the ages of 0 and 74 years of residents of neighbourhoods with different levels of social advantage and disadvantage in Australia between 2006 and 2016. Without going into all study’s findings, I will mention the following among the 35-74 year-old group:

  • following the Australian population’s steadily declining death rate over the last century, the decline slowed in 35-74 year-olds during 2006-2016;
  • the death rate was even slower (roughly half the rate) during 2011-2016 than during 2006-2011. The slowing occurred in males and females;
  • during 2011-2016 the death rate did not decrease at all in males or females in the most disadvantaged 20% of neighbourhoods;
  • in 2011 the death rate among males living in the most disadvantaged 20% of neighbourhoods was 1.97 times greater than the rate among males in the most advantaged 20%. By 2016 this had increased to 2.11, an increase of 14%;
  • the corresponding findings for females were 1.78 in 2011 and 1.98 in 2016, an increase of 26%.

The study and its findings received quite a bit of coverage in the popular media. What should one make of these findings, however?

First, there is nothing new about finding that disadvantaged people have higher death rates than more advantaged people – indeed, newspapers have been presenting such findings with ‘shock, horror’ headlines every six months or so for as long as I can remember. The finding is well-established whether advantage-disadvantage is measured using, for instance, an individual’s personal (or in some cases household) income, wealth, level of education or occupation or using the average of such characteristics among residents of particular areas. It is also well-established that disadvantaged people have a higher incidence of most specific causes of death (heart disease, cancer, accidents, etc.), of most health problems and illnesses, of most health risk factors, and of difficulties accessing health care. Similar relationships are observed across the whole age range and in all countries that have reliable statistics. So, ‘nothing to see here folks, please move along’? Not quite.

It is important to note that not only the most disadvantaged people in society suffer worse health and earlier death. Rather, there is a gradient going all the way from the most disadvantaged to the most advantaged groups in society whereby a little bit more, let’s call it, privilege (more income or wealth, better education or housing, for instance) is associated with better health, a lower death rate and longer life expectancy. (Note that I am talking at the population level here – about averages across social groups. A few impoverished individuals become centenarians and a few affluent individuals die very young but that’s not the overall pattern.)

This gradient of unequal health status across the social hierarchy has been known about for centuries. Following the second world war many ‘western’ nations created some form of welfare state.  Whether and to what extent the general population was given better access to, for instance, free or subsidised health services, education and housing, income support if unemployed, and aged and disability pensions varied from nation to nation. There was, however, a widespread assumption that many of the social inequalities that were rife before the war, including health inequalities, would slowly disappear. The good news is that during the 1950s, ‘60s and ‘70s overall levels of health improved, and most groups within societies experienced some health improvement. The bad news is that serious health inequalities persisted. The publication of the Black Report in the UK in 1980 was pivotal in revealing this surprise.

Since the Black Report there has been an explosion of research and reports that have examined health inequalities within and between countries and across the whole globe, and truck-loads of recommendations have been made to tackle them. Regrettably, as last week’s article in the The Conversation demonstrates, health inequalities have still not disappeared and may even be increasing. And equally worrying, the improving death rates that have been experienced in all groups over the last century, albeit at different rates in different groups, seem to have ground to a halt in some of the most disadvantaged sections of the population.

Over the last 40 years considerable research and commentary has explored explanations for the existence of health inequalities. This has had two main goals. First, to understand the explanations that people hold in their heads for the existence of health inequalities, because these explanations influence the attitude of an individual (politician or public servant for instance) to the existence of inequalities and what, if anything, should be done about them. Second, to generate reliable scientific evidence about the causes, perpetuation and possible mitigation of the inequalities, with the hope of influencing social policy.

Three of the explanations offered for the existence of health inequalities, and social inequalities more generally, illustrate differing world views:

  • a belief that it is god’s will that some people are poor and sick might focus a person’s responses on resigned acceptance of the situation, or prayer to ask for god’s intervention, or charity to allay the worst of someone’s suffering (and possibly generate a warm inner glow for the giver). A belief that god created disadvantage is not so unusual as you might think. The Christian hymn ‘All things bright and beautiful’, published in 1848 in ‘Hymns for Little Children’ (none-too-subtle social conditioning for poor children to accept their lot meekly and wealthy kids to believe their good fortune was god’s choice), contains the verse:

The rich man in his castle,

The poor man at his gate,

God made them high and lowly,

And ordered their estate.

Couldn’t put it much plainer than that, even if that verse is often omitted nowadays.

  • a belief that poor health results from unhealthy personal behaviours (e.g. smoking, excess alcohol intake, poor diet, inactivity, overweight), whether attributable to cultural norms or individual ignorance or irresponsibility, might lead to individuals and groups being blamed for their ill health (‘it’s her/his/their own fault’, ‘what do you expect of people like that?’) and minimal action being taken. Interventions that have occurred have often focused on health education. The problem with health education, however, is that not everyone has equal access to it, and not everyone is equally able to do what the educators recommend. Consequently, the groups that take up health information and advice the quickest and most effectively tend to be the more affluent, better educated, more articulate – the ones who have the best health to begin with. Outcome: even wider health inequalities. In fairness, I should point out that research indicates that about a quarter or a third of the size of health inequalities can be attributed to differences in personal behaviours. But that begs the question, why do poor or poorly educated or poorly housed people tend to behave ‘poorly’ when it comes to looking after their own health? Fecklessness or circumstances?
  • perhaps the fundamental causes of social and health inequalities are to be found not in god’s will or personal (healthy or unhealthy) behaviours but in the structure and functioning of society at large. Perhaps disadvantaged people are less able to afford nutritious food, secure housing in a crime-free, well-resourced, environmentally clean neighbourhood, and climate-appropriate clothing. Perhaps they are less likely to get a good education and hence safe, well-paid employment. Perhaps they are more likely to suffer discrimination at school, in the workplace and by the authorities, and less likely to be able to access all the benefits to which they are entitled. And importantly, perhaps these impediments to a healthy life owe little if anything to personal ‘weaknesses’ but rather to the way society systematically deprives disadvantaged people of life opportunities.

A casual glance at the media recently confirms that issues such as these are common: opposition to an increase in the minimum wage; Aboriginal deaths in custody; recognition of the illegality of Robodebt; Rio Tinto legally blowing up a 46,000 year old Aboriginal cave dwelling; casual workers, temporary visa holders and non-private university employees excluded from JobKeeper; the inequality of resources and facilities between public and private schools. All of these examples are way beyond the capacity of any individual or group to correct.

Responses to problems such as these require community support for and government action to change the way society is structured: better working conditions and pay rates, including reduced remuneration differentials; equal employment opportunity; a taxation system that more fairly distributes income and wealth; a welfare system that treats recipients as valuable citizens who are as deserving of respect and a decent a life as everyone else; possibly a universal basic income; affordable childcare; an education system that gives all kids an equal chance at fulfilling their potential; universal health insurance; equal access to the legal system; decent housing for all; elimination of discrimination and inequity based on gender, race, sexual orientation, etc. Changes such as these require structural change to the whole of society, not simply a more compassionate approach to disadvantaged people; a better safety net is not enough. Tackling inequity requires a change in power structures and collective decision making.

If, like me, you believe that the way society is structured is the dominant creator of privilege and disadvantage, it’s obvious why the health inequalities revealed in the research highlighted above are not new, and why similar results would be found in most wealthy nations. Governments, even left leaning ones, have simply not been prepared to tackle the task of eliminating preventable inequalities in society. Some have tinkered around the edges of inequalities, and some have had a little success, but none has been serious about changing social structures and power relationships. And whatever else we do, social justice and health equity will evade us in Australia until we negotiate a respectful, just relationship with the Indigenous population.

(To be clear, I imply no criticism of the authors of the article in The Conversation. It is essential that rigorous studies such as theirs be undertaken to monitor the details of changing patterns of health inequalities and to assist with the development of appropriate public policies.)

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Peter Sainsbury is a retired public health worker with a long interest in social policy, particularly social justice, and now focusing on climate change and environmental sustainability. He is extremely pessimistic about the world avoiding catastrophic global warming.

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