Charity begins at home – An insight into inequality and health in Australia

Much of this blog has been looking at issues of inequality around the world and their impacts on health outcomes. Here in Australia, we have some of the highest living standards in the world. As a nation, we enjoy significant political and economic stability, and are not plagued by war, famine and infectious disease. Furthermore, many have applauded our universal access to health care through systems such as Medicare. In light of such relative comforts its easy to forget that inequality does exist in Australia also, and that with it comes consequences those disadvantaged.

Despite its accolades , the largest health gap in the world is that between Indigenous and Non-Indigenous Australians. Sadly , this group lags far behind urban Australia in terms of education, wealth, income and of course health.This gap is even more prominent in remote Aboriginal communities where access to sound primary health care is far more limited.

When it comes to health outcomes, its quite clear that Aboriginal Australians have it far worse than non-Aboriginals. For example life expectancy for an Aboriginal child born in 2012 was on average 10 years less than for a non-Aboriginal, and their infant mortality rate is three times the national average (15.2 v 5 per 1000).

To make matters worse , Aboriginal Australians have a significantly greater incidence of several chronic illnesses  as well as infectious diseases relative to the wider population.

  • Diabetes is almost 4 times more common in Aboriginal people than among non-Aboriginal persons.
  • CVD was responsible for 25% of the deaths of Indigenous people living in NSW, Qld, WA, SA and the NT. After adjusting for age, this rate is almost twice that for non-Aboriginals.
  • Aboriginal people suffer from higher incidence of infectious and communicable diseases compared to non aboriginals
    •  TB notifications were 11 times higher for Aboriginal people than non- Aboriginal people between 2005-2009.
    •  Hepatitis C rates were 3 times higher in Aboriginal people than for non- Aboriginal people.
    •  Notification rates for Gonorrhea, Syphilis and Chlamydia were higher for Aboriginal people than for non-Aboriginal people in 2010-12

Factors contributing to these adverse health outcomes

  • Discrimination and racism
    • Discrimination and racism can impact ones chances of employment, diminish self worth and can even reduce likelihood to seek medical care.
    • In 2007, 27% of Aboriginal and Torres Strait Islanders over the age of 15 reported experiencing some form of discrimination in the past 12 months.
  •  Access to health
    • Access to health facilities for Aboriginal Australians is more limited than that for non-Aboriginals. Remoteness and isolation is a major contributor to this, however, issues such as discrimination and ability to provide care with cultural sensitivity may help explain the subpar access to health facilities in this group.
  • Education
    • Though this is improving, levels of education in Aboriginal populations far from ideal. In 2008, the proportion of Aboriginal and Torres Strait Islander children completing year 12 was only 22%. In remote communities, this rate was only 16% , while slightly better in non-remote communities at 29%.
    • Lack of education increases the likelihood of making poor health choices such as smoking, alcohol abuse and drugs. Furthermore, children not at school are more likely to be involved in delinquent activities.
  • Income
    • 49% of Aboriginal people earn incomes in the bottom quartile of the national average. Lower incomes mean that people are less likely to seek medical care for non-urgent ailments. These issues are more likely to progress into more serious health problems later.

A major challenge facing the medical system is the declining willingness of medical graduates to enter general practice. This is worsened by the fact that an even smaller proportion of those who do are actually inclined to provide services in rural and remote communities.This is a problem that must be addressed , as without increased primary care in remote Australia, these health discrepancies will persist.

This problem of inequality, however, will not be fixed simply by sending more doctors and healthcare professionals. The challenge must also be addressed from a sociocultural perspective. Possible interventions include:

 

  • Developing positive relationships with Aboriginal communities, promoting good health practices in a culturally sensitive way.
  • Training healthcare workers in cultural competence. This helps to foster better relationships with those in Aboriginal communities ,resulting in better more trusting relationships with healthcare providers.
  • Increased involvement of Aboriginal persons in policy making and advisory committees for these regions. This allows decisions to be made with  a direct insight into the needs and requirements of the Aboriginal communities we are trying to help.
  • Local councils must work to improve employment and education opportunities for people in these communities. Such measures help reduce income inequality and thus make people more likely to seek medical attention when they actually should ! A stable income also ensures access to good quality food, which can be somewhat expensive in remote areas.
  • Foster supportive environments for young Aboriginals to enance community participation. Such settings could include council  funded sports, childcare services and health facilities. This helps prevent youth from going astray down paths of delinquency or drug and alcohol abuse.

While it is important that we continue to advocate and do our part for alleviating inequality around the world , we must not forget that similar issues are present in our own backyard. We must act individual , governmental and societal levels to do whatever can be done to close this gap!

Here’s a video from Oxfam Australia about their initiative ‘Closing the Gap’

Leave a comment if you agree or disagree with what has been said, as feedback and debate on the matter are encouraged and appreciated!

 

From the Mind the Gap team.

When it all works , we get Sweden !

What would we expect if we succeed in our campaign to promote and realize global equality and its effect on health? Lets look at things economically first, since from a biopsychosocial perspective, this is still an important aspect to consider in health outcomes as a part of the social determinants of health.

Sweden is one of the few advanced and successfully low income inequality countries. By studying their benefits and detriments, we can understand the benefit of an equal global society, and how that would impact health.

In Sweden, there is an almost egalitarian distribution of income and low rate of poverty compared to similarly advanced countries such as the USA and UK. In fact, the living standards of the poor are close to those of median citizens than in other advanced countries.

Sweden’s war against poverty is so well done that poverty is rarely seen as part of public discussion as opposed to other advanced and developed countries. In fact, just among children, only 8.2% fall below the poverty line in Sweden compared to the 15.1% in Australia and the 21.2% in the United States of America.

How has Sweden produced such an egalitarian income distribution and reduce inequality? Much of the success is found in Sweden’s high tax and transfer systems in combination with factors that directly or indirectly skewed labor demand in favour of the less-skilled workers, creating a higher income, less wage inequality economy. The latter is done through a variety of Swedish policies which incentivize workers to not work more than their contracted hours (five-week mandated vacation, parental leave, holiday time, incentive to call in sick, high marginal taxes etc) in combination with wage compression (where differences in pay do not vary much despite experience, skill sets etc*) which come together to produce massive “work sharing”, reducing wage inequality in Sweden.

These policies, by reducing work hours and incentivizing vacation/holiday/sick leave often cause Swedes to rate their health and happiness higher than those in say America. In fact Sweden nets a higher happiness level according to surveys, with a net happiness level of 91% compared to USA’s 84%.

Swedish policy also highly benefits those with disability, whereby the massive work sharing effect spills over, improving employment in the disabled. Those employers who employ the disabled, are also subsidized for sick leave and money lost due to the disability by tax payers money.

Overall, Swedish policy also reduces inequality for the disabled. US citizens with no disability had an employment rate of around 85% (compared to Swedens 90%) while those with some kind of disability had an employment rate of 45% (compared to Swedens 63%). This improves the psychological well being of the disabled, which often benefits from their ability to function and provide in an economy and community, which by the biopsychosocial model of health, greatly improves their overall health. The high employment in those with disability would also reflect a better ability for those with disabilities to comfortably pay for their health care bills compared to the USA.

Of course Sweden has its own problems with inequality, and is not entirely the egalitarian Utopia many imagine it to be. While Sweden does in fact have a low income inequality, it has a high wealth inequality, with the top 1% of earners controlling 25-40% of all wealth (large range due to inaccuracy caused by high tax evasion, a downfall caused by high taxes). This issue however is to a degree, counteracted by the punitive high tax rates which devalue those assets.

Another issue is that belonging to the upper class in Sweden is dependent more on blood than on wealth, the opposite of the USA, making class mobility much harder in Sweden than in the USA.

Despite this, Sweden remains as one of the most successful economies in lowering inequality, which has benefitted their health outcomes clearly, with a life expectancy of 81 years, compared to that of the more wealthy, but more unequal USA with a life expectancy of 78 years, on top of the lower poverty in Sweden compared to the US. What is it that produces better health outcomes in the less economically unequal countries?

Of course poverty and poor health go hand in hand, so by reducing poverty, we improve health, but research shows that inequality is detrimental to the health of not just the poor, but the affluent too. This is hypothesized to be due to inequalities detrimental effects on social cohesion, which leads to more stress, fear, and insecurity for everyone, which by the biopsychosocial model of health, would negatively affect health of the whole population.

So what lessons can be learnt from Sweden? Sweden shows that wealth of a nation does not at all mean it has the best health, but rather, it is the way in which that wealth is distributed. Sweden has stronger taxes compared to the USA, however Sweden is more effective and efficient in its transfers, efficiently lower income inequality, and providing an equally efficient and effective health care system.

We contend to you, that despite Sweden’s low GDP of 725 Billion USD compared to Americas high GDP of 22.1 Trillion USD, Swedens more equitable economy has meant that Sweden not only has health outcomes comparable to the USA, but their health outcomes are in fact better!

Sweden serves as an almost perfect example of why we fight for equality, and the bountiful benefits it has on health.

 

Leave a comment if you agree or disagree with what has been said, as feedback and debate on the matter are encouraged and appreciated!

 

From the ‘Mind the Gap’ team.

Big Pharma against the Developing World

A major challenge faced in developing countries is that of infectious diseases. The upside about this is that many of these diseases are easily treatable or preventable with modern medicine. Yet high costs of these medications puts them out of the grasp of those who really need it.

A little instrument of intellectual property law, known as a Patent has meant that there is a continual struggle between ensuring pharmaceutical companies have the incentive to undertake research and development and keeping medical therapies affordable.

When a pharmaceutical company develops a new drug, what it essentially seeks to acquire is a patent.  A patent gives such a company exclusive rights to manufacture, market and sell that product, essentially giving it monopoly status over the drug. For the manufacturer this means the ability to charge often-exorbitant prices for these drugs, especially if they are essential to patients.  Patents on drugs typically last for 20 years (yes, quite a long time!). The desire to acquire a patent is a huge motivator for large pharmaceuticals to undertake the expensive R&D to develop new and innovative drugs and therapies. However the ongoing issue at hand is whether it is equitable to charge such high prices that those truly in need cannot access the drugs.

In 1995, the World Trade Organization introduced the TRIPS (Trade-Related Aspects of Intellectual Property Rights) agreement, to which 148 countries are signatories. Simply put, this meant that patents were enforceable not just in the country of manufacture but across all member states. While this is great news for Big Pharma, it often means restricted access to vital and lifesaving drugs for many in the developing world

A great example HIV/AIDS is a massive pandemic in Sub-Saharan Africa and parts of Asia. The prevalence of this disease is far higher here than anywhere in the developed world. The development of Anti-Retroviral (ARV) drugs was a groundbreaking innovation in the management of HIV, with the potential to significantly slow the progression of the disease and reduce mortality associated with this. However, the cost of the treatment was a staggering $10000 – $15000 per year. Sadly, almost a billion people in the developing world live on less than $1 a day, meaning that even though an effective treatment for HIV/AIDS exists , for many it remains simply a dream.

 

So what’s being done? What is the way forward?

Countries such as South Africa and Brazil have taken a stand to prevent those in dire need from receiving healthcare access. For example , in 1997 SA passed a law  allowing government to import or  manufacture cheap alternatives to the treatments. Brazil’s government in a similar move began to offer free ARV treatment to AIDS patients. Unsurprisingly this was met with much opposition from pharmaceutical companies as well as the US, however cases were dropped.

Fortunately, there is a provision in the TRIPS agreement allowing ‘Compulsory Licensing’. What this means is that a member nation under certain circumstances such as a national pandemic can grant someone else the right to produce a patented product without the patent holder’s permission. Such third parties could then produce these drugs at a fraction of the price, as they do not have to recoup the cost of R&D undertaken by the original patent holder

So, problem solved right? No not quite! Overuse such provisions, and we’re back to square one. No pharmaceutical company is going to want to undergo R&D if their patent rights are just going to be ousted by compulsory licenses.

What are some things that might work?

  • Developing an R&D agenda whereby pharmaceutical companies work in conjunction with the WHO, prioritizing research for diseases, which constitute major health, concerns.
  •   Implementing differential pricing between developed and developing nations in regard to drugs considered essential.
  • Improving health infrastructure in developing countries to limit the spread of such pandemic diseases.
  •  Promoting R&D within developing countries with a focus on developing therapies to combat local diseases.

Overall, health care access in developing nations need to be viewed not just as a health issue, but as an economic one also. Government and industry must work in such a way that both efficiency and equity are attained, and that people in developing nations are not denied the right to preventative or curative therapies.

 

Leave a comment if you agree or disagree with what has been said, as feedback and debate on the matter are encouraged and appreciated!

From the ‘Mind the Gap’ team

The USA – Does wealthy really mean healthy ?

 

We often tend to have this misconception that by increasing a nation’s GDP, we increase the quality of health within it. While there is an element of truth to this, it must be considered that inequities across a range of  areas prevent attaining the highest level of health for all individuals and groups in a population.

The USA has the highest GDP in the world and ranks 5th on the United Nations Human Development index. However despite this overall bright picture for this nation , health outcomes within the country and across population subgroups are far from ideal !

Despite being what the layman would consider a ‘wealthy’ or ‘developed’ nation , here are some facts that suggest that “wealth does not necessarily mean health”, and that disparities and inequities within a population can have significant impacts on its health status.

  • The American healthcare system is ranked at 37th in the world.
  • According to the William Johnson & Joseph Hickey Academic Class model, 14-20% of the American population would be classified as being “Lower Class”.
  • McMichael reported mortality rates to respiratory diseases and digestive diseases to be four times higher in the lower class than for the highest class.
    • Therefore we can estimate the mortality rates of 14-20% of the American population to be around 4 times higher for respiratory diseases and digestive diseases.
  • America has a growing divergence between the upper and lower class in terms of healthy eating. This means the upper class are becoming healthier while the lower class are become less healthy.
Growing class divergence in healthy eating

Growing class divergence in healthy eating

  • Income inequality (measured by Gini Coefficient, where a coefficient of 0 means perfect income equality) has been steadily growing.
Increasing Gini coefficient indicates rising levels of inequality

Increasing Gini coefficient indicates rising levels of inequality

  • Neglected tropical diseases such as Chagas (normally considered to be a disease of poverty in developing tropical countries) are becoming a problem, concentrating in the poorest parts of the cities. It is thought that poor housing due to low income, environmental destruction, and poor access to healthcare are important factors attributing to the rise of this disease.

When we begin to look at subgroups rather than a nation as a whole it becomes quite clear what crippling effects inequity has. In the USA , health outcomes vary across a range of areas.

  • Strong associations between Race/Ethnicity and health outcomes
    • Native Americans , African Americans , Latinos are more likely to rate their health status as ‘poor’ compared to White Americans and Asians.
    • For women in similar socioeconomic backgrounds , African Americans and Native Americans.
    • Native Americans and African Americans experience higher levels of mortality than Whites or Asians across each age groups.
  • Women of colour are at greater risk of adverse outcomes
    • African American women were around  twice as likely to be diagnosed with hypertension than white women.
    • African American and Latina women experience higher prevalence of diabetes than White women.
    • African American women were more likely to delay or forego medical care compared to White women. This could be for a range of reasons such as cost, lack of insurance, inadequate access to services , or family/work commitments.

In the US, public health benefit schemes are far less comprehensive than ones such as   Australia’s ‘Medicare’. Whereas many developed nations have a universal healthcare scheme, health services are predominantly provided by the private sector. Thus , access to basic healthcare is quite heavily dependent on having private health insurance. Lack of insurance could thus have adverse effects on a person’s health as they are less likely to seek medical treatment for preventable ailments and thus more likely to experience more severe illness.

Income and ethnicity tend to be the greatest determinants of  whether or not an individual is covered by health insurance. For many , the high cost of health insurance prices them out of being able to access health services in all but the most severe circumstances. Very often it is those in the greatest need of medical treatment who are unable to access it.

Ethnic minorities* now make up approximately a third of the US population however they make up around half of those who are uninsured. This is again linked to the fact that many people of ethnic minority groups also fall into those with socioeconomic disadvantage.

Despite the powerhouse of an economy that the US has, its health and healthcare fall short, with a myriad of social, economic, and health inequalities plaguing the country, there is a lot that should be done. It is easy to see what should be done, however the difficulty lies in applying a solution. Most countries reduce income inequalities with high taxation and transfer strategies, however with the rich of the US having so much power over the government, it would be highly unlikely to be able to enforce such policies. It is also likely that poorly made policies would in fact hurt the lower class more should the upper class transfer their losses to the lower class through increasing price of goods to make up for taxes. Nonetheless, something must be done! How do you think US policy makers should act to reduce inequality in the USA?

Leave a comment if you agree or disagree with what has been said, as feedback and debate on the matter are encouraged and appreciated!

From the ‘Mind the Gap’ team

Somalia- A Lawless State of Inequality

The inequality we seek to put an end to, is the inequality that inhibits the progression of mankind. It is dangerous to the point that the World Economic Forum’s Global Risk Report rated inequality as the number 1 global threat in 2013, and labeled as dangerous and divisive by the IMF.

How can global inequality have an impact on global health? Lets look at income inequality on its own. The top 100 billionaires of the world had accumulated $240 billion in wealth in 2012, enough to end world poverty four times over. Had this income been equally distributed across the globe, access to basic necessities would be guaranteed, and mortality across the globe to a host of health problems related to poverty such as malnutrition and malaria would be drastically reduced. This is a world we dream of. And it is one that we must constantly strive to push for and advocate.

Somalia can be considered the peak of inequality, corruption and poverty. The country is in a state of constant civil war plagued by a lack of functioning government, terrorists, pirates and armed forces. The ongoing civil war has severely damaged the country’s education infrastructure such as the schools.

Many schools have been abandoned due to prevailing high levels of insecurity. It was estimated that less than 25% of children had access to primary school education between 2000 and 2008, while secondary school attendance for the same period was 6%. The conflict has thus created a ‘missing generation’ in Somalia, where hundred of thousands of young people are deprived of access to basic education, an inequality in education, with illiterate individuals having a life expectancy up to 10 years lower than that of the national average.

This inequality also fuels corruption and enrolment to piracy to generate an income and survive. Meanwhile, corruption and military power allow the build up of riches to those who are best at surviving in such a harsh environment.

Despite this, the country continues without a properly functioning government, which is the most likely cause for poor health services, and access to clean food and water, both of which are detrimental to health outcomes. Poor safe-water infrastructure has made acute watery diarrhea (AWD) and cholera a frequent and widespread center of disease outbreaks in Somalia. Only recent efforts by WHO to reduce the inequality in safe water infrastructure was able to reduce the specific mortality rate associated with AWD by 80% in 2009 to 324 deaths from 1076 in 2007.

Inequality in health care access in Somalia means that only 9% of births are being attended by a skilled birth attendants, leaving one out of every 12 women to die due to pregnancy related causes. It is even estimated that one out of every ten Somali children die before seeing their first birthday. It is believed that the leading causes of child mortality are illnesses such as pneumonia (24%), diarrhea (19%) and measles (12%), all of which are diseases predominant in countries chained down by heavy poverty and inequality.

And what drives these inequalities in Somalia? Big US oil-companies who disempower Somali governments to send the country into war which allows them to hold power over areas rich in oil freely, making millions on the lives of those Somali who are now cut so short by their country wrought with corruption, conflict and inequality.

It is important therefore that we consistently urge global organisations such as the WHO to make these companies accountable, and redistribute the income made from these areas, back to the reestablishment of their central governments, and reorganization of socioeconomic infrastructure such as schools and the sanitary access to clean water and food.

Currently, donors efforts provide aid in food, medicine, establishment of schools, basic infrastructure and clean drinking water, however what we are not doing is addressing the causes of these failures in the first place. Somalia has always been underhandedly dealt with by monolith oil companies, causing the repeated toppling of their governments, and creating constant conflict within the country. It needs infrastructure which allows safe and appropriate access to rural areas to secure local food production such as roads and communications, and requires less discretionary assistance, and more guaranteed social protection, such as cash transfers to the poor households in times of crisis (cash transfers should be preferred over food since often supply is not the problem, and food aid often cripples local suppliers) which allows for more rapid responses such as in the 2011 Somalia drought.

It is important therefore that we consistently urge global organisations such as the WHO to make Oil companies acting on Somalia accountable, and to redistribute the income made from these areas, back to the reestablishment of their central governments, and reorganization of socioeconomic infrastructure such as schools, roads, communications and the sanitary access to clean water and food.

“If you don’t share your stability and economic success with the poor, the poor will share their instability and their poverty with you”

 

Leave a comment if you agree or disagree with what has been said, as feedback and debate on the matter are encouraged and appreciated!

 

From the ‘Mind the Gap’ team.

Just a bit of perspective

Living here in Australia, we tend to take for granted the relative freedom, safety, comfort and wealth we have relative to many parts of the world.

So just for a moment, stop and think about the 2 billion plus people living in poverty across the world! Why is it that we live healthier lives than they do? Why is it that we have significantly longer life expectancies? A range of factors in fact: disparities in infrastructure, healthcare, education and of-course, gross income have significant connections to overall health outcomes in a population.

But what is health? The definition of health has evolved greatly as our understanding of what influences health has improved. It has become glaringly apparent that health is not just the outcome of genetic or biological processes, but is also influenced by the social and economic conditions in which we live. These influences are known as the social determinants of health.

You might then assume that the wealthiest nations are the ones with the best health outcomes; this is anything but the truth.

The USA , with the world’s highest GDP of 17.4 trillion USD (IMF World Economic Outlook October 2014) has a life expectancy of only 79 (WHO World Health Statistics 2014) compared to Australia’s 83 with a GDP of 1.4 trillion USD. Perhaps one would argue that this is because Australia has a higher GDP per capita. What if we look at the USA compared to the Czech Republic? The USA has a GDP per capita of 54.7 thousand USD, while the Czech Republic has one of 19 thousand USD, yet despite this drastic difference, the life expectancy of the Czechs averages at 78, only one year less than that of the USA. A small difference maybe, but a significant one nonetheless, and shows that a nations health is not directly related to its wealth.

What is the cause of this disparity? The social determinants of health can possibly explain this through inequalities that exist in a country such as the USA which are less pronounced in a country such as the Czech Republic, or Sweden. These factors are described in the World Health Organisations (WHO) definition of social determinants as “the social conditions in which people live [which] powerfully influence their chances to be healthy… factors such as poverty, food insecurity, social exclusion and discrimination, poor housing, unhealthy early childhood conditions and low occupational status are important determinants of most diseases, deaths and health inequalities between and within countries”.

 

Indeed, when comparing these factors in the US compared to the Czech Republic, we can see why the US presents with poorer health outcomes relative to their stronger economy. In the US 15.1% of the population live below the poverty line compared to the Czech Republics 9%, not only does this drastically lower the health of that group (it is well known that poverty and poor health go hand in hand), but it also affects the health of the whole population, as a larger population stricken by poverty means weaker social cohesion, which often grows stress, fear, greed, violence and crime, all of which negatively affect health outcomes.

Eventually the only way for the people at the bottom to survive is to claw their way to the top, even if its at the cost of others.

Poverty is a highly influential factor of inequality on health, so much so, that year after year its reduction is made an important goal for global health organisations such as the WHO, and it is important that we as capable and blessed people do everything we can to assist those in need, not just in poverty stricken countries such as in Africa, but in your own communities and cities.

It is also important to consistently remind the government of the plight of the less fortunate, as the mouths of the rich are always at the governments ear for their own benefit. Should you see inequality in your own nation, let your government know! Let your representative bodies know! In Australia there exists much inequality between the Aboriginal People of Australia, and the non-Aboriginal People of Australia. It is up to each and every one of you to remind the government to make the closing of the gap a top priority, as the spill over effects from the reduction in inequality and improvement of social cohesion would be significant in improving national health outcomes.

The issue is not just one between rich and poor, but that bridging the levels of inequality across a range of indicia within a nation are vital in improving the health outcomes within it.

For now , here is a TED talk which puts things into perspective and shows us just how important minimizing inequity is !

 

Leave a comment if you agree or disagree with what has been said, as feedback and debate on the matter are encouraged and appreciated!