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Addressing health inequalities: some important questions for those who wield power

How do society’s powerbrokers contribute to social injustices and health inequities?

If we are to create a fairer distribution of health, we must recognise the powerful roles that individuals and the institutions of governance play in delivering and perpetuating unjust social treatment.

That’s according to Associate Professor Marilyn Wise, who recently delivered the Eberhard Wenzel Oration at the Australian Health Promotion Association’s recent National Conference.

 Below is a summary of her presentation.

****

Reflections on health equity: why is progress so slow and what else can we do?

Marilyn Wise writes:

Australians were among the longest-lived people  (ranked 3rd) in the world in 2010. Between 1901 and 2006, the average life expectancy at birth for all Australians increased by more than 20 years, including an increase of almost 10 years between 1960 and 2006.

However, Indigenous Australians’ life expectancy in 2010 was closer to that of countries ranked 150 for males and 140 for females. Between 1960 and 2004 life expectancy among Indigenous Australians increased by 8 years for males and 14 years for females.

In 2007 Australian Aboriginal peoples’ and Torres Strait Islanders’ life expectancy was the lowest among the indigenous populations of Canada, New Zealand, and the United States.

It is not possible to obtain data on the life expectancy of Indigenous Australians between 1901 and 1960. Between 1901 and 1967 the Australian Commonwealth Constitution Act stated that ‘in reckoning the numbers of the people of the Commonwealth […], aboriginal natives shall not be counted.’

Aboriginal people who were invited to complete the census in 1911 were required to state what proportion of their heritage was Aboriginal. If they were more than half Aboriginal, they were excluded from the Census results.

Not until 1984 were all states and territories required to fully identify Indigenous Australians in their births, deaths and data collections.

One result of this exclusion of Aboriginal peoples from the Census is that contemporary census and deaths data continue to be unreliable so that the magnitude of he life expectancy gap and mortality rates can only be based on ‘semi-theoretical’ modelling.

The life expectancy gap between the most and least socioeconomically advantaged fifths of the population in 1998 – 2000 was 4 years for males and 2 years for females.

In 2010, the life expectancy gap between the Indigenous and non-Indigenous populations born 2005-2007 was estimated to be 12 years for males and 10 years for females.

Since the 1980s there has been growing evidence of inequalities in the distribution of health in populations, and of the biological and behavioural and, later, social determinants of health (economic and social conditions that influence individual and group differences in health status).

Over the last two decades there has been growing evidence confirming that socioeconomic status and health status are strongly, positively associated: the more affluent you are, the better your health is likely to be.

Over the same period, many nations have made significant progress in reducing population-wide premature mortality from specific diseases and injuries and in reducing risks to health using a combination of health promotion and public health interventions including changes in social and economic policies. The scale of at least some of these successes has been large and the effects have been significant.

Barriers to reducing inequalities

Why, though, have high-income democracies such as Australia (and many others) found it so difficult to reduce inequalities in health?

Among the many reasons proposed to date, there are some that appear to have been under-examined.

This analysis rests on the contention that the causes of health inequity have not been separated sufficiently clearly from the causes of inequalities in health.

Health inequalities are differences, variations or disparities in the health achievements of individuals and social groups.

Inequalities in health are inevitable, they can be measured, and they are not inherently unjust or unfair.  However, some inequalities are unfair and stem from social treatment that is considered to be unjust.

‘The identification of inequity is not a scientific matter but is, rather, a judgement conditioned by ethical and moral criteria and political priorities.’

When linked with an implicit commitment to social justice, inequalities are considered to be morally wrong (by most, although not all, people) when they arise from unjust, unfair social treatment (that is beyond the control of individuals).  Such inequalities are considered to be inequitable, and to merit remedy by society and the state.

This distinction is critical in two ways.

First, there are wide differences in the priority given to equality as a core value of social justice – some view liberty and efficiency as values of higher priority. Others view inequalities as a necessary, inevitable consequence of a market economy.

Such differences have been codified in the platforms and policies of political parties, and in the policies and practices of social institutions and their actors.

Second, in all societies, some social groups have been systematically, and persistently discriminated against on the grounds of biological or social characteristics (e.g. race, religion, or location of residence).

This discrimination has included being excluded from the structures and processes of social decision-making and hence, being denied the power to decide when inequalities are inequitable – to decide when social treatment is unjust and unfair and merits social remedy.

Whitehead identified seven determinants of inequalities in health, and judged three of them to be unjust social treatment – inequitable.

The three determinants were:

• social institutions and actors that do not act to reduce people’s exposure to unhealthy, stressful, living and working conditions;

• social institutions and actors that deny people equal opportunities to access essential health, education, and other social goods and services;

• and social institutions and actors that leave people to engage in health damaging behaviours because they have not been provided with opportunities and resources to make healthier choices.

These findings were a clear re-statement of the knowledge that had underpinned the field of public health since the 19th century.

Important though it is to review contemporary experience, it is also important to reflect on reasons for the lack of success in achieving sustained changes in the distribution of health in populations.

It is of particular concern that there has been little shift in the composition of the social groups experiencing the greatest burden of unjust social treatment, or in the effectiveness of actions in reducing the burden on these groups.

Who decides?

This points to the need to look beyond ‘what to do’ and to re-examine ‘who decides’ what to do.

If it is accepted that inequalities are inequitable only when it is decided that they are unfair and unjust, who decides?

Who decides whether eliminating inequity (or another value) is to be a priority goal of policies or programs or projects?

Who decides on the issues that are included on the public agenda? Who decides on the priorities for and amount of investment? Who decides what policies are needed? Who decides what actions are to be taken?

Who is responsible for implementation? Who decides what constitutes success or failure? How do these decisions influence health equity?

The implication of this is to understand and recognise the ways in which the institutions and the actors responsible for legislation, policy, and service delivery (including health and health promotion/public health) influence the distribution of social goods, services, rewards, and burdens – positively or negatively.

There are many reasons for slow progress in reducing inequities in health.

But lacking in so much current analysis has been the lack of recognition of the powerful roles that individuals and the institutions of governance play in delivering and perpetuating unjust social treatment.

The values and beliefs embedded in our social institutions, in their policies and practices, and within each individual influence when we decide that people and groups are being treated unfairly and unjustly, and when we decide what actions should be taken, by whom, to remedy this.

Paul Keating, in his famous Redfern Speech recognised that change to ‘find just solutions to the problems which beset the first Australians – the people to whom the most injustice has been done. … the starting point might be to recognise that the problem starts with us non-Aboriginal Australians. It begins, I think, with that act of recognition.’

• Marilyn Wise is Conjoint Associate Professor at the Centre for Primary Health Care and Equity, University of New South Wales

• References are available upon request to Croakey.

****

For previous coverage of #AHPA2013:

Helpful hints for making an app

• What does it take to create healthier environments for children?

• What’s making the health promotion news on Twitter?

• Converging crises of environmental degradation and social injustice

 Indigenous tweeps out in force

• Conference preview by Suzanne Gleeson

In collaboration with conference organisers and tweeters, the Croakey Conference Reporting Service provided an overview of key sessions and discussions.

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