Griffith Review has kindly allowed republication here of the essay below by Australian health journalist and medical student Amy Corderoy.
In this #LongRead titled ‘The Sickness of social organisation: inequality will be the death of us‘, Corderoy explores the impact of the social determinants of health, including through the work of World Medical Association president Sir Michael Marmot, a New Zealand study that shows how early life experiences of disadvantage shape people’s ‘choices’ well into their adult lives, and a drive across Sydney to meet up with her friend and fellow medical student.
Her essay first appeared in GriffithReview 55: Millennials Strike Back <https://griffithreview.com/editions/millennials-strike-back/>, edited by Julianne Schultz and Jareth Head.
Amy Corderoy writes
TAKE A LOOK in your medicine cabinet; these days, it’s where wellness lives. No longer satisfied with treating illness when it occurs, we strive for something more. Every part of our body, inside and out, has a ‘natural’ product aimed at improving it. We take pills for energy during the day and pills to help us sleep at night. Few of these products have any evidence that even vaguely supports the promise that they work, let alone proof. In fact, they may be doing you harm – even the relatively mainstream, like vitamin C, vitamin E and beta carotene. (The jury is still out on a definitive answer, but all of these, and some other vitamins, have been linked to cancer deaths when taken at high doses.)
Australians are currently spending around four billion dollars a year on complementary and alternative medicines and therapies. That’s more than double the entire annual health budget of the Northern Territory. It is our fastest-growing area of health spending. The federal drug regulator provides an ongoing catalogue of the failings of the more bizarre products to which we direct our wellness dollars: herbal detoxes that contain illegal ingredients; vaginal probiotics; naturopathic arthritis medication.
While the worried-well shell out great amounts stockpiling placebos, the poor get sicker. What if all those billions of dollars were poured into some real wellness? Perhaps along with our tobacco tax, we need to introduce a snake- oil tax as well. We need to start thinking of this waste of wellness dollars as an ethical issue. Because the money is needed elsewhere. And desperately.
Growing gap between the haves and have-nots
FIXING HEALTH INEQUALITY in Australia really is a life-or-death issue. As a nation we are spending big on our health, but the gap between the haves and have-nots is growing. Perhaps the most famous and shocking gap in Australia’s health outcomes is between Indigenous and non-Indigenous Australians, where the ten-year life expectancy difference has remained, despite a polity that purports to have placed a high priority on the issue. But there are other gaps, all around us. These gaps are infiltrating every area of life, punching so many holes in our so-called ‘universal’ healthcare that they threaten to destroy it, leaving nothing but a moth-eaten dream of a system we used to be proud of.
Take the life expectancy gap between people with a serious mental illness and the rest of Australia. Only two out of every ten people with a condition such as schizophrenia or bipolar disorder can expect to make it to the average Australian life expectancy. Or the difference between city and country, where the further out you go the more likely you are to die an avoidable death. And even if you don’t have an obvious risk factor such as a mental illness, there is one clear way of predicting your chances of living a longer or shorter life: your income. When researchers divide Australians into five income group-ings, they find a steady increase in the rate of deaths as they move from the very richest to the very poorest. So much so that a man in the poorest group can expect to live about four years less than a man in the richest group.
Australia’s peak health-statistics body estimates 54,200 lives could have been saved between 2009 and 2011 alone, if everyone in Australia had the same mortality rate as those at the very top. Just think about that. Fifty-four thousand. In only two years. The choices we are making not only about how to distribute our health spending, but how to organise our society, are costing lives.
SYDNEY IS NOW Australia’s most unequal city when it comes to income, a phenomenon I can see written all over the streets on my drive from my home in leafy Bellevue Hill, where the median weekly income is more than $2,500, to visit my friend Yusuf in Punchbowl, median income $920. A child born in my area can expect to live about two years longer than a child born at my destination. I drive past the offices of Prime Minister Malcolm Turnbull, (conveniently located not too far from his Point Piper mansion, valued at approximately fifty million dollars), through the exhaust-clogged M5 tunnel, before hitting the wide streets and low-rise spread of south-west Sydney.
I meet Yusuf at a restaurant called Jasmin1, around the corner from where he went to the then-notorious Punchbowl Boys High School. Many of the suburbs in south-west Sydney have some of the poorest health outcomes in NSW, and also happen to be the most socio-economically disadvantaged. Yusuf went to Punchbowl Boys in the early 2000s, in the days before NSW politician and former headmaster Jihad Dib rose to fame for turning the school around, and I want to talk to him about how life in a poor suburb can influence your wellbeing not only when you are young, but throughout your whole life.
We chow down on smoky shawarma on a bed of hummus, baba ganoush and fatoush salad while Yusuf casually tells me stories of a school surrounded by barbed wire, where kids brought knives to class and he quickly learned that physical strength was the only way to get through. ‘I never wanted to be smart, I never wanted to learn anything, to study – that’s what got you beat-up,’ he says. Once, classes were interrupted when gunshots rang out from the nearby streets, fired during the infamous war between two local crime families, the Darwiches and the Razzaks. ‘I think it did change the kids that went there. I saw them come into year seven, and lots of them were good kids, smart kids. But it wasn’t about learning. It was only about becoming a gangster; fighting, smoking and sleeping around.’
Yusuf estimates he was one of only three in his Year 12 class who got a UAI above thirty in the HSC and was able to go directly to university. When you start adult life with disadvantage like this, it affects more than just your long-term earning abilities.
Pervasive role of the social determinants of health
A FEW YEARS ago, I was working as a health reporter at the Sydney Morning Herald, on a project where I matched obesity, preventable hospital admissions, smoking and other health problems with data from the Australian Bureau of Statistics on disadvantage. When I arranged my data by social- disadvantage figures, I gasped. Numbers that had been all over the place ordered themselves as if by design, with the poorest suburbs having the worst health outcomes and the richest having the best.
If you are unemployed or in a low-wage job, it turns out this has lasting impacts on your health. Not only are you likely to die younger, you are more likely to live sick. Smoking, obesity and high blood pressure all run higher the lower you sit on the socio-economic ladder. Perhaps unsurprisingly, too, chronic diseases such as diabetes, osteoarthritis, cancer and even Parkinson’s disease are all more common among the less well off than the wealthy, and show a clear gradient from poorest to richest. ‘Growing up, I never felt safe,’ Yusuf explains. ‘If you don’t feel safe, why would you be worried about getting your teeth fixed, or eating healthily? You have to take comfort from something – food, drugs, something.’
The only health issue in my report for the Herald that didn’t follow this pattern was long-term alcohol-related illness. And so, the next day, the headline on the story I’d been researching for so long screamed: ‘Booze the problem in wealthy suburbs.’
Looking back, I wonder if I missed the bigger story. The truly powerful figures were perhaps not those showing the difference between the richest and the poorest – it was those showing the steady gradient in between. After all, most people are not surprised by the fact that the very poor tend to get sicker. They have less access to healthy food, gym memberships, jobs in which their health is not damaged, and less education about how to make their lives healthier. But what about the people in the middle? The statistics show that when it comes to heart disease, diabetes, even death, while there is a dramatic difference between the richest and the poorest, everyone’s health is to some degree influenced by their income relative to the rest of society. Those fifty-four thousand extra deaths weren’t just among the very poorest, they were lives taken from everyone except the very richest. Take a look at your boss: should you really accept that it’s fair enough that you are (statistically) more likely to get heart disease or diabetes than him or her? To die younger?
SICKNESS AND DEATH are an inevitable part of life. But perhaps the reason we are all so susceptible to wellness claims is that we sense this inequality, and crave a way to stake our claim among the healthy. Millennials have grown up as one of the most privileged generations when it comes to health. Medicare as we know it came into operation less than a month after I was born, in 1984. We’ve also been the beneficiaries of huge advances in knowledge about lifestyle and medical risk. We know we can influence our health trajectory by the choices we make. Smoke, and you are more likely than not to die from cancer or some other tobacco-related disease. Eat badly, and you will at best get fat, at worst get sick – and so on. Nowadays we have apps and wearable devices to monitor (and obsess over) those choices, watching everything from our food intake, our exercise, our mood, even our menstrual cycles.
But it’s also a lot more complicated than that.
The eminent British epidemiologist, Professor Sir Michael Marmot, President of the World Medical Association and presenter of 2016’s ABC Boyer Lectures, has shown that a person’s lifestyle and health choices (what medical types like to call your ‘risk factors’) simply cannot account for the differences seen in death and disease among people of different incomes. In his landmark Whitehall study, which examined British men working in different levels of the public service, those on the lowest grade of employment still had double the risk of dying from heart disease – even when accounting for all the factors we traditionally think of as causes. There was a clear gradient of risk between levels, with deaths decreasing as the public servants climbed the employment ladder.
Marmot became the father of a movement that is pushing to see health as a social-justice issue by convincingly arguing that something more than lifestyle influences health: social status. He believes a person’s autonomy over their life and a sense of social connectedness are key factors in maintaining good health. Low control not only makes it difficult to lead a healthy lifestyle, it also leads to chronic stress – a daily assault on our body that predisposes us to illness. Just think about that: the more unequal society becomes – the more exploited and powerless people feel in their workplaces and lives – the more likely they are to get sick.
When society gives children a tough start, do we all pay for it later?
BY THE TIME Yusuf started at Punchbowl Boys, he had been to seven different primary schools. As a child of refugee parents, he had already faced the kind of adversity that many Australians never experience. Increasingly, research shows that it’s not enough to attempt to tackle inequality among adults: the seeds sown in early life alone can be enough to set some up to fail. A ground-breaking study published at the end of 2016 indicates just how powerful these effects can be. The Dunedin Multidisciplinary Health and Development Study has followed more than a thousand New Zealanders from age three all the way through to age thirty-eight, attempting to create a detailed picture of health, development and behaviour. In their most recent analysis of the group, the researchers decided to examine how much of a role early-life adversity played in a number of – to use their term – ‘economically burdensome outcomes’. That is, when a society gives children a tough start to life, do we all pay for it later?
The results are astounding. The team identified a fifth of the group who had the highest risk of being ‘economically burdensome’, due to a combination of childhood deprivation, maltreatment, low IQ and poor self-control. By the time these children had grown up, they accounted for a huge proportion of health and criminal-justice spending; by age thirty-eight they had used two-thirds of the group’s welfare benefits, accounted for just over three- quarters of the year’s children that lived without a father, smoked more than half of the group’s cigarettes, carried 40 per cent of the excess kilograms, occupied well over half of the hospital-bed nights, filled more than three- quarters of all prescriptions, and were convicted of 81 per cent of the crimes charged to the group. These early life experiences of disadvantage were shaping their ‘choices’ well into their adult life.
The researchers demonstrated that their model could predict, with about 80 per cent accuracy, the life outcomes between those who would be considered ‘economically burdensome’ and those who wouldn’t, from assessments of their subjects’ intelligence, skills and coping abilities at just three years old. The results, they concluded, had ‘implications for human rights’: adults who appeared to be living the hardest lives, and costing society the most, were starting ‘the race of life from a starting block somewhere behind the rest’.
Starting life with early disadvantage is not an immutable sentence. Yusuf not only graduated from university, but is now studying to become a doctor.
Instead of investing in evidence-based early intervention, political leaders have continued to oversee a relentless march towards inequality, creating more and more children who start ‘the race of life’ behind the rest, and have far less chance of living a fulfilled and healthy life. They leave us with our self- monitoring, our alternative treatments and lifestyle ‘choices’, as if our wellbeing can be outsourced to the individual. But the truth is, it gets inside you, this disadvantage, creeps into your cells and changes the very core of your being.
Genetic impact and lifetime risks of ‘toxic stress’
AN APPARENT PUBLIC obsession with genetic determinism has emerged in recent years, one that conveniently places the health of the individual in the hands of dual gods: biological parents and personal choices. We inherit our genetically determined life from our parents, and from then on our health – and life – depends on the interaction of our lifestyle choices with this complex chain of programmed instructions. But the emerging science of epigenetics shows life experiences can actually change the way a person’s genes are expressed.
DNA, our genetic code, works by placing different molecules in various combinations, which, when ‘read’ by the body, instruct it in the production of every protein necessary for growth and function. But a whole family of enzymes exist that chop and change the functioning of DNA, so that a gene that might have produced a trait – or a health effect – in one person can be switched off in another. Simply adding an extra chemical chain to two DNA molecules in particular – cytosine and adenine – changes the instruction manual read by the body, a process known as ‘methylation’. Our standard of living, and poverty in particular, is emerging as a particularly important pathway through which these enzymes are manipulated.
Over the past ten years, at least 27 studies in humans, and many in other animals, have identified one candidate gene in particular, known as NR3C1, which appears to be linked to methylation-induced changes in response to early life adversity and parental stress. NR3C1 alters a receptor in cells that binds to cortisol, and is involved in inflammatory responses as well as cell proliferation and development. And NR3C1 is just one such gene. A number of other genes, including MAOA – the so-called ‘warrior gene’, which affects neurotransmitters such as dopamine, norepi-nephrine and serotonin – have also been identified as undergoing methylation in response to early life adversity.
Studies in monkeys indicate that such methylation-induced changes are deep and far reaching, with altered levels of hormones linked to hypertension, infertility, susceptibility to infectious diseases and behavioral disorders, and even preferences for energy-dense foods. These life experiences have been described by scientists working at the cutting edge of this research as creating a kind of ‘toxic stress’, which embeds itself as ‘a physiological memory’, conferring a lifetime risk of illness well beyond the initial insult. The effect is so strong that the American Academy of Pediatrics has recommended that many common adult diseases should in fact be viewed as developmental disorders.
These changes run all the way, in some cases, to the next generation. A recent review in the journal Nature described how animal and human studies indicate changes induced by diet or stress can be seen in the children of people who experience adversity such as famine or war.
This research, while preliminary, should not be confined to the domain of science. It can already begin to guide how we think about organising society and run government services to help those in need. There is a good chance that the decisions we make about how much inequality to allow, about how much to spend on improving the lives of those at the very bottom of the socio-economic ladder, could have health effects for generations to come.
Leading child-health experts now believe that glaring health gaps across the country will not be closed until the social problems that entrench health disadvantage in the earliest years are addressed, and safe, supportive environments for children are created at the earliest possible stage. There is a moral sickness in a society where the powerful pursue policies that advance their own economic and social interests at the cost of the least powerful. Australia is shaping a future that is far less egalitarian, more divided by wealth and status, than we realise.
What are we (all) willing to give up for good health?
ALREADY POLITICAL LEADERS claim that health spending is ‘unsustainable’. These baby boomer politicians will form part of the ageing population likely to make up much of the financial burden, yet young people will be left with an economic landscape shaped by their choices. The unspoken assumption is that by cutting government health spending and asking individuals to take on more of the burden, sustainability will be achieved. But if inequality increases, and access to care decreases, we risk simply creating more sickness.
It will also shift the pattern of health spending. Poorer people will avoid treatment until they are very sick – when the personal cost, suffering and system costs are greatest – while the well-off will buy the most convincing cure. The outlines of this trend are already clear, and research has found wealthier Australian women are less likely to seek hospital treatment than poorer women, but are much more likely to receive alternative treatments. After all, this push towards a self-monitoring wellness culture comes from knowing the value of good health.
Michael Marmot argues that the quality of its citizens’ health should be the key factor on which the functioning of a democracy is judged. This is a radical proposition, because equality of health requires not only changes from each of us, but major social reorganisation to prevent entrenched social disadvantage setting people on a life path of ill-health from birth.
‘Good health’ might seem a narrow proposition on which to judge a democracy (political freedoms, happiness, participation all spring to mind as alternatives), but it’s worth at least considering in order to help us understand why so many are willing to spend their money and time in the pursuit of it – and what we are really willing to give up to achieve it.
Some names have been changed to protect privacy.
For references see griffithreview.com
Amy Corderoy is a freelance journalist and former health editor at The Sydney Morning Herald. She has received the National Press Club’s Excellence in Health Journalism award, the Public Health Association of Australia’s President’s award, and the National Prescribing Service media award. In 2016, she left full-time journalism to study medicine at the University of Notre Dame, Australia.
Her essay ‘The sickness of social organisation’ first appeared in GriffithReview 55: Millennials Strike Back <https://griffithreview.com/editions/millennials-strike-back/>, edited by Julianne Schultz and Jareth Head.
The edition features millennial writers – those born in the final decades of the 20th century – on work, technology, identity, housing, globalisation, connectivity, music, casualisation and automation, environment, economics, family, prejudice, politics, protest and dreams for the future.