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The AMA advocates on behalf of the medical profession and the public - operating at a federal level and within each state and territory. Interventions to address inequalities can be referred to as occurring upstream, midstream or downstream.
Upstream determinants are those that occur at the macro level and include global forces and government policies. Midstream determinants are intermediate factors such as health behaviours while downstream determinants occur at the micro level and include one's genetics 1. Central to this is the recognition that not everyone has the same level of health or capacity to deal with their health problems, and it may therefore be important to deal with people differently in order to work towards equal outcomes.
Australians generally have good health. Australia is consistently ranked in the top 10 of OECD nations in many areas, including life expectancy and mortality rates 2. But many Australians, particularly Aboriginal peoples and Torres Strait Islanders and people who are socio economically disadvantaged suffer poor health compared with the rest of the population.
In these cases, there are profound health and life expectancy inequities. It could be argued that the extensive health and social inequities experienced by Indigenous Australians overshadow the inequities experienced by other population groups in Australia. The social determinants of health have always been important to health.
They underpinned much of the early public health with its focus on living conditions. Prior to the development of effective medications and other measures it was only the social determinants that could be influenced to improve health. However, with improvements in medication and specific treatments for specific diseases, coupled with an increasing political focus on individuals and their locus of control, social determinants have not always been at the forefront of ways to influence and improve health.
In order to decrease health inequities, it is critical to not only include treating diseases and modifying risk factors such as smoking but also to increase the focus on the social determinants that make these risk factors and subsequent diseases more prevalent. In addition this position statement recognises that there is a role for individual responsibility in determining a person's health. There are large economic costs associated with health inequalities.
Countries that have fewer income inequalities also appear to have lower mortality rates. Also countries that prioritise redistribution of income through fiscal and social policy have lower health inequalities and better overall population health than those that do not 3.
As societies with high levels of income inequality tend to have more violent crime and less social cohesion addressing health inequities is important to all of us. In their document, Inequity and Health: A call to action, the Royal Australasian College of Physicians identified health inequities as one of the most pressing problems currently facing Australia.
Social determinants are the social and environmental conditions in which people live and work, and include the following:. A social gradient of health runs across society and, while the most profound differences in health can be seen between the most and least disadvantaged, a gradient exists across the population in which, for example, those in the upper middle of least disadvantage will have better health than those in the lower middle of least disadvantage 4.
Disadvantage has many forms and can be absolute eg not having access to education or unemployment , or relative eg poorer education, insecure employment. Each of life's many transitions - such as leaving school, getting a first job - can affect health by moving people onto a more advantaged or less advantaged path. People who have been disadvantaged in the past are at greater risk in every subsequent transition.
Disadvantages tend to congregate among the same people and their effects tend to accumulate through life and are passed on from generation to generation 4. Continuing anxiety, insecurity, social isolation, and lack of control over work and home life are examples of such stressors. As well as contributing to poor mental health, the inappropriate and regular activation of the body's stress response impacts negatively on the cardiovascular and immune systems.
While not a concern in the short term, in the long term these feelings of stress make people more vulnerable to conditions such as infections, obesity, diabetes, hypertension, stroke and depression. In industrialised countries, these conditions are more common in people who live in the lower levels of the social hierarchy 4. Slow growth and poor early experience become biologically embedded during development.
They increase the lifetime risk of poor emotional health and reduce physical cognitive and emotional functioning into adulthood. Poor experiences during pregnancy such as nutritional deficiencies, maternal smoking, alcohol and drug use, and inadequate prenatal care can lead to poor foetal development, which is a risk in itself for poor health later in life 4. Poverty denies people access to full participation in the life of the community.
In the international context, those who are homeless have the highest rates of premature death. Social exclusion also results from racism, discrimination, stigmatisation and unemployment. The greater the length of time that people live in disadvantaged circumstances the greater the risk for ill-health, particularly cardiovascular disease. As people move in and out of poverty during their life, the prevalence of people who have experienced social exclusion and its negative impact is greater than the current incidence 4.
Poor education means a person is less likely to attain secure and well paid employment and this can lead to poverty and other predictors of ill health. However stress at work increases the risk of disease.
Jobs that are demanding and where employees have little control or decision making in their employment are the most detrimental to health. Improved work conditions will lead to a healthier workforce, which will, in turn, improve productivity and decrease absenteeism 4. Occupation is often used as a measure of socio-economic status. These risks are higher in regions where there is widespread unemployment and when the risks relate to the psychological and financial particularly debt effects.
The health effects begin when people first feel their jobs are under threat, prior to becoming unemployed. Job insecurity or very unsatisfactory employment can be as harmful as unemployment, with increasing effects on mental health, heart disease, and the risk factors for heart disease 4.
After a certain income there is no longer a correlation between increased income and Upstream And Downstream Problems Class 10 No increased health. However, the health benefits of increased socio-economic status become smaller as socio-economic status increases 4. In the past 20 years, income inequality has been increasing in Australia. As an example, between and there was a 20 per cent increase in the taxable income of Australians. However, the poorest postcodes achieved an increase of only 16 per cent whereas the wealthiest postcodes achieved an average increase of 25 per cent.
This trend also exists internationally within and between countries with income inequality increasing in nearly all countries since the s. All these aspects have a protective effect on health and provide a buffer against health problems.
Without them people are likely to experience less well-being, more depression, and higher levels of disability from chronic diseases. At the societal level, social cohesion the quality of social relationships and the existence of trust, mutual obligations and respect in communities helps to protect people and their health. Societies that have high levels of income inequality tend to have less social cohesion and more violent crime 4.
Often people turn to alcohol and other drugs as a way of reducing the pain of harsh social and economic realities. Unfortunately, apart from a temporary release, these substances only intensify the factors that lead to the use in the first place.
These substances are a large drain on people's incomes, reduce participation in society, and are a large cause of ill-health and premature death 4. Food poverty can exist side by side with food plenty, while access to good quality food makes a greater difference to what people eat than nutritional education.
Generally, people on low incomes - such as young families, elderly people and those who are unemployed - are least able to eat well 4. In Australia, there is a particular issue with food security for isolated Aboriginal and Torres Strait Islander communities. Fresh fruit and vegetables must be carried many hundreds of kilometres, often in un-refrigerated, trucks and much of the nutrient value of the food perishes in the journey.
Once it arrives at the local store, it may or may not be able to be stored in conditions to maximise the nutrient value and it is definitely many times higher in cost than what would be paid in urban areas. Often there is also not the appropriate kitchen and cooking facilities to be able to prepare the fresh food into proper meals. Under nutrition can lead to susceptibility to disease in addition to specific disorders. An increase in food and fluid energy intake particularly with a energy dense of high sugar content is a factor in the development of obesity which is increasing rapidly in prevalence.
Some studies have shown that more affluent areas more likely to not have take away food stores. This implies that there is the market in less affluent areas for cheap take away type food.
People without private transport and people in places with poor or no public transport are less able to participate fully in the life of the community and its concomitant health impacts 4. But the issue that has the greatest impact on equity in health outcomes is racism whether it is at an individual level or institutionalised. Institutional racism refers to the ways in which racist beliefs or values have been built into the operations of social institutions in such a way as to discriminate against, control and oppress various minority groups.
It has been argued that institutional racism is embedded in Australian institutions. Often, institutional racism is covert or even unrecognised by the agents involved in it. Racism can affect diagnosis and treatment and therefore health outcomes.
Those with disabilities are more likely to be living in poverty and experiencing social exclusion than the general population. The presence of a criminal record can severely limit employment Upstream And Downstream Problems Class 10 Am prospects leading to poor health. Prisoners also require equity in access to health services given their burden of disease. People with a criminal record are less likely to be employed. It can be argued that all health practitioners have a responsibility to address equity in their work.
While upstream and midstream determinants influence the type, likelihood, number and severity of diseases that affect a person, downstream inequities come into play when a person becomes ill. They are at many levels:. People from higher socio-economic groups are more comfortable standing up for their rights, more able to educate themselves on their condition and challenge or ask doctors for specific treatments all assist in being able to work in partnership with their doctor.
Often these inequities are made invisible under the guise of treatments decisions eg risk of poor outcomes due to multiple other health problems; complicated lives; lack of transport etc to keep appointments; challenging treatments such as transplant and lack of carer support therefore encouraged 'just to have chemotherapy'. This is a human rights issue and Australia's greatest shame.
The AMA calls on the government to do this as a human rights issue. It is time for a public debate on health inequities and immediate interventions to reduce them. The AMA calls on government for initiatives with the explicit intent of reducing health inequities. All current and future policies must be assessed according to their impact on health and equity. Governments must stop policies and funding decisions that exacerbate inequities.
Systems must be established to monitor for unintended consequences of policies that may increase inequality. While monitoring changes in levels of inequality is important and necessary, priority must be given to research that identifies and evaluates interventions to reduce inequities. Targets in reducing inequality would be set Upstream And Downstream Problems Class 10 Windows and regular reported against at COAG meetings.
Prime Minister and Cabinet and the Premiers departments at state level should have carriage of, and be responsible for, initiatives to address inequities in the social determinants. This is imperative in order to reduce inequalities based on race. These should be publicly available and reported against annually. Heads of education should be responsible for adopting and meeting the targets.
Employment contracts should provide security of employment and 'quality living' conditions.
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