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2/10/2016
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Ad astra
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One Plus One
I expect most of you would answer with a resounding
YES. They make us sick when they lie, break promises, assail us with mendacious rhetoric, engage in adversarial behaviour, fail to recognise this nation's problems, seek to blame their opponents for any ills we have, and exhibit incompetence in doing what they are well paid to do.
They make us sick, though, in other ways - through their legislative actions. This piece will describe how policies can and do result in illness in individuals and groups in our society. It draws on the work of celebrated epidemiologist Professor Sir Michael Marmot, president of the World Medical Association, who is currently visiting this country. His book:
The Health Gap: The Challenge of an Unequal World is rich with information garnered over many years of studying inequities in health and their causes. He is a medical doctor who moved from clinical medicine to public health because he saw that it was necessary to look for the 'causes of the causes' of ill health, the causes behind the traditional medical causes. He saw that social factors were central in the genesis of ill health. He has made a life-long study of the 'social determinants of health' and headed a World Health Organization commission that published
Social Determinants of Health, Closing the Gap in a Generation in 2008.
Before looking at social factors in depth, let's examine some basic principles of cause and effect. The tubercle bacillus is a necessary factor in the genesis of tuberculosis, which usually affects the lungs, but sometimes other organs. But it is not the only factor. Some people exposed to the bacillus contract tuberculosis; others do not. A homely analogy is the 'seed and the soil' concept. No matter how potent the seed, it will germinate only in fertile soil, and wither on barren soil. Likewise, the tubercle bacillus needs a 'fertile' human environment to survive and cause disease. In the era of rampant tuberculosis in earlier centuries, there were the underprivileged who lived in cold, damp dwellings, who worked in dusty, demanding and dangerous occupations and who suffered malnutrition, whose bodies were thereby susceptible to the bacillus. The tubercle bacillus was therefore a necessary but insufficient factor in contracting tuberculosis. The susceptible host was the other necessary factor, and that factor derived from poor work and living conditions and poverty - all social factors.
Michael Marmot takes a holistic view of health. While acknowledging the importance of medical science in health and illness, he insists that there is so much more to it. In the introduction to his book he writes:
Knowledge of medicine and public health is not so much wrong, as too limited. Health is too important to be left solely to doctors. Health is related not only to access to technical solutions but to the nature of society. We are being foolish in ignoring a broader array of evidence, which shows that the conditions in which people are born, grow, live, work and age have profound influence on health and inequalities in health in childhood, working age and older age.
He illustrates his assertions with evidence. One of his most important is that the gradient of health parallels the social gradient. He contrasted life expectancy in two suburbs of Glasgow, Calton and Lenzie. He reported:
If a man dies in his prime in Calton, a down-at-heel part of Glasgow, it may be a tragedy, but it’s not a surprise. Actually, the question of what constitutes his ‘prime’ in Calton is moot. Life expectancy for men, when I first looked at figures from 1998–2002, was fifty-four. In Lenzie, a much more upmarket place a few kilometres away, ‘in his prime’ has an altogether different meaning: life expectancy for men was eighty-two. That converts to a twenty-eight-year gap in life expectancy in one Scottish city.
He carried out similar studies in several countries, with the same conclusion.
The social gradient in life expectancy runs all the way from top to bottom. It doesn’t just feel better at the top. It is better. At the top, not only do you live longer but the quality of life is better – you spend more years free from disability... The social gradient in disability-free life expectancy is even steeper than it is for life expectancy. ‘Disability’ here is quite broadly defined: any limiting long-standing illness. Talk about adding insult to injury: the more deprived people spend more of their shorter lives with ‘disability’. On average people at the top live twelve years of their lives with disability, people at the bottom twenty years.
I could go on quoting his many other studies, but will satisfy myself with his famous 'Whitehall' study of British public servants. The details are fascinating. Here's an abbreviated account of how Marmot described that experience:
The British Civil Service changed my life. Not very romantic, a bit like being inspired by a chartered accountant. The measured pace and careful rhythms of Her Majesty’s loyal servants had a profound effect on everything I did subsequently. Well, not quite the conservatism of the actual practices of the civil service, but the drama of the patterns of health that we found there. Inequality is central. The civil service seems the very antithesis of dramatic.
Please bear with me. You have been, let’s say, invited to a meeting with a top-grade civil servant. It is a trial by hierarchy. You arrive at the building and someone is watching the door – he is part of the office support grades, as is the person who checks your bag and lets you through the security gate. A clerical assistant checks your name and calls up to the office on the fifth floor. A higher-grade clerical person comes to escort you upstairs, where a low-grade executive officer greets you. Two technical people, a doctor and a statistician, who will be joining the meeting, are already waiting. Then the great man’s, or woman’s, high-flying junior administrator says that Richard, or Fiona, will be ready shortly. Finally you are ushered in to the real deal where studied informality is now the rule. In the last ten minutes you have completed a journey up the civil service ranking ladder – takes some people a lifetime: office support grades, through clerical assistants, clerical officers, executive grades, professionals, junior administrators to, at the pinnacle, senior administrators. So far so boring: little different from a private insurance company.
The striking thing about this procession up the bureaucratic ladder is that health maps on to it, remarkably closely. Those at the bottom, the men at the door, have the worst health, on average. And so it goes. Each person we meet has worse health, and shorter life expectancy, than the next one a little higher up the ladder, but better health than the one lower down. Health is correlated with seniority. In our first study, 1978–1984, of mortality of civil servants (the Whitehall Study), who were all men unfortunately, men at the bottom had a mortality rate four times higher than the men at the top – they were four times more likely to die in a specific period of time. In between top and bottom, health improved steadily with rank. This linking of social position with health – higher rank, better health – I call the social gradient in health. Investigating the causes of the gradient, teasing out the policy implications of such health inequalities, and advocating for change, have been at the centre of my activities since.
The difference between top and bottom was attributed to work stress. While initially it was postulated that those at the top had higher demand and more stress and therefore should have poorer health, that was shown to be wrong. There was another factor. Marmot puts it this way:
It was not high demand that was stressful, but a combination of high demand and low control. To describe it as a Eureka moment goes too far, but it did provide a potential explanation of the Whitehall findings. Whoever spread the rumour that it is more stressful at the top? People up there have more psychological demands, but they also have more control.
Having control over one's life, one's destiny, is a necessary factor for having a more healthy life.
Let's now look at how some policy decisions and legislative moves that the federal government has made, are likely to influence health. There are many; I shall select just a representative few.
Contemplate how those on welfare must have felt when Joe Hockey declared 'the end of the age of entitlement', when he tagged welfare recipients as 'leaners', supported by the good guys, the 'lifters', who worked and paid taxes to support them in their indolence, and when he brought in his punitive 2014 Budget designed to punish them. His behaviour increased their stress, reinforced any feelings of inadequacy they may have been harbouring, and deprived them of control over their destiny. They were in his careless hands. Hockey's policies and actions, supported by his leader and his party, created conditions conductive to anxiety, depression, feelings of inferiority and inadequacy, all manifestations of ill health. And the longer his rhetoric lasted, the more vulnerable they became.
This ideologically-driven politician made them sick.
Reflect on Eric Abetz' declaration that those on welfare must complete forty job applications a month - twice the number previously - for the very limited number of jobs in his home state of Tasmania. How did they feel about this demanding yet pointless imposition? Did that affect their mental health?
Liberals just can't give up on 'welfare dependency'. Minister Christian Porter was at it again last week. Although he clothed his policy recommendations in words of support for those in that predicament, the prime purpose was clear - to reduce the burden of welfare on the federal Budget. He exaggerated his case by using 'lifetime' projections of cost that soared into the trillions, neglecting though to point out that this figure was but a tiny proportion of the multi-trillion revenue budget over the same 'lifetime' period. Ideology dominated his thinking. But the effect on the targeted was as always - demeaning, demanding, destructive to their wellbeing and mental health. Porter's move would make them sick despite his stated intention to make their life better, sincere though it purported to be.
Remember the attempts to increase the required waiting period to receive the dole from one week to six months, a measure designed to save the Budget $1.8 billion over five years. Imagine how potential recipients felt about being without income for a long six months! The threat of this Coalition move must have made them sick with worry and apprehension.
This is what Peter Martin had to say on this subject.
Attacks on welfare create anxiety, increase uncertainty, demean the recipients, and make them sick.
Reflect on the plebiscite on marriage equality, which PM Turnbull insists he is bound to implement. Already we are hearing of the distress the LGBTI community is feeling at the prospect of a bitter, biased, and likely bigoted public debate about whether they should be afforded the right to declare and publicly confirm their love and commitment as do heterosexual couples. Their right to do so is to be subject to the whims of the ACL and other opposing bodies. Will the LGBTI community feel they have been placed like insects under the public microscope? Will their mental health, already fragile from past experiences in 'coming out', deteriorate? Will suicide, that some contemplated when 'coming out', become more inviting? It seems hard to avoid the conclusion that some will take this course.
The policy of subjecting this matter to a plebiscite will make some of our community sick. Politicians do make us sick!
I could go on, but these examples, taken against the profusion of evidence that Michael Marmot has documented in his book, ought to caution us not to inflict any more distress and misery on those amongst us who are vulnerable. We have no right; politicians have no right to make us sick through making decisions, by legislating policies that can have no other health outcome among our most distressed, underprivileged and marginalised than to make them sick, even sicker than they are already.
If you wish to learn more about Michael Marmot's work on health inequality,
watch Jane Hutcheon interviewing him on One Plus One on ABC TV.
For even more information, listen to
Professor Marmot's Boyer Lectures.
Politicians do make us sick. They need not; they ought not; but they do.
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