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Editorial
Toni Schofield
Behavioural & Community Health Sciences, University of Sydney, NSW, Australia
Abstract
Article Text
For anybody with even a cursory connection to global health issues, the vast disparities in health between those ‘in the West' and those outside, are a regular reminder of the privilege that ‘we in the West' enjoy by comparison with the rest of the world. Nothing lets us know more swiftly and immediately of ‘our' superior good fortune than images of ravaged or emaciated sick people in sub-Saharan Africa or South Asia. The comparatively poor health of much of the world is one of the most powerful symbols of a globally divided identity of winners and losers. Here in Australia, few would have any doubts about which side of the divide we are on, and there is solid evidence for such a view. Most of us are doing extremely well in terms of longevity; there have been major gains in relation to managing the pain and suffering associated with chronic illness conditions and disabilities; and the death of mothers in pregnancy and childbirth is practically unheard of. However, the health privilege that Australia enjoys does not include its indigenous people. Large sections of the indigenous population may as well be living in sub-Saharan Africa or parts of South Asia where, as those media images suggest, life can be short and very nasty.
This special issue of Health Sociology Review is not about Australian Indigenous health. It is about the social arrangements and dynamics involved in producing the kinds of starkly differentiated health patterns embodied in the disparate health fortunes of Indigenous and non-Indigenous Australians. This issue focuses on what has emerged as one of the most pressing issues of global health governance - health inequities or inequalities. These are explored from diverse methodological perspectives and national settings, and by contributors from various national locations including Australia, Bulgaria, Canada, India, Norway and the United States. Despite these differences, a clearly discernible unanimity emerges from the collection. Although the right to health for all was enshrined in the Constitution of the World Health Organisation in 1946, the means for realising it remain unequally distributed both within and between countries internationally. Yet this disparity, as the authors show, is played out within a plurality of ways that are nonetheless underpinned by entrenched social divisions and differences. Moreover, the local and contingent character of this inequity demands close and systematic social investigation if policy makers are to come up with effective interventions.
The first article on health inequity and the social determinants of health explores this theme in some detail and argues that the predominant scientific approach to framing and analysing the problem of health inequalities - epidemiology - is a necessary but insufficient social scientific basis for understanding and addressing the social complexities and dynamics associated with the production of health inequity. Informed by the frameworks and methods of critical sociology, this article proposes that such an approach may make a significant contribution to identifying and analysing the specific structures of practice involved in health inequities and, in turn, to more efficacious policy interventions.
Lorraine Greaves' article takes up one of the major global health policy interventions to have emerged over the last twenty years - tobacco control. As her work shows, it faces a major challenge in the 21st century with tobacco smoking having assumed epidemic proportions throughout the world. Some progress has been made in the ‘developed world', but the overall burden of tobacco production and tobacco use remains as onerous as ever with low and middle income countries now shouldering most of it. And while men's rates of tobacco use globally have peaked, and are starting to decline, the picture is different for women. The epidemic for women is estimated to be still gathering force and unlikely to reach its peak until later this century. In fact the rate of global female smoking is expected to increase to 20 % from the current 12% by 2025. The exploding tobacco epidemic will thus have a particularly marked effect on women and low and middle income countries. As Greaves proposes, if the tobacco control movement and its associated public interventions are to be successful, it is vital that they embrace gender equality measures in order to tackle the gendered health inequities posed by tobacco production and its use.
Stephanie Short and her colleagues turn their attention to the inequities in accessing health care and health resources when a universal health insurance scheme permits providers to demand out-of-pocket payments for health services and goods. Based on a study of the introduction of a universal health insurance scheme in Bulgaria, this article reveals that equitable access to health care is a ‘mirage'; as the vast bulk of health care is self-funded. Accordingly, those who are least able to pay, or who face other kinds of serious barriers to health care, such as geographical isolation, suffer the least access to health services and goods. The authors' conclusions have particular significance for understanding the social complexities faced by post-communist states in their attempts to achieve equitable health service outcomes through social democratic health policy reforms.
The possibility of health policy interventions to tackle the inequitable pattern of death rates in Norway, particularly in relation to education, is explored by Espen Dahl and his colleagues. They address this issue by asking ‘whether the educational gradient in avoidable mortality differs from overall and non-avoidable mortality among men and women in Norway'. They explain that avoidable deaths are those ‘caused by diseases that are either treatable if given appropriate medical care, or preventable if available preventive measures were implemented'. Their results provide compelling evidence of the relationship between low education and higher rates of ‘avoidable mortality': a sound basis, they propose, for more focused public health and medical interventions among the least educated members of Norwegian society.
Anant Kumar explores the efficacy of ‘self-help groups' in improving the health of women from poor and low-caste backgrounds in India. Self-help groups are designed to encourage poor and marginalised people to become financially more self-reliant by establishing and engaging collectively in market-based activities that are expected to generate income. They are strongly supported by the World Bank and the United Nations, having also been identified as a useful strategy for improving women's health. Based on a large, comparative study of women from different class and caste backgrounds who were participants of the same self-help group, Kumar's findings raise serious doubts about the power of such an intervention to make any positive impact on the health of India's most marginalised and impoverished citizens.
Liza Hopkins' article, based on a study of the health and social impact of creating an electronic community in an Australian high-rise public housing estate over a four year period, is unable to draw such a decisive conclusion. The study was part of a project that provided residents with access to personal computers, computer training, an intranet, internet and email, as well as establishing a training room, open access computer lab, repairs workshop and a help desk service for computer users. There was good evidence from the study that people suffering a combination of economic and social disadvantages can and do take advantage of new technology to improve their own, and especially their children's, access to the technological underpinnings of the contemporary knowledge society. There was no evidence, however, that this translated into self-reported better health.
The health impact of the dislocation that children and adolescents experience in response to the HIV/AIDS crisis in Africa is understood to be a significant global health issue but little is known about the specific day-to-day dimensions of the problem and how they are related to health. The final article in this collection examines the impact on the health of adolescent women in Kenya of living in non adult-headed households. According to the study's findings, adolescent women in such households face an increased range of health problems that their counterparts in adult-headed households do not have to confront. Resoundingly, ongoing education is a major strategy in reducing the likelihood of illness, especially among those identified as ‘emerging adults'. Early marriage, however, is more likely to compound the risk of deteriorating health. Protecting the assets of young women when parents die may be a further potential strategy in maintaining their health because of the strong association between good health and wealth that the study found.
The findings and analyses of the studies presented in this special issue are not all informed by rigorously applied sociological frameworks and methods. Most of them nevertheless demonstrate that the social dynamics associated with health inequalities are complex and contingent. Specifically how these dynamics work, under what conditions, and with what consequences, are questions that remain largely unaddressed and unanswered by social scientific research; including that conducted by sociologists. Perhaps it is time for sociologists to re-engage with the problem of health inequity and consider how our research practice might contribute to these questions.
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