Читать книгу Contemporary Health Studies - Louise Warwick-Booth - Страница 72

 Gender health inequalities, e.g. risk behaviours such as drinking alcohol, are more prevalent among men, and older groups of the population.

 Social class inequalities, e.g. people in high social classes have better health outcomes compared to those in the lower social classes.

 Geographical inequalities, e.g. health is generally poorer in the north of England compared to the south of England.

 Ethnic inequalities, e.g. suicide rates in young Asian women are more than double those for young white women in the UK.

 Age inequalities, e.g. many risk factors for poor health, such as obesity, hypertension, disability and poverty increase with age, and the importance of adverse childhood experiences in shaping health outcomes is now evidenced.

Sources: Raleigh and Polato (2004); Warwick-Booth (2019)

Health inequity refers to those differences that are perceived to be unfair and unjust (Graham and Kelly 2004). For example, it can be argued that everyone has the right to health care; however, despite the presence of health care in many countries, not everyone is able access it, which results in health inequity.

Mental health Mental-health issues are often neglected in a world that tends to prioritize physical health. However, separating mental, social and physical health contradicts our understanding of the holistic nature of health. As a whole person, the domains of health are inextricably linked and influence each other. Achieving good mental health is fundamentally important in daily functioning, quality of life and integral to the health of individuals and communities (Brundtland, 2001). Rehm and Shield (2019) point out that mental health and addictive disorders affected more than one billion people globally, causing 7% of all global burden of disease and 19% of all years lived with disability; therefore mental health is a significant contemporary challenge. Statistics are likely to be a significant underestimation, as they only capture data about people who are classified and diagnosed as ‘disordered’. Many people experience anxiety and poor mental health without ever receiving a diagnosis of illness or disorder. A major issue for mental-health sufferers is the serious stigma and discrimination associated with poor psychological and psychiatric status. Indeed, stigma is a major barrier to both mental-health treatment and recovery (Pinto-Foltz and Logsdon, 2009). Lewis (2019) points out that nearly one in three British young people had been exposed to trauma by the age of eighteen, which increases their risk of mental-health disorders; however, stigma and shame affected their ability to access services. Roberts et al. (2018) discuss the fact that failure to seek treatment for common mental-health disorders is a global problem, associated with people experiencing less disabling symptoms, as well as holding perceptions that they do not need health care. They argue that that there are different views about the ‘treatment gap’ between professionals and patients, because some statistics over-estimate unmet need for care when compared to perceptions within the target population. So, while mental-health problems are evident as a contemporary threat to health, they do not always require medical treatment.

Mental-health problems are increasingly understood to be linked to the social determinants of health, such as the environments in which we live. The mental-health impacts of climate change have already been discussed; but what, too, of our usual living conditions? Elliot (2016) reports that poverty increases the likelihood that people will experience mental-health problems, so it can be a consequence of inequality, but it can also be causal and so lead to poverty because of the complex relationships at play. Exposure to trauma is associated with mental-health problems, with conditions such as post-traumatic stress disorder, anxiety and depression following experiences of violence noted in the literature (Ophius et al., 2018). Increasing levels of chronic disease and sedentary lifestyles have also been discussed as detrimental to mental health. Kondo et al. (2020) report that the average American child spends almost eight hours daily on screen-time, creating health conditions as they move to adulthood; therefore they suggest prescribing nature as a tool for physical and mental health promotion to combat lifestyle problems including depression. Concerns about declining mental health among young people are all too frequently discussed in the UK media. Windsor-Shellard (2019) report growing suicide rates among young people in the UK; 2018 statistics showed that among 10 to 24-year-old females suicide rates had increased by 83% when compared to 2012. Young men in the same age bracket also saw a 25% increase in their rate compared to the previous year. Rates of self-harm have also increased among young people (particularly young women), arguably as a way for them to release emotional distress. The role of exposure to early childhood trauma, and the increased use of social media among younger people have been cited as causal factors but more research is needed (Windsor-Shellard, 2019).

Infectious diseases The media are forever drawing our attention to the problem of infectious diseases. In 2009 there were concerns about the possibility of a swine-flu pandemic, with many countries stock-piling vaccinations, implementing vaccination programmes, offering health advice and developing emergency plans. Here a political economy perspective would critically examine the role of the pharmaceutical industry as part of the construction of this health threat (see chapter 4 for further discussion of Marxist understandings of health and illness). This is interesting, given that it is the case that at least once a year an epidemic occurs somewhere in the world. There are many infectious diseases that threaten the health of humans, such as rotavirus, ebola, HIV and the more recently discovered SARS, H5N1 – bird flu (Kaufmann, 2009) and coronavirus, COVID-19 (Boni, 2020). The emergence of COVID-19 across the globe, starting in 2019 and continuing during 2020, led to a huge increase in excess deaths, particularly among older and more vulnerable groups with pre-existing health conditions, as well as unprecedented government action (lockdowns and social distancing rules) in an attempt to control the spread of the virus. At the time of writing more than ten million people have been infected, and over half a million people have died as a result of this new disease (WHO, 2020d), with infections continuing to spread and localized outbreaks occurring. The lack of effective treatment has been a challenge for all health systems, with many hospitals struggling to meet demand. The need to develop a vaccination is now high on the global agenda, resulting in world leaders pledging money towards this (WHO, 2020e). Furthermore, the implications of this disease in relation to inequality require consideration, for example there have been much higher death rates reported among BAME community members, in care homes in the UK and across economically poorer regions. Aside from the urgent threat of loss of life and potential disability resulting from COVID-19, there are many issues for future consideration in relation to the broader social determinants of health. For example, children have missed out on education, ‘non-essential’ health-care appointments have been delayed (WHO, 2020e), and many industries have been negatively affected, leading to increased unemployment; all of which are likely to impact more negatively upon health outcomes. Epidemics such as COVID-19 are transnational, have no boundaries and are hard to control. As a consequence, they instil fear in many people, and the associated social policy measures of lockdown and social distancing are likely to lead to adverse mental-health outcomes for some people. Our experience of infectious diseases varies according to where we live in the world, our own personal characteristics (social determinants), as well as the ways in which such threats are framed by the media and politicians.

In higher-income countries, we all experience coughs, colds and sore throats, generally for a few days and then we feel restored back to normal health. These minor illnesses are often the result of contact with viruses and are experienced as inconveniences rather than as a major threat to health. Almost 2.38 million deaths were caused by lower respiratory infections in 2016, making lower respiratory infections the sixth leading cause of mortality for all ages and the leading cause of death among children younger than five years (Naghavi et al., 2016). This is also true of diarrhoeal diseases. In high-income countries bouts of diarrhoea are unpleasant but generally do not cause a major health impact or result in death (this can happen in rare cases of cholera or e-coli infection when prompt medical attention is not sought), whereas in lower-income countries death is not an uncommon result (Kaufmann, 2009), especially in the under-fives (WHO, 2017b). This issue of the disproportionate burden is the same story for lower-income countries for most infectious diseases, including measles, HIV and AIDS, dysentery, cholera, typhoid and polio, to name but a few. Rossman and Badham (2019) point out that the media pay attention to ebola, with widespread coverage of this disease. In the Democratic Republic of the Congo, however, measles has proved much more fatal, killing three times as many people, yet this is under-reported.

HIV as an infectious disease is often seen as being a major contemporary threat to health and, as highlighted earlier, has received much media attention. WHO (2020c) reports that 770,000 people died of HIV-related illnesses worldwide in 2018, with 61% of these deaths occurring in the Africa region. The major problem with the prevention of HIV lies in the relationship between prevention and behaviour change (see chapter 6 for an in-depth discussion of behaviour change). Currently an effective vaccination has yet to be developed, therefore prevention via condom use and behaviour change (such as abstinence from sexual encounters) is advocated. However, some individuals find themselves powerless to negotiate safe sex and strong cultural traditions also serve to influence individual perceptions of risk.

The re-emergence of old infectious diseases On some occasions, a number of infectious diseases has been declared to have been ‘defeated’ and eradicated, only later to reappear and pose a threat to the health of humans. Tuberculosis is one such example within contemporary society (Kaufmann, 2009). This is because of TB’s close relationship with those infected with the HIV virus, so people often develop TB as a result of their weakened immune systems. In addition, the situation has been made worse by the bacterium that causes TB becoming increasingly resistant to drugs and treatment. Borgdorff and van Soolingen (2013) argue that drug-resistant TB is a major threat worldwide. WHO (2019d) report that TB was one of the top ten causes of death worldwide in 2018, yet only one in three people who need treatment are receiving it. The WHO has clear guidelines for the treatment of TB, and there is a vaccination available, but this only protects against a specific strain of the disease more common among children. Hence the disease remains a problem in that outbreaks continue to occur within specific populations, once again especially among those living in poverty because this is an ideal breeding ground for such an infectious disease. The principal reasons for the re-emergence of the disease are overcrowded housing, increasing homelessness, rising immigration rates, poor urban living conditions and rising levels of HIV infection (Kaufmann, 2009). Vaccination uptake can also be a factor, for example, the UK lost its WHO measles-free status in 2019 because of rising case numbers, and associated loss of herd immunity, attributed to fewer people being vaccinated.

Lifestyle diseases Whereas the social determinants of health approach emphasize the larger structural influences that affect our health (chapter 4 discusses both structure and agency in relation to health), in recent years threats to our health are also seen to be related to our own illness behaviour and the lifestyle choices that we make. The way in which we all live our lives is argued to have a huge impact upon our health. Lupton (1993) argues that risk discourse is used to blame the victim and to displace the real reasons for ill-health. Risks are located at the level of the individual, which serves to avoid people from examining broader, structural determinants. Perceptions of health risks are indeed changing (Giddens, 1999) and are numerous, as this chapter tells us; populations are generally ageing and patterns of physical activity, alcohol and tobacco consumption are also shifting, leaving many countries facing a burden of increasing chronic and non-communicable diseases (WHO, 2017), often labelled as lifestyle diseases.

The types of food we choose to consume, levels of inactivity, our sexual behaviour, attitudes to alcohol and recreational drug use, as well as attitudes to risk, are all having a huge impact on our health, and this is borne out in evidence of changing social trends. Hamilton and Sumnall (2019) point out that alcohol deaths in the UK remain high, with 7,551 people dying in the UK in 2018. Patterns of UK alcohol consumption are changing, with young people drinking less but older groups of people are continuing to drink alcohol heavily (Nicholls, 2019). UK obesity rates are also reflective of unhealthy lifestyles, with the Health Survey for England (2017) estimating that 28.7% of adults in England are obese and that another 35.6% are overweight. Changing lifestyles are cited as a significant causal factor in relation to obesity, as well as in relation to a number of different health problems. Hamilton and Stevens (2019) also report that every year since 2013, the UK’s Office for National Statistics reports increases in drug-related deaths, with the highest burden in deprived areas. These lifestyle theories are used to explain the social variations and gradients that exist between the different social classes. Thus, the lower social classes arguably smoke more, consume more alcohol and dietary fat, and exercise less and, as a consequence, these factors are used to explain their higher rates of cancers and heart disease by some commentators. However, the evidence between lifestyle choices and disease is incredibly complex and much research has been criticized for lacking scientific rigour (Skrabenek and McCormick, 1989). There is also the issue of moral judgements being made here in relation to lifestyle choices, about people who make ‘wrong’ and unhealthy choices, with personal volition increasingly used as a mechanism to label the deserving and undeserving sick. Therefore, the idea of lifestyle choices as a threat to our health has been associated with victim blaming and in some instances the treatment of individuals with lifestyle diseases has become highly politicized in the media. For example, there have been debates about the refusal of treatment for smokers, those who are obese and individuals who are seen to ‘refuse’ to change their behaviour without broader recognition of the structural factors underpinning the causation of lifestyle diseases.

In conclusion, the population of the world faces some large health risks and lower-income countries face even more of a risk because populations living there are exposed to multiple risk factors and face the increased risks associated with poverty. Indeed, there are some commentators who argue that we are living in a ‘risk society’ (Beck, 1992), where the main risks that we produce are the result of our own activity, for example, pollution and terrorism. However, the measurement of risk, now possible as a result of increased technology, the availability of large data sets, and improved computer capacity allows perhaps too many risks to be highlighted. Wainwright (2009a) argues that although many identified risks are genuine, the evidence for others is ‘weak’ and based upon spurious relationships such as the links between some lifestyle choices and specific conditions. Thus, risk ratios often used to demonstrate specific threats to health can be misleading and misreported in the media, affecting our perception of the actual risks that we face, which, according to research, is often skewed and incorrect (Duffy, 2019). On a more positive note, we do have the capability to measure these threats and to try to control them within modern society (Giddens, 1999).