tag:theconversation.com,2011:/id/topics/health-inequality-5734/articlesHealth inequality – The Conversation2024-01-05T13:46:39Ztag:theconversation.com,2011:article/2173572024-01-05T13:46:39Z2024-01-05T13:46:39ZLiterature inspired my medical career: Why the humanities are needed in health care<figure><img src="https://images.theconversation.com/files/564561/original/file-20231208-17-e51tzu.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C1998%2C1494&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Medicine is as much about the human experience as it is about biology.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/two-hands-connected-by-a-dramatic-graph-royalty-free-image/545248093">Jonathan Knowles/Stone via Getty Images</a></span></figcaption></figure><p>While there is a long history of doctor-poets – one giant of mid-20th-century poetry, <a href="https://poets.org/poet/william-carlos-williams">William Carlos Williams</a>, was famously also a pediatrician – few people seem to know this or understand the power of combining the humanities and medicine.</p>
<p>As a <a href="https://www.tremblingpillowpress.com/orogeny">published poet</a> and <a href="https://med.virginia.edu/biomedical-ethics/people/irene%E2%80%8B-mathieu/">scholar of the health humanities and ethics</a>, I have a foot squarely planted in each field – or perhaps more accurately, I stand in what I perceive as the overlapping field of healing and poetic practices.</p>
<p>Literature has had a large role in helping me define the kind of physician I strive to be – one who is not only empathetic and a good listener but also a fierce advocate for changing the sociopolitical forces that affect my patients’ lives. I think literature can do this for other health care providers, too.</p>
<h2>Narrative competence in medicine</h2>
<p>Despite having physicians for parents – or perhaps because of it – initially I had no interest in medicine. It seemed too clinical, too sterile. The work stories my parents shared over the dinner table were intentionally devoid of the personal details that would have interested me.</p>
<p>I was preoccupied with characters in the books I read – who lived in conflict zones, who as children were working instead of playing, who had struggles I couldn’t imagine – and wondered why I had my life and not theirs. What intangible forces shaped their lives in ways different from my own? Now I can directly trace my early infatuation with the written word to my chosen career as a pediatrician and public health researcher.</p>
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<figcaption><span class="caption">Medicine is a confluence of scientific and literary thinking.</span></figcaption>
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<p>Narrative medicine is the practice of close reading and reflective writing to build <a href="https://doi.org/10.1001/jama.286.15.1897">narrative competence</a>. Physician and narrative medicine scholar Rita Charon describes narrative competence as “the ability to acknowledge, absorb, interpret and act on the stories and plights of others.” </p>
<p>Narrative competence, then, could inspire a person to pursue a career in health care and possibly make them a better clinician. In fact, studies of narrative medicine programs have demonstrated that they tend to not only increase students’ <a href="https://doi.org/10.3352%2Fjeehp.2020.17.3">empathy and communication skills</a> but also their <a href="https://doi.org/10.1007/s11606-017-4275-8">tolerance for ambiguity and self-confidence</a>. They also improve their <a href="https://doi.org/10.3390%2Fijerph17041135">open-mindedness, ethical inquiry</a> and <a href="http://dx.doi.org/10.1136/bmjopen-2019-031568">perspective taking</a>.</p>
<p>Books introduced me to the breadth and diversity of human experiences and perspectives, as well as to searing inequalities in life outcomes. I wanted to positively change those outcomes in some way – a desire that led me into the arms of medicine, despite my initial misgivings about it.</p>
<h2>Using the humanities to address health inequity</h2>
<p>Might narrative competence also expand clinicians’ understanding of health disparities and urge them to act in ways that lectures full of statistics couldn’t?</p>
<p>The burgeoning field of <a href="https://doi.org/10.1097/acm.0000000000002871">critical health humanities</a> theorizes that stories and art can help clinicians understand the unequal realities of different people’s lives and make clinician-patient relationships more therapeutic. It can do this by cultivating clinicians’ awareness of the power differences and structural forces that affect their patients and themselves.</p>
<p>Defining features of this field are collaboration between disciplines – such as between medicine and literature – and a broad understanding of narrative medicine beyond the clinical encounter. Understanding not only human biology but also fields like the history of medicine, queer and disability studies, critical race theory and <a href="https://doi.org/10.1097/acm.0000000000002871">other forms of knowledge</a> can inform and improve clinical practice. </p>
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<a href="https://images.theconversation.com/files/564566/original/file-20231208-15-3bb3il.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Clinician in scrubs sitting on a table between library shelves, reading a book" src="https://images.theconversation.com/files/564566/original/file-20231208-15-3bb3il.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/564566/original/file-20231208-15-3bb3il.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/564566/original/file-20231208-15-3bb3il.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/564566/original/file-20231208-15-3bb3il.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/564566/original/file-20231208-15-3bb3il.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/564566/original/file-20231208-15-3bb3il.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/564566/original/file-20231208-15-3bb3il.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Medical trainees often aren’t given the space to engage with the humanities.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/female-intern-finds-quiet-spot-in-library-to-study-royalty-free-image/1434731417">SDI Productions/E+ via Getty Images</a></span>
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<p>For example, a clinician might turn to research from the social sciences to learn about the experiences of people with disabilities. This could lead her to make her practice <a href="https://adata.org/factsheet/accessible-health-care">more accessible to her patients</a> – an action that would improve equity in health care for people with disabilities.</p>
<p>Before ever meeting my first patient, I gained an expanded knowledge of the diversity of human experience from the books I read. It made me curious about my patients’ stories. And when I felt this curiosity flagging because of stress, exhaustion or burnout, refocusing on the stories seemed to help.</p>
<p>However, medical students are inundated with information about the human body in their training and <a href="https://www.aamc.org/news/medical-schools-overhaul-curricula-fight-inequities">barely have time</a> to learn about the nonmedical aspects of patient experiences. This negates the fact that disease and health happen in varied and disparate social, cultural and political contexts.</p>
<p>For example, <a href="https://doi.org/10.2337/dci20-0053">diabetes is a very different illness</a> for a patient experiencing homelessness and racism compared with a wealthy patient who doesn’t experience racism. A patient’s access to resources and their <a href="https://theconversation.com/how-racism-in-us-health-system-hinders-care-and-costs-lives-of-african-americans-139425">interactions with health care staff</a> affect their ability to get the care they need and the degree to which their basic needs are being met. Rarely are these nuances discussed in a medical school’s endocrinology lecture about diabetes.</p>
<h2>Fitting in health humanities education</h2>
<p>I believe that physicians must find ways to practice their humanity – perhaps using the humanities – if they wish to be effective healers. But how might they actually do this? </p>
<p>There are ways to fit in more health humanities in all the busyness and bustle of notoriously grueling medical education. As a senior resident, I often distributed poems to my team, printing and posting them above the computers in our cramped hospital workrooms or attaching them to email updates about patient care. Once, during a rare quiet moment in the pediatric ICU, with permission from my colleagues, I read a couple of poems out loud. I remember watching my colleagues’ eyes close and their bodies visibly relax as the words washed over them.</p>
<p>Since then, I have shared poems – my own and others’ – in talks at my institution and across the country. I’ve also led other health care providers in creative writing exercises during workshops, lectures and classes. Many institutions host book clubs, story slams, film screenings and other opportunities for medical learners to engage with the humanities.</p>
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<a href="https://images.theconversation.com/files/564571/original/file-20231208-23-vpq5kw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Clinician holding stethoscope over the chest of a toddler sitting in the lap of their parent" src="https://images.theconversation.com/files/564571/original/file-20231208-23-vpq5kw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/564571/original/file-20231208-23-vpq5kw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/564571/original/file-20231208-23-vpq5kw.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/564571/original/file-20231208-23-vpq5kw.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/564571/original/file-20231208-23-vpq5kw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/564571/original/file-20231208-23-vpq5kw.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/564571/original/file-20231208-23-vpq5kw.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Exposing clinicians to the breadth of human experience through the humanities can help them better understand where their patients are coming from.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/male-nurse-examining-baby-girl-with-stethoscope-in-royalty-free-image/1309071117">The Good Brigade/Digital Vision via Getty Images</a></span>
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<p>While poetry can be intimidating to some, many contemporary poems provide approachable emotional experiences.</p>
<p>Pieces like Safiya Sinclair’s “<a href="https://www.triquarterly.org/issues/issue-150/notes-state-virginia-ii">Notes on the State of Virginia, II</a>” viscerally illustrate how a place that seems innocuous or even beautiful to some can be haunting and traumatic for others. </p>
<p>Monica Sok’s “<a href="https://www.poetryfoundation.org/poetrymagazine/poems/144805/abc-for-refugees">ABC for Refugees</a>” powerfully paints a portrait of a young child caught between languages and cultures – a reality that many pediatric patients face. </p>
<p>“<a href="https://www.poetryfoundation.org/poems/155120/ode-to-small-towns">Ode to Small Towns</a>” by Tyree Daye upends common assumptions about rural life and demonstrates the meaning of place in hymnlike vernacular. </p>
<p>In “<a href="https://verse.press/poem/medical-history-7786213513888859947">Medical History</a>,” Nicole Sealey shares a many-layered patient perspective on a part of health care that, for many of my students and colleagues, has been reduced to a series of check boxes on a computer screen. </p>
<p>These and other poems – not to mention short stories, novels, personal essays, films, podcasts and comedy shorts, among other genres of storytelling – provide fertile ground for enhanced understanding of the human condition, as well as inspiration for a clinician’s own potentially transformative reflective writing.</p>
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<img alt="A square box with the words 'Art & Science Collide' and a drawing of a circle surrounding a lightbulb with its wire filament in the shape of a brain." src="https://images.theconversation.com/files/567788/original/file-20240103-23-yg479z.png?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/567788/original/file-20240103-23-yg479z.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=600&fit=crop&dpr=1 600w, https://images.theconversation.com/files/567788/original/file-20240103-23-yg479z.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=600&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/567788/original/file-20240103-23-yg479z.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=600&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/567788/original/file-20240103-23-yg479z.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=754&fit=crop&dpr=1 754w, https://images.theconversation.com/files/567788/original/file-20240103-23-yg479z.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=754&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/567788/original/file-20240103-23-yg479z.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=754&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Art & Science Collide series.</span>
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<p><em><strong><a href="https://theconversation.com/us/topics/art-in-science-series-2024-149583">This article is part of Art & Science Collide</a></strong>, a series examining the intersections between art and science.</em></p>
<p><em>You may be interested in:</em></p>
<p><a href="https://theconversation.com/art-and-science-entwined-this-course-explores-the-long-interrelated-history-of-two-ways-of-seeing-the-world-210250">Art and science entwined: This course explores the long, interrelated history of two ways of seeing the world </a></p>
<p><a href="https://theconversation.com/art-illuminates-the-beauty-of-science-and-could-inspire-the-next-generation-of-scientists-young-and-old-168925">Art illuminates the beauty of science – and could inspire the next generation of scientists young and old</a> </p>
<p><a href="https://theconversation.com/visualizing-the-inside-of-cells-at-previously-impossible-resolutions-provides-vivid-insights-into-how-they-work-195873">Visualizing the inside of cells at previously impossible resolutions provides vivid insights into how they work</a></p>
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<h2>Melding literature and medicine</h2>
<p>The possibilities for collaboration between literature and medicine are wide open. In a country that <a href="https://www.commonwealthfund.org/publications/issue-briefs/2023/oct/high-us-health-care-spending-where-is-it-all-going#">spends more per capita on health care</a> than economically similar nations yet continues to have extreme inequalities in outcomes, it’s clear that the U.S. needs to do things differently. </p>
<p>I believe <a href="https://doi.org/10.1186/s13010-023-00149-1">all clinicians have a role</a> in recognizing and grappling with how everyone has been shaped by an inequitable society. The history, sociopolitical context, imaginative perspective and reflective practices the humanities offer may improve the practice of medicine.</p>
<p>Through understanding others’ experiences and reflecting critically on their own, every clinician can move closer to being the kind of healer they intend to be.</p><img src="https://counter.theconversation.com/content/217357/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Irène Mathieu, MD, MPH is an iTHRIV Scholar. The iTHRIV Scholars Program is supported in part by the National Center for Advancing Translational Sciences of the National Institutes of Health under award numbers UL1TR003015 and KL2TR003016.</span></em></p>While medical school may teach students about how the body works, it often neglects the social, political and cultural factors that determine health and disease. The humanities can help.Irène Mathieu, Assistant Professor of Pediatrics, University of VirginiaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2197822023-12-15T15:33:34Z2023-12-15T15:33:34ZCancer: people living in England’s poorest areas at higher risk of death – new study<figure><img src="https://images.theconversation.com/files/566056/original/file-20231215-21-pjzlb6.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C4991%2C2801&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Those living in London had the lowest risk of dying from cancer.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/patient-sat-on-bed-looked-out-1687562503">namtipStudio/ Shutterstock</a></span></figcaption></figure><p>Nationally, the risk of dying from most cancers is falling thanks to improvements in <a href="https://www.nature.com/articles/bjc2016304">screening, diagnostics and treatment</a>. But <a href="https://www.thelancet.com/journals/lanonc/article/PIIS1470-2045(23)00530-2/fulltext">new research</a> shows stark health inequalities still exist in England when it comes to cancer care. The study found that people who live in the poorest parts of England have more than a 70% higher risk of dying from cancer compared with those who live in more affluent areas.</p>
<p>To conduct their study, the researchers analysed data from the Office for National Statistics on the ten cancers that caused the most deaths between 2002-2019 across 314 districts of England. The postcode at the time of a person’s death was used to assign each cancer death with a district.</p>
<p>Each district’s socioeconomic status was measured using data from the <a href="https://www.gov.uk/government/collections/english-indices-of-deprivation">English Indices of Deprivation</a>. This estimates the proportion of the population experiencing deprivation due to low income. </p>
<p>The team only included cancer deaths that occurred before the age of 80. This was to ensure the data was accurate, as multi-morbidity (the presence of two or more long-term health conditions) becomes more common after 80, and this makes it difficult to know whether a person has died from cancer or a different cause. </p>
<p>This study was the first to explore trends in cancer deaths at a district level. </p>
<p>The findings show that people from cities in the north of England – including Hull, Liverpool, Manchester and Newcastle – as well as those living in coastal areas to the east of London, had the highest probabilities of dying from cancer. Those living in London had the lowest risk of dying from cancer. Even people living in poorer parts of London still had a lower risk of dying from cancer compared to those living in equally deprived areas of the country. </p>
<p>A woman’s risk of dying from cancer was one in ten in Westminster compared to one in six if she lived in Manchester. For men, the risk of dying from cancer was one in eight if he lived in Harrow, but was one in five in Manchester.</p>
<p>While the overall risk of dying from cancer decreased in all districts of England from 2002-2019, these reductions weren’t equal. For men, overall risk of dying from cancer decreased by 37% if he lived in London – while in Blackpool, a man’s overall risk only decreased by 13%. For women, their overall risk of dying from cancer decreased by 30% if they lived in London – while in Essex, a woman’s overall risk only decreased by 7%.</p>
<p>The types of cancer people were most at risk of dying from also varied by region. Those living in the most impoverished districts had a greater risk of dying from lung, colorectal, oesophageal and bladder cancer. These types of cancer are associated with modifiable lifestyle risk factors (such as smoking, excess drinking, poor diet and obesity). These deaths could have potentially been prevented with better access to screening and treatment.</p>
<p>There was less geographic variation in a person’s risk of dying from lymphoma, multiple myeloma and leukaemia. These types of cancer tend not to be associated with modifiable risk factors.</p>
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<img alt="A female doctor explains lung x-ray results to older female patient." src="https://images.theconversation.com/files/566057/original/file-20231215-21-pk9sfm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/566057/original/file-20231215-21-pk9sfm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=338&fit=crop&dpr=1 600w, https://images.theconversation.com/files/566057/original/file-20231215-21-pk9sfm.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=338&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/566057/original/file-20231215-21-pk9sfm.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=338&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/566057/original/file-20231215-21-pk9sfm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=424&fit=crop&dpr=1 754w, https://images.theconversation.com/files/566057/original/file-20231215-21-pk9sfm.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=424&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/566057/original/file-20231215-21-pk9sfm.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=424&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">People living in impoverished districts had greater risk of dying from lung cancer.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/doctor-shows-results-old-patient-xray-2184021869">Dragana Gordic/ Shutterstock</a></span>
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<p>One shortcoming of the study that the researchers acknowledge is that they didn’t have reliable data on ethnicity. This will be important for future studies to consider, as certain ethnic groups are shown to have <a href="https://www.nature.com/articles/s41416-022-01847-x">poorer cancer outcomes</a>.</p>
<p>A further limitation is that the data only indicates the place a person was living at the time of their death. This might not always be representative of where the person grew up and lived, which could have affected their likelihood of developing certain types of cancer. </p>
<h2>The importance of place</h2>
<p>The findings from this study reinforce the vital importance of place on health outcomes. </p>
<p>Research has consistently shown that people living in the most deprived parts of England experience <a href="https://www.gov.uk/government/publications/chief-medical-officers-annual-report-2021-health-in-coastal-communities">worse health outcomes</a>. Some of the most deprived parts of the country are <a href="https://www.bmj.com/content/374/bmj.n2214.full">under-resourced coastal and rural areas</a>.</p>
<p>There are numerous reasons why people living in deprived areas experience greater health inequality.</p>
<p>First, people in deprived areas face <a href="https://bjgpopen.org/content/3/2/bjgpopen19X101646.full">greater challenges</a> accessing good quality healthcare – including cancer care – compared to those living in cities. <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3755018/">Some of the barriers</a> that prevent people in these areas from receiving preventative care and cancer treatment can include lack of transportation to appointments and poor medical care infrastructure. </p>
<p>Health literacy also tends to be lower in people from <a href="https://onlinelibrary.wiley.com/doi/10.1111/hex.12440">more deprived areas</a>. This is probably due to a range of factors, including existing poor health and lower socioeconomic status. This is important, as being unable to obtain, read, understand and use health information puts a person at greater risk of <a href="https://www.tandfonline.com/doi/full/10.1080/10810730.2010.499985">poor health outcomes</a>. Improving health literacy in local communities could help to improve cancer outcomes. </p>
<p>Poverty is another clear, fundamental <a href="https://www.who.int/health-topics/social-determinants-of-health#tab=tab_1">determinant of health</a>. <a href="https://patient.info/doctor/health-and-social-class">Deprived areas</a> tend to have high rates of smoking, excess alcohol consumption, poor diet and lower rates of physical activity. All of these factors can increase a person’s risk of poor health outcomes.</p>
<p>Public health programmes and interventions that target modifiable cancer risk factors, as well as increasing access to and use of <a href="https://www.magonlinelibrary.com/doi/full/10.12968/bjon.2022.31.10.S14">screening and diagnostic tools</a>, may help to reduce cancer incidence and improve survival in deprived areas. </p>
<p><a href="https://aacrjournals.org/cebp/article/26/12/1679/71343/Mobile-Screening-Units-for-the-Early-Detection-of">Mobile screening services</a> offered within the community – outside of formal healthcare settings – could be one such way to increase access to, and engagement with, cancer screening. It will also be important to ensure people receiving cancer treatment and follow-up care are able to access it, regardless of where they live.</p><img src="https://counter.theconversation.com/content/219782/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>David currently receives research funding from Cancer Research UK. He also holds a professional registration with the UK charity, Macmillan Cancer Support.</span></em></p>People living in the poorest parts of England were at a more than 70% higher risk of dying from cancer compared to those living in more affluent areas.David Nelson, Research Fellow in Rural Health and Care, University of LincolnLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2112662023-08-22T18:54:13Z2023-08-22T18:54:13ZAging with a healthy brain: How lifestyle changes could help prevent up to 40% of dementia cases<figure><img src="https://images.theconversation.com/files/543822/original/file-20230821-21-8h55nn.jpg?ixlib=rb-1.1.0&rect=0%2C11%2C7360%2C4451&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Modifiable risk factors for dementia include high blood pressure, obesity, physical inactivity, diabetes, smoking, excessive alcohol consumption and infrequent social contact.</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><iframe style="width: 100%; height: 100px; border: none; position: relative; z-index: 1;" allowtransparency="" allow="clipboard-read; clipboard-write" src="https://narrations.ad-auris.com/widget/the-conversation-canada/aging-with-a-healthy-brain-how-lifestyle-changes-could-help-prevent-up-to-40-of-dementia-cases" width="100%" height="400"></iframe>
<p>A 65-year-old woman repeatedly seeks medical help for her failing memory. She is first told it’s nothing to worry about, then, a year later, that it’s “just normal aging.” Until finally, the penny drops: “It’s Alzheimer’s. There is no cure.” </p>
<p>Scenarios like this one are too common.</p>
<p>Dementia remains largely underdetected, even in high-income countries such as Canada where <a href="https://doi.org/10.1136%2Fbmjopen-2016-011146">rates of undetected cases exceed 60 per cent</a>. Beliefs that cognitive deficits are normal in elderly people, and the lack of knowledge of dementia symptoms and of diagnostic criteria amongst medical doctors have been identified as the <a href="https://doi.org/10.1590%2FS1980-57642011DN05040011">main culprits of missed cases and delayed diagnosis</a>.</p>
<p>Age-related memory losses should not be shaken off as just part of normal aging. Occasionally forgetting where we parked the car or where we left our keys can happen to everyone, but when these situations become frequent it’s important to seek medical advice. </p>
<p>While many individuals experiencing mild changes in their ability to think and remember information will not go on to develop dementia, in others, these declines constitute an early warning sign. Research has shown <a href="https://doi.org/10.1111/acps.12336">that people with mild changes in cognition</a> are at a greater risk of developing dementia later in life. </p>
<p>In fact, it has been demonstrated that <a href="https://doi.org/10.3390/ijms20225536">the disease process (changes in the brain’s structure and metabolism)</a> starts decades before the appearance of symptoms such as memory loss. Moreover, it is <a href="https://doi.org/10.1038/s43587-022-00269-x">increasingly recognized in the scientific community</a> that interventions that aim to slow down or <a href="https://doi.org/10.1016/S0140-6736(15)60461-5">prevent</a> disease development are more likely to be effective when initiated early in the disease course. </p>
<p>Despite this, protocols for early detection <a href="https://canadiantaskforce.ca/guidelines/published-guidelines/cognitive-impairment/">are not standard</a> in the medical community, in part because significant gaps remain in our understanding of dementia. </p>
<h2>Dementia and an aging population</h2>
<p>In my research, I use advanced brain MRI methods to characterize brain health in older adults who are at high risk of developing dementia. The goal is to identify new biomarkers of early pathology, which could lead to improved detection methods in the future. </p>
<figure class="align-center ">
<img alt="A woman with gray hair with health care worker in scrubs." src="https://images.theconversation.com/files/543761/original/file-20230821-27-g1ams7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/543761/original/file-20230821-27-g1ams7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/543761/original/file-20230821-27-g1ams7.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/543761/original/file-20230821-27-g1ams7.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/543761/original/file-20230821-27-g1ams7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/543761/original/file-20230821-27-g1ams7.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/543761/original/file-20230821-27-g1ams7.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">By 2050, the number of Canadians living with dementia is expected to exceed 1.7 million.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>The proportion of senior Canadians is growing in our population. Dementia is strongly associated with aging, so the number of Canadians diagnosed with dementia — including Alzheimer’s — is expected to rise considerably in the next few decades, reaching an expected <a href="https://www.ctvnews.ca/health/nearly-one-million-canadians-will-live-with-dementia-by-2030-alzheimer-society-predicts-1.6056849">1.7 million</a> Canadians by 2050. That’s more than the <a href="https://www150.statcan.gc.ca/t1/tbl1/en/tv.action?pid=1710000901">population of Manitoba</a>! </p>
<p>This projected increase will put an enormous pressure on our already strained health-care systems if no significant actions are taken to reverse this trend. This means that effective prevention strategies are now more urgent than ever.</p>
<p>Recent <a href="https://www.ctvnews.ca/health/promising-new-drug-to-treat-alzheimer-s-in-pipeline-of-approval-in-canada-1.6443850">news about promising new drugs</a> to treat Alzheimer’s disease also highlight the need for early detection. <a href="https://doi.org/10.1056/NEJMoa2212948">Clinical trials</a> showed that these drugs are most effective at slowing cognitive decline when administered early in the disease course. </p>
<p>Although these new treatment options represent breakthroughs for the Alzheimer’s field, more research is needed. These new therapies act on only one disease process (lowering the levels of amyloid, a substance thought to be toxic for neurons), so they may slow cognitive decline in <a href="https://doi.org/10.1093/braincomms/fcad175">only a narrow subset of patients</a>. A proper characterization of other processes, on a personalized basis, is required to combine these treatments with other strategies. </p>
<p>This is not to mention the significant increase in financial and human resources that will be necessary to deliver these new treatments, which could hinder access to them, especially in low- and middle-income countries, where <a href="https://doi.org/10.1016/S0140-6736(20)30367-6">dementia cases are rising the most</a>.</p>
<h2>Lifestyle and brain health</h2>
<figure class="align-center ">
<img alt="Five older adults seated and doing arm exercises" src="https://images.theconversation.com/files/543760/original/file-20230821-25-z8e7mg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/543760/original/file-20230821-25-z8e7mg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/543760/original/file-20230821-25-z8e7mg.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/543760/original/file-20230821-25-z8e7mg.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/543760/original/file-20230821-25-z8e7mg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/543760/original/file-20230821-25-z8e7mg.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/543760/original/file-20230821-25-z8e7mg.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Seniors participating in a seated exercise class. Physical inactivity is a modifiable risk factor for dementia.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>Lifestyle changes, on the other hand, have been shown to decrease the risk of developing dementia with minimal costs and no side-effects. By making dementia risk assessment a part of routine medical visits for older adults, those who are most at risk could be identified and counselled on how to maintain brain health and cognition. </p>
<p>At-risk individuals likely need those interventions the most (potentially a combination of pharmaceutical and lifestyle interventions), but anyone can benefit from adopting healthy lifestyle habits, which are known to protect from diseases not only of the brain, but also of the heart and other organs.</p>
<p>According to an <a href="https://www.thelancet.com/article/S0140-6736(20)30367-6/fulltext">influential report</a>, published in <em>The Lancet</em> in 2020, 40 per cent of dementia cases can be attributed to 12 modifiable risk factors. These include high blood pressure, obesity, physical inactivity, diabetes, smoking, excessive alcohol consumption and infrequent social contact. </p>
<p>This means that, by adopting positive lifestyle habits, we could theoretically prevent about 40 per cent of dementias, according to the report. While there is no guarantee of warding off cognitive decline, people can greatly reduce their risk of dementia by increasing their physical activity levels, ensuring they are mentally active and increasing social contact, while avoiding smoking and limiting alcohol consumption. </p>
<figure class="align-center ">
<img alt="A group of older adults attending an art class, and their teacher" src="https://images.theconversation.com/files/543759/original/file-20230821-27982-v420lw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/543759/original/file-20230821-27982-v420lw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/543759/original/file-20230821-27982-v420lw.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/543759/original/file-20230821-27982-v420lw.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/543759/original/file-20230821-27982-v420lw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/543759/original/file-20230821-27982-v420lw.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/543759/original/file-20230821-27982-v420lw.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">By encouraging people to be physically, mentally and socially active, we can potentially keep a significant number of dementia cases at bay.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>Some evidence also suggests that a <a href="https://doi.org/10.3945/an.117.015495">Mediterranean diet</a>, which emphasizes high consumption of plants (especially leafy greens) while reducing saturated fats and meat intake, <a href="https://doi.org/10.1093/ajcn/nqx070">is also beneficial for brain health</a>. </p>
<p>In short, by encouraging people to be physically, mentally and socially active, a significant number of dementia cases could potentially be kept at bay. </p>
<h2>Barriers to healthy lifestyles</h2>
<p>At the same time, focusing on policy changes could address the societal inequalities that lead to the occurrence of several risk factors, <a href="https://aaic.alz.org/downloads2020/2020_Race_and_Ethnicity_Fact_Sheet.pdf">and higher prevalence of dementia</a>, in <a href="https://content.iospress.com/articles/journal-of-alzheimers-disease/jad201209">ethnic minorities</a> and vulnerable populations. Despite having a universal health-care system, Canada still has health inequalities. People <a href="https://www.canada.ca/en/public-health/services/health-promotion/population-health/what-determines-health.html">at greater risk of health conditions</a> include those with lower socioeconomic status, people with disabilities, Indigenous people, racialized people, immigrants, ethnic minorities and LGBTQ2S people.</p>
<p>Policy changes could address these inequalities not only by promoting healthy lifestyles, but also by taking action to improve the <a href="https://doi.org/10.1016/j.joclim.2021.100035">circumstances in which people of these communities live</a>. Examples include <a href="https://doi.org/10.1093/heapro/dav022">improving access to sport centres</a> or prevention clinics for people with lower incomes and designing cities that are conducive to active lifestyles. Governments need to evaluate and address the barriers that prevent people from specific groups from adopting healthy lifestyle habits. </p>
<p>We must be ambitious about prevention. The future of our health-care system and that of our own health depends on it.</p><img src="https://counter.theconversation.com/content/211266/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Stefanie Tremblay receives funding from the Canadian Institutes of Health Research (CIHR). She is affiliated with Dragonfly Mental Health, a not-for-profit organization advocating for better mental health in academia. </span></em></p>While there is no guarantee of warding off cognitive decline, encouraging people to be physically, mentally and socially active could potentially keep a significant number of dementia cases at bay.Stefanie Tremblay, PhD candidate in medical physics, studying MRI biomarkers of declining brain health in aging, Concordia UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1946912023-06-15T12:37:48Z2023-06-15T12:37:48ZAmerican Indians forced to attend boarding schools as children are more likely to be in poor health as adults<figure><img src="https://images.theconversation.com/files/503911/original/file-20230110-24-749og5.jpg?ixlib=rb-1.1.0&rect=13%2C19%2C4341%2C2883&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Research reveals what generations of tribes know firsthand: that forced assimilation and unhealthy conditions at compulsory boarding schools takes a permanent toll.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/senior-healthcare-assistance-in-a-home-royalty-free-image/1397246903?adppopup=true">RichLegg/E+ via Getty Images</a></span></figcaption></figure><p>Many American Indians attended compulsory boarding schools in the 1900s or have relatives who did. My family is no different. Three generations of Running Bears – my grandparents, parents and those from my own generation – attended these residential schools over a period stretching from approximately 1907 to the mid-1970s. </p>
<p>American Indians are very resilient, given the harsh history we have endured. Drawing upon the strengths of our spirituality, cultural practices and family and community interconnections, we continue to persevere. </p>
<p>Even so, as a young adult I recognized that – compared with the broader society – my community experienced <a href="https://doi.org/10.1007/s00127-018-1494-1">higher rates of mental</a> and <a href="https://doi.org/10.1371/journal.pone.0242934">physical health problems</a>: depression, anxiety, suicide, diabetes and cancer, to name just a few. I wondered whether attending compulsory boarding school – an experience that sets American Indians apart from other minority groups – contributed to these health disparities. </p>
<p>I’m a <a href="https://und.edu/directory/ursula.runningbear">scholar who studies public health</a>, so this question – and the fact that little quantitative scientific inquiry into it had been undertaken – was at the forefront of my thoughts when I had the opportunity to investigate the health effects of boarding schools on American Indians. </p>
<h2>Truth in the data</h2>
<p>When I embarked on this research in 2014, I began by analyzing a portion of the <a href="https://doi.org/10.1176/appi.ajp.162.9.1723">data collected from</a> the American Indian Service Utilization, Psychiatric Epidemiology, Risk and Protective Factors Project. That project focused on the prevalence of mental health disorders and service utilization among Northern Plains and Southwest tribes and collected some data on boarding school attendance and experiences. </p>
<p>For my study, I used the Northern Plains sample that included more than 1,600 randomly selected tribal-enrolled members from the Northern Plains and assessed quality of life – specifically overall physical functioning and well-being. I found that those who attended boarding school had on average <a href="https://doi.org/10.1007/s11482-017-9549-0">statistically significantly lower scores</a> than those who did not attend. </p>
<p>As a researcher, I felt vindicated to find a statistically significant relationship between boarding school attendance and poor physical health – quantitative evidence of what I and many other American Indians already knew instinctively. Yet this finding was also deeply painful. Throughout my life I have sensed the unspoken pain and emotion of my family’s boarding school experiences. </p>
<p>These results made their devastation undeniable and much more tangible. </p>
<h2>Forced assimilation takes a physical toll</h2>
<p>American Indian boarding schools used brutal methods to assimilate their students into the dominant culture and inculcate Christian beliefs and practices. Although <a href="https://theconversation.com/truth-and-healing-commission-could-help-native-american-communities-traumatized-by-government-run-boarding-schools-that-tried-to-destroy-indian-culture-169240">those practices are well documented</a>, quantitative research into whether they had an effect on the long-term physical health of American Indian people who were subjected to them was hard to come by. </p>
<p>Using a subset of the Northern Plains sample, which included more than 700 American Indians who had attended boarding school, I examined the effects of five well-established aspects of boarding school experience. They included an age of first attendance of 7 or younger, rare or nonexistent visits with family, forced church attendance, punishment for use of their native language and a prohibition on the practice of American Indian cultural traditions.</p>
<p>I found that those who endured these experiences during boarding school had worse physical health status than those who did not. </p>
<p>However, the poorest physical health status occurred <a href="https://doi.org/10.1007/s11136-017-1742-y">among people who had been older than 7</a> when they entered boarding school and had also experienced punishment for speaking their tribal language. I am not sure why this is the case, but one possibility is that older children were more proficient in their first, tribal, language, making it more difficult to transition to English, which led, in turn, to more punishment for failure to speak the colonizing language.</p>
<p>Again, although the findings hit me deeply, I was not surprised. Fortunately, today there are efforts to revitalize and restore American Indian languages and culture, such as the <a href="https://sicangucdc.org/wakanyeja-tokeyahci">Wakanyeja Tokeyahci Lakota Immersion School</a>.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/Kfpz8Jn8ZQM?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">In this 2021 MSNBC report, former attendees of American Indian boarding schools recount experiences of emotional, physical and sexual abuse.</span></figcaption>
</figure>
<h2>Chronic health issues</h2>
<p>Recognizing the seriousness of all of this, and its potential effect on my immediate family, I examined whether <a href="https://doi.org/10.1097%2FFCH.0000000000000205">15 chronic health conditions</a> were statistically associated with having attended boarding school. These conditions include diabetes, hypertension, arthritis and kidney disease, among others. I found that former boarding school attendees were 44% more likely to have chronic physical health conditions, with seven out of the 15 chronic conditions statistically related to boarding school attendance. </p>
<p>For example, those who had attended boarding schools were more than twice as likely to <a href="https://doi.org/10.1111/napa.12092">report tuberculosis</a>. This, too, was not surprising, since historical accounts and health reports have <a href="https://narf.org/nill/resources/meriam.html">documented the overcrowded conditions</a>. In addition, windows were often boarded to prevent students from running away, which led to inadequate ventilation. </p>
<p>Boarding school attendees likewise had nearly four times the risk of any type of cancer as those who were not subjected to boarding school. One reason for this could be <a href="https://www.cdc.gov/biomonitoring/DDT_FactSheet.html#">exposure to the pesticide DDT</a>, which was banned in the U.S. in 1972. Upon arriving for the school year, <a href="https://www.npr.org/2022/10/17/1129402172/interior-secretary-haaland-is-documenting-abuse-in-federal-indian-boarding-schoo">students were often coated in DDT powder</a> to target disease-bearing insects like mosquitoes. </p>
<p>I also found higher rates of diabetes, high cholesterol, anemia and gallbladder issues – diseases that can be associated with changing from a whole food diet to one higher in sugars, starches and fats. Given that this shift has been widely reported throughout the American Indian population in recent decades, it is worth noting that these effects appear to be even more pronounced in former boarding school students than in their peers who did not attend.</p>
<h2>Generational effects</h2>
<p>Finally, I examined whether a participant’s mother’s and father’s attendance was related to the number of chronic physical health conditions the person experienced. </p>
<p>I found that someone whose father attended boarding school had, on average, <a href="https://doi.org/10.1097/fch.0000000000000205">36% more chronic physical health conditions</a> than someone whose father did not attend. Notably, I did not find this effect from a mother’s boarding school attendance, although the reasons for that aren’t yet clear.</p>
<p>Although this study did not specifically look at epigenetics – shifts in gene expression that are heritable – <a href="https://doi.org/10.4161/epi.6.7.16222">it points to the possibility of epigenetic effects</a> that can produce biological changes that span generations.</p>
<p>All of this is to say that compulsory residential boarding school education has had profound consequences for several generations of American Indians. As troubling as that is, I have faith that, as evidence mounts on the impacts of boarding school attendance on American Indians, our communities and their allies will develop solutions that improve health and healing for all of our people.</p><img src="https://counter.theconversation.com/content/194691/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Ursula Running Bear receives funding from the National Institute of General Medical Sciences of the National Institutes of Health.
Research reported in this publication was supported by the National Institute on Minority Health and Health Disparities.
The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.. </span></em></p>Native Americans sent to government-funded schools now experience significantly higher rates of mental and physical health problems than those who did not.Ursula Running Bear, Assistant Professor of Population Health, University of North DakotaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1944482022-11-16T18:49:24Z2022-11-16T18:49:24ZLower speed limits don’t just save lives – they make NZ towns and cities better places to live<figure><img src="https://images.theconversation.com/files/495504/original/file-20221115-17-8efebt.jpg?ixlib=rb-1.1.0&rect=8%2C16%2C5455%2C3620&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Getty Images</span></span></figcaption></figure><p>It seems New Zealand is about to slow down, with proposals to reduce urban speed limits right across the country, as well as on <a href="https://www.rnz.co.nz/news/national/478767/plan-to-reduce-speed-limits-on-some-highways-will-save-lives-automobile-association-says">state highways</a>. And while there has been some resistance, the evidence suggests it’s the right move.</p>
<p>The changes are part of Waka Kotahi’s <a href="https://www.nzta.govt.nz/safety/what-waka-kotahi-is-doing/nz-road-safety-strategy/">Road to Zero</a> project, which tasked local councils with developing <a href="https://www.nzta.govt.nz/safety/partners/speed-and-infrastructure/safe-and-appropriate-speed-limits/speed-management-guide/">speed management plans</a> to reduce transport-related deaths. Generally, those plans will set 30 kilometre per hour (km/h) limits around schools and 40km/h limits in many residential areas of <a href="https://www.stuff.co.nz/national/traffic-updates/300701197/lower-speed-limits-en-route-for-more-than-1600-auckland-roads">Auckland</a>, <a href="https://www.stuff.co.nz/dominion-post/news/wellington/128852060/wellington-speed-limits-on-80-of-roads-could-drop-to-30kph-under-council-proposal">Wellington</a>, <a href="https://www.stuff.co.nz/the-press/news/129946716/30kpm-speed-limits-proposed-for-many-christchurch-roads--to-save-lives">Christchurch</a> and <a href="https://www.dunedin.govt.nz/services/roads-and-footpaths/road-safety/speed-limit-changes">Dunedin</a>. </p>
<p>There’s no doubt <a href="https://www.transport.govt.nz/statistics-and-insights/safety-annual-statistics/sheet/speed">speed</a> is a major factor in the number of deaths and injuries on New Zealand roads. It causes more injuries than <a href="https://www.transport.govt.nz/statistics-and-insights/safety-annual-statistics/alcohol-and-drugs/">alcohol and drugs</a>, and it’s estimated that 87% of current speed limits are <a href="https://www.newshub.co.nz/home/politics/2022/10/exclusive-map-shows-unsafe-road-speed-limits-across-new-zealand.html">incorrectly set</a>. </p>
<p>But there’s a counter argument that speed limits should only be reduced in “<a href="https://www.times.co.nz/news/speed-limits-being-slashed-on-local-roads/">high-risk areas</a>”, with school environs being the most common example. Widespread speed limit reduction, the argument goes, will waste drivers’ time and damage the economy. </p>
<p>But this assumes the only way speed limits affect society is through crash-related deaths and injuries, and through time lost travelling. So it’s important we recognise the other significant benefits that come from slowing traffic down.</p>
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<h2>Death and injury</h2>
<p>The risk of injury or death if you are hit by a vehicle is <a href="https://futuretransport.info/human-impact/">substantially lower</a> at speeds below 50km/h. At 40km/h, for example, the risk of dying drops from around 90% to around 10%. For injuries, the greater reductions are seen at speeds of 20 or 30km/h. </p>
<p><a href="https://www.bmj.com/content/339/bmj.b4469">Research in the UK</a> found the introduction of 20 miles per hour (mp/h) zones resulted in a 42% reduction in road casualties, and the reduction was greatest in younger children. There was also no evidence of more people moving to drive on adjacent streets with higher speed limits. </p>
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Read more:
<a href="https://theconversation.com/why-giving-the-commerce-commission-the-power-to-set-fair-fuel-prices-is-unfair-on-nzs-climate-targets-194250">Why giving the Commerce Commission the power to set 'fair' fuel prices is unfair on NZ’s climate targets</a>
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<p>Recent <a href="https://media.service.gov.wales/news/new-research-shows-20mph-speed-limit-could-save-the-welsh-nhs-up-to-gbp-100m-in-first-year">research in Wales</a>, a country with a population of 3.1 million that implemented a default urban speed limit of 20mp/h (30km/h), found the economic value of savings from lower accident rates to be in the region of NZ$180m in the first year alone. The total value is far greater if <a href="https://blogs.napier.ac.uk/tri/wp-content/uploads/sites/56/2022/11/TRI-Technical-Paper-101.The-value-of-Prevention.AD_.pdf">other benefits are included</a>. </p>
<p>What statistics don’t show is the reality of the suffering road crash deaths and injuries cause. But survivors’ stories, such as those <a href="https://abley.com/abley-insights/unhealthy-attitudes-to-speed-limit-reductions/">recorded</a> by transportation consultant Jeanette Ward, also powerfully demonstrate how lower speeds can save lives.</p>
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<h2>Economics and emissions</h2>
<p>But what of the argument that slowing drivers down and prolonging trips mean the economy will suffer? There are two answers to this.</p>
<p>The first is that <a href="https://www.nzta.govt.nz/assets/resources/568/RR-568-Travel-time-savings-and-speed-actual-and-perceived.pdf">evidence shows</a> lower speed limits in urban areas add virtually <a href="https://futuretransport.info/impact-of-maximum-speed-on-journey-times/">no time to journeys</a>. You can see why in this simple <a href="http://videos.futuretransport.info/cars_15_20_30_test_car96.mp4">simulation</a> that compares traffic with different speed limits. </p>
<p>The second is that people don’t always productively use the time saved by faster travel. In fact, <a href="https://www.greaterauckland.org.nz/wp-content/uploads/2009/10/Metz-2008.pdf">research suggests</a> people often choose to travel further, especially for their daily commute. Making journeys faster can also encourage people to travel more often. This is called <a href="https://theconversation.com/climate-explained-does-building-and-expanding-motorways-really-reduce-congestion-and-emissions-147024">induced demand</a> and it adds to congestion. </p>
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<em>
<strong>
Read more:
<a href="https://theconversation.com/climate-explained-does-building-and-expanding-motorways-really-reduce-congestion-and-emissions-147024">Climate explained: does building and expanding motorways really reduce congestion and emissions?</a>
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<p>Furthermore, there is a reasonably established relationship between the speed a vehicle travels and greenhouse gas emissions, with the lowest emissions being produced when a vehicle travels at around 55-80km/h.</p>
<p>However, this assumes a vehicle is moving smoothly, without stops and starts. <a href="https://www.fueleconomy.gov/feg/factors.shtml">Higher emissions</a> are created when a vehicle has to repeatedly brake and accelerate. While individual driver behaviour can be a factor, the road environment and volume of traffic play a role too. </p>
<p>Research has actually found that in urban areas the <a href="https://futuretransport.info/urban-traffic-research">optimum speed limit</a> to minimise emissions for small petrol cars is 28.2km/h. For larger vehicles, diesels and SUVs, CO<sub>2</sub> emissions are minimised with a maximum speed of 20km/h. </p>
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<em>
<strong>
Read more:
<a href="https://theconversation.com/climate-explained-does-your-driving-speed-make-any-difference-to-your-cars-emissions-140246">Climate explained: does your driving speed make any difference to your car's emissions?</a>
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<h2>Pollution, noise and health</h2>
<p>Nitrogen dioxide from traffic is estimated to <a href="https://www.stuff.co.nz/environment/129187840/air-pollution-contributes-to-premature-deaths-of-3300-adults-in-one-year">cause 2,000 deaths</a> each year in New Zealand. <a href="https://futuretransport.info/urban-traffic-research/">Emissions are lowest</a> with 20km/h speed limits. </p>
<p>The World Health Organization estimates traffic noise is the <a href="https://www.euro.who.int/__data/assets/pdf_file/0008/136466/e94888.pdf">second-biggest environmental stressor</a> on public health after air pollution. Lower speeds significantly reduce noise, with <a href="http://cfile240.uf.daum.net/attach/023FD13B50EBB0D50C66C8">research finding</a> that “in urban areas with speeds of between 30 and 60kp/h, reducing speeds by 10kp/h would cut noise levels by up to 40%”.</p>
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<img alt="" src="https://images.theconversation.com/files/495516/original/file-20221115-25-tucxey.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/495516/original/file-20221115-25-tucxey.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=903&fit=crop&dpr=1 600w, https://images.theconversation.com/files/495516/original/file-20221115-25-tucxey.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=903&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/495516/original/file-20221115-25-tucxey.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=903&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/495516/original/file-20221115-25-tucxey.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1135&fit=crop&dpr=1 754w, https://images.theconversation.com/files/495516/original/file-20221115-25-tucxey.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1135&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/495516/original/file-20221115-25-tucxey.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1135&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<p>Lower speed limits have also been shown to reduce health inequalities. One of the UK’s most eminent experts, Oxford University’s Professor Danny Dorling, <a href="https://www.thebritishacademy.ac.uk/publications/cohesive-societies-local-actions-reduce-health-inequalities/">said a 20 mile per hour (30km/h) speed limit</a> was “the most effective thing a local authority can do to reduce health inequalities”. </p>
<p>This is particularly important, given rates of road injury and death in New Zealand <a href="https://www.ehinz.ac.nz/indicators/transport/road-traffic-injury-deaths-and-hospitalisations/">disproportionately affect</a> Māori, younger people and low-income communities. </p>
<p>A range of other benefits from reducing speed limits are identified by Paul Tranter and Rod Tolley in their book <a href="https://doi.org/10.1016/C2017-0-03013-6">Slow Cities</a>. These include more physical activity from walking and cycling, time saved from not having to earn the money necessary to own and operate a car, and broader economic benefits for individuals and businesses. </p>
<p>Overall, reduced speed limits in urban areas would not only reduce injuries and deaths, they would also make our towns and cities better places to live.</p><img src="https://counter.theconversation.com/content/194448/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Simon Kingham is seconded two days a week to the New Zealand Ministry of Transport as Chief Science Advisor.</span></em></p>Despite claims that lowering speed limits will harm the economy, evidence suggests journey times are hardly affected. And beyond reducing the road toll, there are health and climate benefits, too.Simon Kingham, Professor of Human Geography, University of CanterburyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1900352022-09-08T17:13:06Z2022-09-08T17:13:06ZCost of living crisis: the health risks of not turning the heating on in winter<figure><img src="https://images.theconversation.com/files/483197/original/file-20220907-16-oi2zhy.jpg?ixlib=rb-1.1.0&rect=18%2C0%2C6227%2C4167&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/close-hand-adjusting-heating-thermostat-574538638">SpeedKingz/Shutterstock</a></span></figcaption></figure><p>People in the UK might be tempted to keep their heating turned off to offset the large increases in energy bills this winter. A recent <a href="https://yougov.co.uk/topics/politics/articles-reports/2011/10/11/feeling-chill">YouGov poll</a>, revealed that 21% of respondents would not turn their heating on until at least November. Could the health of these people be endangered?</p>
<p>Before COVID, an average of 25,000 extra deaths occurred between December and March compared with any other <a href="https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/bulletins/excesswintermortalityinenglandandwales/2020to2021provisionaland2019to2020final">four-month period of the year</a>. Even if COVID did not exist, the cost of living crisis could result in the toll from the coming winter being worse than usual. </p>
<p>The <a href="https://www.instituteofhealthequity.org/resources-reports/the-health-impacts-of-cold-homes-and-fuel-poverty/the-health-impacts-of-cold-homes-and-fuel-poverty.pdf">Marmot review</a> (a report investigating the effects of cold homes and fuel poverty) estimated that 21.5% of all excess winter deaths could be attributed to the coldest 25% of homes in the UK population.</p>
<p>This would suggest that 5,000 extra deaths occur in winter because people live in cold homes. But this does not mean the cold homes cause the deaths. People who live in cold homes may have other disadvantages, making them less able to survive winter. </p>
<p>Would it make any difference whether they leave their heating on or off? Studies suggest temperatures should be kept to at <a href="https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/1031106/UKHSA_Cold_Weather_Plan_for_England.pdf">least 18°C</a> to minimise the risk to health, but how easy is it to maintain this if homes are poorly insulated? </p>
<p>Research into what is best for people’s health ideally relies on randomised controlled trials to tell us about cause and effect. But it would be unethical to conduct a trial where some people were told to leave their heating off and others were told to keep it on to see if it had any effect on mortality. Instead, we have to rely on what are known as “longitudinal studies” where people are followed over many years and respond regularly to questionnaires. </p>
<p>In one such study in the 1970s, the British Regional Heart Study recruited thousands of men, then in middle age, from across Great Britain. In 2014, around 1,400 of these men, then aged 74-96 years, answered a questionnaire that included <a href="https://www.sciencedirect.com/science/article/pii/S1047279717306622">questions on home heating</a>.</p>
<p>One question asked whether, during the previous winter, the respondent had: “Turned off the heating, even when you were cold because you were worried about the cost?” One hundred and thirty men (9.4%) said yes. These men seemed no more likely to die in the following two years than men who had replied no. </p>
<p>A larger study would have given a more robust answer. And in the absence of other direct evidence, we have to draw conclusions from indirect evidence, such as this. </p>
<h2>The most vulnerable</h2>
<p>Recently, researchers in Sweden tried to assess a range of questions about the effects of energy use, fuel poverty and energy efficiency improvements on people’s health. They systematically reviewed <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9223700/">all the relevant studies on the topic</a>. One of their findings showed consistently across four studies the link between fuel poverty and premature death. </p>
<p>The British Regional Heart Study showed that fuel poverty was more likely to be found among people who were single, poor and working class. This suggests that people who are the most financially vulnerable will be those most likely to leave the heating off. As with climate change, the poorest are hit hardest.</p>
<p>So far I have only discussed effects on health in terms of death, which in the UK concerns mainly older people. The winter deaths that occur are usually the result of heart disease, stroke and respiratory disease. Yet increasing attention has also been paid to the strong effects of the cold on mental health.</p>
<p>The Marmot review quoted studies that drew attention to the depressive effect of living in a cold home. Children in adolescent years may seek respite and privacy away from home, with consequent exposure to mental health risks. The misery caused by financial pressures only add to this burden.</p>
<p>Because the most financially vulnerable people are also the most vulnerable in their health, it should follow that interventions at government level are urgently needed to offset the likely health crisis looming from increased energy costs. </p>
<p>The most vulnerable will need the most help. Yet a common paradox seen in public health is that interventions applying to the whole population will lead to more lives saved than those targeted only to <a href="https://academic.oup.com/ije/article/30/3/427/736897">those at greatest risk</a>. </p>
<p>This is because there are far more people in the population at moderate risk than at high risk. Only a modest proportion of people at moderate risk will benefit. Yet because this group is so much larger than the high-risk group, more lives may be saved among those at moderate risk. </p>
<p>Buildings in the UK clearly need to be better insulated, but these sorts of interventions will come too late for this winter. Mitigating the rising costs of energy must be the only way forward to allow homes to be heated to a comfortable level and prevent a tidal wave of excess winter deaths.</p><img src="https://counter.theconversation.com/content/190035/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Richard Morris carried out research on this topic while employed by UCL (up to 2014) and University of Bristol (2014-2020): these employments were both HEFCE funded. </span></em></p>Government intervention is urgently needed to offset the likely health crisis looming from the increased energy costs.Richard Morris, Honorary Professor in Medical Statistics, University of BristolLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1858212022-07-05T10:16:59Z2022-07-05T10:16:59ZPoliticians live longer than the populations they represent: new research<figure><img src="https://images.theconversation.com/files/471857/original/file-20220630-22-izd6m9.jpg?ixlib=rb-1.1.0&rect=149%2C7%2C4842%2C3255&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Joe Biden is the oldest person to be sworn in as US president. New research shows politicians are likely to live longer than the populations they represent.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/washington-dc-usa-january-20-2021-1936930486">BiksuTong / Shutterstock</a></span></figcaption></figure><p>In many countries, inequalities in income and wealth have been rising since the 1980s. It has been estimated that the top 1% of income earners globally earn <a href="https://equalitytrust.org.uk/scale-economic-inequality-uk">20% of total income</a>. But inequality isn’t just about wealth – elite groups also have advantages over the rest of society in areas such as <a href="https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/811045/Elitist_Britain_2019.pdf">education</a> and <a href="https://www.nejm.org/doi/full/10.1056/NEJM199307083290210">health</a>. They also tend to live longer. Life expectancy of the top 1% of income earners in the US is <a href="https://jamanetwork.com/journals/jama/article-abstract/2513561">almost 15 years longer</a> than the bottom 1%. </p>
<p>Typically highly educated, and with salaries well above average population levels, politicians are one important elite group. They are often accused of being too unlike those they represent, and slow to make policies that would improve the welfare of everyday people. In a <a href="https://link.springer.com/article/10.1007/s10654-022-00885-2">recent study</a> we investigated differences in mortality between politicians and the public and found that politicians generally live longer than the populations they represent.</p>
<p>Our analysis is the most comprehensive so far, based on data from 11 high-income countries: Australia, Austria, Canada, France, Germany, Italy, the Netherlands, New Zealand, Switzerland, the UK and the US. Previously, similar studies tracking long-term trends in health inequalities have focused on just a few countries, such as <a href="https://link.springer.com/article/10.1007/s10654-020-00685-6">Sweden</a> and the <a href="https://www.sciencedirect.com/science/article/pii/S0014498311000246">Netherlands</a>. </p>
<p>Our study was based on more than 57,000 politicians, using historical data that in some cases dated back two centuries. To measure the inequalities, we matched each politician according to their country, age and gender to mortality data for the general public. Then, we compared the number of politicians who died each year with the number expected based on population mortality rates. We also calculated the difference in remaining life expectancy at the age of 45 (which is when, on average, politicians first get elected to office) between politicians and the public.</p>
<p>For nearly all countries, politicians had similar mortality to the general population in the late 19th and early 20th centuries. But throughout the second half of the 20th century, lifespans of politicians grew more rapidly, meaning that in all countries we studied they lived longer than the general population. </p>
<figure class="align-center ">
<img alt="Chart showing that remaining life expectancy at age 45 is longer for politicians than general populations in 11 countries." src="https://images.theconversation.com/files/472268/original/file-20220704-20-jd8a24.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/472268/original/file-20220704-20-jd8a24.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=280&fit=crop&dpr=1 600w, https://images.theconversation.com/files/472268/original/file-20220704-20-jd8a24.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=280&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/472268/original/file-20220704-20-jd8a24.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=280&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/472268/original/file-20220704-20-jd8a24.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=352&fit=crop&dpr=1 754w, https://images.theconversation.com/files/472268/original/file-20220704-20-jd8a24.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=352&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/472268/original/file-20220704-20-jd8a24.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=352&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Remaining life expectancy of 45-year-old politicians and the general populations in 11 countries.</span>
<span class="attribution"><span class="license">Author provided</span></span>
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</figure>
<p>The graph above shows the most recent estimates of life expectancy for politicians and the public. While life expectancy varies across countries, there is much less variation in the life expectancy of politicians. In most countries, politicians’ remaining life expectancy at the age of 45 is around 40 years. The general public’s life expectancy across countries is lower and more varied (ranging from 34.5 years in the US to 37.8 years in Australia). Currently, politicians can expect to live between three and seven years longer than the public.</p>
<p>Over much of the 20th century, the remaining life expectancy of 45-year-old politicians across all countries with available data increased by an average of 14.6 years. For the general population across the same countries, the average increase was 10.2 years.</p>
<h2>Why politicians might be living longer</h2>
<p>While gaps in income and wealth may partly explain these trends, they do not appear to be the only factor. Income inequality (measured by the share of overall income belonging to the richest in society) began to rise in the 1980s. In contrast, differences in life expectancy between politicians and the public began to widen as early as the 1940s.</p>
<p>Politicians’ survival advantage may be due to a variety of factors, including differences in standards of healthcare and lifestyle factors such as smoking and diet. Cigarettes were widely popular in the <a href="https://www.britannica.com/topic/smoking-tobacco/A-social-and-cultural-history-of-smoking">first half of the 20th century</a> and smoking was prevalent across <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2085438/pdf/brmedj03396-0011.pdf">all sections of society</a> by the 1950s. This is no longer the case. Public health measures, starting with bans on tobacco advertising, mean smoking rates have fallen, especially among more advantaged professional groups, such as politicians.</p>
<figure class="align-center ">
<img alt="Black and white photo of Winston Churchill in an open-top car, wearing a top hat and with a cigar in his mouth, giving the v for victory sign" src="https://images.theconversation.com/files/472049/original/file-20220701-18-s342fa.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/472049/original/file-20220701-18-s342fa.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=585&fit=crop&dpr=1 600w, https://images.theconversation.com/files/472049/original/file-20220701-18-s342fa.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=585&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/472049/original/file-20220701-18-s342fa.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=585&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/472049/original/file-20220701-18-s342fa.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=736&fit=crop&dpr=1 754w, https://images.theconversation.com/files/472049/original/file-20220701-18-s342fa.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=736&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/472049/original/file-20220701-18-s342fa.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=736&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">In the past, it was far more common to see politicians smoking.</span>
<span class="attribution"><a class="source" href="https://upload.wikimedia.org/wikipedia/commons/a/a1/Winston_Churchill%2C_cigar_in_mouth%2C_gives_his_famous_%27V%27_for_victory_sign_during_a_visit_to_Bradford%2C_4_December_1942._H25966.jpg">War Office official photographer, Horton (Capt), via Wikimedia Commons</a></span>
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<p>It is also possible that the introduction of new campaigning methods (including television broadcasting and social media) changed the type of person who became a politician. </p>
<p>Women tend to live longer than men generally, but in most countries, data on female politicians were available only after 1960. We found that trends in life expectancy gaps between politicians and the general public were similar for women and men.</p>
<p>In many countries, the public expects transparency and disclosure about politicians’ earnings. The other advantages they have, such as longer life expectancy, have been much less appreciated. Our study focused only on politicians in high-income, democratic countries where data were readily available. Conducting more analysis, particularly of low and middle-income countries, could improve our understanding of global health inequality trends and help find solutions.</p><img src="https://counter.theconversation.com/content/185821/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Philip Clarke receives funding from NIHR, MRC, NHMRC and NIH. </span></em></p><p class="fine-print"><em><span>An Tran-Duy receives funding from the National Health and Medical Research Council and Medical Research Future Fund.</span></em></p><p class="fine-print"><em><span>Laurence Roope receives funding from the Economic and Social Research Council, the Medical Research Council and the NIHR Oxford Biomedical Research Centre.</span></em></p>The public expects transparency about politicians’ earnings, but it’s not the only area where elite groups have an advantage.Philip Clarke, Professor of Health Economics, University of OxfordAn Tran-Duy, Senior Research Fellow, Centre for Health Policy, The University of MelbourneLaurence Roope, Senior Researcher, Health Economics, University of OxfordLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1855492022-06-27T15:35:07Z2022-06-27T15:35:07ZEngland appoints first ever women’s health ambassador – here’s what she should focus on<figure><img src="https://images.theconversation.com/files/470546/original/file-20220623-51658-gj9nrl.jpg?ixlib=rb-1.1.0&rect=14%2C42%2C9475%2C6260&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/applying-contraceptive-hrt-estrogen-birth-control-2032605695">Andrey Popov/Shutterstock</a></span></figcaption></figure><p>The government recently appointed Dame Lesley Regan, professor of obstetrics and gynaecology at Imperial College London, as the <a href="https://www.gov.uk/government/news/dame-lesley-regan-appointed-womens-health-ambassador">first women’s health ambassador</a> for England. The new role has been created to help close the gender health gap. </p>
<p>Women make up <a href="https://www.ethnicity-facts-figures.service.gov.uk/uk-population-by-ethnicity/demographics/male-and-female-populations/latest">51% of the population</a> in England and Wales, yet persistent gender-based inequalities in health, social care, living standards and employment mean women spend more years than men in poor health. And for the first time in a century, their <a href="https://www.health.org.uk/publications/reports/the-marmot-review-10-years-on">life expectancy is declining</a> – and women in deprived areas are the most affected.</p>
<p>Women from underserved and underrepresented racial and ethnic groups face <a href="https://pubmed.ncbi.nlm.nih.gov/34735797/">consistently poor outcomes</a>, even after taking socioeconomic factors into account. Black mothers are <a href="https://www.npeu.ox.ac.uk/assets/downloads/mbrrace-uk/reports/maternal-report-2021/MBRRACE-UK_Maternal_Report_2021_-_Lay_Summary_v10.pdf">four times more likely to die in pregnancy and childbirth</a> than white mothers. </p>
<p>Timely, inclusive and relevant research based on woman-centred care is key to addressing the above problems. Regan has highlighted the immediate need to focus on areas that affect almost all women – such as menopause, menstrual problems, and contraception. She has also highlighted the importance of empowering women to access the healthcare they need across their whole life.</p>
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<h2>Across the lifespan</h2>
<p>Women’s health needs to be viewed across the whole lifespan. For example, conditions such as <a href="https://www.nhs.uk/conditions/polycystic-ovary-syndrome-pcos/">polycystic ovary syndrome</a> have different symptoms at different stages of a woman’s life. Menstrual irregularities and facial hair are common in adolescence, but other symptoms – such as infertility, diabetes during pregnancy, and even complications such as high blood pressure and type 2 diabetes, stroke, and heart attack – are common in the long term. A single strategy targeting polycystic ovary syndrome across the woman’s life will have a positive effect on her short and long-term health.</p>
<p>Another important area that needs more attention is pregnancy in women with underlying complications, such as epilepsy. Compared with more than 200 randomised trials involving the general population with epilepsy, there is only <a href="https://www.journalslibrary.nihr.ac.uk/hta/hta22230/#/abstract">one trial involving pregnant women</a>. Despite improvements in maternity care, <a href="https://www.npeu.ox.ac.uk/assets/downloads/mbrrace-uk/reports/maternal-report-2021/MBRRACE-UK_Maternal_Report_2021_-_FINAL_-_WEB_VERSION.pdf">maternal deaths are increasing</a> in women with epilepsy, mainly because seizure risks in pregnancy are not being properly identified.</p>
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Read more:
<a href="https://theconversation.com/research-into-pregnancy-birth-and-infant-care-is-historically-underfunded-and-women-are-paying-the-price-126629">Research into pregnancy, birth and infant care is historically underfunded – and women are paying the price</a>
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<p>Effective communication of the risks, benefits, and treatments during pregnancy is an essential component of woman-centred care. The recent <a href="https://www.immdsreview.org.uk/downloads/IMMDSReview_Web.pdf">Cumberlege review</a> on complications in babies exposed to the drug valproate (an epilepsy drug) in pregnancy highlights the lack of communication with women about the risks. For women to make informed decisions about the treatments they are offered, they need reliable information on the long-term effect of drugs taken during pregnancy. </p>
<p>Pregnancy and breastfeeding should not be reasons for excluding women from drug trials. The recent report <a href="https://www.birminghamhealthpartners.co.uk/wp-content/uploads/2021/01/21560-Policy-Commission-Maternal-Health-Report-AW-accessible.pdf">Safe and Effective Medicines for Use in Pregnancy</a> sets out how research can be managed to mitigate safety concerns and give confidence to women and their doctors.</p>
<h2>Racial and ethnic disparities</h2>
<p>To optimise the health of all women, we need to tackle the disparities in health outcomes arising from <a href="https://pubmed.ncbi.nlm.nih.gov/34735797/">race, ethnicity and socioeconomic factors</a>. The first step is to really understand the burden of the problem facing women across different regions and for specific conditions, and provide targeted funding. We need to identify those women at risk of ill health early, and target interventions to prevent complications. Moreover, complications in pregnancy adversely affect babies in the long-term. This intergenerational impact can further widen race and ethnicity related inequalities. </p>
<p>It will also be important to invest more in research that promotes women’s health. This can be achieved by drawing on academic expertise in the UK, putting more robust financial investment into these areas, building infrastructure within the NHS and providing training opportunities for early career researchers and clinicians. Seamless integration of academic and health services is critical to the successful delivery of the research. </p>
<p>Any effort to improve women’s health can only succeed when women and their families are involved from the start to the end of the research. Women should guide, support, lead and disseminate research. We need dedicated, inclusive, and representative patient and public involvement groups to promote women’s health research. </p>
<p>The appointment of a dedicated women’s health ambassador is the first step toward achieving the ambitious goal of removing gender, race, and income-based health inequalities to benefit all women and future generations.</p><img src="https://counter.theconversation.com/content/185549/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Shakila Thangaratinam receives funding from NIHR, MRC, WHO. </span></em></p>Regan, England’s first women’s health tsar, has her work cut out for her.Shakila Thangaratinam, Professor of Maternal and Perinatal health, University of BirminghamLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1772242022-02-18T00:25:04Z2022-02-18T00:25:04ZAustralia is failing marginalised people, and it shows in COVID death rates<p>Newly released Australian Bureau of Statistics (ABS) data <a href="https://www.abs.gov.au/articles/covid-19-mortality-australia#death-due-to-covid-19-country-of-birth">show</a> people living in poverty or disadvantage are three times more likely to die from COVID than the wealthy. </p>
<p>This statistic is alarming, but it gets worse when we begin to look more closely at particular communities.</p>
<p>ABS data show the rate of death from COVID for people living in Australia who were born overseas was almost <a href="https://www.abs.gov.au/articles/covid-19-mortality-australia#death-due-to-covid-19-country-of-birth">three times more</a> than those born in Australia when standardised for age (6.8 deaths per 100,000 vs 2.3 deaths).</p>
<p>The rate of death from COVID for people living in Australia from the Middle East was <a href="https://www.abs.gov.au/articles/covid-19-mortality-australia#death-due-to-covid-19-country-of-birth">over 12 times</a> that of people born in Australia (29.3 people per 100,000). </p>
<p>These statistics are damning. They tell us you’re more likely to survive COVID if you were born here, grew up speaking and reading English, are educated, and earn a good income.</p>
<p>They undermine the idea that Australia has good quality universal health care that has been accessible during the pandemic.</p>
<h2>Poverty makes you sick</h2>
<p>Most health problems, and the care needed to address them, follow what we call “<a href="https://pubmed.ncbi.nlm.nih.gov/26369339/">the social gradient</a>”.</p>
<p>This term is shorthand for the idea that those with the most resources – be it money or education – have better health and get better treatment than those with fewer resources.</p>
<p>In short, poverty makes you sick. It does this by limiting your access to services and supports, through money or other factors such as the type of job you work. </p>
<p>People at the “lower end” of the social gradient also tend to receive <a href="https://www.sciencedirect.com/science/article/pii/S014067367192410X">poorer quality health care</a>.</p>
<p>Unfortunately, this social gradient is now clear in the data on Australian COVID deaths.</p>
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<p>For example, some people from Middle Eastern countries and other migrant or refugee communities have poorer employment conditions, such as janitorial jobs in hospitals. These jobs expose people to COVID, who then bring the virus home. They have also needed to keep working in these high risk jobs throughout the pandemic so they can afford basic living costs like food and rent.</p>
<p>There are also <a href="https://www.redcross.org.au/globalassets/corporatecms-migration/publications-research--reports/australian-red-cross-covid-19-tempvisa-report-web.pdf">major barriers to medical care</a> for, and information about, COVID for particular communities. During the Delta variant wave in Victoria and New South Wales, we saw this result in <a href="https://www.abc.net.au/news/2021-09-27/australians-dying-at-home-with-covid-19-sydney-melbourne/100482978">people from refugee and migrant backgrounds dying at home</a> before receiving any medical care for COVID.</p>
<p>Authorities attributed this to a <a href="https://www.abc.net.au/news/2021-08-26/why-are-people-dying-of-covid-19-at-home/100273630">reluctance to seek health care</a>. This reluctance can stem from <a href="https://www.ijhpm.com/article_4027.html">a lack of culturally and linguistically appropriate health care</a> communication and services.</p>
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Read more:
<a href="https://theconversation.com/using-military-language-and-presence-might-not-be-the-best-approach-to-covid-and-public-health-166019">Using military language and presence might not be the best approach to COVID and public health</a>
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<p>Many people also distrust authorities, including the police and army, due to experiences in people’s home countries. Being scared of authorities is a legitimate fear when you have come from a country where authorities may kill you.</p>
<p>This has been exacerbated by governments in Australia <a href="https://theconversation.com/using-military-language-and-presence-might-not-be-the-best-approach-to-covid-and-public-health-166019">choosing to</a> “police” the pandemic. Large fines were threatened to people who broke COVID public health orders.</p>
<p>This fear of fines and authorities likely contributed to a reluctance to seek medical care, and in turn more deaths. And messaging around authoritarian approaches to those who break COVID health orders are likely to have exacerbated this. </p>
<p>Many have also been excluded from government support.</p>
<p>Australian governments and health services have been failing parts of our community, from those with low incomes to people from non-English speaking backgrounds. </p>
<h2>What can we do right now?</h2>
<p>There are a range of actions we can take to rectify the high rates of death amongst refugee and migrant communities.</p>
<p>Policy wise, the federal government could extend access to Medicare and social safety net support for <a href="https://refugeehealthguide.org.au/asylum-seekers/">people experiencing issues with temporary visas</a>, such as asylum seekers living in the community who are appealing a decision on a visa application, and are not eligible for Medicare. Adding <a href="https://www.ijhpm.com/article_4027.html">specific Medicare items for refugees and migrants</a> may also encourage more culturally and linguisticaly inclusive medical care in the health system.</p>
<p>These changes would help provide more affordable, accessible and inclusive health care, particularly for asylum seekers and refugees dealing with visa issues, and help prevent loss of life. </p>
<p>Governments should also involve refugee and migrant communities in the development and implementation of actions to reduce COVID deaths. Communities know what they need in a crisis – we need to find new ways of listening. A top-down, <a href="https://www.gemmacarey.space/_files/ugd/aa1ed8_884477c6b0974b31984124e0e1182cb3.pdf">middle class response</a> to a pandemic will create services and supports that only work for the middle class.</p>
<p>It’s vital we look to the <a href="https://theconversation.com/building-trust-with-migrant-and-refugee-communities-is-crucial-for-public-health-measures-to-work-167180">evidence of what may best help refugee and migrant communities</a> reduce the risk of infection, involve them meaningfully in this process, and sharpen our focus on making life in Australia fairer, more inclusive and, hopefully, safer for all.</p>
<h2>What has to happen next?</h2>
<p>Currently, there are major gaps in understanding what may best support refugee and migrant communities to reduce the risk of infection and harm from COVID.</p>
<p>More research is needed. However that research needs to be led by peers in communities and be easy to access and participate in. In other words, we cannot repeat the mistake of creating approaches that work for just the middle class.</p>
<p>Best practice tells us multiple forms of research are required, and in culturally and linguistically inclusive ways.</p>
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Read more:
<a href="https://theconversation.com/the-real-challenge-to-covid-19-vaccination-rates-isnt-hesitancy-its-equal-access-for-maori-and-pacific-people-161676">The real challenge to COVID-19 vaccination rates isn’t hesitancy — it’s equal access for Māori and Pacific people</a>
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<p>Survey-based research must be conducted in hospitals, health centres and other clinical environments to understand how barriers to medical care and information for COVID can be addressed to better meet the needs of people from refugee and migrant communities. The research could identify more culturally inclusive ways of managing vaccinations, testing and recovery from virus symptoms.</p>
<p>This must be backed up by in-depth research to explore the experiences of a diverse range of communities. Just as disadvantaged groups are not all alike, neither are refugee and migrant communities (despite being commonly lumped under the term “culturally and linguisticaly diverse”).</p>
<p>Communities who are recently arrived or longer settled – all from different countries – have different needs.</p>
<p>We need more listening, and less punitive approaches.</p><img src="https://counter.theconversation.com/content/177224/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Ben O'Mara has previously received funding from VicHealth, the Department of Heath and Ageing and the Australian and New Zealand School of Government. O'Mara also works as an Adjunct Fellow at Swinburne University and he is the Information Resources Manager at Motor Neurone Disease Australia.</span></em></p><p class="fine-print"><em><span>Gemma Carey does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>People living in poverty or disadvantage are three times more likely to die from COVID than the wealthy.Gemma Carey, Professor, UNSW SydneyBen O'Mara, Adjunct Fellow, UNSW SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1728422021-12-06T13:41:58Z2021-12-06T13:41:58ZWhy addressing racism against Black women in health care is key to ending the US HIV epidemic<figure><img src="https://images.theconversation.com/files/435449/original/file-20211202-20099-1a4zath.jpg?ixlib=rb-1.1.0&rect=7%2C202%2C5184%2C2981&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">When Black patients are treated by Black doctors, they have better health outcomes – but fewer than 6 in 100 American doctors are Black.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/smiling-senior-doctor-talking-to-patient-in-royalty-free-image/1309073221?adppopup=true">The Good Brigade/Digital Vision via Getty Images</a></span></figcaption></figure><p>Forty years into the HIV/AIDS epidemic, Black women continue to bear the highest burden of HIV among women.</p>
<p>Although Black women represent only <a href="https://www.census.gov/quickfacts/fact/table/US/LFE046219">13% of the female population</a>, they accounted for over half of HIV diagnoses among all females in the U.S. in 2018, according to <a href="https://www.cdc.gov/hiv/library/reports/hiv-surveillance/vol-31/content/women.html">data from the U.S. Centers for Disease Control and Prevention</a>. White women, who are 62% of the female population, <a href="https://www.cdc.gov/hiv/library/reports/hiv-surveillance/vol-31/content/women.html">accounted for 21%</a> of HIV diagnoses. </p>
<p>Black women are also <a href="https://doi.org/10.1371/journal.pone.0189973">less likely</a> than white women to <a href="https://www.cdc.gov/mmwr/volumes/67/wr/mm6741a3.htm">receive the antiretroviral therapies</a> that are highly effective at preventing HIV infection and are more likely <a href="https://www.idsociety.org/news--publications-new/articles/2021/study-shows-black-women-with-hiv-had-highest-rates-of-premature-mortality-between-1998-2018/">to die of causes related to HIV</a>. </p>
<p>This year’s World AIDS Day theme included <a href="https://www.unaids.org/en/World_AIDS_Day">ending inequalities</a> in HIV and AIDS care. But in order to address the inequities, it will require examining the root causes of them. In the United States, the most prominent reasons for these disparities are <a href="https://doi.org/10.1056/NEJMms2025396">structural and systemic racism</a>. </p>
<p>I am the co-founder and director of a research center at Columbia University, <a href="https://sig.columbia.edu/content/get-involved">the Social Intervention Group</a>. In the past 30 years, more than a thousand Black women living with or at risk for HIV have participated in the center’s studies of the <a href="https://scholar.google.com/scholar?q=nabila+el+bassel&hl=en&as_sdt=0,39&as_vis=1">causes and dynamics of HIV, substance abuse and gender-based violence</a>. These include <a href="https://scholar.google.com/scholar?hl=en&as_sdt=0%2C39&as_vis=1&q=nabila+el+bassel+HIV&btnG=">intervention studies</a> to put new strategies into practice and evaluate their impacts.</p>
<p>We have identified three approaches that can help improve the health of this population of at-risk women, as well as their access to health care.</p>
<h2>Addressing life contexts and experiences</h2>
<p>Many women who participated <a href="https://doi.org/10.1001/jamanetworkopen.2021.5226">in our studies</a> told us that their health providers rarely pay attention to their life context.</p>
<p>Life context includes racism, discrimination, poverty, a history of homelessness, incarceration, partner violence, stigma and trauma. Black women often <a href="https://doi.org/10.1001/amajethics.2021.156">lack integrated health services</a> to address these co-occurring issues, and simultaneously <a href="https://doi.org/10.1073/pnas.1516047113">their needs are often ignored</a> by their health care providers, which means <a href="https://dx.doi.org/10.2105/AJPH.2008.140541">they do not receive the treatment they need</a>.</p>
<p>The data affirm these women’s personal experiences. Black women are almost <a href="https://www.americanprogress.org/article/basic-facts-women-poverty/">three times as likely to live in poverty</a> and to <a href="https://www.cdc.gov/healthequity/features/maternal-mortality/index.html">die from pregnancy-related causes</a> than white women. They are also more likely to <a href="https://www.nationalpartnership.org/our-work/resources/health-care/black-womens-health-insurance-coverage.pdf">hold low-wage jobs that do not provide health benefits</a>.</p>
<p>Black Americans overall remain more likely to <a href="https://www.kff.org/racial-equity-and-health-policy/issue-brief/health-coverage-by-race-and-ethnicity/">lack health insurance</a> than their white counterparts. They often <a href="https://dx.doi.org/10.1007%2Fs11113-016-9416-y">lose insurance coverage more quickly</a>. </p>
<p>To help overcome these inequities, the Social Intervention Group has developed an intervention called “Empowering African American Women on the Road to Health,” <a href="https://sig.columbia.edu/research-projects/eworth">or E-WORTH</a>. This study was designed by and for Black women to decrease HIV transmission and improve access to care, and it evaluated whether its methods improve participants’ health outcomes in practice.</p>
<p>E-WORTH is a new cultural adaptation of an HIV intervention for Black women called <a href="https://doi.org/10.1371/journal.pone.0111528">Project WORTH</a>, which was selected as <a href="https://www.cdc.gov/hiv/pdf/research/interventionresearch/compendium/rr/cdc-hiv-worth_best_rr.pdf">a best practice by the CDC</a>. </p>
<h2>Culturally tailored HIV care</h2>
<p>A total of 352 women participated in <a href="https://dx.doi.org/10.1001/jamanetworkopen.2021.5226">our E-WORTH intervention study</a>, which started in November 2015 and concluded in August 2019. The intervention included a one-hour individual HIV testing and orientation session, and four weekly 90-minute group sessions. </p>
<p>These sessions included raising awareness about HIV and other sexually transmitted infection risks, proper condom use, sexual negotiation skills, risk reduction goal settings, increasing social support and linkage to services, intimate partner violence screening, safety planning and referral to violence prevention services. </p>
<p>The participants were provided with opportunities to discuss their experiences of barriers to health care and other services, and how racism affected their access to services. </p>
<p>These unique intervention components had a positive effect. We found at the 12-month follow-up that compared with women participating in a one-session HIV testing intervention, the women in the five-session E-WORTH intervention had 54% lower odds of testing positive for any sexually transmitted infection. They also reported 38% fewer acts of condomless vaginal or anal intercourse.</p>
<p>The findings suggest that implementing an HIV/sexually transmitted infection intervention that is culturally tailored and designed for Black women holds promise for reducing the disproportionate burden of these infections in this population.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/435664/original/file-20211203-21-vc7qqa.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A Black female doctor peers into the mouth of a patient." src="https://images.theconversation.com/files/435664/original/file-20211203-21-vc7qqa.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/435664/original/file-20211203-21-vc7qqa.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=394&fit=crop&dpr=1 600w, https://images.theconversation.com/files/435664/original/file-20211203-21-vc7qqa.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=394&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/435664/original/file-20211203-21-vc7qqa.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=394&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/435664/original/file-20211203-21-vc7qqa.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=495&fit=crop&dpr=1 754w, https://images.theconversation.com/files/435664/original/file-20211203-21-vc7qqa.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=495&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/435664/original/file-20211203-21-vc7qqa.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=495&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Culturally tailored health care shows promise for improving health outcomes for Black women.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/woman-receives-a-physical-the-daybreak-community-health-news-photo/540612512?adppopup=true">Gregory Smith/Corbis Historical via Getty Images</a></span>
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<p>Research shows that Black women often don’t receive adequate care because <a href="https://doi.org/10.1073/pnas.1516047113">care providers frequently do not believe their pain is real</a>. Several participants in E-WORTH <a href="https://sig.columbia.edu/news/new-publication-protocol-prevent-hiv-and-violence-among-black-women">reported that</a> in their overall experiences with the health care system, “No one ever believes me.”</p>
<p>In contrast, because of the trust and respect shown by facilitators and study staff, women participating in E-WORTH reported <a href="https://sig.columbia.edu/news/new-publication-protocol-prevent-hiv-and-violence-among-black-women">feeling heard and believed</a>.</p>
<p>These same women have also told us that sometimes clinical staff blame them for contracting HIV and <a href="https://www.healthline.com/health-news/the-discrimination-black-americans-face-when-it-comes-to-pain-management#Racial-bias-in-medical-care">fail to discuss or offer treatment and care options</a>, which prevents them from accessing or staying in care. </p>
<p>To address life context, E-WORTH is interwoven with Afrocentric themes of trauma and resiliency. These draw on Black Americans’ historical and lived experiences, from slavery to Jim Crow to the mass incarceration of Black individuals. Multimedia sequences in the sessions are intentionally infused with conversations about historical oppression, race and culture as well as systemic issues such as the overpolicing of Black communities and <a href="https://www.sentencingproject.org/issues/racial-disparity/">disproportionate sentencing laws</a>. </p>
<p>The facilitators of the intervention sessions led discussions exploring how intersecting identities related to race and ethnicity are at the heart of the HIV epidemic for Black women. The scripts used by facilitators featured Afrocentric language, based on input from prior focus groups of Black women, including character names. Afrocentric graphics were used, such as purple for royalty. </p>
<h2>A need for Black doctors and structural racism training</h2>
<p>Researchers have found that <a href="https://www.scientificamerican.com/article/we-need-more-black-physicians/">the health outcomes of Black patients improve</a> when they are treated by Black doctors. Further, Black women are more likely to trust doctors who <a href="https://doi.org/10.1353/hpu.2018.0036">live in their communities</a>.</p>
<p>However, a <a href="https://doi.org/10.1007/s11606-021-06745-1">recent study</a> found that only <a href="https://www.usnews.com/news/health-news/articles/2021-04-21/little-progress-in-boosting-numbers-of-black-american-doctors">5.4% of American doctors are Black</a>, and only <a href="https://www.usnews.com/news/health-news/articles/2021-04-21/little-progress-in-boosting-numbers-of-black-american-doctors">2.8% of them are women</a>. </p>
<p><a href="https://doi.org/10.1001/jamanetworkopen.2020.15220">Another recent study</a> suggests that creating medical education programs at <a href="https://theconversation.com/us/topics/hbcus-38001">historically Black colleges and universities</a> could increase the number of Black doctors. This supports other studies confirming <a href="https://dx.doi.org/10.3934%2Fpublichealth.2017.6.579">the importance of these schools</a> in expanding America’s ranks of Black doctors.</p>
<p>Increasing the number of Black providers is only part of the solution, however. <a href="https://www.aamc.org/media/37286/download?attachment">Fewer than half of U.S. medical schools</a> provide some sort of instruction or training on addressing structural racism and racial disparities in medical care. </p>
<p>[<em>Get the best of The Conversation’s politics, science or religion articles each week.</em><a href="https://memberservices.theconversation.com/newsletters/?source=inline-best">Sign up today</a>.]</p>
<p>Over the past few years, medical schools as well as schools for allied health professions have made greater commitments to <a href="https://www.aamc.org/news-insights/medical-schools-overhaul-curricula-fight-inequities">training the next generation of health professionals</a> to address racism. </p>
<p>While research has shown structural racism to be <a href="https://doi.org/10.1056/NEJMms2025396">a powerful driver of health disparities</a>, a <a href="https://doi.org/10.1016/S0140-6736(17)30569-X">wide gap exists</a> in the literature on the <a href="https://dx.doi.org/10.1007%2Fs40615-021-01137-x">impact of these trainings</a> on medical staff practices and their patients’ health outcomes. This underscores the need for more attention to <a href="https://doi.org/10.1177/0002764213487341">this type of research</a>. </p>
<h2>Underpinnings of racism in the medical system</h2>
<p>In late 2020, the American Medical Association declared <a href="https://www.ama-assn.org/delivering-care/health-equity/ama-racism-threat-public-health">structural racism a public health threat</a> and emphasized the urgent need to prepare the U.S. health care workforce to redress it.</p>
<p>“Without systemic and structural-level change, health inequities will continue to exist,” <a href="https://www.ama-assn.org/delivering-care/health-equity/ama-racism-threat-public-health">wrote AMA Board member Willarda V. Edwards</a>. “Declaring racism as an urgent public health threat is a step in the right direction toward advancing equity in medicine and public health.”</p>
<p>The Social Intervention Group continues to develop and evaluate solutions to curbing the HIV crisis among Black women. Our research findings suggest that when these women are actively engaged in all stages of their health care services and research, they can improve their health and lives. But this will require that medical professionals also address the health care system’s inherent structural racism.</p><img src="https://counter.theconversation.com/content/172842/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Nabila El-Bassel does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Black American women have disproportionate HIV infection rates – in part because of systemic and structural racism in the health care system.Nabila El-Bassel, Professor of Social Work, Director of Social Intervention Group, Columbia UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1709212021-11-15T16:49:33Z2021-11-15T16:49:33ZWorkplaces can help promote exercise, but job conditions remain a major hurdle<figure><img src="https://images.theconversation.com/files/431725/original/file-20211112-15587-uttb3l.jpg?ixlib=rb-1.1.0&rect=172%2C43%2C4794%2C3768&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Many workplace fitness facilities — like standing desks, on-site gyms and showers, and easy access to walking paths — are mostly available to white-collar, higher-income workers who already face fewer barriers to exercise outside of work.</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><p>We know regular exercise is really good for health, but even with the best of intentions, <a href="https://www.doi.org/10.25318/82-003-x202000900002-eng">many workers do not exercise as much as they should</a>. To get more workers in all types of workplaces to be active, public health messaging must move away from making it only an individual’s responsibility to be more active. It should instead recognize the important role employers can play in creating the conditions for workers to focus on exercise.</p>
<p>There’s much to be said for this approach. From a public health perspective, focusing on workplaces can seem like low-hanging fruit, since they are settings where people already go every day. Consider the resources that would otherwise be required to build activity-friendly environments, let alone address <a href="https://doi.org/10.1093/heapro/dav022">the root social causes of physical inactivity</a>. However, the reality is more complicated. </p>
<figure class="align-right ">
<img alt="Stairs with each step labelled with the number of calories burned" src="https://images.theconversation.com/files/431440/original/file-20211111-13-11upi69.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/431440/original/file-20211111-13-11upi69.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=800&fit=crop&dpr=1 600w, https://images.theconversation.com/files/431440/original/file-20211111-13-11upi69.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=800&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/431440/original/file-20211111-13-11upi69.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=800&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/431440/original/file-20211111-13-11upi69.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1005&fit=crop&dpr=1 754w, https://images.theconversation.com/files/431440/original/file-20211111-13-11upi69.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1005&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/431440/original/file-20211111-13-11upi69.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1005&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">On-site gyms and access to walking paths or stairs support workplace fitness.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
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<p>The World Health Organization’s <a href="https://www.who.int/news-room/fact-sheets/detail/physical-activity">physical activity guidelines</a> recommend adults strive for at least 150-300 minutes of moderate-intensity aerobic physical activity, or 75-150 minutes of vigorous-intensity aerobic physical activity, or an equivalent combination every week. To meet these recommendations, for 80 per cent of working-age Canadians <a href="https://doi.org/10.25318/1410032701-eng">in full-time jobs</a>, it means finding time to exercise before, after or at work.</p>
<p>That’s easier for some than others. I am part of a team at the <a href="https://www.iwh.on.ca">Institute for Work and Health</a> that <a href="http://dx.doi.org/10.1136/oemed-2019-106158">published a paper</a> showing that people in certain work conditions are less likely to exercise. These are workers who: report long work hours, have little say in how to use their skills, or are in physically or psychologically demanding jobs. </p>
<p><a href="https://doi.org/10.1123/jpah.2013-0098">Other</a> <a href="https://doi.org/10.1016/j.amepre.2010.12.015">studies</a> have reported the same. These findings <a href="https://doi.org/10.1080/02678373.2017.1303759">support the theory</a> that stressful and strenuous working conditions can increase a worker’s fatigue and decrease motivation and perceived time available to exercise.</p>
<h2>Workplace spillover</h2>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/431726/original/file-20211112-13043-1ht05jo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A warehouse with a worker in the foreground sealing a box with packing tape on a conveyor belt and two other workers in the background" src="https://images.theconversation.com/files/431726/original/file-20211112-13043-1ht05jo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/431726/original/file-20211112-13043-1ht05jo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/431726/original/file-20211112-13043-1ht05jo.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/431726/original/file-20211112-13043-1ht05jo.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/431726/original/file-20211112-13043-1ht05jo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/431726/original/file-20211112-13043-1ht05jo.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/431726/original/file-20211112-13043-1ht05jo.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Job-related physical activity often does not provide the same health benefits of leisure-time exercise.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
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<p>The spillover of strenuous working lives on exercise participation is a reality for many people — especially when there are competing demands such as taking care of children. But the ability to overcome these barriers can depend on job type. </p>
<p>Supportive workplace facilities that offer standing desks, stairs, on-site showers and gyms and easy access to walking paths <a href="https://doi.org/10.1016/j.pmedr.2018.03.013">can make it easier for people to fit in exercise</a> and reduce sedentary time. However, these are mostly available to white-collar, higher-income workers who already face fewer barriers to exercise outside of work.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/lack-of-exercise-linked-to-increased-risk-of-severe-covid-19-163865">Lack of exercise linked to increased risk of severe COVID-19</a>
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</p>
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<p>Emphasizing worker responsibility for exercising more can exacerbate health inequalities between high- and low-income workers. Low-income workers in non-standard or precarious jobs often have little say about how they spend their work time. These workers <a href="https://doi.org/10.2105/AJPH.2010.300075">also have few opportunities to exercise and engage in other healthy behaviours outside work</a>. </p>
<p>Some manual labour jobs involve high levels of physical activity with little time to rest, while workers in service sector jobs can spend long periods of time standing. A body of research is showing the <a href="http://dx.doi.org/10.1136/bjsports-2017-097965">potential harm of these occupational activities</a> — including the risks of physical activity for people doing such jobs. Job-related physical activity often does not provide the same health benefits of leisure-time exercise, and can even have negative effects because of factors like the nature of the movements and duration of work.</p>
<h2>Healthy workers are safer workers</h2>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/431446/original/file-20211111-12594-1l48yqf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A woman in a blue apron ironing in an industrial laundry" src="https://images.theconversation.com/files/431446/original/file-20211111-12594-1l48yqf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/431446/original/file-20211111-12594-1l48yqf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/431446/original/file-20211111-12594-1l48yqf.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/431446/original/file-20211111-12594-1l48yqf.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/431446/original/file-20211111-12594-1l48yqf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/431446/original/file-20211111-12594-1l48yqf.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/431446/original/file-20211111-12594-1l48yqf.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Many employees have little say in how they spend their work time.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
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</figure>
<p>Physical activity guidelines aimed at all adults will not be achievable for many workers. A more inclusive solution is for employers to create the conditions for their workers to thrive so that they can also prioritize their health. </p>
<p>This approach pushes for employers to think of workplace policies as levers to address the safety, health and well-being of their workers. Research shows that <a href="https://doi.org/10.2105/AJPH.2006.086900">healthy workers are safe workers</a>, and this concept is endorsed by <a href="https://labordoc.ilo.org/permalink/41ILO_INST/kc2336/alma994681343402676">international labour agencies</a> and the <a href="https://www.cdc.gov/niosh/twh/default.html">Total Worker Health program</a> in the United States.</p>
<p>What could such an approach look like? One example is the case of an insurance company offering flexible scheduling and telecommuting options to help its workers reduce their stress. This <a href="https://www.cdc.gov/niosh/TWH/newsletter/TWHnewsv6n1.html#Promising%20Practices%20for%20Total%20Worker%20Health">led to workers walking more, taking breaks away from their desks and engaging in stress-reducing social activities</a> such as ping-pong competitions and indoor nerf basketball tournaments. </p>
<p>At one construction company, a 14-week intervention focused on health education, reinforcing safety and health behaviours and improving work-life balance. The result was <a href="https://www.doi.org/10.1097/JOM.0000000000001290">more workers reporting exercising at least 30 minutes a day</a>. </p>
<p>In another example, a police department reduced the number of night shifts for its officers. It also offered mental health support and allowed staff to take one hour off each shift to exercise. The result was <a href="https://www.cdc.gov/niosh/twh/newsletter/twhnewsv7n4.html#3">a reduction in workplace injuries</a>.</p>
<h2>Enhancing working conditions</h2>
<figure class="align-center ">
<img alt="An open-plan office with workers at tables and in cubicles" src="https://images.theconversation.com/files/431458/original/file-20211111-17-1xlp070.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/431458/original/file-20211111-17-1xlp070.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/431458/original/file-20211111-17-1xlp070.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/431458/original/file-20211111-17-1xlp070.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/431458/original/file-20211111-17-1xlp070.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/431458/original/file-20211111-17-1xlp070.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/431458/original/file-20211111-17-1xlp070.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Employers should discuss supportive policies and practices with workers to create a workplace environment that supports the safety, health and well-being of their employees.</span>
<span class="attribution"><span class="source">(Unsplash/Arlington Research)</span></span>
</figcaption>
</figure>
<p>So how do we get more employers to get behind this? <a href="https://doi.org/10.1177/15248399211028154">Our team’s research</a> in Canada and <a href="https://centerforworkhealth.sph.harvard.edu/resources/guidelines-implementing-integrated-approach">other studies</a> have highlighted the importance of convincing employers with data that this approach can be successful. For example, an employer-led approach has <a href="https://doi.org/10.1037/0000149-000">increased participation in safety and wellness efforts, and reduced workplace injuries and health-care costs</a>. </p>
<p>Employers that want to create an environment conducive to the safety, health and well-being of their employees should discuss with their workers how policies and practices could support those goals.</p>
<p>While there is no simple solution to getting workers more physically active, an important step forward is to get employers involved in enhancing working conditions so that more Canadian workers are supported in getting the health benefits of regular exercise.</p><img src="https://counter.theconversation.com/content/170921/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Aviroop Biswas receives funding from the Canadian Institutes for Health Research, WorkSafeBC, and the University of Toronto Data Science Seed Cluster. The Institute for Work & Health is supported by funding from the Ontario Ministry of Labour, Training and Skills Development.</span></em></p>To get more workers to be active, public health messaging must recognize the important role employers can play in creating the conditions for workers to focus on exercise.Aviroop Biswas, Associate Scientist, Institute for Work & Health. Assistant Professor, Dalla Lana School of Public Health, University of TorontoLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1693622021-10-13T03:05:52Z2021-10-13T03:05:52ZHome rapid antigen testing is on its way. But we need to make sure everyone has access<figure><img src="https://images.theconversation.com/files/426076/original/file-20211012-21-7ojewt.jpg?ixlib=rb-1.1.0&rect=1%2C0%2C997%2C666&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/woman-using-cotton-swab-while-doing-1967366755">Shutterstock</a></span></figcaption></figure><p>As Australia opens up and we learn to live with COVID-19, rapid antigen tests are likely to play an increasingly important role in limiting the spread of the virus.</p>
<p>So we can expect growing demand for these tests, which can give a result in minutes, and are already used in other countries, including the <a href="https://www.abc.net.au/news/2021-07-30/rapid-antigen-tests-widely-used-in-the-uk/13477332">United Kingdom</a>.</p>
<p>Airline travel, accommodation, entry to ticketed events and school attendance may depend on this type of testing. Large-scale family gatherings and community events will also want to ensure the safety of all attendees, especially if some, for whatever reason, are unvaccinated. </p>
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<em>
<strong>
Read more:
<a href="https://theconversation.com/rapid-antigen-tests-have-long-been-used-overseas-to-detect-covid-heres-what-australia-can-learn-168490">Rapid antigen tests have long been used overseas to detect COVID. Here's what Australia can learn</a>
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<h2>What are rapid antigen tests?</h2>
<p>Rapid antigen tests have many advantages over the polymerase chain reaction (PCR) tests used at public testing centres. They are cheaper,
can be used anywhere at any time, and results are available within minutes. But they are also <a href="https://theconversation.com/rapid-antigen-tests-have-long-been-used-overseas-to-detect-covid-heres-what-australia-can-learn-168490">less reliable</a> than PCR tests.</p>
<p>The Therapeutic Goods Administration (TGA) has <a href="https://www.tga.gov.au/covid-19-test-kits-included-artg-legal-supply-australia">approved</a> dozens of these rapid antigen tests. But these are only available for use in health care, aged care, schools and workplaces. </p>
<p>These tests are not commercially available for home use, although this is <a href="https://www.tga.gov.au/covid-19-rapid-antigen-point-care-and-self-tests">on its way</a>. Health Minister Greg Hunt <a href="https://www.abc.net.au/news/2021-09-28/covid-19-rapid-antigen-home-tests-available-from-november/100496776">expects</a> home tests will be available from November 1.</p>
<p>Between now and then, here are four issues we need to consider if individuals and families are expected to use these tests and if rapid antigen testing is to be an effective and equitable gateway to activities and services.</p>
<h2>1. Do they work?</h2>
<p>The TGA will need to ensure the tests, many of which were developed more than a year ago, perform well with the Delta variant.</p>
<p>A <a href="https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD013705.pub2/full">Cochrane review</a> recommends evaluations of the tests in the settings where they are intended to be used to fully establish how well they work in practice. It is not clear if this research is being done in Australia.</p>
<p>Tests from different manufacturers vary in accuracy and are <a href="https://www.medrxiv.org/content/10.1101/2021.03.19.21253964v2.full.pdf">less accurate</a> in people without symptoms and/or with low viral loads – when they will most likely be used.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/rapid-antigen-testing-isnt-perfect-but-it-could-be-a-useful-part-of-australias-covid-response-164873">Rapid antigen testing isn't perfect. But it could be a useful part of Australia's COVID response</a>
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<p>Many home tests <a href="https://www.nytimes.com/2021/10/07/well/live/covid-rapid-at-home-test.html?referringSource=articleShare">advise testing twice</a> over a three-day period, with at least 36 hours between tests; they work best when testing is done <a href="https://theconversation.com/over-the-counter-rapid-antigen-tests-can-help-slow-the-spread-of-covid-19-heres-how-to-use-them-effectively-166869">regularly</a>.</p>
<p>Appropriate consumer information material needs to be included with the tests to ensure people are using and interpreting them correctly at home. </p>
<p>There also needs to be a back-up service (such as a telephone hotline) for people who are confused, get unexpected results, and for those who test positive and <a href="https://www.tga.gov.au/covid-19-rapid-antigen-point-care-and-self-tests">need PCR testing</a> to confirm their status.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/426081/original/file-20211012-22-1shq1ic.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Person at home dropping reagent into a rapid antigen test" src="https://images.theconversation.com/files/426081/original/file-20211012-22-1shq1ic.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/426081/original/file-20211012-22-1shq1ic.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/426081/original/file-20211012-22-1shq1ic.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/426081/original/file-20211012-22-1shq1ic.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/426081/original/file-20211012-22-1shq1ic.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/426081/original/file-20211012-22-1shq1ic.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/426081/original/file-20211012-22-1shq1ic.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">People need adequate instructions to use these tests correctly.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/closeup-young-caucasian-man-sitting-on-1914468733">Shutterstock</a></span>
</figcaption>
</figure>
<h2>2. Do we have enough tests?</h2>
<p>There are already signs supply of these tests could be a problem.</p>
<p>The biggest Australian manufacturer of rapid antigen tests has a <a href="https://www.ellumehealth.com/2021/02/01/ellume-announces-231-8-million-agreement-with-the-u-s-government-to-scale-up-production-of-covid-19-home-tests/#:%7E:text=Digital%20diagnostics%20company%20Ellume%20today,its%20COVID%2D19%20home%20tests.">large government supply contract</a> with the United States, where supply of such tests cannot keep pace with <a href="https://www.washingtonpost.com/health/2021/10/06/biden-rapid-at-home-covid-tests/">demand</a>.</p>
<p>India has also <a href="https://timesofindia.indiatimes.com/india/centre-restricts-export-of-covid-19-rapid-antigen-testing-kits-amid-third-wave-concerns/articleshow/85382639.cms">recently acted</a> to restrict export of rapid antigen tests. </p>
<p>There are <a href="https://www.health.gov.au/news/rapid-antigen-testing-in-aged-care">indications</a> the federal government has supplies for distribution to aged-care facilities and local government areas as needed. However, the extent of the stockpile – and whether tests might be released from the stockpile for home use – is unknown.</p>
<h2>3. What will they cost?</h2>
<p>Once approved for use at home, people will most likely be able to buy these tests in pharmacies. However, there’s been no suggestion these will be subsidised or their price controlled. </p>
<p>There are different international approaches. In the <a href="https://www.nhs.uk/conditions/coronavirus-covid-19/testing/regular-rapid-coronavirus-tests-if-you-do-not-have-symptoms/">UK</a>, people can order two packs of seven tests free from a government website and can pick them up from places including pharmacies and libraries. </p>
<p>In <a href="https://www.euronews.com/2021/03/07/rapid-covid-tests-available-in-german-supermarkets-as-europe-records-1-million-covid-cases">Germany</a>, people can buy tests in supermarkets for about €25 (about AU$39) for a pack of five. </p>
<p>In the US, there are <a href="https://www.nbcnews.com/health/health-news/why-do-covid-rapid-tests-cost-so-much-even-after-n1278934">huge price variations</a> with <a href="https://www.washingtonpost.com/health/2021/02/01/coronavirus-home-test-ellume/">each test costing</a> <a href="https://abbott.mediaroom.com/2020-08-26-Abbotts-Fast-5-15-Minute-Easy-to-Use-COVID-19-Antigen-Test-Receives-FDA-Emergency-Use-Authorization-Mobile-App-Displays-Test-Results-to-Help-Our-Return-to-Daily-Life-Ramping-Production-to-50-Million-Tests-a-Month">US$5-30</a> (about AU$6.80-$40.90).</p>
<p>In Australia, <a href="https://agwa.com.au/AGWA/Media/Articles/20210823-COVID-NSW.aspx">worksites in Sydney</a> can buy tests direct from suppliers for AU$8.50-$12.50 (depending on quantity). But they also need to employ a health-care professional to oversee their use.</p>
<p>Companies providing rapid antigen tests are <a href="https://www.smh.com.au/national/nsw/private-sydney-school-to-run-covid-19-tests-before-trial-hsc-exams-20210802-p58f81.html">reportedly</a> contacting schools, saying they can supply tests at A$15 each (with additional costs for a nurse and administration). </p>
<p>It will not be sustainable to ask parents of schoolchildren and university students to pay such costs on an ongoing basis.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/keeping-workers-covid-safe-requires-more-than-just-following-public-health-orders-169617">Keeping workers COVID-safe requires more than just following public health orders</a>
</strong>
</em>
</p>
<hr>
<h2>4. How do we ensure equity?</h2>
<p><a href="https://www.prnewswire.com/news-releases/new-national-study-shows-strong-bipartisan-support-to-make-rapid-covid-19-testing-free-and-widely-available-301234042.html">US survey results</a> indicate Americans’ willingness to regularly use home testing is price sensitive. That surely is also the case in Australia.</p>
<p>To date, all the signs are the federal government is taking a hands-off approach to the introduction of rapid antigen testing for home use. But it’s essential we have effective distribution mechanisms to cover all of Australia. We also need a regulated price structure and/or subsidies to make the cost of these tests affordable. </p>
<p>Failure to ensure availability and affordability of home testing will further disadvantage Australians <a href="https://theconversation.com/as-lockdowns-ease-vaccination-disparities-risk-further-entrenching-disadvantage-169261">already disproportionately affected</a> by the pandemic.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/as-lockdowns-ease-vaccination-disparities-risk-further-entrenching-disadvantage-169261">As lockdowns ease, vaccination disparities risk further entrenching disadvantage</a>
</strong>
</em>
</p>
<hr>
<img src="https://counter.theconversation.com/content/169362/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Lesley Russell does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Rapid antigen testing might be convenient. But high prices for home kits will put people off, compounding disadvantage.Lesley Russell, Adjunct Associate Professor, Menzies Centre for Health Policy, University of SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1692612021-10-08T01:37:22Z2021-10-08T01:37:22ZAs lockdowns ease, vaccination disparities risk further entrenching disadvantage<figure><img src="https://images.theconversation.com/files/425193/original/file-20211007-21-1njavif.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://photos.aap.com.au/">Joel Carrett/AAP</a></span></figcaption></figure><p>Sydney’s lockdown <a href="https://www.nsw.gov.au/covid-19/easing-covid-19-restrictions/70-percent">ends on Monday</a> and Melbourne <a href="https://www.dhhs.vic.gov.au/victorias-restriction-levels-covid-19">follows later this month</a>, with fully vaccinated people gaining a number of social and economic privileges not available to those who are yet to be vaccinated. </p>
<p>Freedoms for those who are double-vaccinated will vary between states, but include greater access to employment, education and other activities, such as having visitors in your home, going shopping or going to the gym.</p>
<p>With vaccination rates <a href="https://phidu.torrens.edu.au/current/maps/sha-topics/covid_vacc/LGA-double-map/atlas.html">generally lower</a> among low socioeconomic groups, this is likely to further increase the <a href="https://www.australianpopulationstudies.org/index.php/aps/article/view/62">inequality</a> between the most and least socioeconomically advantaged Australians.</p>
<p>Australia faces two main COVID challenges: how to increase vaccination rates in priority populations and how to continue to protect these groups.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/opening-up-when-80-of-eligible-adults-are-vaccinated-wont-be-safe-for-all-australians-166818">Opening up when 80% of eligible adults are vaccinated won’t be ‘safe’ for all Australians</a>
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</em>
</p>
<hr>
<h2>How vaccination rates compare</h2>
<p>This week’s vaccination <a href="https://www.health.gov.au/resources/collections/covid-19-vaccination-geographic-vaccination-rates-lga">data</a> by local government area (LGA) in Victoria show continued uptake of COVID-19 vaccination in most government areas. </p>
<p>The graph below shows the distribution of first and second doses, as well as the required percentage to reach 95% full coverage, in the <a href="https://www.abs.gov.au/ausstats/abs@.nsf/Lookup/by%20Subject/2033.0.55.001%7E2016%7EMain%20Features%7EIRSD%20Interactive%20Map%7E15">three most and three least socioeconomically disadvantaged LGAs</a>.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/425159/original/file-20211007-19-pt3q32.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/425159/original/file-20211007-19-pt3q32.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/425159/original/file-20211007-19-pt3q32.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=403&fit=crop&dpr=1 600w, https://images.theconversation.com/files/425159/original/file-20211007-19-pt3q32.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=403&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/425159/original/file-20211007-19-pt3q32.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=403&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/425159/original/file-20211007-19-pt3q32.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=507&fit=crop&dpr=1 754w, https://images.theconversation.com/files/425159/original/file-20211007-19-pt3q32.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=507&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/425159/original/file-20211007-19-pt3q32.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=507&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Vaccination rates, comparison between least (Brimbank, Greater Dandenong and Hume) and most socioeconomically advantaged LGAs (Stonnington, Broondara and Glen Eira) in Metro Melbourne.</span>
<span class="attribution"><a class="source" href="https://www.abs.gov.au/ausstats/abs@.nsf/Lookup/by%20Subject/2033.0.55.001~2016~Main%20Features~IRSD%20Interactive%20Map~15">ABS</a></span>
</figcaption>
</figure>
<p>Sydney reports a similar distribution between low and high socioeconomic LGAs but is ahead of Melbourne in overall vaccination rates.</p>
<h2>Pandemic of the poor and disadvantaged</h2>
<p>COVID-19 is quickly becoming a pandemic of the poor and disadvantaged. <a href="https://www.aihw.gov.au/reports/burden-of-disease/the-first-year-of-covid-19-in-australia/summary">Four times</a> as many poorer Australians died of COVID in 2020 than those from wealthier backgrounds.</p>
<p>COVID infection rates are higher where there are <a href="https://www.aihw.gov.au/reports/burden-of-disease/the-first-year-of-covid-19-in-australia/summary">higher numbers</a> of essential workers, larger family groups under one roof, and people living in shared homes. </p>
<p>This trend is also seen in a range of other countries, including <a href="https://pubmed.ncbi.nlm.nih.gov/33906968/">Chile</a> and <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8183100/">Israel</a>. </p>
<p>Indigenous Australians have one of the highest risks of dying from COVID-19. At the end of September, just <a href="https://www.theage.com.au/politics/federal/fewer-than-one-in-three-indigenous-australians-fully-vaccinated-20210928-p58vcp.html?btis">30% of First Nations Australians</a> were fully vaccinated, despite being a <a href="https://www.health.gov.au/sites/default/files/documents/2021/01/covid-19-vaccination-australia-s-covid-19-vaccine-national-roll-out-strategy.pdf">priority population</a>. Currently this <a href="https://www.health.gov.au/resources/publications/covid-19-vaccination-geographic-vaccination-rates-sa4-indigenous-population-6-october-2021">rate is at 41%</a>, showing progress but still insufficient protection.</p>
<p>Disability advocates <a href="https://www.abc.net.au/news/2021-09-27/covid-vaccine-rolllout-disability-australia/100493464">have warned</a> Australia could face a similar situation to the United Kingdom, where <a href="https://www.medrxiv.org/content/10.1101/2021.06.10.21258693v1">60% of people who</a> died from COVID had a disability. </p>
<p>As of September 15, only <a href="https://www.theguardian.com/australia-news/2021/sep/27/unconscionable-to-lift-lockdowns-before-all-australians-with-disability-can-be-vaccinated-inquiry-says">40% of NDIS participants</a> were fully vaccinated, despite also being a <a href="https://www.health.gov.au/sites/default/files/documents/2021/01/covid-19-vaccination-australia-s-covid-19-vaccine-national-roll-out-strategy.pdf">priority population</a>.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/children-with-disability-are-prioritised-in-the-vaccine-rollout-but-many-struggle-to-get-an-appointment-168755">Children with disability are prioritised in the vaccine rollout, but many struggle to get an appointment</a>
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<hr>
<h2>New disease, but old health problems</h2>
<p><a href="https://www.vu.edu.au/mitchell-institute/australian-health-tracker-series/australia-s-health-tracker-by-socioeconomic-status-2021">Disadvantaged groups</a> are much more likely to suffer one or more chronic illness such as diabetes, heart disease and lung disease. These conditions put them at higher risk of severe illness or death if they contract COVID.</p>
<p>These underlying health conditions mean the poorest 20% of Australians <a href="https://www.vu.edu.au/mitchell-institute/policy-solutions/getting-australias-health-on-track-2021">die up to 6.4 years earlier</a> than the wealthiest 20%. </p>
<p>People with a severe mental illness <a href="https://www.vu.edu.au/mitchell-institute/policy-solutions/being-equally-well-roadmap">die up to 23 years earlier</a>, mostly due to physical ill health.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/vaccinations-need-to-reach-90-of-first-nations-adults-and-teens-to-protect-vulnerable-communities-167800">Vaccinations need to reach 90% of First Nations adults and teens to protect vulnerable communities</a>
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</p>
<hr>
<p>Poor and disadvantaged Australians are also at <a href="https://www.cidrap.umn.edu/news-perspective/2021/05/income-inequality-tied-more-covid-19-cases-deaths">greatest risk</a> of getting COVID and becoming seriously ill. </p>
<p>Yet the <a href="https://www.premier.vic.gov.au/sites/default/files/2021-09/210919%20-%20Burnet%20Institute%20-%20Vic%20Roadmap.pdf">modelling</a> for <a href="https://www.doherty.edu.au/uploads/content_doc/DohertyModelling_NationalPlan_and_Addendum_20210810.pdf">easing restrictions</a> does not take into account how “opening up” will affect these groups.</p>
<p>Our health and recovery policies must not leave these groups behind. Targeted and bespoke <a href="https://www.vu.edu.au/mitchell-institute/policy-solutions/getting-australias-health-on-track-2021">information and services</a> are needed for disadvantaged Australians to overcome these barriers.</p>
<h2>So what needs to happen?</h2>
<p>COVID cases are expected to rise when restrictions are lifted and public health measures eased. This will leave vulnerable groups at greater risk of COVID.</p>
<p>As other researchers have argued, in addition to high overall vaccination targets, preventing further lockdowns will require a <a href="https://theconversation.com/relying-only-on-vaccination-in-nsw-from-december-1-isnt-enough-heres-what-we-need-for-sustained-freedom-168833">layered plan</a> that includes:</p>
<ul>
<li>specific vaccine targets for priority populations</li>
<li>making indoor air safer</li>
<li>maintaining high rates of testing and tracing </li>
<li>booster shots.</li>
</ul>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/relying-only-on-vaccination-in-nsw-from-december-1-isnt-enough-heres-what-we-need-for-sustained-freedom-168833">Relying only on vaccination in NSW from December 1 isn't enough – here's what we need for sustained freedom</a>
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</p>
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<p>Such a layered plan combined with staggered lifting of restrictions is critical to prevent high case numbers and potential severe illness and deaths in populations already disproportionately affected by other health conditions.</p>
<p>We also need to boost the health literacy of disadvantaged Australians so they can better understand and have greater confidence in the information about their health in general, including in relation to COVID and beyond.</p>
<hr>
<p><em>Stella McNamara, research assistant at the Mitchell Institute, co-authored this article</em></p><img src="https://counter.theconversation.com/content/169261/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Maximilian de Courten is the director of the Mitchell Institute a Think Tank for Education and Health Policy.</span></em></p><p class="fine-print"><em><span>Jora Broerse does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>As lockdowns ease and those who are double-vaccinated gain extra freedoms, we’re likely to see a greater divide between the rich, who tend to have higher vaccination rates, and the poor.Maximilian de Courten, Professor in Global Public Health and Director of the Mitchell Institute, Victoria UniversityJora Broerse, Research Fellow in Public Health at Mitchell Institute for Education and Health Policy, Victoria UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1678712021-10-01T12:12:46Z2021-10-01T12:12:46ZAmericans are in a mental health crisis – especially African Americans. Can churches help?<figure><img src="https://images.theconversation.com/files/423910/original/file-20210929-22-3d6wqk.jpg?ixlib=rb-1.1.0&rect=121%2C82%2C4128%2C2739&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The 160-year-old John Wesley AME Zion Church is one of the few predominantly African American churches that still exists in downtown Washington, D.C.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/the-160-years-old-john-wesley-ame-zion-church-is-one-of-the-news-photo/141796246?adppopup=true">Marvin Joseph/The Washington Post via Getty Images</a></span></figcaption></figure><p>Centuries of systemic racism and <a href="https://doi.org/10.1080/13811118.2019.1660287">everyday discrimination</a> in the U.S. have left a major <a href="https://doi.org/10.1111/1475-6773.13115">mental health burden</a> on African American communities, and the past few years have dealt especially heavy blows.</p>
<p><a href="https://www.cdc.gov/coronavirus/2019-ncov/covid-data/investigations-discovery/hospitalization-death-by-race-ethnicity.html">Data from the Centers for Disease Control and Prevention</a> indicate that Black Americans are twice as likely to die of COVID-19, compared with white Americans. Their communities have also been <a href="https://www.cbpp.org/research/poverty-and-inequality/tracking-the-covid-19-economys-effects-on-food-housing-and">hit disproportionately</a> by job losses, food insecurity and homelessness as a result of the pandemic.</p>
<p>Meanwhile, racial injustice and high-profile police killings of Black men have <a href="https://www.usnews.com/news/healthiest-communities/articles/2020-08-13/black-mental-health-threatened-by-coronavirus-george-floyd-killing">amplified stress</a>. During the summer of 2020, amid both the pandemic and Black Lives Matter protests, <a href="https://www.cdc.gov/mmwr/volumes/69/wr/mm6932a1.htm?s_cid=mm6932a1_w">a CDC survey</a> found that 15% of Black respondents had “seriously considered suicide in the past 30 days,” compared with 8% of white respondents. </p>
<p>For a variety of reasons, many African Americans face barriers to mental health care. But <a href="https://oneill.indiana.edu/faculty-research/directory/profiles/faculty/full-time/fulton-brad.html">as a sociologist</a> who focuses on community-based organizations, I find that strengthening relationships between churches and mental health providers can be one way to increase access to needed services. In research with my collaborators <a href="https://www.rand.org/about/people/w/wong_eunice_c.html">Eunice Wong</a> and <a href="https://www.umass.edu/sphhs/person/kathryn-p-derose">Kathryn Derose</a>, I analyzed data on <a href="https://doi.org/10.1176/appi.ps.201600457">the prevalence of mental health care provision</a> among religious congregations and found that many African American congregations offer such programs.</p>
<h2>Need versus access</h2>
<p>Roughly <a href="https://www.samhsa.gov/data/sites/default/files/reports/rpt29393/2019NSDUHFFRPDFWHTML/2019NSDUHFFR1PDFW090120.pdf">1 in 5</a> Americans experience mental illness in a given year. Yet fewer than <a href="https://www.nimh.nih.gov/health/statistics/mental-illness#part_154785">half of adults</a> with a mental health condition receive mental health services. </p>
<p>African Americans utilize mental health services at about <a href="https://www.samhsa.gov/data/sites/default/files/MHServicesUseAmongAdults/MHServicesUseAmongAdults.pdf">one-half the rate</a> of white Americans. In part, this underuse may stem from African Americans’ <a href="https://doi.org/10.1016/S0140-6736(20)32032-8">often fraught relationship</a> with medical establishments in the U.S., given their <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2593958/">histories of racial bias</a> and malpractice against people of color. Part of the reason may also derive from <a href="https://dx.doi.org/10.22229/afa1112020">stigma</a> among some African Americans perceiving mental illness and seeking help as signs of weakness. <a href="https://doi.org/10.1007/s10488-016-0743-4">Treatment “deserts”</a> where mental health providers are scarce may also be a factor.</p>
<figure class="align-center ">
<img alt="Students participate in an activity about mental health and suicide prevention at Uplift Hampton Preparatory School in Dallas." src="https://images.theconversation.com/files/423917/original/file-20210929-16-1inibqj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/423917/original/file-20210929-16-1inibqj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=399&fit=crop&dpr=1 600w, https://images.theconversation.com/files/423917/original/file-20210929-16-1inibqj.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=399&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/423917/original/file-20210929-16-1inibqj.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=399&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/423917/original/file-20210929-16-1inibqj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=501&fit=crop&dpr=1 754w, https://images.theconversation.com/files/423917/original/file-20210929-16-1inibqj.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=501&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/423917/original/file-20210929-16-1inibqj.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=501&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Students participate in an activity about mental health and suicide prevention at Uplift Hampton Preparatory School in Dallas in 2018.</span>
<span class="attribution"><a class="source" href="https://newsroom.ap.org/detail/MentalHealthEducation/b4c5b8b9fc494820ac1dd3f98f7d39c5/photo?Query=%22mental%20health%22&mediaType=photo&sortBy=&dateRange=Anytime&totalCount=3980&currentItemNo=121">AP Photo/Benny Snyder</a></span>
</figcaption>
</figure>
<h2>Care at church</h2>
<p>One often overlooked resource for mental health care, however, are churches. For the past decade, the <a href="https://sites.duke.edu/ncsweb/">National Congregations Study</a> has documented the prevalence of mental health care provision among places of worship in the U.S. Based on data from the <a href="https://www.thearda.com/ncs/ncs2018/year_millness.asp">NCS’ 2018 survey</a>, 26% of congregations provide mental health programming, and 37% of people who attend religious services attend one of these congregations. Such programming can include support groups, meetings and classes focused on addressing mental health concerns.</p>
<p>Previously, my co-researchers and I <a href="https://ps.psychiatryonline.org/doi/10.1176/appi.ps.201600457">analyzed 2012 NCS data</a> to better understand mental health resources within religious congregations. One of our goals was to identify factors that contribute to a congregation offering mental health care. These factors include having more members, employing staff for social service programs and providing health-focused programs. Other significant predictors include conducting community needs assessments, hosting speakers from social service organizations and being located in a predominantly African American community. </p>
<p>Based on the new <a href="https://www.thearda.com/ncs/ncs2018/trad3_millness.asp">2018 survey</a>, 45% percent of African American congregations offer some form of mental health service and nearly half of all African American churchgoers attend a congregation with such programs. These rates show an increase since 2012, and are roughly 50% greater than those among predominantly white congregations.</p>
<p>This research supports <a href="https://www.dukeupress.edu/the-black-church-in-the-african-american-experience">longstanding observations</a> about African American congregations as critical sources of spiritual, emotional and social support for their communities. Many religious people see their spiritual health and mental health as intertwined, and <a href="https://doi.org/10.1037/11872-000">research indicates</a> that spiritual practices, such as prayer and meditation, can also support mental health. </p>
<h2>Strengthening support</h2>
<p><a href="https://doi.org/10.1176/appi.ps.201600457">Our research</a> suggests that building collaborations between African American congregations and the mental health sector is a promising strategy to increase access to needed services. Given that 61% of African Americans say <a href="https://www.pewforum.org/wp-content/uploads/sites/7/2021/02/PF_02.16.21_Black.religion.topline.pdf">they attend worship services</a> at least a few times a year, congregations may provide an accessible resource. </p>
<p>At times, pairing religion and mental health may prove harmful. Some congregations see mental health problems as a product of <a href="https://doi.org/10.1080/13674670600903049">personal sin</a>, for example, and stigmatize people suffering from mental illness.</p>
<p>[<em>This week in religion, a global roundup each Thursday.</em> <a href="https://theconversation.com/us/newsletters/this-week-in-religion-76/?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=religion-global-roundup">Sign up.</a>]</p>
<p>But congregations can also be helpful environments. When clinical treatment is <a href="https://doi.org/10.1146/annurev.publhealth.28.021406.144016">supplemented with social support</a>, the likelihood of successful outcomes is greater, and houses of worship often provide built-in social networks. People participating in a congregation-led grief recovery group, for example, can be involved in the congregation beyond their weekly meeting. In addition, some <a href="https://doi.org/10.1093/acrefore/9780190228613.013.226">mental health professionals</a> provide pro bono services for congregation-based programs. </p>
<p>Social worker <a href="https://www.ncdhhs.gov/divisions/mental-health-developmental-disabilities-and-substance-abuse/victor-armstrong">Victor Armstrong</a>, the director of North Carolina’s Division of Mental Health, Developmental Disabilities and Substance Abuse Services, <a href="https://afsp.org/story/the-role-of-the-church-in-improving-mental-wellness-in-the-african-american-commu">asserts</a> that African American faith leaders can play a “pivotal role” in mental wellness. He suggests shifting language to focus on “wellness” rather than “illness” in order to decrease stigma, among other recommendations.</p>
<p>Greater collaboration between congregations and mental health providers could help stem the growing mental health crisis, particularly within African American communities.</p><img src="https://counter.theconversation.com/content/167871/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Translational editorial assistance was provided by Emily Mace.</span></em></p>More houses of worship are offering mental health programs, especially African American congregations.Brad R. Fulton, Associate Professor, Indiana UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1611322021-05-20T10:51:29Z2021-05-20T10:51:29ZCOVID-19: how rising inequalities unfolded and why we cannot afford to ignore it<figure><img src="https://images.theconversation.com/files/401633/original/file-20210519-19-rwstpl.jpg?ixlib=rb-1.1.0&rect=4%2C0%2C994%2C561&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/concept-worsening-income-poverty-gap-miniature-1259727142">Hyejin Kang/Shutterstock</a></span></figcaption></figure><p>Historian Walter Scheidel argues in <a href="https://press.princeton.edu/books/paperback/9780691183251/the-great-leveler">The Great Leveler</a> that pandemics are among the four great horsemen that, through history, have led to greater equality – the others being war, revolution and state failure. Economist Thomas Piketty in <a href="https://www.theguardian.com/books/2014/jul/17/capital-twenty-first-century-thomas-piketty-review">Capital in the Twenty-First Century</a> similarly points out that the world wars and the flu pandemic in 1918 and 1919 contributed to the decline in inequality after 1945. But while mass death can drive up workers’ wages through a reduction in the workforce, pandemics are neither a necessary nor sufficient basis for reducing inequality. </p>
<p>Far from being a “great equaliser”, COVID-19 has revealed and compounded existing inequalities in wealth, race, gender, age, education and geographical location.</p>
<p>The pandemic of 2020 does not compare to the Black Death, which killed a third of Europe’s population, or the 1918 flu, which killed around a third of the world’s population. The consequence of this pandemic is <a href="https://www.bbc.co.uk/news/business-52660591#:%7E:text=The%20start%20of%20the%20pandemic%20saw%20a%20big%20increase%20in,of%20people%20counted%20as%20unemployed.&text=This%20compares%20with%201.4%20million,pandemic%20began%20to%20take%20effect.">rising unemployment</a>, not <a href="https://voxeu.org/article/inequality-total-war-great-leveller">a shortage of available labour</a>, as was the case with these earlier crises. Meanwhile, <a href="https://theconversation.com/how-a-radical-interpretation-of-the-great-depression-became-the-orthodoxy-behind-solving-the-covid-economic-crisis-158584">unlike the Great Depression</a> and previous periods of crisis, during COVID-19 <a href="https://www.vox.com/business-and-finance/22421417/stock-market-pandemic-economy">stock markets</a> and the <a href="https://www.bbc.co.uk/news/world-55793575">assets of the wealthy</a> soared in value, widening the gap between rich and poor.</p>
<p>To assume this pandemic will inevitably lead to reductions in inequality and usher in a better world would be irresponsible. The first world war was certainly no great leveller. Far from it leading to better conditions, inequality in many countries peaked <a href="https://www.stlouisfed.org/on-the-economy/2016/june/how-has-income-inequality-changed-years">in the early 1920s</a>. By the 1930s, with the onset of the Great Depression, there was widespread unemployment and destitution in the US, UK and Europe. The contrast <a href="https://www.jstor.org/stable/j.ctvjghwk4">with the progress</a> that followed the second world war reveals that we cannot tell in advance what these cataclysmic crises will bring. It is human actions and leaders that shape societies, not simply events.</p>
<p>In my book <a href="https://www.hachette.co.uk/titles/ian-goldin/rescue/9781529366877/">Rescue: From Global Crisis to a Better World</a>, I identify how individuals, businesses and governments can precipitate change to reduce inequality, which was rising in both Europe and the US <a href="https://www.pewresearch.org/fact-tank/2020/08/06/many-around-the-world-were-pessimistic-about-inequality-even-before-pandemic/">before COVID-19 struck</a>. The pandemic only accelerated this trend.</p>
<p>After being relatively stable in the decades following the second world war, the labour share of total income has been falling in the US, Europe and UK since the 1980s. This is mainly due to the tide of liberalisation that was ushered in when Margaret Thatcher in Britain and Ronald Reagan in the US initiated a race to the bottom in taxation, attacks on trade unions, and a weakening of competition policy, which all allowed for the growing concentration and strength of employers.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/401848/original/file-20210520-13-14o3xtj.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/401848/original/file-20210520-13-14o3xtj.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/401848/original/file-20210520-13-14o3xtj.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=428&fit=crop&dpr=1 600w, https://images.theconversation.com/files/401848/original/file-20210520-13-14o3xtj.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=428&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/401848/original/file-20210520-13-14o3xtj.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=428&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/401848/original/file-20210520-13-14o3xtj.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=538&fit=crop&dpr=1 754w, https://images.theconversation.com/files/401848/original/file-20210520-13-14o3xtj.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=538&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/401848/original/file-20210520-13-14o3xtj.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=538&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption"></span>
<span class="attribution"><a class="source" href="https://ourworldindata.org/grapher/share-of-top-1-in-pre-tax-national-income?time=1980..latest&country=GBR~USA~DEU~FRA~DNK~AUS~SWE~ZAF~NLD">Our World in Data</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
</figure>
<h2>The public spending gap</h2>
<p>Now, among high-income countries, the US is by far the most unequal, followed by the UK. It is in these countries that the neoliberal crusade – which sought to reduce the size of government through reducing taxes and redistribution, privatise state enterprises and utilities, undermine the power of trade unions, and roll back rules that limited the free rein of the private sector – has advanced the furthest. Lower levels of inequality in northern European countries and in East Asia since the 1970s <a href="https://www.hup.harvard.edu/catalog.php?isbn=9780674980822">are due to</a> both higher levels of welfare payments for those in need, and higher public investment in education, health and housing, <a href="https://www.hup.harvard.edu/catalog.php?isbn=9780674979789">which are financed</a> by higher levels of taxes on the wealthy. </p>
<p>Both require considerable budgetary resources, and since the financial crisis of 2008, with rising unemployment and a deterioration of already weak public finances, southern European countries have been less able to afford the largesse that in Germany accounts <a href="https://www.hup.harvard.edu/catalog.php?isbn=9780674979789">for over 20% of government spending</a>. Workers in Italy, Spain and eastern European countries such as Poland and Hungary have not seen anything like the levels of support enjoyed by their northern neighbours. The result has been a rapid increase in inequality in the southern countries and growing divides within Europe.</p>
<h2>How inequalities unfolded</h2>
<p>The pandemic increased both economic and health inequalities due to a range of intersecting factors, which compounded each other. The wealthy were not only able to keep their well-paid jobs but also benefited from soaring stock markets and rising house prices. Low-paid workers were, in contrast, more likely to have jobs in the sectors that suspended activities, including hospitality and tourism. They were also more likely to work in essential services such as nursing, policing, teaching, cleaning, waste removal and as shop assistants – in all of which occupations, they had a higher likelihood of being exposed to COVID-19. The risk of contagion was further elevated by their living in more crowded homes, apartment buildings with communal lifts and entrances, and on their being more reliant on public transport.</p>
<p>As COVID-19 peaked in their neighbourhoods, they were also more likely to be locked down, which further undermined incomes. Weaker health facilities in their neighbourhoods meant mortality rates were higher, with a higher incidence of existing health problems also increasing their vulnerability.</p>
<p>A higher share of poor workers are in precarious hourly paid employment, making them less able to access social security, health insurance and emergency benefits that could cushion the decline in income and the effect of COVID-19 on their lives. The pandemic has come on top of a decade of austerity and stagnating wages in the UK, US and many other countries, deepening the hardship endured by growing numbers of people.</p>
<p>Taxes that fund redistributive spending – in the form of health and education, as well as social security, housing, child, disability and other benefits – can all significantly help overcome inequality. Before taking account of taxes and government spending, inequality is almost as high in France as in the US and UK, and even higher in Ireland, which without redistribution would be the most unequal of the world’s 34 richest countries. However, in Ireland and France, taxation and redistribution have reduced inequality to levels that are well below that in the UK.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/401851/original/file-20210520-21-1wxtsdm.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/401851/original/file-20210520-21-1wxtsdm.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/401851/original/file-20210520-21-1wxtsdm.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=421&fit=crop&dpr=1 600w, https://images.theconversation.com/files/401851/original/file-20210520-21-1wxtsdm.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=421&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/401851/original/file-20210520-21-1wxtsdm.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=421&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/401851/original/file-20210520-21-1wxtsdm.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=529&fit=crop&dpr=1 754w, https://images.theconversation.com/files/401851/original/file-20210520-21-1wxtsdm.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=529&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/401851/original/file-20210520-21-1wxtsdm.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=529&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption"></span>
<span class="attribution"><a class="source" href="https://ourworldindata.org/income-inequality">Our World in Data</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
</figure>
<p>Meanwhile, the failure of successive governments in the US to use taxation and spending to overcome inequality means it is the most persistently unequal of all the rich countries. Overcoming inequality requires higher wealth and inheritance taxes for the upper-income families who have seen their wealth rise dramatically in recent decades.</p>
<p>As I show in <a href="https://www.hachette.co.uk/titles/ian-goldin/rescue/9781529366877/">Rescue</a>, young people have been particularly hard-hit by the pandemic. To protect the health of the elderly, they have sacrificed their education, job prospects and social lives, and in future years will inherit much higher levels of public debt. Now, as happened after the second world war, we need to ensure that they can look forward to a sustainable and brighter future. This requires higher levels of investment in education, improved job prospects and a focus on social mobility, including through higher levels of inheritance and wealth taxes.</p>
<p>COVID-19, by exacerbating and further revealing the extent of inequality and discrimination, has made the case for addressing these injustices more compelling than ever. In response to the pandemic, governments and businesses have acted in ways that would not have been considered possible in January 2020. The challenge now is to build on these initiatives to reduce discrimination and inequality everywhere.</p>
<p><em>The <a href="https://covidandsociety.com/about-ippo/">International Public Policy Observatory</a>, of which The Conversation is a partner, is holding a major Action On Inequalities event on Tuesday June 15, from 10am. If you are interested in attending, email ippo@ucl.ac.uk or sign up <a href="https://www.eventbrite.co.uk/e/action-on-inequalities-what-should-be-in-post-covid-recovery-plans-tickets-154366224533">here</a>.</em></p><img src="https://counter.theconversation.com/content/161132/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Ian Goldin receives funding from Oxford Martin School, Oxford University. He is affiliated with Core-econ.org. He is the author of Rescue: From Global Crisis to a Better World</span></em></p>It’s been argued that pandemics are the great leveller, but with COVID the opposite is true – and we can’t afford to ignore it.Ian Goldin, Professor of Globalisation and Development; Director of the Oxford Martin Programmes on Technological and Economic Change and Future of Development, University of OxfordLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1573082021-05-13T16:12:00Z2021-05-13T16:12:00ZParks and green spaces helped us get through lockdown – but not everyone has equal access<figure><img src="https://images.theconversation.com/files/400546/original/file-20210513-22-57g1md.jpg?ixlib=rb-1.1.0&rect=4%2C5%2C994%2C660&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/avenue-cheery-blossom-trees-pittencrieff-park-1715159545">Cliff Hands/Shutterstock</a></span></figcaption></figure><blockquote>
<p>What we could all see was solace: it was clear that nature at its loveliest and most inspiring, in springtime’s wondrous transformations, could offer people comfort at a moment of tragedy and great stress.</p>
<p><em>Michael McCarthy, nature writer</em></p>
</blockquote>
<p>For many, the COVID-19 pandemic has had a <a href="https://jech.bmj.com/content/75/3/224.abstract">damaging impact on their psychological health</a>, but the chance to get out into nature provided some much needed respite and escape during a difficult year.</p>
<p>Following restrictions in March 2020 that saw the UK closing non-essential retail and hospitality, and limiting people to leaving the house once a day for essential reasons, it’s no surprise that some discovered a heightened appreciation of their local green spaces. Whether it was a park, a nature reserve or a canalside walk, stories of people finding comfort and consolation in nature at this distressing time have been <a href="https://www.theguardian.com/books/2020/oct/03/nature-got-us-through-lockdown-heres-how-it-can-get-us-through-the-next-one">well documented</a>.</p>
<p>This was emphasised by the UK housing, communities and local government minister, Robert Jenrick, who stated that parks and other public green spaces must be kept open for <a href="https://www.bbc.co.uk/news/uk-52339266">“the health of the nation”</a>.</p>
<p>However, <a href="https://bmjopen.bmj.com/content/11/3/e044067">our research</a> during this period found that the majority of the UK population (63%) were spending less time in green spaces than before lockdown. This was likely <a href="https://news.sky.com/story/coronavirus-half-a-million-people-with-cancer-are-too-scared-to-leave-the-house-research-shows-12017108">linked to feelings of anxiety</a> when venturing out of the house, especially for those over 70 or anyone <a href="https://www.gov.uk/government/speeches/pm-statement-on-coronavirus-16-march-2020">advised to shield</a> for health reasons. </p>
<p>We conducted an online survey through <a href="https://yougov.co.uk/about/">YouGov</a> to investigate how the UK population had altered the amount of time spent in parks during the first lockdown, and whether their experiences of these places had changed. The survey was answered by 2,252 adults from across the UK, drawn from a representative panel of over 800,000 participants. In this research, we defined green spaces as any place outside of the home where people can experience nature, plants and trees. </p>
<figure class="align-center ">
<img alt="A goldfinch sitting in a cherry tree in full blossom with white flowers." src="https://images.theconversation.com/files/400551/original/file-20210513-22-hga32e.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/400551/original/file-20210513-22-hga32e.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/400551/original/file-20210513-22-hga32e.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/400551/original/file-20210513-22-hga32e.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/400551/original/file-20210513-22-hga32e.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/400551/original/file-20210513-22-hga32e.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/400551/original/file-20210513-22-hga32e.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Immersing ourselves in nature can help relieve anxiety.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/wild-adult-european-goldfinch-carduelis-amongst-655528300">Mark Caunt/Shutterstock</a></span>
</figcaption>
</figure>
<h2>Widening gap</h2>
<p>Inequalities in the use of green space, and changes in the way it is being used, are likely to be associated with occupation, especially during lockdown, when certain workers were advised to work from home. <a href="https://theconversation.com/coronavirus-class-divide-the-jobs-most-at-risk-of-contracting-and-dying-from-covid-19-138857">One report</a> stated that less than 10% of manual workers worked from home during the initial lockdown, compared to 75% of managerial and professional workers.</p>
<p>This data highlights that those in the professional group had more opportunity to visit green spaces during lockdown and so were more able to benefit. Manual workers unable to do their jobs at home may have had less time and opportunity to visit green spaces – such as walking in the local park. </p>
<p>We found that the initial lockdown increased existing inequalities in the use of green spaces. Before the pandemic, manual workers like shop assistants and labourers were a third less likely to visit green spaces than those who worked in managerial occupations, such as business owners and senior executives. This difference could be partly explained by a <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5580619/">lack of access</a> to decent parks for more disadvantaged groups, or the fact that these groups are <a href="https://www.sciencedirect.com/science/article/abs/pii/S0169204618300914">less interested in using green spaces</a>. </p>
<p>This pattern of inequality actually worsened during lockdown, with the difference in use increasing between the two social groups. We found that manual workers were two-thirds less likely to visit a park after lockdown restrictions were enforced. This is despite ONS <a href="https://www.ons.gov.uk/economy/environmentalaccounts/articles/oneineightbritishhouseholdshasnogarden/2020-05-14">research</a> finding that parks are most accessible in the poorest areas of the UK.</p>
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<a href="https://theconversation.com/ecotherapy-aims-to-tap-into-nature-to-improve-your-wellbeing-128433">Ecotherapy aims to tap into nature to improve your wellbeing</a>
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<p>However, other <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5580619/">research</a> shows that poorer areas are more likely to have low-quality green spaces. This could mean that even if someone lived close to a park, they might not want to use it due to a lack of amenities such as seating and toilets, or high crime levels or too much litter. </p>
<p>Older adults (aged 65+) and women spent less time in green spaces during lockdown, compared to younger age groups and men. These will likely lead to <a href="https://www.gla.ac.uk/media/Media_757600_smxx.pdf">widening health inequalities</a> if no action is taken, and compound the devastating impact of the pandemic for older people, who experienced more social isolation. This is because they were <a href="https://www.bmj.com/content/369/bmj.m1557">less likely</a> to be online and more likely to live alone and be <a href="https://www.gov.uk/government/speeches/pm-statement-on-coronavirus-16-march-2020">shielding</a>. Meanwhile, the inequality in use between the sexes could be explained by the fact that <a href="https://www.kcl.ac.uk/news/women-doing-more-childcare-under-lockdown-but-men-more-likely-to-feel-their-jobs-are-suffering">women spent more time on childcare</a> than men during the first lockdown. They also make up <a href="https://www.bmj.com/content/369/bmj.m2167">77% of the NHS workforce</a> and 89% of nursing staff in the UK.</p>
<h2>Benefits of green space in lockdown</h2>
<p>Green space has positive effects on physical and mental health, especially through things like “<a href="https://www.forestryengland.uk/blog/forest-bathing">forest bathing</a>” – a mindful, immersive walk in the woods, and <a href="https://nhsforest.org/covid-19-recovery-strategy-using-green-prescribing-health">green prescribing</a>, where doctors advocate a dose of nature rather than medication. Both are currently being <a href="https://tfb.institute/scientific-research/">researched</a> and implemented across the UK.</p>
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<p>But how did green spaces affect the population’s mental health during the first lockdown? We know that <a href="https://www.bbc.co.uk/news/health-54616688">suicidal thoughts increased</a> during lockdown and antidepressant use is now “<a href="https://www.theguardian.com/society/2021/jan/01/covid-antidepressant-use-at-all-time-high-as-access-to-counselling-in-england-plunges">soaring</a>”.</p>
<p>Our research found that around two-thirds (65%) of individuals reported that spending time in green spaces benefited their mental health more during the lockdown than before. This would suggest that green spaces have the capacity to counteract the impact of the pandemic on the population’s mental health.</p>
<p>Previous <a href="https://cresh.org.uk/2013/11/08/what-is-equigenesis-and-how-might-it-help-narrow-health-inequalities/">research</a> has shown that the positive effects of being immersed in green space can help reduce health inequalities by benefiting less advantaged people more. Other <a href="https://cresh.org.uk/2015/04/21/more-reasons-to-think-green-space-may-be-equigenic-a-new-study-of-34-european-nations/">studies</a> have found that inequalities in mental wellbeing are smaller among those who have better access to green space compared to those who do not have access to a local park. More recently, a <a href="https://www.gla.ac.uk/media/Media_779126_smxx.pdf">report</a> by Public Health Scotland found that nine in ten people said that being in green open spaces improved their mental health. </p>
<p>These findings emphasise the importance of parks and nature reserves remaining open during any future lockdowns. We believe our research highlights green spaces as an essential resource for mental health and wellbeing, and they must be <a href="https://www.gla.ac.uk/media/Media_757600_smxx.pdf">protected and prioritised</a> in any future fiscal squeeze to ensure the most disadvantaged and vulnerable do not lose out.</p><img src="https://counter.theconversation.com/content/157308/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Hannah Burnett receives funding for her PhD from the Medical Research Council and University of Glasgow College of Medical, Veterinary and Life Sciences. </span></em></p><p class="fine-print"><em><span>Jonathan Olsen receives funding from the Medical Research Council and the Chief Scientist Office (Scotland) as part of the Places and Health Programme (MC_UU_00022/4; SPHSU19) at the MRC/CSO Social and Health Sciences Unit (SPHSU), University of Glasgow.</span></em></p><p class="fine-print"><em><span>Rich Mitchell receives funding from the Medical Research Council and the Chief Scientist Office (Scotland) as part of the Places and Health Programme (MC_UU_00022/4; SPHSU19) at the MRC/CSO Social and Health Sciences Unit (SPHSU), University of Glasgow.</span></em></p>Spending time in nature is an essential resource for mental wellbeing, but lockdown increased existing inequalities in the way our green spaces are used - and who is able to benefit from them.Hannah Burnett, PhD Researcher in Public Health, University of GlasgowJonathan Olsen, Research Fellow, University of GlasgowRich Mitchell, Professor Of Health and Environment, University of GlasgowLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1594252021-04-22T00:33:26Z2021-04-22T00:33:26ZNew authority could transform Māori health, but only if it’s a leader, not a partner<figure><img src="https://images.theconversation.com/files/396416/original/file-20210421-13-1bwrw1q.jpg?ixlib=rb-1.1.0&rect=1261%2C24%2C4130%2C3564&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Getty Images/Hagen Hopkins</span></span></figcaption></figure><p>As part of a <a href="https://www.beehive.govt.nz/release/major-reforms-will-make-healthcare-accessible-all-nzers">major overhaul of the health system</a>, health minister Andrew Little yesterday <a href="https://www.beehive.govt.nz/speech/building-new-zealand-health-service-works-all-new-zealanders">announced</a> a new Māori health authority. </p>
<p>The authority will be able to commission primary health services and make joint decisions with a newly created centralised health agency. It’s a simple idea, and one with radically transformative potential. But it’s not new. </p>
<p>In 2019, the <a href="https://waitangitribunal.govt.nz/news/report-on-stage-one-of-health-services-and-outcomes-released/">Waitangi Tribunal</a> found consistent Crown failure in the health care and well-being of Māori. It recommended establishing an independent authority to oversee Māori primary health services.</p>
<p>The government’s announcement responds to a 2020 <a href="https://systemreview.health.govt.nz/">Health and Disability System review</a>, which also called for a separate Māori health authority, but could not come to a consensus on the powers it should have. Four of the six members thought the idea that it should have the power to commission health services had such merit they <a href="https://www.newsroom.co.nz/disputes-over-powers-of-proposed-mori-health-authority">dissented</a> from the recommendation the authority should have only advisory powers. </p>
<p>The potential is for a Māori primary health system explicitly focused on Māori needs. Māori decision makers would decide what needs to be done, how and by whom. The success of the authority hinges on how independent it will be, and its accountability to Māori people.</p>
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<h2>By Māori for Māori</h2>
<p>The 2019 Waitangi Tribunal report also found that decision-making models don’t adequately reflect Māori experiences of what works and why. Tureiti Lady Moxon, one of the claimants to the tribunal, <a href="https://www.stuff.co.nz/national/health/300035517/the-mori-health-authority-plan-that-divided-health-review-panel">explained</a> the proposed authority’s logic:</p>
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<p>We would prefer to be the designers of our own destiny.</p>
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<p>While the new authority will provide policy advice, its most important influence will come from the decisions it makes about the primary health services to purchase and from whom. It will then be able to decide whether these providers do a good enough job to have their funding continued. </p>
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Read more:
<a href="https://theconversation.com/maori-and-pasifika-leaders-report-racism-in-government-health-advisory-groups-112779">Māori and Pasifika leaders report racism in government health advisory groups</a>
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<p>Opposition leader Judith Collins claimed there wouldn’t be much public support for a “<a href="https://www.stuff.co.nz/national/politics/124903179/judith-collins-lashes-dhb-overhaul-as-too-much-wellington-bureaucracy-and-a-separatist-model">separatist model</a>” that would give “people operations based on race, not on need”. </p>
<p>But the idea that anybody would demand an operation they don’t need is not a sensible starting point for the serious debate we need to have about how the authority should work with other parts of the revamped health system.</p>
<h2>Getting funding levels right and eliminating racism</h2>
<p>The tribunal found chronic underfunding is one of the reasons for poor Māori health outcomes. It recommended the Crown and the health inquiry claimants work out a methodology for determining how much money is needed to achieve fair outcomes. </p>
<p>It’s a complex question at the intersection of <a href="https://archives.govt.nz/discover-our-stories/the-treaty-of-waitangi">te Tiriti o Waitangi</a> policy, moral philosophy and health economics. Answering it accurately will determine how well the authority can do its job.</p>
<p>But an equally important question is the institutional racism the tribunal found in the health system, and how this gets in the way of people’s opportunities for good health. </p>
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<p>Many questions remain about the scope the authority will have to develop the health system to give everybody the same opportunity for good health. </p>
<p>How will it be accountable to Māori as well as to the health minister? How will Māori be able to show they have confidence in the knowledge and expertise of the people appointed to the authority?</p>
<p>What relationships will it have with the ministry of health and the newly created public health agency? How independent will it be and will there be significant Māori engagement in the ministry’s oversight function? </p>
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<strong>
Read more:
<a href="https://theconversation.com/two-inquiries-find-unfair-treatment-and-healthcare-for-maori-this-is-how-we-fix-it-144939">Two inquiries find unfair treatment and healthcare for Māori. This is how we fix it</a>
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<p>Yesterday’s announcement spoke of enabling Māori “<a href="https://www.beehive.govt.nz/speech/building-new-zealand-health-service-works-all-new-zealanders">leadership and partnership</a>”. But leadership and partnership don’t always work well together. </p>
<p>The <a href="https://books.google.com.au/books?id=XFMTMq0pNyUC&printsec=frontcover#v=onepage&q&f=false">bicultural partnership</a> people often read into te Tiriti o Waitangi (the Māori text) or the Treaty of Waitangi (English version) usually positions the Crown as senior partner and Māori as the junior partner. This view doesn’t foster the independent leadership the authority will need if it’s to make a real difference and, as the health minister said, give “<a href="https://www.beehive.govt.nz/speech/building-new-zealand-health-service-works-all-new-zealanders">true effect to tino rangatiratanga</a>”, or Māori people’s authority to make decisions for themselves.</p>
<h2>Considering te Tiriti in all decisions</h2>
<p>We have developed the <a href="https://journals.sagepub.com/doi/metrics/10.1177/1468796819896466">Critical Tiriti Analysis</a> policy framework, which could help ensure the transformed health system respects te Tiriti and puts the Māori health authority in the best position to succeed. </p>
<p>The framework requires policy makers to consider how te Tiriti informs both existing and new policies. In relation to yesterday’s announcements, it provokes the following questions:</p>
<ul>
<li><p>How will the health system maintain tika (correct) relationships with mana whenua (groups with authority over land), mātāwaka (kinship groups) and other Māori communities?</p></li>
<li><p>How will the health system’s processes, actions and decision making be informed and shaped by Māori worldviews?</p></li>
<li><p>How will Māori-led decision making and leadership (which is a bigger aspiration than partnership) be put into practice across the sector?</p></li>
<li><p>How will barriers to Māori advancement, such as institutional racism, be eliminated?</p></li>
<li><p>Given the history of health inequities, how will resources be distributed and prioritised to ensure equitable outcomes for Māori?</p></li>
<li><p>How will Māori worldviews, values, tikanga (correct processes) and wairuatanga (spirituality) be normalised within the health system?</p></li>
</ul>
<p>The proposed changes are potentially transformative. But just how transformative depends on how these questions are answered and on the strength of the government’s commitment to no further breaches of te Tiriti. </p>
<p>Abolishing the authority, as the opposition National party proposes, would be such a breach.</p><img src="https://counter.theconversation.com/content/159425/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Dominic O’Sullivan was a parliamentary candidate for the Labour party in 1990 and 1993.</span></em></p><p class="fine-print"><em><span>Heather Came is affiliated with New Zealand Public Health Association, STIR: Stop Institutional Racism and Tāmaki Tiriti Workers. </span></em></p>The announcement of a new Māori health authority could radically transform health outcomes for Māori, but its success depends on how independent and accountable it will be.Dominic O'Sullivan, Adjunct Professor, Faculty of Health and Environmental Sciences, Auckland University of Technology and Professor of Political Science, Charles Sturt UniversityHeather Came, Senior Lecturer, Auckland University of TechnologyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1493142020-11-11T15:40:20Z2020-11-11T15:40:20ZCoronavirus: inequalities in healthcare may explain worse outcomes for BAME people<figure><img src="https://images.theconversation.com/files/368839/original/file-20201111-21-h4s347.jpg?ixlib=rb-1.1.0&rect=119%2C137%2C3790%2C2449&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/africanamerican-man-wearing-protective-face-mask-1664878084">Robin J Gentry/Shutterstock</a></span></figcaption></figure><p>With Britain now in its second lockdown, and the <a href="https://www.bbc.co.uk/news/uk-54773196">government predicting</a> that the second wave could be worse than the first, it’s critical to examine why there are large racial disparities in the effects of COVID-19 and what could be done to reduce these.</p>
<p>In England and Wales, black men are around <a href="https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/articles/updatingethniccontrastsindeathsinvolvingthecoronaviruscovid19englandandwales/deathsoccurring2marchto28july2020">2.7 times more likely</a> than white men to die from the disease. For Bangladeshi men the figure is around 2.5 times as likely and Pakistani men nearly twice as likely. There’s a significant increased risk for black, Asian and minority ethnic (BAME) women too. </p>
<p>In the weeks leading up to the second lockdown, this issue became the subject of fierce debate between the UK government and its critics. The government, while acknowledging the problem, made clear it was not prepared to see the issue as a manifestation of systemic racism. Dr Raghib Ali, the government’s expert adviser on COVID-19 and ethnicity, suggested it was time to <a href="https://www.bbc.co.uk/news/health-54634721">stop using ethnicity</a> when deciding who needed help, as socioeconomic factors were far more important. </p>
<h2>A long tradition</h2>
<p>This emphasis on socioeconomic factors has historical precedent. In Britain, there is a powerful research tradition that has linked socioeconomic status with poor health. This started with the <a href="https://pubmed.ncbi.nlm.nih.gov/7118327/">Black Report</a> in 1980, which found that relative inequality in health outcomes, especially between rich and poor, had widened despite the creation of the NHS. A further major investigation in <a href="https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/265503/ih.pdf">1998</a> and the Marmot Review in <a href="https://www.parliament.uk/globalassets/documents/fair-society-healthy-lives-full-report.pdf">2010</a> found that little had changed. Indeed, the wealthiest people today still live <a href="https://www.ucl.ac.uk/news/2020/jan/wealth-adds-nine-years-healthy-life-expectancy">nearly a decade longer</a> than the poorest.</p>
<p>Given this, it’s not surprising that most official attention in the UK has centred on using socioeconomic differences to explain health disparities. These factors do have some explanatory power.</p>
<figure class="align-center ">
<img alt="A row of terraced houses" src="https://images.theconversation.com/files/368850/original/file-20201111-23-123kol3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/368850/original/file-20201111-23-123kol3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/368850/original/file-20201111-23-123kol3.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/368850/original/file-20201111-23-123kol3.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/368850/original/file-20201111-23-123kol3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/368850/original/file-20201111-23-123kol3.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/368850/original/file-20201111-23-123kol3.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Factors such as housing can explain higher rates of coronavirus infection, but not worse outcomes from COVID-19.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/row-typical-english-terraced-houses-277410944">Jozef Sowa/Shutterstock</a></span>
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<p>BAME communities are on average poorer, with more people living in overcrowded conditions in multi-generational households, which are thought to drive viral transmission. And BAME workers are <a href="https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/908434/Disparities_in_the_risk_and_outcomes_of_COVID_August_2020_update.pdf">over-represented in frontline jobs</a>, meaning they can’t work at home and are more likely to be exposed to the virus. </p>
<p>But when we try to explain death rates rather than infection rates, it becomes clear this isn’t the whole story. When UK government statisticians examined the evidence, they found that these were at best only partial explanations for differences in COVID-19 deaths. Even when correcting for age and socioeconomic status, BAME death rates were <a href="https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/908434/Disparities_in_the_risk_and_outcomes_of_COVID_August_2020_update.pdf">1.5 to two times</a> those of white people.</p>
<p>One theory is that BAME people suffer more frequently from underlying conditions – such as diabetes and high blood pressure – that increase vulnerability to COVID-19. But this has been shown to have <a href="https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/articles/updatingethniccontrastsindeathsinvolvingthecoronaviruscovid19englandandwales/deathsoccurring2marchto28july2020">little explanatory power</a>. Likewise, the idea that there are genetic differences that increase disease susceptibility and follow racial lines <a href="https://theconversation.com/coronavirus-its-impact-cannot-be-explained-away-through-the-prism-of-race-138046">seems unlikely</a>.</p>
<h2>What else might be going on?</h2>
<p>One explanation has been <a href="https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/892376/COVID_stakeholder_engagement_synthesis_beyond_the_data.pdf">advanced by BAME groups</a> in response to Public Health England data. They argue that there is implicit and explicit bias in the broader healthcare system, which has discouraged BAME people from seeking timely treatment. Indeed, evidence suggests that that BAME patients with COVID-19 arrive in A&E with <a href="https://www.ippr.org/blog/ethnic-inequalities-in-covid-19-are-playing-out-again-how-can-we-stop-them">more severe symptoms</a> and are more likely to be immediately transferred to intensive care. It’s also clear that primary care and public health provision is <a href="https://www.nuffieldtrust.org.uk/public/files/2020-01/quality_inequality/v2/">often poorer in deprived areas</a> that are disproportionately home to BAME people.</p>
<p>Advocacy groups <a href="https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/892376/COVID_stakeholder_engagement_synthesis_beyond_the_data.pdf">also argue</a> that systemic racism is a factor in the way BAME people are treated once they enter the healthcare system. UK research has shown that BAME patients report <a href="https://www.kingsfund.org.uk/sites/default/files/2020-04/BSA_2019_NT-KF_WEB_update.pdf">lower satisfaction</a> with the NHS as well as a <a href="https://bmjopen.bmj.com/content/bmjopen/6/6/e011938.full.pdf">less positive experience</a> with nurses and doctors than white patients while being treated for serious conditions such as cancer. Over 60% of black people <a href="https://committees.parliament.uk/publications/3376/documents/32359/default/">do not believe</a> their health is as equally protected by the NHS compared to white people – and in places the data seems to support this. Black women in the UK are <a href="https://www.theguardian.com/uk-news/2020/jun/11/the-data-was-there-so-why-did-it-take-coronavirus-to-wake-us-up-to-racial-health-inequalities">five times more likely</a> than white women to die during childbirth, for example.</p>
<p>This contrasts with the publicly held view of NHS as a fair system that provides equal access for all. But the fact that there’s virtually the same racial disparity in death rates from COVID-19 in <a href="https://www.cdc.gov/nchs/nvss/vsrr/covid19/health_disparities.htm">the US</a> and Britain – despite America’s two-tier healthcare system, with limited access for poorer people – strengthens the view that deeper issues, such as racism, may be present in UK healthcare. </p>
<p>Indeed, such factors have long been documented in the US.</p>
<p>Thirty-five years ago, the US government’s <a href="https://minorityhealth.hhs.gov/heckler30/">Heckler Report</a> documented racial and ethnic disparities in the country’s healthcare. It noted the under-representation of black physicians and poorer access that BAME people had to good hospitals. Little had changed by 2003, when a <a href="https://www.nap.edu/catalog/12875/unequal-treatment-confronting-racial-and-ethnic-disparities-in-health-care">National Academies of Science report</a> showed implicit and express bias in the of treatment of black patients, a segregated healthcare system, and systemic discrimination against black doctors. And studies show inequality continues to this day, for instance in how <a href="https://academic.oup.com/painmedicine/article/13/2/150/1935962">black patients’ pain is treated</a>.</p>
<p>The US research points to the myriad ways that discrimination within a healthcare system might occur. Indeed, the fact that BAME doctors and other health staff in the UK are suffering higher rates of COVID-19 infection – <a href="https://www.bma.org.uk/advice-and-support/covid-19/your-health/covid-19-the-risk-to-bame-doctors">perhaps because of a lack of PPE</a> – and are less likely to be <a href="https://www.theguardian.com/society/2020/oct/21/racial-discrimination-widespread-in-nhs-job-offers-says-report?CMP=Share_iOSApp_Other">promoted to senior management positions</a> echoes some of America’s problems. This gives additional weight to the idea that racism in the health system could be a problem here too.</p>
<p>Powerful voices, including the <a href="https://labour.org.uk/press/labour-demands-immediate-action-for-black-asian-and-minority-ethnic-communities-as-new-report-lays-bare-pandemic-suffering/t">Labour Party</a>, are saying it’s now time for systemic racism to be investigated in the UK as a potential cause of disparities in COVID-19 outcomes. If this work is to be successful, it will need to question the prevailing research paradigm and look beyond socioeconomic factors. </p>
<p>Checking for – and resolving – potential biases in healthcare, and adopting ameliorative measures that recognise the greater vulnerability of BAME individuals, both within their communities and within the NHS, could not be more urgent.</p><img src="https://counter.theconversation.com/content/149314/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Steve Schifferes does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The government should look beyond traditional socioeconomic arguments for why some patients are at greater risk.Steve Schifferes, Honorary Research Fellow, City Political Economy Research Centre, City, University of LondonLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1487542020-11-11T10:48:47Z2020-11-11T10:48:47ZShielding the vulnerable using a risk calculator – here’s why it won’t be enough<figure><img src="https://images.theconversation.com/files/367967/original/file-20201106-21-12u9g1a.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C5491%2C3655&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/social-distancing-among-family-grandma-grandchild-1688780242">Miriam Doerr Martin Frommherz/Shutterstock</a></span></figcaption></figure><p>In recent weeks, there have been <a href="https://gbdeclaration.org/">controversial proposals</a> to ask older, more vulnerable adults to isolate from society, while younger adults build herd immunity to COVID-19. These strategies have been criticised by leading figures as “<a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)32153-X/fulltext">practically impossible</a>” and “<a href="https://news.un.org/en/story/2020/10/1075232">unethical</a>”. Yet calls for shielding from COVID “<a href="https://www.bmj.com/content/369/bmj.m2063">stratified by risk</a>” persist.</p>
<p>A new high-quality algorithm to predict people’s risk of catching and dying from COVID-19, <a href="https://www.bmj.com/content/371/bmj.m3731">published in the BMJ</a>, may add credence to these proposals. This algorithm could be useful for enhancing shielding support measures for high-risk individuals through furlough schemes or GP advice. But the predictions won’t be as accurate if lower-risk adults, assuming they are safe, <a href="https://www.bmj.com/content/371/bmj.m3777">are less cautious and increase their risk of catching COVID</a>. Given how quickly coronavirus can spread, an algorithm-based approach that asks young people to risk getting sick could make the <a href="https://theconversation.com/a-level-results-why-algorithms-get-things-so-wrong-and-what-we-can-do-to-fix-them-142879">A-level results algorithm</a> look like a success.</p>
<p>To properly inform someone that they are at a “low risk” from COVID, we would need better information on exactly what they are at a low risk of. While the algorithm can predict risk of hospitalisation and death from the disease, we can’t yet adequately predict the risk of long-term health effects, known as “long COVID”. </p>
<p><a href="https://www.bmj.com/content/370/bmj.m3489">Long COVID</a> is poorly understood, but reports of it causing <a href="https://www.bmj.com/content/370/bmj.M3026.full">debilitating fatigue, brain fog or shortness of breath</a> for months in young, healthy people with milder cases suggest that it is an outcome that shouldn’t be ignored.</p>
<p>Lower risk doesn’t mean low risk. Deciding who is at an acceptably low risk – and how many of us this would amount to – will be complex. While most COVID deaths were concentrated in older adults or those with health conditions, half of the admissions to critical care due to COVID were in <a href="https://www.icnarc.org/Our-Audit/Audits/Cmp/Reports">adults aged under 60 years</a>. Therefore, we may need to shield a considerable proportion of the working population. Many employees will want to decide for themselves whether the risk is acceptable to them, and they may struggle to say no to a boss who wants them back at work.</p>
<p>With infectious disease, the main issue isn’t necessarily individual risk, <a href="https://www.bmj.com/content/370/bmj.m3181">it’s group risk</a>. Many young people live in multigenerational households, and their main desire may be not to pass it on to more vulnerable loved ones. While rises in infections often start in the young, they quickly pass on to <a href="https://www.npr.org/sections/health-shots/2020/09/29/916634414/when-young-people-get-covid-19-infections-soon-rise-among-older-adults?t=1602251019684">older</a> groups. </p>
<h2>Not workable</h2>
<p>Separating households for months isn’t a workable solution, especially for families with informal caring responsibilities – and employers may be hesitant to allow low-risk workers who live with high-risk adults to work from home.</p>
<p>Although shielding advice can be helpful, it may not be enough to protect higher-risk people if we were to encourage or accept a higher level of infections in younger populations. The algorithm’s predictions, trained using data when shielding and precautions were in place, show that groups advised to shield remained at a massively <a href="https://www.medrxiv.org/content/10.1101/2020.09.17.20196436v1.full.pdf">disproportionate risk of death</a>.</p>
<p>A further difficulty for shielding strategies could be providing safe medical care for their other health conditions. People receiving chemotherapy may be classed as high risk from COVID but would need to reduce their shielding in order to continue to receive treatment. </p>
<p>Although every effort is being made to <a href="https://www.bmj.com/content/369/bmj.m2013">make hospitals COVID-free</a>, increased incidence in younger populations, including doctors, nurses, carers and taxi drivers, would make attendance for medical treatments riskier.</p>
<p>Structural inequalities and racism will affect who is able to <a href="https://www.nature.com/articles/s41584-020-00524-8">work from home</a>, take sick leave, rely on public transport and live in crowded households. These all put working-class and minority ethnic individuals at a <a href="https://www.medrxiv.org/content/10.1101/2020.10.04.20206318v1">greater risk from COVID-19</a>. </p>
<p>The desire to reduce these discrepancies probably led to the inclusion of ethnicity and deprivation indicators into the algorithms. However, using an algorithm to selectively exclude people from society and workplaces based on race, age, deprivation or health conditions, isn’t an equitable solution. Particularly if those who are most likely to be asked to isolate live in cramped households. </p>
<p>With a <a href="https://tribunemag.co.uk/2020/10/the-government-is-leading-britain-to-an-unemployment-crisis">recession looming</a>, already marginalised workers could risk losing their jobs, training or promotions based on their postcode and ethnicity.</p>
<p>Asking vulnerable adults to shoulder the burden of the pandemic, in fearful isolation for an unknown period, would undermine core principles of public health. Isolating everybody indefinitely or having repeated lockdowns do not sound like appealing solutions either. The UK is already in a second lockdown and if it doesn’t get infections low enough to fit on an <a href="https://theconversation.com/why-you-should-never-use-microsoft-excel-to-count-coronavirus-cases-147681">Excel spreadsheet</a>, it could be facing a third.</p>
<p>Difficult decisions lie ahead on whether we need to pursue a more aggressive suppression strategy in order to reopen more fully.</p><img src="https://counter.theconversation.com/content/148754/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Andrew Kunzmann is affiliated with Independent Scientific Advocacy Group (ISAG)
A Better Way Forward: Towards A Zero-COVID Island. </span></em></p><p class="fine-print"><em><span>Justin Feldman does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Shielding people based on their individual risk profile has been proposed by some experts.Andrew Kunzmann, Patrick G. Johnston Fellow, Queen's University BelfastJustin Feldman, Health & Human Rights Fellow, Harvard UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1455972020-09-09T13:32:38Z2020-09-09T13:32:38ZWe’ve known for over a century that our environment shapes our health, so why are we still blaming unhealthy lifestyles?<p>We’re healthier and live longer than our <a href="https://ourworldindata.org/a-history-of-global-living-conditions-in-5-charts">ancestors</a>, yet we’re constantly reminded of deaths caused by <a href="https://www.bbc.co.uk/news/health-47371078">war, terrorism and natural disasters</a>. As terrible as these events are, they accounted for less than 1% of the <a href="https://ourworldindata.org/causes-of-death">56 million worldwide</a> deaths in 2017.</p>
<p>Another colossal distraction is the focus on lifestyle as a way to better people’s health and reduce health inequalities. Of course, what people eat, how much they exercise, whether they smoke and how much alcohol they drink have a bearing on their health. But what matters much more is the circumstances in which people are born, live, work and age – the <a href="https://www.gov.uk/government/publications/health-profile-for-england/chapter-6-social-determinants-of-health">“social determinants” of health</a>.</p>
<p>The fact that the environment shapes people’s lives and health has been known for a long time. In 1842, Edwin Chadwick’s <a href="https://www.parliament.uk/about/living-heritage/transformingsociety/livinglearning/coll-9-health1/health-02/">Report on the Sanitary Condition of the Labouring Population of Great Britain</a> highlighted how the ill health of the poor was not the result of their idleness but of their terrible living conditions. </p>
<p>In his semi-autobiographical novel <a href="http://www.unionhistory.info/ragged/ragged.php">The Ragged Trousered Philanthropists</a>, written over a century ago, Robert Tressell explained how the poor health of the hero of the book, impoverished painter and decorator Frank Owen, could not be solved by medicine alone. It was social medicine that he needed:</p>
<blockquote>
<p>The medicine they prescribed [Frank Owen] and which he had to buy did him no good, for the truth was that it was not medicine that he – like thousands of others – needed, but proper conditions of life and proper food.</p>
</blockquote>
<p>And over 70 years ago, <a href="https://www.nationalarchives.gov.uk/education/resources/attlees-britain/five-giants/">Sir William Beveridge</a>, the architect of the British welfare state, called for action to tackle the root causes of poor health: poverty, low education, unemployment, poor housing and other public health issues, such as malnutrition and inadequate healthcare. </p>
<p>There is no denying that great progress has been made since the work of Chadwick, Tressell and Beveridge. Far fewer people in the UK experience the absolute poverty, <a href="https://www.bl.uk/romantics-and-victorians/articles/slums">squalor and overcrowding</a> they described. </p>
<p>But the fact remains: the profound health inequalities between rich and poor that have been highlighted throughout the past century – most notably in the <a href="https://www.sochealth.co.uk/national-health-service/public-health-and-wellbeing/poverty-and-inequality/the-black-report-1980/">Black Report, which was published 40 years ago</a> – remain today. In 2020, a baby boy born in wealthy Kensington, London, can expect to live over ten years longer – and nearly 20 more years in good health – than a baby boy born in relatively deprived <a href="https://news.liverpool.ac.uk/2017/09/18/tackling-health-inequalities-needs-start-early-years/">Kensington, Liverpool</a>. </p>
<h2>Absolute poverty</h2>
<p>Today, a proportion of children still live in <a href="https://www.ifs.org.uk/uploads/publications/comms/R114.pdf">absolute poverty</a>. They lack sufficient nutritious food and their families rely on <a href="https://www.bmj.com/content/350/bmj.h1775">food charity</a>. They don’t have a <a href="http://england.shelter.org.uk/__data/assets/pdf_file/0003/1039530/FINAL_SAFE_AND_DECENT_HOMES_REPORT-_USE_FOR_LAUNCH.pdf">stable, decent home</a> and are exposed to damp, excess cold, and dangerous levels of carbon monoxide. The proportion of people <a href="https://www.theguardian.com/society/2018/nov/22/at-least-320000-homeless-people-in-britain-says-shelter">sleeping rough</a> is also rising. </p>
<p>Beveridge saw employment as the solution to poverty, yet the number of people in <a href="https://www.jrf.org.uk/report/what-has-driven-rise-work-poverty">in-work poverty</a> is close to 4 million, and a growing number of jobs are <a href="https://www.theguardian.com/commentisfree/2013/may/21/job-security-welfare-flexible-labour-precariat">part time, low paid or temporary</a>.</p>
<h2>An ounce of prevention</h2>
<p>The <a href="https://www.nationalarchives.gov.uk/education/resources/attlees-britain/five-giants/">solution to poor health</a> is to prevent it from happening in the first place. But rather than taking a preventative approach and fostering healthy lives through bettering the environments and conditions in which people live, national health services, such as the UK’s NHS, are primarily set up to treat the symptoms of poor health. </p>
<p>Essentially, the UK has a National Disease Service. It’s an incredibly good one, but the primary drive should be to prevent these expensive-to-treat chronic health conditions arising in the first place. Unfortunately, the <a href="https://www.publicfinance.co.uk/news/2018/12/government-slammed-public-health-grant-cuts">big loss</a> in public-health grant funding for local councils in the UK in recent years is testament to the government’s continued focus on treatment. </p>
<p>The public health education campaigns that do exist encourage people to <a href="https://www.gov.uk/government/publications/physical-activity-applying-all-our-health/physical-activity-applying-all-our-health">move more</a>, <a href="https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/742746/A_quick_guide_to_govt_healthy_eating_update.pdf">eat healthier</a> and limit <a href="https://www.gov.uk/government/publications/alcohol-applying-all-our-health/alcohol-applying-all-our-health">alcohol consumption</a>. They disregard underlying economic factors and neglect the fact that many people simply don’t have the same opportunities or resources to be as healthy as others do. </p>
<p>The economic basis of poor health is all too relevant today given the increasing return of <a href="https://www.theguardian.com/society/2017/dec/23/poorer-children-disproportionately-need-hospital-treatment">diseases of poverty</a> and the emergence of devastating new <a href="https://blogs.bmj.com/bmj/2020/05/22/covid-19-we-are-not-all-in-it-together-less-privileged-in-society-are-suffering-the-brunt-of-the-damage/">epidemics such as COVID-19</a>. </p>
<p>The reality is that people’s health choices are heavily influenced by the <a href="https://www.annualreviews.org/doi/10.1146/annurev-publhealth-031210-101218?url_ver=Z39.88-2003&rfr_id=ori%3Arid%3Acrossref.org&rfr_dat=cr_pub++0pubmed">conditions in which they live</a>. Whether they have a job that’s safe, secure and decently paid, and one that gives them control, flexibility and meaning. Whether they’re able to afford a well-heated, well-lit, stable home in a safe area. Whether they have the money, time and resources to buy and cook healthy food and have an active lifestyle. Whether they have a walkable community that provides access to green space and essential services.</p>
<p>Lifestyle is also important for health, but lifestyle behaviours have causes and these <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(17)32848-9/fulltext">causes have causes, too</a>. It’s these <a href="http://www.instituteofhealthequity.org/resources-reports/fair-society-healthy-lives-the-marmot-review">wider determinants of health</a> that affect our health most. </p>
<p>That the most deprived areas experience almost ten times as many <a href="https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/695781/Reducing_unintentional_injuries_on_the_roads_among_children_and_young_people_.pdf">child pedestrian fatalities</a> than the least deprived areas is a fitting example of how – still to this day – where you live can kill you.</p><img src="https://counter.theconversation.com/content/145597/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Rob Noonan does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Public health education campaigns disregard economic factors.Rob Noonan, Lecturer, Appetite and Obesity, University of LiverpoolLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1436582020-09-09T12:37:42Z2020-09-09T12:37:42ZNurses are on the coronavirus frontline, so why are they being left out of the response?<p>More than 600 nurses worldwide have died from COVID-19 <a href="https://www.icn.ch/news/more-600-nurses-die-covid-19-worldwide">during the pandemic</a>. This should not be a surprise: we are the <a href="https://www.who.int/hrh/news/2017/NursingApril2017-2.pdf?ua=1">largest group of healthcare workers in the world</a>, dedicated to preventing the spread of coronavirus, and we are also engaged in caring for those who are suffering. </p>
<p>But although we are on the frontline of this crisis, nurses are too often being left out of responses to the pandemic. </p>
<h2>Uniquely at risk</h2>
<p>In the UK and other countries with high rates of coronavirus deaths, there are increasing inequalities in health outcomes for different income groups. In England and Wales, the mortality rates from COVID-19 in the most deprived areas are <a href="https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/bulletins/deathsinvolvingcovid19bylocalareasanddeprivation/deathsoccurringbetween1marchand31may2020#:%7E:text=In%20England%2C%20the%20age%2Dstandardised,(58.8%20deaths%20per%20100%2C000">more than double the least deprived</a>. </p>
<p>In general, the risk of ill health increases for people who live on a low income. Common <a href="https://publichealthmatters.blog.gov.uk/2019/03/04/health-matters-ambitions-to-tackle-persisting-inequalities-in-cardiovascular-disease/#:%7E:text=Cardiovascular%20disease%3A%20A%20major%20cause%20of%20health%20inequalities&text=It%20is%20also%20one%20of,in%20the%20least%20deprived%20area">health issues</a> that affect these groups include high blood pressure, coronary heart disease, lung disease, type 2 diabetes and obesity. All of these put people at higher risk of becoming sicker and dying from COVID-19. Death rates are <a href="https://theconversation.com/why-are-black-and-asian-people-at-greater-risk-of-coronavirus-heres-what-we-found-140584">highest</a> among people from Black, Asian and minority ethnic backgrounds. </p>
<p>These communities are also disproportionately <a href="https://www.hsj.co.uk/exclusive-deaths-of-nhs-staff-from-covid-19-analysed/7027471.article#:%7E:text=Among%20all%20staff%20employed%20by,in%20the%20same%20staff%20groups">represented among nursing staff</a> some of whom are <a href="https://www.huffingtonpost.co.uk/entry/nurses-generations-reveal-realities-low-pay-nhs_uk_595de3b3e4b02e9bdb0a40c2">living on the lowest wages</a>. </p>
<h2>Lacking equipment</h2>
<p>Nurses working in hospitals, care homes and within communities are often put at greater risk from COVID-19 because they have not been given adequate personal protective equipment, or PPE. </p>
<p>A <a href="https://www.thelancet.com/journals/lanpub/article/PIIS2468-2667(20)30164-X/fulltext#seccestitle70">study</a> of nearly 100,000 health workers in the UK and US found that people working on the frontline of the coronavirus pandemic were three times more likely to test positive for the disease than the general community. Health workers from a Black, Asian or minority ethnic background were found to be five times more likely to test positive than white people who did not work in healthcare. Workers who reported a lack of adequate PPE in their healthcare institutions were at greater risk still. </p>
<p>Another <a href="https://www.rcn.org.uk/news-and-events/news/uk-bame-nursing-staff-experiencing-greater-ppe-shortages-covid-19-280520">study</a> by the UK’s Royal College of Nursing, meanwhile, found that more than half of Black, Asian and minority ethnic respondents have felt pressure to work without the correct PPE compared to just over a third of other respondents. These groups were also asked to reuse PPE more frequently than their white counterparts. </p>
<h2>Denied a voice</h2>
<p>It’s a painful irony that as nurses battle against the coronavirus pandemic, 2020 is the World Health Organization’s <a href="https://www.who.int/campaigns/year-of-the-nurse-and-the-midwife-2020">Year of the Nurse and Midwife</a> which was supposed to raise the profile and perceptions of nurses globally. </p>
<p>But the response to the pandemic in the UK has starkly shown that our expertise and experience as a profession is not being called upon and our potential is not recognised. We are the biggest work force for health in the UK working in hospitals, care homes and community settings to care for those with COVID-19 and help prevent its spread yet we have no representation on the official <a href="https://www.gov.uk/government/publications/scientific-advisory-group-for-emergencies-sage-coronavirus-covid-19-response-membership/list-of-participants-of-sage-and-related-sub-groups">scientific advisory group</a> (SAGE), which advises the government on its coronavirus response. Nor are we represented on the rival <a href="https://www.independentsage.org/who-is-on-the-independent-sage/">Independent SAGE</a> group.</p>
<p>Our role in policy development and planning is negligible despite the invaluable insights our unique position in health systems gives us. Our lack of representation and reward means that we are also suffering from the impacts of inequalities along with those we care for. </p>
<p>Given the chance, nurses could help guide coronavirus policy in a number of ways. First, by being a witness to the health impacts of COVID-19 on our local communities and staff, recording and researching inequity of access to services. Second, we can advise on how to provide prevention and treatment resources to those most at risk. Finally, we can set a positive example in terms of equality of opportunity, fair working conditions, protection from infection and pay. This could start with ensuring equal provision of PPE for all staff.</p>
<p>Nurses are at the forefront of trying to reduce existing health inequalities which are being made worse by COVID-19. We are also victims of those inequalities – a feminised, racialised workforce dealing with poor conditions and lacking a political voice. Care and prevention of disease are not perceived as being as important as finding a cure or a vaccine, but in the global recovery from COVID-19, all these elements are equally vital. </p>
<p>We have already lost too many colleagues in the fight against this disease. It’s time our work is recognised and we are given an official voice to help us all recover from the coronavirus pandemic.</p><img src="https://counter.theconversation.com/content/143658/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Ann Hemingway is a Registered Nurse and has a PhD.</span></em></p>Nurses are uniquely at risk of COVID-19, and are affected by many of the health inequalities that the pandemic has exposed. But no one is listening to them.Ann Hemingway, Professor of Public Health, Bournemouth UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1423222020-08-07T13:12:20Z2020-08-07T13:12:20ZParks and green spaces are important for our mental health – but we need to make sure that everyone can benefit<figure><img src="https://images.theconversation.com/files/351634/original/file-20200806-20-1beykzt.jpg?ixlib=rb-1.1.0&rect=20%2C0%2C4550%2C3430&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/autumn-beech-tree-leaves-seen-below-1785535916">Shutterstock</a></span></figcaption></figure><p>How does walking through a forest make you feel? Peaceful? Blissful? Reflective? For many people, lockdown brought a new appreciation of nature and what it means for our well-being. The health benefits of immersing ourselves in “<a href="https://www.greenspacescotland.org.uk/what-is-greenspace">greenspace</a>” are now widely accepted. Living in areas with grass and trees has been <a href="http://diposit.ub.edu/dspace/bitstream/2445/99572/1/gascon2015_2007.pdf">linked</a> to lower risk of various health conditions such as high blood pressure and cardiovascular disease. As well as physical health, greenspace is associated with <a href="https://www.tandfonline.com/doi/abs/10.1080/09638237.2020.1755027?journalCode=ijmh20">positive mental health</a>.</p>
<p>A <a href="https://www.nature.com/articles/s41598-019-44097-3">recent study</a> found that people who spent at least two hours in nature per week were consistently more likely to report higher levels of health and well-being compared to people who spent less time in nature.</p>
<p>Our work seeks to understand exactly how <a href="https://greencarecoalition.org.uk/about/how-does-green-care-differ-from-other-nature-based-activities/">greenspace programmes</a> can improve mental health. A greenspace programme, or <a href="http://publications.naturalengland.org.uk/publication/4513819616346112">nature-based intervention</a>, is a health project typically run outside in parks, woodland, forests and other greenspace areas.</p>
<p>These programmes can be designed for anyone, but have been shown to be particularly beneficial for those with <a href="https://www.independent.co.uk/environment/nature-prescriptions-nhs-mental-health-nature-wellbeing-a9148751.html">poorer mental health</a>. Projects can range from structured therapy programmes such as adventure, wilderness and horticultural therapies, to less formal activities such as community gardening, guided walks and the Japanese notion of “<a href="https://time.com/5259602/japanese-forest-bathing/">forest bathing</a>” or <em>shinrin-yoku</em>. </p>
<p>We are currently working on developing a framework for those wishing to start up such initiatives. This is an important area of research, because while there is an <a href="https://www.mdpi.com/1660-4601/17/10/3460/htm">increasing number</a> of greenspace programmes for mental health, there is still limited understanding of the key components that make these projects successful. This makes it difficult to develop and implement new programmes and evaluate them successfully.</p>
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<h2>Mental health and nature</h2>
<p>In our <a href="https://www.sciencedirect.com/science/article/pii/S1353829219310962">recent review</a> we showed that greenspace programmes are successful in improving mental health due to seven interacting factors: the feeling of escape and getting away; having space to reflect; physical activity; learning to deal with things; having a purpose; relationships with programme leaders; and shared social experiences. Using these components we created a new framework for greenspace programmes for mental health that showed exactly how positive outcomes can be best achieved. </p>
<p>We believe this framework could provide a working model for future programme development. However, our findings also show that greenspace programmes do not work for everybody equally and seem to be more successful in improving mental health for some people than others.</p>
<p>For example, mobility issues may limit a person’s ability to take part in physically demanding programmes. Wilderness projects might not be appropriate for people who may suffer from conditions such as psychosis. And overnight programmes or early starts may not be suitable for those on daily pick-up prescriptions such as methadone.</p>
<p>Greenspace programmes have been successful in supporting people who have been involved in offending – but these individuals might be limited to where they can go. These inequalities in programme suitability are important to highlight, since the people who are not able to access these initiatives might be the ones who benefit the most.</p>
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<h2>Greenspace and inequality</h2>
<p>Recently, COVID-19 has revealed the inequalities that exist when it comes to access to green spaces. There have been many petitions to keep parks and gardens open for public use, with green spaces described as <a href="https://theconversation.com/coronavirus-urban-parks-can-be-a-lifeline-if-we-respect-lockdown-rules-134185">crucial for our well-being</a>.</p>
<p>But the availability of greenspace differs depending on where you live. <a href="https://eprints.gla.ac.uk/118255/1/118255.pdf">Affluence</a> allows people to buy homes in areas that have more green spaces and access to nature, less air pollution and more space for physical activity. If someone has less access to local parks, gardens and playing fields, they are far less likely to gain the benefits that those spaces can provide. </p>
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<em>
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Read more:
<a href="https://theconversation.com/ecotherapy-aims-to-tap-into-nature-to-improve-your-wellbeing-128433">Ecotherapy aims to tap into nature to improve your wellbeing</a>
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</em>
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<p>These inequalities clearly existed before COVID-19, but the pandemic brought a wider awareness that easy access to existing green spaces was <a href="https://www.theguardian.com/world/2020/apr/23/trapped-in-coronavirus-lockdown-uk-no-garden-outside-space">not an opportunity available to everyone</a>. Using London as an example, the wealthiest areas have around 10% more public space compared to the most deprived areas. Approximately <a href="https://www.theguardian.com/uk-news/2020/apr/10/coronavirus-park-closures-hit-bame-and-poor-londoners-most#_=_">half</a> of the residents in the most deprived areas of London are from minority backgrounds.</p>
<p>Some evidence shows that those living in the most deprived areas will actually benefit more from local green spaces, compared to those in more affluent areas – and that greenspace can help <a href="https://www.nhs.uk/news/lifestyle-and-exercise/green-space-and-health/">reduce the health inequality</a> between high and low income groups. This could be <a href="https://www.sciencedirect.com/science/article/pii/S0277953614001270">due</a> to poorer communities spending more time in their local areas, and affluence allowing people to travel further from their homes more regularly. </p>
<p>High-quality green spaces and access to nature should be available and easily accessible for everyone, but it is clear that this is currently not the case. With <a href="https://www.unison.org.uk/news/2018/06/budget-cuts-put-parks-need-urgent-attention/">further funding cuts</a> to the quantity and quality of green spaces, it is likely that the poorest communities will suffer the most.</p>
<h2>What should be done?</h2>
<p>Funding for public services is now going to be stretched even further. But it is more important than ever that continued government funding for parks and green spaces is kept as a high priority, particularly when mental health is reported to have <a href="https://www.theguardian.com/society/2020/jun/30/uks-mental-health-has-deteriorated-during-lockdown-says-mind">deteriorated</a> during lockdown.</p>
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<img alt="View of Kelvingrove Art Gallery from Kelvingrove Park, Glasgow." src="https://images.theconversation.com/files/351637/original/file-20200806-20-102dh94.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/351637/original/file-20200806-20-102dh94.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/351637/original/file-20200806-20-102dh94.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/351637/original/file-20200806-20-102dh94.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/351637/original/file-20200806-20-102dh94.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/351637/original/file-20200806-20-102dh94.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/351637/original/file-20200806-20-102dh94.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Public parks are crucial for access to nature for all citizens.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/salvia-begonia-flowers-flower-beds-kelvingrove-1285095358">Shutterstock</a></span>
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<p>This funding must not be limited to popular beauty spots or tourist areas, but be prioritised to areas where people who are commonly overlooked may benefit the most. Not only are parks and green spaces crucial for our mental health and important for reducing inequalities, but quality spaces and green development are <a href="https://theconversation.com/when-climate-comes-unhinged-we-need-to-re-think-how-to-build-our-cities-91258">essential</a> in the ongoing fight against climate change – it’s good for people and it’s good for the planet.</p><img src="https://counter.theconversation.com/content/142322/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Wendy Masterton receives funding for her PhD from the Economic and Social Research Council and Scottish Graduate School of Social Science</span></em></p><p class="fine-print"><em><span>Hannah Carver receives funding from The Salvation Army, Chief Scientist Office Scotland, National Institutes for Health Research and a range of other public organisations to do work connected to the issues raised in this article.</span></em></p><p class="fine-print"><em><span>Tessa Parkes received funding as lead supervisor from the Economic and Social Research Council and Scottish Graduate School of Social Science for an interdisciplinary PhD studentship on the use of greenspace to prevent substance use problems. She also receives funding from a wide variety of research funders including the Chief Scientist Office for Scotland, The Salvation Army, Scottish Government, National Institutes for Health Research and NHS Boards. </span></em></p>We know that spending time in nature is good for physical and mental well-being, but social inequality means not everyone has easy access to parks, gardens and woodland.Wendy Masterton, Doctoral Researcher, Social and Natural Sciences, University of StirlingHannah Carver, Lecturer in Substance Use, University of StirlingTessa Parkes, Research Director, University of StirlingLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1423452020-07-17T13:32:54Z2020-07-17T13:32:54ZPoorest Americans drink a lot more sugary drinks than the richest – which is why soda taxes could help reduce gaping health inequalities<figure><img src="https://images.theconversation.com/files/348142/original/file-20200717-37-tjdn6g.jpg?ixlib=rb-1.1.0&rect=219%2C78%2C5628%2C3410&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Soda contributes to obesity and other diseases. </span> </figcaption></figure><p>Many countries such as the <a href="https://www.lshtm.ac.uk/research/research-action/features/uk-sugar-tax-will-it-work">U.K.</a> and <a href="https://www.latimes.com/science/sciencenow/la-sci-sn-soda-tax-mexico-20161102-story.html">Mexico</a> and a handful of U.S. cities such as <a href="https://drexel.edu/now/archive/2020/February/Soda-Tax-and-Beverage-Consumption/">Philadelphia</a> and <a href="https://sftreasurer.org/business/taxes-fees/sugary-drinks-tax">San Francisco</a> have imposed soda taxes in an effort to fight rising obesity. </p>
<p>Lots of research shows a link between drinking sugary substances and a <a href="https://www.cdc.gov/nutrition/data-statistics/sugar-sweetened-beverages-intake.html#:%7E:text=Frequently%20drinking%20sugar%2Dsweetened%20beverages,gout%2C%20a%20type%20of%20arthritis">whole host of negative health outcomes</a>, including type 2 diabetes, heart disease, liver disease, tooth decay and gout. </p>
<p>As economists who study <a href="https://www.researchgate.net/profile/Jay_Zagorsky">economic status</a> and <a href="http://www-personal.umd.umich.edu/%7Epksmith/research.htm">health</a>, we wanted to look at this from another perspective: Does how wealthy you are affect how much soda you consume? And could reducing sugary beverage consumption narrow the <a href="https://www.nationalacademies.org/news/2017/01/new-report-identifies-root-causes-of-health-inequity-in-the-us-outlines-solutions-for-communities-to-advance-health-equity">double-digit life expectancy gap</a> between the richest and poorest Americans? </p>
<h2>Wealth and soda</h2>
<p><a href="https://www.doi.org/10.1016/j.ehb.2020.100888">We analyzed data</a> for over 24,000 U.S. adults in two nationally representative random samples from the <a href="http://www.nlsinfo.org/">National Longitudinal Surveys</a>, which follow groups of people over a period of time, asking them hundreds of questions each year on a variety of topics like employment, health and attitudes. Some questions are asked every year, while others are included less frequently. </p>
<p>We looked at two groups of people. The first is referred to as the <a href="https://www.nlsinfo.org/content/cohorts/nlsy79">NLS 1979 cohort</a> and includes people born from 1957 to 1964. They were asked how often they consumed sugary drinks in the previous week every other year from 2008 to 2016, meaning the respondents were in their 40s and 50s when asked the question. </p>
<p>The second group is known as the <a href="https://www.nlsinfo.org/content/cohorts/nlsy97">NLS 1997 cohort</a> and includes people born from 1980 to 1984. They were asked the sugary drink question four times from 2009 to 2015, putting them in their 20s and 30s. </p>
<p><a href="https://www.cdc.gov/nchs/products/databriefs/db122.htm">Prior studies</a> <a href="http://www.doi.org/10.3945/ajcn.111.018366">have found</a> that consumption of sugary drinks <a href="http://www.doi.org/10.1016/j.jand.2012.09.016">tend to rise</a> as income falls. But few of them controlled for the range of other factors that could also matter, such as gender, race and ethnicity, education, cognitive skills and interest in health and nutrition. Moreover, none of them focused on wealth, which can offer unique insights on the issue. </p>
<p>Wealth represents an accumulation of resources rather than a regular flow of income. Newly graduated doctors have high income and low wealth, while retirees may have high wealth, but little income. The difference between income and wealth means they could affect consumption patterns differently. Wealth is distributed much more unequally. In addition, individuals may signal their membership in the upper economic echelons through the foods they consume.</p>
<p>[<em><a href="https://theconversation.com/us/newsletters/the-daily-3?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=experts">Expertise in your inbox. Sign up for The Conversation’s newsletter and get expert takes on today’s news, every day.</a></em>]</p>
<p>We first looked at the share of respondents who reported drinking any sugar-sweetened beverages in the survey week by income and wealth deciles, which divides them into 10 equal groups depending on their income or wealth. </p>
<p>The number of sugar-sweetened beverages consumed generally falls as income rises. We found the same pattern when we looked at wealth, but the differences by wealth are more pronounced. Our analysis suggests that adults living in the richest 10% of families drink about 2.5 fewer sugary drinks a week than those in the poorest 10%. </p>
<p>This decline in sugary drink consumption as income and wealth rise holds up even after taking into account things like education, race, gender, cognitive abilities and interest in nutrition. </p>
<p>What’s the impact of 2.5 more sugar drinks a week? Rough calculations based on the typical sugar amounts in these drinks – <a href="https://sphhp.buffalo.edu/content/dam/sphhp/emergency-responder-human-performance/understanding-nutrition-labels.pdf">about 9.5 teaspoons</a> per 12-ounce can – suggest that it could result in <a href="https://www.livestrong.com/article/532975-how-to-calculate-how-many-calories-comes-from-sugar/">about 5.6 pounds of weight gain</a> over a year, assuming no increase in physical activity or decrease in consumption of calories from other sources.</p>
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<h2>For richer or poorer</h2>
<p>We also wondered whether soda consumption might change as people gain or lose wealth or make more or less money. Would increases in economic status correlate with decreases in sugary drink consumption?</p>
<p>Over the four-year periods we could observe, changes in income and wealth, even large ones, were not correlated to changes in sugary drink intake. We did not observe that adults who had gotten richer tended to report a drop in the number of sugary drinks consumed.</p>
<p>One possible explanation is that while economic status shapes our early drinking habits, those habits don’t much change in adulthood. Another possible explanation is that four years is not enough time for noticeable changes in sugar-sweetened beverage consumption to happen.</p>
<p>Our finding that people who are wealthier or make more money consume fewer sugary drinks supports the idea that soda consumption contributes to <a href="https://www.nationalacademies.org/news/2017/01/new-report-identifies-root-causes-of-health-inequity-in-the-us-outlines-solutions-for-communities-to-advance-health-equity">health inequities</a> along the economic distribution.</p>
<p>However, that doesn’t mean soda taxes are the best way to reduce these inequities. Since we find that sugary beverage consumption is higher for poorer Americans, these taxes can be regressive – meaning they fall more heavily on those with less income. On the other hand, if people with lower incomes respond to the higher prices caused by “soda taxes” by cutting consumption substantially, they can avoid the tax and improve their health. </p>
<p>A <a href="http://doi.org/10.1161/CIRCULATIONAHA.119.042956">just-published study</a> suggests that some soda taxes may be more effective than others at changing drinking habits. Specifically, it found that taxes based on the quantity of sugar in a drink are more successful than those simply based on volume, which <a href="https://www.cnn.com/2020/06/22/health/soda-tax-sugar-content-wellness/index.html">are more common in the U.S.</a></p>
<p>So well-designed soda taxes can help reduce rich-poor health disparities, but we’ll need a range of strategies to achieve that goal.</p><img src="https://counter.theconversation.com/content/142345/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>But the taxes have to be well-designed to avoid being overly regressive and targeting the poor.Patricia Smith, Professor of Economics, University of MichiganJay L. Zagorsky, Senior Lecturer, Questrom School of Business, Boston UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1324282020-07-12T20:00:35Z2020-07-12T20:00:35ZWhere are the most disadvantaged parts of Australia? New research shows it’s not just income that matters<figure><img src="https://images.theconversation.com/files/346775/original/file-20200710-87071-u3v5zi.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Dan Peled/AAP</span></span></figcaption></figure><p>New research on disadvantage in Australia has found the gap between rich and poor is very wide in Sydney, while much of Queensland struggles with educational disadvantage and regional NSW and Victoria are both more disadvantaged when it comes to health.</p>
<p>Previous research on poverty has placed a heavy emphasis on income and economic outcomes at a given point in time. But disadvantage often goes beyond just economic factors. It’s also necessary to analyse the educational, health and social inequities in society to get a more accurate understanding of disadvantage.</p>
<p>At the core of our new research, published in our <a href="https://mappingthepotential.cssa.org.au/index.php/about/">Mapping the Potential report</a>, is the idea that disadvantage in Australia is more varied and complex than many people may think. </p>
<h2>How we conducted our research</h2>
<p>This research, conducted by the ANU Centre for Social Research and Methods and commissioned by Catholic Social Services Australia, expands on the socioeconomic indexes produced by the Australian Bureau of Statistics by adding more detailed variables across health, education, social and economic domains. </p>
<p>We also incorporated a “persistence” element to disadvantage – in that, disadvantage isn’t tied to a singular point in time, but persists for a longer period.</p>
<p>In our research, disadvantage was data-driven. And to quantify disadvantage, we chose variables that were generally considered relevant for each area. For economic disadvantage, for instance, we looked at low incomes, low-skilled jobs and unemployment. Areas with a large share of people with these characteristics tended to be more disadvantaged. </p>
<p>Health disadvantage was based on various chronic health conditions, such as diabetes, heart and circulatory conditions, and obesity. </p>
<p>Educational disadvantage focused on levels of educational attainment and child educational disadvantage - both cognitive and physical development. We used data from the <a href="https://www.education.gov.au/australian-early-development-census#:%7E:text=The%20Australian%20Early%20Development%20Census,in%20the%20community%2C%20not%20individuals.">Australian Educational Development Census</a> to gauge this. </p>
<p>Social disadvantage was less clearly defined. We focused on variables that contribute to <a href="https://www.oecd.org/insights/37966934.pdf">social capital</a>, or the interpersonal networks that help a society function effectively. Regions with social disadvantage, for example, tended to have low rates of volunteering, internet connection and social cohesion.</p>
<p>Geographically, we analysed these variables at the <a href="https://www.abs.gov.au/websitedbs/D3310114.nsf/home/Australian+Statistical+Geography+Standard+(ASGS)">SA2 level</a> (areas comprised roughly of suburbs and towns) across Australia. We then aggregated the results to the federal electorate level to avoid singling out and possibly stigmatising individual suburbs. </p>
<p>For comparison purposes, each index was standardised to an average score of 1,000 across all SA2s. Nearly all SA2s (95%) had a score between 800 (high disadvantaged) and 1,200 (low disadvantage).</p>
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<p>To better understand differences between our major populations, we further aggregated our results to nine larger geographic entities: the five major capitals, the regional areas of NSW, Queensland and Victoria and a “catch all” remainder of Australia region. This last grouping was used due to the small number of electorates in some states and territories.</p>
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<h2>The most disadvantaged parts of Australia</h2>
<p>The key finding of the report is there is considerable variation in the types of disadvantage experienced across Australia. Moreover, the types of disadvantage varied between locations, as well.</p>
<p>Australia’s most disadvantaged electorate overall was Hinkler in regional Queensland. Hinkler ranks poorly in three of the disadvantage domains we tracked: health, economic and social. </p>
<p>Australia’s least disadvantaged electorate is North Sydney.</p>
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<p>When we looked at each type of disadvantage individually, we found that electorates had very different needs. </p>
<p>From an economic perspective, for example, our most disadvantaged electorate is Blaxland in Western Sydney. Our most disadvantaged health electorate is Braddon in regional Tasmania. </p>
<p>The most disadvantaged educationally was Spence in the northern suburbs of Adelaide. Socially, the most disadvantaged electorate was Parkes in regional NSW.</p>
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<p>When comparing the larger regions in our report, we found Adelaide faces the most disadvantage overall, while Sydney and Perth have, on average, the least overall disadvantage.</p>
<p>Even the best-performing regions have pockets of high disadvantage. For example, while Sydney has a relatively strong overall result, it also has the most economically disadvantaged electorate in Australia (Blaxland) and several suburbs with scores below 800. </p>
<p>The research also shows the vast disparities between urban and regional areas in Australia. For example, according to our data, nearly the whole of regional NSW is considered disadvantaged. In contrast, the inner suburbs of Sydney are much better-off.</p>
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<img alt="" src="https://images.theconversation.com/files/316985/original/file-20200225-24694-1eticck.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/316985/original/file-20200225-24694-1eticck.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=424&fit=crop&dpr=1 600w, https://images.theconversation.com/files/316985/original/file-20200225-24694-1eticck.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=424&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/316985/original/file-20200225-24694-1eticck.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=424&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/316985/original/file-20200225-24694-1eticck.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=533&fit=crop&dpr=1 754w, https://images.theconversation.com/files/316985/original/file-20200225-24694-1eticck.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=533&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/316985/original/file-20200225-24694-1eticck.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=533&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Differences in disadvantage between regional NSW and greater Sydney.</span>
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<p>Most concerning was the deep level of disadvantage found in predominantly Indigenous communities, mostly in the Northern Territory. The electorate of Lingiari, for instance, has a marked split between the
relatively advantaged suburbs around Darwin and the deeply disadvantaged areas outside the city. </p>
<p>We also found a number of electorates in coastal NSW, Queensland and Tasmania with significant health disadvantage. This is concerning given the threat of future outbreaks of COVID-19.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/educational-disadvantage-is-a-huge-problem-in-australia-we-cant-just-carry-on-the-same-74530">Educational disadvantage is a huge problem in Australia – we can't just carry on the same</a>
</strong>
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<h2>Why this data matters</h2>
<p>The indexes remind us that despite nearly 30 years of continued economic growth in Australia, prosperity has not come to all parts of the country. Nor is economic advantage necessarily an indication of other facets of well-being, such as educational or health equality.</p>
<p>This data is important because it can help non-profit organisations make better-informed decisions on where and how to allocate future resources and investments. </p>
<p>It will also help governments at all levels gain a deeper understanding of the types of disadvantage that exist within regions and how their programs and other methods of assistance – both financial or non-financial – can be most effective. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/new-evidence-suggests-we-may-need-to-rethink-policies-aimed-at-poverty-92268">New evidence suggests we may need to rethink policies aimed at poverty</a>
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</em>
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<img src="https://counter.theconversation.com/content/132428/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Ben Phillips has undertaken a range of consulting work for various organisations and receives funding from the Australian Research Council.</span></em></p><p class="fine-print"><em><span>Brenton Prosser has received funding from the Australian Research Council and was previously employed as Director (Research) for Catholic Social Services Australia.</span></em></p>A new mapping project shows where different types of disadvantage are most prevalent. The picture is more varied and complex than many people think.Ben Phillips, Associate Professor, Centre for Social Research and Methods, Director, Centre for Economic Policy Research (CEPR), Australian National UniversityBrenton Prosser, Professor, University of CanberraLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1372962020-07-08T14:41:44Z2020-07-08T14:41:44ZHow the dimensions of human inequality affect who and what we are<figure><img src="https://images.theconversation.com/files/343562/original/file-20200623-188891-5rq20f.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A Black Lives Matter protester in Senegal.</span> <span class="attribution"><span class="source">JOHN WESSELS/AFP via Getty Images</span></span></figcaption></figure><p>What does it mean to be human today? It is an <a href="https://stias.ac.za/2017/08/what-do-we-wish-to-change-with-regard-to-race-racism-and-racialism/">excellent starting point</a> for thinking about human inequality. </p>
<p>To be human, in an elementary sense, means three things.</p>
<p>First, you are a sexed living organism, capable of feeling pain and pleasure and of reproduction, with a delimited lifespan of development and decay, subject to vicissitudes of health and illness.</p>
<p>Secondly, you are a person, with a self and a reflexive capacity, flourishing or suffering in social environments.</p>
<p>Thirdly, you are a creative, goal-oriented actor, collective as well as individual, endowed with resources of varying size and kind.</p>
<p>The possibilities of flourishing as a human are shaped by processes of (in)equality. Differences are either given – by God or by Nature – or chosen as lifestyles. </p>
<p>Unlike difference, inequality is a <a href="https://theconversation.com/why-does-racism-prevail-leading-scholars-apply-their-minds-138363">historical social construction</a>.</p>
<p>The three-dimensionality of humanity gives us three kinds of human inequality. These are vital, existential and resource.</p>
<h2>The three kinds of human inequality</h2>
<p>Vital inequality refers to socially determined distributions of health and ill health and of your lifespan. It can be measured in life expectancy and in health expectancy or your years without serious illness. Where demographic life tables are missing, infant and child mortality are more accessible indicators.</p>
<p>Existential inequality sums up the unequal social treatment of persons. On one end of the spectrum resides denial of recognition, autonomy, existential security, dignity and respect. These can be achieved through acts of neglect, bullying, degradation and humiliation. The ultimate result is a denial of their humanness. At the opposite end are selective attention, freedom, emotional security, encouragement, respect and admiration.</p>
<p>Existential inequality is structured and processed by categories and lenses of othering – such as sex, race, ethnicity, caste or religion. It is arguably the most hurtful and wounding of inequalities. It has given rise to a range of egalitarian movements – feminist, anti-racist, nationalist, anti-caste, anti-bigotry. It has been an important driver of workers’ movements, in which the demand for recognition of workers’ human dignity has been central.</p>
<p>So far, however, existential inequality has received little systematic <a href="https://www.researchgate.net/publication/235388737_The_Killing_Fields_of_Inequality">analysis</a> and <a href="https://books.google.co.za/books/about/Between_Sex_and_Power.html?id=7oQlkfj_MKkC&redir_esc=y">study</a>. </p>
<p>It is hardly quantifiable and is difficult to compare. Legal practices and public norms, recurrent demographic and health surveys, opinion surveys, anthropological studies, autobiographies and media reporting provide qualitative evidence.</p>
<p>Resource inequality expresses the unequal allocation of resources to act among human actors. It is most frequently gauged through distributions of income and wealth and of so-called human capital. Less studied in this context, although highly relevant, are distributions of power and rights.</p>
<p>The three dimensions of inequality are interconnected and interact or “<a href="https://theconversation.com/explainer-what-does-intersectionality-mean-104937">intersect</a>”, but each has its own dynamic and trajectory, globally and nationally.</p>
<h2>What othering does</h2>
<p>Othering means seeing and treating a set of people as being of a different kind than you and your type of people, as strange, peculiar and (usually) inferior.
Viewing “race” as a category of existential othering means highlighting its character as a socio-cultural construction that is subject to change. This occurs alongside <a href="https://www.theguardian.com/inequality/2017/nov/08/us-vs-them-the-sinister-techniques-of-othering-and-how-to-avoid-them">many other constructs</a> such as gender, ethnicity, caste and religion. </p>
<p>In early 20th century Europe, “race” was often synonymous with ethnicity. For example, “the British race” or references to geo-ethnic groups, such as the “Alpine” or “Mediterranean race”. In continental Europe today, “race” is hardly used at all. </p>
<p>This does not mean that discriminatory and hateful othering has disappeared. It means it is now operating with other labels like Arabs, Muslims, immigrants, Africans…</p>
<p>The existential perspective leads us to human self-formation and its connection with capability formation. The very meaning of racism and of patriarchy is to deny self-esteem and self-confidence – indeed any self at all – especially to black (or any other racial target) and girl children. It installs shame, self-contempt and fear instead. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/why-does-racism-prevail-leading-scholars-apply-their-minds-138363">Why does racism prevail? Leading scholars apply their minds</a>
</strong>
</em>
</p>
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<p>Such punitive processes are, of course, not always successful. But they often inflict lasting wounds. Prejudice and stigma act as stressors on the victims and have both somatic (bodily) and psychological <a href="https://www.researchgate.net/publication/4901753_Discrimination_Social_Identity_and_Durable_Inequalities">effects</a>. They also, by themselves, cause under-performance by the targets. Psychology experiments have shown that when marginalised groups are told they are inferior, they <a href="https://www.researchgate.net/publication/247505973_Stereotype_Threat_When_minority_members_underperform">perform badly</a> on given tasks. Conversely, when told they are expected to be superior, their performance improves.</p>
<h2>Two sets of burdens</h2>
<p>Children of poor, oppressed and/or discriminated populations are loaded with two sets of heavy burdens. These cause many or most of them to under perform. One is the burden of social determinants, of ill-health and stunted development, which goes along with not enough emotional security and positive social stimulation. In other words, vital inequality, which bears upon capability formation. The other operates through the negative impacts on self-development of esteem, confidence and ambition by existential processes of stigmatisation, humiliation and fear. </p>
<p>Both these childhood experiences tend to have lifelong effects, beginning life-curves of cumulated disadvantages. Furthermore, they provide reinforcing and reproducing confirmatory evidence of inferiority of the race, gender or caste. </p>
<p>And when some individuals of the put-down race, gender or caste manage to break through their discrimination and oppression, this is often used as further evidence of the inferiority of the category in question. The losers are regarded as deficient persons, of low-life existence. To hardcore racists, this is inherent and inherited. But after the liberation of Auschwitz, existential inequality is more effective when leaving its genetic background unnamed.</p>
<h2>Why racism prevails</h2>
<p>Unequal personal selves are produced by existential inequality. And they are fortified by early cognitive and social capability formation. This can explain much of the enduring longevity of racism, patriarchy, caste and religious disadvantage, even after their formative institutions are abolished. </p>
<p>Such institutions of inferiority-cum-superiority have no internal dialectic of change. Change comes exogenously, from the outside, from contingent cracks of the pillars sustaining the institutions. </p>
<p>Sub-institutional change, of everyday existential inequality, will require broader social and cultural <a href="https://stias.ac.za/2015/08/goran-therborn-singles-out-health-and-education-as-key-long-term-solutions-to-inequality/">transformations</a>. It will require equalising processes of self and capability formation. The current hardening of nationalism in power – the existing nation-states nationalism – and fundamentalist religious revival tend rather in the opposite direction.</p>
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<p><em>This article is part of a <a href="https://theconversation.com/africa/search?utf8=%E2%9C%93&q=RaceSeries&sort=relevancy&language=en&date=all&date_from=&date_to=">series</a> of six. Other authors include Nina Jablonski, Barney Pityana, George Chaplin, Kira Erwin, Kathryn Pillay and Njabulo Ndebele.</em> </p>
<p><em>The three edited volumes of essays published by African Sun Media in 2018 (<a href="https://stias.ac.za/ideas/publications/volume-11-the-effects-of-race/">The Effects of Race</a>, edited by Nina G. Jablonski and Gerhard Maré), 2019 (<a href="https://stias.ac.za/ideas/publications/stias-series-volume-13-race-in-education/">Race in Education</a>, edited by Gerhard Maré), and 2020 (<a href="https://stias.ac.za/ideas/publications/stias-series-volume-15-persistence-of-race/">Persistence of Race</a>, edited by Nina G. Jablonski) contain the complete representation of the project’s scholarship.</em></p><img src="https://counter.theconversation.com/content/137296/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Göran Therborn does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>A leading sociologist explains how different dimensions of humanity produce different kinds of inequality - and what that does to the least equal in society.Göran Therborn, Professor emeritus of Sociology, University of CambridgeLicensed as Creative Commons – attribution, no derivatives.