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SOCIETAL FACTORS AND HEALTH

by Dr PHUA Kai Lit
School of Medicine and Health Sciences
Monash University Sunway Campus
Bandar Sunway, Malaysia


SOCIAL EPIDEMIOLOGY

The distribution of disabilities and disease is NOT random
Different social groups have different risks for different diseases.
Even the distribution of so-called road traffic "accidents" is not random!

Unequal Distribution by Ethnicity: In all countries in the world, minority ethnic groups tend to have worse health than majority ethnic groups. In Malaysia, the Orang Asli are the worst off - they have higher infant mortality rates, higher maternal mortality rates, more malnutrition, more preventable diseases and shorter life expectancy (i.e. they die earlier). In Australia, the same holds true for the Aborigines when compared to the white population. In New Zealand, the Maori are worse off compared to the white majority. As for India, the worst off are the Dalit (untouchables) and aboriginal groups.

Unequal Distribution by Social Class: Social class is measured by a person's annual income or occupation. The general relationship is that the lower the social class, the lower the health status. This finding is consistent in country after country in the world. Lower class people in Malaysia include urban squatters, poor peasants in the countryside and illegal immigrants.

Differences by Gender: On the average, woomen tend to live longer than men. In Malaysia in 1996, the life expectancy of women is 73 years while that of men is 68.7 years.
Disease patterns also differ by gender - men have higher rates of lung cancer, road traffic accidents, liver cirrhosis, drug addiction. They also suffer from higher rates of sex-linked conditions e.g. colour blindness.
Women have higher rates of breast cancer and are more likely to be the victims of domestic violence and sexual assault. In China and India, sex-selective abortion of female fetuses is occurring.

Dr Wong Yut Lin on women and medical education

Women and Health

Inequalities by Region: Generally, people in rural areas have lower health status than urban people. Also, low income countries have poorer health indicators than high income countries. BUT, certain lower income countries or regions such as Cuba and the Indian state of Kerala have good health indicators although these societies remain relatively poor.

UNICEF: The State of the World's Children

BASIC HEALTH INDICATORS

Infant Mortality Rate: Deaths of infants under age 1 per 1,000 live births.
IMR of very poor countries can be as high as 200 per 1,000 live births. Malaysian IMR is about 8 per 1,000 live births.

Maternal Mortality Rate: Maternal deaths per 100,000 births

Life Expectancy at Birth

UNEQUAL ACCESS TO HEALTH SERVICES

Barriers to equal access - financial, geographic, cultural

MULTIFACTORIAL CAUSATION OF DISEASE

You should think of disease as the outcome of many interacting factors. NOT just the result of exposure to bacteria, viruses and other pathogens alone.

EXAMPLE: DEATH FROM CHOLERA

Poverty ---> poor diet, slum housing (no piped water and lack of proper toilets)
Poor diet ---> malnutrition and lowered resistance to disease
No piped water/bad toilets ---> water supply from wells or river is contaminated
Lack of education ---> drinking of unboiled, contaminated water during a cholera epidemic
Lack of access to healthcare ---> no treatment or delay in treatment (e.g. with ORT or Oral Rehydration Therapy)
Result: death from cholera

DISEASES ASSOCIATED WITH POVERTY

Protein-energy malnutrition
Deficiency diseases e.g. iron-deficiency anaemia, vitamin A deficiency and nightblindness
Water-borne diseases e.g. diarrhoeal diseases
Helminthic infections e.g. ascariasis & other worm infections
Other countries - Guinea worm, schistosomiasis

DISEASES ASSOCIATED WITH RISING NATIONAL INCOME

Cardiovascular diseases (CVDs) e.g. coronary heart disease
Stroke
Diabetes
Breast cancer (?)
Industralisation - industrial accidents, occupational diseases

DISEASES LINKED TO INDIVIDUAL BEHAVIOUR

Lung cancer - tobacco use
Liver cirrhosis - alcohol abuse
Road accidents - dangerous driving, drunk driving
STDs - visiting prostitutes, sexual promiscuity
Drug overdose deaths - drug abuse
Parasuicides and suicides - self-inflicted injuries and deaths

SOCIETAL FACTORS IN SPREAD OF HIV/AIDS IN MALAYSIA

Lack of sex education in schools
Lack of promotion of condom use
Significant drug abuse problem
Lack of knowledge of how to sterilize needles among drug addicts
Sex tourism to neighbouring countries

Other countries:
Poverty and female prostitution
Loose sexual norms e.g. acceptable for males to visit prostitutes in Thailand
Male migrant workers
Truck drivers
Governments deny that a serious problem exists

Reasons for severity of HIV/AIDS epidemic in Africa (I)

Reasons for severity of HIV/AIDS epidemic in Africa (II)

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