Response to John Lynch

1
Response to John Lynch

• Fran Baum
• Public Health
• Flinders University

2
What has Johns presentation shown us

• Persistent pattern of health inequalities shown
  in disease outcomes, behavioural risk factors,
  and related to place
• Addictive behaviours also generally related to
  socio-economic risk factors
• Distinction between equality (sameness) and
  equity (fairness) and implication for policy
• Raised questions about social processes and
  understanding how these contribute to health

3
Issues to examine in more detail

• Need to consider social theory in imaginative way
  
• Considering explanations at different levels
  (especially population versus individual)
• Globalisation/socialcapital debates and how they
  might be related to addiction
• Limitations of survey research in understanding
  why inequalities exist

4
More imaginative social theoretical debates

• Agency/structure debate the on-going issue of
  sociology
• Why do rates of addiction differ between groups
  and then between countries?
• Matters because can determine responses e.g.
  clinical versus population

5
Island of misery or Tip of iceberg

• Developed by Richard Eckersley in relation to
  youth suicide
• Argued that tip of iceberg theory makes most
  sense in relation to youth suicide because rising
  rates of suicide reflect general despair among
  young people

See Eckersley, R (2004) Well Good, Melbourne
Text Publishing
6
Island of Misery Theory

• Problem behaviours (suicide, gambling, smoking,
  illicit drugs, alcoholism) are symptoms of sick
  individuals
• High risk people should be the target of
  intervention because they are deviant in terms of
  the rest of the population

7
Tip of the Iceberg

• The extreme problem behaviour is just the worse
  expression of wider social problem so in terms of
  addiction heavy smokers, persistent gamblers and
  heavy drinkers are just one expression of wider
  population problem
• Need to tackle whole population expression of
  problem
• Compatible with public health approach

8
Geoffrey Rose

• Continuum of disease or disorder not binary (an
  individual has them or they dont)
• Relationship between the mean of a characteristic
  in a population and the prevalence of deviance
• The visible part of the iceberg (prevalence) is
  a function of its total mass (the population
  average)
• So population change is important

9
Whats the logic of population change rather than
high risk individuals?

• More effective in terms of outcomes across the
  population because of the prevention paradox.

10
Prevention Paradox

• Treating diseased or high risk individuals does
  not have much impact on the population as a
  whole. But changing a risk factor across a whole
  population by just a small (and often clinically
  in significant amount) can have a large impact on
  the incidence of a disease or problem in the
  community
• Rose, Geoffrey (1992) The Strategy of Preventive
  Medicine, Oxford

11
Examples

• So if we can change the overall consumption of
  alcohol by a relative small amount this will have
  more impact on population health than dealing
  with a few people with serious alcohol problems
• It is more effective to reduce overall smoking
  prevalence a little than stop a few heavy smokers

12

• a preventive measure which brings much benefit
  to the population offers little to each
  participating individual
• Rose (1985) Sick individuals and sick
  populations, IJE, 14,1, p. 38.

13
Social Theory Explanations at different levels

• Agency structure upstream/downstream
• Again why does this theory matter?
• Helps define what we understand as inequities
• Affects the extent of victim blaming

14

• Agency (ability for people to take action)
• Practices (activities that make and transform our
  world)
• Social Structures (the rules and resources in
  society)
• Lets consider just one of current debates about
  structures .

15
Globalisation/declining social capital debates
and how they might be related to addiction

• Free market capitalism
• Dislocation (a la Alexander, 2001)
• Substitute lifestyles that involve addiction
• Ignoring the broader structures will led to band
  aid solutions

16
Declining social relations - weaker communities

• Extent and quality
• Less trust (especially in institutions)
• More anomie
• Less community and communal activities
• Rate of change
• Invisible forces that are hard to monitor and
  track and attribute change to
• But need to always bear in mind broader social
  climate

17
Limitations of survey research

• Survey have become the basis of most social
  epidemiology
• Make many assumptions about robustness of the
  method
• Ticks in boxes may not be very accurate
• We assume a robustness/standardisation across
  groups that may not be there
• Bias of non-response important when considering
  social exclusion/class

18
Limitations of survey research

• Simplification of complex social phenomenon
  especially behaviours and attitudes
• De- contextualise information and assume one
  experience is same in all contexts

19
Broaden the epidemiological canvas

• Sociology, anthropology, political science etc
• Not well-supported by NHMRC little social
  science representation on Council, RC or Grant
  Assessment Panels
• Still suspect methodology in the medical sciences

20
What could a broader methodological canvas offer
understanding of addictions and inequalities?

• Social structures how the rules of society
  support addictions and direct resources at
  addictive behaviour
• Practices what impact the activities of various
  actors (Corporations, law enforcement, pubs etc)
  have on addictive behaviour
• Agency WHY individuals make the decisions they do

21
Examples Gambling research New Focus Research

• Catherine Palmer - Anthropologist
• The study investigated and evaluated the
  effectiveness of services in Victoria for problem
  gamblers, to determine the most appropriate types
  of services and interventions provided by problem
  gambling services, and to identify gaps in
  existing services.
• Focus groups and telephone interviews

22
Impact of gambling

• poor work/study performance
• debts/bankruptcy
• loss of housing, poorer nutrition (of individual
  and of loved ones, especially children)
• health-related problems (especially stress and
  anxiety-related problems) for both the gambler
  and their loved ones
• high rates of divorce/separation (reflecting the
  impact of gambling on personal relationships and
  families)
• suicide ideation

23
Why gamble? Grief Loss

• For me, it was when a girl I was going to marry
  got pregnant to my mate. I got into drugs and
  other things then, so the gambling was just one
  of many things, but it was the thing that got me
  

24
Why Gamble? Stress Relief

• The reason I started is a bit to do with the
  fact that Im an idiot! I was uncertain about my
  employmentthings werent going so well, I was
  wondering whether I would have a job
• I work in Welfare, in Child Protection, I had a
  bad case when a child was murdered. I used to go
  just to clear my head. Because Im single, I had
  no one to come home to talk to. It was a
  debriefing I could have done without

25
Why Gamble? Loneliness

• I am a pensioner and I live alone. I started
  going with a friend and playing Kenothen I found
  the pokies

26
Social Environment of Gambling

• Places of safety and security
• Glamorous he attraction is that people get
  blown away by it, by the glamour
• Out of reality feeling problem its dark
  outside and inside everything is oneyou become
  obsessed by the machine.

27
Social Environment of Gambling

• Part of community The problem is that lots of
  parties and leaving dos are held at the pub. We
  need to go somewhere where there is no
  temptation. I went to a wedding recently. Thirty
  per cent of the guests would be sneaking out
  every 20 minutes to play the pokies and have a
  smoke
• Time stands still You do get carried away and
  lose track of time Five minutes turns
  into one hour, even though they have clocks and
  everything

28
Gambling Alone Communities Without Interaction

• curious contradiction between sociality and
  social isolation
• theres coffee and biscuits, its a group place
  but you dont have to talk to anybody.
• I only go for the companyits not the people at
  the venue, its the machines that
• are my company

29
Commodity Fetishism machines as lovers and best
friends

• mesmerising, seductive experience visiting my
  best friend
• I used to dream about them, I used to smell them
  in my dreams
• You just fall in love with them. They can give a
  feeling that nothing else can give you. It fills
  a gap in your lifejust the thrill of seeing it
  spin. I could go and sit all day and just play
  three lines.

30
Seeing the good in addiction

• Smoking in social context having a fag gives
  structure to day and one of few ways of having
  break from kids and release from stress (Graham,
  1987) Interaction between addictive behaviour and
  dislocation and land loss with Aboriginal
  peoples(in Alexanders terms severe dislocation)

31
Seeing the good in addiction

• Engels (Reynolds, 1989) observed that liquor was
  almost their only source of pleasure for workers
  in industrial towns and that the working man
  comes home from his work tired, exhausted, finds
  his home comfortless, damp, dirty, repulsive he
  has an urgent need of recreation, he must have
  something to make work worth his trouble, to make
  the prospect of the next day endurable.

32
More research?

• Social/work settings
• Historical experiences
• Life experiences
• Practices of agencies that profit from addiction
• Addiction society???
• Is it disrupted societies where rates of
  addiction are high?

33
Finally, is more data what we need or more
understanding?

• Consider the differences in health status between
  rich countries and poor countries

34
International comparison of health indicators
(1999)
35
Economic roots

• About half the worlds population, 3 billion
  people, live on less than US2 a day and of those
  about 1 billion live in extreme poverty of below
  US1 a day. (UNDP, 198)
• (UNDP, 1998)

36
Yet what action over the past 20 years to change
these inequities? None Situation is getting
worse
37
So will more data solve health inequities?

• Inequities are tackled when there is a political
  and social will to do so
• Szreter points to progressive era in US, post-2WW
  in UK and we might say Whitlam Government in
  Australia, Playford and Dunstan in SA
• Need studies of political processes to understand
  this