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Summary

Developmental outcomes and pathways

The current and generally accepted model of development views children's development as the result of the ongoing interaction and transactions between the children and the environment they grow up in. Those interactions have effects on both the child and the environment, and include transactions between the child's family, the neighbourhood and the wider community. All are variously affected as well by the policies and the structures of the government and the broader society in which they exist (Bronfenbrenner 1979; Shonkoff and Phillips 2000).

Throughout their development, children follow various pathways to particular physical, social, emotional and cognitive developmental outcomes. There is no single straight pathway from early to later development but a number of ‘straight and devious’ pathways to various developmental outcomes (Robins and Rutter 1990). Children may reach the same outcome or 'point’ in different areas of development by a number of different pathways, but the research evidence suggests that certain adverse outcomes in adolescence and adulthood such as criminal behaviour and substance abuse are continuations of anti-social behaviour and mental health problems in childhood (Farrington 1994; Nagin and Tremblay 1999; National Crime Prevention 1999; Robins and Rutter 1990; Werner 1987).

At various points along the pathway, there are a number of points of change or transitions which involve major re-orientations in how a child relates to his or her environment (Shonkoff and Phillips, 2000). These are important because they tend to be periods when individuals and/or others around them are looking for information and are likely to be more open to some assistance or intervention. Transitions may occur as particular aspects of the child's development (for example, when children are acquiring language or trying to increase their independence from their parents, either as toddlers or as adolescents) and they may also be a result of changes imposed by the child's environment or stage of life. Such life-stage transitions include entering child-care or school, changing from primary to secondary school, and getting a job and leaving home. In addition, certain life events such as moving to a new area, changing schools, and changes in family structure as a result of divorce, the birth of a sibling or the death of a family member also bring with them changes in various aspects of a child's life.

Summary

Introduction

The healthy cities movement is not new; it began in the late 19th century in response to industrial city slums. The problems of polluted water, filthy streets and fetid air, together with the lack of any natural parkland gave rise to modern town planning. The role of health professionals in this movement was very significant. This chapter will gather some perspective from the history of settlements before showing how we are facing a set of issues just as critical as those that faced the first industrial cities. It will try to show what those problems are and how some settlements are facing them. The role of health professionals in gaining acceptance of the required integrative approach will be stressed, as will the need for a sense of hope in these debates.

The physical environment of our cities presents a range of problems that concern health professionals: indoor air pollution, toxic chemicals in the workplace, industrial pollution, toxic site remediation, and so on. The focus of this chapter is on the physical environment as it relates to the transport and land use issues associated with the automobile. As with all physical environmental issues, we must consider their social and economic context.

Healthy cities in history

The health profession was a major factor in changing the nature of cities in the 19th century. The rapid growth of industrial cities meant that often, simple needs like separating water from waste (well known in every indigenous culture) were unmet. John Snow's ‘discovery’ that a sewage-contaminated well was causing cholera in London was said to have led to a burst of public health awareness in the late 1840s. Sewers were built, and public health approaches were adopted from that period but these improvements were outpaced by the growth of the cities and their polluting industries.

By the 1890s, the worst depression ever known had led to terrible poverty and crime throughout industrial cities. The air was full of the smoke and smells of the ‘dark satanic mills'. People crowded into tenements, and all the services were overwhelmed. Garbage filled the streets, and epidemics raged through the slums.

The social, economic and environmental problems of the cities dominated political and academic agendas. In response, the resulting ‘hygiene’ movement spread through the developed world's cities.

Summary

Introduction

In the 1970s, I spent two years travelling overseas - through Africa, Western and Eastern Europe, the Soviet Union and Asia. The most difficult cultural adjustment I had to make was on my return to Australia. My initial celebration of the material abundance and comfort of the Western way of life soon gave way to a growing apprehension about its emotional harshness and spiritual desiccation. In a way I hadn't anticipated, the experience allowed me to view my native culture from the outside, and in ways I hadn't appreciated before, I realised ours was a tough culture.

In his book, Biology and the Riddle of Life, the biologist Charles Birch says science inevitably leads to mechanical analyses. Is there nothing more to be said, he asks:

I think there is. It is to propose that there are two points of view - the inside and the outside, the subjective and the objective, from within and from without… There is an enormous gap between what science describes and what we experience … (T)he solution to the riddle of life is only possible through the proper connection of the outer with the inner experience (1999, p 58, italics in original).

This chapter is concerned with this connection as it relates to the social determinants of health, and as it is expressed in the relationships between cultural and socio-economic factors. 'Culture’ is a difficult concept because it is defined and used differently between different disciplines, and even within the same discipline. Culture can be taken to include all aspects of society, to describe an entire way of life of a people. However, it is often distinguished from social structure, with a key research goal being a better understanding of how the two interact (Swidler 1986). Larazus (1991, pp 349-83), in his study of emotion and adaptation, distinguishes between ‘culture’ and ‘social structure’ in this way: ‘culture’ provides a set of internalised meanings that we carry into our interactions with the social and physical environment; 'social structure’ refers to the detailed patterns of social relationships and transactions among people with different roles and status within a social system.

However, Hays (1994) challenges the separation of culture and social structure. Culture, she argues, is a social structure, both internal and external, subjective and objective, ideal and material.

Summary

Aboriginal health and social disadvantage

In Aboriginal health it is generally assumed that the determinants of mortality and morbidity are complex and multidimensional. The parameters of Aboriginal health disadvantage have been well documented. For example, Aboriginal and Torres Strait Islander life expectancy at birth for the period 1991-6 was estimated to be 56.9 years for males and 61.7 years for females. Life expectancy for nonAboriginal people during the same period was 75.2 years for males and 81.1 years for females. (AIHW 1999, p 134). Death rates, according to available data, are elevated in all age groups of Aboriginal and Torres Strait Islanders relative to nonAboriginal Australians (AIHW 1999, p 131). Aboriginal disadvantage is also well documented with respect to a range of other social indicators. For instance, according to the 1996 census:

Summary

Introduction

The health status and life opportunities of those in poorer communities are less than those elsewhere (Australian Institute of Health and Welfare 1998). Responding to this situation is internationally recognised as requiring a multifaceted national as well as community approach that includes both social and economic initiatives (World Health Organization 1986a). This chapter explores the potential for social capital to provide a framework for developing communities in such a way that the health and life opportunities of poorer communities are improved.

We address the relationship between social capital and the health and life opportunities of people in communities. This includes not only the individual health of those in communities, as often measured by mortality, morbidity, and quality of life instruments, but also the idea that there are ‘healthy communities’ in and of themselves - communities in which there is a good stock of social capital and other forms of resource. ‘Life opportunities’ refers to the equality of opportunity that comes about through the local availability of many types of resources - for example, access to local childcare to encourage early child development that is so important to later achievements at school and beyond. Indeed, where access to and availability of social, economic and cultural resources are limited, so the life opportunities are also limited and this eventually becomes reflected in health statistics.

The breadth of views about social capital necessitates a brief investigation of its historical origins and the way different disciplines have conceptualised the links to health and life opportunities. We begin with the theoretical underpinnings, address some of the key empirical findings and them describe the Adelaide study of health development and social capital. This is a study that pays attention to levels and types of local participation in community life, the role of organisations and groups in the generation of social capital in communities, and the predictive value of social capital on health status.

Historical and theoretical underpinnings

The 1960s saw the adoption of ideas about social capital as the source for social action in a range of community studies.

Summary

Why publish yet another book about the social determinants of health? This was the initial reaction of a reader to whom Cambridge University Press sent our book proposal. The response is unsurprising. The past decade has seen the publication of some 15 books, major reports or special journal issues dealing with the social determinants of health. The number of individual journal articles has soared.

Can there really be a need for another overview of the subject? Cambridge's reader went on to say the initial scepticism was immediately dispelled by the originality of the material and the arguments put forward by the individual contributors: ‘I am persuaded that this book will make a substantial, and novel, contribution to the literature, both in Australasia as well as internationally.'

We are also confident of the value of this book—for two main reasons. First, the existing literature has focused on the North American and European situations; we want to put the Antipodes on the social epidemiological map. Secondly, the recent literature has concentrated on socio-economic inequality as a prime determinant of health; we believe this book adds important historical, global and cultural dimensions to the social sources of health and well-being.

The book has its origins in the establishment of the Health Inequalities Research Collaboration by the Australian Commonwealth Department of Health and Aged Care to promote a better understanding of why some groups in the community are healthier than others. One of the early tasks of the Collaboration was to organise a major conference, held in Canberra in July 2000. Its aim was to build scientific, public and policy recognition of the importance of the social determinants of health. New Zealand participants and perspectives were included because research and policy development in this area are more advanced there than in Australia.

From the conference came the book. It brings together leading scholars from both countries to establish a baseline of what we know and what we need to do. There are, inevitably, omissions. Between conference and book, a few contributions fell by the wayside. But other perspectives were added, particularly on the implications for policy, intervention and research.

Summary

Our virtues? – We probably still have our virtues too, although of course they will not be those trusting and muscular virtues for which we hold our grandfathers in honor – but also slightly at arm's length. We Europeans from the day after tomorrow, we firstborn of the twentieth century, – with all of our dangerous curiosity, our diversity and art of disguises, our worn-out and, as it were, saccharine cruelty in sense and in spirit, – if we happen to have virtues, they will presumably only be the ones that have learned best how to get along with our most secret and heartfelt propensities, with our most fervent desires. So let us look for them in our labyrinths! where, as we know, so many things lose their way, so many things get entirely lost. And is there anything more beautiful than looking for your own virtues? Doesn't this almost mean: believing in your own virtue? But this “believing in your own virtue” – isn't this basically what people used to call their “good conscience,” that venerable, long-haired pigtail of a concept that hung on the back of our grandfathers' heads, and often enough behind their intellects too? And so it seems that however up-to-date and unworthy of grandfatherly honor we might otherwise appear, there is nevertheless one respect in which we are the worthy grandchildren of these grandfathers, we last Europeans with a good conscience: we still wear their pigtail.

Summary

Suppose that truth is a woman – and why not? Aren't there reasons for suspecting that all philosophers, to the extent that they have been dogmatists, have not really understood women? That the grotesque seriousness of their approach towards the truth and the clumsy advances they have made so far are unsuitable ways of pressing their suit with a woman? What is certain is that she has spurned them – leaving dogmatism of all types standing sad and discouraged. If it is even left standing! Because there are those who make fun of dogmatism, claiming that it has fallen over, that it is lying flat on its face, or more, that dogmatism is in its last gasps. But seriously, there are good reasons for hoping that all dogmatizing in philosophy was just noble (though childish) ambling and preambling, however solemn, settled and decisive it might have seemed. And perhaps the time is very near when we will realize again and again just what actually served as the cornerstone of those sublime and unconditional philosophical edifices that the dogmatists used to build – some piece of folk superstition from time immemorial (like the soul-superstition that still causes trouble as the superstition of the subject or I), some word-play perhaps, a seduction of grammar or an over-eager generalization from facts that are really very local, very personal, very human-all-too-human.

Summary

O sancta simplicitas! What a strange simplification and falsification people live in! The wonders never cease, for those who devote their eyes to such wondering. How we have made everything around us so bright and easy and free and simple! How we have given our senses a carte blanche for everything superficial, given our thoughts a divine craving for high-spirited leaps and false inferences! – How we have known from the start to hold on to our ignorance in order to enjoy a barely comprehensible freedom, thoughtlessness, recklessness, bravery, and joy in life; to delight in life itself! And, until now, science could arise only on this solidified, granite foundation of ignorance, the will to know rising up on the foundation of a much more powerful will, the will to not know, to uncertainty, to untruth! Not as its opposite, but rather – as its refinement! Even when language, here as elsewhere, cannot get over its crassness and keeps talking about opposites where there are only degrees and multiple, subtle shades of gradation; even when the ingrained tartuffery of morals (which is now part of our “flesh and blood,” and cannot be overcome) twists the words in our mouths (we who should know better); now and then we still realize what is happening, and laugh about how it is precisely the best science that will best know how to keep us in this simplified, utterly artificial, well-invented, well-falsified world, how unwillingly willing science loves error because, being alive, – it loves life!

Summary

In Europe these days, moral sentiment is just as refined, late, multiple, sensitive, and subtle as the “science of morals” (which belongs with it) is young, neophyte, clumsy, and crude: – an attractive contrast, and one that occasionally becomes visible, embodied in the person of the moralist himself. Considering what it signifies, the very phrase “science of morals” is much too arrogant and offends good taste, which always tends to prefer more modest terms. We should admit to ourselves with all due severity exactly what will be necessary for a long time to come and what is provisionally correct, namely: collecting material, formulating concepts, and putting into order the tremendous realm of tender value feelings and value distinctions that live, grow, reproduce, and are destroyed, – and, perhaps, attempting to illustrate the recurring and more frequent shapes of this living crystallization, – all of which would be a preparation for a typology of morals. Of course, people have not generally been this modest. Philosophers have all demanded (with ridiculously stubborn seriousness) something much more exalted, ambitious, and solemn as soon as they took up morality as a science: they wanted morality to be grounded, – and every philosopher so far has thought that he has provided a ground for morality. Morality itself, however, was thought to be “given.” What a distance between this sort of crass pride and that supposedly modest little descriptive project, left in rot and ruin, even though the subtlest hands and senses could hardly be subtle enough for it.

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15 - Family, early development and the life course: common risk and protective factors in pathways to prevention

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11 - Human settlements: health and the physical environment

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4 - Culture, health and well-being

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Part D - Developmental and biological perspectives

Part E - Implications for policy, interventions and health research

List of figures and tables

Frontmatter

Index

18 - Aboriginal health, policy and modelling in social epidemiology

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13 - Health, inequities, community and social capital

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Bibliography

Preface

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Part B - Explaining health inequalities

Acknowledgements

Part 7 - Our virtues

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Preface

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Part 2 - The free spirit

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Part 5 - On the natural history of morals

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Index

Beyond Good and Evil

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