Health and Social Change
How does South Africa, Russia and 19th Century Sweden compare?
Points of departure …
• Transitions that are fundamental and rapid have immediate,
profound effects on health.
• Changes in the labour market, social structure and social
security systems put a heavy burden on people’s occupational
flexibility, social adaptability, and ability to find economic
safety for themselves and their families.
• In times of rapid change, old rules, norms, and institutions
no longer function as efficiently as they did before.
• If social and geographical mobility increases, some people
benefit while others lose out.
Health and Social Change
How does South Africa, Russia and 19th Century Sweden compare?
Points of departure …
• Welfare and health also depend on gender, age, and social
class.
• Cultural and gender factors within a particular epidemiological
setting often have different effects on the health of men and
women.
• The negative effects, even when change is positive in the long
run, can be summarized as “social stress”.
Health and Social Change
How does South Africa, Russia and 19th Century Sweden compare?
Points of departure …
• The impact of change is always filtered through formal and
informal institutions.
• “Social capital” is one factor that determines who will become
winners and losers.
• Public institutions can distribute and redistribute material
resources, welfare, and social capital
• Informal institutions - such as voluntary associations, social
networks in the workplace or among neighbours, the family,
and other primary groups - and the way civil society functions
can enhance social capital and are essential for social stability
and security.
Facts and trends 1
Factor
Political change
19th C. Sweden
Moderate
Russia
Yes
RSA
Yes
Economic & Social Change
Changes in production
Changes in agriculture
De-industrialization
Employment crisis
Pauperization
Increased inequality
Welfare provision crisis
Yes
Yes
No industrialisation
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Demographic Change
Population size
Migration to cities
Infant & child mortality
Adult female mortality
Adult male mortality
Family/household structure
Up
Yes
Down
Down
Up
Crisis
Stable->down?
Yes
Stable?
Slightly up
Up
Crisis
Stable->down?
Yes
Up
Up
Up
Crisis
Epidemilogical change
STD’s/HIV
Tuberculosis
Other infectious diseases
STD’s high
High
High>down
HIV up
Up?
Low>up?
HIV up
High>up
High>?
Facts and trends 2
Factor
19th C. Sweden
Russia
RSA
By gender
Yes
Yes
Yes?
By marital status
Yes
Yes
Yes?
By class/ethnicity/”race”
Yes
Yes
Yes
By region
Yes
Yes
Yes
Urban/rural
Yes
Yes
Yes
Uprooted societies
Yes
Yes
Yes
Norm crisis
Yes
Yes
Yes
Social losers`
Yes
Yes
Yes
Abuse of alcohol and drugs
Up
Up
Up
Violence
Up
Up
Up
Juvenile delinquency
Up
Up
Up
Other crimes
Up
Up
Up
Health differentials
Socio-cultural change
Health and Social Change
How does South Africa, Russia and 19th Century Sweden compare?
Fig 1. Social structure of the agricultural population. Sweden 1751
and 1850. Number of male heads of household.
250000
peasants
200000
landless
150000
100000
50000
0
1751
1850
Health and Social Change
SoDS: Population and health III
How does South Africa, Russia and 19th Century Sweden compare?
Sweden early 19th century
Cities
* In-migration
* Pauperisation
* High average age of marriage among the poor
• High illegitimacy rate
* High male mortality
* Uprootedness
* Class divisions
* Social conflict
* Old rules do not work
* Drunkenness among men
* Crime increases violence and theft
Health and Social Change
How does South Africa, Russia and 19th Century Sweden compare?
Why infant and child mortality down?
* Functioning local communities
*
*
*
*
*
*
*
Breast feeding campaigns
Better child care
Smallpox vaccination
Small - important hygienic measures in cities
Synergy effects increases resistance
Trained midwives – lower maternal mortality
Healthy children means healthier adults
Health and Social Change
How does South Africa, Russia and 19th Century Sweden compare?
SoDS:
Population and health III
19th c. Sweden
Female adult mortality declines, male adult mortality reacts negatively
40
150
50-54 years
35
30
140
25
20
130
15
10
male
120
female
5
0
ratio
110
1750 1760 1770 1780 1790 1800 1810 1820 1830 1840 1850 1860 1870 1880 1890 1900
Health and Social Change
How does South Africa, Russia and 19th Century Sweden compare?
SoDS: Population and health III
19th c. Sweden
Female adult mortality declines,
male adult mortality reacts
negatively
F ig 3 b . S e x d if f e r e n c e s f o r s e le c t e d c a u s e s o f d e a t h ,
2 5 -4 9 y e a rs o f a g e . S w e d e n 1 7 7 6 -8 0 a n d 1 8 2 6 -3 0
2
1 7 7 6 -8 0
1 ,5
1 8 2 6 -3 0
1
difference per 1.000
•
0 ,5
0
- 0 ,5
-1
- 1 ,5
-2
tu b e r c .
i n fe c t.
s tr o k e
e x te r n a l
m a te r n a l
o th e r
Health and Social Change
How does South Africa, Russia and 19th Century Sweden compare?
SoDS:
Population and health III
•
•
19th c. Sweden
Alcohol – the painkiller
Men’s gender roles make
them vulnerable
Fig 4. Acute alcohol intoxication (deaths or autopsies) per 1,000000
1804-1870.
25
20
15
10
5
deaths
autopsies
0
1800
1810
1820
1830
1840
1850
1860
1870
Health and social Change – Sweden c. 1800-1850.
PLAGUE
EC = economic capital
CC = cultural capital
SC= social capital
HEALTH
EC
CC
SC
K
UNSTABLE
HOUSEHOLD
S
AGRICULTURAL
AGRICULTURAL
CHANGE
CHANGE
UNEMPLOYMENT
POVERTY
UPROOTED
CITIZENS
MIGRATION
MIGRATION
DEMOGRAPHIC
DEMOGRAPHIC
GROWTHAMONG
AMONG
GROWTH
CHILDREN
CHILDREN
ANDWOMEN
WOMEN
AND
ALCOHOL
VIOLENCE
THEFTS
Long
Longterm
termtrends
trendsin
inlife
lifeexpectancy
expectancyat
atbirth
birthsince
since1890:
1890:
France,
France,Japan,
Japan,Russia
Russiaand
andthe
theUSA.
USA.
90
90
FEMALES
80
80
70
70
60
Russia
USA
Japan
France
50
Life expectancy at birth in years
Life expectancy at birth in years
M ALES
60
Russia
USA
Japan
France
50
40
40
30
30
20
1890 1900 1910 1920 1930 1940 1950 1960 1970 1980 1990 2000
20
1890 1900 1910 1920 1930 1940 1950 1960 1970 1980 1990 2000
Ye ar
Ye ar
Historical gap, its reduction in the 1950s and the new health crisis in 1965-2000
85
85
80
80
Life expectancy in years
Life expectancy in years
HSC – Week 3
Russia 1970 - 2000
75
70
65
75
70
65
60
60
55
1970
55
1970
1980
1990
2000
Year
UK
Hungary
Estonia
Russia
1980
1990
2000
Year
Poland
UK
Hungary
Estonia
Russia
Poland
Variation in the life expectancy decrease for men across regions of
European Russia
Walberg et al., 1998
Associations with the pace of economic reform, psychosocial
stress, and social cohesion are detected.
Russia
Male surplus mortality by age
2,0
Males, total difference = 14.6 years
Contribution in years
1,5
External
Ill-defined
Other
1,0
Digestive
Respiratory
0,5
Circulatory
Neoplasms
Infectious
0,0
-0,5
0
1
5
10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85
Age
Russia
Female surplus mortality by age
2,0
Females, total difference = 7.0 years
Contribution in years
1,5
External
Ill-defined
Other
1,0
Digestive
Respiratory
0,5
Circulatory
Neoplasms
Infectious
0,0
-0,5
0
1
5
10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85
Age
(ASDR(lower,cause)-ASDR(higher,cause))/ASDR(lower,total)
O TH E R
D IG E S T IV E
0 .5
IN J U R IE S A N D V IO L E N C E
0 .4
0 .3
R E S P IR A T O R Y
C IR C U L A T O R Y
0 .2
0 .1
NE O P LA S M S
IN F E C T IO U S
65
60
55
50
45
40
35
30
25
20
0
AGE
F E M A L E S
0.6
D IG E S T IV E
O TH E R
0.5
0.4
R E S P IR A T O R Y
IN J U R IE S A N D V IO L E N C E
0.3
0.2
C IR C U L A T O R Y
0.1
NE O P LA S M S
IN F E C T IO U S
AGE
65
60
55
50
45
40
35
30
25
0
20
Clear similarity with the
Russia-West gap for total
populations
M A L E S
0 .6
(ASDR(lower,cause)-ASDR(higher,cause))/ASDR(lower,total)
Russia
Russia
Proportional
Proportional
differences
differencesin
in
age
agespecific
specific
death
deathrates
rates
between
betweenthe
the
lower*
lower*and
andthe
the
upper
upper
educational
educational
groups
groupsby
by
cause
causeof
ofdeath,
death,
1989
1989
Shkolnikov et al, 1998
Russia 1965 - 2000
A
ge-standardisedrateper100,000
600
16
Alcohol
consumpt ion
15
14
300
13
Mortal ity rate
12
11
0
1965
10
1970
1975
1980
1985
1990
1995
A
ge-standardisedrateper 100,000
“Coronary heart disease” and acute alcohol
poisoning mortality in Russia
450
400
350
140
120
Men aged 30-59
100
300
“CHD”
250
80
200
60
150
40
100
Acute alcohol pois on in g
50
0
20
0
1965
1970
1975
1980
1985
1990
1995
Percapitaconsum
ptionlitrespurealcohol/year
Injuries, poisoning and violence mortality
(excluding acute alcohol poisoning)
Men aged 30-59
South Africa
Age standardised death rates (per 1 000)
by province – year 2000 estimate
The legacy of apartheid and HIV/AIDS
M
Index
F
Index
Rank
KwaZulu Natal
20.51
141
15.49
165
(1)
Mpumalanga
20.02
14.76
(2)
Free State
18.56
13.34
(3)
North West
18.28
13.08
(4)
Eastern Cape
17.90
12.83
(5)
Limpopo
17.84
12.68
(6)
Gauteng
17.03
11.94
(7)
Northern Cape
15.84
10.82
(8)
Western Cape
14.45
100
9.46
100
National
1831
127
1303
125
Factors: Urban/rural; Poor/”rich”
(9)
South Africa – Estimated age-specific
male and female mortality 1985-2000
0.012
0.01
RATE
HIV, external causes
CHD, obesity
The unfinished
Epid. revolution
+ the new diseases
Female mortality
0.008
1985
0.006
1995
0.004
1999/00
0.002
Male
mortality
0.025
0
15- 20- 25- 30- 35- 40- 45- 5019 24 29 34 39 44 49 54
0.02
RATE
AGE
1985
0.015
1995
0.01
1999/00
0.005
0
15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54
AGE
South Africa – external causes of death
8000
7000
6000
5000
4000
3000
2000
1000
0
Homicide
Suicide
Male (n=13556)
Accident
Female (n=301
1600
1400
1200
1000
800
600
400
H o m ic id e ( n = 6 9 6 3 )
S u ic id e ( n = 1 4 3 0 )
65
+
55
-5
9
45
-4
9
35
-3
9
25
-2
9
15
-1
9
5_
9
<1
200
0
A c c id e n t ( n = 5 2 1 9 )
0
Metropole
Tygerberg West
Tygerberg East
South Peninsula
Oostenberg
Nyanga
Mitchells Plain
Khayelitsha
Helderberg
Central
Blaauwberg
Athlone
South Africa
Non-communicable age standardised deaths per 100 000 in 2001
Cape Town districts
1000
900
800
700
600
500
400
300
200
100
South Africa – Death profile
Khayelitsha, Cape Town
Top causes of death (%)
Men
Women
1. Homicide 27.7
1. HIV/AIDS 22.9
2. TB 13.5
2. TB 14.6
3. Traffic accidents 9.9
3. Lower respiratory 4.2
4. Lower respiratory 4.2
4. Hypertensive … 5.8
5. Hypertensive heart 3.1
5. Homicide 4.9
6. Fires 2.9
6. Diarrhoeal disease
7. Renal failure 2.2
7. Traffic accidents 3.1
8. Suicide & self-inflicted 2.0
8. Stroke 2.7
Sum 1-8:
65.6 %
61.7 %
3.5
Additional points (StatsSA, 2002)
b
b
b
b
b
Males aged 15-39 experienced the highest mortality caused by
unnatural causes
Females in the same age group died primarily as a result of HIV/AIDS
For young children, intestinal infections is still one of the leading
causes of death but declining over time
Influenza and pneumonia are other leading causes of death for
children
In SA, there is a unique racial topology of mortality.
• Black African and Coloured males - unspecified unnatural causes and
TB
• Indian and White males – ischaemic heart disease and unspecified
natural causes
• Black African females – HIV/AIDS
• Coloured females – Cerebrovascular diseases
• Indian and White females – ischaemic heart disease
Health, capital and social change: Russia - RSA
HIV
Political
change
EC = economic capital
CC = cultural capital
SC= social capital
HEALTH
GLOBALISATION
GLOBALISATION
EC
CC
ECONOMIC
ECONOMIC
CHANGE
CHANGE
SC
DE-INDUSTRIALISATION
REGRESSION
IN COUNTRYSIDE
UNEMPLOYMENT
POVERTY
WEAK HOUSEHOLDS
UPROOTED
CITIZENS
UNSTABLE
SOCIETIES
MIGRATION
MIGRATION
DRUG ABUSE
VIOLENCE
CRIME
Challenges of Change
Mending the weak society – weak
community model
PLAGUE
POLITICAL INSTITUTIONS
FRIENDS, NEIGHBOURS, KIN, ETC.
HOUSEHOLD AND FAMILY
WAR
INDIVIDUAL
HUNGER
What turn the tide in Sweden (Western Europe)
from c. 1870 onwards?
Should/could it be repeated?
Hygienism – cleaning cities
•The epidemiological revolution
• Stable work
• Stable family structures
• Industrial work discipline
• the role of local institutions
• Workers discipline themselves by:
• Voluntary associations
• Free churches
• Temperance movements
• Trade unions
• Political parties
• Democracy for men 1906
• and for women 1919 (!)
• Institutions for social safety
• I. e. tools for the people to interpret
and handle the new society
Towards the welfare society