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Health and Social ChangeHealth and Social ChangeHow doesHow does South Africa, Russia and 19th Century SwedenSouth Africa, Russia and 19th Century Sweden comparecompare??

PointsPoints of of departure 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.


Points Points of of departuredeparture ……

• Welfare and health also depend on gender, age, and social class.

• Cultural and gender factors within a particular epidemiologicalsetting 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”.


PointsPoints of of departure 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 19th C. Sweden Russia RSAPolitical change Moderate Yes Yes

Economic & Social ChangeChanges in production Yes Yes YesChanges in agriculture Yes Yes YesDe-industrialization No industrialisation Yes YesEmployment crisis Yes Yes YesPauperization Yes Yes YesIncreased inequality Yes Yes YesWelfare provision crisis Yes Yes Yes

Demographic ChangePopulation size Up Stable->down? Stable->down?Migration to cities Yes Yes YesInfant & child mortality Down Stable? UpAdult female mortality Down Slightly up UpAdult male mortality Up Up UpFamily/household structure Crisis Crisis Crisis

Epidemilogical changeSTD’s/HIV STD’s high HIV up HIV up

Tuberculosis High Up? High>upOther infectious diseases High>down Low>up? High>?

Facts and trends 2

Factor 19th C. Sweden Russia RSA

Health differentials

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

Socio-cultural change

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


Fig 1. Social structure of the agricultural population. Sweden 1751 and 1850. Number of male heads of household.

0

50000

100000

150000

200000

250000

1751 1850

peasants

landless

Sweden early 19th centuryCities* 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

SoDS: Population and health IIIHealth and Social ChangeHealth and Social ChangeHow doesHow does South Africa, Russia and 19th Century SwedenSouth Africa, Russia and 19th Century Sweden comparecompare??


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

SoDS: Population and health III

50-54 years

0

5

10

15

20

25

30

35

40

1750 1760 1770 1780 1790 1800 1810 1820 1830 1840 1850 1860 1870 1880 1890 1900110

120

130

140

150

malefemaleratio

19th c. SwedenFemale adult mortality declines, male adult mortality reacts negatively


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 re n c e s f o r s e le c te d c a u s e s o f d e a th , 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 ,5

- 1

- 0 ,5

0

0 ,5

1

1 ,5

2

tu b e rc . i n fe c t. s tro k e e x te rn a l m a te rn a l o th e r

diffe

renc

e pe

r 1.0

00

1 7 7 6 - 8 01 8 2 6 - 3 0


SoDS: Population and health III• 19th c. Sweden

Alcohol – the painkiller• Men’s gender roles make

them vulnerableFig 4. Acute alcohol intoxication (deaths or autopsies) per 1,000000

1804-1870.

0

5

10

15

20

25

1800 1810 1820 1830 1840 1850 1860 1870

deaths autopsies


HEALTH

CC EC

SCK

AGRICULTURALCHANGE

AGRICULTURALCHANGE

UNEMPLOYMENTPOVERTY

ALCOHOLVIOLENCETHEFTSMIGRATIONMIGRATION

UNSTABLEHOUSEHOLDS

UPROOTEDCITIZENS

DEMOGRAPHIC GROWTH AMONG CHILDRENAND WOMEN

DEMOGRAPHIC GROWTH AMONG CHILDRENAND WOMEN

Health and social Change – Sweden c. 1800-1850.

PLAGUEEC = economic capitalCC = cultural capital

SC= social capital

Long term trends in life expectancy at birth since 1890:France, Japan, Russia and the USA.

Long term trends in life expectancy at birth since 1890:France, Japan, Russia and the USA.

20

30

40

50

60

70

80

90

1890 1900 1910 1920 1930 1940 1950 1960 1970 1980 1990 2000

Year

Life

exp

ecta

ncy

at b

irth

in y

ears

Russia

USA

Japan

France

MALES

20

30

40

50

60

70

80

90

1890 1900 1910 1920 1930 1940 1950 1960 1970 1980 1990 2000

Year

Life

exp

ecta

ncy

at b

irth

in y

ears

Russia

USA

Japan

France

FEMALES

Historical gap, its reduction in the 1950s and the new health crisis in 1965-2000

55

60

65

70

75

80

85

1970 1980 1990 2000

Year

Life

exp

ecta

ncy

in y

ears

UK Hungary Poland

Estonia Russia

55

60

65

70

75

80

85

1970 1980 1990 2000

Year

Life

exp

ecta

ncy

in y

ears

UK Hungary Poland

Estonia Russia

HSC HSC –– Week 3Week 3Russia 1970 Russia 1970 -- 20002000

Variation in the life expectancy decrease for men across regions of European Russia

Associations with the pace of economic reform, psychosocial stress, and social cohesion are detected.

Walberg et al., 1998

-0,5

0,0

0,5

1,0

1,5

2,0

0 1 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85

Age

Con

trib

utio

n in

yea

rs

External

Ill-definedOther

Digestive

Respiratory

Circulatory

Neoplasms

Infectious

Males, total difference = 14.6 years

RussiaRussia

Male surplus mortality by age

RussiaRussia

-0,5

0,0

0,5

1,0

1,5

2,0

0 1 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85

Age

Con

trib

utio

n in

yea

rs

External

Ill-defined

Other

Digestive

Respiratory

Circulatory

Neoplasms

Infectious

Females, total difference = 7.0 years

Female surplus mortality by age

RussiaProportional differences in age specific death rates between the

lower* and the upper

educational groups by

cause of death, 1989

RussiaProportional differences in age specific death rates between the

lower* and the upper

educational groups by

cause of death, 1989

0

0 . 1

0 . 2

0 . 3

0 . 4

0 . 5

0 . 6

20 25 30 35 40 45 50 55 60 65

A G E

(ASD

R(lo

wer

,cau

se)-A

SDR

(hig

her,c

ause

))/A

SDR

(low

er,to

tal)

D IG E S T IV E

IN F E C T IO U S

O T H E R

N E O P L A S M S

C IR C U L A T O R Y

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

M A L E S

0

0 . 1

0 . 2

0 . 3

0 . 4

0 . 5

0 . 6

20 25 30 35 40 45 50 55 60 65

A G E

(ASD

R(lo

wer

,cau

se)-A

SDR

(hig

her,c

ause

))/A

SDR

(low

er,to

tal)

D IG E S T IV E

IN F E C T IO U S

O T H E R

N E O P L A S M S

C IR C U L A T O R Y

R E S P IR A T O R YIN J U R IE S A N D V IO L E N C E

F E M A L E S

Clear similarity with the Russia-West gap for total populations

Shkolnikov et al, 1998

Injuries, poisoning and violence mortalityInjuries, poisoning and violence mortality(excluding acute alcohol poisoning)(excluding acute alcohol poisoning)

Men aged 30-59Men aged 30-59

0

300

600

1965 1970 1975 1980 1985 1990 199510

11

12

13

14

15

16

Age

-stand

ardised rate per 100

,000

Per capita consumption litres pure alcohol/year

Mortality rateMortality rate

Alcohol Alcohol consumptionconsumption

“Coronary heart disease” and acute alcohol“Coronary heart disease” and acute alcoholpoisoning mortality in Russiapoisoning mortality in Russia

050

100150200250300350400450

1965 1970 1975 1980 1985 1990 19950

20

40

60

80

100

120

140

Age

-stand

ardised rate per 100

,000

Acute alcohol poisoningAcute alcohol poisoning

“CHD”“CHD”

Men aged 30-59Men aged 30-59

Russia 1965 Russia 1965 -- 20002000

South AfricaSouth AfricaAge standardised death rates (per 1 000)Age standardised death rates (per 1 000)

by province by province –– year 2000 estimateyear 2000 estimateThe legacy of apartheid and HIV/AIDSThe 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 (9)

National 1831 127 1303 125

Factors: Urban/rural; Poor/”rich”

HIV, external causesCHD, obesityThe unfinishedEpid. revolution+ the new diseases

0

0.002

0.004

0.006

0.008

0.01

0.012

15-19

20-24

25-29

30-34

35-39

40-44

45-49

50-54

AGE

RA

TE

1985

1995

1999/00

0

0.005

0.01

0.015

0.02

0.025

15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54

AGE

RA

TE

198519951999/00

Female mortality

Male mortality

South AfricaSouth Africa –– EstimatedEstimated ageage--specific specific male male and and female mortality female mortality 19851985--20002000

010002000300040005000600070008000

Homicide Suicide Accident

Male (n=13556) Female (n=301

South Africa South Africa –– external causes external causes of deathof death

02 0 04 0 06 0 08 0 0

1 0 0 01 2 0 01 4 0 01 6 0 0

<1 5_9

15-19

25-29

35-39

45-49

55-59 65

+

H o m ic id e ( n = 6 9 6 3 ) S u ic id e ( n = 1 4 3 0 ) A c c id e n t ( n = 5 2 1 9 )

0

100

200

300

400

500

600

700

800

900

1000

Ath

lone

Bla

auw

berg

Cen

tral

Hel

derb

erg

Kha

yelit

sha

Nya

nga

Oos

tenb

erg

Sou

th P

enin

sula

Tyge

rber

g E

ast

Tyg

erbe

rg W

est

Met

ropo

le

Mitc

hells

Pla

in

South AfricaSouth AfricaNonNon--communicable age standardised deaths per 100 000 in 2001communicable age standardised deaths per 100 000 in 2001

Cape Town Cape Town districtsdistricts

South Africa South Africa –– Death profile Death profile KhayelitshaKhayelitsha, Cape Town, 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 3.5

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 %

Additional points (Additional points (StatsSAStatsSA, 2002), 2002)

bb Males aged 15Males aged 15--39 experienced the highest mortality caused by 39 experienced the highest mortality caused by unnatural causesunnatural causes

bb Females in the same age group died primarily as a result of HIV/Females in the same age group died primarily as a result of HIV/AIDSAIDSbb For young children, intestinal infections is still one of the leFor young children, intestinal infections is still one of the leading ading

causes of death but declining over timecauses of death but declining over timebb Influenza and pneumonia are other leading causes of death for Influenza and pneumonia are other leading causes of death for

childrenchildrenbb In SA, there is a unique racial topology of mortality. In SA, there is a unique racial topology of mortality.

•• Black African and Black African and ColouredColoured malesmales -- unspecified unnatural causes and unspecified unnatural causes and TBTB

•• Indian and White Indian and White malesmales –– ischaemicischaemic heart disease and unspecified heart disease and unspecified natural causesnatural causes

•• Black African Black African females females –– HIV/AIDSHIV/AIDS•• ColouredColoured femalesfemales –– CerebrovascularCerebrovascular diseasesdiseases•• Indian and WhiteIndian and White females females –– ischaemicischaemic heart diseaseheart disease

HEALTH

CC EC

SC

GLOBALISATIONGLOBALISATION

ECONOMICCHANGE

ECONOMICCHANGE

DE-INDUSTRIALISATIONREGRESSIONIN COUNTRYSIDEUNEMPLOYMENTPOVERTYWEAK HOUSEHOLDS

DRUG ABUSEVIOLENCECRIME

MIGRATIONMIGRATION

UNSTABLESOCIETIES

UPROOTEDCITIZENS

Health, capital and social change: Russia - RSAHIV

EC = economic capitalCC = cultural capitalSC= social capital

Political change

POLITICAL INSTITUTIONS

FRIENDS, NEIGHBOURS, KIN, ETC.

HOUSEHOLD AND FAMILY

INDIVIDUAL

Challenges of ChangeMending the weak society – weak community model

PLAGUE

WAR

HUNGER

What turn the tide in Sweden (Western Europe) What turn the tide in Sweden (Western Europe) from c. 1870 onwards?from c. 1870 onwards?

Should/could it be repeated?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 societyTowards the welfare society

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