Examination of health statistics reveals significant variations by socio-economic position, geographic location and indigenous status.
Overall the residents of NSW enjoy a very high standard of health and good access to quality health care services. In 2007 a newborn male could expect to live just over 79 years and a newborn female close to 84 years, placing the State in the top echelons of international life expectancy standings.
Good health and access to services however, are not universally shared across the State. Examination of health statistics reveals significant variations by socio-economic position, geographic location and indigenous status. Much illness and mortality in the State (as in the other states and territories) is unnecessary; that is, potentially avoidable. Reducing this avoidable burden of disease and increasing equity in health status and service accessibility is the main health challenge facing the State.
One of the State’s broad cleavages in health is a ‘Metropolitan Sydney-Country NSW’ divide in favour of the former. For example, in the case of the four mapped mortality variables the aggregate Country standardised death ratios range between 12% to 19% higher than the Metropolitan ones. The provision of many health services is similarly skewed in favour of residents of Sydney and other major cities. Medicare data on general practitioners (full-time work equivalent) for 2006-07, for instance, indicated the following GPs per 100,000 population ratios: Major Cities – 106.9; Inner Regional – 82.0; Outer Regional – 67.7; Remote – 86.9;
Very Remote – 25.3.
The broad ‘Metropolitan Sydney’-‘Country’ and ‘major cities’, ‘inner regional’, ‘outer regional’, ‘remote’ and ‘very remote’ classifications provide useful summary geographical overviews, but full appreciation of the spatial inequalities in health across the State requires going down to smaller areal units. The four accompanying maps do this, charting variations across the State’s approximately 200 Statistical Local Areas (SLAs).
The All Causes, Death Rate map gives a useful overall comparative areal perspective of health as measured by total mortality (all causes, all ages) in each SLA, the rates being standardised to control for differences in population age structures between the areas. The map pinpoints the most pronounced elements of the Country disadvantage discussed above to generally be found in the distant western sections of the State.
Differences in socio-economic well-being play the biggest role in explaining this pattern; in formal analytical terms a quarter of the State-wide variation in the standardised death rates is statistically explained by the SLAs’ Australian Bureau of Statistics (ABS) SEIFA Index of Relative Social Disadvantage (IRSD) scores. Inequalities in access to health services are also important. In several of the SLAs with the highest death rates (e.g. Brewarrina, Central Darling, Walgett) large Aboriginal components in the populations and the unfortunate multiple disadvantage frequently borne by indigenous communities are a significant allied factor. New experimental life expectancy estimates for the Aboriginal and Torres Strait Islander (ATSI) population released by the ABS in 2009 suggested a 9 year life expectancy disadvantage for NSW indigenous newborn compared with the State’s infants as a whole.
Efforts to improve health require digging beneath the total mortality pattern and identifying the main contributory health disorders. Also, while ill health at all ages is important, reducing premature mortality (i.e. deaths at ages below what could be considered a normal life span) deserves special attention. The cancer and circulatory disease maps included here provide some insights to these aspects, showing the differential mortality from those causes of death across the State for people under 75 years of age. Both maps though still cover very broad groupings of disease and epidemiological analyses and interventionary programs need to be focused at more tightly defined cause of death categories; for example, lung cancer, colorectal cancer; ischaemic heart disease, stroke.
While death ultimately comes to all, much premature loss of life is potentially avoidable through prevention (e.g. by reducing smoking and obesity) and/or treatment (e.g. through early detection, radiotherapy). NSW Health estimates that the rate of avoidable death in the State in 2006 was 155 per 100,000 persons aged under 75 years. Cancer (36%) is the leading cause of avoidable death, followed by cardiovascular (circulatory) diseases (30%) and injury and poisoning (13%). As the accompanying map shows, rates of avoidable mortality vary greatly between different parts of the State and point to the need for geographically targeted health promotion actions. In the case of cancer the Cancer Council estimates that between 1996 and 2006 almost 51,000 NSW cancer patients eligible for radiotherapy did not receive it due to lack of resources, resulting in nearly 40,000 years of additional life being lost.
The discussion above focuses on mortality. A full picture of population health though also needs to encompass the types and degree of ill-health (morbidity) experienced by the population. One glimpse into this side of health is provided by the presented table on long term health conditions identified in the latest National Health Survey. These most frequently cited problems are all non-fatal conditions. Another important side of morbidity is the incidence and prevalence of serious disorders that ultimately frequently lead to death (e.g. various cancers, heart disease, respiratory disorders).
Some things can be reasonably confidently predicted; others are more speculative. As the graph of standardised death rates shows there have been significant improvements in recent years and there are good reasons for believing further gains will be enjoyed over coming decades. Solid gains are factored into the ABS’s population projections. At the same time, it is equally likely that substantial socio-economic disadvantage will persist within the population and thus any such improvements will not be equally shared.
One demographic certainty is a marked ageing of the population and this will bring in train numerous health consequences. With a greater proportion of the population in the older age groups there will be an increase in absolute ‘case-load’ numbers for all health disorders with progressive age incidence and prevalence – e.g. dementia, impaired cardiovascular functioning, certain cancers, physical disabilities, etc. The number of people with dementia, for instance,
has been projected to increase from around 1% of the State’s population
at present to 2.7% in 2050. The increase will in turn vary considerably
between regions in line with differential population ageing.
Into the more speculative realm, there are the possible health changes that may come with global warming – e.g. increased morbidity and mortality from extreme weather events, a possible wider spread of vector-borne infectious diseases (e.g. Ross River virus, dengue fever), increases in food-borne infectious diseases (e.g. gastroenteritis), increases in urban air pollution, etc.
In short, NSW residents as a whole will likely continue to be favoured with very good health levels. But both old (e.g. the social and geographic gradients to health, the Indigenous health gap, the avoidable ill health burden) and new health challenges (e.g. associated with population ageing and climate change) will need to be faced.
Dr Kevin McCracken, Macquarie University and Mr Frank Siciliano, Macquarie University