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Triple Jeopardy? Environmental, Triple Jeopardy? Environmental, social and health inequalities in social and health inequalities in

New Zealand and the UKNew Zealand and the UKNew Zealand and the UK. New Zealand and the UK.

Jamie PearceJamie Pearce

Centre for Research on Environment, Society and Health (CRESH)Centre for Research on Environment, Society and Health (CRESH)I tit t f G h S h l f G S iI tit t f G h S h l f G S iInstitute of Geography, School of GeoSciencesInstitute of Geography, School of GeoSciences

University of EdinburghUniversity of Edinburgh

jamie.pearce@ed.ac.ukjamie.pearce@ed.ac.ukwww.cresh.org.ukwww.cresh.org.uk

OverviewOverview

1.1. Setting the scene: the ‘localism’ agendaSetting the scene: the ‘localism’ agenda

2.2. Monitoring geographical inequalities in Monitoring geographical inequalities in healthhealth

3.3. The place of the neighbourhoodThe place of the neighbourhood

4.4. Environmental inequalities and healthEnvironmental inequalities and health

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Localism in the UKLocalism in the UK

May 2010 May 2010 –– Coalition GovernmentCoalition Government(Conservative/Liberal Democrats)(Conservative/Liberal Democrats)(Conservative/Liberal Democrats)(Conservative/Liberal Democrats)Implementing radical agendaImplementing radical agenda–– Budget cutsBudget cuts–– Central government spendCentral government spend–– Local government spendLocal government spend–– Greatest cuts Greatest cuts –– most disadvantaged groups/ placesmost disadvantaged groups/ places

Implications include:Implications include:–– Increase Value Added Tax (VAT)Increase Value Added Tax (VAT)Increase Value Added Tax (VAT)Increase Value Added Tax (VAT)–– Removing ‘Education Maintenance Allowance’Removing ‘Education Maintenance Allowance’–– Tripling student feesTripling student fees–– WelfareWelfare–– National Health Service restructuringNational Health Service restructuring

Wholesale redefinition of the relationship Wholesale redefinition of the relationship between the individual and the state…?between the individual and the state…?

Localism AgendaLocalism Agenda‘Big Society’:‘Big Society’:–– transfer of power & rights from transfer of power & rights from centrecentre to to locallocal–– Increase role for community groups and thirdIncrease role for community groups and thirdIncrease role for community groups and third Increase role for community groups and third

sector organisations sector organisations –– delivery of servicesdelivery of services–– do things for yourself rather than the statedo things for yourself rather than the state

Localism Bill:Localism Bill:–– Placing power at the heart of local communities?Placing power at the heart of local communities?–– Reinforce local democracy?Reinforce local democracy?–– Devolving responsibility?Devolving responsibility?

I li ti i l dI li ti i l dImplications include:Implications include:–– return funds from business rates to councils that return funds from business rates to councils that

earn themearn themrather than distribute according to needrather than distribute according to need

–– removal of national housing targetsremoval of national housing targets

Localism the shield for a sizeable Localism the shield for a sizeable redistributionredistribution from poor to rich? from poor to rich?

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Deficit reduction, localism and Deficit reduction, localism and SDOHSDOH

SocioSocio--ecological perspective:ecological perspective:–– Social distribution in health Social distribution in health -- underlain by underlain by

unequal distribution of resources fundamentalunequal distribution of resources fundamentalunequal distribution of resources fundamental unequal distribution of resources fundamental to a healthful lifeto a healthful life

–– Wealth, education, employment, access to Wealth, education, employment, access to health care, health care, environment (physical, social, environment (physical, social, built etc)built etc) in which people live….in which people live….

Fundamental implications for SDOH?Fundamental implications for SDOH?–– rise in social & economic inequalitiesrise in social & economic inequalities–– welfare supportwelfare support

food sec ritfood sec rit–– food securityfood security–– housinghousing–– migrationmigration–– etcetc

Local environment (neighbourhoods) Local environment (neighbourhoods) –– increasingly pertinent increasingly pertinent –– public health/ health public health/ health

inequalities?inequalities?

Monitoring Monitoring geographicalgeographicalinequalities in healthinequalities in health

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Source: Pearce & Dorling. International Journal of Epidemiology 2006;35:597–603

Health Inequalities: Mortality

http://www.statistics.gov.uk/STATBASE/Product.asp?vlnk=6638

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Life expectancy in GlasgowLife expectancy in Glasgow

14km apart: 28 year difference in

LenzieLife expectancy=82

year difference in life expectancy

CaltonLife expectancy=54

Source: Thomas et al (2010) BMJ

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The place of the neighbourhoodThe place of the neighbourhood

Pearce, Witten, Hiscock & Blakely. International Journal of Epidemiology 2007;36:348–355

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Source: Pearce, Witten & Bartie. Journal of Epidemiology & Community Health 2006;60;389-395

Source: Pearce, Day & Witten. Urban Policy & Research 26: 2008; 213–27

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Gambling venues in NZGambling venues in NZ

Source: Pearce, Mason, Hiscock, Day. Journal of Epidemiology & Community Health 2008;62:862-8

Fast food outletsFast food outlets

Source: Pearce, Blakely, Witten & Bartie. American Journal of Preventive Medicine 2007;32:375–382

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Source: Day & Pearce. American Journal of Preventive Medicine 2011;40(2):113–121

K Function Clustering

High degree clustering around schools

Up to 5.5 times more than expected

Particularly socially deprived schools

Source: Day & Pearce. American Journal of Preventive Medicine2011;40(2):113–121

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Advertising Advertising around schoolsaround schools

Route to school Route to school mapped for allmapped for allmapped for all mapped for all pupilspupils

Average no. of food Average no. of food advertisements advertisements (unhealthy) (unhealthy) greatest for pupilsgreatest for pupilsgreatest for pupils greatest for pupils at most deprived at most deprived schoolschool

Source: Walton, Pearce & Day. Health & Place15; 2009: 811–818

Tobacco outlets and smokingTobacco outlets and smoking

Source: Pearce et al. Journal of Epidemiology and Community Health 2009; 63, 69-77.

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ButButBut….But….

Neighbourhood Destination Accessibility Index (NDAI): infrastructure support for neighbourhood physical activity

Source: Witten, Pearce & Day. Environment & Planning A 43: 2011; 205-23

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Median travel time to 16 sub-domains of community resources in deprivation quintiles across New Zealand

Source: Pearce et al. International Journal of Epidemiology2007;36:348–355

Health/ behaviour effectsHealth/ behaviour effects

Associations between community resource access and Associations between community resource access and health in NZ neighbourhoods:health in NZ neighbourhoods:gg

Access to fast food outlets

•No association with BMI

•No association with diet

(Pearce et al. Health and Place2009; 15 193-197)

Access to supermarkets & convenience stores

•No association with fruit consumption

2009; 15, 193-197) •No association with vegetable consumption

(Pearce et al. Journal of Epidemiology and Community Health 2008; 62, 198-200)

Access to green space

•No association with CVD

(Richardson, Pearce et al. BMC Public Health 2010; 10(1):240.)

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Environmental inequalities & Environmental inequalities & healthhealth

Funded by Natural and Environmental Research Council (NERC) 2008-10 (with R Mitchell and N Shortt)

Environmental justice and health Environmental justice and health inequalitiesinequalities

Lack of work at intersection: Lack of work at intersection: health inequalitieshealth inequalities environmentalenvironmental–– health inequalitieshealth inequalities –– environmental environmental disparitiesdisparities (environmental (in)justice)(environmental (in)justice)

Implications of Implications of environmentalenvironmentalinequalities for inequalities for healthhealth inequalities?inequalities?–– Dissimilar effects on communities with Dissimilar effects on communities with

varying sociovarying socio--economic profiles?economic profiles?y gy g pp

–– Does SES modify the relationship Does SES modify the relationship between the environment and health?between the environment and health?

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Research AimsResearch Aims

Consider the social dimensions of Consider the social dimensions of multiple environmental risk factors:multiple environmental risk factors:pp

1.1. Assess socioAssess socio--spatial distribution of spatial distribution of multiple dimensions of the physical multiple dimensions of the physical environment (related to health)environment (related to health)

2.2. Test the tool to assess implications for Test the tool to assess implications for pphealthhealth and and health inequalitieshealth inequalities

Socioeconomic deprivationSocioeconomic deprivation

Socioeconomic deprivation:Socioeconomic deprivation:–– MultiMulti--dimensional e g :dimensional e g :–– MultiMulti--dimensional, e.g.:dimensional, e.g.:

Measures of Multiple Socioeconomic DeprivationMeasures of Multiple Socioeconomic Deprivation

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Environmental deprivation Environmental deprivation

Physical environmental deprivation:Physical environmental deprivation:–– MultiMulti--dimensional e g :dimensional e g :–– MultiMulti--dimensional, e.g.:dimensional, e.g.:

Measures of Multiple Measures of Multiple Physical Environmental Deprivation?Physical Environmental Deprivation?

Richardson EA, Mitchell RJ, Shortt NK, Pearce J, Dawson T, 2009. Evidence-based selection of environmental factors and datasets for measuring multiple environmental deprivation in epidemiological research. Environmental Health 8 (Suppl 1): S18.

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MEDIx score

-2

-1

0

+1

+2

MEDIx score -2 = Least environmentally deprived wards (‘healthiest’ places, theoretically)

MEDIx score +3 = 2

+3 MEDIx score +3 = Most environmentally deprived wards (‘unhealthiest’ places)

0 150 30075km

Multiple Environmental Multiple Environmental Deprivation Index Deprivation Index

(MEDIx)(MEDIx)

Mean values for environmental factors that influence health in the UK

by quintiles of incomedeprivation (1=low, 5=high)

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All cause mortality

1 00

1.20

1.40

1.60

1.80

ed m

orta

lity

ratio

Cardiovascular disease

1 00

1.20

1.40

1.60

1.80

ed m

orta

lity

ratio

Respiratory disease

1 00

1.20

1.40

1.60

1.80

ed m

orta

lity

ratio

Standardised Mortality Ratios and confidence intervals across quintiles of socio-economic deprivation, unadjusted and adjusted for physical environmental deprivation

0.40

0.60

0.80

1.00

1 (Low) 2 3 4 5 (High)

Socio-economic deprivation quintile

Sta

ndar

dise

Unadjusted Adjusted

0.40

0.60

0.80

1.00

1 (Low) 2 3 4 5 (High)

Socio-economic deprivation quintile

Sta

ndar

dis

Unadjusted Adjusted

0.40

0.60

0.80

1.00

1 (Low) 2 3 4 5 (High)

Socio-economic deprivation quintile

Sta

ndar

dise

Unadjusted Adjusted

Colorectal cancer

1.60

1.80

o

Oesophageal cancer

1.60

1.80

o

0.40

0.60

0.80

1.00

1.20

1.40

1 (Low) 2 3 4 5 (High)

Socio-economic deprivation quintile

Sta

ndar

dise

d m

orta

lity

ratio

Unadjusted Adjusted

0.40

0.60

0.80

1.00

1.20

1.40

1 (Low) 2 3 4 5 (High)

Socio-economic deprivation quintile

Sta

ndar

dise

d m

orta

lity

ratio

Unadjusted Adjusted

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ConclusionConclusionTriple jeopardy?Triple jeopardy?–– UK evidence supportiveUK evidence supportive

Mixed evidence from neighbourhoods in NZMixed evidence from neighbourhoods in NZ–– Questions some aspects of the neoQuestions some aspects of the neo--material material

understanding of health inequalitiesunderstanding of health inequalities

Public health perspective on ‘Big Society’Public health perspective on ‘Big Society’–– Localism agenda Localism agenda – Building community resilience and devolving local– Building community resilience and devolving local

services?– Or putting a sticking plaster over the wound caused

by macro-structural inequalities in power and resources?

–– Challenge to efforts to reduce health inequalities?Challenge to efforts to reduce health inequalities?