diseases and disorders such as dementia.
Universal state pension schemes to keep older people out of extreme poverty may not be able support the increased growth in over-65s.
Preparing health providers and societies to meet the needs of elderly people is essential: training for health professionals on old-age care; preventing and managing age-associated chronic diseases; designing sustainable policies on long-term care; and developing age-friendly services and settings. Work around promoting positive images of older people, social isolation and quality of life may be also be crucial for older populations.
Safety, security and fear A whole range of related issues can be considered under the terms ‘safety and security’. These all impact upon health and are summarized in table 2.3.
The above issues are commonly not perceived as being public-health threats in their own right but are seen superficially in terms of how public health should be providing health-care responses (Geiger, 2001). Crime and terrorism are constructed as media/moral panics that potentially exaggerate the risks and create a culture of fear but in some areas of conflict there is great evidence that fear impacts upon holistic health, while the direct effects also have a large health impact (Bleich, Gelkopf and Soloman, 2003).
Table 2.3 The impact of safety and security upon health
| Issue | Potential effects | Reference |
|---|---|---|
| Conflict and war | Deaths and injuries on the battlefield Displacement of populations (internally and externally) Breakdown of health and social services Sexual violence Heightened risk of disease transmission Psychosocial impact of living with conflict Reduction on development and maintenance of infrastructure Disruption of subsistence agriculture Increased risk of further violence | Murray et al. (2002) Levy and Sidel (2016) |
| Domestic violence | Effects upon health fall into four categories: physical impact (injuries and death); sexual and reproductive consequences (unwanted pregnancies, infections); mental health (depression); and behavioural issues such as self-harm and substance misuse | Campbell (2002) WHO (2012) |
| Crime | Death and injury Emotional impact of long term stress – lower personal well-being and increased anxiety Loss of work earning Property destruction | Dubourg et al. (2005) ONS (2015) |
| Terrorism Bombing Bioterrorism Kidnapping | Direct death and injury Rape as an instrument of war Direct effect of psychological impact of trauma and fear (long-term physical and mental-health effects) Indirect effect on society living in fear of terrorism even if the actual threat is low Physical and mental health impacts on first responders | Bleich, Gelkopf and Soloman (2003) Alexis-Martin (2018) |
War and conflict pose a major threat to health, not only in direct ways as we may expect, but also as economic and social development are impeded. Basic infrastructure such as roads, sanitation and commercial settings can be devastated, affecting the ability for basic human needs (e.g. food and shelter) to be satisfied. Displaced persons who have been fleeing their homes in order to avoid the effects of armed conflict and violations of human rights experience much poorer health as a result of this displacement, which can exist for generations (UN, 2017).
Poverty and inequality There is a large amount of evidence to show that among all threats to health risks, it is poverty and inequality that are much more likely to limit the achievement of full health. Lewer et al. (2019) report that over 900,000 deaths in England have occurred prematurely as a result of social inequalities, and if everyone in England had the same mortality rate as those residing in the richest locations, there would have been 877,000 fewer premature deaths between 2003 and 2018 (see chapters 10 and 12 for more on this).
In recent years, evidence has been used to demonstrate that material deprivation plays a huge role in the causation of disease (see chapter 4 for further discussion of health inequalities). This social determinants of health model shows a strong social gradient for most diseases, with those who are poorer experiencing higher rates of disease than those who are richer (Wainwright, 2009a; CSDH, 2008; Marmot 2019). WHO (2017) data demonstrate this when discussing the global burden of disease statistics, which illustrate large differences in health and disease burden, depending upon level of socio-economic development. Schrecker (2019) points out that there is no talk about inequality as an emergency because its consequences are less visible, with lives ending sooner and more painfully than they should.
Health inequality refers to the differences in health status between people and/or places and manifests in many ways, as box 2.2 demonstrates.
Box 2.2 Examples of wide-ranging health inequalities
Gender health inequalities, e.g. risk behaviours such as drinking alcohol, are more prevalent among men, and older groups of the population.
Social class inequalities, e.g. people in high social classes have better health outcomes compared to those in the lower social classes.
Geographical inequalities, e.g. health is generally poorer in the north of England compared to the south of England.
Ethnic inequalities, e.g. suicide rates in young Asian women are more than double those for young white women in the UK.
Age inequalities, e.g. many risk factors for poor health, such as obesity, hypertension, disability and poverty increase with age, and the importance of adverse childhood experiences in shaping health outcomes is now evidenced.
Sources: Raleigh and Polato (2004); Warwick-Booth (2019)
Health inequity refers to those differences that are perceived to be unfair and unjust (Graham and Kelly 2004). For example, it can be argued that everyone has the right to health care; however, despite the presence of health care in many countries, not everyone is able access it, which results in health inequity.
Mental health Mental-health issues are often neglected in a world that tends to prioritize physical health. However, separating mental, social and physical health contradicts our understanding of the holistic nature of health. As a whole person, the domains of health are inextricably linked and influence each other. Achieving good mental health is fundamentally important in daily functioning, quality of life and integral to the health of individuals and communities (Brundtland, 2001). Rehm and Shield (2019) point out that mental health and addictive disorders affected more than one billion people globally, causing 7% of all global burden of disease and 19% of all years lived with disability; therefore mental health is a significant contemporary challenge. Statistics are likely to be a significant underestimation, as they only capture data about people who are classified and diagnosed as ‘disordered’. Many people experience anxiety and poor mental health without ever receiving a diagnosis of illness or disorder. A major issue for mental-health sufferers is the serious stigma and discrimination associated with poor psychological
