First do no harm

In the context of the current interventions in the Northern Territory by the Australian Government, it is important to understand how social factors can directly impact on health.

Twenty-five years ago I was privileged to be part of a study with the Mowanjum community based near Derby in the north of Western Australia. We looked at the impact of temporary reversion to traditional hunter gatherer lifestyle on the health of a group of middle-aged people with diabetes. These people had retained the knowledge and ability to live as hunter-gatherers - which is the reason this study was possible.

After only seven weeks there was a profound improvement in all of the metabolic abnormalities of diabetes and all the risk markers for heart disease.

But in addition, I was struck by changes which I could not measure at the time - wonderful changes in people’s demeanour. When the people in this study went back to their own land - even for only a few weeks - they changed greatly. They were confident, competent and articulate practitioners of their traditional lifestyle. They seemed to physically grow in stature! What I was witnessing was the dramatically positive impact of mastery and control.

The intervention in the NT risks producing the opposite - the loss of any sense of mastery and control - and the consequences of such disempowerment are likely to be dire indeed.

It is well-established that extreme poverty, characterised by poor education, poor nutrition, overcrowded and unsanitary living conditions, and inadequate medical care, impacts adversely on health outcomes and life expectancy. And this of course is very relevant to poor health outcomes in many Indigenous communities especially in remote Australia.

What is less well known is that it is not just the physical and environmental aspects of such poverty that are bad for your health, psychosocial factors are also very important.

The Whitehall Study - looking at the long term health of British civil servants - has examined the impact of employment grade on health outcome. All of these people are employed - so extreme poverty is excluded. However what they have observed is that, relative to those highest in the pecking order (the top administrators), those lowest in the hierarchy (unskilled messengers for example) had 2.5 times higher mortality after 10 years.

What was even more striking was that those in the professional and executive level (just below the top administrators) had significantly higher mortality than their bosses. And this despite being well-educated and highly paid - people such as lawyers and doctors.

So what is the explanation?

Some of the differential is explained by health-related behaviours - such as smoking, physical activity, alcohol consumption and diet. However, much of the gradient is explained by psychological factors. Indeed, it is now recognised that differences in some of the behavioural factors may also be secondary to these same psychological factors.

How is this relevant to what is going on in the NT?