Healthy, Wealthy and Wise

This trio of desiderata is no less valid today than when we were children, but the recipe for success, summarised as ‘ early to bed, early to rise’, appears to be too simplistic in a complex world we live in today.

And yet, if you ask a hundred people, particularly those of a certain age, when they have started to realise that they are not indestructible any more, what is the most valuable thing in life, the majority would choose health as the most urgent priority.

Compared to most countries in the world, Malta is a healthy nation. We are also a happy-go-lucky nation where it seems that some things go reasonably well more through luck than through wise management.

Surveys have shown that Maltese consider themselves some of the happiest in the world. In a scale that ranked happiness in countries around the world, Malta is listed as the 30th out of 157 countries, beating countries like France, Italy, Cyprus, Japan, etc.1 This index was built up from different components, namely: GDP per capita, social support, healthy life expectancy, freedom to make life choices, degree of generosity, perception of corruption, etc.  So this is not just a subjective judgement of happiness, but is based on a number of socially-related factors.  One factor which was not emphasized in this report is the efficiency of the health profession in producing this very acceptable state of affairs.

A more subjective Gallup survey consisted of interviews with people in 155 countries to obtain a ‘life evaluation’ score which varied  on a scale from 1 to 10.  Questions were asked relating to their experiences on the day previous to the interview and enquired about whether they felt well-rested, respected, free of pain, and intellectually challenged. On this scale also, subjective as it is, Malta ranked in the top quarter (at 38th position).2

One important issue that comes out of the above study is that while 40% of Maltese were considered as ‘thriving’, nearly half of the population were classed as ‘struggling’, and 12% as actually ‘suffering’.

Looking at any collection of data around the world, it becomes obvious that poor nations are also unhealthy nations.  Not only are infectious diseases still the scourge of these nations, their short life is a constant battle for survival. The most obvious manifestation of poverty can now be seen as an explosion of people making the hazardous, often  fatal rush to leave their country of origin and seek a home elsewhere, where the standard of living  is higher and the future appears brighter.

Compared to the post-war period, when poverty was rife and the Maltese also had to leave these shores for pressing economic reasons, Malta has made gigantic economic progress. The standard of living is generally very good. The average salary has soared, from just over 10,000 euro in 2001 to over 17,000 euro in 2016,3 a staggering 4% p.a.

In a recent publication The Health Gap4, Sir Michael Marmot, former President of the British Medical Association, emphasized the point that while poverty and ill-health are causally related, there is, however, a level of wealth above which additional increments are unlikely to have a significant effect.  He analysed the effect of income on life expectancy, and while confirming that those countries with the lowest incomes also have the lowest life-expectancies, he concluded that “above a national income of $10,000, there is little relation between income and life expectancy”.  In fact, he points out, that while the income is widely different in US compared to Cuba, there is little difference in life expectancy in US and Cuba. It would seem then that Malta, having now exceeded this critical wage level, is unlikely to witness a further increase in life expectancy through an increase in salaries.

The major point made by Marmot in this publication is the emphasis he made on issues  impacting on health which are well beyond what a medical education equips us to deal with, issues with are rarely dealt with in medical textbooks or medical journals.

These factors relate to what he calls ‘the social gradient in health’.  While there have been great advances in the provision of medical facilities, including standards of hospital and medical practice in general, there is still quite an enormous variation within any one particular country between outcomes for those at the top of the social scale compared to those at the bottom. This differential is often the effect of social determinants of health which seem to be present in all ‘developed’ countries including Malta.

Life expectancy, for instance, is very much socially determined and varies significantly within a nation. Marmot gives as an example the fact that in the UK, for instance, if one takes the underground train (‘Tube’) from Westminster in central London, where better-off people are to be found, and move eastwards to the deprived areas of East London, life expectancy drops a year with every train stop!

Doctors and health practitioners in general deal with individuals to the best of their ability. They fix body ailments as best they can, and serve also as a repository of knowledge which they pass on to their patients and clients. They do not, in general feel obliged to delve deeply into the causation of disease, leaving this to public health professionals and researchers.

One major cause of ill-health which has not perhaps been given sufficient importance, but which now has taken centre stage, is the role of social inequality in perpetrating ill health amongst the community.  There is no doubt that an unequal society, that is, one where there is a major differential between the well-off and those at the bottom of the social scale, leads invariably to a differential between the health of its citizens.  While the western world is considered to be a rich and healthy world, there are invariably sections of the population where citizens are hit hard and health is at a nadir. Take for instance the US, a country which spends more on health than any other nation on earth, there is still a considerable proportion of citizens who have a markedly reduced life expectancy, and reduced access to health care, compared to much more ‘equal’ societies like Norway or Sweden.

Malta, a small country which is now actually doing well economically, one would have thought, qualifies as an equal society, with equal access to facilities and little differential between rich and poor. However, there is no doubt that here also we find pockets of want, and whole families at risk of poverty and ill-health.

The economist Lawrence Zammit claims that while the ‘middle class’ has increased   significantly in size in Malta over the past 25 years, in recent years in Malta, we still find that  up to 15.4% are at risk-of-poverty level.5

Moreover, certain localities in Malta are distinctly at a social disadvantage compared to the average. One objective yardstick is the distribution of social benefits by local area. A recent article published in The Times lists localities with the highest number of single parents in receipt of children allowance.6  This report states that as of 2016 there were nearly 11,000 persons receiving such an allowance.  St Paul’s Bay and Birkirkara (the most populous localities in Malta) were at the top of the list.  While females constituted the majority of these persons, about one-fifth of these single parents were males.

Social issues have been shown to play a very significant part in ensuring the creation and perpetuation of health issues. The general practitioner in particular, working at the coalface, is often considered to be the ideal person to detect the causes of ill-health. This option is, however, coming more and more under threat as a result of the fluidity of relationships between patient and doctor. The one-to-one relationship which used to be de rigueur in the past has been eroded, and with it the ability to diagnose familial, social, and other background factors which lead to disease in certain at-risk individuals and families.

References

  1. Helliwell J, Layard R, Sachs J (eds.). World Happiness Report (Vol 1). 2016. Available from: http://worldhappiness.report/wp-content/uploads/sites/2/2016/03/HR-V1_web.pdf
  1. Malta ranks high in ‘happiness’ ranking, but many are ‘struggling’. Times of Malta, Friday, July 30, 2010. Available from: http://www.timesofmalta.com/articles/view/20100730/local/malta-ranks-high-in-happiness ranking-but-many-are-struggling.320118
  1. http://www.tradingeconomics.com/malta/wages
  1. Marmot M. The Health Gap: The Challenge of an Unequal World. Bloomsbury. 2015.
  2. 5. Zammit L. The middle-class society. Times of Malta, Friday, December 7, 2012. Available from: http://www.timesofmalta.com/articles/view/20121207/business-news/The-middle-class-society.
  1. “11,000 single parents on allowance”,Times of Malta, Tuesday, June 21, 2016. Available from: http://www.timesofmalta.com/articles/view/20160621/local/11000-single-parents-on-allowance.616243

[Published in The Synapse Medical Magazine 2016; 15(5):7-8.]

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