CHAPTER 2 The health of Australians
Part of understanding the health care system of any country requires having some knowledge of the patterns of disease. This knowledge allows you to make some judgments about what kind of health system would best meet the needs of the population. Knowledge of patterns of disease is referred to as epidemiology.
Epidemiology is a process of identifying the incidence and location of diseases in order to control them. One of the first recorded epidemiologists was Dr John Snow, who was concerned about the cholera epidemics that were occurring in London in the 1830s and 1840s. He was convinced that this disease was not transmitted through the air as was then believed but through people coming into contact with each other, in particular through contact with the vomit and excreta of cholera patients.
During the outbreak of another epidemic in 1854 he decided to record on a map the incidence of each cholera case in central London and noticed as he did so that most were congregated around certain street pumps. In those days there was no running water in the houses and water had to be collected by pail from the nearest street pump. Dr Snow’s map indicated that some street pumps had no surrounding incidences of cholera while others had a very high incidence. When Snow matched the two water companies that provided water to London’s city pumps he found that one (the one with many cholera cases adjacent to their pumps — amounting to up to 200 deaths per day) was collecting water from the Thames River below the sewerage outlet, while the other (which had no cholera cases adjacent to their pumps) was collecting water from high up the river, above the sewerage outlet. He then marched the city fathers down to one of the contaminated pumps and removed the handle, forcing local residents to use safer pumps. The number of cholera cases in that area dropped immediately, thus proving his theory that cholera was a contagious disease transmitted through body fluids from person to person, and in this case via the medium of water.
Over the past 100 years we have gained an extra 25 years of life expectancy. Currently Australia has one of the highest life expectancies worldwide at 77.6 years for males and 83.5 for females (Japan has the highest with 78 and 85 respectively). By 2050 in Australia these figures will rise to 90 years for females and 86 for males (Commonwealth Department of the Treasury 2007). Overall our health expenditure appears well managed at around 9–10% of the Gross Domestic Product (GDP) — this is very comparable with other OECD countries. The total expenditure on health in 2004–05 was $87.3 billion, or 9.8% of GDP, with an average of $3369 per non-indigenous person and $3974 per Indigenous person (Australian Institute of Health and Welfare [AIHW] 2006b). Hospital services took up 33.3% of these costs, while the rest was spent on medication (12.4%), dental services (5.8%), other health practitioner services, for example, physiotherapy and chiropractic (2.8%), health promotion (1.7%), aids and appliances, and research.
Eighty-six percent of diseases in developed countries nowadays are non-communicable. These include heart and vascular diseases, cancers, most diseases of the muscular, joint and respiratory systems and mental illness. What do these diseases cost the health care system?
From Table 2.1 it is interesting to note that health expenditure is not necessarily tied to rates of death. For example, cancer has the second highest rate of death at 28.7% but the amount of money spent on it is lower than on musculoskeletal diseases with a death rate only around 4%. This is because cancer tends to be a much shorter-term illness and therefore claims less in terms of hospital and other medical costs than longer-term diseases.
Heart and related diseases kill more Australians than any other disease group, resulting in 38% of all deaths with around 3.5 million out of 20 million people being affected at any one time. This costs the government $5.5 billion annually (ABS 2006a). As heart, stroke, and vascular diseases largely affect older people, this number is expected to increase with the ageing of the population. The risk factors identified for heart disease are: being overweight, having low physical activity levels, having high blood cholesterol and high blood pressure, and indulging in heavy smoking and drinking habits. The presence of a diagnosis of diabetes is also a predisposing factor. Ninety percent of Australian adults have at least one of these risk factors present and 25% have three or more risk factors present (Heart Foundation 2004). In 1907 circulatory diseases made up around 20% of deaths. This percentage increased to almost 60% between the 1950s and the 1970s, reducing over the last 20 years as diet and exercise have improved and the incidence of tobacco smoking dropped by about half.
This grouping includes arthritis of varying kinds, osteoporosis and chronic back pain and 33% of Australians (over 6 million of the population) suffer from these conditions at any one time, costing the health care system around $4.6 billion (ABS 2006b) with out-of-hospital expenses accounting for the highest proportion of costs of any disease group (AIHW 2005b). The various forms of arthritis (15% experienced by more women than men) involve inflammation or degeneration of the joints. Osteoporosis (3%) involves progressive loss of bone density, and back pain (15%) is usually linked to muscular strain or displaced spinal discs (ABS 2006b). There is often a genetic predisposition to arthritis which may be triggered by a virus or bacterial infection and aggravated by physical inactivity and being overweight. For osteoporosis, the main risk factors are being underweight, smoking, drinking to excess and not exercising regularly (AIHW 2005b).
Accidents, injuries and poisoning include any cuts, falls, bites, stings or vehicle accidents which require medical attention as well as the fatalities involving murder and suicide. As motor vehicle accidents have decreased markedly since 1990 the numbers of people suffering such accidents almost halved. Most of the $4 billion spent on this area goes on hospital costs, physiotherapists and chiropractors (ABS 2005a).
Approximately one in five people in Australia have a mental/behavioural disorder with slightly more females than males experiencing this and with separated or divorced people experiencing almost double the rates compared with those who are partnered/married. Disorders include anxiety, depression, bipolar illness and harm gained from excessive alcohol and drug use. The risk factors for mental health problems lie largely in excess alcohol and drug use and inactivity (ABS 2006c).
For both males and females the incidence of cancer is also on the decline. In 2004, 28% of deaths were caused by cancer, in particular of the lung, prostate, breast, colorectal area and lymph glands. Hospital separations have decreased from 9% to 7% (ABS 2006a) and health expenditure on cancer is around $2.9 billion (AIHW 2005a) but this does not reflect the lifetime cost (from diagnosis to death) for all those diagnosed. In 2005 this cost was estimated at around $94.6 billion (Access Economics 2007). Australians are four times more likely to develop a common skin cancer than any other form of cancer, with over 380 000 Australians being treated for skin cancer each year — that is over 1000 people every day with over 1500 Australians dying from skin cancer each year (AIHW 2004a). Skin cancer costs the health system around $300 million annually, the highest cost of all cancers (AIHW 2005a).