Poor suburbs and poor health : exploring the potential of a locational approach to reducing health disadvantage in Australian cities

Poor urban Australians face a substantial health disadvantage: on average, they can expect to die earlier and suffer more physical disease, mental illness and injuries than wealthier Australians. This thesis examines the potential of one approach to reducing the problem of health disadvantage, namely, systematically intervening in disadvantaged locations. Such an approach is gaining support, especially in the United Kingdom and Australia; there is therefore a need to determine its possibilities and limitations. The thesis is written from the theoretical perspectives of critical social science and political economy of health. The research synthesises empirical data and critical analysis, combining findings from the health inequalities literature and analyses of contemporary political and economic contexts. It also includes two original studies: a quantitative analysis of the patterning of socio-economic disadvantage in Sydney suburbs, and a qualitative case study of a disadvantaged location: Mt Druitt, NSW. The health inequalities research shows that reducing health disadvantage is largely a question of reducing socio-economic disadvantage. A model of social exclusion is used to show how socio-economic disadvantage develops in capitalist societies. Following from this analysis, it is argued that a locational approach can have little impact on the macro political and economic antecedents of socio-economic and health disadvantage. Given these macro constraints, the thesis examines the possible ameliorative impact of a locational approach to health disadvantage here too, there are many limitations. A locational approach would have a limited population reach as most health disadvantaged people do not live in identifiably disadvantaged locations. Location itself creates only a modest independent burden on health, thus improving the amenity of disadvantaged locations will contribute little to reducing health disadvantage. In Australia, the creation of the most visibly disadvantaged urban locations is almost entirely a consequence of policies to concentrate public housing. Although it can be expected that locational interventions will be focused in these locations, there are substantial policy barriers to addressing the major socioeconomic determinants of health , low income, unemployment and sole parent poverty, in public housing estates, Location based policies to alleviate aspects of health and socio-economic disadvantage are assessed. In general locational policies and interventions have had a disappointing track record in buffering populations against issues such as poverty, unemployment and childhood disadvantage. Four specific policies are examined. There is a case to provide improved health services in disadvantaged locations. Measures to improve social capital or change the social mix of locations will have a very small, if any, impact on health. Early intervention in disadvantaged locations is rational in that the precursors of health and socioeconomic disadvantage occur in early life; however, population reach is limited and only the most expensive and intensive of these programs have produced good results. The case study of Mt Druitt shows that agencies are willing to implement a wide range of interventions to alleviate location based socio-economic and health disadvantage. Some of these interventions can be expected to have good results for some individuals. However, there is a lack of a systematic approach to problems in this location, and substantial barriers exist to creating widespread positive change. Overall, despite growing interest in a locational approach to addressing health disadvantage, and evidence of considerable energy at grass root level, a locational approach can be expected to contribute little to improving the health of socio-economically disadvantaged urban Australians