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3.0 Introduction

Australians have one of the highest life expectancies in the world, but does this mean we are healthy? What does it mean to measure the health of a nation? And can we say, with such a diverse population, that we are doing better or worse across the board?

Death rates continue to drop in Australia, and not only are people living longer, but they are living with more years free of disability.

We have access to increasingly innovative and sophisticated health care, including improved detection, diagnosis and treatments that were not available to past generations.

Most deaths in Australia are caused by chronic disease rather than acute illnesses that were the cause of most deaths a hundred years ago. But many of these diseases, such as cardiovascular diseases, some cancers, chronic obstructive pulmonary disease and diabetes, are increasing because of changes to our lifestyles.

Chronic diseases not only have a profound effect on an individual's health, but they are placing an increasing burden on our national health-care system, including increased pressure on paying for and staffing our health system.

What is also clear is that not all Australians are as healthy as they could be. While we're doing better on many fronts, inequalities in health continue to exist for many population groups, including Indigenous Australians where the health gap is narrowing. However, big disparities, for instance in life expectancy, continue to exist.

Certain population groups, for example people living in lower socioeconomic areas, experience increased health risk factors compared with other Australians.

Assessing the health of Australians is a complex task, and involves looking at multiple aspects of health, including both physical health and mental health and wellbeing. This information can be derived from a number of sources, including from an individual's perspective via self-reporting, for example, through health surveys, and from health-care providers, for example, via information recorded in health records and on death certificates.

This chapter attempts to paint a summary picture of the ways Australia as a nation is healthy, and areas where we could be doing better.

It gives key measures that allow us to assess how healthy we are, including information on leading causes of death and life expectancy. It also includes an overview of changes in health status over time, attempting to answer the question, 'Are we getting healthier?'

Knowing where we are at in terms of our health helps governments plan and allocate for health care into the future, helps health-care professionals and researchers target research and innovation, and helps individuals and population groups assess their own health.

3.1 Life expectancy

Life expectancy is the most commonly used measure of the overall health of a population. It can be defined as how long, on average, a person can expect to live, based on current death rates at different ages for males and females.

Life expectancy is often expressed as either the number of years a newborn baby is expected to live, or as the expected number of years of life remaining for a person at a given age. Life expectancy changes over a person's lifetime because as a person survives the periods of birth, childhood and adolescence, their chances of reaching older ages increases.

Life expectancy varies over time and between population groups. Differences in life expectancy between population groups and geographical regions can indicate underlying health inequalities due to social, environmental or other factors.

Life expectancy at different ages

  • Life expectancy in Australia for a boy born in 2012 was 79.9 years, and for a girl, 84.3 years.
  • Men who had survived to the age of 65 in 2012 could have expected to live, on average, an additional 19.1 years (to 84.1 years), and women an additional 22.0 years (to 87.0 years).

Trends in life expectancy

  • Life expectancy in Australia has risen by more than 30 years since the late 1800s (Figure 3.1).
  • A boy born in 1890 had a life expectancy of 47.2 years; for girls it was 50.8 years.

Figure 3.1: Life expectancy at birth, Australia, by sex, 1890 to 2012

Line chart showing the trending increase in life expectancy at birth from 1890 to 2012 for males and females, from approximately 50 to 80 years.

Note: Data points on this graph are based on either a 3- or 10-year period ending in the year shown to reduce the effect of fluctuations in death rates from year to year—for example the 2012 figure refers to babies born in 2010–2012, and the figure for 1890 is for babies born in 1881–1890.

Sources: ABS 2008, 2013.

Life expectancy by state and territory

  • In 2012, babies born in the Australian Capital Territory enjoyed the longest life expectancy of any state or territory in Australia— 81.2 years for boys and 85.1 years for girls (Table 3.1).
  • The Northern Territory had the lowest life expectancy—74.7 years for boys in 2012, and 80.0 years for girls.
  • Indigenous life expectancy continues to be substantially lower than for the non-Indigenous population (see Chapter 7 'Indigenous life expectancy and death rates').
Table 3.1: Life expectancy (years) at birth, by sex, by state and territory, 2012
State or territory Males Females
New South Wales 79.9 84.2
Victoria 80.5 84.5
Queensland 79.5 84.0
South Australia 79.8 84.2
Western Australia 80.1 84.8
Tasmania 78.7 82.6
Northern Territory 74.7 80.0
Australian Capital Territory 81.2 85.1

Source: ABS 2013.

How does Australia compare?

  • In 2011, Australia was ranked 6th among OECD countries for life expectancy at birth for males, and 7th for females (Table 3.2).
  • The highest life expectancy at birth in 2011 was 80.7 for males in Iceland and 85.9 for females in Japan.
  • Over the last 2 decades, Australia has consistently ranked in the top 10 of OECD countries for life expectancy at birth (see Chapter 9 'International comparisons').
Table 3.2: Life expectancy (years) at birth, by sex, top 10 OECD countries, 2011
Rank
Country
Males
Country
Females
1 Iceland 80.7 Japan 85.9
2 Switzerland 80.5 France 85.7
3 Italy 80.1 Spain 85.4
4 Sweden 79.9 Italy 85.3
5 Israel 79.9 Switzerland 85.0
6 Australia   79.7   Korea 84.5
7 Japan 79.4 Australia   84.2  
8 Spain 79.4 Iceland 84.1
9 Netherlands 79.4 Portugal 84.0
10 New Zealand 79.4 Austria 83.9

Source: OECD 2013.

What is missing from the picture?

There are currently no national data to describe the relationship between life expectancy and long-term health conditions or lifestyle behaviours—for example, life expectancy of smokers compared with non-smokers.

Similarly, no data are available on life expectancy by socioeconomic factors, country of birth, employment, or level of education.

Where do I go for more information?

Information about life expectancy is published on AIHW.

References

ABS (Australian Bureau of Statistics) 2008. Australian historical population statistics, 2008: life tables. ABS cat. no. 3105.0.65.001. Canberra: ABS.

ABS 2013. Deaths, Australia, 2012. ABS cat. no. 3302.0. Canberra: ABS.

OECD (Organisation for Economic Co-operation and Development) 2013. OECD health at a glance 2013: OECD indicators. Paris: OECD Publishing.

3.2 Leading causes of death in Australia

Examining leading causes of death can help us to understand health in different populations and population groups. Exploring changes over time can help us to evaluate the effects of health policies, interventions, and new treatments.

Changes in the pattern of causes of death may also reflect changes in behaviours, exposures, and social and environmental circumstances.

About deaths data

Causes of death are documented on death certificates completed by medical practitioners or coroners, and coded using the World Health Organization (WHO) International Statistical Classification of Diseases and Related Health Problems (ICD) by the Australian Bureau of Statistics.

The ICD allows for the categorisation of causes of death into disease groups in a way that is meaningful for public health purposes. The AIHW uses the disease groups recommended by WHO (Becker et al. 2006) with minor modifications to suit the Australian context.

'Leading causes of death' analyses are based solely on what is called the underlying cause of death, which, broadly, is the disease or injury that initiated the train of events leading to death. Most deaths, however, are the result of more than one contributing disease or condition (see Chapter 3 'Multiple causes of death in Australia').

What are the leading underlying causes of death in Australia?

  • There were 146,932 deaths in Australia in 2011.
  • The leading underlying cause of death was coronary heart disease, accounting for 11,733 male deaths and 9,780 female deaths (Figure 3.2).
  • For males the next most common causes of death were lung cancer (4,959 deaths) and cerebrovascular diseases (which include stroke) (4,427 deaths).
  • For females the next most common causes of death were cerebrovascular diseases (6,824 deaths), and dementia and Alzheimer disease (6,596 deaths).

Have leading causes of death changed over time?

  • For both males and females, the 5 leading causes of death were the same in 2001 and 2011, albeit with different rankings (Figure 3.2).
  • The leading cause of death in both years was coronary heart disease, accounting for 20% of deaths in 2001 and 15% in 2011.
  • For males, the largest changes in leading causes of death from 2001 to 2011 were the rise of dementia and Alzheimer disease from 13th to 6th place, and the fall of land transport accidents from 9th to 17th place.
  • For males, 2 leading external causes of death (land transport accidents and suicides) fell in rank over this period while many cancer causes of death rose in rank (lung, prostate and pancreatic cancers, and cancers with unknown or ill-defined site).
  • For females, many leading cancer causes of death (breast, colorectal, pancreatic and ovarian) fell in rank over this period—for example, breast cancer fell from 3rd in 2001 to 5th in 2011. Meanwhile, lung cancer deaths rose in rank, from 5th in 2001 to 4th in 2011.

Figure 3.2: Leading underlying causes of death, males and females, Australia, 2001 compared with 2011

Figure comparing the underlying causes of death in males in Australia in 2001 compared with 2011. Coronary heart disease was the biggest killer in both cases, causing 20.8% of deaths in 2001, and 15.6% of deaths in 2011. Figure comparing the underlying causes of death in females in Australia in 2001 compared with 2011. Coronary heart disease was the biggest killer in both cases, causing 20.0% of deaths in 2001, and 13.7% of deaths in 2011.

Source: AIHW National Mortality Database.

Notes

  1. Rankings are based on number of deaths; a decline in rank does not necessarily indicate a decline in the number of deaths.
  2. Codes refer to the International Classification of Diseases, 10th revision (ICD-10).
  3. Data for 2011 are based on the preliminary version of cause of death data and are subject to further revision by the ABS. Causes of death that are likely to be affected by the revisions process are particular external causes of death, such as suicide and land transport accidents. Revised and finalised data may reflect higher counts of both suicide and land transport accidents.
  4. Coloured lines point to the cause as ranked in 2011; causes in bold indicate they have moved into the leading 20 causes in 2011 while those in grey have moved out since 2001.

Do leading causes of death vary depending on where you live?

  • Coronary heart disease was the leading cause of death in all areas, from Major cities to Very remote, in 2009–2011.
  • Diabetes ranked higher as a cause of death among people living in Remote and Very remote areas compared with regional and city areas.
  • Cerebrovascular diseases, and dementia and Alzheimer disease ranked higher among diseases causing death in Major cities, and Inner regional and Outer regional areas compared with the more remote areas.
  • Land transport accidents ranked more highly with increasing remoteness—they were not in the top 15 in Major cities or Inner regional areas, but ranked 13th in Outer regional areas, 8th in Remote areas and 4th in Very remote areas.
  • Deaths from suicide accounted for a greater proportion of all deaths in Remote and Very remote areas, 4% and 3%, respectively, compared with 2% or less in other areas.
  • Causes of death that ranked in the leading 15 causes of death in Remote and Very remote areas and not in Major cities and regional areas include perinatal and congenital conditions, cirrhosis and other diseases of the liver and unknown and ill-defined causes.

What is missing from the picture?

Socioeconomic factors such as highest level of education achieved and main occupation are known to be associated with mortality and particular causes of death. This information is not collected in Australian deaths data.

The leading causes of death presented here are based purely on counts of deaths in a particular year; the extra impact of early deaths due to particular causes is not assessed. Burden of disease analyses do, however, quantify the effects of diseases and injuries in terms of 'healthy life' lost due to premature death or disability (see Chapter 4 'Burden of disease').

Where do I go for more information?

More information on deaths and leading causes of death in Australia, including by different age groups, is available.

Information on variations in leading causes of death by socioeconomic status, remoteness and other socio-demographic variables will be available in a forthcoming AIHW publication Mortality inequalities in Australia.

3.3 Multiple causes of death in Australia

Death statistics are usually analysed and reported using the underlying cause of death only (see Chapter 3 'Leading causes of death in Australia'). In most cases, however, more than 1 cause is recorded on the death certificate.

Examining multiple causes of death may offer better insights into all the disease processes occurring at the end of life, which can in turn be useful for developing better prevention and treatment policies and practices, refining disease surveillance activities, guiding research investment and enhancing burden of disease estimates (see Chapter 4 'Burden of disease').

Box 3.1: What are multiple causes of death?

The underlying cause of death is the disease or injury that initiated the train of events leading directly to death, or the circumstances of the accident or violence that produced the fatal injury. Deaths are referred to here as 'due to' the underlying cause of death.

Associated causes of death are all causes listed on the death certificate, other than the underlying cause of death. They include the immediate cause, any intervening causes, and conditions which contributed to the death but were not related to the disease or condition causing the death.

Multiple causes of death are defined here as all causes listed on the death certificate. This includes the underlying cause of death and all associated causes of death (ABS 2013).

The work presented here focuses on natural causes of death. These are deaths that were not due to external causes such as accidents, injury and poisoning, or due to ill-defined causes.

  • Of the 146,932 deaths in Australia in 2011, 94% (137,809 deaths) were due to natural causes.
  • In 2011, 81% of natural deaths had more than 1 cause and, on average, 3.2 diseases or conditions were recorded on the death certificate.

Chronic diseases as causes of death

Analysis of multiple causes of death is particularly useful in relation to chronic diseases, which were commonly recorded in combinations of 2 or more. In 2011:

  • Coronary heart disease was an associated cause of death for 51% of deaths due to diabetes, 28% of deaths due to chronic and unspecified kidney failure and 19% of deaths due to chronic obstructive pulmonary disease (COPD).
  • Hypertensive disease was an associated cause of death for 35% of deaths due to diabetes, 28% of deaths due to cerebrovascular diseases (which include stroke) and 21% of deaths due to coronary heart disease.
  • Kidney failure was an associated cause of death for 26% of deaths due to diabetes.
  • Influenza and pneumonia was also a common associated cause of death—more specifically, for 31% of deaths due to asthma, 30% of deaths due to COPD and 29% of deaths due to dementia and Alzheimer disease.

Underlying versus associated causes of death

  • Chronic diseases that are more likely to be reported as the underlying cause of death rather than as an associated cause of death include prostate, breast, colorectal (bowel), liver and lung cancers (Figure 3.3).
  • Chronic diseases that are more likely to be reported as associated causes of death include chronic and unspecified kidney failure, diabetes, asthma, COPD, and dementia and Alzheimer disease.
  • When deaths are reported by the underlying cause of death only, the involvement of certain diseases in overall mortality may be underestimated. This is particularly evident for chronic and unspecified kidney failure, diabetes, asthma, COPD, and dementia and Alzheimer disease.

Figure 3.3: Selected chronic diseases as underlying and associated causes of death, 2011 (per cent)

Chart showing selected chronic diseases as underlying and associated causes of death in 2011. Chronic and unspecified kidney failure was an associated cause of death in approximately 80% of cases. Lung cancer was an underlying cause in over 90%.

Notes

  1. Deaths registered in 2011 are based on the preliminary version of cause of death data and are subject to further revision by the ABS.
  2. Underlying refers to deaths with the disease recorded as the underlying cause of death, regardless of whether the disease was also recorded as an associated cause of death. Associated refers to deaths with the disease recorded only as an associated cause of death.

Source: AIHW National Mortality Database.

What is missing from the picture?

Socioeconomic factors such as highest level of education achieved and main occupation are known to be associated with mortality and particular causes of death. This information is not collected in Australian deaths data.

Where do I go for more information?

More information on multiple causes of death in Australia is available. The report Multiple causes of death in Australia: an analysis of all natural and selected chronic disease causes of death 1997–2007 is also available for free download.

References

ABS (Australian Bureau of Statistics) 2013. Causes of death, Australia, 2011. ABS cat. no. 3303.0. Canberra: ABS.

3.4 Are we getting healthier?

Australians have one of the longest life expectancies in the world, but does this mean we are healthier than our parents or grandparents?

The concept of what it is to be 'healthy' encompasses more than just how many years a person lives—for example, it could also include consideration of how many of those years are spent in good health or with disability or chronic illness.

While a baby born today can expect to live about 30 more years than a baby born in the late 1800s, he or she will face a set of different health challenges, largely driven by lifestyle factors not encountered by previous generations.

Extra 'healthy' years

A boy born in 1881–1890 had a life expectancy of 47.2 years and a baby girl 50.8 years. Today, a baby boy can expect to live to 79.9 and a baby girl to 84.3 (see Chapter 3 'Life expectancy').

Importantly, we are not just living longer, but have more years living free of disability. A baby boy born in 2012 could expect to live 62.4 years free of disability and 17.5 years with some form of disability. This compares with a baby boy born in 1998 who could expect to live 58 years free of disability and 17.9 years with some form of disability. A baby girl born in 2012 could expect to live 64.5 years free of disability and 19.8 years with some form of disability. This compares with a baby girl born in 1998 who could expect to live 62.1 years free of disability and 19.4 years with some form of disability (AIHW forthcoming) (see Chapter 6 'Ageing and the health system').

Box 3.2: Age-standardisation

'Age-standardised' refers to removing, statistically, the influence of differing age structures when comparing populations. See Glossary for more information.

There has been a long and continuing decline in death rates in Australia. Between 1907 and 2012, the age-standardised death rate fell by more than 70%, from 2,054 to 550 deaths per 100,000 population (ABS 2013d; AIHW 2013c) (see Figure 3.4).

Figure 3.4: Age-standardised death rates, by sex, 1907–2012

Line chart showing the trending decline in the standardised death rate (per 100,000 population), by sex, between 1907 and 2012.

Sources: ABS 2013d; AIHW 2013c.

The rate of potentially avoidable deaths (deaths among people younger than 75 that are potentially avoidable within the present health-care system) has also been in decline.

Potentially avoidable deaths are divided into potentially preventable deaths (those amenable to screening and primary prevention, such as immunisation) and deaths from potentially treatable conditions (those amenable to therapeutic interventions). Preventable death rates fell by 36% between 1997 and 2010 (from 142 to 91 deaths per 100,000) and rates of deaths from treatable conditions fell by 41% between 1997 and 2010 (from 97 to 57 deaths per 100,000) (see Chapter 9 'Indicators of Australia's health').

We're dying of different things than in the past

In 1900, people could mainly expect to die from pneumonia, influenza, tuberculosis, gastrointestinal infections, heart disease and strokes (Jones et al. 2012).

In 2011, the top 5 causes of death in Australia for males were coronary heart disease, followed by lung cancer, cerebrovascular disease (including stroke), prostate cancer and chronic lower respiratory disease. For females, the top 5 causes were coronary heart disease, cerebrovascular disease, dementia and Alzheimer disease, lung cancer and breast cancer (see Chapter 3 'Leading causes of death in Australia').

Why the change and what does it mean for our health status?

Since the 1900s, sanitation and housing have improved and vaccines have been developed to help our fight against infectious diseases. In many parts of the world, diseases that killed our ancestors no longer prove fatal; however, while we have capitalised on medical advances and technological innovations to treat and prevent these diseases, new threats have emerged.

Changing lifestyles

We are now dealing with different causes of illness than past generations. Compared with previous generations, life for many of us today is increasingly inactive.

In the early 20th century, people ate fewer processed foods, walked more, did more manual labour, lived with fewer labour-saving appliances and gadgets, and spent less time in front of televisions and other screens.

According to the latest ABS Australian Health Survey (AHS), in 2011–12 adults spent an average of just over 30 minutes a day doing physical activity. When measured against the National Physical Activity Guidelines for adults 'to do at least 30 minutes of moderate intensity physical activity on most days', only 43% met the 'sufficiently active' threshold (ABS 2013c).

Children and teenagers aged 5–17 spent 1.5 hours a day doing physical activity and more than 2 hours a day in screen-based activity (watching TV, DVDs or playing electronic games). Moreover, physical activity fell as children got older (ABS 2013c).

As we are discovering, lifestyle factors such as this can have a profound effect on our health and increase our likelihood of being ill with chronic disease.

Today, nearly two-thirds of Australian adults are overweight or obese (63%), an increase from 56.3% in 1995 and 61.2% in 2007–08 (ABS 2013c). There are an estimated 1 million people aged 2 and over with diagnosed diabetes in Australia. However, this is likely to be an underestimate—for every 4 adults with diagnosed diabetes, there is estimated to be 1 with undiagnosed diabetes (AIHW 2013d) (see Chapter 4 'Diabetes').

As well as not getting enough exercise and carrying too much weight, many of us do not eat sufficient fruit and vegetables and some of us smoke tobacco or consume alcohol at risky levels.

In 2011–12, less than half of Australian adults (48.5%) reported that they usually ate the recommended 2 serves of fruit per day and only 8% that they ate the recommended 5 or more serves of vegetables per day. Overall, only 5.5% of Australian adults ate the recommended daily intake of both fruit and vegetables (ABS 2013c).

These self-reported findings were similar to those from the 2007–08 National Health Survey where 9% of people aged 15 and over did not usually consume sufficient serves of vegetables and about half (49%) did not usually consume sufficient serves of fruit (AIHW 2012).

Older Australians (aged 65 and over) in both surveys were more likely to meet the guidelines than younger Australians.

Smoking rates in Australia are still falling, continuing a long-term downtrend trend over the past 50 years. In 1964, 43% of Australian adults smoked (OECD 2013), but by 2010 this rate had dropped to 16%. Moreover, fewer younger people are now taking up smoking. In 2001, about one-quarter of 18- to 24-year-olds smoked daily—by 2010, this had fallen to 16% (see Chapter 5 'Tobacco smoking').

Results from the 2010 National Drug Strategy Household Survey showed that while daily drinking declined between 2007 (8.1%) and 2010 (7.2%), 1 in 5 people drank at a level that put them at risk of harm over their lifetime. The rate of people drinking at a level that put them at risk of harm over their lifetime has remained stable since 2001 (see Chapter 5 'Alcohol risk and harm').

These behaviours put us at an increased risk for a range of chronic diseases, including heart disease, stroke and cancer (see Table 3.3 and Chapter 4 'Chronic disease—Australia's biggest health challenge').

Table 3.3: Relationship between selected chronic conditions and risk factors
Conditions Behavioural - Tobacco smoking Behavioural - Physical inactivity Behavioural - Risky alcohol consumption Biomedical - Poor diet Biomedical - Obesity Biomedical - Hypertension(a)   Biomedical - High blood fats
Ischaemic heart disease Yes Yes No Yes Yes Yes Yes
Stroke Yes Yes Yes Yes Yes Yes Yes
Type 2 diabetes Yes Yes No Yes Yes Yes No
Kidney disease Yes Yes No Yes Yes Yes No
Arthritis Yes(b)   Yes(c)   No No Yes(c)   No No
Osteoporosis Yes Yes Yes Yes No No No
Lung cancer Yes No No No No No No
Colorectal cancer No Yes Yes Yes Yes No No
Chronic obstructive pulmonary disease Yes No No No No No No
Asthma Yes No No No No No No
Depression No Yes Yes No Yes No No
Oral health Yes No Yes Yes No No No
  1. High blood pressure.
  2. Relates to rheumatoid arthritis.
  3. Relates to osteoarthritis.

Note: The relationships shown above relate to the causation (development) of the chronic diseases. They do not to reflect the determinant's role (effect) on management of the chronic disease.

Source: AIHW 2012 adapted from AIHW 2008.

Stress of everyday life

Today's generation faces emotional, mental and physical stressors that are fuelled by living in a fast-moving, ever-changing world.

Stress has been associated with a range of illnesses, from headaches and sleep disorders to autoimmune diseases and heart problems (mindhealthconnect 2012). Stress can be triggered by a multitude of causes, from running late for an appointment to a life-changing event such as the death of a family member or partner. Common everyday stressors include job insecurity, financial worries and relationship difficulties.

While a British review of research into the health benefits of work found that, in general, work improved physical and mental health and wellbeing (Waddell & Burton 2006), work stress has been shown to increase the risk of developing mood and anxiety disorders, coronary heart disease and metabolic syndrome, which can be a precursor to type 2 diabetes, stroke and heart disease (Chandola et al. 2006; Marmot et al. 1997; Rosengren et al. 2004; Szeto & Dobson 2013) (see Chapter 6 'The health of our working age population').

Indigenous health

Indigenous Australians experience poorer health and have worse health outcomes than other Australians. They have a burden of disease 2–3 times greater than the general Australian population, and are more likely to die at younger ages, experience disability and report their health as fair or poor (see Chapter 7 'How healthy are Indigenous Australians?').

The gap in the health of Indigenous and non-Indigenous Australians is best illustrated by differences in life expectancy. Life expectancy at birth for Indigenous Australians in 2010–2012 was 73.7 years for females and 69.1 years for males, compared with 83.1 and 79.7 years for non-Indigenous females and males respectively (ABS 2013e) (see Chapter 7 'Indigenous life expectancy and death rates'). These differences in health start at birth and continue throughout life. Babies born to Indigenous mothers are more likely to be of low birthweight than babies born to non-Indigenous mothers and Indigenous children die at more than twice the rate of non-Indigenous children. Between 2008 and 2012, 203 out of 100,000 Indigenous children aged 0–4 died compared with 91 out of 100,000 non-Indigenous children. Indigenous adults of all ages also died at a higher rate than non-Indigenous Australians (AIHW 2013a; SCRGSP forthcoming) (see Chapter 7 'Indigenous life expectancy and death rates').

Despite this continuing health gap, there have been improvements in recent years. Overall mortality for Indigenous Australians fell by 19% from 1991 to 2011, and Indigenous infant mortality rates fell by 62% from 2001 to 2012 (AIHW 2013a).

While mortality rates for chronic diseases were much higher for Indigenous Australians (over 5 times the rate of non-Indigenous Australians for diabetes and twice the rate for circulatory diseases in 2007–11), deaths due to circulatory disease fell by 41% and deaths due to respiratory disease fell by 39% from 1997 to 2010 (AIHW 2013a). However, in the same period, there was a large increase (96%) in incidence rates of treated end-stage renal disease among Indigenous Australians (currently 7 times the rate for non-Indigenous Australians) and Indigenous Australians were twice as likely to be hospitalised for mental and behavioural disorders, and injury and poisoning, as non-Indigenous Australians between July 2010 and June 2012 (see Chapter 7 'How healthy are Indigenous Australians?').

Living with ill health

In the 19th and early 20th centuries, many people who became acutely ill died quickly. And, as outlined earlier, today many of these acute illnesses have been replaced by chronic, non-communicable illnesses that now cause most of the disease burden—in 2011, 90% of all Australian deaths were caused by a chronic disease (see Chapter 4 'Chronic disease—Australia's biggest health challenge').

Typically, chronic conditions are long-lasting, have persistent effects, and can range from conditions such as short- or long-sightedness to debilitating arthritis and low back pain, to life-threatening heart disease and cancers. Once present, chronic conditions often persist throughout life—which means that although Australians are now living longer, many people live with some type of ill health for many years, with a need for long-term management.

ABS Australian Health Survey data for 2011–12 indicate that about 3.3 million Australians (14.8% of the population) have arthritis, 2.3 million (10.2%) have asthma, 1 million have heart disease (5%) and 1 million have diabetes (5%) (ABS 2013b; 2013c).

Living with chronic illness

Living with a chronic illness can affect many aspects of a person's life. For example, people with asthma rate their health as worse than people without the condition, with most of the impact on their physical functioning and social and work life (ACAM 2011).

And while people who control their asthma with medication and a management plan can lead a normal life (National Asthma Council Australia 2013), most people with asthma do not have a written action plan, and poor asthma control (frequent symptoms and asthma exacerbations) is a common problem in both adults and children (ACAM 2011).

The burden of chronic conditions extends far beyond personal costs and results in a significant national economic burden. Estimates based on allocated health care expenditure indicate that the 4 most expensive disease groups are chronic—cardiovascular diseases, oral health, mental disorders, and musculoskeletal—incurring direct health-care costs of $32 billion, or 43% of all allocated health expenditure in 2008–09 (see Chapter 4 'Chronic disease—Australia's biggest health challenge').

New health responses

Although Australians now face the challenges of rises in non-communicable diseases which have a long latency period and are more frequent with ageing (Hetzel 2001), we also have new answers to those challenges. Today we have access to an increasingly innovative and sophisticated health system providing care and treatment regimens that were not available in the past. Cancer is one such example.

Cancer is the second leading cause of death in Australia (after cardiovascular disease) but despite a rise in new cases diagnosed, the mortality rate has fallen and people are living longer after diagnosis. Why? Detection and treatment have improved markedly in recent years, and national screening programs have been established for breast, bowel and cervical cancer (see Chapter 4 'Cancer in Australia'). So, while more people are being diagnosed with cancer, more people are surviving due to early detection (which is associated with more successful treatment, generally) and better treatment technology and delivery.

Inequalities

Presenting a broad picture of health status to some extent masks that there are clear inequalities in health for many Australians, particularly Indigenous Australians (as described earlier), people living in rural and remote areas, and the socioeconomically disadvantaged.

People living outside Australia's major cities have worse outcomes on leading indicators of health and access to care. They have higher rates of obesity, smoking and risky alcohol consumption, their rates of potentially preventable hospitalisations are also higher and they are less likely to gain timely access to aged care (COAG Reform Council 2013). The COAG Reform Council report, Healthcare 2011–12: comparing outcomes by remoteness, also found that people living outside major cities were more likely to defer access to dental services and general practitioners due to cost and were more likely to wait longer than 1 year for access to public dental services.

It has been suggested that socioeconomic factors have the largest impact on health, accounting for up to 40% of all influences compared with health behaviours (30%), clinical care (20%) and the physical environment (10%) (The British Academy 2014).

The World Health Organization's Commission on Social Determinants of Health concluded that social inequalities in health arise because of inequalities in the conditions of daily life and the fundamental drivers that give rise to them: inequities in power, money and resources (Commission on Social Determinants of Health 2008).

The WHO describes a 'social gradient in health' which shows that, in general, the lower an individual's socioeconomic position the worse their health. Where people are in the social hierarchy affects the conditions in which they grow, learn, live, work and age, their vulnerability to ill health and the consequences of ill health (WHO 2014).

So, are we healthier?

The change in the patterns and causes of illness and deaths in Australia and many other countries has been described as the 'health transition' from a pattern of high mortality from infectious diseases to one of lower overall mortality from non-communicable disease and injury (Hetzel 2001).

It could be argued that we are both healthier and unhealthier in different ways compared with the past, and that we have, perhaps, more control of our health. Today there are medications and treatments that were not available to our predecessors—medical technologies such as minimally invasive surgery and devices such as pacemakers and hip replacements offer not just more treatment options, but in some cases treatments that were previously not available at all.

Emerging technologies such as telehealth enable people to monitor chronic conditions such as diabetes and hypertension in their own homes, with the support of health professionals (see Chapter 2 'Australia's health system'). Avenues such as online health forums and websites provide better access to health information, making it easier to take more personal responsibility for our own health management.

How do we rate our own health?

According to the Australian Health Survey, in 2011–12 more than half (55.1%) of all Australians aged 15 and over considered themselves to be in 'excellent' or 'very good' health, and another 30.3% in 'good' health. Just over 1 in 10 (10.7%) rated their health as 'fair', and 4.0% as 'poor'. These ratings are slightly better than those recorded in 1995 when 54.3% rated their health as 'excellent' or 'very good', 28.3% as 'good', 13% as 'fair' and 4.2% as 'poor' (ABS 2006; 2013c).

Older Australians generally rated themselves as having poorer health than younger people. People aged 75–84, and 85 and over, recorded the highest proportions of 'fair' health (21.6% and 23.3% respectively) and 'poor' health (9.7% and 14.2%). About 35% of people aged 75–84 rated their health as 'excellent' or 'very good', and a further 33% as 'good'. About 30% of those aged 85 and over rated their health as 'excellent' or 'very good' and 32% as 'good' (ABS 2013c).

In comparison with figures given earlier for all Australians, only 39% of Indigenous Australians rated their health as 'excellent' or 'very good', 36% as 'good', 18% as 'fair' and 7% as 'poor' in 2012–13 (ABS 2013a).

Where do I go for more information?

Detailed information on Australians' health and wellbeing, including on leading causes of ill health and risk factors, is available at the AIHW website. Detailed information on the ABS Australian Health Survey is available.

References

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