In the next installment of my as-yet-unfortunately named Why Am I (x)? Trilogy, I am going to address another of the biggest areas of socially defined health; lung disease. I am also going to introduce those of you who are unlucky enough to have never had much exposure to the public health sphere to a key idea. It’s called the social determinants of health. For those of you who are public health nerds or, more likely, who can’t be bothered to read several hundred words on a subject with so many syllables, skip ahead to the subtitle ‘smoking’ and save yourself what I can only assume is minutes of agony.

Seriously. Minutes.

The basic idea of social determinants of health is something that I alluded to quite a bit in my last, seriously incredible, blog post. Essentially what it says is that whilst an individual can have a great amount of control over their lives, the biggest impact on any group of people’s health is environmental. In this context, environmental means everything to do with your lived environment. For example, a great way to get fit is to cycle. Not only is cycling a great way to get fit, it is increasingly being promoted as one of the best ways in which to increase the overall fitness (and therefore health) of the population. In a very real sense, having the ability to cycle can change your health for the better. Now, take a look at the cycling map of Sydney;

Green is cycleway, grey is road, baby blue is oncoming Horde of the Unliving

Whilst this is better than a lot of cities, you might notice something. There’s a really nice green area around the centre of Sydney, with a few outlying dense areas towards the north and west. These also happen to be some of the richest areas in Australia. And the social elements of exercise don’t end there. Gym equipment in parks? Something overwhelmingly afforded to the wealthier suburbs. The all-too-often ignored fact is that being born (or living) in a ‘better’ suburb simply makes it more likely that you will have access to exercise. For everyone else, getting the recommended 30 minutes of cardio a day is significantly more difficult. Notice I’m not saying impossible. But when push comes to shove, rich people have more access to forms of exercise that are both easy and fun, and naturally they will use these.

The rest of us will have to make do with the lesser known sport of chocolate smearing

Smoking fits neatly into our social determinants of health. Things that make you more likely to smoke are very closely tied to social status. Education and income are two of the biggest determinants of whether you will end up coughing your life away at the age of 35 or having the lungs of a 35-year-old when you are on your deathbed at the age of 95. In some countries, being a woman makes you more likely to smoke, although in most it’s men who are the biggest smokers. Where you live effects your smoking chances, with wealthy inner-city suburbs as much as 4x less likely to smoke than less well-off regional areas.

But remember, smoking is a choice.

For those living in an inner-city suburb, whose parents didn’t smoke and who have ample opportunities to quit, who can afford to spend significant sums on any one of the a multitude of methods, who are lucky enough to be educated in why smoking is bad; smoking is a choice. For those living in areas where everyone they know smoke, and who can’t afford to do anything other than trudge to the corner store and buy another pack of increasingly-expensive cigarettes that they know are bad for them but what the heck they can’t be that bad right; smoking is far less of a choice.

No one’s forcing them to smoke. But they have far less ability to quit. And if you are still living in the 50s and haven’t heard; smoking kills. If you can’t be bothered clicking that link, it describes smoking as the single greatest cause of lost life in the world. 1 billion people are expected to die of smoking in the near future. One seventh of the current population of the world is going to breathe their last, after years of struggling to climb stairs as their lungs slowly give out.

Seriously. Smoking kills.

Smoking; crutch of the Poor and the Eyebrowed

Asbestos is one of those scary hangovers from the 70s, much like Mick Jagger’s increasingly creviced face. Everyone has heard of mesothelioma, which is surprising for a cancer with so many syllables. If they haven’t, they’ve definitely heard of asbestosis. And these are scary diseases. The survival time for both is often measured in months, not years, unlike Jagger’s face which is likely to outlive us all by centuries.

Deep within those wrinkles lies the elixir of life

And again, asbestos exposure becomes massively more likely if you are less well-off. Salary has a huge impact on asbestos exposure. Education too. Living and working in a less affluent suburb. Any number of factors that are often decided by how much money your parents make can decide whether you are picking out high schools for your children (or, for the lucky childless few, mansions) at age 40 or having fluid drained from your lungs as you struggle to breathe in a hospital bed.

It’s never fun to think that we might not be as much in control as we think.

There are a myriad of other social determinants of poor lung health. Living near a motorway is more likely for low SES families, and has a serious impact on your long-term lung health. The school you go to as a child can be the difference between good lungs and bad later in life. It’s all too clear that where you are born, who your parents are and what you do can have a far greater impact on your health than any changes you make in your life by choice.

And this is where the story gets infuriating, because despite all of our successes with decreasing smoking rates in Australia (and really, we have done amazingly), we still talk all too often of lung health as a choice. We design policy that assumes that everyone lives in Balmain with the lowest smoking rates in the country rather than the Grampians with the highest. Or we assume that everyone can dispose of their asbestos safely. Or we make one of many thousands of assumptions that completely ignore the reality of how our lived environment determines who we are and how long we live.

And it’s time to stop.

Epidemiologist. Writer. Podcaster. Twitter https://twitter.com/GidMK FB www.facebook.com/gidmkhealthnerd/ Email gidmk.healthnerd@gmail.com