There is a heavy burden of disease associated with family violence, discrimination, bullying and social exclusion.
These important causes of suffering and loss of productivity all relate to a very fundamental feature of human existence and civil(ised) societies — the way we treat each other. We can, and do, make each other sick.
Reducing the resultant human and economic costs has major implications for the way we distribute opportunity, wealth and amenity.
These, in turn, have implications for the way we protect and empower minority groups, and for legislation, education and the availability of, and access to, services.
The way we treat each other has the potential not only to affect our health and wellbeing, but also to engender significant social and economic costs to society. In a landmark study, Vos and colleagues found that intimate partner violence is the most important preventable cause of illness among women aged 18–44 years.1 The effects of violence manifest themselves as suicide, depression, anxiety and substance misuse. The overall economic cost of domestic violence in Australia was estimated to be $8.1 billion in the financial year 2002–03.2 The annual cost of child abuse and neglect in Australia in the financial year 2001–02 was estimated to be $4929 million,3 and elder abuse (often psychological and financial in nature) is both prevalent and costly.4
Bullying is associated with psychosomatic symptoms in children.5,6 Bond and colleagues from the Centre for Adolescent Health have estimated that up to 30% of depressive symptoms are associated with bullying in previous years at school.7 Bullying in the workplace is common and costly. It appears to be a relatively frequent experience across the industrialised world, and the European Parliament has accepted a baseline bullying incidence estimate of around 8% per year.8 Not surprisingly, workplace bullying has been found to be a strong risk factor for depressive symptoms in working populations.9
Apart from the human suffering it causes, workplace bullying lowers productivity and costs employers and taxpayers considerable sums of money. Sheehan and colleagues (cited in Mayhew and Chappel8) have estimated that bullying costs Australian employers $6–13 billion a year if both hidden and lost opportunity costs are included. Their review reported that workplace bullying was a contributing factor in up to 83% of staff turnover and 87% of absenteeism, and that it was associated with a drop of 21%–58% in efficiency and a decline of 19%–28% in work quality. Further, up to 18% of victims sought counselling, 10% initiated mediation or grievance proceedings, 10% showed increased error margins, 3% lodged workers compensation claims, 2% took antidiscrimination action, and 1% made an application to the Industrial Relations Commission.8 Behaving badly is behaving unproductively and inefficiently.
Discrimination in all its forms appears to be a major cause of ill health. Racial and ethnic discrimination is associated with multiple indicators of poorer physical and, especially, mental health status.10,11 The most recent systematic review of the relationship between self-reported racism and health showed significant associations between racism and tobacco smoking and alcohol and drug misuse in 62% of the relevant studies.8
Social exclusion can come in many forms, and people who are socially isolated are at risk of dying prematurely at a rate two to fives times higher than those with strong ties to family, friends and community.12 Students who have poor school connectedness and interpersonal conflict in early secondary school are more likely to have mental health problems and to smoke cigarettes regularly, use marijuana and consume alcohol in later years of schooling.13 How students are treated also affects their learning — low connectedness and bullying limit chances of completing school.
Our understanding of the role of social exclusion in the genesis of physical disease, and not only psychological or psychiatric disorders, is growing. A review by Bunker et al found that there is “strong and consistent evidence of an independent causal association between social isolation, lack of quality social support and depression and the causes and prognosis of coronary heart disease”.14 They also showed that the increased risk is of similar order to the widely recognised coronary heart disease risk factors such as smoking, dyslipidaemia and hypertension.
Perhaps one of the most worrying examples of the effect of exclusion has been the treatment of genuine refugees in Australia. We have shown that we can very successfully incubate mental illness by detaining them in our immigration centres.15,16 On releasing many detainees, the government went one step further in ensuring that they existed in a state of uncertainty by providing them with temporary protection visas, which allowed them temporary residence in Australia without any guarantee of access to services. Not surprisingly, they have been shown to do much worse in terms of “their mental health and their prospects for a secure resettlement trajectory” than those with permanent protection visas.17
Social exclusion, bullying, discrimination, and violence are all to do with a very basic feature of human existence — the way we treat each other. As Homo sapiens (literally, wise or knowing man), we are fundamentally social beings. We interact constantly, and we constantly talk of community, neighbourhoods and society. In families and in workplaces, although we have a need for autonomy, it is combined with the need for support from other family members or work colleagues.18,19
My view is that the way we treat each other is such an inherent part of our lives, such a banal concept, that we don’t see it as an important determinant of our health, let alone of our wellbeing and productivity. In a 2001 survey of 600 people, two-thirds of the participants thought that bullying was part of the Australian culture, but only 10% felt it should be so.20
Although the overwhelming majority of respondents (97% or more) did not believe that violence could be justified, sizeable proportions believed that there are circumstances in which it can be excused. Nearly 1 in 4 respondents believed that domestic violence can be excused if the perpetrator genuinely regrets what they have done afterwards or if the violence results from a temporary loss of control . . . Nearly two in five respondents believed that rape results from men not being able to control their need for sex.21
There has been much popular debate about the social, economic and political inequalities, let alone health inequalities, that exist in Australia and across the globe. Are not these just reflections of the way we treat each other, but at the larger national and international levels?
The other aspect that is often overlooked is that it is not only the victims of bullying, discrimination or violence that suffer, but also, in some cases, the perpetrators. Kaltiala-Heino and colleagues found an increased prevalence of depression and severe suicidal ideation among both those who were bullied and those who were bullies in Finnish schools.22 A recent multinational study, which examined the relationship between levels of patriarchy and male health by comparing female homicide rates with male mortality within countries, found that “oppression and exploitation harm the oppressors as well as those they oppress, and that men’s higher mortality is a preventable social condition”.23
A common response to violence and discrimination is the belief that they are simply part of human nature. It is exactly this approach that I wish to confront. If it is simply human nature, then why, for example, do countries such as Greece, Italy, Ireland, Norway and Spain have child death rates from maltreatment 10–15 times lower than those of the United States and Portugal? And why do child death rates correspond closely to rates of adult deaths from assault?24
Levinson, in analysing 90 different societies,25 found that “wife-beating” societies were ones in which men had the economic and decision-making power; women did not have easy access to divorce; adults routinely resorted to violence to solve their problems; women’s work groups were scarce or absent; rigid gender roles prevailed; and notions of manhood were linked to dominance, male honour and aggression. Are these societies fixed and unchangeable? Of course not.
There is no doubt that resolution of issues such as violence and discrimination is complex, but the response that they are part of a natural, unchangeable state of human existence is one that simply reinforces the problems.
Flood and Pease have said that “to prevent violence against women, we must not only change community attitudes, we must also address the structural conditions that perpetuate violence”.26 Similarly, if we are to reduce discrimination, bullying and social exclusion, there are major implications for the way we structure our society.
We therefore need to examine some of the more important ways that we can improve how we treat each other. To date, most of the work done to reduce discrimination, bullying, violence and social exclusion occurs outside the health sector. This is maybe as it should be, given the health sector’s role in “mopping up” societal ills, but what we must add is that there is a strong health imperative for society to reduce these harms.
There is a need to ensure protection of civil and political rights, including protection from discrimination and vilification, as outlined, for example, in the newly introduced Victorian Human Rights Charter.27 Such initiatives provide frameworks for the way we behave, but much more is needed.
There is a premise that much prejudice and discrimination is due to ignorance and a lack of constructive contact between different groups. Allport (cited in Pettigrew and Tropp28) postulated in 1954 that reduced prejudice results when the following four features are present:
equal status between groups;
common goals among groups;
intergroup cooperation; and
the support of authorities, law or custom.
A meta-analysis of intergroup work in the US has shown that prejudice and discrimination can be reduced by applying Allport’s conditions.28 This implies that we need to create many more long-term and practical avenues for working towards equal status, common goals and intergroup cooperation and learning, and for removing institutionalised prejudice. Doing this would foster the integration and long-term settlement of the many new arrivals in Australia each year, and, equally importantly, would improve Indigenous health by reducing the huge burden of discrimination and racism that Australian Indigenous people face today.
Olweus, the “father” of antibullying programs, developed an approach in the 1980s in Norway that reduced bullying by 50%. The program was based on restructuring the learning environment to create a social climate characterised by supportive adult involvement, positive adult role models, firm limits, and consistent, non-corporal penalties for bullying behaviour.29
Australian studies of workplace bullying have also recommended that organisations establish antiviolence policies and programs. These involve monitoring the incidence of violence, developing codes of rights for victims, suspending perpetrators before their negotiation of return to work, quarantining victims from bullies, and retraining perpetrators. They also suggest the need for occupational health and safety “duty of care” legislative provisions that recognise explicitly that bullying is physically and psychologically damaging.8
Reducing family violence requires a combination of legislation and its enforcement. It also requires communications and marketing, education, and immediate access to intervention programs in community services, police and the courts. The response, “it’s just a ‘domestic’”, is simply no longer good enough.
Community attitudes are not the only factor driving violence against women, but violence-tolerating attitudes are associated with perpetration of violence and have a negative influence on the responses of victims, service providers and the wider community.30
So, changing these attitudes must include long-term, scaled-up and repeated education programs about violence against women targeted to key sectors of the workforce, such as the police, the justice system, and health and social services. In addition, such programs need to target institutions and organisations that have shown greater tolerance of violence towards women, such as some sporting organisations. This may also require partnerships with faith-based institutions and religious leaders to address attitudes towards violence against women.21
In 1990, the National Committee on Violence produced a report entitled Violence: directions for Australia,31 with 138 detailed recommendations for prevention and treatment of violence in Australia. It is clear, 18 years later, that many of these are yet to be implemented, and we could sensibly start by finding out why they haven’t been and what needs to be changed to ensure that they are.
The phenomenon of social exclusion covers an enormous area of social activity, but a good example is the way we treat our unemployed workers. In a recent article in The Age, economics editor Tim Colebatch said:
. . . if you’re out of work, you’re on your own. The OECD’s [Organisation for Economic Co-operation and Development’s] Employment Outlook reports that Australia spends just 0.04 per cent of its GDP [gross domestic product] on training unemployed workers, the third lowest of the 24 rich OECD countries surveyed. New Zealand and Ireland spend four times more, Finland 10 times more and Denmark 13 times more.32
Colebatch quotes Howe from his new book Weighing up Australia’s values, in which the author says that equality of opportunity in education should be our goal and that it should be delivered through lifelong learning:
The challenge is to put in place new institutional arrangements which ensure that people with little education and few skills will be able to add to their knowledge and skills during their adult working life . . . A failure to address this issue will lead to further polarisation in the labour market and will further entrench inequality.32
One of the most interesting international reports of late to shed light on the way we treat each other is the UNICEF report entitled Child poverty in perspective: an overview of child well-being in rich countries.33 The report reviewed 40 indicators of child wellbeing in six domains (material wellbeing; health and safety; education; peer and family relationships; behaviours and risks; and young people’s own subjective sense of wellbeing). These domains all relate in one way or another to forms of social inclusion and reflect the way we treat our young people. The authors say that:
. . . above all, we seek to know whether children feel loved, cherished, special and supported, within the family and community, and whether the family and community are being supported in this task by public policy and resources.
They admit that the report’s measures “fall short of such nuanced knowledge . . . but a start has been made”.33 The authors concluded that, among the 21 countries, The Netherlands, Sweden, Denmark, Finland, Spain, Switzerland and Norway had the highest levels of wellbeing and the United Kingdom and the US had the lowest. Australia could not provide enough data over all the dimensions to be included in the analysis.
Although I am not entirely convinced of the worth of league tables, it is interesting to note the results. Do the top countries do better because they have more inclusive social policies, greater social cohesion, and more equal distribution of wealth and amenity distribution? And to which countries should Australia be looking for inspiration in this area? Does the ranking have anything to do with active public policy based on a collective approach rather than on individualism? The United Nations Development Programme’s Human Development Index —which measures life expectancy, literacy and GDP per capita — reflects similar patterns. Among over 175 countries, the US has consistently ranked eighth or ninth over the past few years, with Australia ranked third or fourth.34
If we are interested in promoting inclusion and reducing discrimination, bullying and violence in our society as a whole, we need to look at our own behaviour. Good mental health begins at home and in the workplace. How do we, as individuals, discriminate less, bully less, and change our own workplaces, given that bullying and discrimination are rife in the health professions?35-37
We need to start by improving our own emotional, psychological and spiritual health. Just as physical health doesn’t advance without daily inputs of healthy food and exercise, our emotional health will not improve without regular investment of time and effort — be it prayer, yoga, meditation or walking the dog. As an example of the positive effect of such practices, Monash University medical students are learning how to practise mindfulness meditation, with beneficial results for themselves and, potentially, their future work colleagues and patients (Craig Hassed, Senior Lecturer, Monash University, personal communication).
As a society, we have many opportunities for making each other depressed, anxious, unproductive and, ultimately, physically ill. We can choose, as some do, to claim that these are merely manifestations of the natural state of human existence. On the other hand, there is ample evidence that safe, inclusive and supportive families, neighbourhoods and workplaces produce a happier, healthier and more productive society. It is clearly possible, if we have the will, to create the latter type of society. We can learn from our own experience and from that of many other cultures, societies and countries. But positive change requires high-level organisation — optimal legislation, constant communication, expansion of services on the ground, research, funding and political and community support.
Treating each other — individuals, families, communities and nations — respectfully and justly, as truly civilised Homo sapiens should, is essential to our health and wellbeing. Tomorrow, why not start to practise, as the bumper sticker says, “random acts of kindness and senseless acts of beauty”.
- 1. Vos T, Astbury J, Piers LS, et al. Measuring the impact of intimate partner violence on the health of women in Victoria, Australia. Bull World Health Organ 2006; 84: 739-744.
- 2. Access Economics. The cost of domestic violence to the Australian economy. Part 1. Canberra: Commonwealth of Australia, 2004. http://www.accesseconomics.com.au/publicationsreports/search.php?searchfor=domestic+violence&from=0 (accessed Mar 2007).
- 3. Report into the cost of child abuse and neglect in Australia. Brisbane: Keatsdale Pty Ltd, 2003. http://www.kidsfirst.com.au/documents/Cost%20of%20child%20abuse%20to%20the%20Australian%20economy%202003.pdf (accessed Feb 2008).
- 4. Queensland Government. The strategic plan for the prevention of elder abuse in Queensland. Brisbane: Prevention of Elder Abuse Taskforce, 2001. http://www.un-instraw.org/en/docs/ageing/Strategic_Plan.pdf (accessed Feb 2008).
- 5. Fekkes M, Pijpers FI, Fredriks AM, et al. Do bullied children get ill, or do ill children get bullied? A prospective cohort study on the relationship between bullying and health-related symptoms. Pediatrics 2006; 117: 1568-1574.
- 6. Burns JM, Andrews G, Szabo M. Depression in young people: what causes it and can we prevent it? Med J Aust 2002; 177 (7 Suppl): S93-S96. <MJA full text>
- 7. Bond L, Carlin JB, Thomas L, et al. Does bullying cause emotional problems? A prospective study of young teenagers. BMJ 2001; 323: 480-484.
- 8. Mayhew C, Chappel D. Internal violence (or bullying) and the health workforce. Discussion paper No. 3. Sydney: University of New South Wales, 2001.
- 9. Niedhammer I, David S, Degioanni S. Association between workplace bullying and depressive symptoms in the French working population. J Psychosom Res 2006; 61: 251-259.
- 10. Williams DR, Neighbors HW, Jackson JS. Racial/ethnic discrimination and health: findings from community studies. Am J Public Health 2003; 93: 200-208.
- 11. Paradies Y. A systematic review of empirical research on self-reported racism and health. Int J Epidemiol 2006; 35: 888-901.
- 12. Berkman LF, Glass T. Social integration, social networks, social support and health. In: Berkman LF, Kawachi I, editors. Social epidemiology. New York: Oxford University Press, 2000.
- 13. Bond L, Butler H, Thomas L, et al. Social and school connectedness in early secondary school as predictors of late teenage substance abuse, mental health and academic outcomes. J Adolesc Health 2007; 40: 357.
- 14. Bunker SJ, Colquhoun DM, Esler MD, et al. “Stress” and coronary heart disease: psychosocial risk factors. National Heart Foundation of Australia position statement update. Med J Aust 2003; 178: 272-276. <MJA full text>
- 15. Mares S, Jureidini J. Psychiatric assessment of children and families in immigration detention — clinical, administrative and ethical issues. Aust N Z J Public Health 2004; 28: 520-526.
- 16. Steel Z, Silove DM. The mental health implications of detaining asylum seekers. Med J Aust 2001; 175: 596-599. <MJA full text>
- 17. Momartin S, Steel Z, Coello M, et al. A comparison of the mental health of refugees with temporary versus permanent protection visas. Med J Aust 2006; 185: 357-361. <MJA full text>
- 18. Langer N, Ribarich M. Aunts, uncles — nieces, nephews: kinship relations over the lifespan. Educ Gerontol 2007; 33: 75-83.
- 19. AbuAlRub RF. Job stress, job performance, and social support among hospital nurses. J Nurs Scholarsh 2004; 36: 73-78.
- 20. VicHealth. Victorians’ attitudes towards bullying. Melbourne: The Wallis Group, 2001.
- 21. VicHealth. Two steps forward, one step back. Community attitudes to violence against women: progress and challenges in creating safe, respectful and healthy environments for Victorian women. Melbourne: VicHealth, 2006. http://www.vichealth.vic.gov.au/assets/contentFiles/CAS-Longer_summary.pdf (accessed Mar 2007).
- 22. Kaltiala-Heino R, Rimpelä M, Marttunen M, et al. Bullying, depression, and suicidal ideation in Finnish adolescents: school survey. BMJ 1999; 319: 348-351.
- 23. Stanistreet D, Bambra C, Scott-Samuel A. Is patriarchy the source of men’s higher mortality? J Epidemiol Community Health 2005; 59: 873-876.
- 24. UNICEF. A league table of child maltreatment deaths in rich nations. Innocenti Report Card No. 5. Florence: UNICEF Innocenti Research Centre, 2003. http://www.unicef-icdc.org/publications/pdf/repcard5e.pdf (accessed Feb 2008).
- 25. Levinson D. Family violence in cross-cultural perspective. Newbury Park, Calif: SAGE Publications, 1989.
- 26. Flood M, Pease R. The factors influencing community attitudes in relation to violence against women: a critical review of the literature. Paper 3 of the Violence Against Women Community Attitudes Project. Melbourne: VicHealth, 2006. http://www.vichealth.vic.gov.au/assets/contentFiles/CAS_Paper3_CriticalLiterature.pdf (accessed Mar 2007).
- 27. Victorian Department of Justice. Human rights charter. http://www.justice.vic.gov.au/wps/wcm/connect/DOJ+Internet/Home/Your+Rights/Human+Rights/Human+Rights+Charter/ (accessed Feb 2008).
- 28. Pettigrew TF, Tropp LR. A meta-analytic test of inter-group contact theory. J Pers Soc Psychol 2006; 90: 751-783.
- 29. Education World. Bullying intervention strategies that work. http://www.educationworld.com/a_issues/issues/issues103.shtml (accessed Mar 2007).
- 30. VicHealth. Two steps forward, one step back. Community attitudes to violence against women: progress and challenges in creating safe and healthy environments for Victorian women. A summary of findings. Melbourne: VicHealth, 2006. http://www.vichealth.vic.gov.au/assets/contentFiles/CAS_TwoSteps_FINAL.pdf (accessed Mar 2007).
- 31. National Committee on Violence. Violence: directions for Australia. Canberra: Australian Institute of Criminology, 1990. http://www.aic.gov.au/publications/vda/ (accessed Nov 2007).
- 32. Colebatch T. The new forgotten people. The Age (Melbourne) 2007; 20 Feb. http://www.theage.com.au/news/tim-colebatch/the-new-forgotten-people/2007/02/19/1171733680358.html (accessed Feb 2007).
- 33. UNICEF. Child poverty in perspective: an overview of child well-being in rich countries. Innocenti Report Card No. 7. Florence: UNICEF Innocenti Research Centre, 2007. http://www.unicef-irc.org/cgi-bin/unicef/Lunga.sql?ProductID=445 (accessed Feb 2008).
- 34. United Nations Development Programme. Human development reports. 1996–2006. http://hdr.undp.org/en/reports (accessed Feb 2008).
- 35. Stevenson K, Randle J, Grayling I. Inter-group conflict in health care: UK students’ experiences of bullying and the need for organisational solutions. Online J Issues Nurs 2006; 11: 6.
- 36. Barton GM, Morrison E. What happens when the harassment is personal? J Med Pract Manage 2006; 21: 211-214.
- 37. Nuttall JL. Professional discretion, courtesy and plain good manners: an anecdotal and personal view. Med J Aust 2005; 183: 627-628. <MJA full text>
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