Poverty makes us sick: time to tackle health inequality

12 Jun 2020 Nick Garbutt    Last updated: 12 Jun 2020

Treating illness is only part of the solution. Pic: Unsplash

If we’ve learned anything from the pandemic, surely it is that there is nothing more important than our health and wellbeing.

It follows from this that the health of its population is one of any nation’s greatest assets. Having a healthy population is vital to a thriving economy.

Post pandemic there will be calls to invest more in the health service. And this will be a very good thing. Yet we are never going to make a big difference to the health of the nation by this alone.

This is because treating illness is a relatively small component of determining overall health – a 2019 WHO report put it at just 10%. Much more important are factors such as housing, education, welfare and work.

Yet for many years now spending on the health service has been ring-fenced, whilst that on these more important social determinants of health has been cut.

A few weeks before lockdown the effects of this policy were exposed in a devastating report.  Health Equity in England was a follow-up to the Marmot Review of 2010 which examined health inequalities. 

It found that during that period life expectancy in England had stalled for the first time in more than a century. The report directly attributed this to government policies of austerity.

This was a study of impacts in England, but there can be no doubt that it applies to Northern Ireland as well – perhaps even more so given the levels of deprivation in many communities here.

It found: “Government spending as a percentage of GDP declined by seven percentage points between 2009/10 and 2018/19, from 42 percent to 35 percent.

“But it is not just the impact of overall cuts: it is how and where they have fallen which has impacted most on inequalities. The cuts over the period shown have been regressive and inequitable – they have been greatest in areas where need is highest and conditions are generally worse.”

So whilst the health and longevity of people living in London and the south east improved, areas of high deprivation in the north of the country declined.

They found the same depressing pattern, everywhere they looked. The more deprived the area the shorter the life expectancy. And the situation was deteriorating:  Among women in the most deprived 10 percent of areas, life expectancy fell between 2010-12 and 2016-18.

Every bit as troubling were these conclusions: “There has been no sign of a decrease in mortality for people under 50. In fact, mortality rates have increased for people aged 45-49. It is likely that social and economic conditions have undermined health at these ages.

And: “The gradient in healthy life expectancy is steeper than that of life expectancy. It means that people in more deprived areas spend more of their shorter lives in ill-health than those in less deprived areas.”

A separate report from The Health Foundation, Creating Healthy Lives compares the situation in the UK to other countries. 

It shows that the share of the UK population in good health is 24% lower in the lowest income bracket than in the highest. In contrast, in countries such as New Zealand, Greece and France, there is a gap of only 5–10% between the lowest and highest socioeconomic groups.

Internationally, the UK ranks 22 out of 38 OECD countries for life expectancy.

Austerity costs lives.

It also has other unintended consequences. The Marmot Review estimates that around 40% of health care costs involve treating preventable illness. Cutting housing, welfare and education budgets transfers many of the costs to the health service. This increased demand leads to more health spending and less investment elsewhere: a vicious spiral which leads to further ill-health. These avoidable differences in health are known as inequalities.

There is a pressing need for change.

However this will require greater public understanding: not just about the real drivers of ill health, but also about the often-pedalled mantra around better lifestyle choices.

Let’s just take one example. We are in the midst of an obesity crisis. We also know that obese people have been shown to be more vulnerable to Covid-19 than the general population.

Prime Minister Johnson has a personal investment in this issue.

But whilst individual behaviour – choosing a good diet – would be enormously helpful, the argument cannot begin and end with telling people to choose better food. Healthier diets are more expensive. Welfare payments are set so low that even meeting very basic nutritional guidelines is unaffordable for many families. And healthy foods may not be available in local shops.

The 18-year gap in healthy life expectancy between the least and most socioeconomically deprived populations is not the result of people making bad choices – it is the result of government not creating the conditions for everyone to lead healthy lives.

So what we should be expecting is for a concerted drive, across the UK, involving all governments to arrive at a position whereby people living in all areas have the same life expectancy as those living in London and the south east of England. Nothing less will do.

If we are to succeed in that we need to treat health as the precious national asset that it is, and improving health and wellbeing and reducing inequality is as important as improving GDP.

The costs of poor health are not just to be measured in health spending. They also include welfare payments to those with ill-health, early retirements, people giving up work to care for others, overall falls in productivity. A flourishing nation needs to be in flourishing health. The UK isn’t, and the situation is deteriorating. 

 Northern Ireland has the potential to make great progress in this regard. Its Programme for Government is organised around improving wellbeing.

And we need to recapture the vision of our ancestors who had a much greater understanding of the drivers of health and wellbeing.

Today we fetishize the health service. Yet earlier measures have had just as much impact on our wellbeing as the creation of the NHS.  For example the Public Health Act (Ireland) of 1878 which ensured adequate supplies of water and proper sewage disposal transformed health outcomes in 19th Century Ireland.

Improving public health involves a whole of government approach with every department contributing. And it is a long-term project. Cross-departmental, long term projects are difficult for governments which tend to operate short-term. A Future Generations Act on the Welsh model might help. Scope analysed this here.

Inequalities in health between different groups are mainly the result of the conditions in which they live.  These vary. The extent to which people have access to the spaces, services and social networks varies across Northern Ireland, just as it does across the UK.

It follows that local communities are best placed to know what is needed to improve their environment. And it follows from that that they rather than central or local government or outside experts need to be in the lead when it comes to change.

Strong communities are also an important contributor to individuals’ well-being. Empowering communities is therefore central to improving public health.

In future editions of Scope we will examine what specific issues need to be addressed in Northern Ireland to improve public health


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