The truth about health inequality

6 May 2021 Nick Garbutt    Last updated: 7 May 2021

Pic: Unsplash

If everyone were able to live healthier lives for longer, everyone would benefit.

For this to happen  everyone would need to get the same opportunities to lead a healthy life, no matter where they live or who they are. Few would disagree with this simple proposition.

Yet health inequalities remain, as stubborn and persistent as they have ever been – an affront to all those who believe in fairness, equality and human dignity.

One of the reasons why this has become so intractable is because of the fundamental misconception that improving our health is all about improving health care. The reality is that it is more influenced by a vast range of other factors, many inter-connected which are not within the power of health care professionals to change.  The most important of these is poverty.

To understand this let’s briefly look at how health inequality pans out over life’s journey and at some of the groups most blighted by it.

The best start to life

Breastfeeding gets babies off to the best possible start in life, reducing the risk of many infections and making obesity much less likely. It also is good for bonding with the mother who also enjoys health benefits, reducing her risk of obesity and also that of breast and cervical cancer.

Whilst 48.4% of mothers take up breastfeeding, those living in the most deprived areas are half as likely to as those in the least deprived areas. However health inequality can start even before the moment of birth. Pregnant mothers who smoke can risk having low weight and/or preterm babies and those from the most deprived areas are almost five times more likely to smoke than those from the most affluent districts.    

Early Years

All experts agree that the most important time of all in terms of health and wellbeing are the first 1,000 days - the time when the brain is developing rapidly.  Good care during this period brings significant benefits in later life not just in terms of physical and mental health but also educational achievement and economic status.

The related issues of family poverty and poor diet are just two of the many factors connected to inequality that can negatively influence infant development at this crucial time.


Those who do well at school are more likely to adopt healthy lifestyles, get decent jobs and less likely to take risks. It can break the cycle of poverty. Sadly too many young people do not reach their full potential and don’t have either the knowledge or support to make healthy life choices.

Yet again inequality is a significant factor. In Northern Ireland 90.3% of those who get five or more GCSEs are not entitled to free school meals. The figure for those who do get them is just 49.5%.

Peoples’ intelligence is not determined by their parents’ wealth nor should their opportunities to fulfil their full potential. Many children who do not do well at school have, sadly, been on a trajectory that started even before they were born.

Teenage pregnancy

There is a 400% gap between the teenage birth rate in the most deprived as opposed to the most affluent areas. This also exacerbates inequality – having a child so young inevitably disrupts educational opportunities, shrinking life and development chances at a very early age.

All young people in Northern Ireland should have the information and the skills to make their own informed decisions about their sexual health.


Poverty is the most significant factor that leads to health inequality. Most of the others are linked to it in one way or another. The biggest contribution that could be made to our collective health is to reduce or better still eliminate it.

The most recent statistics state that around 350,000 (19%) people in Northern Ireland live in relative income poverty including approximately 107,000 (24%) children. And according to Housing Executive figures around 22% of the population live in fuel poverty. The economic impacts of the pandemic are likely to increase these numbers.

How this ultimately plays out is surely unacceptable regardless of our political perspectives. The best measure of this is healthy life expectancy – which is defined as being “without irreversible limitation of activity in daily life or incapacities.”

For females in Northern Ireland the figures are 66 for those from the least deprived areas – compared with 50.8 from those from the most deprived areas. The gap is very slightly less for men. If that’s not shocking, it’s hard to know what is.


Where you live affects your health as well. There is a very strong link between the strength of communities and the health of the people who live within  them.

We saw a dramatic example of this during the Covid-19 pandemic when so many individuals and groups came together to look out for vulnerable people within their communities and helped them during a time of need.

Moreover communities know better than anyone else what their areas need to help promote health and wellbeing, whether that be through improvements to the environment, the services that are available and the amenities and facilities in the neighbourhood.

So whilst working with communities is critical to better health and reducing health inequality it also follows that weaker communities mean weaker health outcomes and that needs to be addressed as well.


Obesity, with all the chronic conditions associated with it is – quite literally - a growing problem.

Figures show 22% of children entering primary school are overweight or obese, a figure which rises to 28% in Year 8. By adulthood the problem worsens - 65% of us are overweight of which 27% are obese. Once more those living in the most deprived areas are most likely to be obese.

Healthier diets may be part of the answer – but healthier foods need to be more affordable, which links directly back to poverty.

Alcohol and drugs misuse is yet another example of health inequalities – with people living in the most deprived areas five times more likely to die drug- related deaths and four times more likely to die from alcohol abuse than those from the most affluent districts. There are also significantly higher levels of smoking in areas of deprivation.

Mental Health and Wellbeing

Mental ill-health can affect anyone but it should be no surprise that it is also closely associated with inequalities including including poverty, unemployment, homelessness and incarceration as well as those suffering from stigma, discrimination, social isolation and exclusion.

Vulnerable Groups

All of this is before we get onto some of the most vulnerable groups in society. The average age of death for homeless men is 44, for women it is 42. The homeless often have multiple needs in terms of both physical and mental health.

Traveller men live 15.1 years less and women 11.5 years less than the general population. And for men suicide rates are seven times higher. 

Ethnic minorities also experience lower life expectancy, often linked to deprivation and can also – often compounded by language barriers – lack the understanding of what services are available and where they can go for help.

Our prison population contains many individuals with complex physical and mental health conditions which can include drugs and other substance misuse.

Other vulnerable groups include members of the LGBT+ communities who are especially vulnerable to social exclusion and stigmatisation which are factors in heightened levels of poor mental health and an increased risk of suicide. All this can be compounded by many feeling that their specific needs are not always taken into account in their care.


This is not intended to be a comprehensive list of all health inequalities but more an illustration of the extent to which they impact our lives.

Tackling it – or at least reducing it – goes far beyond the remit of the Department of Health. Indeed 40% of health outcomes are determined by socio- economic factors, 10% by our physical environment and 30% by our (health) behaviours, leaving just 20% to healthcare itself.

This is a task for all of us – but most of all it is one which should be front of mind for all of our policy-makers and politicians when they come to shape our next Programme for Government.



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