Archive for November, 2007

Inequality – the human cost

November 15, 2007


by DL, an NHS worker and supporter of the Campaign for a New Workers’ Party

Public Health in Devon

The most recent Annual Report of the Devon Directors of Public Health (‘Health in Devon’, December 2006) makes shocking reading. Acknowledging the persistent health inequalities in the county, it states ‘Recently published data from the south west public health observatory indicates a life expectancy gap of 18 years between the people living in the healthiest geographical areas of Devon, and the unhealthiest’. Yes, 18 years, in picturesque, sunny Devon, in the fourth richest country in the world. 

The report does acknowledge that the following factors can contribute to poor health:  Poor access to education, training and skills; inability to secure employment, low income and poverty, poor housing and poor access to health and other mainstream services. This is particularly the case in some areas of Devon that are amongst the 20% most deprived in the country – parts of Barnstaple, Bideford, Ilfracombe, Newton Abbot and Teignmouth. This list would also include parts of Plymouth and Torbay but these areas are covered by their own Public Health Directors separate from the rest of Devon. 

Despite listing the other contributions to poor health, it only recommends that local Primary Healthcare Trusts and other organisations plan and allocate resources based on national priorities –  encourage eating more fruit and vegetables, giving up smoking, reducing obesity, improving sexual health, reducing harm from alcohol and substance misuse and improving mental health. All very worthy no doubt and with the best of intentions.  

Public health failure

Unfortunately, the truth is that, despite all the time, effort and money already spent on various public health and other initiatives down the years, of the whole of Europe, Britain still has the highest rates of obesity, teenage pregnancies, sexually transmitted diseases, one of the highest rates of alcohol abuse and heads Europe in the amount of drug abuse (according to a 2006 report by the Organisation for Economic Co-operation and Development).  

Putting the emphasis on public health promotion and/or tackling just health inequalities is clearly failing but this only makes health care and government people merely try harder to ‘get the message across’ or ‘raise awareness’.  

Even now, despite the abject failure of these approaches, virtually every week on the TV and in the newspapers, we have some organisation or individual going on about what we need to do to improve our health, announcing more initiatives and resources to reach people with the same old messages. This comes across almost like missionary work and no doubt, in private, the mask sometimes slips and the despair takes over – ‘they’re too thick’, ‘they don’t want to change’.  As if we haven’t worked out by now that smoking and obesity are bad for us. For many working class people smoking, alcohol, drugs and junk food are all short-term crutches against the pressures of everyday life – that’s the reality. The long-term is not something many working class people are inclined to dwell on. That’s why no-one should really have been surprised this year when it was reported that women in Rotherham were passing chips to their children at school – for the poor, tastier ‘comfort’ food is much more preferable than more expensive salad-type alternatives. 

Inequality – the biggest killer of all

The main reason for all these seemingly unsolvable problems is the gross social and economic inequality between rich and poor – which is wider in Britain than in any other European country. Two recent books provide substantial evidence to back this up – Michael Marmot’s ‘Status Syndrome’ and Richard Wilkinson’s ‘The Impact of Inequality’. These books are – or, rather, should be – political dynamite. 

Marmot and others undertook an extensive piece of research into the health of seventeen thousand staff working in Whitehall civil service departments. Even amongst just those white collar office staff, the gaps in ill health and life expectancy between those in the lowest grades and those in the highest followed a consistent pattern – even taking into account such matters as smoking, diet and amount of exercise.  

Marmot points out that “’Adjusting for these risk factors explains less than a third of the social gradient in mortality from heart disease” and that ‘whatever the level of risk factor, being a low grade is worse for your health than being of high grade…For mortality as a whole, taking all causes together, the social gradient in mortality was nearly as steep in non-smokers as it was in smokers. A similar conclusion applied to other risk factors’ (Marmot, p44-5) 

Marmot then posed the question: ‘if these aspects of lifestyle account for less than a third of the social gradient in mortality, what accounts for the other two-thirds?’ (Marmot, p45)  

He presents compelling evidence that health follows a social gradient – in other words, the higher the status in society’s pecking order, the healthier someone is likelier to be. 

Even though the health effects of inequality do weigh down heaviest on the poorest in society i.e. the working class, it’s not poverty as such that has the most drastic effect on health, but the extent of the gap between the poorest and richest in society.

It isn’t about just income differences either, although it certainly true that since incomes widened over the last quarter of the last century, life expectancy in Britain has slipped compared with other countries. Other measures of social ranking are of relatively greater importance –the type and grade of job we do, level of education reached and the area we live in, especially one which is run-down, dirty and generally unpleasant, with an atmosphere of mistrust, little community activity/spirit, an ever-present threat of violence and widespread crime (often un-reported now): ‘Social position has overwhelmingly powerful consequences…Living in a working class area it is impossible not to confront the presence of a powerful force touching all of our lives; whether it be a force that drives one to steal, be violent, use drugs, suffer mental illness or be quiet, resigned to misery, or, the most usual response, going out to forget one’s problems (with drink or drugs), there is something at work in society that has affected the working class very deeply, that has created fear, insecurity and disillusionment’ (Wilkinson, p66). And politicians seriously wonder why so many people don’t bother to vote anymore!

Illness and the working class

The long-term stress and strains of living in a society that has such divisions in wealth and resources between people, affects the health of working class people the worst: ‘The psychological experience of inequality has profound effects on body systems. The evidence…suggests that this may be a major factor in generating the social gradient in health’ (Marmot, p7), ‘Sustained, chronic and long-term stress is linked to lower control over life circumstances’ (Marmot, p109). 

Wilkinson has identified the specific biological mechanisms involved: “The accumulated physiological costs of …secondary effects of chronic stress have been called ’allostatic load’. The term is used to refer to the long-term physiological changes resulting from exposure to chronic arousal. It is marked by higher basal cortisol levels, higher blood pressure, increased insulin resistance, increased tendency for blood clots, abdominal obesity, and suppressed immune function, among other problems. The higher the load, the greater the risks of cardio-vascular disease, cancer, and infection, and the faster the decline in mental functioning in old age” (Wilkinson, p278). Furthermore, ‘Social problems – such as violence, drug use, depression, teenage pregnancy, and poor educational performance of schoolchildren are rooted in the same insecurities, anxieties, and other sources of chronic stress as those that affect our ability to withstand disease, the functioning of our cardiovascular and immune systems, and how rapidly we age’ (Wilkinson, p20) 

Apart from an unnecessarily shortened life for so many people, that life itself is often of poor quality. A major consequence of inequality is the lack of control over key aspects of life, at home, in the area we live and at work – where many people experience soul-destroying, boring, low paid work that is demanding and sometimes dangerous – yet they have little or no control over this. Constant money worries and the threat of unmanageable debt add to this unhappiness. 

Working class people are much more likely to suffer from depression (particularly women), be on the receiving end of acts of violence and other crime, binge-drink and use drugs. For men in poorer areas, their perceived low status in society fuels the anger and frustration that lead to the high rates of homicide and violence and increased risk-taking (leading to a relatively greater incidence of accidents and sexually transmitted diseases). Respect (or lack of it) is a crucial factor in this – the lack of more tangible markers of status, such as money, jobs, housing or cars means that other ways to assert self-worth, pride and dignity have to be found.  

It is the unfortunate reality that the lower the social status, the fewer the resources, the more bitter the need for men in particular to grab what they can and, at the same time, cling desperately to the illusion of superiority over someone in virtually the same position, particularly women or an easily and readily identifiable rival/enemy e.g. a racial minority Or, failing that, the need to keep or extend your control over ‘your own territory’ against a rival gang.   

Inequality also has powerful effects on the family life of poorer working class people – the increased stress leading to greater marital conflict, domestic violence, maternal depression and children with behavioural problems. Teenage pregnancy rates are also a direct result of inequality and low social status. 


Even the one relative recent public health ‘success’ story – the falling number of people committing suicide – is tempered by the fact that, according to Ian Banks, President of the Men’s Health Forum, ‘These figures confirm that social class is the biggest single factor for suicide among young men. It is almost exclusively among the lowest income families that suicide is taking place.’  Also, it’s not so much a public health success story but curiously a result of the extent of inequality. Wilkinson explains: 

‘Perhaps surprisingly, suicide is one of the few causes of death that actually tends internationally to be lower where there is more inequality…Suicide and violence tend to move inversely: in more aggressive societies with more social conflict, people are more likely to blame others when things go wrong, but in societies where the social order is seen as just and has a high degree of moral authority, people are more likely to blame themselves. It is as if, in a more pronounced status hierarchy, people have become more defended against shame in order to maintain their self-esteem against the shame inflicted by low social status. In [poverty stricken] Harlem…suicides were the only important cause of death found to be lower, rather than higher, than elsewhere in the United States’ (Wilkinson, p167) 

New Labour, Tory and Liberal Democrats – spot the difference

People working in public health, those who develop social policies or run local and national government could acknowledge the cold, hard reality of all this, which might mean being forced to actually do something effective about the situation.  

This won’t happen. The three main political parties are all committed to the social and economic policies (neo-liberalism) that have been responsible for this state of affairs. New Labour has been in power for 10 years. The New Labour Governments and the previous Tory ones introduced policies that have led to the obscene gap we now have between the rich and poor in this country. 

What if…

Both Marmot and Wilkinsons’ evidence showed varying degrees of inequality  within and between many countries at different times over the past few decades. What this proves is that the level of inequality we have in Britain isn’t inevitable and that even small changes in the gap between the poor and the rich lead to very real improvements in peoples’ lives. The strong link between homicide rates and levels of inequality is powerful evidence for this.

‘…re-distributing income from rich to poor improves health no matter the mechanism’ (Wilkinson, p143)



So it isn’t just stupid daydreaming to imagine what life really could be like, for many millions of people in Britain and elsewhere, if there was a drastic reduction in inequality.  

We would experience the effect in so many ways – many more people would be healthier and living longer, there would be much less reliance on artificial means to escape from what had been the misery of life, less alcohol and drug related crime, murder and violence, less abused and battered women, fewer broken homes, more contented childhoods, less racial tension and greater educational opportunities for working class children to reach their true potential. Isn’t that worth fighting for?

‘What good does it do to treat people’s illnesses…then send them back to the conditions that made them sick?’ (Michael Marmot, at a ‘Tackling Health Inequalities’ conference, London, October 2005)