IMAGINE the outrage if a newspaper ran a story stating that a million people in the UK had died from a treatable medical condition over the past five years. Health ministers would be interrogated, government enquiries promised 鈥� and the public would be left with a terrible feeling of unease.
But those people really did die, and from a preventable condition: health inequality. The scary but real figure came from Fair Society, Healthy Lives, the 2010 report I produced when asked by the UK government to review health inequalities, and was repeated in The Health Gap, my latest book. I calculated that if everyone in England over 30 had the same low mortality rate as university-educated people, there would be 202,000 fewer deaths each year 鈥� almost half the current total.
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This pattern of lost years is a global phenomenon. Last month, the US National Academy of Sciences reported that at the age of 50, life expectancy for a man in the US in the poorest 20 per cent of the population had declined slightly in the last 30 years to 26.1 years. By contrast, life expectancy in the richest 20 per cent had improved by 7.1 years to 38.8 years 鈥� a difference of 12.7 years.
So the problem of health inequalities endures or is getting worse. Is anyone listening? Do we know how to reduce those inequalities? Are we doing it? The answer to all three questions is yes, but with major qualifications: the problem and the solution are complex, and are reflected very differently in different countries.
In the UK, at least, people are listening. Health minister Jeremy Hunt recently cited my book as showing an 18-year gap in male life expectancy between the richest and poorest in the London borough of Westminster 鈥� one of the richest spots on the planet. He added we should be ashamed, a clear indication he agrees that we should be able to do something about it.
Listening isn鈥檛 doing, of course, but it is a good first step. There is a great deal of listening going on in Latin America, India, the eastern Mediterranean and the European region of the World Health Organization. This shows up in the resolutions of the WHO鈥檚 World Health Assembly.
Those who do listen are beginning to see the complexity of the issues. We no longer have to deal with 19th-century squalor and its consequences, but there are new ways of doing without and new pressures that are just as devastating. The health gap didn鈥檛 widen in the past 30 years in the US and UK for lack of indoor toilets, but because people are not able to live lives that they value.
Such disempowerment arises from adverse social and psycho-social conditions. A causal thread links health inequalities to life conditions, from the quality of input surrounding early child development, through inequalities in education, employment and working milieu, to the conditions for older people.
There is evidence, though, that improvements at any stage of life can make a difference. Action at community and whole society level is important. Take British Columbia, with a shockingly high suicide rate in young aboriginal Canadians. Communities within the province with control over their own services have avoided this epidemic. And at country level, health inequalities in Brazil have fallen from a very high level, due in part to schemes where poor families receive cash subsidies for meeting conditions such as taking their children to nutrition clinics. This may explain why inequalities in the growth of young children have been sharply reduced.
That leads to my third question: why aren鈥檛 governments taking the actions we know improve health and reduce health inequalities? Ever the optimist, I would say that some countries are, but that not one is doing enough. The problem is that to act on the social determinants of health, they must get past the assumption that inequalities in health arise from inequalities in healthcare.
In the UK, with universal access, healthcare isn鈥檛 the issue. Having discovered prevention, the reflex of health authorities is to focus on educating us to behave better. But we have known for a long time that this doesn鈥檛 work: it ignores the reasons why people have poor diets, drink too much, smoke and are physically inactive 鈥� in other words, the causes of the causes.
There is a much bigger conceptual problem: health inequalities aren鈥檛 confined to poor health for the poor and good health for everyone else. There is a gradient in health running from top to bottom of the social hierarchy. We should all be calling for action across the whole of society because we are all affected by inequalities in health.
鈥淲e should all be calling for action across society because we all are affected by health inequalities鈥�
But governments have other priorities. Austerity has caught on like an epidemic, flying in the face of mainstream economists鈥� views that it damages economic growth. And there is plenty of evidence that health is damaged by austerity: take Greece, where rising suicide is the most dramatic example. More generally, Will Hutton, head of Big Innovation Centre, sees the UK as 鈥渂ecoming the laboratory for a libertarian, anti-social justice experiment鈥� based on neo-liberal economics. Unchecked, I believe that these will increase health inequalities.
As president of the World Medical Association for the coming year, I have signalled that my themes will be social justice and health, and health equity. There is a well of enthusiasm from doctors to make a difference to the social environment in which their patients are born, grow, live, work and age. But enthusiasm from government, backed by an informed public, is also essential.
As I say at the end of my book, if you live in a country with poorly developed social systems, do something because it will make a difference. If your country has started to make improvements, do more. And if you live in one of the Nordic countries, do it better.
(Image: Andrzej Krauze)
This article appeared in print under the headline 鈥淎 gap too far鈥�
