In 2010, Sir Michael Marmot estimated that the annual cost to the UK of illness-related health inequalities was £31bn–£33bn in lost productivity, £20bn–£32bn in lost tax revenues and increased welfare costs, and over £5.5bn in direct health care costs.
His extensive reviews of the evidence for the UN and the UK government show we know how to prevent these inequities in health, and so their persistence is deeply unjust. He showed that it is the wider determinants of health that drive health injustices.1 The health care community deals with the consequences of health inequalities every day, but health care-led actions rarely tackle the underlying causes. However, clinicians can shine a light on ‘the causes of the causes’.
In 1854 Dr John Snow removed the handle of the Broad Street pump in Soho and proved that cholera was carried by contaminated water. Lots of people didn’t believe him and the water companies who supplied foul water resisted, but over the next 50 years, sewers were built, clean water supplies engineered and cholera ceased to threaten London. The occurrence of cholera is socially patterned: cases of cholera are more prevalent where there is greater poverty and deprivation, and 19th century Soho was a slum area. While Dr Snow discovered the cause of cholera, fixing the problem was the work of engineers, architects, planners and politicians. Doctors (and other clinicians) continue to try to understand the causes of disease, but very often it is concerted action across society that prevents it.
Improved social conditions and a huge range of medically evidenced interventions (for example vaccination programmes) led to over a century of increasing life expectancy for all. However, while life expectancy gaps between social groups have fluctuated, they remain stubbornly wide and may once again be increasing.
Extensive research on the social determinants of health has reached some important conclusions:
- Good or poor health in society is neither equally nor randomly distributed – it is socially patterned.
- This unequal distribution can be changed. It is caused by inequalities in the way we organise our society and economy – the wider determinants of health. Better choices about how we do so can lead to better health for all.
The wider determinants in action
Joe was a 52-year-old alcoholic who died in a London hospital this year. Liver disease was given as the cause of death. NHS staff working with homeless patients see these kinds of deaths all the time, but why did Joe die 31 years earlier than a man born in Kensington (the district of the UK with the highest average life expectancy2)? He missed nearly a third of the average UK lifespan.3
Joe was born in 1963. His parents lived in poor quality housing. They fought, there was not enough money, and by the age of seven he was in a children’s home. He attended school but was bullied for being in care. Having not had anyone to read to him regularly he struggled with literacy; having not witnessed many positive relationships he struggled to make friends.
By his early teens he was identified as a ‘troublemaker’ and regularly ran away from the children’s home. He went to a borstal, found alcohol, ducked and dived on the streets. In the 1980s, as a single man, he was judged under the regulations not ‘to be in priority need’ for housing. By the age of 35 he was labelled an ‘entrenched rough sleeper with a personality disorder’. Services tried to work with him, but his experience had taught him not to trust anyone. He was survived by his dog, who he cared for deeply. The nurses who cared for him as he died said he was a gentleman.
For Joe, post-war housing policy didn’t move fast enough to help his parents. Their pinched backgrounds undermined their ability to care for him, while the poverty that surrounded his early years, the lack of a stable home, and perhaps the awareness that other children judged him, pushed him to the margins. Each step reinforced the last. Unfortunately for Joe he reached adulthood in the middle of the 1980s, when prospects for poorly educated, working-class boys were at a particularly low point and the government sought to blame the unemployed for their problems.4 Even later, a more generous response to housing might have helped.
If Joe’s parents had had a secure home and some income, he might not have been ‘different’ at school. A better-resourced secondary school might have managed his challenging behaviour, and so on. Harms accumulated as Joe’s life progressed and his capacity to overcome each additional insult diminished. These are the wider determinants of health in action. Joe’s story is an extreme example, but the wider determinants of health affect everyone. The obesity epidemic is socially patterned; smoking is socially patterned; environmental quality is often worse in poorer areas. Underneath these patterns are structural social and economic inequalities: in housing, pay, wealth and control over life. The harms are greater the further down the social scale you travel. Structural responses – policies for cleaner air, safer roads, good housing, secure employment and a more even spread of wealth – would be better for us all, but they would bring most health gains to those at the very bottom. And, according to Sir Michael Marmot, action on the wider determinants of health might also save us £50bn–£70bn each year.
Dr Alex Bax
Chief Executive, Pathway