In Stockton-on-Tees life expectancy varies by 17 years between the richest and poorest parts. How can that be possible in 21st century Britain? How can it be acceptable?
Michael Marmot’s Fair Society, Healthy Lives: A Strategic Review of Health Inequalities in England Post-2010 underlined what we already knew, and had been clear in the 1980 Black Paper - that health is often determined by inequality and unequal power. We have known for decades about the critical role that social and economic conditions play in shaping the distribution of health and disease within and across populations.
There is a very close link between where you are on the socio-economic ladder and your health - the higher the rank, the better the health - Marmot’s social gradient in health. This affects everyone - we are all part of the gradient.
You don’t just die younger if you are poor but you live with ill health for longer. Deteriorating health occurs at a progressively faster rate the lower down the social hierarchy you are.
What has been happening in the last few years? Simply (though, of course, none of this is simple) two things: the century-long rise in life expectancy has stalled since 2010 and inequalities on all 15 indicators have widened since 2010-12.
Making clear links between austerity, worsening health outcomes and an increased health inequality gap is not straightforward. But we know there was a rise in health inequalities during the Thatcher years and this was matched at the same time in other countries pursuing neo-liberal policies, like New Zealand.
Whatever the complexities, when the data is analysed the reality is that it is politics driving these changes and that class is the key determinant of who comes off worst.
These phenomena appear at a group level - inequality produces different effects depending on who you are and where you live. People on low incomes in poor areas do worse than people on similar incomes in richer areas. People with insecure and badly paid jobs with little say are more at risk of heart attacks than those with so-called stressful senior and well paid positions.
Can national and local strategic interventions reduce health inequalities? It certainly looks like they can have some effect. The last Labour government’s strategy on health inequalities seems to show that the places where the strategy was implemented did see a narrowing in the life expectancy gap with the rest of England through initiatives like Sure Start, the New Deal and neighbourhood renewal. And this ended once the strategy finished. Post-2010, despite the rhetoric, there has been little in the way of national direction.
But fundamentally we can’t provide sustainable solutions to the two nation story of health and wellbeing through individual interventions, when the real causes are socio-economic and political.
Who you are, how poor you are, where you live - all profoundly affect your wellbeing. Turning this around is about turning around how society is organised. It isn’t that we don’t have wealth in the UK - or indeed globally, where the differences between countries are even more stark - but it is how that wealth is distributed. And greater inequality means the gap in health between the better off and the poor is exacerbated - the argument reiterated by Richard Wilkinson and Kate Pickett in The Spirit Level.
As Mike Haynes explains: “What separates societies, therefore, is less the per capita income over this level than the degree to which it is unequally distributed, and the scale of relative deprivation between different social groups. People in a country can be twice as well off on average as those in another country without benefit to their mortality rates if the distribution of income and wealth is unequal.” (Capitalism, class, health and medicine, Mike Haynes, International Socialism).
And it is a vicious circle: understanding the causes of the causes is critical. Smoking is bad for your health but what causes smoking to be more prevalent in some groups? Fast food isn’t good for you but we know fast food outlets accumulate in the poorest areas. To understand the health gradient we need to be clear about what lies behind it. Which is why, of course, however much Theresa May says she is committed to reducing health inequality, a neo-liberal government can never do so because it is not able to address the societal and political reasons behind it. Indeed it will tend to make it worse - with those with little control over their lives being the ones hit the most by government decisions.
An unequal society produces income inequality, but also the social mechanisms that cause ill health. People who suffer from pressures such as job insecurity, poor housing and a bad environment often have less resilience for dealing with the unequal outcomes they produce.
Would a Corbyn-led Labour government be able to transform the health and wellbeing outcomes for those who today face daily struggles?
Of course the Labour manifesto was a step forward in rejecting, for example, the marketisation of health, and in promising to build thousands of new homes. These individual commitments, however, need to be seen as part of a more general transformation of society, delivered through mass campaigns and a focused socialist programme - a programme that will determine the overall distribution of income and the redistributive impact of the welfare state.
Mike Haynes reminds us that there can be radical shifts in society - “For instance, in the UK in the Second World War, despite the conflict, civilian health improved as radical changes had a dramatic short-term effect and health delivery was shifted towards a new basis.”
Surely it isn’t utopian to imagine this happening again following a Corbyn-led government committed to sustainable socialist reform?