Let's get tough on the causes of health inequality
Doctors have a duty to draw public attention to social injustice
as a cause of ill health
Iona Heath, general practitioner, London
BMJ 2007;334:1301 (23 June)
The UK government has a clearly stated commitment to tackling
health inequalities, while perversely allowing disparities in
wealth to widen. The problem is that health inequality is
directly related to socioeconomic inequality and cannot be
separated from its underlying cause or solved independently. It
is convenient for governments to believe that this can be done
but the medical profession should not collude with them. There
has been some attempt to tackle health inequalities by
initiatives across government, but the rhetoric has outweighed
the substantive achievement by a considerable distance and the
health service still seems to be expected to make the major
contribution.
Two entirely different but potentially complementary approaches
to tackling health inequalities date back to the 1840s. During
that decade both Edwin Chadwick and Friedrich Engels described
the appalling conditions endured by poor people in 19th century
Britain. Chadwick published his Report into the Sanitary
Conditions of the Labouring Population of Great Britain in 1842
and, two years later, Engels followed with The Condition of the
Working Class in England.
Chadwick laid out a statistical analysis and proposed technical
solutions. Engels used a much more polemical argument and
advocated political action. Chadwick demonstrated that the poor
lived in squalid and overcrowded conditions and that these
caused illness and disease, which then made many people too sick
to work and trapped them in a downward cycle of worsening
poverty and destitution. He also showed that violence, and
alcohol and opium abuse, were consequences rather than causes of
the conditions of poverty. His principal recommendation was a
proper system of drainage and sewage disposal combined with
clean water supplies and regular refuse collection. Engels, in
response to precisely the same situation, argued for fundamental
social change, and in 1848 he collaborated with Karl Marx to
write The Communist Manifesto.
There is no doubt that Chadwick's interventions were enormously
beneficial, saved many lives, and redressed health inequalities
to some extent. However, they did nothing about poverty as such
or about the unresolved injustice it expresses. In contrast,
Engels was primarily concerned with social justice and his work
and influence led eventually to profound social upheaval and
change in many countries, with enduring benefits for the poorest
people. Neither the technical nor the political response is
sufficient on its own; both are required.
As a general practitioner working in the same deprived urban
area for many years, I find it impossible not to be keenly aware
of the lottery of social conditions and the resulting
differences between people: differences in their power, their
hopes, their opportunities. Many people are obliged by
circumstance to live lives leached of dignity and respect and
clouded by a sense of having been wronged. Such lives are
exacerbated by the arrogance and complacency of those who have
the good fortune to find themselves on the winning side of our
unequal society. This profound social injustice is untouched by
effective sewers or even today's technical expedients, which
ostensibly include the financial incentives of the quality and
outcomes framework and the ever more extensive prescribing of
preventive pharmaceuticals.
Invaluable epidemiological research over the past two decades
has documented the extent of health inequalities and has
succeeded in turning this form of inequality into a political
issue. Democratically elected politicians, responsible to the
entire adult population, will always be discomfited by
documented evidence of inequality and injustice, although it
remains a mystery why governments can be shamed so much more
readily by inequalities in health than by those in wealth. The
problem is that while epidemiology can identify the problem, it
cannot provide the answer, whatever the claims for the quality
and outcomes framework. Further, we now seem to have developed a
health inequalities "industry," which is rapidly becoming
another employment opportunity for the affluent (piggybacking on
the distress of the poor a becomes a substitute for difficult
political effort—opium for the intellectual masses).
Perhaps the British have always favoured technical remedies but
here is the impasse—some health problems require a political
response. The productive complementarity between Chadwick and
Engels has shifted damagingly towards the technical. Does
reducing health care to standardised tick-box interventions
really address the challenges of health inequalities? Yes, of
course, to some meagre extent it does, and the health
opportunities of some patients with diabetes and other
conditions have been improved as a result, but the fundamental
causes of the inequality are left entirely intact. The
challenges of ensuring dignity and self efficacy and a sense of
justice are ignored.
The UK remains a markedly unequal society, ranked 21st out of
the 27 countries of the European Union in terms of the
proportion of the population living in relative poverty. In
these adverse circumstances, health opportunities will be
substantially altered only by genuine political and social
change. Disease and disability are caused by biology but also by
the ways in which society is organised and in whose interests it
operates. Doctors have a clear responsibility to pursue
political answers alongside technical ones and to seek out and
draw public attention to injustice wherever it is implicated as
a cause of ill health. Once acknowledged, injustice demands
redress, and so doctors also have a responsibility for
advocacy—to speak to the powerful on behalf of the powerless.
Only in these ways can medicine contribute fully to the
narrowing of health inequalities.
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