Social exclusion and health

Poor people die younger, enjoy poorer health and make less use of health services than richer people. The services they get tend to be of poorer quality. This “Inverse Care Law” was expounded by Dr Julian Tudor Hart a long time ago. The work of Richard Wilkinson and others has demonstrated how inequality of income affects the health of all members of a society, not just the poor. This inequality gradient can be demonstrated between different racial groups and geographically, where people who may live in close proximity but in different circumstances may have very different health prospects. We are now allowed to talk about this problem, as we weren’t under the Tories, but can we do anything about it?

Unpicking the mechanisms of causation is a very difficult task. There are clearly effects at the level of an individual, and although it is true that people who are ill tend to become poor it is much clearer that poor people tend to become ill. Wilkinson has demonstrated that absolute income is not related to health in developed countries, although Lynch and others contend that this depends on which countries are included in the analysis. He goes on to argue that psycho-social pathways are the main determinants of ill health among the poor in developed countries: awareness of your low social standing is a source of stress. Inequality inhibits engagement in community life and the social integration which is an important determinant of health. They argue that the effect of income inequality “reflects a combination of negative exposures and lack of resources held by individuals, along with systematic underinvestment across a wide range of human, physical, health and social infrastructure.” If Lynch and co are right then investment in public infrastructure should have a beneficial effect on health. If Wilkinson is right then only a reduction in inequality (which implies an assault on the rich) will have much effect.

Given the importance of globalisation and the political unpopularity of taxing the rich until the pips squeak it may be that investment in public infrastructure is the only politically possible course of action. It is certainly true that health services on their own have only a marginal part to play in reducing inequality. By the time people get to hospital the damage has been done by poor housing, inadequate education and other factors outside the influence of the health service. There is evidence to support the view that malnutrition of the mother during and even before pregnancy has consequences throughout the life of an individual. Reducing poverty needs a long term strategy. The 20 years Tony Blair has set himself to abolish child poverty may not be enough. Especially if he doesn’t win all the elections on the way. The National Health Service is significant not only because of the healthcare it provides to those who could not otherwise afford it, but also because of the message it sends about the sort of society in which we live. A message which says that every person’s life and health is valued, regardless of their place in society. Over the last twenty years that message has become a bit obscured. Private affluence has contrasted with public squalor. Waiting lists have risen. Newspapers have endless stories of people raising money to get the best treatment privately or abroad because it wasn’t available on the NHS. That is why the National Plan for the NHS is so important. Most doctors would probably concede that more direct health gain could be produced by spending the very considerable extra resources on improving the quality of housing for the poor. But we cannot afford to let the NHS be seen to be run down, and for the middle classes to desert it. The NHS is a central symbol of social solidarity, perhaps the only one left since the collapse of the Iron Curtain. If money will cure its problems then the National Plan should do the business, although the increasing pace of medical advances may outstrip the increased resources.

Martin Rathfelder