Keeping the Vulnerable, Vulnerable
Given the current climate it seemed appropriate to talk about inequality, specifically health inequality. The distribution of health is governed by a multitude of factors; individual lifestyle, community, living and working conditions and general social conditions (1). These determinants, their intrinsic link and the impact they have on health are, I’m sure, as obvious to you as they are to me, so why did Jeremey Cunt never get the memo?
Way back in 1982 the aptly named ‘Black Report’ linked social class and life expectancy (2) and following on from this some bright spark recognised that the NHS, a free at the point of entry health service, had done nothing to conquer life expectancy inequality – so this is not a new conversation. For years it’s been more obvious than your hangover on a Sunday morning. Health care is so much more than to treat and cure.
Now you might be wondering why I am banging on so seriously, well to be quite frank inequality (of any sort) really gets on my tits. These damning statistics illustrate why the culture of western medicine must evolve towards a more preventative stance including recognition of the impact of Socioeconomic Status (SES) on health. However, such evolution rarely happens when bureaucratic bastards are behind the systems and drivers stalling change for sake of their own pride.
A profound 2010 review (The Marmot Review) suggested the government focused on some very important areas;
“Give every child the best start in life, enable all children, young people and adults to maximise their capabilities and have control over their lives, create fair employment and good work for all, ensure a healthy standard of living for all, create and develop healthy and sustainable places and communities.” (3)
That’d be nice wouldn’t it, to give every child the best start, seemingly one of the most obvious objectives for a government. Said review also smashed it out the park by saying government was (surprisingly) splashing its cash in all the wrong places leading to those in the most deprived neighbourhoods being likely to die seven years earlier to those in the most affluent and also being more likely to live with a disability. And yet Marmot and his cronies said this would be largely preventable if health care moved from its ‘treat and cure’ model and addressed those wider determinants of housing, income, education, social isolation and disability – well fuck me.
The problem being here that it would require a huge systematic shift within health and social care culture, GP’s would actually have to recommend none medicinal treatment (social prescribing), Nurses would have to be given the time to talk about preventative health care, sacré bleu! But worst of all money may have to be put into the public sector and third sector enabling a community voice and whole sector thinking. Just as a reminder all evidence suggests this would reduce life expectancy inequality whilst also reducing acute care cost, no brainer, right?
And so, we come to today, ten years on from the Marmot review and guess what…
… YOU GUESSED IT health is shown to be getting worse for those living in deprived areas, health inequalities have increased and health as a whole is declining (4). There is an over-representation of those sitting within the strands of inequality; race, disability, gender, sexual orientation, religion and belief and age in terms of poor health. Oh, and funding within public health and family support services has been dropped.
There has been much talk over the past week relating to the systemic racism we face within society. In the UK those of a Pakistani and Bangladeshi ethnicity have the lowest life expectancy and Non-British Whites the highest (4). BME groups also have a lower quality of life than other ethnic groups in the UK (5).
The Joseph Rowntree Foundation captured within its 2017 report that 70 percent of children from working families face child poverty which was an increase of 10 percent the previous year (6). The Institute for Fiscal Studies illustrated that nearly half of those in poverty have a disability and that poverty was disproportionately weighted towards Black, Bangladeshi and Pakistani origin. Sadly, the Organisation for Economic Co-operation and Development hypothesised that such inequality within social poverty could take five generations of a family to reach average income (7).
I don’t know about you, but I think this is rather gross, in fact I think its fucking disgusting.
It is clear that the system is not fit for purpose and is directly resulting in deterioration of health and life expectancy for those most vulnerable. Socioeconomic Status continues to defeat health care reform because having status always increases or limits an individual's resource in particular access, in the widest sense. Therefore, it seems the westernised medicine model faces a systemic and social barrier neither of which can change without the other.
“If the problem is cholera, for example, a person with greater resources is better able to avoid areas where the disease is rampant, and highly resourced communities are better able to prohibit entry of infected persons.” (8).
A poignant illustration as we see Covid-19 disproportionately affecting the most vulnerable today (9).
It would seem therefore health inequality has persisted, if not worsened in UK society over the past decade, despite many movements to change the culture within the medical profession and wider public sector. There seem to be many contributing factors to this including; lack of funding within preventative care strategies and use of a top-down target driven approach that fails to engage key stakeholders. However, it seems undeniable the crucial issue lies within the inability of ‘the system’ to fit a methodology that incorporates the recognition of Socioeconomic Status because the system is not fit for purpose.
This echoes a message that has been heard loud this week within the Black Lives Matter movement;
Racism is a disease coded into the DNA of society. But the symptoms are deadly.
Prof. Kehinde Andrews 2020 @Kenhinde_Andrews
Peace and Love.