Clare Bambra
In 1842, the English social reformer Edwin Chadwick documented a 30-year discrepancy between the life expectancy of men in the poorest social classes and the gentry. He also found a North-South health divide with people from all social classes faring better in the rural South than in the industrial North.
Today, these inequalities persist. People in the most affluent areas of the United Kingdom, such as Kensington and Chelsea, can expect to live 14 years longer than that those in the poorest areas, such as Glasgow or Blackpool. Men and women in the North of England will, on average die 2 years earlier than those in the South. Scottish people also suffer a health penalty with the highest mortality rates in Western Europe.
Such geographical inequalities in health exist, to varying degrees, in all high-income countries. People living in more deprived areas fare particularly badly in the casiono capitalism of the United States; where gaps in life expectancy between rich and poor areas of some cities, such as New Orleans, are as large as 25 years. Indeed, the US as a whole has a significant health disadvantage in comparisson to other high-income countries with, for example, American men living on average 3 years less than their counterparts in France and 5 years less than Swiss men.
Understanding and reducing these health inequalities remains a major public-policy challenge worldwide and has garnered significant recent political attention. For example, in her opening speech on the steps of 10 Downing Street, the new British Prime Minister Theresa May highlighted the nine-year gap in life expectancy between the richest and the poorest boys in England. It is not only a moral issue though; health inequalities carry significant economic costs to individuals and society (e.g. NHS costs, lost productivity). But the causes of such inequalities are complex and the solutions contested.
Explaining Health and Place
In my new book, Health Divides: where you live can kill you published by Policy Press today, I show that where you live effects how long you live and that the health of different places is determined both by determined by the population composition (who lives here) and the environmental context (where you live).
Who lives here? The demographic, health behaviours and socio-economic profile of the people within a place influences its health outcomes. Generally speaking, health deteriorates with age, women live longer than men, and health status also varies by ethnicity. Levels of smoking, alcohol, physical activity, diet, and drugs – all influence the health of populations significantly. The socio-economic status – or social class in “old money” – of people living in a country also matters as those with higher occupational status (e.g. professionals such as teachers or lawyers) have better health outcomes than non-professional workers (e.g. manual workers). So differences in the characteristics of people living in a country, city or neighbourhood will impact on the health of that place.
However, my book also shows strongly that where you live matters. The economic environment of a country, such as poverty rates, unemployment rates, or wage levels can all influence public health. The social environment, including the services provided within a country to support people in their daily lives such as child care or health care and welfare, can also impact on population level health. The physical environment is also important determinant with research suggesting that proximity to waste facilities and brownfield or contaminated land, as well as levels of air pollution can negatively affect health. So countries, cities or neighbourhoods with worse economic, social or physical environments will have worse health outcomes.
Case study: North and South, East and West
Regional inequalities in health exist across all high-income countries. England however has the largest regional inequalities in Europe, epitomised by the North South health divide: those in the North of England live on average live two years less than those in the South. These spatial inequalities in health between North and South have been documented since the mid-18th century and have fluctuated over time, rising from the 1980s onwards. Since 1965, the ‘health penalty’ paid by the North has amounted to 1.5 million excess premature deaths. The scale of the regional health divide in England is now greater than the gap between the former West Germany and post-communist East Germany. In 1990, the East-West life expectancy gap was almost three years between women and three and a half years between men. This gap has rapidly narrowed in the following decades so that by 2010 it had dwindled to just a few months for women and just over one year for men. So why has the English health divide persisted whilst the German one has closed in a generation?
Firstly, living standards of East Germans improved with the economic terms of the reunification whereby the West German Deutsche Mark (a strong internationally traded currency) replaced the East German mark (considered almost worthless outside of the Eastern bloc) as the official currency – a mark for a mark. This meant that salaries and savings were replaced equally, one to one, by the much higher value Deutsche Mark. Substantial investment was also made into the industries of Eastern Germany and transfer payments were made by the West German government to ensure the future funding of social welfare programs in the East. This meant that between by as early as 1996, wages in the East rose very rapidly to around 75% of Western levels from being less than 40% in 1990. This increase in incomes was also experienced by old age pensioners. Research by the Max Planck Institute for Demographic Research in Rostock has shown that the rapid improvement in life expectancy in 1990s East Germany was largely a result of falling death rates amongst pensioners. Access to a variety of foods and consumer goods also increased as West German shops and companies set up in the East. These economic improvements were funded by a special Solidarity Surcharge. This was levied at a rate of up to 5.5% on income taxes owed (e.g. a tax bill of €5000 attracts a solidarity surcharge €275).
Secondly, immediately after reunification, considerable financial support was given to modernise the hospitals and health care equipment in the East and the availability of nursing care, screening and pharmaceuticals also increased. This raised standards of health care in the East so that they were comparable to those of the West within just a few years. This had notable impacts on, for example, improvements in neonatal mortality and cardiovascular disease.
Both the economic reforms and the increased investment in health care were the result of the deep and sustained political decision to reunify Germany as fully as possible so that “what belongs together will grow together”. Germany’s lessons for the English divide are therefore two-fold: firstly, even large health divides can be significantly reduced and within a short time period; secondly, the tools to do this are largely economic but – crucially – within the control of politics and politicians. Ultimately, the German experience shows that if there is a sufficient political desire to reduce health divides, it can be done. It shows the primacy of politics and therefore a need for a political dimension to our understanding of health and place.
Reducing health inequalities
However, even though both composition and context matter, and can be supported by scientific evidence, politics can matter more than science in determining which strategies policymakers pursue to reduce health divides – or if they even care about inequalities at all. After all, some potential solutions are politically easier to implement within existing systems than others.
For example, interventions aimed at changing individual health behaviours are far less challenging to prevailing power structures than those that demand extensive investment in improving the social economic environment. Indeed, by blaming people for their own health problems, such interventions let governments and businesses off the hook for the wider economic, social and environmental determinants of health inequalities.
Such “downstream” approaches only tackle one side of the coin and there is little evidence that lifestyle interventions are effective in reducing health inequalities: more comprehensive measures are needed. As my book shows, most of the health gains over the nineteenth and twentieth centuries were brought about by far-reaching economic, political, and social reforms which improved the wider environment and also significantly improved the financial position of the poorest people.
It has been clearly demonstrated that more equal societies almost always do better in health terms and the poorest and most vulnerable groups, say in Sweden or Norway, are far healthier and live longer than the equivalent groups in the UK or the US. These countries have done so through the development of stable, inclusive economy, a supportive welfare system and a high standard of living.
So, where you live matters for how long you live – and changing how we live could reduce health inequalties.
Clare Bambra is Professor of Public Health Geography, Department of Geography, Durham University and Associate Director of Fuse: the Centre for Translational Research in Public Health, Newcastle University. Health Divides: where you live can kill you is available now from Policy Press.