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 those in the poorest areas, such as Glasgow or Blackpool. Men and women in the North of England will, on average die two years earlier than those in the South. Scottish people also suffer a health penalty with the highest mortality rates in Western Europe.
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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
Where you live affects how long you live and the health of different places is determined both 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, 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 an 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.
Reducing health inequalities
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. 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 a 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.
Professor Bambra’s book Health Divides: where you live can kill you is available now from Policy Press.
Professor of Public Health Geography, Department of Geography, Durham University, Associate Director of Fuse: the Centre for Translational Research in Public Health and lead of the Health Inequalities research programme
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