SOCIO-ECONOMIC FACTORS
41. However, these lifestyle-related causes of health
inequalities reflect what are frequently referred to as the underlying
causes—income, socio-economic group, employment status and
educational attainment. There are many reasons why the poorest
in society are less likely to adopt beneficial health behaviours.
Firstly, information about how to behave healthily may not reach
some groups of society; secondly, they may lack the material resources
to live healthily, and the environments in which they live may
make this doubly hard; behaviours such as smoking tend to be more
heavily entrenched in those from lower socio-economic groups which
makes positive change harder; and finally, for people living difficult
lives, who may be faced with pressing problems with income, employment
or even personal safety, changing health behaviour is unlikely
to be a major priority.
42. Sir Michael Marmot, Professor of Epidemiology
and Public Health, University College London, and Chairman of
the Commission on Social Determinants of Health, set out for us
in simple terms why having sufficient resources is essential for
health:
Professor Jerry Morris, I think after his 90th birthday,
calculated the minimum income for healthy living for a pensioner
and he did it by consensus. He went round to the various experts
and said, "How much does it cost to eat a healthy diet?",
and, "Is it reasonable to expect people to buy presents for
their grandchildren and make visits to friends and so on? How
much would all that cost?", and he summed it up. Then he
looked at what a single pensioner gets with the state pension
and there is a huge gap. People who rely on the state pension
who are pensioners do not have enough money to lead a healthy
life. That is the clear judgment and it is the same for a couple.
They do not have enough money to live a healthy life. We can give
all the health education we like. If people cannot actually afford
to do the things they need to do to remain healthy then they are
not going to be healthy. That has to be a key issue in inequalities
and we have not solved that one.[27]
43. Socio-economic circumstances can also have a
negative effect on health behaviour as future health is not a
high priority for people who face much more immediate and serious
problems, such as crime and unemployment:
Smoking is not a key issue for people living in relative
poverty when they have a number of other key issues that concern
them more immediately …If you look at Washington DC, young
black men have a life expectancy of 57. Young black men also have
a one third probability of being incarcerated for drug dealing
between the ages of 18 and 24, so they are either going to die
early or they are going to be put in prison. You go to those young
men and say, "You know, you really shouldn't smoke because
you might get lung cancer when you are 60" … I do not
think you would get a very welcome reception. That is an extreme
case but I think some of that goes on if people have multiple
problems and smoking does not rank so highly on their list of
problems that they are willing to do something about it.[28]
44. Richard Wilkinson, Professor of Social Epidemiology
at the University of Nottingham, expanded on this point, arguing
that 'health-related behaviour is all about resolutions to give
up the things you do not want to give up and to do the things
you do not want to do. You cannot do that, you cannot make the
resolutions and stick to them, unless you are feeling on top of
life."[29]
45. But socio-economic factors appear to go beyond
the direct influence socio-economic circumstances may have on
lifestyle, as these graphs demonstrate, which reveal that people
from high socio-economic classes who smoke live longer than those
from lower socio- economic classes who smoke:
Smokers survival by social class
Females
Males
Source - Gruer et al[30]
46. Much debate has centred on whether health problems
are more common in lower socio-economic groups because they are
absolutely poorer—as in Professor Marmot's example of a
pensioner who could not afford to live a healthy life—or
because they are relatively poorer. According to Professor Marmot,
relative differences are also crucial:
Relative differences matter because even though our
children all now have enough to eat they do not all have the latest
Nike trainers or latest mobile phone, which is really very important.
That is not trivial, that is central. If a kid does not have what
the other kids have, even though he has got all the basic material
provisions he needs, that is really terribly important, he is
on the outside, and the evidence is that he is relatively deprived
in the space of income but absolutely deprived in the measure
of what he can do, of his capability to lead a healthy, flourishing
life.[31]
47. There is also a hypothesis, called 'competing
causes of death', which argues that irrespective of advances in
health care and lifestyle the poor will continue to die earlier
than the rich unless 'fundamental' or 'upstream' causes of inequality
like income inequalities are tackled. In the 1930s the main cause
of inequalities was infectious diseases; now it is chronic diseases
arising from lifestyle factors, such as cancer and coronary heart
disease. The consequence of eliminating the present major causes
of death, such as heart disease or lung cancer, will be that the
poor will continue to die earlier than the rich but from other
causes which will inevitably replace today's major diseases.[32]
In other words, it is argued that inequalities in health between
rich and poor persist irrespective of the diseases which happen
to be currently most prevalent. There is a large research literature
referring to this phenomenon, but, while this literature discusses
the fact that when one cause of death becomes less prominent,
others take its place, there is no published research on the social
class distribution of this phenomenon.
48. Although associations between socio-economic
inequalities and health inequalities are apparent, controversy
remains in this area, as seen by a recent publication in Health
Economics which did not find a highly significant relationship
between socio-economic inequalities and health inequalities.[33]
Moreover, while the view that reducing relative income inequalities
was the key to reducing health inequalities has many enthusiastic
proponents, we did not see any conclusive evidence that suggested
changing tax and benefit policies to reduce income inequalities
would lead to a reduction in health inequalities. Such claims
tended to centre on theoretical assertions rather than be supported
by robust evaluative evidence. We note that the Government has
commissioned research, to be carried out by Professor Sir Michael
Marmot, into the evidence about these wider determinants of health.
49. Health in
the UK is improving, but over the last ten years health inequalities
between the social classes have widened—the gap has increased
by 4% amongst men, and by 11% amongst women. Health inequalities
are not only apparent between people of different socio-economic
groups—they exist between different genders, different ethnic
groups, and the elderly and people suffering from mental health
problems or learning disabilities also have worse health than
the rest of the population. The causes of health inequalities
are complex, and include lifestyle factors—smoking, nutrition,
exercise to name only a few—and also wider determinants
such as poverty, housing and education. Access to healthcare may
play a role, but this appears to be less significant than other
determinants.
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