Feature

Unequal chances of a lifetime

Inequalities in health persist, yet attract little official research funding. David Blane wonders why

Some of the best people I know think health inequalities are a diversion from more important issues. They argue that most workers already know their health is damaged by poor housing and hazardous work and that attention would be better directed against cuts in the health service.

I seriously doubt whether the first part of this argument is correct. Most people are aware of health education’s hostility to cigarettes and a fatty diet and, in consequence, tend to blame themselves rather than circumstances for their poor health. I am also unconvinced by the second part of the argument. Sustaining health and treating disease are not competing alternatives, but two sides of the same human need.

If it were not absurdly paranoid, I would suspect these socialist militants of being in cahoots with those who control the state’s health apparatus (I refer of course to the Yes Minister types at the Department of Health and their friends and relations at the Medical Research Council.) Like most of us, I have never actually seen any of these people, but I hear rumours and the rumours all suggest a distinct lack of interest in health inequalities.

Unable to deny the existence of social class differences in health (research, after all, regularly confirms that class is one of the strongest and most consistent predictors of health), they console themselves with the belief that these are due to healthy people moving up the social hierarchy and unhealthy people moving down. It’s all social selection, and perish the thought that living conditions might affect health.

You might think ‘they would say that wouldn’t they’, but before dismissing them as bargain basement Machiavellis it is charitable to consider the diagnosis of social naivety. Spending their lives among people much like themselves, perhaps they really believe that everyone, apart from the occasional homeless beggar, lives more or less as they do.

I once sat with a colleague and compared his life as a hospital porter with mine as a medical school academic. He started work at age 15, I at 23. He had held numerous jobs previously, including some which had exposed him to recognised health hazards; I had spent my whole working like in the same white collar career. He had known hunger as a child; I had known it only as the sign of a good appetite. His basic working week was 40 hours, and he regarded himself as fortunate if he could do anything up to an extra 20 hours overtime; my basic week was 38 hours and if I worked for longer than that it was mainly because my work as a pleasure.

His work involved frequent spells between tasks, waiting in an overcrowded room full of stale cigarette smoke and petty squabbling; I had my own office, organised my work into a continuous flow, took a break when I needed one and went home when I had finished. He had three weeks holiday a year but rarely sufficient money to get away; I had five weeks, left the city and did something different.

It was physically impossible for him to perform his job when unwell and inadequate sick pay invariably forced him back to work before full recovery; in similar circumstances I organised a reduced but manageable work load. Up to a third of him pay came from unpredictable overtime and bonuses, so financial planning was extremely difficult; my pay was steady and included two pay rises a year. His basic hourly rate was one fifth of mine. And so the differences went on.

In nearly every instance the social structure put him at a disadvantage compared with me and, it is worth emphasising, he and I by no means represented the extremes of the social structure. Each of these differences, when taken on their own, can plausibly be related to physical and mental wellbeing. Taken together, however, they combine and accumulate over a lifetime, it is impossible to believe they do not have a major impact on health.

More than a decade ago the Department of health’s own research working group reached the same conclusions (the Black report) and recommended research into such materialist explanations of health inequalities. What has been the response of our health supremos? To this academic’s eyes at least, obfuscation, weasle words and penny pinching. As a recent review has demonstrated, very little research into materialist factors has been undertaken during the past decade.

A Medical Research Council grandee has tortuously argued that health inequalities are due to genetic factors, so even in this area the MRC’s fascination with gene probes has been legitimised. And the few studies of health inequalities that have been funded have all carefully placed social selection at the centre of their inquiries. Of course there are some excellent and honourable exceptions, but they do not alter the general picture.

Why should we care? Why should anyone be concerned with health inequalities? The cynical answer is that it is always worth looking closely at things our betters so obviously wish to avoid. The human answer is the wish to document honestly the effects of life as we are forced to live it. And the medical answer is the chance to identify the hazards of everyday life and the possibility of preventing their effects. Those who welcomed the Black report at the time of its publication could try to ensure that its research recommendations are followed. The MRC and DoH are spending our money, after all.