Health and social Equality

October 21, 2009 at 4:26 pm | Posted in Articles | Leave a comment

Below is the text of a speech i delivered to the irish Practice Nurses Association conference in Westport on October 17th. I have been asked to make it available.

Introduction

 I want to begin with a rather well-known quotation. It’s from Maev-Ann Wren’s book Unhealthy State – Anatomy of a Sick Society (2003: 50).

 Irish people die younger because they tolerate an inequality between them which breeds ill-health, and they accept a health care system and a view of health care which implicitly places lesser value on the lives of those with lesser means.

 This is an extraordinary and disturbing sentence or, at least, it should be extraordinary and disturbing. Since 2002/3, when her book was written, we have had a further four years of unprecedented economic growth and prosperity. Does her judgement still ring true? Let me quote now from the more recent book – published this year – by Sara Burke which is provocatively entitled Irish Apartheid – Healthcare Inequality in Ireland.

 We have an apartheid system of healthcare, where those who can afford to, have quick access to what can be life-saving diagnosis and treatment, quicker than those who can’t afford private care. This has always been the case but, in the last decade, the two-tier system of healthcare has been accentuated, with increasing numbers of people incentivised to take out private insurance, privileging them over those who cannot afford to skip the queue (2009: 4).

 What is going on here? What is being described in these books? Is this simply an administrative defect which results merely in inconvenience but little real harm? No, as we know, it is not. This structure of our health system has real implications. A recent report from the Institute of Public Health has shown that 5,400 people die prematurely each year in Ireland due to inequality and poverty. 5,400 people – more than 100 each week. That is a figure so large it almost cannot be comprehended. It is only when this statistic becomes personalised around an individual – such as with Susie Long – that there is any political or media reaction. Susie Long died in October 2007 – two years ago. Has this reality changed? No.

 In this presentation today I want to make a very simple argument. The pattern of illness and sickness in our society tells us something fundamental about our society. Equally, the social structure of our society – particularly the pattern of social inequality within it – tells us something fundamental about the causes and distribution of illness in our society. In other words, there is a clear and demonstrable connection between the pattern of illness and the pattern of social inequality. This connection is so close that we can say that social inequality is a health issue. It is far more than just that of course but it is absolutely a health issue as well. Extraordinarily, far from being a contentious claim, this is widely acknowledged and understood even by those who run our health service. For example, Dr. John Kelleher, the Ass. Nat. Dir. For Health Protection in the HSE was quoted in The Irish Times in Sept 2006 as saying:

 ‘The fundamental issue in relation to poor health is income; if you don’t have that, you’re never going to be healthy again.’ 

 Ireland is a seriously unequal society. This, in turn, has a significant impact on the pattern of illness in our society. In simple terms, the greater the level of social inequality the greater the level of illness and the more unevenly distributed those illnesses are among the population. In short, the poor will be sicker than the wealthy.

 However, and this is important, social inequality is not a phenomenon that only has negative impacts on the poor and disadvantaged. Crucially, it has negative impacts for all in society. If we want a healthy and well functioning society, the most important and effective method by which this can be achieved is by creating and sustaining social equality. At this time of economic and social crisis, the great project of hope which we could grasp onto is to finally bring about a socially equal and just Ireland which would truly transform all our lives, not just the lives of the poor.

 I have made a number of assertions! Let me try now and systematically, if I can, ground these assertions in empirical data. First, is Ireland unequal? Second, does this inequality impact on our pattern of health? Third, does achieving social equality really make such a difference? I will do all this without a single powerpoint slide so I’m going to try to avoid too many statistics!

 Is Ireland Unequal?

It may be difficult for some people to think of Ireland as an unequal society. After all, we don’t seem to have people starving on the streets. But poverty is always a relative concept. You are poor when measured relative to the norms within your given society. In aggregate terms we have been, and remain, a wealthy society. However, the critical factor in understanding poverty in a society is how that wealth is distributed. The key determinant in triggering social consequences and shaping the society is the distribution of that wealth – in other words, the real issue is how big is the gap between the wealthy and the poor.

 Relative to the rest of the EU, particularly Western Europe, and relative to other aggregately wealthy societies, Ireland shows a very high level of social inequality. Only the United States performs worse than us consistently in international terms among the top 20 wealthy societies.

 Some – few! – statistics. Various studies and reports show that we have approximately 16 to 17% of our population living in relative poverty (i.e. with incomes less than 60% of the median income). That’s about 720,000 people. About 6.5% of our population live in consistent poverty (i.e. lack consistently a number of basic material indicators for a comfortable average existence). That’s about 290,000 people. Let me quote now from another Irish Times report in 2006:

Around half of the State’s 1,000,000 children are affected by income poverty at some stage during their childhood. A major study by the ESRI published yesterday, which tracked children between 1994 and 2001, found that young people tended to move in and out of poverty based on factors such as the employment, education and health status of their parents. Of the State’s just over 1,000,000 children, 535,000 experienced poverty at some stage over this period. A quarter of all children (246,000) experienced poverty for a relatively short time of between one and two years. However, just under a fifth (182,000) remained “locked” in poverty for between five and eight years. One in five children experience relative income poverty at any one point in time.

Bank of Ireland’s Wealth of the Nation Report in 2007 showed that the wealthiest 1% of the population owned 20% of the country’s wealth. The top 5% owned 40% of the nation’s wealth. This means that the other 95% of the population had the remaining 60% of the country’s wealth.

 Within this huge group of poor people, certain categories of people are deeply embedded in poverty and deprivation. These include Travellers, asylum seekers, lone parents (38% of whom are at risk of poverty), elderly people, the unemployed (of whom we now have over 400,000).

 One final internationally recognised measure of social equality is the gini coefficient. This is a way of measuring income distribution. If all income went to 1 person and none to everyone else the coefficient would be 100. If everyone had the exact same income the coefficient would be 0. So, the lower the value, the more equal the society. In the mid-1980s Ireland’s gini coefficient was 33.1. In the mid-1990s it was 32.4. By 2000 it had improved to 30. However, by 2005 it had risen again to 32. This can be compared to 23 in Sweden, 24 in Denmark, 28 in France, Germany and Norway.

 The point is that over that twenty-year period – from the grim 1980s to the booming mid-noughties – our level of relative poverty and therefore social inequality remained largely unchanged. We are not a socially equal society. The question that worries me is whether we really want to be or whether we – the relatively comfortable and secure – are happy with the way things are. Poverty seems to be invisible. It is rarely highlighted as a pressing social issue. It is rarely the stuff of heated political debates. It’s almost as if poverty is not our concern. I want to show shortly that this is not so – social inequality affects us all.

 Impact of inequality on health

 We have known for a long time that physical and material conditions have a decisive impact on the patterns of health. Once, within what can be called a bio-medical model of health, it was assumed that the causes of ill-health lay exclusively within the patient’s body and that treatment simply involved identifying the broken or damaged part and fixing it. This was a very mechanical, reductionist perspective.

 We now know of course that each human being is embedded within a complex socio-cultural and ecological setting and that the quality of that setting profoundly affects individual well-being. This occurs to such an extent that the causes for ill-health and mental stress are more likely to lie outside the individual than within. This has come to be called the social model of health.

 Yet even though I am claiming that this is well understood and recognised, it is extraordinary how rarely we hear health debated publicly in terms of the social model. Rather, when talking about health and the health service, our focus tends to be on medicine, on service provision, on treatment regimes and resources. In this sense we have a sickness service not a health service. We are less inclined to enquire into the deep causes of ill-health in our society and enquire into how we can address these fundamental causes in the first place so that we can reduce the number of sick people rather than continuing to focus on expanding our capacity to manage more sick people. As is clear we just can’t keep up. So, it is important to ask, why are so many of us sick? What is going on in the wider society?

 To answer this, we need to understand the social causes of illness. These include assessing the immediate social and environmental circumstances surrounding individuals. What is the quality of the social world? Can people access social services? Are they well connected to the wider society? Are they experiencing stress? Do they feel respected? What is the crime rate? Is there good public transport?

 It also includes the macro social and environmental context. Is the society wealthy? Are the society’s resources available to all or to a few? Are there employment prospects for all? Is the air clean, and the water pure? Does government policy support inclusion and service provision?

 Individual lifestyle is crucial as well. What is the quality of diet? Can people access and afford good quality and healthy food? Do they exercise? Can they access and afford sports and recreation facilities?

 Indeed, when we think about the ingredients of what constitutes a healthy life (both physical and mental) – exercise, food, low stress, social inclusion and connection, comprehensive service provision and access – we can readily see that we are almost entirely thinking about social causes. In this sense, sickness is not simply something you just ‘get’, something that unfortunately ‘happens’. It has clear patterns many of which are identifiable and predictable, patterns which have their roots in the nature and quality of the social world around us.

 We know that social inequality leads to greater levels of sickness. The poorer you are the more likely you are to be ill and in need of medical services. Yet interestingly the key finding of numerous studies is that the key issue here is not the amount of absolute poverty in the society – rather, it is the amount of relative poverty. In other words, it is the level of social inequality that is the determining factor for the pattern of illness. The bigger the gap between the wealthy and the poor, the greater the level of illness generally, and the more those illnesses will be disproportionately experienced by the poor.

 Back to some statistics! Take death. If we compare death rates from various diseases for the richest and poorest socioeconomic groups we find that the poorest have twice the likelihood of dying from cancer than the wealthiest, three times the likelihood of dying from heart disease, almost four times the likelihood from stroke, over five times the likelihood from suicide, six times from accident, almost sixteen times from mental or behavioural disorders, and sixteen times more likelihood from alcohol abuse.[1]

 I have already mentioned the appalling figure of 5,400 deaths per annum directly due to poverty and inequality. Social inequality kills the poor but it degrades all of us.

 Elizebeth Cullen, in an important article in the FEASTA Review of 2004 which reviewed large amounts of data linking poverty and ill-health, has written:

 A report in 2002 found that medical card holders had higher incidences of cardiovascular disease, stroke, hypertension, asthma, osteoarthritis, skin cancer and all other cancers, underactive thyroid, kidney stones, osteoporosis, gallstones, duodenal and gastric ulcers, and diabetes. A further report found that 52.9% of medical card holders suffered from one or more health conditions, in contrast to 22.7% of private insurance holders.

 I could go on and on. But there are is only so much data one can absorb – especially without powerpoint! Let me quote finally from the editors of the British Medical Journal, writing as far back as 1996, in a review of studies confirming the link between income inequality and health:

 The big idea is that what matters in determining mortality and health in a society is less the overall wealth of that society and more how evenly wealth is distributed. The more equally wealth is distributed the better the health of that society.

 Does achieving social equality really make such a difference?

Instead, let me return to the question does achieving social equality really make such a difference? To answer this, I want to rely on a very interesting and important book recently published called The Spirit Level – Why more equal societies almost always do better. It is written by Richard Wilkinson and Kate Pickett.

 The argument of this book is straightforward and not by any means original. They set out to show that the benefits (both socially and in terms of health) of economic growth in rich countries have reached their limit. Now, the quality of life is determined they argue by the equal distribution of wealth. It should be clear that this is a position that I, and most social scientists, would agree with.

 What is particularly important about this book however is the impressive amount of empirical data that they present from around the world to support this argument. They show – I think compellingly – that income equality creates better outcomes across a whole range of social indicators. Specifically, they examine:

  •  Community life and social relations (social capital and trust)
  • Mental health and drug use
  • Physical health and life expectancy
  • Obesity
  • Educational performance
  • Teenage births
  • Violence
  • Imprisonment
  • Social mobility (opportunities).

 They demonstrate that in rich countries health and social problems are closely related to the level of inequality in those countries. In short, the more unequal the society, the greater the level of problems in these nine areas. It is a simple but elegant argument.

 Why might social equality be so important? The answer lies I think in understanding that we are fundamentally social beings who need to belong to the social groups within which we live. We have a compelling need to be accepted, to be able to participate, to be able to access the resources of that society. If we can’t, if we are repulsed, marginalised, isolated, ill-treated, then it has devastating effects on us. To have distance placed between you and the society to which you belong places you in an extremely unsettling position. These distances may be symbolic (the wrong accent, the wrong clothes) or actual (the wrong address, the wrong ethnicity) or, indeed, both. Where income differences are bigger, social distances (symbolic and actual) are greater. The materially comfortable and the poor may live in the same country but they live in different social worlds.

 For their part, Wilkinson and Pickett suggest that social inequality causes wider social problems because it leads to

  •  A rise in anxiety
  • Loss of self-esteem and social security
  • Threats to the social self
  • Loss of pride, increase in shame and loss of status and,
  • Inequality increases social evaluation anxieties

 Status is so important for the social creature that we humans are. Having low status has a direct and immediate impact on our well-being. It raises our stress levels, suppresses our immune levels, causes us anxiety. It makes us isolated, marginalised and reduced in our very humanity. To quote Wilkinson and Pickett again – ‘Chronic stress wears us down and wears us out’.

 Their argument is that social equality leads directly to social improvements in regards to each of their nine social indicators. It improves community life and social relations, improves mental and physical health, improves educational performance, reduces violence and the need for imprisonment and increases social opportunities and mobility. Hence, equal societies nearly always perform better.

Conclusion

The conclusion I think is that we need income equality in order to create socially and environmentally sustainable societies and, of course, to create healthy societies. The point is that equality is a matter that should concern us all. We all live in society. The better that society is, the better for all of us. None of us can be isolated and asocial unless we wish to live in a hyper-privatised world of private education, private hospitals, private security, private gated communities, etc. This surely is more a dystopian image of the world than something we might aspire to.

 Equality is a health issue. We are of course not used to thinking like this, or putting it like this. Thus, the greatest single contribution we can make to improving the health status of our society is to bring about social equality. That we have done precisely the opposite in Ireland should therefore cause us no surprise when today we see huge amounts of illness and waiting lists and demands for medical services both primary and hospital. Just why are we so ill? What is wrong with us? Why are we surprised that our society is producing so much physical and mental sickness? What I am arguing is that one of the most important reasons is our level of social inequality.

 It seems clear to me that when we are thinking about our society and about its health we are not thinking deeply enough. Our debate is not at a deep enough level. In our present economic crisis, we are proceeding by reflex, by an accounting template of cutting services for all and raising taxes for all. In addition, crucial decisions, which will shape our society, are being made in reality according to the power of various vested sectional interests. When this happens the poor and weak lose – again.

 What we don’t have is a social plan which contains a vision for what type of country we want to have. We have apparently economic-based plans centred on a ‘smart economy’. What about a social plan centred on a ‘just and equal society’? Especially if it turns out that a smart society is in fact a just and equal society. This is surely essential to do so that as we go through this present phase of suffering and pain we can do so with the hope and expectation that we are finally building an Ireland of social equality and inclusion.

I say this on the assumption of course that this is what we really want. I hope it is. Such a society is not an airy-fairy unrealisable dream. We have the models all around us – in Norway and Denmark, for example – countries of comparable size to us and with similar histories.  Let’s study them, copy them directly if need be, at least see what they have learned and apply it to our own situation. We need this vision in order to give ourselves in this dark time a horizon of hope. The bottom line is that achieving social equality is not just about the poor – it’s about all of us. We all benefit.

 


[1] Balanda and White in Health in Ireland – an unequal state. Public Health Alliance Ireland, Institute of Public Health, 2004.

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