by Jean Shaoul
The health gap between rich and poor in the UK has widened since
1980, according to a recent report. The Labour government
commissioned Sir Donald Acheson, Chief Medical Officer of Health
under the Conservatives in the 1980s, to write the report.
"The mortality gap among men has widened for coronary heart disease,
stroke, lung cancer and suicide and, for women, in lung cancer and
respiratory disease. Health inequalities affect the whole of society and
can be identified from foetus to old age," Acheson said. He added that a
mother's own birth weight and her pre-pregnancy weight were key
factors in low-weight babies.
The report presents a mass of empirical evidence showing that the
incidence of premature death, obesity, high blood pressure, accidents
and mental health problems is higher among the poor and unskilled than
among the well-off. In the early 1970s the mortality rate for unskilled men
of working age was almost twice that for professional men. Today it is
almost three times higher.
Inequalities in health are directly linked to inequalities in income, the
report acknowledges. About 60 percent of the population have below
average income. But the numbers of those with less than half average
income (the European Union definition of poverty) have grown from 10
percent in 1961 to 20 percent in 1991.
Poverty has a disproportionate effect on children. One in three children
were living in poverty in the mid-1990s, and many people on low
incomes do not have the money needed to ensure good health, the report
states. Often money allocated for food is used to meet emergencies,
forcing mothers to sometimes go without eating. In addition, many
pregnant women receiving welfare benefits have inadequate diets,
especially women under 25 years of age.
The poor are not only victims of low income, unemployment (which in
some areas is three times higher than 30 years ago) and changing
employment patterns. The report points out that many working class
neighbourhoods have become "food deserts" as planning authorities allow
supermarkets to move to edge-of-town sites only accessible by car. This
makes fresh produce almost impossible to obtain at reasonable prices
due to inadequate or prohibitively expensive public transport. Mothers
often shop alone to curtail expenditure and shop frequently to prevent
food being eaten before it is essential.
The report also states that housing conditions have a major impact on
health. In the mid-1990s some 8 percent of dwellings in England were
unfit and a steep rise in homelessness was observed. Over half of
165,690 households accepted as homeless by Local Authorities had
dependent children and a further tenth had a pregnant household
Pollution from traffic is another major cause of ill health. This particularly
affects the poor living in inner cities who have neither the benefit of their
own car nor good public transport.
Acheson refutes the argument that ignorance or personal choice are
responsible for the "health gap". To reduce health inequalities, his report
argues, the UK must become a much more equal society in terms of
"Policies which increase the income of the poorest are likely to improve
their living standards, such as nutrition and heating, and so lead to
improvements in health. This can be done by improving social security
benefits, specifically for families with young children and pensioners, by
increasing employment opportunities and through changes to the tax
system.... We consider that without a shift of resources to the less well
off, both in and out of work, little will be accomplished."
Efforts to merely "target" help on the least advantaged is not the answer,
the report continues, because health inequality follows a gradient.
Professionals fare better than managers, managers better than skilled
workers and so on down the line. Removing all the health disadvantage
of the bottom fifth would remove just 40 percent of health inequality.
Many issues are raised by the report. First of all, the "health divide"
new. Twenty years ago, the last Labour government commissioned Sir
Douglas Black to review health inequalities and suggest policy. When it
was published, it put health inequalities on the agenda around the world
and made recommendations not dissimilar to those made by Acheson.
But the Black report made very specific proposals: a big increase in child
benefit, a quadrupling of the maternity grant, and free school meals for all
children, to name but a few. The incoming Thatcher Tory government
costed these proposals at £5 billion (in today's prices), printed a mere
260 copies of the report, and then refused Black a press conference to
launch it, in order to bury his proposals.
Throughout 18 years in opposition, the Labour Party complained at the
Tories' treatment of the Black report. They promised that when in
government, they would commission an independent review into
inequalities in health. When launching the inquiry in July 1997, the new
Labour Public Health Minister criticised the health strategy of the
previous government for "its excessive emphasis on lifestyle issues" which
"cast the responsibility back on the individual".
However, Blair gave Acheson a very limited brief that required him only
to identify priority areas for future government policy to develop
cost-effective and affordable measures. As a consequence, the reports
recommendations are very general and are neither costed nor prioritised.
Even so, the report and its recommendations are an embarrassment for
Labour. They are an indictment of the free market policies pursued over
the last two decades, which Labour is continuing.
Acheson's remarks about the futility of "targeting" healthcare also directly
contradicts the government's own piecemeal and cosmetic approach. In
the last period, Labour has made much play of "targeting" certain
problem areas as a means of destroying universal healthcare. For
example, it has allocated some additional funding to reduce
ever-increasing hospital waiting lists, but hospitals now have to bid for
this finance, speciality by speciality, on a competitive basis.
Acheson recommends that all policies likely to have a direct or indirect
effect on health should be evaluated in terms of their impact on health
inequalities, and should favour the less well-off. However, under
conditions in which the UK now leads the developed world in income
inequality and child poverty, this would require a redistribution of wealth
towards the poor never achieved by the "welfare state", even in its
heyday at the beginning of the post-war period. Moreover, the allocation
of billions of pounds towards the less well-off would necessitate a
complete reversal in social policy. At the very least it would mean an end
to the corporate tax breaks that have been showered on big business
over the last period.
Blair's government has made clear that it is opposed to such a change.
is committed to cutting public spending and so-called "expensive welfare
provisions". Whilst publicly welcoming the report, Labour has remained
silent on what it intends to do now. Acheson's report may fare no better
under Labour than the Black report did under the Tories