Divided we fall
BMJ 1994; 308 doi: https://doi.org/10.1136/bmj.308.6937.1113 (Published 30 April 1994) Cite this as: BMJ 1994;308:1113
- Richard G Wilkinson
The poor pay the price of increased social inequality with their health
In Britain, as in many other countries, the scale of the excess mortality associated with lower social status dwarfs almost every other health problem. The Whitehall study hasshown that the most junior office staff have three times the all cause mortality and six times the sickness absence rates of the most senior staff working in the same government offices.1 2 In this week's journal Phillimore and colleagues report that mortality in those aged 0-64 years is four times higher in the poorest than in the most affluent electoral wards of the Northern region of England. As an indicator of the effect of socioeconomic factors on the demand for services, over three quarters of the regional variation in the number of prescriptions provided per head of population is associated with differences in regional levels of unemployment.3
If risks as great as these resulted from exposure to toxic materials then offices would be closed down and populations evacuated from contaminated areas. The research reported by Phillimore and colleagues suggests that the more deprived sections of the population have paid a heavy price for the official failure to take the social causes of disease seriously. Although the apparent widening in mortality differentials between social classes before the 1980s was treated with some scepticism, particularly by those who were unaware of the gradual increase in relative poverty since the early 1950s,4 few will be surprised by the finding of widening mortality differences between richer and poorer electoral wards in the Northern region during the 1980s.
The 1980s were marked by an unprecedented widening of income differences and a growth of relative poverty in Britain, as in several other developed countries. Official figures of incomes after taxes and benefits, adjusted for household size, show that at the start of the decade the incomes of the richest 20% of the population were four times as large as those of the poorest 20%. By 1991 they were almost six times as large.5 That the late 1980s saw not only the most rapid part of this unprecedented widening of income differences, but a simultaneous cessation in the long term fall in national mortality rates among men and women aged 15-44, begs questions about the relation between the two.
The suggestion that the halt in the fall in mortality could have reflected hidden AIDS related mortality is implausible given the simultaneous slowing of the fall in mortality among infants and children. The Phillimore paper casts important new light on the processes underlying these national trends. Widening material differences during the decade were accompanied by widening differences in mortality and by a substantial rise in mortality among men aged 15-44 in the poorer electoral wards. Similar evidence has come from Glasgow. As the most deprived area of Scotland, its previously stable mortality disadvantage increased during the years in which income differentials increased throughout Britain.6 Mortality differentials also widened within Glasgow. The report from the British Regional Heart Study of a doubling of mortality rates associated with job loss is no doubt part of this picture (p 1135).7
The implication is that increased relative deprivation exerts a powerful influence on national mortality trends. That this is so is confirmed by the international cross sectional association between income distribution and national mortality. It also explains why life expectancy has increased fastest in those developed nations where income differences have narrowed.8 9
On the slide
Growing socioeconomic divisions are likely to be an important part of the reason why average life expectancy in Britain slipped from 12th to 17th position among the 24 nations belonging to the Organisation to Economic Cooperation and Development between 1970 and 1990. As Power describes, several other governments have started to put together policies designed to tackle the effects of disadvantage on health (p 1153).10 If the British government is serious about its health targets it must do so too.
Once it seemed possible that health was best served by faster economic growth, which was incompatible with greater equity. Among the rich nations, however, little or no relation exists between growth and the rate of fall in mortality: the problem is relative not absolute deprivation. Indeed, there is evidence to suggest that national infant mortality rises if the rich get richer while the real incomes of the poor remain constant.11 In addition, economists are now changing their minds about the supposed trade off between growth and equity. All eight of the high performing Asian economies reduced their income differences during the period 1960-80, and there is an increasing belief that narrower income differences and increased investment in human capital now play an important role in facilitating modern economic growth.*RF 12-14* Rather than Britain's poor health performance being a reflection of its poor economic performance, it seems that both have common roots in the social divisions and wastage of human skills and abilities among a substantial proportion of the population.
Policies intended to divorce health from deprivation have proved largely ineffective. Reducing the burden of excess mortality attributable to relative deprivation depends on reducing social and economic inequalities themselves. At a recent conference on social variations in coronary heart disease, emeritus professor Jerry Morris made an impassioned plea for a royal commission on policy related to social divisions and national prosperity.
The deep divisions in our society are both a reflection and a cause of financial and human waste on a scale we cannot afford. Their effects reach far beyond health into all areas of human functioning, from economic performance to the quality of life. It is not just a matter of recognising that society exists or of expressing the vain hope of making it classless. It is a matter of discovering how to achieve a more harmonious integration of social and economic forces capable of ensuring our future prosperity and wellbeing. Morris argued that a royal commission was needed because so many government departments have a role. This is an urgent, complicated, and technical issue, and it is one in which many countries are making much better progress than Britain. The pressures to defend political records or gain party advantage are not conducive to the kind of thinking that is needed.