Chapter 2

Chapter 2

“Health inequalities are unfair and avoidable differences in health across the population (…) These conditions influence our opportunities for good health, and how we think, feel and act, and this shapes our mental health, physical health and wellbeing”- NHS England56 .

In this chapter, there will be an analysis of the perpetuated and wholly avoidable health inequalities that exacerbate the disproportionate obstacles disabled people face. In addition, there will be an investigation into the effects that cost-cutting policy and legislation have on the general wellbeing of disabled people throughout the UK. Inequalities in health are regularly under review, with governments seemingly stuck in a Groundhog Day scenario, repeatedly commissioning reports and not actioning the findings or recommendations. The evidence is damning, and the lack of action surrounding the publication of these reports is deafening.

Health inequalities that affect everyone.

There are a number of universally recognised factors that affect public health, they are for example: unemployment, low income and living in a deprived area. These will all have an effect on the health of the entire population. Deprivation is defined by the Cambridge dictionary as: ‘A situation in which you do not have things or conditions that are usually considered necessary for a pleasant life57’. Subsections of deprivation are categorised by the

56 NHS, Definitions for Health Inequalities, [n.d.] <https://www.england.nhs.uk/ltphimenu/definitions-forhealth-inequalities/> [Accessed 27 November 2020] (para. 2 of 8). 57 Cambridge dictionary, deprivation, [n.d.] <https://dictionary.cambridge.org/dictionary/english/deprivation> [Accessed 21 January 2021]

NHS as, “Income Deprivation, Employment Deprivation; Education, Skills and Training Deprivation; Health Deprivation and Disability; Crime; Barriers to Housing and Services; Living Environment Deprivation.”58 Examples of specific vulnerable groups within society, or ‘inclusion health’ groups are: Migrants; Gypsy, Roma and Traveller communities; homeless people and rough sleepers; and sex workers. Another factor is geography and the different challenges faced in either rural or urban areas.59 Many people experience several of these factors which all contribute to the national standard of public health, not only for people with disabilities.

In 2008 the World Health Organisation’s former Director-General JW Lee, set up a commission under the ‘Social Determinants of Health (SDH)’. The objective was to collate evidence on the social determinants of health and the interaction with inequality in public health. From then the commission would formulate advice on how to create a cross border (whether that be local or international) health equality. The aim was to create global action to banish the reality of postcode lottery health systems. 60

The report found that the same trajectory was identified globally, that the lower the socioeconomic position, the worse the health. This report stated that where health inequities were found to be preventable, they would be labelled as an unfair and unjust systematic failure.

58 NHS, Definitions for Health Inequalities. (para. 4 of 8) [Accessed 27 November 2020] 59 NHS, Definitions for Health Inequalities. (para. 5 of 8) [Accessed 27 November 2020] 60 World Health Organisation, Closing the gap in a generation: Health equity through action on the social determinants of health. Final Report of the Commission on Social Determinants of Health, (2008) <https://apps.who.int/iris/bitstream/handle/10665/43943/9789241563703_eng.pdf;jsessionid=2F85FA2BB1B2F E9D0B0BA0DB068D8DC0?sequence=1> [Accessed 30 November 2020] (pp. 1-Note from the chair)

“It does not have to be this way and it is not right that it should be like this61”

The report concludes that internationally closing the health inequalities attainment gap could be achieved within a generation’s timescale. However, it is amended to ‘an aspiration not a prediction’62 . Primary author Sir Michael Marmot deems it not unrealistic and states that in many international talks.63 The study also looks at the varying life expectancy data across the globe, claiming that, if the strategies they suggest are followed correctly, they could rectify this gap. In order to close the gap the main elements need to be implemented globally. 64

In chapter one under the subheading, A new agenda for health, equity, and Development, the commission writes, “We start from the proposition that there is no necessary biological reason why a girl in one part of the world, say Lesotho, should have a life expectancy at birth (LEB) shorter by 42 year than a girl in another, say Japan. Similarly, there is no necessary biological reason why there should be a difference in LEB of 20 years or more between social groups in any given country. Change the social determinants of health and there will be dramatic improvements in health equity.65” The three top recommendations were: “Improve daily living conditions. Tackle the inequitable distribution of power, money, and resources. Measure and understand the

61 World Health Organisation, Closing the gap in a generation, [Accessed 30 November 2020] (pp. 1- 26)

62 World Health Organisation, Closing the gap in a generation, [Accessed 30 November 2020] (pp. 7- 1)

63 Michael Marmot, Social Justice and Health Equity: A talk with Sir Michael Marmot, Online video, YouTube, 16 December 2018, <https://www.youtube.com/watch?v=UZlYnE3OhRE&t=639s> [Accessed 30 November 2020]

64 World Health Organisation, Closing the gap in a generation, [Accessed 30 November 2020] (pp. 7- 26) 65 World Health Organisation, Closing the gap in a generation, [Accessed 30 November 2020] (pp. 6- 26)

problem and assess the impact of action.66” The highlighted elements that this essay will now focus on are: the upgraded development of daily environments specifically focusing on child early development ensuring each child has the best start in life67 . The education attainment gap must be closed68 . The unequal distribution of authority wealth and resource must be confronted69 . Suitable employment and working conditions must be upgraded for all70 . A healthy standard of living must be universally and non-discriminatorily available and applied71 .

In 2008 governments were armed with the knowledge and means to close that fatal gap and they were presented with a choice, they were given the opportunity to save lives, (entailing implementation of the recommendations made by the commission) or to ignore the commission and allow people to die from avoidable causes:

“This ends the debate decisively. Health care is an important determinant of health. Lifestyles are important determinants of health. But, let me emphasize, it is factors in the social environment that determine access to health services and influence lifestyle choices in the first place.” -Director-General Dr Margaret Chan, at the launch of the final report of the CSDH72

66 World Health Organisation, Closing the gap in a generation, [Accessed 30 November 2020] (pp. 1-2)

67 World Health Organisation, Closing the gap in a generation, [Accessed 30 November 2020] (pp. 1-202) 68 World Health Organisation, Closing the gap in a generation, [Accessed 30 November 2020] (pp. 5-202) 69 World Health Organisation, Closing the gap in a generation, [Accessed 30 November 2020] (pp. 1-204) 70 World Health Organisation, Closing the gap in a generation, [Accessed 30 November 2020] (pp. 16-202)

71 World Health Organisation, Closing the gap in a generation, [Accessed 30 November 2020] (pp. 9-202) 72 World Health Organisation, Dr Margaret Chan, Launch of the final report of the Commission on Social Determinants of Health: Statement to Press, [n.d.] <https://www.who.int/dg/speeches/2008/20080828/en/ > [Accessed 1 December 2020]

Returning to the social determinants of health that affect different local authorities uniquely, it should be known that they fluctuate across county borders dramatically due to varying priorities of different localities. Cuts to public resources and services promote a society with uneven resource allocation and authoritative control. Prejudiced distribution of wealth formulates thoroughly avoidable inequalities. The commission’s report is clear that unequal health experiences are not a natural occurrence. The findings of the report are that inadequately informed social policy made at government level in conjunction with an imbalanced economic arrangement creates systemic disablism which has been labelled as toxic.

Sir Michael Marmot, a pivotal figure of critical social justice reforms from University College London, delivered a talk at the 2014 World Minds Annual Symposium.73 After the World Health Organisation’s commissioned the report, he spoke about how the UK government invited him to advise on applying its global findings to Great Britain. Sir Michael then provided the specific report calling it: Fair society, healthy lives. The report details that if we put equality at the heart of new legislation, that public health would improve, across the board. The standard of the concept of fairness which is referred to is: when foresight is available, to take action on preventable causes of public ill-health. If a crisis is avoidable, and a government or institution chooses not to avoid it, they choose to perpetuate social injustice.

73 Michael Marmot, Sir Michael Marmot: Social Determinants of Health (2014 WORLD.MINDS), Online video, YouTube, 4 December 2014 <https://www.youtube.com/watch?v=h-2bf205upQ&t=55s [Accessed 1 December 2020]

It is not just poverty that is a significant factor in public ill-health. Inequality has been persistently highlighted as a primary cause. To expand further: if it was purely a case of poverty then people who have enough, who live comfortably above the poverty line should have the same health benefits as those in the highest bracket of wealth. They do not, from which we can infer that this is an issue of systematic inequality. 74

To prevent these disparities, all government departments must work together under the resounding banner of ‘All government sectors are healthcare sectors.’ All the conditions of daily life affect public health. It cannot be the health sector’s sole responsibility to tackle these social symptoms. Many are only prominent because they come from the resulting ripple effect other sectors’ policies have on health. The health sector is the recipient of the side effects of policies from other departments. Every policy should take into account the impact that the specific legislation will have on public health.

Marmot presented this slide when he delivered his talk to the university of California Berkeley (pictured below) representing all the departments that requested he delivered a talk on the social determinants of health research75 .

74 Michael Marmot, Sir Michael Marmot: Social Determinants of Health [Accessed 1 December 2020] 75 Michael Marmot, Sir Michael Marmot: Social Determinants of Health [Accessed 1 December 2020]

Fig. 2. Michael Marmot, Social Justice and Health Equity: A talk with Sir Michael Marmot, (Screenshot of online video, YouTube, 16 December 2018) <https://www.youtube.com/watch?v=UZlYnE3OhRE&t=639s> [Accessed 30 November 2020]

Marmot devised a recipe of quintessential, critical, and necessary actions that needed to be implemented by the government urgently in order to bridge the gap between local authority health inequality discrepancies. They were not implemented.

Examples of disability specific health inequalities.

The Equality for Human Rights Commission (EHRC) produced a report called: Being disabled in Britain: a journey less equal (2016) 76 . This paper reported that although some progress had been made, it was minimal and there were far more barriers for disabled people than ever before. Through evidence-based findings, they identified the top six areas of life to review for disabled citizens: Education, Work, Standard of living, Health and Care, Justice and Detention, and Participation and Identity.

76 Equality and Human Rights Commission, Being disabled in Britain: A journey less equal [Accessed 1 December 2020]