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You Can’t Tackle Health Inequality Without Tackling Social Injustice

The 2020 Marmot Review shows the impact of health inequality in England's Covid deaths. Challenging it will require a new kind of health policy – one that looks beyond the NHS to broader social ills.

Despite the existence of a universal, free health service, we are yet to come close to health equality in England. It has become a persistent fact of life that white, affluent, middle-class and able-bodied people live much healthier, and as such, longer lives.

This week, a new report by world-leading epidemiologist Professor Michael Marmot has put the spotlight back on these inequalities. His research reiterates the extent of health inequality in our country, and implicates those inequalities as a key factor in our disastrous Covid outcomes. Had we spent the last decade focusing on narrowing health inequality, he concludes, we would have been in a far better position once the pandemic struck. Instead, the government spent ten years exacerbating them through their failed austerity project.

Alarmingly, the response to Covid is set to aggravate these inequalities further. Lockdowns, limitations to job support schemes, poor protection and support for key workers, and disruption to education – all have disproportionately impacted the most marginalised people living in the poorest parts of our country. Without action, they will force the health gap even wider.

So there’s never been a more urgent need – in Marmot’s own words – to ‘build back fairer’. We desperately need to make progress on the country’s alarming levels of health inequality. To do that, we’ll need not just a strong NHS, but more progressive social, welfare and economic policy too.

Looking Beyond the NHS

The temptation is to focus our approach to health inequality on the ‘health sector’ and, more specifically, on the NHS. It’s health inequality, during and after a health crisis, so we should focus on the healthcare system – right?

There are certainly places we can make progress. The brutal impact of austerity on NHS funding has left it struggling to cope, meaning less protection for those who most need it. At the start of the decade, the government cut back the amount of NHS funding targeted at ending inequalities from 15 percent to 10 percent of funds. And while nowhere has escaped cuts to local public health budgets, the most brutal of them have been reserved for the most deprived areas.

But it would be a critical mistake to stop there. The vast majority of the 10-year difference in life expectancy between rich and poor is attributable to policy outside the NHS. It’s down to factors like education, job, finances, diet or exposure to pollution – that is, to a full gamut of social and economic policy outside of the Department of Health and Social Care’s control.

Marcus Rashford has bought one key example of this to the forefront of the public’s attention: food and nutrition.

Despite being one of the wealthiest counties on Earth, we still have four million children living in food insecurity. That means hunger and malnourishment, and the impact on school results, self-esteem, and long-term life chances that follow. It can also mean a reliance on cheap, unhealthy food, which is advertised without restraint by big food corporations, using tactics pioneered by the tobacco industry. In modern Britain, poor children are more likely to be hungry, malnourished and obese – sometimes, all at once – with all the severe health consequences that that entails.

Subsidising healthy food for every family on free school meals for a year would come to the same cost as two months of the Eat Out to Help Out scheme. But where the government is happy to subsidise gastro-pub lunches, it hesitates in providing school meals.

This is one example. But it is demonstrative of the topics that a serious strategy on health inequalities would include, and the types of demands it would make.

Race, Racism and Health

This lesson is not only crucial in tackling health inequalities reflected in the most and least deprived parts of our country. It’s also critical to tackling pernicious racial inequalities.

At the start of the pandemic, many reflexively declared that mortality differences between people of different ethnicities could be explained by genetics. Others claimed it was being driven by underlying health conditions. Both are wrong. Ethnic disparities in Covid-19 are driven by the structural racism that affects the conditions in which people are born, grow, live, work and age.

The government has buried its head in the sand. In fact, it has gone as far as to deny the role of structural racism in determining health. But recent research by IPPR and Runnymede Trust has put the question beyond doubt, finding that almost 60,000 additional deaths would have occurred in England and Wales during the first wave of Covid if the white population experienced the same risk of death as the black population.

Mayor of Bristol Marvin Rees has called structural racism a ‘robbery of resilience’. He’s referring not only to everyday experiences of discrimination, but to the greater exposure to adverse social and economic conditions that minority ethnic communities face. Racism in this form has led to thousands to die unnecessarily from Covid-19.

This kind of analysis informs what genuinely effective solutions might look like. In particular, it reminds us that people aren’t either black or poor: they can be both. And the best solutions will address how class and race intersect to determine health.

For example, nearly one-third of Bangladeshi households and 15 percent of Black African households are classified as overcrowded, compared to only 2 percent of white households. Bangladeshi and Black African households also have only 10p for every £1 in savings held per White British household, and are more likely to be working in shut-down sectors.

Covid-19 has placed the health consequences of social and economic conditions front and centre. Self-isolation is difficult – less than 20 percent of people with symptoms isolate appropriately – but poor housing and financial precarity can make it almost impossible. This isn’t unique to Covid. These are structural issues which have always carried a risk of physical and mental ill-health; the pandemic has simply amplified them.

Better housing and more financial security might not seem the immediately intuitive parts of a health inequality strategy, but once we take a more nuanced approach to health inequality as a problem, we see that they’re crucial.

Health is a Measure of Society

In a separate report, released in February – before the worst of the pandemic had struck the UK – Professor Marmot had a plain message: ‘Put simply, if health has stopped improving, it is a sign that society has stopped improving.’

His point is this: health inequalities don’t just measure the success of our health system. Rather, they test how effective and fair our whole system of government and policy is. They provide a basis on which to judge our approach to welfare, the economy, and society.

That they are getting worse is a damning indictment on the last decade.

But it’s not irredeemable. If the government can put health at the heart of their approach to welfare, fiscal, and social policy, they stand a chance of doing better. We must hope that they do. The alternative will be thousands upon thousands of avoidable deaths every year, long after the pandemic is done.