The establishment of a free NHS in 1948 came just two days late for my fifth birthday. By the time I’d reached my twenties it was widely assumed to have eliminated health inequalities: almost no one knew whether life expectancy was longer at the top or bottom of the social ladder. Even doctors mistakenly believed “executive stress” was the biggest risk for heart attacks.
As a research student in the 1970s, my attention was drawn to official data showing not only that most of the major causes of death were two to three times more common among unskilled manual workers and their families than among professionals, but also that the gap in death rates had widened since the 1930s. Such large class differences in death rates came as a shock. Full of righteous indignation, I wrote a newspaper article addressed to the secretary of state for health, David Ennals, urging him to set up an urgent inquiry to address these issues.
A few months later, in 1977, he set up the Working Group on Inequalities in Health, chaired by Sir Douglas Black, the first such commission anywhere in the world. The Black report followed, in 1980 – exactly 40 years ago this month – and established the truth of health inequalities in the UK. Commissioned by a Labour government, the report was rejected by Margaret Thatcher’s new Conservative government. Her health minister, Patrick Jenkin, said: “I must make it clear that additional expenditure on the scale which could result from the report’s recommendations – the amount involved could be upwards of £2 billion a year – is quite unrealistic in present or any foreseeable economic circumstances.” Despite publishing only 260 mimeograph copies on a bank holiday weekend, the report caused an immediate furore.
Yet successive governments have failed to make any real difference to the problem. New Labour made some progress, but from 2010 onwards health inequalities increased again. The gap in life expectancy between people living in the most and least deprived 10% of areas in England now stands at over seven years for women and over nine years for men. The difference in how long people live in good health is even larger – close to 20 years for both sexes.
The coronavirus pandemic has thrown these inequalities into sharp relief. It is the poor, those living in deprived areas, and people of black, Asian or minority ethnic status who have suffered the worst of Covid-19. The UK’s unacceptable social and economic inequalities have undermined our resilience and exposed us to more disease and death than any of our European neighbours.
The Black report discussed health inequalities exclusively in terms of material factors – diet, occupational hazards, smoking etc. Stress was hardly mentioned. But 40 years on, we know that it is chronic stress that lies at the heart of our vulnerability to poor health; stress is related to such a wide range of diseases that its effects look like more rapid ageing.
We also now know that the most potent generators of chronic stress are embedded in the social fabric, in our lives and relationships with one another. Three aspects stand out above others: the damaging effects of low social status, whether that is due to poverty, racism or any other cause; the quality of care in early childhood; and the strongly protective effects of friendship and social integration.
Relationships matter so much because other people can be our best sources of security, comfort and cooperation or our worst rivals. Just as bad relationships are highly stressful, friendship is relaxing and restorative. We have evolved an extraordinary sensitivity to relationships, because getting them right has always been crucial to our survival.
Experiments have shown that it is threats to self-esteem or social status, where other people can judge us negatively, that most reliably raise our stress hormones. These feelings are so potent, causing anything from fury to stomach-clenching shame. Even simple experiments have shown they have serious consequences, including slower wound healing and weaker resistance to infection.
Stress responses evolved to help us cope in brief emergencies, but if we worry for weeks and years, our health and wellbeing suffer. To understand what is going on, it helps to think about monkey dominance hierarchies. They are essentially bullying hierarchies, held together by fear, with the strongest at the top and the weakest at the bottom. Low-status monkeys have more biological signs of stress, including high levels of blood-clotting hormones which increase the risk of heart disease. Low social status has exactly the same biological consequences in humans. And it isn’t only our bodies that are affected, low social status also shapes how we think and feel. Psychologists have repeatedly shown that people score much less well on tests of ability if the experiment contains even a subtle reminder that they belong to a category of people who are thought to perform less well.
Beyond physical health, low social status and poor relationships with other people also contribute to most of the other problems associated with relative deprivation – including worse mental health, lower educational performance among school children, loss of social cohesion and the increase in violence triggered by disrespect, loss of face and humiliation.
We all want to be valued and appreciated: being looked down on, shamed or rejected is agonising. The experiences of low social status and racism are deeply stigmatising. To be treated as inferior, to be devalued and thought less of – whether on grounds of class, ethnicity, sexuality, or gender – is intolerable.
The coronavirus pandemic has again exposed our health and economic inequalities, just as the death of George Floyd again exposed the awfulness of racism. It is good that current public debate is turning to the possibilities of “building back better” rather than simply returning to the status quo.
So what can be done to ensure our health and resilience? The key is that class and status, prejudice and discrimination are strengthened by larger income differences. As George Bernard Shaw said: “Inequality of income takes the broad, safe, and fertile plane of human society and stands it on its edge,” with the result that some people are valued very much more than others. The rich are made to seem more superior and the poor more inferior, inequalities in health and in young people’s life chances increase, while social mobility slows.
The picture could hardly be simpler: almost all the problems that we know are related to social status within our society get worse when status differences are increased. If we want a less dysfunctional society and a healthier population, building back better means addressing the scourge of income inequality.
• Richard Wilkinson is a researcher in social inequalities in health. He is emeritus professor of public health at the University of Nottingham
Source: The Guardian