Theresa May, in her first speech as prime minister, stood on the steps of Downing Street and referred to the glaring injustice of gaps in life expectancy and declared her intention to solve it by governing for everyone. I had a moment of hope for concerted action to increase health equity. That’s not looking bright at the moment; the government’s attention is elsewhere.
For many young people in Britain today – what with student debts, rental costs, the decline in home ownership, the gig economy and the economic uncertainties of Brexit – times are challenging.
A 15-year-old boy expects to be immortal, but evidence shows that expectation is less justified in the UK than in more than a score of other countries. The probability that a 15-year-old boy will die before his 60th birthday is 85 out of 1,000 in the UK. Is that a lot? It is higher than the best, Switzerland, at 61 per 1,000.
The UK ranks 22nd among all 185 countries for which the World Health Organisation reports this measure. Not terrible, but worse than Spain, Italy, Malta, Singapore, the United Arab Emirates, the Maldives, the Nordic countries, the Netherlands and Japan.
The US has a disastrous level of health for young and middle-aged adults
My colleagues and I at University College London’s Institute of Health Equity recently drew attention to the fact that the rise of life expectancy in the UK has stalled – a much more marked slowdown than in other European countries. Most of that levelling off is because of deaths at older ages.
I want here to focus on younger adults. You may ask why I worry about 61 in Switzerland compared with 85 in the UK. It seems like a small difference. But these figures represent something deeper: the quality of social conditions, how we are doing as a society. In the UK, we are not doing so well.
The US is doing worse. It ranks 44th on the probability that a 15-year-old boy will die before his 60th birthday. Mostly, this is not due to healthcare issues. The US spends more on healthcare, per person, than any other country, but has a disastrous level of health for young and middle-aged adults.
It is worth focusing on the US because it may have lessons for the UK. Anne Case and Angus Deaton of Princeton University recently updated their 2015 report showing that there has been a big rise in mortality rates among non-Hispanic whites; a rise that that was not seen in Hispanics or African Americans. The causes: poisonings from drugs and alcohol – in part, caused by medical care, because of over-prescription of opioids; suicides; and chronic liver disease, which is commonly alcohol-related. This adds to the toll of violent deaths. Medical care will not address the underlying social angst that gives rise to these causes of death.
Two important features of this US mortality in non-Hispanic whites have lessons for the UK. First, the fewer the years of education, the steeper the mortality increase, thus contributing to increase in health inequalities.
Second, Shannon Monnat of Penn State University looked at the geographic distribution of deaths from drugs, alcohol and suicide (pdf), and found that the greater the economic distress of an area, the higher the mortality rate. Monnat found, in the industrial midwest particularly, the higher the rate of these deaths the greater the 2016 vote for Trump, compared with Romney four years earlier. Trump didn’t cause these deaths, but these deaths may have caused Trump. More precisely, economic distress led both to death by drugs, alcohol and suicide and a greater likelihood of voting Trump.
In the UK we do not have the same appalling toll of drug and alcohol deaths, but we do see higher mortality in areas of economic distress. People in those areas were more likely to vote Brexit – perhaps prompted by the same dissatisfactions that led to the Trump vote in the US.
There is, though, much that can and is being done at local level. In London, for example, there has been a sharp reduction in inequalities (pdf) between children from poor families and the average in early child development and educational performance.
Coventry has become a “Marmot city”. It has taken the recommendations from my 2010 health inequalities review, Fair Society, Healthy Lives, and is implementing the recommendations.
Elsewhere, in addition to dedicated doctors and nurses, occupational therapists are supporting older people to remain independent at home. In the West Midlands and Merseyside, fire services are, as they put it, improving lives to save lives; they use their time and community commitment to get young people active, look after their homes, support older people and engage with improving people’s social lives.
None of this should let central government off the hook. We need an end to austerity, a reversal of plans to make the tax and benefit system less progressive, and real attention to regional inequalities. But the action of dedicated professionals at local level is an inspiring example of what can be done.
- Michael Marmot is professor of epidemiology at University College London. He will be speaking at the King’s Fund annual conference on 29 and 30 November 2017
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