Why are inequalities in health greater now than at any times since the 1920s?

Why are inequalities in health greater now than at any times since the 1920s?

Danny DorlingTalking Points Lecture,10th February 2010Medical School Lecture Theatre 2, University of SheffieldOrganized by Yorkshire and Humber Teaching Public Health Networkand co-hosted by the School of Health and Related Research (ScHARR)

Thanks to all who contributed to this lecture, especially the Worldmapper group (Graham Allsopp, Anna Barford,

Benjamin Hennig, Mark Newman [University of Michigan], John Pritchard and Ben Wheeler [University of Cornwall]),Bethan Thomas and George Davey Smith [University of

Bristol] for the most recent work on inequalities in Britain,

and to Dan Vickers and Dimitris Ballas who helped with some of the others on the work on inequalities in

Sheffield.

Watch the full lecture as a video-multimedia presentation at

http://sasi.group.shef.ac.uk/presentations/healthinequalities/







Why are inequalities in health greater now than at any times since the 1920s?

Are they?

Why are they?

What to do?

Three Parts

Answers

Are they? they are for Britain by area, since

1930s

Why are they? much else polarized

What to do? realise how much all are harmed

by rising inequality – from national life expectancy to local housing, education and labour markets…

Are they? Here I will only talk about geographical

inequalities – your chances depending on where you were born and live – not to whom you were born.

We don’t have enough information to be able to answer this question worldwide, or for Sheffield, but we can for Britain.

People migrating in geographically selective ways appears to matter more now than it did in the 1920s and 1930s when inequalities were driven most strongly by material deprivation, occupational and (still) infectious hazards.

Today, in Britain, social inequality itself creates injustice.

Worldwide It can help to put local experiences in national

and international contexts for perspective; Inequality in health between countries fell, at

least until the 1980s and then rose; Superficially the rise could be accounted for

by young deaths due to AIDS; But worldwide inequalities in income and

wealth were also growing at this time. Infant mortality rates for my grandparents

generation were as high as in the poorest countries today.

Global Life Expectancy (years)

Dorling, D. et al. BMJ 2006;332:662-664

Copyright ©2006 BMJ Publishing Group Ltd.

Global life expectancy slope index of inequality between nation states (in years).

Black triangle shows estimated index in 2000-5 with impact of AIDS removed

GDP development 1955-2000s Sustaining postwar growth in rich nations after the

70s would have required another planet, or redistribution.

Instead there was a hugely inefficient redistribution of wealth to the richest nations.A more equal world would have seen far fewer young deaths than now occur.

Decadal growth rates (in GDP)

19731969

19681977

Age of Death: Infants (aged under 1) 8,142,016 deaths

Age of Death: 1-4 2,556,272 deaths

Age of Death: 5-9 863,022 deaths



















Age of Death: 100+ 92,585 deaths

Causes of death trends illustrate what is possible with medical progress and an NHS Change in Chance of Dying by Cause of Death

in England and Wales 1851-1990

Source: Very old graph from: A New Social Atlas of Britain (Wiley 1995), page 154: http://sasi.group.shef.ac.uk/publications/new_social_atlas/chapter5.pdf

NHS

Sheffield – A tale of two cities

http://www.sasi.group.shef.ac.uk/

research/sheffield/

Now, turn from the world to a single city in the middle of Britain.

How have inequalities in life chances changed here over time and inequalities in health responded?

This report was an attempt to collate most of what we know about spatial

inequalities in Sheffield. And how they have changed since the

late 1960s, the earliestdate have much

date for.

www.shef.ac.uk/sasi

Unemployment inequalities tell us a lot

Source: A Tale of two Cities. The Sheffield Project. http://www.sasi.group.shef.ac.uk/research/sheffield/

Life Expectancy 1851-1900by Registration District (years)

Data taken from Szreter, S. & Mooney, G. (1998): Urbanization, mortality, and the standard of living debate: new estimates of the expectation of life at birth in nineteenth-century British cities. Economic History Review, LI, 1 (1998), pp. 84-112.

1851-601861-70

1871-801881-90

1891- 1900

Sheffield 34 33 35 38 39Ecclesha

ll 40 40 42 43 46GAP 6 7 7 5 7

Average life expectancy in Sheffield Average life expectancy varies by 20 years at the

extreme (for women) and 16 years (for men) – by very small area

This inequality is slightly higher than in earlier years, but in general inequalities in health within Sheffield have fallen at times and have not risen as much as has occurred nationally, despite the huge wealth inequalities within this city.

Inequalities in life expectancy in BritainNationally there have been rapid increases in inequality since

2002 by area Difference between best and worst-off districts by life

expectancy (years)

Inequalities in life expectancy in Britain...and even getting worse in 2007 and 2008 Difference between best and worst-off districts by life

expectancy (years)

0 5 10 15 20 25 30 35 40 45

250

200

150

100

50

0

% Poverty

SMR <65

Poverty, deprivation and health:the dose-response has been known for many years

Source: Modified graph from Shaw, Dorling, Gordon & Smith (1999): The widening gap. Health inequalities and policy in Britain. The Policy Press. Bristol.

Scatterplot of standardized mortality ratio for deaths under 65 and % of households living in poverty (Breadline Britain index), for parliamentary constituencies (Britain (1991-1995)

Mortality Patterns in Britain 1921-2005Rates of inequality fell then rose from 1973 Change in SMR by Local Area Poverty Rate (pre 1974

boundaries)

1

0.9

1.2

1.1

Mortality Patterns in Britain 1921-2005Some more unusual maps are need to see:

Mortality Mosaics: SMR 1921-1925 10:10 ratio of deciles: 2.02

Created by John Pritchardhttp://sasi.group.shef.ac.uk/research/mortality_mosaics/

Mortality Mosaics: SMR 1926-1930


10:10 ratio of deciles: 2.41































Inequalities in premature mortalityhere is another way of looking at the ratesGeographical Inequalities in premature mortality

(SMR<65) 1921-2006

Note that the time periods vary due to data limitations; in particular, there is a large gap between 1939 and 1950. For 1990 (included in 1990-92), 1991 population figures were used. For 2006 (included in 2004-06), 2005 mid-year estimates (the latest available at small area geography) were used. Note that the final column does not follow on but overlaps; it is the latest 3 years for which mortality data were available for all of Britain.

Polarisation even for the rarest causesPoverty and Murder in BritainChange in SMR for Murder by Ward Poverty,

1981/85-1996/00

Source: Data from Dorling, Gordon, Hillyard, Pantazis, Pemberton, &Tombs (2008): Criminal obsessions: why harm matters more than crime. Second Edition. London: Centre for Crime and Justice Studies. http://www.crimeandjustice.org.uk/

And it is worth rememberingwhat the key causes now are:Main Cause for people dying in Britain (by age)in the period 1981-2004 Age Cause

0 Other conditions in the perinatal period 1-4 Congenital malformations of heart 5-14Pedestrian and motor vehicle accidents 15-34Other motor vehicle accidents

(driver/passenger/cyclist) 35-95Heart attack and chronic heart disease

Source: Dorling, D. (2008). Supplementary memorandum from Professor Danny Dorling, pages Ev 323- 324 House of Commons Transport Committee: Ending the Scandal of Complacency: Road Safety beyond 2010.

Full details given in the preface of Shaw, M. et al., 2008, The Grim Reaper’s Road Map, Bristol: Policy Press.

Underlying inequalities in health isIncome inequality in Britain: the trend

As a result of what first became politically possible and then, apparently, politically impossible, inequality fell and then rose. It is hard to believe this trend is unconnected

What the richest1% get

(post tax)

From this

The most harmful cost of inequality

In more unequal times, and in the aftermath of the shock of mass unemployment, more people in poorer areas die young as compared to other times and places. The prospects of the wealthy also move away from those of the average. The line marked by squares shows how much lower the age-sex standardized under age 65 mortality rate of the best-off 10% by area is as compared to the average. The line marked by dark diamonds shows how much higher that of the worst-off 30% is than the average. (Source Dorling and Thomas 2009, derived from Table 4.3 with interpolation between five year rates in some circumstances)

Best and worse off area –

differences from average

Inequality in health –

premature mortality

What to do? - read somebody else’s book!Inequalities have a direct impact on

health, so they need to be reduced in all areas of life!

Image Source

What to do?Inequalities have a direct impact on

health, so they need to be reduced in all areas of life!

Health: GPs where they are needed(like nurses) – it is easier in a time of crisis (like the NHS after the war).

20mph speed limit in residential areas should be a key public health policy.

Education: In affluent countries with elitist education all children do worse at school. – Solutions: Ensure the nearest school to every child is funded by need, not just numbers.

Poverty: NOT means testing – this results in a JSA of £9 a day.

Source: http://risingtide.org.uk/book/print/269

ww

w.polyp.org.uk

References Day, P., Pearce, J., and Dorling, D. (2008). Twelve worlds: A geo-

demographic comparison of global inequalities in mortality. Journal of Epidemiology and Community Health, 62, 1002-1010

Dorling, D., Shaw, M. and Davey Smith, G. (2006). HIV and global health: Global inequality of life expectancy due to AIDS. BMJ, 332, 662-664.

Dorling D. and Thomas, B. (2009). Geographical inequalities in health over the last century, Chapter 1.3 in Graham H. (Ed.) Understanding Health Inequalities, Open University Press. Pp. 66‐83.

Mortality mosaic maps by John Pritchard World maps by the Worldmapper team Slides created by Benjamin Hennig

Slides available on

http://www.slideshare.net/GeoSaSI

Credits

www.polyp.org.uk



The original slides are available as a free downloadable PowerPoint file on

http://sheffield.ac.uk/geography/staff/dorling_danny/lectures.html



The original slides are available as a free downloadable PowerPoint file on

http://sheffield.ac.uk/geography/staff/dorling_danny/lectures.html

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