Prescription for fairness

Key points

• Health inequalities are unfair, because they are heavily influenced by socio-economic inequalities, which themselves arise from unfair distribution of resources and opportunities
• Health inequalities are stark. Examples: Working-age adults in the poorest areas have been almost four times more likely to die from Covid-19. Between January and November 2020, 60 per cent of all deaths involving the coronavirus were amongst disabled people. Our ethnic minority communities had devastating mortality rates, with men from black African communities at a 3.7 times greater risk of dying than white men in the first wave. People living in England’s most deprived areas are likely to develop a significant long-term health condition 19 years earlier than those in the wealthiest areas. People living in the poorest areas in England will on average die seven years earlier than those in the richest. Women with learning disabilities live on average 27 fewer years than the rest of the population. Black women are four times more likely to die in pregnancy or childbirth. People from South Asian backgrounds are more likely to develop type 2 diabetes.
• Health inequalities are bad for everyone. Health inequalities are preventable, yet the annual cost of inequality is around £40bn in lost taxes, lost productivity, welfare payments, and NHS costs.

• Because health inequalities are driven by socio-economic inequalities, the best way to tackle them is by tackling the underlying socio-economic inequalities.
• Ethnic minorities suffer disproportionately from socio-economic inequalities (where people live, what jobs they do, their income and wealth), and so they suffer disproportionately from health inequalities (leaving aside the negative health impacts of racial discrimination). Unequal distribution of resources between ethnic groups – such as wealth, income, work, welfare, education and housing – leads to an unequal capability to be healthy.
• Structural racism and health inequalities are not the same problem but have a common base: both stem from the unequal distribution of resource and opportunity.
• Some of the most effective tools to dismantle structural racism and health inequalities are population-wide not group-specific. E.g. better protections for gig economy workers, more social housing, minimum income etc.
• The most effective policies to dismantle structural racism are the same policy prescriptions required to reduce economic inequalities, health inequalities, tackle the climate emergency and enhance democracy.

• Need to integrate health inequalities with the ‘equalities’ agenda around protected characterstics (eg disabled people) [link to sentence about poverty and disability]
• We need to challenge overstatements of the contribution of lifestyle factors to health inequalities. For example, we know that social isolation is at least as important as smoking, excessive drinking and obesity in determining health and wellbeing.
• [Universal vs targeted is a false dichotomoy - need a system that benefits all, but with extra support for those in greater need, including disabled people, rather than separate targeted schemes that stigmatise recipients, exacerbate inequality and alienate those who are not beneficiaries] - including welfare but also e.g. inclusive education
• The public may be getting closer to John Hills’ evidence based comment that “there is no them and us – just us”, as we all pay in to the welfare state and often ‘get out’ close to our contributions.

• For the sector, health is primarily a product of societal systems. Solutions must, in turn, be designed at the level of society. For the public, health is understood at the individual level: individual behaviour and choices are seen as the main source of health issues and the main site for solutions. This gap is at the root of all the other gaps between the sector and the public on this issue.
• The sector explains that inequalities in power, wealth and resources lie at the root of health disparities. The public, by contrast, is largely unaware of how discrimination, racism and other power imbalances shape health. They understand the link between wealth and health only in terms of individual purchasing power and fail to see how economic inequality is bound up with other forms of inequality.
• These gaps between sector and public understandings of health need to be addressed to shift thinking and open up space for a different public conversation – a conversation capable of boosting support for new solutions and government action.
• Explaining the causal links between different social and environmental factors and health outcomes is critical to this effort. For example, communicators might explain how lack of access to a good education leads to limited employment options; how this in turn affects people’s housing conditions; how all of these things conspire to decrease individual power; leading to specific effects on physical and mental health.
• A productive issue frame for health inequality is to make it about life expectancy going down in some parts of the country. Health inequalities are about some people living shorter lives than others based on where they live.