Professor Sir Michael Marmot, who is giving the Human City Institute (HCI) 8th annual lecture on 7th February 2018, continues to make the most significant contribution to our understanding of health inequalities. He asserts that inequities in health are not inevitable nor immutable, stressing the importance of the social determinants of health in structuring people’s lives and opportunities.
The social determinants of health are the factors that explain health inequalities in mortality and morbidity rates, arranged in a social gradient of inequality. The lower down the social gradient, in terms of class, income and social status, the lower the health outcomes. Conversely, people occupying higher positions on the social gradient have better health and live longer. Socio-economic factors include education, employment, income – poverty, family and social support, community safety. And quality of the built environment, such as housing, traffic and transport, green spaces and leisure opportunities. These are not within the remit of the NHS but are crucial to the existence and persistence of health inequalities.
Public health now sits within local government, where it is better placed to help tackle locally created social determinants. But since there have been massive funding cuts from central government to local government, especially in urban areas, this has meant that many earlier health improvement initiatives, such as Healthy Cities, Health for All, Sure Start, Healthy Places, Healthy Lives, and area regeneration, are no longer funded.
The West Midlands conurbation has three of the most deprived out of 326 local authorities nationally. Birmingham, Sandwell and Wolverhampton are all ranked in the most deprived 5%.
The conurbation also has significant housing problems. Homelessness has increased by 94% since 2010 and rough sleeping has soared by more than 239%. Use of temporary accommodation to house homeless families has seen a 183% rise over the same time period. And over the last year, waiting list numbers have jumped by 2,600 households, with 56,000 now registered for a dwindling social housing supply.
Taking a public health lens to housing we know that homes and communities are important for health because they are the foundation for life. Housing provides safety and security and is the springboard to education, to work, for family, friends and other relationships and it embeds a sense of belonging to a place, a community, to a neighbourhood. Housing should not just be about counting dwellings, or units, or seeing property as investment, or property ladders, but about a concept of housing as home, where home equals health and wellbeing. Home is the healthy setting for life outcomes where people can live, thrive and age well.
The local press reports that many local authorities are rehousing homeless families up to 50 miles away, wherever they can find a place. At the same time, the national press reports councils are sending homeless families from London boroughs to the West Midlands. This enforced geographical movement of families is stressful. They are taken out of their familiar environment, away from the security of friends, family, from neighbourhoods where they may have spent the whole of their lives so far and dumped in an unknown place. For both mothers and children this is known to cause mental health problems, falling behind at school, no work or knowledge of local employment opportunities, and the loss of a sense of place of belonging. Some have termed this ‘social cleansing’, with movement from better off to poorer areas the norm.
There is also a strong relationship between deprived neighbourhoods and health inequalities. In the conurbation, men living in the bottom fifth most deprived neighbourhoods have a life expectancy at birth of nine years below that of men living in the best fifth. For women, the life expectancy differential is almost eight years. Many people in the West Midlands now face a daily struggle to feed their families, heat their homes (if they have one) and stay shy of destitution, thanks to seven years of austerity, welfare benefit cuts and cuts of local services.
Such a level of deprivation is marked by the now commonplace of collection boxes in food shops and supermarkets, where volunteers ask shoppers to make food donations. There are dozens of food banks in the conurbation. The number of three-day emergency food supplies given out by the Trussell Trust last year in the West Midlands was over 111,000. Food poverty is another dimension of inequalities. Children living in poor families are more likely to be living in unsafe or insecure homes, in overcrowded or poor-quality accommodation. They miss out on school trips, are less likely to visit museums or participate in other cultural and leisure activities. Many of them don’t feel confident at school and have some sort of mental health problem.
Yet public health is not just about socio-economic inequalities. One of the most pressing problems today in the West Midlands air pollution. Air pollution is a social determinant that will cause long-term illness well into the future. Air pollution accounts for up to 900 premature deaths a year. It is linked to a wide range of diseases, including heart disease, asthma, obesity, chronic lung disease and lung cancer, dementia, still births, infant deaths and low birth rate. Children who live in areas with high pollution are four times more likely to have reduced lung function in adult life as a result of air pollution.
Central and local government has to act now to improve air quality – especially in those areas around our city and town centres – where our most disadvantaged communities are often found – and down arterial roads and at motorway junctions.
HCI will be publishing a detailed report highlighting these, and other health inequalities in a few days following the lecture by Sir Michael. The report will feature and map the most recent data for the persistence of key health inequalities. It will also illustrate what can be done to reduce health inequalities, deploying case studies of what local government, social landlords and the charity sector are achieving in our region.