Health Divides: Where You Live Can Kill You, by Clare Bambra

Marcus Chown on a deeply political study that explains why inequality exists and that while ending it will not be easy, it is not impossible

November 3, 2016
Patients sitting in doctors surgery waiting room
Source: Alamy
The doctor is in: the UK, despite overwhelming public support for the NHS, is bent on emulating the non-universal US system

We are of superior stock. If we had been born in one of the poorest areas of the UK, we would have succeeded by dint of our own striving and our own talent. The poor are poor because they are skivers and do not work hard enough. Ridiculous as it seems, this appears to be the view of intelligent people governing Britain. They appear to have no awareness of the luck of their birth, which enabled them to benefit from good housing, good education, social networks of privilege, and so on.

The evidence, however, is that the inequality in the UK is nothing to do with the poor being a hopeless underclass, destined for extinction in a Darwinian world where only the fittest survive. As Clare Bambra, director of the Centre for Health and Inequalities Research at Durham University, spells out, it has everything to do with factors such as poor housing, poor nutrition and lack of educational and employment opportunities.

To some extent, Bambra’s study covers similar material to Sir Michael Marmot’s 2015 book The Health Gap: The Challenge of an Unequal World. Like the Anglo-Australian epidemiologist, she provides a vast quantity of data on the social determinants of health and opportunity, somewhat overwhelming the reader and sometimes making it difficult to see the wood for the trees. This is entirely understandable. However, the evidence is that policymakers are currently not listening to evidence, and soundbite appeals to emotion are also needed to move the scandal of life-limiting inequality up the political agenda.

Where Bambra’s work differs from Marmot’s is in its focus on three examples of dramatic differences in life expectancy and health: between the North and South of England; between England and Scotland; and between the US and the rest of the Western world. It is incredible that the US ranks bottom in pretty much everything from infant mortality rates to life expectancy despite spending far more on health than any other country. It is even more incredible that the UK – despite overwhelming public support for a publicly funded, publicly delivered NHS, one of the cheapest healthcare systems in the world – is bent on emulating the non-universal US system, where one in every three dollars is spent not on patients but on the wasteful bureaucracy of the market system.

Bambra, in this important and well-written book, also differs from Marmot in being explicitly political. She blames neoliberalism – with its privatisation, deregulation and lowering of taxes, with the consequent withering of public services – as a major factor in the increase in inequality over the past 30 years. As alluded to earlier, conservative ideology even sees inequality as a good thing – providing a cheap and compliant workforce – despite evidence showing that the most equal societies are the most economically productive, presumably because the more people who can participate in an economy the better.

According to Bambra, reducing inequality requires a multi-pronged strategy that improves housing, access to education and in particular the early experiences of children. It is far from easy, she admits, but it is certainly not impossible. After German unification, the differences in life expectancy and health between East and West were systematically reduced. The question we face is: do we continue to tolerate millions of lives stunted and truncated by inequality or do we do something about it? As Germany has shown, all it requires is political will.

Marcus Chown, formerly a radio astronomer at the California Institute of Technology, is author of What a Wonderful World: Life, the Universe and Everything in a Nutshell (2014).


Health Divides: Where You Live Can Kill You
By Clare Bambra
Policy Press, 320pp, £12.99
ISBN 9781447330356
Published 30 August 2016

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