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Abstract

Health inequalities are differences in health between groups in society. Despite them being preventable they persist on a grand scale. At the beginning of 2024, the Institute of Health Equity revealed in their report titled: Health Inequalities, Lives Cut Short, that health inequalities caused 1 million early deaths in England over the past decade. While the number of studies on the prevalence of health inequalities in the UK has burgeoned, limited emphasis has been given to exploring the factors contributing to these (widening) health inequalities. In this commentary article I will describe how the Government’s relentless pursuit of economic growth and their failure to implement the necessary regulatory policies to mitigate against the insecurity and health effects neoliberal free market capitalism (referred to as capitalism herein) causes in pursuit of innovation, productivity and growth (economic dynamism) is one key driver underpinning this social injustice. I contend that if the priority really is to tackle health inequalities and ensure health for all then there is an imperative need to move beyond regulation alone to mitigate the worst effects of capitalist production; the goal of the economy has to change to fully restore the balance between economic growth and public health.

Keywords

capitalism economic growth inequality health social medicine

Main Text

Inaction on the Social Determinants of Health

The profound health inequalities between rich and poor which have been highlighted throughout the past century – most notably in the Black Report,¹ published over 40 years ago, remain in England today.^2,3 A baby boy born in relatively deprived Kensington, Liverpool, can expect to live over 10 years less – and nearly 20 fewer years in good health – than a baby boy born in wealthy Kensington, London.⁴ Extensive evidence shows that health inequalities start early in life and are manifested by the environments in which people grow, live, work and age.^5–9 In his landmark report, Fair Society Healthy Lives, Sir Michael Marmot proposed an evidence-based plan to tackle health inequalities. Key to the plan was action on the social determinants of health to enable individuals to take control over their lives. Essentially, the report, like many others before it, argued that the solution to poor health is to prevent it from happening in the first place (e.g.,10–12). It involves ditching the reliance on short-term sticking plaster approaches and instead implementing long-term preventative approaches that tackle the root causes of poor health. Notably, eradicating poverty and providing the building blocks that enable people to lead healthy and meaningful lives: good jobs with fair pay, access to secure housing and much more.¹³

In the decade following Marmot’s call to action on the social determinants of health, population health in England has worsened and health inequalities have widened. For the first time in a century life expectancy has stalled across the country.^2,3 The reasons for these trends are likely multifaceted. Nevertheless, there is no doubt that the Government’s actions have played a key part. Indeed, recent evidence shows that the Government’s policies of austerity - cutting back on public spending, has not only contributed to hundreds of thousands of excess deaths,¹⁴ it has led to more people dying younger,^3,15 and in the years that people do live – spending fewer of them in good health.¹⁶ But that is not all.

On top of decimating public services; a reality captured in the book, Shattered Nation¹⁷ - the Government has failed to protect people’s economic security and have signalled an intent to water down and curtail regulations that keep people healthy. Society is getting sicker as a result.^18,19 More and more people are living with obesity which is a key driver to a range of chronic non-communicable diseases.^20,21 Physical inactivity rates are high.²² Work-related ill health due to stress is rising²³ and mental health is deteriorating with more and more people taking prescription pills to plaster over their psychological suffering.^24–26

Economic historians have highlighted the importance of government intervention and regulation to mitigate against the disruption and resulting insecurity caused by economic growth. They contend that failure to do so only exacerbates the ensuing deprivation which gives rise to more disease and preventable deaths. A process they have called ‘the four Ds’.^27,28 In the decades following the Second World War, the Government attempted to provide security for its people and correct some of the harms of capitalist markets including individual vulnerability to risks, the limited provision of public goods and services and the negative externalities of economic activity.²⁹ Characteristic of this time was the implementation of the welfare state which aimed to tackle society’s ‘five giant evils’ (i.e., Want, Disease, Ignorance, Squalor, and Idleness,³⁰ and in doing so reduce the precarity people experience in life, in terms of food, housing, employment, income and health. While much progress was made in the decades that followed,³¹ over 80 years on, these same ‘five giants’ continue to plague the UK daily.^32,33

Over the past decade there has been a significant rise in economic insecurity due to insecure work which has resulted in far too many people living insecure lives.¹⁸ These people live in constant fear of the future. For how long will their job be secure? For how long can they live in their home, afford food and pay their bills? The Government have pointed out that unemployment is low and record numbers of people are in work, but what they continue to overlook and fail to mention is the quality of the jobs that are surfacing. Lots of people may be working but far too many jobs are increasingly precarious.³⁴ In his book, The Precariat, published in 2011, Guy Standing spoke of a new laboring class of individuals: ‘the precariat’, who hold down temporary jobs, have no sense of career, and receive limited social guarantees in the form of pensions, paid holidays or sickness insurance.³⁵ In the years since, precarious work has only exacerbated in the UK and resulted in a growing number of people leading an intolerable existence; their anxiety worsened by inadequate systems of social protection.^18,36 Zero hours contracts are now at record highs in the UK.³⁷ At the end of 2021, more than 1 million adults of working age (3.2%) were employed on a zero-hours contract compared to only 190,000 a decade ago.³⁸

The architect of the British welfare state, Sir William Beveridge, saw employment as the solution to poverty. Yet the pool of ‘working poor’ is extensive and has been growing – owing to widespread casualised, insecure work and wages and benefits failing to keep pace with rising food, energy and housing costs.^39–43 Roughly 70% of working-age adults in poverty in the UK live in a household where at least one adult is working.⁴⁴ When people are poorly paid and cannot afford to purchase good quality food - their body becomes undernourished and they fall ill. The degrading health impact of absolute material deprivation – inadequate nutritious food and shelter has been known for centuries. In the 1840s Friedrich Engels highlighted in The Condition of the Working Class in England,⁴⁵ how the living and working conditions brought on by the capitalist system resulted in health inequalities and sent the English workers prematurely to the grave. In a similar vein, 70 years later, Robert Tressell, emphasised in his semi-autobiographical novel, The Ragged Trousered Philanthropists, how the poor health of the hero of the book, impoverished painter and decorator Frank Owen, could not be solved by medicine alone. It was social medicine that he needed: ‘proper conditions of life and proper food’⁴⁶: 598).

In Britain – one of the wealthiest nations around – one in seven people face hunger.⁴⁷ Across the country, millions of emergency food parcels are being distributed by food banks every year.⁴⁸ Food is not just fundamental to human survival; it is a key ingredient to physical and mental health and development and the prevention and management of disease.^49–51 Millions of children are going without adequate nutritious food which is contributing to stunted growth and delayed development and a rise in Dickensian like diseases.^52–55 Another clear sign of social injustice is the rise in homelessness.⁵⁶ Millions of UK citizens are struggling to afford a basic human right - a secure place to live.⁵⁷ According to the charity Shelter⁵⁸ there are 1.4 million fewer households living in social housing in England than 40 years ago. Because more social homes are being sold and demolished than are being built - millions of households are being pushed into the private rented sector which is more expensive generally and less secure than social housing tenancies. For the economically insecure who live in poverty, each and every day is a battle to survive and remain afloat. The chronic stress that this gives rise to has a ‘toxic’ effect on both the body and the brain.^59,60

That relative child poverty is rising and so many people face destitution and lack the basic necessities of life,^61,62 at a time when concentrated wealth in Britain has never been so high^63,64 – is clear proof – that something has gone badly wrong with society. UK politicians know that the current [low] rate of social security is pushing many people into poverty and driving destitution. The Government themselves published a report in 2022 highlighting the fact that current social policies do not provide enough money for people to live healthily.³⁹ That the Government are eyeing up more welfare reforms, and publicly praising themselves for diverting much needed funds from the most in need areas^65,66 – contrary to their own Levelling Up policy,⁶⁷ and strong evidence showing the adverse effect that their welfare policies have had on food security, mental health and health inequalities^68–72 - is a shameful indictment of how the social contract is being torn up.

The unjust capitalist system and ‘social murder’ which Engels criticized - almost two centuries ago (45: 107), is very much evident today.⁷³ There are clear signs that capitalism continues to create living and working conditions that harm health and kill. A fraction of society continues to benefit from these effects and are privy to them. That the Government are not only aware of these processes, but do little to mitigate them, through tackling the social and commercial determinants of health for example, shows how people in England, but especially the poorest, continue to be sent prematurely to the grave. As evidenced by the work of Marmot^2,3 and others (e.g.,14,16,18,74–76).

The economic approaches taken by governments have a direct impact on people’s lives and on population health more generally. Indeed, the Government’s relentless pursuit of economic growth under capitalism not only influences labour market regulations which shape the nature of jobs and wages as well as working conditions, it effects policies regarding taxes and welfare and public services spending. For instance, when the Government decides to cut taxes for the wealthy this lessens the distribution of wealth and widens income inequality.^63,64,77 When the Government weakens trade union power this gives employers greater freedom to suppress workers’ wages.⁷⁸ When the Government axes employment and workplace regulations and supports 0 hours contracts this sanctions overwork, underemployment and precarious working conditions thereby endangering worker health and wellbeing.^79–85 When the Government shies away from enforcing the building of new homes and rent controls and weaken tenant’s rights, this intensifies housing insecurity and reduces the quality of life and health for those unable to purchase their own home.^86–88

In the same way, when the Government delay regulations aimed at limiting the marketing of junk food to children this works against public health efforts to reduce the consumption of ultra-processed foods and sweetened beverages which contribute to obesity and harm health.^89–94 When the Government decides to drop regulations that would cut car use they work against public health efforts to improve air quality and make neighbourhoods safer and more walkable.^95,96 Similarly, when the Government make the decision to underfund public services or worse - privatise them, this sanctions underinvestment and corner cutting, and consequently degrades the quality of services which the most vulnerable in society rely upon.⁹⁷

We see this underinvestment in the privatised water system.^98,99 The separation of human faeces from drinking water is one of the finest public health successes of all time.¹⁰⁰ But public health and environmental standards are now slipping with for-profit water companies releasing sewage into waterways and coastal waters hundreds of thousands of times every year¹⁰¹; the places where children play and people swim. Despite the rise in water borne diseases in England, the Government have decided not to enforce tougher regulations on water companies which will permit the discharge of raw sewage into waterways for years to come.^102,103 The privatisation and outsourcing of public services can be a threat to public health in other ways too. For example, the outsourcing of National Health Service (NHS) cleaning and treatment services to for-profit companies in England over the past decade has not only resulted in poorer hygiene and higher rates of hospital-acquired infections,^104,105 it has also led to poorer quality care for patients and increased rates of treatable mortality, due to healthcare providers cutting costs (e.g., reducing staff-to-patient ratios) and prioritising profits (e.g., high priority given to most profitable to treat conditions.^106,107) But market failure and the downsides of the for-profit industry can be managed through taxation and tough regulation in order to usher both the social and commercial determinants of health towards the common good.¹⁰⁸

Nevertheless, to improve population health and reduce inequalities in health, the Government will have to do more than simply enforcing tougher regulations and taxing products harmful to health. They will have to boost public sector capacity, not through more outsourcing, but through long-term investment. Health is an asset that not only enables individuals to thrive but underpins economic activity. It should therefore be seen as an essential investment not an expense.^109,110 In England, the impact of poor health on the economy is all too visible with record numbers of people waiting for care and out of the workforce due to long-term sickness.^111,112 There is a risk that inequality will only intensity if the Government were to cut back on public provision, move more towards a market society (from a market economy) and make money an even greater determining factor in accessing necessities including healthcare.¹¹³

At the heart of deteriorating population health and widening inequalities is the eroding of public services. Local authorities play a vital role in improving the public’s health.¹¹⁴ They have done since the Victorian era. Public baths and wash-houses were introduced to combat poor hygiene and infectious disease, and public parks were seen as the lungs of the city – taking in dirty air to improve the respiratory health of inhabitants.^115,116 Nowadays local authorities provide services such as youth clubs and leisure centres and they continue to maintain our streets, parks, and open spaces – the places where children play and people exercise and walk their dogs. They offer libraries, adult learning and welfare support. They safeguard children and ensure that the most vulnerable in society are cared for and protected. But they are expected to provide these services on threadbare budgets. Local authority budgets have been slashed by almost 80% on average. In some parts of the country this rises to nearer 90%.¹¹⁷ This is why public services are on their knees, and why some councils are going bust.¹¹⁸

Youth clubs are a safe space for young people and provide a sense of belonging.¹¹⁹ Yet, at a time when young people’s mental health is at crisis levels¹²⁰ these vital preventative services are being curtailed.¹²¹ It is well established that Sure Start centres reduce childhood health inequalities.^122–125 Yet despite their positive impact, they have been battered under the Tory Government.¹²⁶ Leisure centres and swimming pools are also vital to the health and wellbeing of communities.^127–129 And to children’s swimming participation and development – which is a national curriculum requirement.¹³⁰ However, many of these facilities too are on the brink of closure and a good number already have.¹³¹

Beyond providing access to books for people to learn, public libraries offer the digitally excluded access to the Internet. They are also important community hubs that support the health of communities and help to tackle social isolation.^132,133 The very same thing that is plaguing the country - as evidenced by the Government’s very own Minister for Loneliness.¹³⁴ The social value that libraries provide could not be clearer.^135–138 Their impact far outweighs their running costs. Although this strong evidence does not prevent them from being shut down.^139,140

A Different Economic Goal

What is saddening is how much of Engels’ and Tressell’s accounts share a striking resemblance with the present day. Yes, living standards have improved since their time. But we still have a capitalist system whose goal is to make money at all costs. And as a consequence, millions still struggle daily and live hand-to-mouth. In the words of Engels: ‘What is to become of those destitute millions, who consume today what they earned yesterday’ (45: 30). Just like the Victorian era, they live on daily wages and have limited job security because of the demise of union power. As Tressell noted, Frank Owen ‘was one of the few lucky ones who had some small share of work. [But still] most of the money he earned went for rent, to pay which they often had to go short of food’ (46: 597).

Improving the health of the nation will require much more than improving the healthcare provided by the NHS. No number of sticking plasters will solve the health crises facing the country; not now nor in the future. In a similar sense, in high-income countries like the UK, poverty and health inequality will not be reduced at scale through boosting productivity and consumption and growing the economy further. What is needed is bold action on the social and commercial determinants of health. These are the underlying causes of ill health and inequality. But doing so will require political willingness across political parties to tackle industry influence by regulating the (legal) products that are lethal to health and the advertising promoting their purchase.¹⁴¹ There is also a requirement for a ‘health in all policies’ approach to ensure joined up thinking across Government. Marmot cities champion a long-term, ‘health in all’ policies approach. That they have been found to reduce health inequalities shows that a fairer approach is possible.¹⁴² Short-term economic benefits have for too long been favoured at the expense of long-term societal costs. This is because preventative approaches and long-term goals like eradicating poverty and achieving health for all, do not fit with short-term electoral cycles or capitalism’s profit motive. That only around 5% of the NHS budget is spent on preventive activity is testament to the priority the Government continues to place on treatment at the expense of prevention.

Recently, Hiam and colleagues¹⁴³ called on the Government to implement policies to tackle poverty so that individuals and families can lead healthy lives. But what we have to remember is, capitalism in its current form works against such a goal. The income and wealth inequality which results in poverty is no accident under capitalism. It is an essential component of the system. Although it is noteworthy that large variations in inequality measures do exist across capitalist countries due to differences in social policy.^144,145 Indeed, social democratic models of governance are capitalist but compared traditional forms of capitalism, they retain a much strong emphasis on welfare, progressive taxation and public investment which in turn supports economic equality and wellbeing.^146–149 The proponents of capitalism contend that self-interest and greed are good for profit and economic growth. The values promoted by capitalism: achievement, power and hedonism (e.g., self-centred satisfaction, control or dominance over people and resources) are in direct psychological conflict with the values underpinning efforts to tackle poverty and the inequitable distribution of power, money and resources. They are more altruistic and rooted in values of social justice, fairness and equity.¹⁵⁰ This is why achieving the societal goals highlighted above, which are core to the United Nations’ Sustainable Development Goals, requires a complete change in economic and political ideology. Not just from the UK Government but from many other high-income countries too.

Growing the economy remains of upmost importance to the Government. But by relentlessly pursing this goal, society is not getting any healthier – it is getting sicker.¹⁵¹ The work of Marmot² and the report published by the British Medical Association¹⁸ offers striking evidence of the scale of the country’s poor and unequal health. The ever-burgeoning evidence on widening discrepancies in other social markers such as rising wealth and income inequality,^63,64,77 air pollution and ecological breakdown and their health impacts^152–157 signal that the costs of economic growth are now exceeding its benefits. Not only has the Government continually disregarded the welfare of a majority of citizens, they are locked in a continuous cycle of spending vast sums of public money to put right the health harms that the capitalist economic system and their own policies have created.¹⁵¹ This is why our obsession with economic growth has to end.

The time has come to change the goal of our economy and our overarching measure of social progress. We need an economy that maximises human wellbeing. An economy like this would value social justice and health over wealth and material growth. There are a range of wellbeing indicators for governments to use alongside economic targets and support policy making towards realising a healthier, more socially just and more sustainable future. In addition to the United Nations Sustainable Development Goals and targets, some of these measures include the Human Development Index, Genuine Progress Indicator, Happy Planet Index, and the Sustainable Wellbeing Index.¹⁵⁸ In the UK, inclusive growth approaches to regional economic development including Community Wealth Building have led to improved health and wellbeing outcomes and lower health inequalities.^159–161 A wellbeing economy would go further, having not just fairness, but human and planetary wellbeing as its goals.¹⁶² A wellbeing-based economy would not only measure the gains to human and planetary wellbeing, but would account for the societal costs associated with economic activity which traditional economic approaches either ignore or downplay.

Wellbeing economy approaches are advocated by the World Health Organization to achieve healthier, fairer, prosperous societies.^163,164 Some European countries (e.g., Finland, Iceland, Scotland and Wales) are already making strides towards shifting to wellbeing economies, albeit in different ways.¹⁶⁵ The World Health Organization Council on the Economics of Health for All recently developed a framework based on four pillars: valuing, financing, innovating for, and strengthening capacity, to reorient economies to deliver what matters - health for all.¹⁶³ While a wellbeing economy that works towards achieving the 17 United Nations Sustainable Development Goals may hold the solution to achieving health for all, the principle remains a long way from being fully adopted by the Government, or indeed any government. Restoring the balance between economic growth and public health has to be a fundamental priority of our time, because every citizen has the right to a healthy and meaningful life.^130,138,149

Footnotes

Acknowledgements

The author would like to thank the two anonymous reviewers for their insightful comments and suggestions to improve the original version of the manuscript.

Declaration of conflicting interests

The author declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Robert J. Noonan

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What Are the Roots of the Nation’s Poor Health and Widening Health Inequalities? Rethinking Economic Growth for a Fairer and Healthier Future

Abstract

Keywords

Main Text

Inaction on the Social Determinants of Health

A Different Economic Goal

Footnotes

Acknowledgements

Declaration of conflicting interests

Funding

ORCID iD

References