Health in the UK: it is the best of times, it is the worst of times, it is an age of wisdom, it is an age of foolishness.
Dear Editor
Whitehead and colleagues are right to highlight the impact of growing inequalities on health during the present pandemic.(1) We fully agree that without intensive immediate, and long-term action the health of disadvantaged individuals, families and communities will be disproportionately affected during the coming years: inequalities will increase.
Many doctors and nurses witness first-hand the detrimental effects of poverty on patients and their families’ health.(2) They will be well aware that social deprivation is a major determinant of poor health status. They will also be aware that for many public health problems including mental health, accident prevention, obesity, and lack of physical activity there are socioeconomic patterns and that the problems have common roots.
There is nothing new or unique about the existence of poverty and inequalities in health.(3) For example, Dickens and Zola eminent writers of the nineteenth century clearly described social and economic factors and the physical environment, that had major influences on families.(4-6) They brought attention to what they regarded as some of the key social issues of his time. Since then there has been a plethora of research on inequalities in health and the evidence for action is compelling.(3, 7-17) The growing health inequalities can, and should be stopped and reversed.
In order to ‘build back fairer’(17) there will need to be actions directed to all dimensions of health inequalities in all sectors of the population. We do, however, welcome the emphasis in the article by Whitehead and colleagues on children and the associated health inequalities and the specific strategies proposed to improve the situation.(1) In particular we endorse the call for reinvestment in Sure Start children’s centres and child mental health services. Addressing the health inequalities in BAME communities for all ages will also be a priority.
The institute of Health Promotion and Education believes that there is need for action at two levels to redress inequalities. We need a raft of social and economic policies and strong national leadership including a new independent national organisation to coordinate, monitor and drive forward actions across sectors.(18) At a local level directors of public health and their multi-disciplinary teams need to be adequately funded so that they can facilitate change by empowering communities and creating health promoting environments.(19-22)
In the past there has been too much focus on individuals rather than creating supportive and health enhancing environments. We need a shift in our thinking away from merely treating ill health and towards promoting positive health. This would include establishing health promoting hospitals, schools and workplaces.(23-24) For example, hospitals should be sites where the health of all staff is maintained and promoted. These broad-based approaches have the potential to reduce inequalities.
As we move out of the current pandemic a new positive health vision is required.(25) The evidence-based strategy should combine diverse but complementary approaches including fiscal measures, legislation, education and organizational change.(26) Crucially long-term investment is needed to protect and promote health and to ensure that all individuals, families and environments are resilient enough for future public health threats and health inequalities are reduced.
18) Watson M C and Tilford S. Health promotion is at a crossroads with the demise of Public Health England. BMJ 2020;370:m3750. https://www.bmj.com/content/370/bmj.m3750
24) Thompson S R, Watson M C, and Tilford S. The Ottawa Charter 30 years on: still an important standard for health promotion. International Journal of Health Promotion and Education. 2018,56(2), 73-84. https://www.tandfonline.com/doi/abs/10.1080/14635240.2017.1415765
25) Watson M C and Owen P. Public health priorities for 2020. Inequalities in 2020: time for a health strategy that unites the country. BMJ 2020;368:m544 https://www.bmj.com/content/368/bmj.m544
Rapid Response:
Health in the UK: it is the best of times, it is the worst of times, it is an age of wisdom, it is an age of foolishness.
Dear Editor
Whitehead and colleagues are right to highlight the impact of growing inequalities on health during the present pandemic.(1) We fully agree that without intensive immediate, and long-term action the health of disadvantaged individuals, families and communities will be disproportionately affected during the coming years: inequalities will increase.
Many doctors and nurses witness first-hand the detrimental effects of poverty on patients and their families’ health.(2) They will be well aware that social deprivation is a major determinant of poor health status. They will also be aware that for many public health problems including mental health, accident prevention, obesity, and lack of physical activity there are socioeconomic patterns and that the problems have common roots.
There is nothing new or unique about the existence of poverty and inequalities in health.(3) For example, Dickens and Zola eminent writers of the nineteenth century clearly described social and economic factors and the physical environment, that had major influences on families.(4-6) They brought attention to what they regarded as some of the key social issues of his time. Since then there has been a plethora of research on inequalities in health and the evidence for action is compelling.(3, 7-17) The growing health inequalities can, and should be stopped and reversed.
In order to ‘build back fairer’(17) there will need to be actions directed to all dimensions of health inequalities in all sectors of the population. We do, however, welcome the emphasis in the article by Whitehead and colleagues on children and the associated health inequalities and the specific strategies proposed to improve the situation.(1) In particular we endorse the call for reinvestment in Sure Start children’s centres and child mental health services. Addressing the health inequalities in BAME communities for all ages will also be a priority.
The institute of Health Promotion and Education believes that there is need for action at two levels to redress inequalities. We need a raft of social and economic policies and strong national leadership including a new independent national organisation to coordinate, monitor and drive forward actions across sectors.(18) At a local level directors of public health and their multi-disciplinary teams need to be adequately funded so that they can facilitate change by empowering communities and creating health promoting environments.(19-22)
In the past there has been too much focus on individuals rather than creating supportive and health enhancing environments. We need a shift in our thinking away from merely treating ill health and towards promoting positive health. This would include establishing health promoting hospitals, schools and workplaces.(23-24) For example, hospitals should be sites where the health of all staff is maintained and promoted. These broad-based approaches have the potential to reduce inequalities.
As we move out of the current pandemic a new positive health vision is required.(25) The evidence-based strategy should combine diverse but complementary approaches including fiscal measures, legislation, education and organizational change.(26) Crucially long-term investment is needed to protect and promote health and to ensure that all individuals, families and environments are resilient enough for future public health threats and health inequalities are reduced.
References
1) Whitehead M, Taylor-Robinson D, Barr B. Poverty, health, and covid-19. BMJ 2021;372:n376
https://www.bmj.com/content/372/bmj.n376
2) British Medical Association. Health at a price: reducing the impact of poverty, 2017.
https://www.bma.org.uk/collective-voice/policy-and-research/public-and-p....
3) Benzeval M, Judge K, Whitehead M. (eds) Tackling inequalities in health: an agenda for action. London, SAGE Publications, 1995.
4) Dickens C. Oliver Twist. Ware, Wordsworth Editions Limited, 1992.
5) Dickens C. A tale of two cities. Oxford, Oxford University Press, 2008.
6) Zola E. Germinal. Oxford, Oxford University Press, 1993.
7) Black, D. Inequalities in Health: Report of a Research Working Group. London, DHSS, 1980.
8) Whitehead, M. The Health Divide: Inequalities in Health in the 1980's. London, Health Education Council, 1987.
9) Wilkinson R. Unhealthy Societies. The Afflictions of Inequality. London, Routledge, 1996.
10) Department of Health. Independent Inquiry into Inequalities of Health: Report (chairman, Sir Donald Acheson). London, The Stationery Office, 1998.
11) Wanless D. Securing Good Health for the Whole Population. Final report. London, HM Treasury, 2004.
12) Marmot M, chair. Fair society, healthy lives (the Marmot review). UCL Institute of Equity, 2010.
http://www.instituteofhealthequity.org/resources-reports/fair-society-he...
13) The Kings Fund. Inequalities in Life Expectancy. London: The Kings Fund, 2015.
https://www.kingsfund.org.uk/publications/inequalities-life-expectancy
14) British Medical Association. Health in all policies: health, austerity and welfare reform. London: British Medical Association, 2016.
http://bmaopac.hosted.exlibrisgroup.com/exlibris/aleph/a23_1/apache_medi...
15) Marmot M, Allen J, Boyce T, Goldblatt P, Morrison J. Health equity in England: the Marmot review 10 years on. Feb 2020.
https://www.health.org.uk/publications/reports/the-marmot-review-10-year...
16) Royal College of Paediatrics and Child Health. State of child health 2020. March 2020.
https://stateofchildhealth.rcpch.ac.uk/
17) Marmot M, Allen J, Goldblatt P, Herd E, Morrison J. Build Back Fairer: The COVID-19 Marmot Review. The Pandemic, Socioeconomic and Health Inequalities in England. December 2020. London: Institute of Health Equity.
https://www.health.org.uk/publications/build-back-fairer-the-covid-19-ma...
18) Watson M C and Tilford S. Health promotion is at a crossroads with the demise of Public Health England. BMJ 2020;370:m3750.
https://www.bmj.com/content/370/bmj.m3750
19) Watson, M., and Tilford S. Directors of Public Health Are Pivotal in Tackling Health Inequalities. BMJ 2016;354:i5013
https://www.bmj.com/content/354/bmj.i5013.long
20) Watson M C and Lloyd J. Need for increased investment in public health BMJ 2016;352:i761.
https://www.bmj.com/content/352/bmj.i761
21) BMA. Funding for ill-health prevention and public health in the UK. May 2017.
http://bit.ly/2quLN3K
22) Watson M C and Thompson S. Government must get serious about prevention. BMJ 2018;360:k1279.
https://www.bmj.com/content/360/bmj.k1279
23) Watson, M. Going for gold: the health promoting general practice. Quality in Primary Care. 2008; 16:177-185. https://pdfs.semanticscholar.org/c1b6/3555f6b033effdc0062235adb7bab3de43...
24) Thompson S R, Watson M C, and Tilford S. The Ottawa Charter 30 years on: still an important standard for health promotion. International Journal of Health Promotion and Education. 2018,56(2), 73-84. https://www.tandfonline.com/doi/abs/10.1080/14635240.2017.1415765
25) Watson M C and Owen P. Public health priorities for 2020. Inequalities in 2020: time for a health strategy that unites the country. BMJ 2020;368:m544
https://www.bmj.com/content/368/bmj.m544
26) World Health Organization. Ottawa Charter for Health Promotion. Copenhagen: World Health Organization, 1986.
https://www.who.int/healthpromotion/conferences/previous/ottawa/en/
Competing interests: No competing interests