A major threat to health

Jonna Monaghan of Belfast Healthy Cities analyses the self-perpetuating links between poverty, social exclusion and health and reviews initiatives to break the spiral.

Men in the least affluent groups in Northern Ireland die, on average, six years younger than men in the most affluent groups. For women, the difference in life expectancy is four years. Less well off people also suffer more illness, and are often living in poorer conditions overall. They are also less able to make choices about their lives, a significant part of the wide definition of health as used in the public health strategy Investing for Health and broadly accepted here.

It is now well documented that those at the lower end of the income scale tend to have poorer health than others. In Northern Ireland, 57 % of households with a gross income of under £10,430 report a long-standing limiting illness, while the figure falls to just over 20 % in households earning over £26,000. Women in the lowest income groups are 60 % more likely to experience mental disorders than those in the highest. These variations are known as inequalities in health, and poverty is a significant cause of many of them.

Whitehead has described the causes of inequalities as a systematic relationship: lower income groups, on average, have more exposure to damaging conditions, while the resulting health damage is worse in more difficult living conditions. In addition, social and economic change tends to hit the lowest income groups hardest, for instance through increasing unemployment. The effect is that of a spiral which can become self-sustaining – poverty worsens other inequalities that in turn can lead back to more poverty.

Education and living conditions

Poverty affects people in different ways but, above all, it tends to cause some key risk factors. To begin with, people in lower income groups tend to have a lower level of education, which means that their choice of jobs may be limited. These jobs are often insecure, low paid and have few or no progress options, while the employee has little control over her/his daily activities. This, in turn, can cause stress, a significant health risk factor. People in lower income groups are also more likely to be unemployed, which in itself can be a cause for both mental and physical health problems.

This chain of consequences also demonstrates the links between education, poverty and health. A good education provides improved job opportunities, but also improves general prospects, which enables people to take more control of their lives.
Low income also means that a household may not be able to afford healthy food, or in some cases sufficient food. Bare Necessities, the first survey of poverty levels in Northern Ireland, showed that 3 % of the population cannot afford a meal with meat or fish every second day, while another 7 % neither have nor want it. On the other hand, obesity is more common in lower income groups, linked to the fact that foods high in sugar, fat and salt are cheaper than healthy foods. They are also more readily available - in small local shops, take-aways and so on - while poorer people may have less access to supermarkets offering wider selections, which often are based out of town, out of reach for people without private transport.

People on low incomes may, in addition, have limited choice of where to live. It is well established that poor housing is most prevalent in deprived areas, which often have few services and may be near polluting industry: a 2001 study of four UK cities, including Belfast, showed that pollution levels were higher in areas defined as deprived. These conditions can cause ill health, while general lack of prospects may also lead to anti social behaviour and apathy. This further degenerates an area and is a cause for breakdown of social structures, stress, fear and related mental health problems.

Better off people can buy themselves better living conditions, which people on low incomes cannot. With a rising income gap, these inequalities would be constantly increasing without inter-ventions at policy level such as minimum wage, social needs funds, and so on.

Social exclusion

However, this is not the full story. Closely linked to poverty is the issue of social exclusion, or the marginalisation of certain population groups. At the heart of this is a situation where the poor - along with the disabled, older people and ethnic minorities - are denied access to opportunities and services mainstream society takes for granted.

An example of social exclusion at work is the so called inverse care law and inverse access law. In essence, both laws hold that those in most need have the least access to services, while the inverse access law suggests that those in most need receive the least support in accessing a service. Across the UK, it has been found that people in deprived areas have a longer trip to a GP, while for example older people may not know about services available.

This inequality is caused by economic and social forces, which tend to en-courage services to accumulate in areas where there already are other services. Typically, good provision is created in affluent areas where residents can afford to spend – and, crucially, have more political power due to their wealth.

Social exclusion is another spiral which originates in marginalised groups’ lack of resources, and results in economic and political invisibility. Put differently, it is a type of structural discrimination.

On the whole, poverty and social exclusion lead to a situation of con-siderable inequity. The WHO defines inequity as ‘differences in health which are not only unnecessary and avoidable, but in addition are considered unjust and unfair.’

Increased attention at policy level

In recent years, inequalities in health and poverty have received increased attention at policy level. Child poverty has been a special focus of the UK government, which aims to halve child poverty by 2010. Emphasis in the child poverty programmes has been on getting parents into work, supported by a range of tax credit measures and increased provision of childcare. A special initiative, SureStart, has also been developed to support children and parents in the most deprived areas.

In Northern Ireland, the current public health strategy, Investing for Health, has reducing inequalities in health as a key target. Reducing poverty in families with children is a specific objective and, as in Britain, action includes welfare reform, training and job creation. There are two cross-departmental programmes aimed at addressing poverty and inequalities; New Targeting Social Need (New TSN) and Promoting Social Inclusion (PSI). At present, however, a consultation on sig-nificant changes to New TSN is ongoing, following a review of results to date.

The World Health Organization is promoting action to tackle inequalities through the Health 21 policy, which sets 21 health targets for the 21st century. Target 2 aims to close the health gap within countries, and lists poverty and poor educational attainment as the major risks to health.

Belfast Healthy Cities, a member of the WHO European Healthy Cities Network, has developed the ‘Equity in Health – Tackling Inequalities’ programme, a training programme aimed at building capacity to tackle inequalities within organisations. The programme is supported by the Eastern Health and Social Services Board, as part of the implementation of Investing for Health targets, and is being arranged for the second time this year following a successful pilot in 2002-03.

Current initiatives have served to highlight the importance of action, and begun to address the most urgent issues. For sustainable change, however, a concerted long term effort aimed at tackling the root causes of poverty and inequality, supported by adequate resources, is required. To be as effective as possible, policies should be based on partnerships and on consultation with target groups. The aim should be – as researchers into inequalities have called for – a more just and caring society, where all individuals have opportunities to fulfil their potential, and where everyone has the means to control their own life. This does not need to be a utopia, provided there is genuine commitment to an agenda of social justice.