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September 01, 2005

When public health aims clash: how health education tends to widen health inequalities

Posted by Anthony Daniels

The issue of health inequality - how the poor die earlier, have higher rates of infant mortality etc. - has once again been raised in the British Medical Journal. The BMJ article publicises the fact that health inequalities are rising in the UK. Dr Anthony Daniels here points out that - as an examination of the figures in the BMJ article shows - while health inequalities may be rising, over the same period the life expectancy of every social class has risen and the infant mortality rates of every social class has fallen. What is more, much of the rise in health inequality may be accounted for by the fact that the middle classes take more notice of public health campaigns than the poor. This raises the question, what is the concerned social engineer to do?

The socially and psychologically erosive obsession with inequality in Britain shows no sign of abating. The British Medical Journal for 20th August carried a news item entitled: "Disparities in health widen between rich and poor in England". This informed readers that the difference between national average life expectancy and the life expectancy of those living in the local authority areas with the lowest life expectancy had widened from 1.94 years for men and 1.46 years for women in 1995-1997 to 2.07 years for men and 1.63 years for women in 2001-2003. And this despite the government's target:

to reduce by 10 per cent the degree to which the fifth of local authorities with the worst figures in… life expectancy fall below the national average, compared with a 1997-1999 baseline figure.
What was true of life expectancy was true of infant mortality. In 1997-1999, infant mortality in the worst areas had been 13 per cent higher than the national average. In 2001-2003 it was 17 per cent higher.

The President of the Faculty of Public Health of the Royal College of Physicians, Professor Griffiths, was reported to have said that:
the government's heart is in the right place on this issue [but that] the task is a monumental one.
In other words, that vast social engineering to achieve the goal of equality is both required and justified.

There is a lot to say about this little item: so much, in fact, that it would take a full length essay, or even a book, to analyse the philosophical and other assumptions contained in it. These assumptions are so much taken for granted, however, that they no longer have even to be argued.

In the first place, it is assumed that relative figures are more important than absolute ones. The fact that the life expectancies of every social class had risen, and the infant mortality rates of every social class had fallen, was detectable only from the figures in the article, and not from anything in the text. In this context, it is always ratios that are considered important. The national average for infant mortality is approximately 5 per 1000 live births: that for the worst areas, 17 per cent higher, is therefore approximately 6 per thousand. The absolute difference is thus 1 per thousand live births.

Of course, the death of every individual child is lamentable; but since we are talking in terms of abstract categories and statistics, not in terms of newspaper sob stories, this difference hardly seems to me to be one requiring enormous social engineering, which always has great costs and unforeseen consequences.

It is interesting to note in the article that only certain disparities are deemed worthy of epidemiological notice and hence of efforts at social engineering. It is well-known, for example, though seldom publicised, that the mortality rates of illegitimate children are considerably higher than those of legitimate children; and since illegitimacy, even in these times of mass bastardy, is concentrated in the lower reaches of society, it might account for a considerable part of statistical disparity alluded to. But such a consideration would lead to very different kinds of social engineering from that envisaged by the British Medical Journal, and is therefore simply not mentioned.

Another difference that is of no interest to right-thinking people is that between the life expectancies of men and women, which is actually twice as great as that which so deeply exercises the government and its bureaucrats. While it might be argued that this difference is biological, because no society has ever failed to exhibit it, precisely the same might be said of class differences in life expectancy: no society ever studied failed to show them.

Using the same figures, however, it could also be argued that the position of women deteriorated between 1997 and 2003. In the former year, women on average lived 106.81 per cent as long as men, but in the latter only 105.48 per cent. Therefore, someone might argue, something ought to be done to preserve the position of women from further deterioration.

However, even the article makes clear that the difference in life expectancy between the average and the worst quintile (74.17 years instead of 76.24 for men and 79.09 years instead of 80.72 for women) is in part, perhaps even in large part, attributable to differences in rates of smoking. According to Professor Griffiths, health education tends to widen the health gap between richest and poorest because only the former take any notice of, and act upon, health information. The rich have given up smoking more than the poor (for whom it remains one of the few easily available pleasures). This is no doubt because, being better educated and probably more intelligent, the rich are more capable of understanding the force of abstract arguments – though, of course, they are also more susceptible to pseudo-information and pseudo-arguments. As Professor Griffiths puts it:

Improving medical knowledge actually tends to widen health disparities because the middle classes are amazingly adept at pouncing on every new snippet of information about healthy lifestyles and incorporating it into their daily activities.
So what is the answer? Abandon health education as being socially divisive? Of course not: heaven forbid, for that would reduce employment opportunities in the public service. The answer is to expand it, by deploying "health trainers" in 12 deprived areas to counsel people about healthy lifestyles, the assumption being that if only they knew that carrots were good for them, they would eat more of them. On the other hand, it seems to me unlikely that the "health trainers" will emphasise very strongly the unhealthyiness of single parenthood, because to do so would be unduly judgmental.

From the point of view of health inequalities, it would have been better if the advance in life expectancy and decline in infant mortality between 1997 and 2003 had not taken place. Better still, of course, would have been an increased death rate among the rich: then the country would have become more equal.

Of course, an increased death rate among the rich was tried during the Twentieth Century as a means of bringing about social equality: with what result, I think everyone knows or ought to know.

Anthony Daniels is a writer and has recently retired as a doctor.

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Well, if people can't tell the difference between levelling up and levelling down, I guess it's too late to explain it to them...

Posted by: Innocent Abroad at September 1, 2005 04:28 PM

Remember last year when the Cheshire borough of Halton hired a 19-stone woman as a "healthy living advisor"? (I blogged about it at the time here).

Posted by: Scott Campbell at Blithering Bunny at September 3, 2005 06:50 PM

Wouldn't the answer be to allow the economy to grow to the point where the poor stop being poor?

Posted by: B's Freak at September 6, 2005 08:38 PM

Two questions to commenters:

(1) Is there an actually example of levelling up anywhere in history?

(2) The American economy is a giant, but have the poor stopped being poor? (Think of New Orleans).

Posted by: Robert H. Olley at September 9, 2005 06:57 PM

"Wouldn't the answer be to allow the economy to grow to the point where the poor stop being poor?"

You'd think. But if the economy took off so that everyone's income doubled, "poverty" would not decrease one jot --- at least not according to the government criteria for what constitutes "poverty". This is the miracle of "relative poverty". Ratios are the only thing of interest to the government mind, since it was found decades ago that poverty as traditionally understood no longer existed in Britain --- which was terrible news for social engineers. Hence the redefinition, and the Alice-In-Wonderland strangeness of poverty statistics. So, for example, using "relative poverty" as one's touchstone means that if the government went out and shovelled everybody's savings into the big government money-burner and shipped all their possessions to Africa, so that everyone ended up with only the clothes they stood up in and a loaf of bread, then poverty, that vile canker in the heart of so-called Great Britain, would have been eliminated! Praise be.

The next time you hear some twit saying that poverty is actually worse in Britain nowadays than it was in some former Soviet Republic or other, think what it is that you can smell...

Posted by: Paul H. at July 18, 2007 11:05 PM

Compassion does not work very well at all when it achieves a certain scale and formalisation (not efficiency I might add). We have long been deluding ourselves of this obvious truth, at least since Elizabethan times, that is to say, from the Poor Laws onwards. Commentators even earlier than Alexis De Tocqueville (1830's) remarked on the abuses of the system over 200 years ago. More importantly, the damage done to moral character was well known enough to reasonably minded men for those in power not to be excused for being ignorant. It is therefore very difficult to extricate the leftist tendency to favour social engineering, from a repugnant sort of sentimentality, which refuses to go away in the face of experience, common-sense, and (some) decent research. The word poverty still holds some kind of magic sway over the populace, in exactly the same way that the word charity does. When the bucket comes round, I ask "What's it for?". Response "It's for charity". I then typically advise that I will need to check for any associated moral hazards before I dip into my pockets. No one seems to understand this challenge, yet it is hugely important. Unreflective charity, help, assistance, giving, donating, equalizing, redistributive policies, levelling up, etc. is inherently dangerous. It has much more to do with a malicious envy, allied to a bubblehead sentiment than any serious efforts to improve the lot of mankind. And of course, as many wise people have known for a very long time, human nature inevitably subverts the good intentions of others.

Posted by: cybn at December 22, 2009 06:08 PM
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