ANALYSIS
Politics of health Given the repeated warnings and attention from international bodies, 3739 why has the UK government failed to act on the social determinants of health? Here, we briefly outline what has been
• Ensure a healthy standard of living for all • Create and develop healthy and sustainable places and communities • Strengthen the role and impact of ill health prevention • Tackle discrimination, racism, and their outcomes • Pursue environmental sustainability and health equity together From 2020 onwards, the covid-19 pandemic intensified and increased the existing inequalities. The UK fared comparatively badly, in part because of the condition of the country before the pandemic. 6263 The Build Back Fairer: COVID-19 Marmot Review detailed short, medium, and long term actions needed on each of the six Marmot principles to reduce inequalities and improve health to build, or rebuild, a healthy society. 64 The profound effect of structural racism on the outcomes of covid-19 led to the addition of the seventh Marmot principle, and the eighth was added in consideration of the climate emergency (box 2). 65 These additional principles are based on empirical observation, but regrettably are often politically partisan. Although central government has failed to act on the robust evidence available, some local governments have acted decisively 66 ; for example, Coventry and Manchester are Marmot cities, acting on the Marmot principles to improve health. 6768 Challenging individualism and the nanny state Two related areas of political ideology, individualism and accusations of the nanny state, act as powerful rhetoric against public health interventions intended to improve the health of the population. Every day, people make decisions that affect their health and wellbeing, but not under conditions of their own choosing. The individualistic approach to health assigns blame to those who show behaviours associated with ill health, and is a convenient mechanism for those in and with power, and wider society, to abrogate responsibility for creating the conditions for a healthy society. Instead, those with the worst health are blamed for their conditions. For example, during the peak of the covid-19 pandemic, people from lower income households, frequently with frontline roles, were unable to work from home and had greater loss of income during quarantine when infected with the virus. 6269 People infected with the virus, including those who died, were frequently blamed for not taking adequate precautions or having weaker immune systems or pre-existing conditions (also linked to deprivation) rather than the wider social context being acknowledged. The pandemic is just one example. Low income, racial, and sex discrimination, commercial exploitation, poor housing (or lack of housing), and lack of access to high quality education are some of the social conditions that diminish the ability of people to live healthy and fulfilling lives. Action to improve these social and economic conditions can and will improve health and reduce the burden on healthcare. If public health is seen as simply instructing people on how to behave, then accusations of the nanny state are understandable. But what is necessary for public health is ensuring that people have a roof over their heads, have sufficient money to buy food to feed their families, can afford heating when the weather turns cold, and can face the weeks and months without fear of eviction, which is different from instructing people on how to behave. Disputes at the margin, however, are inevitable. Some will see Prime Minister Sunak ’ s ambition for a smoke-free generation as a bold step towards improving the public health (although a substantial health problem is looming from the growth in vaping, now shown to markedly increase risks of cardiovascular disease 70 ). Others will see it as a
known for centuries: health is political. Improving health is a political choice
Ten years ago, in 2014, experts wrote an open letter in the Lancet to the then prime minister, David Cameron, highlighting concerns about food poverty. 51 Since then (and before then), multiple reports, research papers, and editorials have called for government action on rising infant mortality rates, child poverty, and growing inequalities. 61521 3652 Many other reports on these problems exist, spanning over a decade, all indicating that the state of health in the UK in 2024 is not unexpected, has not happened without warning, and could feasibly have been prevented. More research is not needed; action is needed. Action to reduce poverty can be taken almost immediately. For example, the decision by the then chancellor, Rishi Sunak, to reverse the temporary increase of £20/week in universal credit during the covid-19 pandemic, which had helped 400 000 children out of poverty, returned the number of children living in poverty to levels before the pandemic of 4.2 million. 53 Notably, fewer children are living in poverty in Scotland than in England, 54 where child benefit payments for more than two children in a family have been maintained, and the Scottish child weekly payment was raised to £25 for any child aged <16 years in a household receiving benefits, a move the children ’ s commissioner in Wales is advocating to replicate. 5556 Child poverty in the UK is a political choice. The economic decline of the UK, exacerbated by Brexit, must be confronted. The Institute for Fiscal Studies has forecast that real household disposable income will not return to pre-pandemic levels before the next election in 2024, after “ another terrible decade ” of poor economic growth. 57 The number of people signed off sick from work has tripled in the past decade, because Britain is sicker than it was a decade ago. 58 Investing in the social determinants of health will improve health, productivity, and thus economic growth. The move from health in all policies to health for all policies acknowledges that progress and improvement in health and health outcomes has substantial benefits for other sectors. 59 Wecannot afford inaction. We know what to do Focused, evidence based recommendations exist on how to improve health in the UK. The 2010 Marmot review called for action on six policy objectives (the first six in box 2), and publication of a framework of indicators and economic analysis followed one year later. 43 Inequalities in Health: the Black Report was commissioned by a Labour government and published under Margaret Thatcher ’ s Conservative government. The report detailed inequalities in poor health and mortality in Britain. 60 Similarly, the Marmot review was commissioned by a Labour government and published under the Conservative-Liberal Democrat coalition government. The coalition focused on implementing austerity, “ doing more for less, ” 61 and the recommendations were not acted upon. Box 2: The Marmot principles • Give every child the best start in life • Create fair employment and good work for all • Enable all children, young people, and adults to maximise their capabilities and have control over their lives
the bmj | BMJ 2024;385:e079389 | doi: 10.1136/bmj-2024-079389
4
35
Powered by FlippingBook