Inequality

I

Prof G why the sudden and recent fixation with inequality? 

There is overwhelming evidence that many health outcomes, including life expectancy, infant mortality, obesity, cancer survival rates, suicide, addiction and many more are linked to the level of economic inequality within society. In short, greater economic inequality leads to worse health outcomes. 

Inequality does not necessarily refer to poverty, but relative poverty in society. For example, somebody in the lowest decile of the income distribution of a rich country such as the UK may not be considered poor by international standards, but relative to other people in the UK they are poor. 

If you are interested in understanding more about this can I suggest you read Danny Dorling’s book “Injustice: Why social inequality still persists”. In this book, he uses the example of not be able to go on a family holiday as been a good indicator of the ‘have-nots’. The corollary is being able to afford an annual family holiday in modern Britain defines you as being one of the ‘haves’. 

Why inequality results in poor health outcomes is complex. Michael Marmot argues in “The Health Gap: The Challenge of an Unequal World” that it causes chronic stress that results in poor outcomes. Please note stress is a biological response and can be measured; when people are stressed they produce excessive cortisol (a steroid) that then triggers a biological cascade that drives many disease processes and behavioural responses. The implications of this are that at a population level stress is bad and to improve outcomes you need population-based interventions to reduce stress. The latter is easier said than done when you have at least half the political establishment pushing a neoliberal (market) agenda that has been shown to increase inequality. 

How does this relate to MS? At the moment we are not sure if inequality affects MS outcomes, but we suspect it does. Many comorbidities associated with inequality, such as smoking, obesity, hypertension, diabetes, stroke and myocardial infarction are associated with a worse MS prognosis. In addition, healthcare literacy and healthcare utilization are also linked to inequality and this is very relevant to MS. 

To address this data gap we are starting a programme of work in the UK to investigate inequality and whether or not it is impacting on MS practice, MS outcomes and access to MS services. Although we started this at Barts-MS the main body of work will be done under one of the MS Academy workstreams we have defined as part of our ‘Raising the Bar’ initiative. Please note this is not just about defining and measuring inequality in MS Service provision and use, but implementing service change to make sure no MSers are left behind

I note many commentators on this blog don’t like us highlighting political issues and would prefer us to focus on science. I would argue healthcare is politics and politics is health. If you are an HCP you can’t practice your trade without getting involved with politics or at least having a position on political issues. 

The one positive outcome for me from the Brexit debacle is that it has made me realise that I didn’t have the background knowledge to have an informed opinion on Brexit and the reasons for Brexit. As a result of the self-exploration Brexit triggered (see Medium post), I have become an amateur economist, behavioural psychologist and geopolitician. All this has changed my worldview. This is why we have launched our #ThinkSocial campaign to raise awareness and make sure every HCP working in the MS space understands how inequality impacts on their patients and rather than accepting the status quo they should do something about it. 

CoI: multiple

About the author

Prof G

Professor of Neurology, Barts & The London. MS & Preventive Neurology thinker, blogger, runner, vegetable gardener, husband, father, cook and wine & food lover.

41 comments

  • Great to see a post about something that comes up in all domains of healthcare. This highlights for me something I have come to realise about medical research. It is a societal activity. If you are committed to making a real difference you have to consider all factors including the social ones.

  • I think the white flag has come out. Despite decades of research we still don’t know the cause of MS and have no effective treatments to stop worsening disability. Surely these two should be the only areas of focus for MS research. When the MS researchers start focusing on socio-economic issues you know that as an MS patient things aren’t looking good.

    What’s your solution to all this inequality Prof G? You’re a man who likes the good life – fancy restaurants, nice wine, nice holidays… are you prepared to pay a lot more tax to address the inequalities in society? I’d like NHS consultants to have a salary max of twice what an NHS nurse earns. I like Labour’s policy of getting rid of the private school system which is the greatest contributor to inequality in U.K. society – 1/3 of MPs, 1/2 of doctors and 3/4 of the judiciary. Are you for against private schools?

    Instead of trying to address what are political / economic / social issues that have been around since societies were created, you could even up the playing field by delivering an effective treatment to stop MS for all the 100,000 MSers in the UK. This would allow real equality as the treatment would work for all – rich or poor etc.

    • I agree with you. Labour is the only political party with policies that truly address inequality, which is why I am card-carrying Labour Party supporter. I think nurses and doctors are paid well, but there are unsavoury changes in employment practices. For example, many HCPs are on zero-hour contracts as part of bank staff. If and when Labour get into power they are promising to ban these contracts.

      • When I was working and earning a low wage under a Labour government, I struggled with the income tax I had to pay. Didn’t feel like equality to me. When Tories came to power, this changed. Though it pains me to say it.

    • Re: “…delivering an effective treatment to stop MS for all the 100,000 MSers in the UK..”

      I would argue we doing this. Barts-MS has very high treatment rates and we have been pushing the treat early and effectively paradigm for some time. This is what our ‘Brain Health: Time Matters’ policy document and activities is trying to achieve. I would recommend you read it if you have the time.

      https://www.msbrainhealth.org/resources

      • Prof G
        You say you push the treat early and effectively paradim.
        Could all neuros not be sent/emailed/given a copy of that policy?

        Could we copy it/send it to PALS at each of our local hospitals?

        What should we look for when going through a hospital’s website when working out how to send the policy to them? Would it be Head of Department, individuals neuros, the Trust’s CEO etc?

        Would you say a printed version would have more impact than emailing them a link?

        In this day of modern technology anyone who sees this blog and uses the internet are in a very easy position to send them the policy aren’t we…
        thank you

    • Re: “Are you for against private schools?”

      Yes and no. At an ideological level private education is a barrier to social mobility. For the record, I was educated in a state co-ed school in Johannesburg. I was the only person in my year to go to medical school; in fact, very few of us went to University (~5% of our year).

      You also need to remember that many private schools were started to educate people without access to education, for example, orphans (Westminister Abbey started Emanuel School for orphans) and girls (Emily Wilding Davison, a suffragette, was an alumna of Kensington High School). Education is also a business and is a big part of UK plc. Closing down a large business sector needs to be carefully considered.

      I would argue that state education, in general, is simply not up to the massive task at hand. Too little investment in teachers, infrastructure, etc. We need to spend more money on education and improve quality. Nationalising private schools may not deliver the improvement in quality we need. Even if private education is banned the liberal elite will find a way to highjack the system. Already in my area of London the cost of houses in the catchment area of the good state schools in between £40K and £80K.

      Our University, Queen Mary University London (QMUL) is doing its best to address lack of social mobility; 90% of our home students are from state schools, 59% are Black Asian Minority Ethnic (BAME), 42% are the first in their families to go into higher education and over 30% are from households where the household income, as assessed by Student Finance England, is less than £15,000. These figures make me very proud.

  • The Brexit referendum turned everyone and their dog into amateur economists, behavioural psychologists and geopoliticians. And that is largely why it was such a stupid idea.

    • For some people it was a very good idea.

      The referendum was promised as part of the Conservative party manifesto in 2015, the country then voted the Conservatives into power, Parliament then legislated and voted for the legislation to became law. Isn’t this democracy? Are you calling democracy a stupid idea?

        • I think the Swiss would disagree with you. There are many who believe direct democracy is the only true democracy and is the form of democracy invented and practised in Athens, by the Athenians in ~600 BC .

          Interestingly, the Swiss voted the same way as Britain in their mini-version of Leave-Remain referendum. I note not many people like to be reminded of this. Why?

          • “the form of democracy invented and practised in Athens, by the Athenians in ~600 BC”

            Could be a bit outdated then.

        • Some of the views coming from the remain side argue that if the EU understood and accepted that England is beyond maximum capacity in population for it’s land size, then many supporters of Brexit would be ok staying in the EU.

          England has a much smaller land area than Germany, France and Scotland. To me this is a point that shouldn’t be dismissed. The pressures on people living in England, to live in such close proximity to other people is too much and pressure the on resources.

          If there was a way to restrict free movement of people for a certain time scale, such as five years and let skilled immigration happen only during this time, and the UK to stay in the EU. But the EU won’t accept this.

          Furthermore, it is EU policy that restricts the number non-EU doctors and nurses coming to the UK.

  • I am acutely aware that inequality is one of the drivers of Brexit, but this post is about the effect of inequality on MS. Can I suggest we restrict the discussion to MS?

    • “At the moment we are not sure if inequality affects MS outcomes, but we suspect it does. ”

      It is so obvious…dmt’s that cost $100,000+ per year..$50,000 for hsct.

  • I would say that the beginning of ‘inequality’ for most PwMS occurs at the time of their MS diagnosis and has precious little to do with economic poverty. Whether or not they are provided with access to the right care and support depends largely on who their consultant is and whether or not they have a decent MS nurse.
    At least 2 people I assessed were well educated, and their financial circumstances allowed them to access private health care for many years. Neither of them were offered MS nurse support or referred to physio or OT for advice and rehab input.
    The assessment highlighted many problems which needed addressing, some of which had been significantly exacerbated by years of ‘neglect’ .
    At the other end of the economic spectrum I assessed someone who simply wanted an increase in, what was at the time, DLA. The assessment indicated that they did not meet the criteria for a higher rate. When offered a course of rehab to improve their mobility they declined. I think you need to be careful not to confuse patient choice with inequality.

  • The indicator of those being able to afford a family holiday I would argue is not a good indicator. Families sometime save hard for a annual holiday, which might be a cheap bucket and spade package holiday to Spain for example. But the family might go without during the year to save for this. Also week holidays to some Mediterranean destinations are often cheaper than a long weekend away in the UK. UK accomodation can be expensive.

    • Prof G didn’t want to tackle inequality in SA so jumped ship over 25 years ago. He’s happy to moan about inequality in the UK. The real test of how unequal a society is, is whether people want to leave or stay. The Home Office is inundated with applications to move to the U.K. and the vast majority of EU citizens have stayed. I saw a programme about immigration to the UK and an Indian woman said that she knew she would remain a cleaner when coming to the U.K, but knew her son could become a doctor. Perhaps this country isn’t so bad after all and we should highlight some positives rather than just slag it off.

      The issue I have with medicine and inequality, is that some specialisms know their diseases well and treat accordingly, and others (neurology) haven’t got a clue (I speak as a person who lost a relate to MND).

      • My reasons for leaving ZA had nothing to do with inequality and have been discussed before on this blog. Therefore no reason to get side-tracked. Can I suggest sticking to the issue at hand; relative inequality in the UK is likely to be impacting on MS and MS-related outcomes. We want to tackle these problems at a local and national level and if successful we could then use different channels to take our #ThinkSocial campaign to other countries.

  • Great post!

    Smoking remains and consumption of low quality sugary foods increasingly are significant risk factors for so many of the physical and mental illnesses affecting patients who walked into my GP surgery every single day over the last 20 years. I had to reach back to distant memories to even try to imagine how it would be to lead lives blighted by continual, daily worry about money, poor access to facilities, polluted neighbourhoods, noisy homes, poor prospects and lack of community and social networks….and then to deal with major complex illness!

    Now with MS myself, it seems absurd to suggest that the incredible stress of modern living and all its bedfellows, so unevenly distributed, would not be a major “Reg Flag” for someone living with MS.

    Facilitating people with MS getting to know each other during educational events run by the NHS as a part of the work up of of every patient in their first year after diagnosis might help. Without meeting others, being diagnosed with MS can be a lonely, miserable business. There is much for everyone to learn after diagnosis and sharing experiences with others is truly therapeutic. Networks can be formed. Friendships made.

    I might suggest that, like in general practice, smoking and weight should be recorded regularly in patients with MS, and those who fail to make progress in the first year be prioritised as high risk and offered appropriately tailored additional help.

    We need to remind politicians of the underlying reasons why it is that people eat junk food, smoke drink and gamble, become unfit, frail and vulnerable. It seems to me that, for example, austerity has been a symptom of a political illness that we ignore at our and our patients peril.

    • austerity has been a symptom of a political illness that we ignore at our and our patients peril.

      Auterity and recessions is good for your health 🙂

      The 2008 recession associated with greater decline in mortality in Europe

      In recent decades, Europe has experienced a downward trend in the annual number of deaths. Not only was this trend not arrested by the economic recession that started in 2008, the rate of decline increased during the recession years. This acceleration is evidenced by the results of a study published in Nature Communications and led by the Barcelona Institute for Global Health.

      https://medicalxpress.com/news/2019-02-recession-greater-decline-mortality-europe.html

    • Not true. Nordic countries show how well socialism can work, i.e. universal healthcare and social cover and a vibrant economy. The only Nordic country that is having a hard time from an economic perspective is Finland with lower than predicted GDP growth. The latter, however, may be related to the fact they are the only Nordic country who has adopted the Euro and hence they are pegged to Germany’s economy. Socialism can work, but it needs to be done properly.

      • Is that perspective not a bit distorted by the fact that Norway has a lot of oil wealth, which they have managed financially very effectively?

        The Euro does not rely totally on Germany’s economy, surely…

          • I don’t know, sounds a bit strange to me. I’m not sure it’s all down to the political system, but a different attitude generally, less class-obsessed society for one thing. Well I have slow PPMS and no, certainly don’t want to live in Sweden – they have nothing for it either. Besides, I’m very happy where I am in Scotland. 😊

        • Re: “The Euro does not rely totally on Germany’s economy, surely…”

          Tragically Germany is the only surplus economy (government and private) in the Euro; Germany recycles its surplus by allowing/forcing other Euro countries to get further into debt. If you interested in reading more about this I would suggest “The Euro: And its Threat to the Future of Europe”, by Joseph Stiglitz.

  • Neoliberalism in UK is like gun possession in US: a dangerous idea that has become normalised. Both dangerous for your health.

By Prof G

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