Let's fix inequality now

Written by Sir Harry Burns on 13 September 2017 in Comment

Public health professor Sir Harry Burns argues treating illness is not enough to create a healthy society

Most stories about ‘health’ are actually about healthcare. Never a week goes past without headlines commenting on waiting times for treatment, access to expensive medications, staff shortages causing bed closures. 

It’s easy to conclude that the health of the nation is solely the business of the health service. However, in 1948 the World Health Organisation defined health as “a state of complete physical, mental and social wellbeing, not merely the absence of illness or infirmity.” 

No matter how good the Scottish NHS is – and it is pretty wonderful – it is clear from the WHO definition that treating illness successfully is not by itself enough to create a truly healthy society.


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We have recently seen a story that reflects a genuine absence of physical, mental and social wellbeing and, as such, it is an important comment on our nation. There has been a dramatic rise in the number of deaths from drug misuse in middle-aged Scots. The predicable response is to oversimplify the problem and find someone – usually the government – to blame.

In this case, cuts are to blame. 

“The Scottish Government has slashed funding to drug and alcohol partnerships by 20 per cent… this was completely the wrong decision,” was a typical response. 

In fact, when you look at the trends in age-related mortality from drug misuse over the past 20 years, it is obvious that what we are seeing is a problem that has been decades in the making. 

The data describes a cohort of individuals, born around the early 1970s, who have an increased risk of drug abuse and are carrying that risk through life. Given that most of this risk is seen in socio-economically deprived areas, it is likely that the social, economic and environmental policies of the time had a powerful adverse impact on their families and their childhood experiences. 

Jimmy Reid, in his 1971 rectorial address to Glasgow University students, described the alienation felt in communities at that time. It was, he said: “The cry of men who feel themselves the victims of blind economic forces beyond their control, the feeling of despair and hopelessness that pervades people who feel they have no say in shaping or determining their own destinies.”

The result, for many is to turn to drugs and alcohol. 

The 40-year-olds dying of drug overdoses today were children in the 1970s when their fathers were being made redundant and their communities saw real decline. Studies from several countries show that adverse experiences in childhood such as neglect or domestic violence greatly increase the chances of children failing in education and growing up to become alcoholics, drug abusers or violent offenders. 

The health inequalities we see in Scotland today have their origins in the economic inequalities created in the past. 

So, what can be done? If our present state of health and wellbeing emerged from the complex social and economic systems of the past, can we change the future for those in difficulty in the present? There is ample evidence that we can.

Jimmy Reid understood the solution. His diagnosis was that despair and hopelessness takes over when you have no purpose or meaning in life. The answer is to give people a sense of being in control. Public services as they are currently structured are not particularly good at that. They define people as having needs. They have systems for assessing those needs and they make decisions on whether the individual has provided evidence that those needs should be met. 

Richard Davis, in his book Responsibility and Public Services, describes how a number of local authorities and public agencies have transformed the lives of citizens by helping them take control in finding solutions to complex problems. Some of these agencies have assessed the financial impact of changing the way they work and the savings in resource in social services, criminal justice and healthcare are significant. In one study, the only public service that saw a rise in spending was education - because children were attending school more frequently. 

An important aspect of helping people living chaotic lives to take control is to alleviate poverty. In Utopia for Realists, Rutger Bregman reviews the evidence for basic income as a way of improving the wellbeing of society.

In studies in the US during the presidency of Richard Nixon, infant health improved, high school graduation rates increased by 30 per cent, hospital admissions fell by 8.5 per cent, but while there was widespread support for extending the scheme, it fell foul of politics. 

Other countries have experimented with basic income and the evidence is consistent. The costs of alleviating poverty by providing a basic income are far outweighed by its benefits. It appears that the most efficient way of solving poverty is to give money to the poor.

Extreme inequality has been a blight on Scottish society for too long. There is plenty of evidence that healthy, successful lives for all are achievable by using existing resources, both human and financial, differently. Scotland could lead the world in the struggle against poverty and inequality. It could be the nation again that led the world into the Enlightenment.

The evidence for what needs to be done is all out there. It would not even be much of a risk. Let’s just get on with it! 

Sir Harry Burns is professor of global public health, University of Strathclyde

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