Article 25 of the Universal Declaration of Human Rights 1948 states that “Everyone has the right to a standard of living adequate for the health, and wellbeing of himself and his family…” The Preamble to the World Health Organisation’s (WHO) constitution also declares that it is one of the fundamental rights of every human being to enjoy “the highest attainable standard of health” where health is defined as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.”
So it is absolutely correct that the Health Inequalities in Scotland report published last week by Audit Scotland is perceived in the media as ‘damning’ of successive Scottish Government attempts to tackle the issue.
It is a national disgrace. Arguably the problem is a breach of many Scots’ fundamental human rights.
The report reminds us that health is very largely socially determined, with people in more affluent areas living longer and having significantly better health.
In Scotland, average health life expectancy is around 18 years lower among people in the most deprived areas compared with those in the least deprived areas. That’s an average figure however. Males in the most deprived areas of Glasgow can expect to live significantly shorter lives than the average life expectancy in the Gaza Strip or Iraq.
While health inequalities blight most developed economies, there is a direct relationship between the more unequal a society is and the extent of the problem. Scotland, as part of the UK, is the fourth most unequal country in the developed world behind the US, Singapore and Portugal.
But even Portugal outperforms Scotland in terms of life expectancy.
And it’s been getting worse and worse and worse. Health inequalities have been accelerating in line with social inequalities generally: the current austerity measures employed by the Coalition Government in Westminster can only make things worse for the poor, with inequality not seen at such levels since Victorian times.
And don’t think I’m letting Labour off the hook. Social mobility has been in decline since at least the 1950s and no Government has seriously tackled it, to the extent that social mobility in the UK is now among the lowest in the developed world.
It is therefore a mistake to think of the issues highlighted in the Audit Scotland report as simply a health problem, one that can be “cured” by our hard pressed health services alone. While programmes aimed at changing health behaviours or risk factors, such as on smoking or breastfeeding are important, these often have the perverse effect of widening health inequalities because the people who best respond to these messages are not the most deprived. Thus the idea that the NHS or the Scottish Government Health Directorates can impact upon health inequalities is 60 years out of date.
It is simply ludicrous. The problems are deep seated, systemic and within the ambit of all Government departments, in both central and local government. It involves action by business and by wider society – particularly action by the Third Sector which is often closest to the communities it exists to serve. (And I don’t mean the notion of Civic Scotland, which is a different kettle of fish altogether.)
Poor health is merely a symptom.
This is a social justice problem.
And that’s where the problem (and thus the solution) lies.
Unfortunately the Audit Scotland report does not adequately address this.
The principle policy driver of Government (and I mean the Scottish Government now) has been, since 2007 (and arguably for as long as can be remembered) about “creating the conditions for sustainable economic growth”.
Why is sustainable economic growth of such paramount importance?
I’m not saying that economic activity is not important. Of course taxation revenues from business (the ones that actually pay taxes) are vital to funding public services. And having a job (or, more accurately, a purpose in life) is one of the single most important factors to human health and wellbeing.
But it’s not the only factor.
Our Chief Medical Officer, Sir Harry Burns, has been working for a number of years to turn attention to “assets based” approaches to public health: focusing attention on those factors that stop us getting ill in the first place. Factors that are well known to have a significant impact upon health and well-being: such as having a good network of friends and social networks (of the real variety, rather than virtual followers on Twitter or Facebook); healthy and supportive relationships; having access to learning opportunities, and good education and skills; feeling safe and that people can be trusted; being able to think clearly and function socially; live a healthy lifestyle; having access to quality public spaces; having a good sustainable local economy with access to quality local produce ; access to the arts, being able to express yourself (if that takes your fancy) in a creative way.
So why don’t all of these “assets” get promoted by government to the same priority as the rest? Why do we emphasise “sustainable economic growth” over everything else, and then surprised when instead of thinking about the arts as being vital to health and well-being, Government support for the arts via Creative Scotland is framed instead in terms of their contribution to the economy? As a consequence we have the bizarre situation where we have a cabal of bankers in charge of arts funding in Scotland.
Some talk about the “arts for arts’ sake”. I don’t. The arts make us feel good and they contribute to well-being. I’m not especially arty or have any particular fetish for the arts per se: I’m equally supportive of community transport networks which allow people to get around. Or libraries. Or parks. Or allotments.
“Sustainable economic growth” is not simply oxymoronic (in the sense that growth cannot be sustained forever, because resources are not infinite).
But then so is ignoring hard hitting and important reports.
In 2008 the World Health Organization’s Commission on Social Determinants of Health reported their findings and recommendations. This Commission had a stellar cast drawn from a whole range of disciplines, including two Nobel prize winners in economics – Amartya Sen and Joseph Stiglitz. It was chaired by Professor Lord Michael Marmot, probably the world’s leading expert in this field.
Their report Closing the Gap in A Generation doesn’t pull any punches. It’s full of enough bite sized quotes for elected representatives to plunder for years to come.
Such as (from the back cover):
“Reducing health inequities is, for the Commission on Social Determinants of Health, an ethical imperative. Social injustice is killing people on a grand scale.”
Social injustice in Scotland is killing people.
Think about that.
Get angry, and then think: what are we going to do about it?
Well, we need to start having a serious conversation on what kind of Scotland we want to be.
A manifesto could be unashamedly cribbed from the recommendations contained in the Closing the Gap in A Generation report. (I’m working on the assumption that if you have won a Nobel Prize you’re pretty smart and probably know what you’re talking about)
The principal priority of the Scottish Government needs to be amended to “Creating the conditions for Scots to live happy, healthy and fulfilled lives”.
We then implement (in full) the three overarching recommendations of the 2008 Commission report:
1. Improve daily living conditions
2. Tackle the inequitable distribution of power, money, and resources
3. Measure and understand the problem and assess the impact of action
If we think about framing all of the spending powers of Scotland towards tackling the social determinants of health, instead of thinking of it as something that the NHS and councils do (as Audit Scotland frame it) then we can actually start tackling this problem once and for all.
Arguably we don’t have the powers at present to do all of this (albeit we could have likely done a lot more with the powers we do have). Tackling the inequitable distribution of power, money and resources for instance, will require a move towards a more Scandinavian style welfarist, high taxation, social democracy. Measuring and understanding the problem will require the type of total systems approach that we currently can’t even begin to imagine in Scotland (but is being tried elsewhere, such as in the state of Victoria, Australia)
A final thought: another quote from the Commission’s report (this time inside the front cover):
“The development of a society, rich or poor, can be judged by the quality of its population’s health, how fairly health is distributed across the social spectrum, and the degree of protection provided from disadvantage as a result of ill-health”
On this measure, can Scotland really consider itself a developed country?
It’s time we grew up.
Michael Roy is a researcher at the Yunus Centre for Social Business and Health at Glasgow Caledonian University.