A picture really is worth a thousand words. A few weeks ago The Irish Times published this photograph of a Traveller woman, aged 67, and her granddaughter, who is about three years old. The photograph illustrated, in the way words never can, what a lifetime of multiple deprivation does to health. The small girl looks like other children of her age – healthy and a normal weight. Inequality has not yet influenced her appearance.
The grandmother, on the other hand, looks unhealthy, much older than her years, has a physical disability requiring a crutch, and is obese. The fact that they are Travellers is irrelevant.
Anyone enduring years of inequality will end up with chronic health problems. Some disadvantaged groups have death rates up to six times that of better-off people. This is nothing new.
Although the Irish health system has made a huge difference to population health since the foundation of the State, it has not eliminated health inequalities. If anything, disparities in health have got worse.
So it was no surprise to read the latest report from the National Cancer Registry, Cancer Inequalities in Ireland by deprivation, urban/rural status and age: A National Cancer Registry report 2016, which showed "strong patterns of inequality by deprivation".
The report assessed inequalities in relation to incidence, five-year survival rates, treatment and co-morbidity for cancer patients in Ireland between 2008 and 2012. Statistically significant findings included a “higher incidence of cancer in more deprived populations, overall, and for stomach, lung and cervical cancers, and “stronger patterns of increasing incidence with increased deprivation for lung cancer and colorectal cancer”.
“Patients from more deprived populations had lower survival rates for six cancer types: stomach, colorectal, lung, breast and prostate cancers, and melanoma.” The findings “point up striking inequalities that need to be targeted for improvement.”
Health experts have known about health inequalities for many years. In 2001 the Institute of Public Health published Inequalities in Mortality which established the "pervasiveness and magnitude of inequalities in Ireland". All causes of mortality in the lowest socio-economic group was up to 200 per cent higher than in the highest socio-economic group.
A follow-up report in 2003, Inequalities in Perceived Health, showed inequalities in mental, physical and social health were "pervasive".
The HSE was established in 2005 so why was tackling health inequalities not its first priority? The word "inequalities" is mentioned once in the HSE's Corporate Plan 2015-2017 and the organisation intends to tackle the problem by trying to change lifestyles.
Margaret Whitehead, an expert in health inequalities, calls this "lifestyle drift": an approach adopted by health experts when they can't think of anything better. People who endure multiple deprivations do not have the same capacity to make healthy choices as people from higher socio-economic groups.
Healthier choice
The healthier choice is not the easier choice for poor people. And it is not just about money. Disadvantaged groups endure many deprivations relating to education, environment, housing, social exclusion, and employment status.
The Cancer Registry Report acknowledges that eliminating inequalities is difficult. "This is a very complex area to tackle, given that we don't fully understand all the factors involved and how they interact."
Health experts may not understand the mechanisms underlying inequalities but economists do. In fact, the most important book about health inequalities published in recent years was written by an economist. Thomas Piketty in Capital in the Twenty-First Century argues that the fiscal policies pursued by developed countries, including Ireland, undermine social democracy, produce economic elites, and a burgeoning disenfranchised and disengaged underclass who are either unemployed or on minimum wages. This inevitably leads to more inequalities.
Eliminating health inequalities is not easy because it involves eliminating all non-health inequalities including anything that privileges one group of people over another.
So all grind and fee-paying schools have to go. The most talented teachers must work in the most deprived schools. All workers must be paid living (nearly €12) instead of minimum wages (€9.15). All citizens must be provided with good housing and safe, aesthetically pleasing, environments.
Flat class systems ensure little difference in health status between lower and higher socio-economic groups. Bringing this about will cost money.
Many Irish people are unwilling to pay separately for well-functioning water and sewage systems. Many don’t want to pay by weight for rubbish collections. It is hard to believe the country will be willing to pay for a fairer society. Politicians will just have to be more persuasive and convince citizens that equal societies are healthier and better for everyone.
Jacky Jones is a former HSE regional manager of health promotion and a member of Healthy Ireland Council.
drjackyjones@gmail.com