1. Why are inequalities in health greater now than at any times since the 1920s? Danny Dorling Talking Points Lecture,10 th February 2010 Medical School Lecture Theatre 2, University of Sheffield Organized by Yorkshire and Humber Teaching Public Health Network and co-hosted by the School of Health and Related Research (ScHARR) Thanks to all who contributed to this lecture, especially the Worldmapper group (Graham Allsopp, Anna Barford, Benjamin Hennig, Mark Newman [University of Michigan], John Pritchard and Ben Wheeler [University of Cornwall]), Bethan Thomas and George Davey Smith [University of Bristol] for the most recent work on inequalities in Britain, and to Dan Vickers and Dimitris Ballas who helped with some of the others on the work on inequalities in Sheffield.

2. Why are inequalities in health greater now than at any times since the 1920s? Are they? Why are they? What to do? Three Parts

3. Answers Are they?  they are for Britain by area, since 1930s Why are they?  much else polarized What to do?  realise how much all are harmed by rising inequality – from national life expectancy to local housing, education and labour markets…

4. Are they?  Here I will only talk about geographical inequalities – your chances depending on where you were born and live – not to whom you were born.  We don’t have enough information to be able to answer this question worldwide, or for Sheffield, but we can for Britain.  People migrating in geographically selective ways appears to matter more now than it did in the 1920s and 1930s when inequalities were driven most strongly by material deprivation, occupational and (still) infectious hazards.  Today, in Britain, social inequality itself creates injustice.

5. Worldwide  It can help to put local experiences in national and international contexts for perspective;  Inequality in health between countries fell, at least until the 1980s and then rose;  Superficially the rise could be accounted for by young deaths due to AIDS;  But worldwide inequalities in income and wealth were also growing at this time.  Infant mortality rates for my grandparents generation were as high as in the poorest countries today.

6. Global Life Expectancy (years) Dorling, D. et al. BMJ 2006;332:662-664 Copyright ©2006 BMJ Publishing Group Ltd. Global life expectancy slope index of inequality between nation states (in years). Black triangle shows estimated index in 2000-5 with impact of AIDS removed

7. GDP development 1955-2000s  Sustaining postwar growth in rich nations after the 70s would have required another planet, or redistribution. Instead there was a hugely inefficient redistribution of wealth to the richest nations. A more equal world would have seen far fewer young deaths than now occur. Decadal growth rates (in GDP) 1973 1969 1968 1977

8. Age of Death: Infants (aged under 1)  8,142,016 deaths

9. Age of Death: 1-4  2,556,272 deaths

10. Age of Death: 5-9  863,022 deaths

11. Age of Death: 10-14  536,950 deaths

12. Age of Death: 15-19  870,915 deaths

13. Age of Death: 20-24  1,273,937 deaths

14. Age of Death: 25-29  1,496,071 deaths

15. Age of Death: 30-34  1,606,806 deaths

16. Age of Death: 35-39  1,652,503 deaths

17. Age of Death: 40-44  1,788,164 deaths

18. Age of Death: 45-49  2,098,466 deaths

19. Age of Death: 50-54  2,412,379 deaths

20. Age of Death: 55-59  2,802,369 deaths

21. Age of Death: 60-64  3,615,847 deaths

22. Age of Death: 65-69  4,548,376 deaths

23. Age of Death: 70-74  5,416,482 deaths

24. Age of Death: 75-79  5,410,001 deaths

25. Age of Death: 80-84  4,381,231 deaths

26. Age of Death: 85-89  3,144,797 deaths

27. Age of Death: 90-94  1,563,557 deaths

28. Age of Death: 95-99  484,416 deaths

29. Age of Death: 100+  92,585 deaths

30. Causes of death trends illustrate what is possible with medical progress and an NHS  Change in Chance of Dying by Cause of Death in England and Wales 1851-1990 Source: Very old graph from: A New Social Atlas of Britain (Wiley 1995), page 154: http://sasi.group.shef.ac.uk/publications/new_social_atlas/chapter5.pdf NHS

31. Sheffield – A tale of two cities http://www.sasi.group.shef.ac.uk/ research/sheffield/ Now, turn from the world to a single city in the middle of Britain. How have inequalities in life chances changed here over time and inequalities in health responded? This report was an attempt to collate most of what we know about spatial inequalities in Sheffield. And how they have changed since the late 1960s, the earliest date have much date for. www.shef.ac.uk/sasi

32. Unemployment inequalities tell us a lot Source: A Tale of two Cities. The Sheffield Project. http://www.sasi.group.shef.ac.uk/research/sheffield/

33. Life Expectancy 1851-1900 by Registration District (years) Data taken from Szreter, S. & Mooney, G. (1998): Urbanization, mortality, and the standard of living debate: new estimates of the expectation of life at birth in nineteenth-century British cities. Economic History Review, LI, 1 (1998), pp. 84-112. 1851-601861-701871-801881-901891- 1900 Sheffield3433353839 Eccleshall40 424346 GAP67757

34. Average life expectancy in Sheffield  Average life expectancy varies by 20 years at the extreme (for women) and 16 years (for men) – by very small area This inequality is slightly higher than in earlier years, but in general inequalities in health within Sheffield have fallen at times and have not risen as much as has occurred nationally, despite the huge wealth inequalities within this city.

35. Inequalities in life expectancy in Britain Nationally there have been rapid increases in inequality since 2002 by area  Difference between best and worst-off districts by life expectancy (years)

36. Inequalities in life expectancy in Britain...and even getting worse in 2007 and 2008  Difference between best and worst-off districts by life expectancy (years)

37. 0 5 10 15 20 25 30 35 40 45 250 200 150 100 50 0 % Poverty SMR <65 Poverty, deprivation and health: the dose-response has been known for many years Source: Modified graph from Shaw, Dorling, Gordon & Smith (1999): The widening gap. Health inequalities and policy in Britain. The Policy Press. Bristol. Scatterplot of standardized mortality ratio for deaths under 65 and % of households living in poverty (Breadline Britain index), for parliamentary constituencies (Britain (1991-1995)

38. Mortality Patterns in Britain 1921-2005 Rates of inequality fell then rose from 1973  Change in SMR by Local Area Poverty Rate (pre 1974 boundaries) 1 0.9 1.2 1.1

39. Mortality Patterns in Britain 1921-2005 Some more unusual maps are need to see:

40. Mortality Mosaics: SMR 1921-1925  10:10 ratio of deciles: 2.02 Created by John Pritchard http://sasi.group.shef.ac.uk/research/mortality_mosaics/

41. Mortality Mosaics: SMR 1926-1930 Created by John Pritchard http://sasi.group.shef.ac.uk/research/mortality_mosaics/  10:10 ratio of deciles: 2.41

42. Mortality Mosaics: SMR 1931-1935 Created by John Pritchard http://sasi.group.shef.ac.uk/research/mortality_mosaics/  10:10 ratio of deciles: 2.35

43. Mortality Mosaics: SMR 1936-1939 Created by John Pritchard http://sasi.group.shef.ac.uk/research/mortality_mosaics/  10:10 ratio of deciles: 2.89

44. Mortality Mosaics: SMR 1950-1953 Created by John Pritchard http://sasi.group.shef.ac.uk/research/mortality_mosaics/  10:10 ratio of deciles: 1.96

45. Mortality Mosaics: SMR 1959-1963 Created by John Pritchard http://sasi.group.shef.ac.uk/research/mortality_mosaics/  10:10 ratio of deciles: 2.25

46. Mortality Mosaics: SMR 1969-1973 Created by John Pritchard http://sasi.group.shef.ac.uk/research/mortality_mosaics/  10:10 ratio of deciles: 1.92

47. Mortality Mosaics: SMR 1981-1985 Created by John Pritchard http://sasi.group.shef.ac.uk/research/mortality_mosaics/  10:10 ratio of deciles: 2.12

48. Mortality Mosaics: SMR 1986-1990 Created by John Pritchard http://sasi.group.shef.ac.uk/research/mortality_mosaics/  10:10 ratio of deciles: 2.22

49. Mortality Mosaics: SMR 1991-1995 Created by John Pritchard http://sasi.group.shef.ac.uk/research/mortality_mosaics/  10:10 ratio of deciles: 2.55

50. Mortality Mosaics: SMR 1996-2000 Created by John Pritchard http://sasi.group.shef.ac.uk/research/mortality_mosaics/  10:10 ratio of deciles: 2.83

51. Mortality Mosaics: SMR 2001-2005 Created by John Pritchard http://sasi.group.shef.ac.uk/research/mortality_mosaics/  10:10 ratio of deciles: 2.84

52. Inequalities in premature mortality here is another way of looking at the rates Geographical Inequalities in premature mortality (SMR<65) 1921-2006 Note that the time periods vary due to data limitations; in particular, there is a large gap between 1939 and 1950. For 1990 (included in 1990-92), 1991 population figures were used. For 2006 (included in 2004-06), 2005 mid-year estimates (the latest available at small area geography) were used. Note that the final column does not follow on but overlaps; it is the latest 3 years for which mortality data were available for all of Britain.

53. Polarisation even for the rarest causes Poverty and Murder in Britain Change in SMR for Murder by Ward Poverty, 1981/85-1996/00 Source: Data from Dorling, Gordon, Hillyard, Pantazis, Pemberton, &Tombs (2008): Criminal obsessions: why harm matters more than crime. Second Edition. London: Centre for Crime and Justice Studies. http://www.crimeandjustice.org.uk/

54. And it is worth remembering what the key causes now are: Main Cause for people dying in Britain (by age) in the period 1981-2004 AgeCause  0 Other conditions in the perinatal period  1-4Congenital malformations of heart  5-14Pedestrian and motor vehicle accidents  15-34Other motor vehicle accidents (driver/passenger/cyclist)  35-95Heart attack and chronic heart disease Source: Dorling, D. (2008). Supplementary memorandum from Professor Danny Dorling, pages Ev 323- 324 House of Commons Transport Committee: Ending the Scandal of Complacency: Road Safety beyond 2010. Full details given in the preface of Shaw, M. et al., 2008, The Grim Reaper’s Road Map, Bristol: Policy Press.

55. Underlying inequalities in health is Income inequality in Britain: the trend  As a result of what first became politically possible and then, apparently, politically impossible, inequality fell and then rose. It is hard to believe this trend is unconnected What the richest 1% get (post tax)

56. From this The most harmful cost of inequality  In more unequal times, and in the aftermath of the shock of mass unemployment, more people in poorer areas die young as compared to other times and places. The prospects of the wealthy also move away from those of the average. The line marked by squares shows how much lower the age-sex standardized under age 65 mortality rate of the best-off 10% by area is as compared to the average. The line marked by dark diamonds shows how much higher that of the worst-off 30% is than the average. (Source Dorling and Thomas 2009, derived from Table 4.3 with interpolation between five year rates in some circumstances) Best and worse off area – differences from average Inequality in health – premature mortality

57. What to do? - read somebody else’s book! Inequalities have a direct impact on health, so they need to be reduced in all areas of life! Image Source

58. What to do? Inequalities have a direct impact on health, so they need to be reduced in all areas of life!  Health: GPs where they are needed (like nurses) – it is easier in a time of crisis (like the NHS after the war).  20mph speed limit in residential areas should be a key public health policy.  Education: In affluent countries with elitist education all children do worse at school. – Solutions: Ensure the nearest school to every child is funded by need, not just numbers.  Poverty: NOT means testing – this results in a JSA of £9 a day. Source: http://risingtide.org.uk/book/print/269 www.polyp.org.uk

59. References  Day, P., Pearce, J., and Dorling, D. (2008). Twelve worlds: A geo-demographic comparison of global inequalities in mortality. Journal of Epidemiology and Community Health, 62, 1002-1010  Dorling, D., Shaw, M. and Davey Smith, G. (2006). HIV and global health: Global inequality of life expectancy due to AIDS. BMJ, 332, 662-664.  Dorling D. and Thomas, B. (2009). Geographical inequalities in health over the last century, Chapter 1.3 in Graham H. (Ed.) Understanding Health Inequalities, Open University Press. Pp. 66 ‐ 83.  Mortality mosaic maps by John Pritchard  World maps by the Worldmapper team  Slides created by Benjamin Hennig  Slides available on http://www.slideshare.net/GeoSaSI Credits www.polyp.org.uk