Dr Michael Fitzpatrick

Doctoring an unhealthy society

The link between social disadvantage and ill health is currently all the rage in medical journals and conferences. At a symposium last month, Dr Iona Heath, a radical North London GP, declared that 'the greatest contemporary challenge facing the discipline of general practice is to find an adequate response to the malign effect of poverty on the health of patients'.

I have followed the poverty-health debate with some bemusement. On one level, it has always seemed so obvious that rich people are healthier than poor people, that detailed surveys of the differentials were of little interest. However, the sheer scale of recent research and discussion of these issues has prompted me to look a little more closely.

My first question is - can it really be true that poverty has suddenly become such a major threat to public health in Britain? I work in Hackney, a borough which is classified as having high levels of deprivation. Yet to draw a parallel between the poverty in Hackney today and that in the nineteenth century seems far fetched. I have, over the past decade, seen a couple of cases of rickets and a few more of TB, but these are far from being the everyday diseases they were in East London up to the 1940s.

When I was a medical student I saw many children suffering from malnutrition in Africa, but I have never seen such a case in Hackney. Many of my patients live on fairly rundown council estates, but conditions of overcrowding, cold and damp are much less common today than they were even when I started in general practice. Central heating - until fairly recently the privilege of the middle classes - is now virtually universal.

According to the Election Briefing published by the Economist, the real income of the average person in Britain has increased by 39 per cent since 1979. It is true that those on higher incomes have done best, but it is only the bottom 10 per cent who have experienced a decline in real living standards. These figures confirm my impression that, while most people are better off, a small section of people, often suffering from a combination of social and medical problems, for some compounded by the effects of discrimination against ethnic minorities or refugees, have experienced increasing hardship.

I fully accept a definition of poverty in relative terms: to participate in society everybody needs not only enough res-ources to ensure physical survival, but sufficient to ensure a customary standard of living. I also recognise one of the key themes of the current debate, that relative poverty is associated with a relatively high level of ill health and probably contributes to an early death. But what I cannot understand is how relative poverty of the sort that exists in Britain today can lead to a rising incidence of rickets or TB.

Furthermore, when I read claims that one third of babies in Britain are born into poverty and that this experience of deprivation explains significant differentials in various indicators of infant mortality - all of which have been steadily declining for decades - I begin to suspect that the statisticians are taking leave of the real world.

All this leads to more questions - why all this concern about poverty and why now? After all, in the 1980s the famous Black Report on inequalities and health and its successor 'The health divide' were alternately suppressed and dismissed by the government as the work of dangerous left wingers. Yet now that the left has collapsed, its old cause of health inequalities is flourishing as never before.

This paradox forms the starting point for some excellent recent work by David Wainwright ('The political transformation of the health inequalities debate', Critical Social Policy, November 1996). Wainwright emphasises that the underlying concern in the new health inequalities debate is not so much with the poor as with the wider problems of society. This point is confirmed by a more recent article which links increasing inequality to declining social cohesion, which in turn leads to rising crime, falling productivity and damage to democracy (I Kawachi and B Kennedy, 'Health and social cohesion: why care about income inequality?', British Medical Journal, 5 April). The discussion of health inequalities shifts to the question of how to control the 'underclass'.

Wainwright focuses on the initiatives that emerge out of the health inequalities debate. On the one hand, there are exhortations to the government to implement policies that reduce poverty and guarantee services to the poor. As he observes, at a time when the pro-market policies of both major parties point in the opposite direction, such pleas are little more than empty rhetoric. On the other hand, various health professionals are engaged in projects directed at policing the personal behaviour of the poor.

Commenting on a survey of more than 100 community health initiatives, Wainwright notes that many are oriented towards regulating the behaviour of young people, using the issues of alcohol, drugs or safety. The more 'person-centred' initiatives tend to have an individualistic focus on stress management, personal and social skills and healthy lifestyles. He is critical of their use of the concept of 'empowerment' to describe activities which elevate survival over social engagement and encourage passivity and acquiescence.

In the Victorian era, radical activists engaged in missionary work among the poor of East London, preaching the virtues of temperance, thrift and clean living. In our secular age, much of this work now falls to GPs and other primary healthcare workers, who preach the gospel of health promotion, against smoking and drinking, for safe sex and exercise and a healthy diet. Meanwhile the system that generates relative poverty alongside relative wealth guarantees that doctors and undertakers will never be short of work.