Next week the Royal Colleges of General
Practitioners, Nursing, and Physicians, the Faculty of Public Health
Medicine, Action in International Medicine (an organisation of colleges
and academies of health professionals with member institutions in 30
countries), and the BMJ will hold a conference on
poverty and health. The conference will be part of worldwide
professional activity to reduce the harmful effects of poverty. This
week the BMJ publishes its fourth issue in two years
that has clustered papers on inequalities in health. Why all the fuss?
Some suggest that it's because the BMJ is politically
motivated. If that means the BMJ wants action on a major
threat to health, it's true. We would like all political parties in
all countries to pay attention to inequalities in health. Many are
reluctant to do so. They are more concerned to cut taxes and so win the
votes of what the economist J K Galbraith calls the comfortable
majority.1
We are publishing these special issues of the journal
for four main reasons. Firstly, anybody interested in health has to pay
attention to wealth. It's the single most important driver of health
worldwide, even more important than smoking. Secondly, a great deal of
research is under way into inequalities in health. It affects every
part of medicine. We are beginning to understand that, for developed
countries, relative poverty (having an income substantially below the
mean for that society) is a more important influence on health than
absolute poverty (lacking the basic means to live). 2 3
And this research is leading to important discoveries on how social
pressures lead to disease outcomes.2 The BMJ
receives many papers on inequalities in health, and many of
them make it through our peer review process. It seems sensible to
cluster them.
Thirdly, things are getting worse not better. The gap between the rich
and poor is tending to widen both between and within countries - with
inevitable effects on health. Our final reason for publishing these
special issues that cluster papers on inequalities in health is that
there is increasing evidence on what health workers and health services
can do to diminish the harmful effects of inequalities in
health.4-6 England's chief medical officer will address
next week's conference, and he and the Department of Health are taking
an increasing interest in inequalities in health.4 7
The overall gains in health that have occurred around the world are
being overshadowed by increasing disparities between rich and poor. The
number of people in absolute poverty increased over the latter half of
the 1980s and now comprises more than one fifth of
humanity.8 Since 1980 economic decline or stagnation has
affected 100 countries, resulting in reduced incomes for 1.6 billion
people. 9
or more in 21 countries, particularly in eastern
Europe and the countries of the former Soviet Union. 9
The net worth of the world's 358 richest individuals is equal to the
combined income of the poorest 45% of the world's population - 2.3
billion people. A comparison of wealth alone would, no doubt, be even
more dramatic since the wealth of poor people is usually much less than
their income.9 Between 1960 and 1991 the ratio of the
shares of the global income of the richest 20% of the world's
population to the poorest 20% increased from 30:1 to
61:1.9
The polarisation of wealth has become grotesque, and we are seeing the
consequences. For example, life expectancy among men has declined in
some of the countries of eastern and central Europe over the past five
years, and in Russia and the Ukraine infant mortality has risen.
Dramatic increases in preventable diseases such as diphtheria, typhoid,
and whooping cough have occurred.9 Worldwide, around a
third of children under 5 show evidence of malnutrition as judged by
their weight for age.8
In Britain, income distribution has become more unequal, and, says the
United Nations Development Programme, it is now one of the most unequal
industrialised countries in the world. 9 For example,
the proportion of people with an income below half the national average
rose from under 10% in 1982 to over 20% in 1993.10 It
has since fallen back to around 19%.10 Unskilled men now
have a mortality three times that of professional men.11
This is a widening from a twofold differential in the early 1970s. In
the 1980s this was equivalent to a five year difference in life
expectancy for men aged 20.12 Now it will be wider.
A study in the north of England showed that there has been a
substantial rise in mortality in men aged 15-44 in poorer electoral
wards as well as widening differences in mortality between rich and
poor.13 The latest national figures in Britain showed a
fall in life expectancy for young men for the first time this
century.14 It's highly likely that poverty and social
inequalities are contributing to this fall.
A prospective study we publish today shows that socioeconomic factors
act cumulatively over a lifetime: men born to fathers with manual jobs,
who started their working life in manual jobs, and remained in them had
an age adjusted relative death rate 70% higher than those who were
born to fathers with non-manual jobs and then worked themselves in
non-manual jobs.15
Next week's London conference is part of a growing range of
international activities to promote greater equity in health and health
care. It was prompted by the "London declaration" produced at a
conference organised by Action in International Medicine and the World
Health Organisation (see box).16 The
declaration has led to worldwide activity. For example, the American
College of Physicians is hosting a symposium on international health at
its 1997 annual meeting. A major conference is planned in Baltimore in
September to discuss the challenges of improving health in deprived
urban environments in North America. In the Philippines the Academy of
Family Physicians has set up a task force on health and poverty and is
discussing with the government how to expand the coverage of primary
care.
The London declaration16
All institutions and associations of health professionals
should:
Urge political leaders of their country to make public
commitments to reduce poverty and improve the health of their
populations
Exchange and disseminate information on trends in health and poverty
and on successful and failed interventions directed at tackling their
causes and effects
Recognise, harness, and enhance the potential energy resource of poor
people themselves
Work to direct more health resources to the district level of their
healthcare systems
Foster and coordinate intersectoral and interagency collaboration,
especially at district level
Work to eliminate the marginalisation of population groups such as
lonely elderly people, disabled people, and refugees
Ensure that front line health workers have appropriate training and the
ability to access and use relevant information
Influence public opinion by liaising with national and international
media
Lobby governments to reduce their economic dependence on harmful
activities, such as the arms trade, narcotics, nicotine, and alcohol. |
|
The World Health Organisation, together with the Swedish
International Development Agency, has called for greater equity in
health and health care17 and is encouraging consultation
on the renewal of its "Health for All" strategy, which includes a
strong commitment to reduce poverty and its consequences for
health.18 United Nations agencies have launched the 20:20
initiative, which proposes that 20% of aid budgets and of developing
country budgets should be allocated to basic social services including
health and education.19 This contrasts with the decline in
overseas development assistance to the lowest level in real terms for
25 years. Of this only a tiny proportion goes to basic education and
health care.20
We now need greater coordination between bodies representing health
professionals, international agencies, and non-governmental
organisations concerned with health and development. Only by concerted
efforts will there be any impact on the policies of national
governments and bodies, such as the World Bank, that are major sources
of funding for health. Health professionals can play an important part
in this process by showing their indignation at the continued wastage
of humanity and acting as advocates for effective policies to reduce
poverty and its consequences for health. Although much effective action
may lie outside the health sector, there is good evidence that cost
effective basic services can improve health in conditions of extreme
poverty,5 and a recent systematic review of effective
interventions for "developed" countries has been conducted by the
NHS Centre for Reviews and Dissemination.6 There is a need
for sustained action because, with growing populations and major
environmental threats to the health of vulnerable populations such as
climate change,21 the toll exacted by poverty on human
health is likely to grow in absolute terms without substantial shifts
in policy and practice.
Doctors won the Nobel peace prize for their international campaign
against nuclear weapons. Now the same worldwide, professional energy
should be concentrated on combatting the damage done by poverty.
Andrew Haines
Professor of primary health care
Joint Department of Primary Care and Population Sciences,
Royal Free Hospital School of Medicine and University College London
Medical School,
London NW3 2 PF
Richard Smith
Editor
BMJ
London WC1H 9JR
References
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