Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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Tackling health equality - let's get tougher on the politicians
- Richard Ma (24 June 2007)
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Communism: only 80 million dead. Why not give it another chance?
- Richard Watson (24 June 2007)
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A missed opportunity
- james n hardy (25 June 2007)
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Diagnosis OK, but treatment...?
- Michael Schachter (25 June 2007)
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Let's get tough on our politicians
- Roger L Weeks (26 June 2007)
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Maybe doctors should bear some responsibility
- stephen black (26 June 2007)
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Re: A missed opportunity
- Richard Watson (27 June 2007)
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Really tackling health inequalities
- Alex Scott-Samuel (30 June 2007)
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Re: Communism: only 80 million dead. Why not give it another chance?
- susanne stevens (2 July 2007)
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Re: Re: Communism: only 80 million dead. Why not give it another chance?
- Richard Watson (3 July 2007)
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health or inequality ?
- L S Lewis (3 July 2007)
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Re: Re: Re: Communism: only 80 million dead. Why not give it another chance?
- Alex Scott-Samuel (9 July 2007)
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Richard Ma, General Practitioner The Village Practice, 115 Isledon Road, London N7 7JJ
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Well done, Iona Heath, for getting tough on the causes of health inequality. As the public health cliché goes, it is far more sensible to prevent people from falling into a river than pulling out the casualties further downstream. We have seen some paradigm shifts in managing health inequalities in the last decade, which coincided with the Labour government taking power in 1997. The Wanless report highlighted the importance of public health practitioners and recommended health policies should be evidence based, meet public health objectives, cost-effective and respect individuals’ rights and autonomy.(1) The public health white paper that followed - Choosing Health - firmly focused on prevention as well as acknowledging the wider determinants of health and inequalities.(2) However, the recent publication of England’s health profile shows there are still marked inequalities in health between the north and south in England.(3) Despite the Government’s commitment to public health, financial resources that were earmarked for Choosing Health initiatives went into balancing PCT budgets. This is in parallel with unprecedented financial and political investments in the “choice” agenda despite evidence from a major national research programme funded by the Department of Health that it merely maintains the inequality divide and does nothing to address quality of health services and health outcomes.(4). In fact, when it comes to "choice", less is more.(5) I think it is about time that we challenged politicians on the shameful waste of recourses on initiatives of dubious value such as Choose and Book and walk-in centres, which increase health inequalities even further as only the well-informed and middle classes seem to benefit the most. References 1 Wanless, D. Securing good health for the whole population. HM Treasury 2004, London. http://www.hm- treasury.gov.uk./consultations_and_legislation/wanless/consult_wanless04_final.cfm accessed 23rd June 2007. 2 Choosing health: making healthy choices easier. Department of Health 2004, London. http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4094550 accessed 23rd June 2007. 3 http://www.communityhealthprofiles.info/index.php accessed 23rd June 2007. 4 Fotaki M, Boyd A, Smith L et al. Patient choice and the organisation and delivery of health services: scoping review. National Co- ordinating Centre for NHS Service Delivery and Organisation R&D. http://www.sdo.lshtm.ac.uk/files/project/80-final-report.pdf accessed 23rd June 2007. 5 Bate P, Robert G. Choice. BMJ 2005; 331: 1488-1489 Competing interests: None declared |
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Richard Watson, General Practitioner 11 Craigallian Avenue, Cambuslang, Glasgow, G72 8 DQ
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"Engels was primarily concerned with social justice and his work and influence led eventually to profound social upheaval and change in many countries, with enduring benefits for the poorest people." writes Dr Heath. The social upheaval was, of course, greatest in the Soviet Union and China. About 20 million were killed in the USSR and maybe 60 million in Communist China. Many more spent decades in the gulags or suffered man -made famines. Hundreds of millions lived in fear and misery for generations. In every country where Engels and Marx's ideas were put into action similar horrors followed1. How can Dr Heath write such a sentence without even a caveat recognising such massive suffering? More importantly, how can you, the editor, publish it? Such disregard for mass slaughter and misery rather overshadows her, and your, purported concern for the health of the poor. Reference. 1 Courtois S, Werth N, Panne J, et al. The Black Book of Communism. Cambridge, Massachusetts: Harvard University Press. 1999. Competing interests: None declared |
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james n hardy, GP principal Bethnal Green Health Centre, 60 Florida Street, London E2 6LL
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Dear Editor, Heath demands that we “get tough on the causes of health inequality”, but with the luxury of a 600 word article fails on two counts – first, she falls short of spelling out exactly what she feels are the causes of health inequality and secondly, as a consequence, does not enlighten us as to her proposed actions. She seems to imply that it’s a rich-poor thing, a widening of the gap between haves and have-nots. But why exactly is the UK 21st out of the 27 European Union countries? Is it because we stand side by side with the United States and are increasingly embracing privatised health? Is it because we have an archaic feudal society? Is it because our expansionist past is finally catching up with us? Well, I don’t know and my guess is that none of us does and so if we choose, as Heath suggests we should to “pursue political answers alongside technical ones” we are reduced at best to nibbling around the edges of something that is so large that it has neither form nor shape. Real change requires inspirational leadership that is strong and sustained. It will also require the debunking of some of our great institutions, not least, the monarchy, which stands at the healm of our divided society. Heath I. Let's get tough on the causes of health inequality. BMJ 2007;334: 1301 Competing interests: None declared |
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Michael Schachter, Senior Lecturer in Clinical Pharmacology St Mary's Hospital London W2 1NY
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Iona Heath makes very valid points about the inequalities in this and all other countries, and the impact this has on health. Unfortunately, she then tells us that the answer to this is an "upheaval"of the sort promoted by Engels and his friend in the British Museum Reading room. Some poor people did indeed benefit from this, if they were lucky enough to escape state-sponsored famines, random executions and deportations to concentration camps. Most of the mass murders of the last century were committed by middle class fantasists with visions of utopia.But the so- called liberal intelligentsia has always been more concerned with the horrid Senator McCarthy being beastly to some luvvies in Hollywood. Competing interests: None declared |
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Roger L Weeks, GP Deanhill Surgery SW14 7DF
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Every week I scour the BMJ for a few gems to liven-up my weekend reading. This week I found one – a big diamond – Heath’s brilliant polemic. Shame on your respondent who seized on the reference to Engels (surely not that communist chappie!) to decry communism thus ignoring the kernel of Heath’s message – that the technical response to health inequality is not enough – there must be a political remedy for the social injustice of health inequality. It is no surprise to ordinary observers of our health service that our politicians (some of the current lot in power even claim to be socialists) have to be reminded that, as Chadwick pointed out, violence, alcohol and opium abuse, are consequences rather than causes of poverty. Engels and others observation of the ghastly condition of the poor gave birth to modern socialism which spawned not only communism but our own Labour party. That party is now so ‘off message’ that, for example, it has
attempted (and signally failed) to deal with the UK’s drug problems with
slogan-lead strategies such as ‘Tackling Drugs to Build a Better
Britain’1. whose leading aims are Let’s get really tough on politicians and, as Heath urges us, speak to the powerful on behalf of the powerless. The only way of eliminating health inequalities is by diminishing massive wealth inequalities. 1. Tackling Drugs to Build a Better Britain - The Government's Ten- Year Strategy for Tackling Drugs Misuse, The Stationary Office April 1998 Competing interests: Roger Weeks runs a clinic for heroin addiction in primary care in London SW14 |
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stephen black, management consultant london sw1w 9sr
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Before rushing to blame the easy target of politicians, there are several questions worth asking. The first is the extent to which health equality can be achieved without draconian constraints on individual freedom. Much of the difference in health among the UK regions is nothing to do with health spend or activity but individual lifestyle choices. In a liberal society the best government can do is influence these choices (eg anti-smoking or healthy-eating advertising). You can't force people to eat their vegetables. This doesn't stop medics from regularly advocating highly illiberal measures of dubious public health benefit (eg the smoking ban or compulsory cycle helmets; both of debatable impact). Sometimes people will choose to behave in ways that are bad for their health and there is nothing we can do about it. Another question worth asking before the medical establishment directs hate mail to MPs, is whether medical practice contributes anything to health inequality. Some of the irate comments about PCT budgets seem to assume that the amount of healthcare delivered is a simple function of the money spent. But this is far from the truth. Inconsistent clinical standards cause far more variation. When many PCTs are still allowing their providers to do utterly useless procedures such as tonsillectomies perhaps the right question would be "how can I spend my budget on things I know will contribute to public health as opposed to things that just waste my budget?" There is a huge opportunity in the UK to stop spending money on activity with no known benefits and to spend it on activity know to help patients. Medical staff in providers could free up large amounts of their budgets (for redirection to more needy areas) by adoting more consistent clinical practices. It is also worth considering who will benefit from current government policy. Many hospitals have had persistently bad quality and efficiency of care over long periods of time. What contributes to inequality is that those poor hospitals effectively have captive markets for patients and kept getting paid whether their care was good or not. The patients most affected were the poor and least mobile. Choice puts power over those providers in the hands of their patients some of whom will choose to go elsewhere, finally providing a strong incentive for the poor providers to get better. A system that is improving because of such incentives will reduce the persistent inequality arising from poor providers. Finally there is a big question to ask even if we accept the link between poor health and inequality (poor health and poverty would be more convincing). The question is how do we fix the problem? It is easy to assume that taking money from the rich and giving it to the poor would help. But one of the problems that makes poverty persistent is dependence on those handouts: what is needed is often a way to take back responsibility for their own lives. If we knew how to achieve that we could tackle a lot of our peristent social problems. Ultimately, blaming the politicians and social inequality for health inequality is passing the buck and begging the question. Competing interests: None declared |
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Richard Watson, General Medical Practitioner 11 Craigallian Avenue, Glasgow, G72 8DQ
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Shame on me for mentioning the consequences of communism? I think not. Suppose an article praised the Nazis, who improved the position of the poor in Germany, without any mention of their negative features. Would you still consider it in bad taste to mention their massacres? Too many unreconstructed leftists still seem to consider the crimes of communism to be something of a joke - "not that communist chapie!". To treat them so lightly and dismiss them as being of no consequence by simply not mentioning them is to insult those who suffered and continue to suffer. Competing interests: None declared |
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Alex Scott-Samuel, Senior Lecturer in Public Health University of Liverpool, L69 3GB
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As a public health physician who has worked with health inequalities for 30 years, I find this correspondence both frustrating and - just a little - inspiring. If there is one thing I have learnt in my 35 years as a medical practitioner, it is the truth of what Virchow said over a century ago - 'medicine is a social science and politics is nothing but medicine writ large.' My own area of public health has benefited immensely from the advent of multidisciplinary public health under the present government, whereby non-medics can now become directors of public health (let us hope that the Brown government allows them to fulfil their potential role in promoting the public health, as opposed to reluctant collusion in the undermining and privatisation of our welfare state, as at present). In my view, medical training should include a lot more social science and should explicitly include political science. One of the reasons that we have the frustrating situation described by Iona Heath is that - unlike medical sociology, health economics etc - the discipline of health politics, concerned with the political determinants of health, still awaits formal recognition. Some of the correspondence betrays ignorance about socialism and socialists. The commonly held view among the so-called liberal intelligentsia - far from representing Stalinist apologism - is that the excellent values and principles of socialism have never been fully implemented. The limited evidence from societies which out-perform their levels of wealth, such as Costa Rica, Cuba and Kerala, is that egalitarian social organisation is of general benefit. In former socialist kibbutzim, there is published evidence that male life expectancy increases towards that of females, by comparison with the surrounding capitalist Israeli society. A key dimension in health inequality which Heath however fails to mention is patriarchy and so-called hegemonic masculinity. Virtually all social and economic inequalities can be traced back to power inequalities which have their roots in the dominant form of masculinity into which our children are socialised. The necessary social revolution which is required if we are to seriously challenge health inequality must also include changes to parenting and socialisation such that we cease to value boys and men who are tough, aggressive, competitive rather than collaborative, who take excessive risks, and who suppress their emotions. It will be a long haul - not least, because the social revolution must involve the successful challenging of the major religions which sustain patriarchy. Best wishes, Alex Scott-Samuel Competing interests: None declared |
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susanne stevens, retired cf5 6su
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Should professionals with political aims be encouraged to at least declare their political interests? In fact very few members of the public or in local communities, especially those who are in unequal relationships with groups in positions of power, will realise practitioners do have political aims which can influence their lives. Those who hold positions on NHS and other committees, or who are involved with party politics may have some degree of influence over local and at times national policy but this is not widely known by members of commmunities including where they work.The public/those registered with practices should in a democracy have a right to know who and what are affecting private as well as public lives. Affiliations/declarations of interests are not declared on practice leaflets for example. Communism had equality as one of it's high ideals but was led by secretive elites who imposed their views on others in contravention of another of it's ideals. Equality for all. Equality of health will not come about if small groups in priveledged positions talk only to each other or only carry out tokenistic exercises to include others. Information needs to be shared with all so that all if they wish they may share debate and decision making and importantly check the influence and control of any particularly political group. This obviously relies on a higher degree of openess and transparency with local communities. Relatively few will have read this article about inequality or have had the chance to respond. It would probably take the same time and effort to publish a piece in a local paper, put up an information poster in a health centre as to publish an article in the BMJ - which is still only available those who can afford or are willing to pay for it. Competing interests: None declared |
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Richard Watson, General Practitioner 11 Craigallian Avenue, Cambuslang, Glasgow, G72 8DQ
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I quite agree that we should reveal our political affiliations. I am not sure about putting them in the practice leaflet, but I am quite happy to put mine up here. I am a member of the Labour Party. What about you, Dr Heath and the other responders? Such political animals must surely be members of a party? Competing interests: I am a member of the Labour Party. |
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L S Lewis, GP Surgery, Newport, Pembrokeshire, SA42 0TJ
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Iona has the two inextricably confused. Why is 'health inequality' a bad thing ? Surely it is Ill-health, poverty, and disease which was the 'bad thing'. If we strive to relieve suffering we will inevitably be able to relieve only the relievable, in only those we can reach - thus perpetuating inequality. But we must do what we can. Soviet and Chinese Communism in practice was indeed murderous, due to evil people, rather than a theoretical failing, some might still believe. I fear that the pursuit of Equality ( or even Equity ) at the expense of other moral goods is precisely Communism's theoretical failing. Respect for Autonomy ( eg: individual liberty, and democratic rule ) are at least worthy being weighed against 'equality', often more highly. Maximising Justice comes high in any Socialist creed, but the utility of different economic structures in delivering Benefits without Harms has been and remains in principle an issue (cf. Capiltalism in Communist China). " Doctors have a duty to draw public attention to social injustice as a cause of ill health " Iona says. Sure - but we have an over-riding duty to deal with ill-health and all its causes ( unjust or not ! ). I think if Iona had said " Decent people have a duty to draw public attention to social injustice " then she would now be in less of a muddle. For our part, Pembrokeshire's VTS has 'Animal Farm' as required reading. Competing interests: None declared |
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Alex Scott-Samuel, Senior Lecturer in Public Health University of Liverpool, L69 3GB
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Delighted to declare my political interests, as Richard Watson requests: I am a feminist, a socialist and a member of the Labour Party. I think it's important to point out that all participants in this correspondence have political interests: those that think otherwise are probably - like most of their 'apolitical' colleagues - implicit supporters of the 'christian democratic' status quo that has ruled our country for several decades, creating or sustaining the inequalities which the present government claims to oppose Competing interests: I am a feminist, a socialist and a member of the Labour Party |
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