Intended for healthcare professionals

Observations Life and Death

R-E-S-P-E-C-T—find out what it means

BMJ 2008; 337 doi: (Published 03 July 2008) Cite this as: BMJ 2008;337:a672
  1. Iona Heath, general practitioner, London
  1. iona.heath{at}

    What reasons underlie the terrifying increase in killings by some children and young adults in Britain?

    “All I’m asking is for a little respect” sang Otis Redding in 1965 and Aretha Franklin two years later with her magnificent cover version. Respect is crucial to human dignity and is central to both the understanding and the mitigation of health inequalities. In the UK at the beginning of the 21st century, the prefix from disrespect has become a powerfully insulting verb. Children and young adults, born into families and homes that are offered scant regard by the rest of society, are killing others at a terrible rate and often in revenge for a perceived lack of respect. The activity of dissing has come to encapsulate the marginalisation of young people deprived of richer opportunity.

    The evidence that poverty undermines health is now overwhelming, and the task for every member of any society worthy of the name is to transform that knowledge into some form of redress. Each of the dimensions of poverty—low income, inadequate education, unemployment, poor housing, social isolation, and even the carrying of knives—have a common core, which is the attrition of hope, opportunity, dignity, and respect. All four are intimately related, and the erosion of one damages each of the others.

    It seems increasingly likely that the hopelessness of poverty undermines health through the destruction of an individual’s sense of agency and so of being even partially in control of their own destiny. Poverty affects health not only through the direct effects of lower absolute material standards of, for example, nutrition, housing, and heating, but also through chronic psychosocial strain caused by increased exposure to violence and chronic emotional stress, and to the compensatory behavioural risks such as smoking, drinking, and drug misuse. Evidence indicates that it is the psychosocial effects of social status, both positive and negative, that explain the larger part of health inequalities in affluent countries. The stress associated with low social status produces physiological change, including higher blood pressure, increased secretion of cortisol, suppressed immune function, central obesity, and adverse serum lipid ratios. By these means we can begin to understand how poverty, by eroding control and agency and by producing insecurity and loss of self esteem, creates chronic psychosocial stress and, through the associated physiological changes, comes to be transformed into disease.

    The challenge of attempting to reverse this process is daunting, but it seems clear that the earlier in this sequence we can intervene the more likely we are to be effective. A primary task of frontline healthcare workers becomes one of trying to locate and foster hope, opportunity, dignity, and respect within the patient’s life story and its context. Recognition, advocacy, and signposting are key roles for general practice—but too often there seems to be no one to advocate to and nowhere for people to go. Too many interventions are stigmatising and demeaning, and there seems always to be insufficient recognition of the enormous reserves of courage and resilience and survival skill hidden within the bald statistics of health inequalities.

    If health professionals are to contribute in any substantive way to the redress of health inequalities, it will be necessary to recognise that organisational change and epidemiological evidence are necessary but not sufficient. A different and much broader approach is required, accommodating not only the importance of genuine respect and dignity but also a commitment to the more equitable distribution of hope and opportunity and the money that underpins them. The government seems to want to deliver respect in the form of choice, but there is neither respect nor much hope in a version of choice that seeks to combine promotional window dressing and ideologically driven manipulation in the commercial interests of privatisation.

    Health service professionals find themselves being held responsible for health inequalities, and indeed the existence of health inequalities was presented as the justification for the Darzi proposals for London. However, health inequalities cannot be detached from their social and economic equivalents, and when politicians allow these to continue to widen while expecting the health service to contain and even reverse the inevitable health consequences it becomes deeply demoralising not only for those whose health suffers on the losing side of inequality but also for those in the frontline of clinical care, particularly in deprived areas. There is a desperate need to distribute health services resources according to need, but this does not fit with the contemporary rhetoric of choice. Poorer people have more illness and more disease, and they need commensurately more access—not less as now; not even the same—to the services of doctors, nurses, and other healthcare professionals. This is the choice that poorer people do not have.

    Why is Julian Tudor Hart’s inverse care law so pervasive even within the NHS, and why are the greater needs for health care in some areas not more accurately reflected in more intensive and focused health care provision? Is the apparent political commitment mere rhetoric? Are more affluent citizens simply not prepared to invest in services for those who are less fortunate? Are we stuck with Nabokov’s polarity of “fatal poverty and fatalistic wealth”?

    Lord Darzi and most politicians and policy makers seem to believe that health inequalities can be reversed simply by organisational change within the NHS, underpinned by condescension and exhortation. They need to listen to more soul music. It seems clear that Otis and Aretha know more about inequality than any of them. Respect means facing the reality and the effects of inequality and injustice, both within society as a whole and within the health service, rather than believing that they can simply be managed away.


    Cite this as: BMJ 2008;337:a672

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