Crocodile tears for health inequality
BMJ 2010; 340 doi: https://doi.org/10.1136/bmj.c2970 (Published 08 June 2010) Cite this as: BMJ 2010;340:c2970
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I always make a beeline to Dr Heath’s column for its insight and my
enjoyment. This week, I found a couple of serious misunderstandings. For
sure, taxation is more distributive in Sweden, inequalities are less and
health is better. It is also colder, snowier and reindeer are more
prevalent. Let’s just be careful about cause and effect. The reason the
tax system is different in Sweden than in the UK, when both are
democracies, must have something to do with public opinion. Groucho Marx
may have said: “Those are my principles, and if you don't like them...
well, I have others”, but marketing professionals will attest to the fact
that brand loyalty is difficult to shake.
Is it a wonder that the politically neutral descendents of
woodcutters in the northern forest will have a more collective world view
than the conglomeration of waves of immigration since before Roman times
who have fought in two World Wars and a host of conflicts around the
world? They vote differently, pay tax differently, look after themselves
differently and look after the rest of society differently. And, given all
that, if Dr Heath really wants to make the tax system fairer to the poor,
by what means does she wish to impose this venture, when the British
public will vote against it?
Democracy is almost certainly better than the alternative, but it
does throw up problems. Israel and Gaza both have democratically elected
governments. The reason that these governments take a hard view towards
each other is that their electorates are terrified. This is not to say
that I agree with Israeli policy in Gaza, any more than I agree with
Hammas sending rockets into Israeli settlements. To describe Israel as
“murderous” shows a superficial understanding that is way beneath the
likes of the author. Let us pursue the argument. If Israel is murderous
and Israel is a democracy, then the Israeli electorate is collectively
murderous. And murder is a crime that should be punished, should it not?
And the punishment is normally life imprisonment (or worse). For 7.5
million people?
No, Israel’s behaviour in Gaza is really bad, and I would like to see
better from a nation that has suffered so much itself. And the extremists
in Gaza are their own population’s worst enemy, and that also saddens me.
But the bottom line is that these are democracies. If we really want to
help, shouting to one side or the other that they are murderers is not
what is needed. All the more so, dare I say it, by someone who looks so
gentle and considerate.
Competing interests:
I pay tax in the UK and I have family in Israel.
Competing interests: No competing interests
I note Dr Heath attributes the difference in under 5 mortality in
Gaza (28/1000)
and Israel(5/1000) to Israel's blockade.
Israel is not blockading Saudi Arabia (one of the world's richest
countries
21/1000) Lebanon (25/1000) Iran (35.5/1000) and is at peace and engages in
medical cooperation with Jordan (21.8/1000)
Perhaps there is another reason..
Perhaps it relates to the ability to create a flourishing economy, a well
organised
and well resourced health service (in spite of not having the oil wealth
of Iran or
Saudi) and a determination to try and minimise the health inequality
within its
society. After all Israelis benefit from an excellent health service, high
health
indices and low infant mortality whether they are Jews Arabs, Bedouin,
Christians or Druze. A visit to the Hadassah hospital in Jerusalem
highlighted the
resources spend in recruiting community workers to ensure that the more
deprived Arab sectors of society are able to benefit from the high
standards of
medical care that the country aspires to for all its citizens
Competing interests:
None declared
Competing interests: No competing interests
I remember Professor James McCormick, another wise and humane doctor,
saying during his address to my Paradox of Progress session at the 1994
RCGP Spring Meeting in Portsmouth, "Poor people don't need health
initiatives, they need more money!".
Competing interests:
None declared
Competing interests: No competing interests
Until that far off day arrives when equality reigns in UK (and it
never was anywhere near, even during the 70's,regardless of the size of
the equality gap itself, re Sebastian Kraemer's letter ) let's get a lot
more real than promoting higher taxes for those in the health politics
business. Ever since the days of Hannah Moore and the Victorian flaneurs'
investigations the well off have found it interesting to subject 'the
poor' the 'vulnerable' to their inescapable gaze and the control of their
unequal position. However there are thankfully differences now in that
people can more speak out for themselves as collectives such as senior
citizens groups, trade unions, those with shared medical conditions.
Rather than advocate a proposal which is very unlikely to be taken up by
enough wealthy people to make a difference, individuals and groups of
medics with shared ideals could voluntarily,anonymously even,contribute
funds to campaigning groups which can make more impact by using their own
voice and insider experience. This of course would remove the power of
being in control. Perhaps the majority of the people being targeted by the
way are totally unable to contribute to the debates in the BMJ, this in
itself is an unacceptable equality gap.
Competing interests:
None declared
Competing interests: No competing interests
Dr. Heath makes the mistake of trying to tamper with
imperfect measures of social inequality in order to
'improve' health inequalities. By all means, go for more
progressive tax, but let's do it for the right reasons.
Most people who suffer from avoidable poor health or poor
access to healthcare do not pay much tax at all - if
anything they are probably on benefits, so have 'negative
taxation'. A more progressive tax regime would make
virtually no difference to their health or healthcare - even
if it were to bring our statistics into line with Sweden.
Dr. Heath is perfectly correct to note that there is little
that healthcare providers can do about health inequalities
as so much is to do with lifestyle, education, and
employment. It is noticeable that, where once cigarette
smoking was an affectation of the rich, it is now an
affliction of the poor, poorly educated, or young enough to
indulge in high-risk pursuits. Ditto lottery tickets.
If we want to change social inequality (and hence health
inequalities) then it has to be by improving the lot of
those at the bottom of the heap, not just batting at those
who are better off. I have no wonder solution to this.
Taxing the rich and giving to the poor sounds good, but
doesn't seem to make things much better for the poor.
Equally, not sure that giving millions in bonuses to bankers
makes them any happier either. Happy to hear of evidence to
the contrary on either point.
Competing interests:
None declared
Competing interests: No competing interests
Inequality is the scourge of the new millennium. In the 1970s - when
the
music was raucous and hair too long, and the decade ended with corpses and
rubbish uncollected - we had in fact the most equal society in our
history,
and were one of the most equal in Europe. The gap between richest and
poorest has since then risen, mostly under Thatcher, until it is back
where it
was before the NHS was founded, and before we'd all been brought together
by a just war against a terrible enemy. Labour stalled the rise, but never
reversed it. Wilkinson and Pickett (2010, see also www.equalitytrust.org)
show
just how poisonous inequality is in all areas of our lives; health,
education,
crime, and ordinary neighbourliness. We are now one of the most unequal
countries in Europe.
Where from the Labour leadership hustings is the call for progressive
taxation
(and, for good measure, land value tax, first proposed by radical Liberals
in
1909)? A socialism that dare not speak its name will fail.
I hope Dr Heath has started a vigorous debate amongst readers of the
bmj, so
that we can indeed use our "powerful voice" ('Doctors are key to closing
UK
health inequalities gap', bmj 2010; 340:c3060) to promote public health
and
wellbeing in the UK. The majority of these readers should be voting to pay
more tax.
Wilkinson R & PIckett K (2010) The Spirit Level: Why Equality is
Better for
Everyone. London: Penguin
Competing interests:
None declared
Competing interests: No competing interests
BMJ and international politics
The BMJ should not be used for personal opinions on International
politics. There are many other newspapers and
journals to let off political steam.
GP Dr.IONA CAROLINE HEATH BChir(Camb.1974) MB(Camb. 1975)
does not give references for her data.
A quick Google search of the 2006 UN World Population Prospects shows
that ISRAEL Under 5y Infant mortality was 5.7 per 1000 live births:NOT
6,which happens to be the UK figure. The Netherlands - 5.9 and Denmark -
5.8.
Having visited ISRAEL over a dozen times,the geographically Middle-
East country is completely WESTERN in style,habits and HYGIENE. Tel Aviv
is "Oxford St by the`Sea". Sun bathers in UK-style swimsuits getting lots
of calciferol producing UV. (GAZA now has private luxury beaches with
waiter service.)
Could not find figures for Gaza. However nearby EGYPT has a mortality
rate of 33.8 so that the GAZA`figure of 28,according to Dr. Heath, is an
improvement. GAZA`also has a better record than MOROCCO at 36.3, IRAN at
35.5 and ALGERIA at 33.2.
Competing interests:
None declared
Competing interests: No competing interests