For healthcare professionals only

Views And Reviews No Holds Barred

Margaret McCartney: Health inequality has to be political

BMJ 2017; 357 doi: (Published 20 June 2017) Cite this as: BMJ 2017;357:j2978
  1. Margaret McCartney, general practitioner
  1. Glasgow
  1. margaret{at}

The horrific fire at Grenfell Tower may prove to be a landmark in the national consciousness. Many of our problems are in plain sight. We’re so used to them that they seem unwieldy, just “the way things are.” The tower block that is now a tomb housed many immigrants on whom London depends—working in jobs that mean antisocial hours, hard graft, and low wages.

The social housing was owned by the local council. The residents’ association repeatedly raised concerns about safety in the block. Whatever an inquiry finds, it’s clear that the residents did not feel listened to, and dozens have died.

We know that poor people die younger. In Glasgow, in common with many cities, life expectancy varies markedly among neighbourhoods. Men live for an average of 73.1 years in poorer areas such as Ruchill and Possilpark but an average of 84.3 years in the wealthier Kelvinside.1 This 11 year gap is magnified again by healthy life expectancy, which is lower by about a decade among the poorest citizens.2 But these deaths usually happen quietly, one by one. These individual tragedies, driven by poverty, are invisible, except on spreadsheets and in retrospect.

What are the raw ingredients for health? I once wrote that my best advice was “don’t be poor,” and I meant it. But financial health is seldom in our full control. It’s easier to be lucky in life if less insecurity is in your way. A decent diet, much physical exercise, good housing, and tobacco use are all bound by money.

What are the raw ingredients for health? I once wrote that my best advice was “don’t be poor”

Particularly in London, discomfort seems to be rising at the divide between rich and poor—near in kilometres but miles apart in living conditions. In 2014 an outcry erupted over “poor doors.”3 Some upmarket apartment blocks in London got planning permission only by committing to build affordable housing. Such blocks were designed—but with separate lobbies, mail collection, and entrances, to divide residents in the affordable and luxury flats. The argument was that, by avoiding a concierge and maintenance fees, they were cheaper, but they also allow one groups to be divided from the other. If we learn anything from the epidemiologist Michael Marmot, it’s that the vast majority lose out when inequalities are so marked.4

The government response has been criticised for being slow. Practical assistance—such as giving people ready cash for clothing and accommodation—has taken days, and many have complained of disorganisation on the ground. The local community, meanwhile, immediately responded and has been devoted to helping people in need since. Naturally, people are sharing in the sorrow as they donate money.

Grenfell was a horrendous event that calls into question the agency that ordinary tenants have when asking a complex organisation for change. Ordinary, less dramatic, early deaths occur every day with poverty as the risk factor. Safe housing and life expectancy are what real public health is about—and this stuff needs to be political. Surely we care enough to pay a little more tax to try to fix it.



View Abstract