by Karim Mitha
A decade ago, Professor Sir Michael Marmot published his landmark review highlighting the stark inequalities in our society. Along with Wilkinson and Pickett’s “The Spirit Level”, the report helped to outline the impact inequalities and other socio-economic factors have on population health, known as the “social determinants of health”. Despite the number of recommendations made, particularly in relation to good and fair employment, healthy places, and improving standard of living, the subsequent decade of austerity did little to make any improvements in tackling these issues. In many cases there has instead been a regression, particularly in relation to housing and employment. The current COVID-19 pandemic has made existing social inequalities in our society achingly visible, and seems likely to compound these divisions further. We already know that certain groups are disproportionately affected by the virus, with BME communities experiencing particular structural and health inequalities including barriers to self-isolation, and the spike in domestic violence in lockdown. As we try to weather this crisis, it seems particularly timely to reflect on the findings of the “The Marmot Review – 10 years on” recently published by the Institute for Health Equity.
“England is faltering”
The report is stark. It portrays a bleak picture of the impact of sustained cuts to social services and how this has exacerbated existing inequalities. The very first words of the report, “England is faltering”, are a call to action – asking how is it that in a high-income country social policies have been implemented to further disadvantage the working class, vulnerable, and marginalised, who experience greater years of life living with disability than those in less deprived backgrounds.
The report acknowledges the debate in the age of austerity regarding prioritising social or economic progress. The Coalition government, from 2010 onwards, used rhetoric of national identity and social solidarity, invoking a nostalgic idea hearkening back to the Second World War of “we are all in this together”, to push through reforms and cuts. This was done under the premise that Britons would band together and accept cuts which were portrayed as necessary to get the economy back on track. Marmot is careful to note it is difficult to establish a direct causal link between these austerity policies and the increase in inequalities over the same period. He does, however, suggest that sustained cuts in health and social care have combined with wider socio-economic factors to jointly reduce individual stability and security, which are important for psychosocial wellbeing. Marmot particularly highlights changes in the employment and housing sectors.
The myth of “we’re all in this together”
Marmot outlines how multiple political and economic factors have combined to contribute to areas, particularly in the North of England, feeling “left-behind” and has helped to compound the experiences within “ignored communities”, where there is little hope for alleviation of poverty or social mobility. The housing crisis, cuts to child and youth centres, and continued disinvestment in particular geographic areas have all played off each other in a negative spiral of disadvantage, further exacerbating and entrenching existing inequalities. The health impacts are severe. Life expectancy overall has stalled and has actually fallen amongst the most deprived. The social gradient of health – where those at the top have the least need – has also worsened. Men living in the 10% most deprived areas will spend 30% of their lives in ill health compared to 15% amongst men living in the 10% least deprived areas. Amongst women, those living in the 10% most deprived areas will spend 34% of their lives in ill health compared to 18% for women living in the 10% least deprived area.
Similar inequalities exist in mental health need. Vulnerable and disadvantaged groups, often concentrated in more deprived areas , tend to be disproportionately represented in mental health service use. The report notes the worrying trend of increased mortality rates amongst middle aged-adults due to “deaths of despair”, deaths due to suicide, alcohol, and/or substance misuse. These can be understood as coping behaviours in response to socio-environmental strain and pressures. Marmot explores ‘avoidable mortality’, defined as deaths which could have been avoided through timely and effective health interventions. Amongst the poorest 10% of English people, deaths of despair are three times higher than amongst those in the richest 10%. This is where examining the influence of wider factors is important as it is often those experiencing the most socio-economic disadvantaged who are particularly susceptible to job insecurity, unemployment, debt, and lack of social support, which are linked with increased suicides.
Overall, the report portrays a bleak picture. Marmot notes that those living in more disadvantaged circumstances have been besieged with substantial changes in many social determinants of health. When people experiencing the greatest socio-economic adversity are socially “written off” and lose a sense of attachment and trust to their local areas , the boundaries of social cohesion are frayed. It is difficult to believe messaging such as “we’re all in this together” when social mobility is increasingly unlikely and already disadvantaged communities feel increasingly marginalised, vulnerable, and forgotten. Given this, it is difficult to not see how these factors have, along with cuts to community and social services, have contributed to higher levels of suffering and despair we can see manifesting as a 'mental health crisis'. It is quite concerning when we see the blanket of the social welfare state fraying – with successive governments failing to understand the long-term and societal implications of policies under austerity.
The politics of poverty and wellbeing
The report critiques the “individualist” agenda - that people’s poor health is a consequence of the choices they make. Marmot notes that being in poverty limits the available choices people can make and thus poor health actually reflects the limited range of choice available, along with the psychological strain and pressures that disadvantage brings (ie: poor quality housing, debt and financial strain, etc). Marmot also notes the impact of cuts to social care and the concomitant increase in youth violence and child and adolescent mental health disorders. Given these factors, it is unsurprising that his recommendations centre on improving children and young people’s environmental living conditions, fairer employment for all, increasing living standards, and creating healthy and sustainable communities.
Marmot also argues that in an era of localisation, it is important for local authorities to embed a social determinants of health perspective into their health and wellbeing strategies, as tackling deprivation can improve health and wellbeing outcomes for all residents. Marmot highlights the “Wellbeing budget and strategy” in New Zealand which looks at wellbeing as an investment for a happier, healthier population.
Marmot views the various social prescribing programmes in England as beneficial. He notes that this approach may help to build those connections and networks, as well as help people to gain confidence and a sense of agency, through being able to be seen as an active citizen. However, he also notes that this may not be able to address some of the underlying and challenging experiences and threats to mental health that those who are the most disadvantaged may be experiencing, and thus social prescribing efforts must be made in conjunction with movement on wider determinants.
Faced with the evidence of what the past decade has dealt onto the most marginalised in society - having the social welfare system and the promise of social mobility pulled away, feeling "left behind", stigmatised, and blamed - it is easy to see the futility of trying to address psychological concerns divorced from socioeconomic context.. Understanding a “whole-systems” approach is essential in being able to address the impacts of heightened neoliberalism and increased inequalities on mental health and wellbeing, particularly for those experiencing multiple forms of disadvantage.
Ultimately, it is clear that a decade under austerity has been detrimental with those most at risk and most vulnerable most affected. If we were to take the approach of countries like New Zealand, and embed wellness into our planning, strategy, and it being an overall aspiring target to achieve, we might be able to overcome these structural factors and facilitate improved physical and mental health and wellbeing of our fellow citizens.
The BMJ has astutely noted that the experience of the COVID-19 pandemic demonstrates the imperative of tackling inequalities and how systemic factors such as structural racism and class inequalities can facilitate susceptibility to disease, which can have global consequences. The pandemic climate has shown us how uniting to tackle inequalities and helping our most vulnerable will actually help improve health outcomes for all. The Marmot review has shown the consequences of failing to do so. In order to address the health of the whole population, it is important to pay particular attention to the most vulnerable and address inequalities. After all, as the proverb goes, “a chain is only as strong as its weakest link”.
Author note: Karim Mitha is a public health professional and a member of PSC. He is completing his part-time PhD in the sociology of mental health at the University of Glasgow.