It’ll take a lot more than a nudge to improve the nation’s health

New research in Birmingham provides yet more evidence that broader investment in communities is the only way to tackle health inequalities, say Peter Patel and Ranjit Sondhi

There is now a large body of evidence showing that inequality is bad for us. More equal societies are healthier, more cohesive, have less crime, better educational attainment, and more efficient economies.

So the eradication of inequality and poverty benefits us all. Greater inequality is also the unmentioned key ingredient in improving happiness and wellbeing, which prime minister David Cameron has pledged to measure via his General Wellbeing Index.

Therefore, predicted widening inequality in the ‘age of austerity’ can only depress the prime minister’s index. Spending cuts in local services, welfare, social housing and area regeneration, which make major contributions to keeping inequalities and poverty at bay, have potentially catastrophic effects for disadvantaged communities.

HCI analysis

The Human City Institute report found neighbourhoods with the lowest life expectancy often had people living in poor and overcrowded housing

Take the case of health inequalities; research by Birmingham’s Human City Institute (HCI) – Unequal Lives: Mapping Health Inequalities in Birmingham’s Asian Communities – shows they are already wide. The gap in life expectancy between inner city areas and the more affluent suburbs can be ten years.

Neighbourhoods with the lowest life expectancies have concentrations of poor and overcrowded housing, escalating fuel poverty, and intense population densities, as well as poorer air quality, rundown local environments and variable access to services.

Overcrowding in inner city neighbourhoods, for example, ranges from 20-30% but is only 2-5% in the leafy suburbs. In these communities, fuel poverty afflicts the majority of households with dampness problems indicated by one third.

Air quality can be three or four times worse. And economic deprivation is shown by the concentration of welfare benefit dependency, low incomes and stalled life chances.

HCI’s research shows that in Birmingham, Asian communities experience high levels of morbidity and are more prone to coronary heart disease, stroke and diabetes, which although associated with lifestyle, especially diet, are also diseases of the poor; a bad diet often flows from low income and reduced opportunities to buy more healthy, and usually, expensive food.

It is no coincidence that we use the word ‘poorly’ when we mean ‘ill’. Being poor kills; it shortens life, heightens morbidity and reduces quality of life. Where we are born is still the major indicator of our health and life chances.

While we welcome the coalition government’s new emphasis on public health as a local government concern and the creation of a Health Inclusion Board to tackle inequalities in the most disadvantaged areas, without greater investment in housing and communities and measures to improve the lot of the most disadvantaged, efforts may be in vain.

The emphasis on ‘nudging’ the population into healthier lifestyles may have an impact, but as with the General Wellbeing approach mentioned earlier, a failure to recognise the corrosive effects of inequality will limit the approach, as the Acheson and Marmot reviews of health inequalities pointed out. This has recently been reinforced by a report from the National Audit Office which estimated the effects of the social determinants of health as significant.

The current pressure on public finances does not have to increase inequality. But first we must acknowledge that inequality persists in how we organise our society and economy.

A more progressive tax system, slower deficit reduction, greater emphasis on pursuing tax evaders rather than benefit claimants, better life opportunities for the disadvantaged and building a more balanced and sustainable economy should be the macro-strategy.

Locally, we need to improve housing conditions, community facilities, access to education, training and employment and invest in people.

  • Peter Patel is president of the Human City Institute (HCI) and Ranjit Sondhi is chair of the Heart of Birmingham Primary Care Trust and is a Tenant Services Authority board member. Unequal Lives: Mapping Health Inequalities in Birmingham’s Asian Communities, by the HCI’s research and development director Kevin Gulliver and Peter Patel, The government’s public health white paper, Healthy Lives, Healthy People, published in November can be found at


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