When the pensions industry starts to make unanticipated profits, because it’s customers are dying earlier than predicted, you can rest assured they are pleased (financially!) but the last paragraph is worth repeating: ” A stalling or reversal of long term improvements in health and increases in health inequalities are of great concern to anyone who cares about health. They should also be a concern to anyone who cares about the society in which we live. Worsening inequalities in social conditions, worsening child poverty, cuts to services and, indeed, voting for Brexit or Trump, will all continue to make society worse. Health inequalities are telling us something fundamental about our society. And we must listen.“ see some of the headlines below.. These allude to some diseases on the rise, some with need for expensive screening and / or genetic treatments, and lack of access to primary care (those who find they cannot get through never seem to use the post for non-emergency care) especially for children. As an aside, most of the litigation and the sexual misconduct applies to doctors from overseas. There’s a message here: stop rationing the training of doctors in the UK: go for overcapacity..
Something is going badly wrong with society in the UK and the US. Is it linked to Brexit and Trump? Of course, but they are the consequence not the cause of problem—although they are wreaking their own havoc. A simple summary measure of the success of a society is its health: life expectancy has fallen in the US for three years in a row,1 and in the UK it has stalled since around 2011.2
When attention was first drawn to the slowing of life expectancy gains in England,34 concern was raised that it was not “real”—perhaps a severe winter was causing a short term fluctuation. That speculation is given the lie by the latest publication from the Office for National Statistics showing that life expectancy has stopped increasing in England and marginally declined between 2015 and 2017 among men and women in Scotland and Wales and among men in Northern Ireland.2 The pensions industry is in no doubt that the slowdown is real—it is making unanticipated profits—and the Institute of Actuaries has downgraded its core projection of cohort life expectancy at age 65.5
As a further indicator of societal ills, health inequalities are increasing in both the UK and the US. In women particularly, life expectancy has fallen in the most deprived areas of England—the more deprived the area, the steeper the decline.6 Inequalities in health derive from inequalities in society.7
Deaths of despair
Initially, the slowing of life expectancy in the UK seemed to come from a rise in mortality in older men and women. The US experience, by contrast, was marked by a rise in mortality in middle aged, non-Hispanic white men and women. The big contributors were deaths from unintentional poisonings, opioids, suicide, and alcohol. In case there was any doubt that this rise in mortality reflected important social trends, leading economists Case and Deaton labelled these as “deaths of despair.” 8 Mortality has also been rising among American Indians and Alaskan Natives and is now rising in African Americans—populations that already had higher mortality rates than white Americans.9
The UK may now be heading in the US direction. Deaths of despair are increasing, albeit on a smaller scale than in the US.15
These trends combined have led to a rise in mortality in young and middle aged adults.10 Alongside other rich countries, the UK rejoices in an infant mortality of three to four deaths per thousand live births. Even here, there is a worrying trend: between 2015 and 2016, infant mortality increased to nearly six per thousand deaths in the most deprived neighbourhoods, compared with a stable rate in the most affluent 10%.11
It is important not only to document these trends but to understand the underlying causes and to do something about them. In the US, deaths of despair follow the social gradient—the shorter the duration of education, the higher the rate. Case and Deaton speculate that cumulative disadvantage exacts a heavier toll on less educated people, with deteriorating job prospects, stalling incomes, social isolation, and relationship breakdown all contributing.
Effect of politics
In the UK, the fact that the break in the long term rise in life expectancy began in 2011 and has been accompanied by an increase in health inequalities must lead to serious questions about whether the government elected in 2010, with its flagship austerity policies, made a difference for the worse. It is difficult to answer such questions with precision, particularly since health inequalities arise over a lifetime of cumulative disadvantage.
Barr and colleagues entered this tricky domain with an evaluation of a government strategy to reduce health inequalities, implemented between 1997 and 2010.12 They examined the gap in life expectancy between the poorest 20% of areas in England and the rest and found that inequalities in life expectancy were increasing before the strategy, diminished during the strategy, and increased again when a new government came in with different policies. These researchers reached similar conclusions about infant mortality.13 Their results chime with analyses from the US of the long term downward trend in infant mortality from 1965 to 2010. When a Republican was in the White House the downward trend slowed a little; when it was a Democrat, the trend was a little faster.14
A stalling or reversal of long term improvements in health and increases in health inequalities are of great concern to anyone who cares about health. They should also be a concern to anyone who cares about the society in which we live. Worsening inequalities in social conditions, worsening child poverty, cuts to services and, indeed, voting for Brexit or Trump, will all continue to make society worse. Health inequalities are telling us something fundamental about our society. And we must listen.