Dimensions of Inequality in Contemporary Britain - Essay Example

Health Inequality in Britain Introduction In society around the world these is debate about the inequalities in the health and healthcare that we observe among populations and among places. Research seeks to improve understanding of the causes of health variation. Such knowledge should provide evidence about how best to influence the causes of health inequality and produce health gain for human populations (Curtis, 2004, p 1-2). The concept of 'health' is open to differing interpretations. The bio-medical perspective on health focuses on presence or absence of diagnosed diseases, but broader definitions include the idea of health as 'a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity' (Curtis, 2004, p 1-2). The inequalities in the health of the nation (Townsend et al., 1988) have been subject to extensive debate and policy initiatives over a number of years. Many of the 'problems' and needs have been long identified but are still awaiting resolution. As long ago as 1980, the Black Report on inequalities in health reported that: One of the most important dimensions of inequality in contemporary Britain is race. Immigrants to this country from the so-called New Commonwealth, whose ethnic identity is clearly visible in the color of their skin, are known to experience greater difficulty in finding work and adequate housing. Given these disabilities, it is to be expected that they might also record higher than average rates of mortality (Townsend et al., 1988:50). "Health inequalities are the systematic, structural differences in health status between and within social groups within the population. The term "health inequalities" is closely linked to "social determinants of health" (Marmot and Wilkinson 1999) as it refers to the multiple influences upon health status, including socioeconomic status, diet, education, employment, housing, and income. It is thus concerned with the "causes of the causes" of disease. Inequalities in health care do exist (notably in access to care) but these are not considered the principal cause of inequalities in health status (Marmot 1999). The social determinants of health and health inequalities pose particular problems for policymakers. The causes are multifaceted and the solutions must be too. Policies may need to be long-term, require the collaboration of multiple agencies, and generate few outcomes measures initially. Unless policy processes are understood, current and future policies may not achieve their goals. Indeed, some policies such as those that have reduced overall levels of smoking have unwittingly increased socioeconomic inequalities in smoking (Jarvis 1997; Evans 2002). Also, the lack of evidence about effective policies is significant given the policies to tackle health inequalities that have been recently proposed by the U.K. government" (Marmont, Michael, 2003). The Macpherson Report The Macpherson Report (1999) has now given a momentum and legitimacy to action against racism rarely seen in the UK before. It created a clear definition of institutional racism that moved away from blaming and labeling individuals as racist to an understanding that long-standing practices can cause organizations to discriminate unwittingly. This has enabled us to take a new approach to racism, moving away from 'witch-hunting' and attributing racism to particular individuals or groups, towards a search for positive solutions (Dylan Ronald Tomlinson, Winston Trew, 2002). Overt racism from individuals remains a very significant problem in the UK, as suggested by findings of the Fourth National Survey of Ethnic Minorities cited earlier. Just over one quarter of white respondents had a preference for a doctor of their own 'ethnic origin' and while 60 per cent of this group stated that this was because they had difficulty understanding a non-white doctor, and thus, for them, overt racism cannot be assumed to be proven, for the other 40 per cent the reasons given suggest, 'more clearly contained elements of prejudice' (Nazroo, 1997:122-3). It has been estimated that there were 382,000 racist incidents in England and Wales during 1995, but only 12,200 of these incidents were reported to and recorded by police (British Crime Survey and Home Office, cited in Social Exclusion Unit, 2000, para. 2.46). Anti-racism and inequality Anti-racism is more than implementing equal opportunity policies (Dominelli, 1988:136). It requires an understanding and recognition of the processes and expression of racism including the power relationships between black and white people. It seeks to challenge racist assumptions and cultural stereotypes in favor of policies, structures and practices that are sensitive to, and valuing of, cultural differences. Nonetheless, the focus on 'difference' between cultures in anti-racist practice has been criticized for its tendency to homogenize ethnic identities and reify cultural boundaries, as well as to affect, in a similar way identities pertaining to disability and sexuality. In this respect, the efforts in the NHS to link equality with quality, and the increasing emphasis on 'managing diversity' as opposed to managing minority problems, are suggestive of a new organizing theme and language for the pursuit of equal opportunities in public services into the twenty-first century. There are of course a number of dimensions to equal opportunity understood in this broader sense (Dylan Ronald Tomlinson, Winston Trew, 2002, p 82-95). There is clear evidence that BME individuals and groups experience barriers to accessing health care services which may in turn affect their health outcomes. For example, Airey and Evans (1999) reporting a national survey of NHS patients seen in general practice found that: - Almost half of Asian women reported being unable to see a female GP either always or sometimes (c.f. 25 per cent white women and 35 per cent black Caribbean or African women) (p. 192); - Seeing a GP of a person's own ethnic group is most important for those who do not speak English (among Chinese people, 17 per cent of English speakers thought it important, compared with 41 per cent of non-English speakers) (p. 193); - White patients were more likely to say they were seen by their GP soon enough (81 per cent against 63 per cent for ethnic minorities) (p. 106); - 32 per cent of Bangladeshi and 33 per cent of Chinese patients said GP consultation was too short (c.f. 25 per cent white and 21 per cent black Caribbean) (p. 118); and - 19 per cent of minority ethnic patients have wanted to complain in the past months but have not done so (c.f. 11 per cent of white patients) (p. 226). Explanations of Social Inequalities in Health Although social differences in the provision of medical care in the United States are pointed to as an explanation of existing social inequalities in health in that country, in the United Kingdom they are a less likely explanation because of universal access under the National Health Service. One way medical care's contribution to health has been assessed is by separating causes of death into two categories: those thought to be amenable to medical intervention and those thought not to be amenable (i.e., where medical care is judged to make no difference to the mortality rate). In the United Kingdom, the improvement in mortality over time is largely the result of the decline in causes of death judged to be nonamenable to medical care. The improvement in mortality has been greater for higher than for lower social classes because there has been a greater decline in the causes of death among the higher classes (Marmot, Michale G., 1994). Just as medical care plays a limited role in generating social inequalities in health; it also plays a limited role in generating international inequalities in health. For example, Japan, like the United Kingdom, spends a relatively small proportion of its GNP on medical care. Unlike the United Kingdom, however, Japan experienced a decline in mortality for both amenable and nonamenable causes of death (Marmot, Michale G., 1994). A second possible explanation for social inequalities in health is health selection, the idea that health may determine social position rather than the reverse. For example, people with schizophrenia tend to be downwardly mobile. However, there is no evidence to support health selection as an explanation of broader social inequalities in health (Marmot, Michale G., 1994). Health Advocacy involves more than just translation and interpreting; it is also about representing the client's needs and requires a longer-term relationship with the client. Advocacy allows cross-cultural communication which simple language translations do not (for instance, because of different concepts of health and illness). Advocacy for minority ethnic groups works at individual, group and population levels. At the individual level it provides that interpreting for non-English speakers is available, that sources of support are identified, and that help for the interpretation and support is secured from mainstream services. At the group level, it provides for health education, promotion of the use of services (such as, for example, screening and immunization), and that people's awareness of their rights is increased. At the level of population, health advocacy works by means of encouraging services to provide better support to groups within the population and assisting in the planning of health care or health improvement programs (Dylan Ronald Tomlinson, Winston Trew, 2002, p 82-95). Without a strong advocacy voice, and the development of these forms of support, many minority groups get ignored or marginalized by mainstream services (SILKAP, 2000). The training of health workers gives little attention to diversity issues, so the educational role they play is important. However, health advocacy still faces major problems in gaining acceptance in the mainstream because its benefits are not widely accepted (the evidence base remains weak from lack of research). It is also marginal to most organizations' lists of priorities. Advocacy services frequently receive short-term funding, making it hard to develop staff and infrastructure. A King's Fund study of voluntary sector funding from the NHS found that the amounts secured were small and that very little of it was for advocacy work or capacity building (Mocroft et al., 1999).The King's Fund is, at the time of writing (April, 2001) concentrating on developing health advocacy in London, and key areas of interest are: integration of health advocacy into NHS mainstream services; means of developing formal training, regulation and accreditation for health advocacy; and ways of helping voluntary sector organizations that are active in this area to get statutory sector contracts (Dylan Ronald Tomlinson, Winston Trew, 2002, p 82-95). Conclusion Improvements in health have become expected in wealthy countries. But both within and between countries there are substantial inequalities in health that have remained despite overall improvements. In some cases, these inequalities have become even more clearly visible. While universal access to high quality, affordable medical care is a social goal that should have high priority, it alone will not eliminate social inequalities in mortality rates. The fact that inequalities in health are not limited to worse health among the poor but that a gradient runs across society, in combination with the close link between income inequalities and health, indicates that relative deprivation is an important determinant of health inequalities. Such deprivation influences life-style choices and differential access to high quality social environments. Providing more people with fulfilling jobs, adequate compensation, and social environments that foster good relationships may be of crucial importance in reducing inequalities in health. Reference: Airey, C. and Erens, B. (Eds) (1999) National Surveys of NHS Patients: General Practice, 1998, a survey for the NHS Executive, London: Stationery Office. Dominelli, L. 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Social Exclusion Unit (2000) Preventing Social Exclusion, London: Stationery Office. Townsend, P., Davidson, N. and Whitehead, M. (Eds) (1988) Inequalities in Health: The Black Report and the Health Divide, Penguin: Harmondsworth. Read More