Place and health

1. Place and health Social Mobility and Life Chances ForumHM Treasury, Monday 14th November 2005 Dr Richard Mitchell The Research Unit in Health, Behaviour and Change is funded by the Chief Scientist Office of The Scottish Executive Health Department (SEHD). The opinions expressed in this workshop are those of the author(s) not of SEHD

2. Source: ONS, 2004. Maps by Ben Wheeler

3. Limiting long-term illness rates in London (NB all age, not standardised)

4. The Govt.’s target on area inequalities • “Starting with local authorities, by 2010 to reduce by at least 10% the gap between the areas with the worst health and deprivation indicators (the spearhead group) and the population as a whole” • “The latest data for 2001–03 indicate that since the baseline (1997–99), the relative gap in life expectancy between England as a whole and the fifth of local authorities with the lowest life expectancy has increased for both males (2%) and females (5%) (continuing a long-standing trend)” Tackling Health Inequalities: Status Report on the Programme for Action, DoH 2005

5. Why might health vary by area? • Three steps to thinking about why geographical inequality happens • 1. Areas are collections of individuals • Individuals have higher and lower risks of poor health depending on their circumstances, behaviour etc. and lots of ‘unhealthy’ individuals in an area = an unhealthy area • 2. BUT an individual’s health-related characteristics and behaviour may well depend on what kind of area they live in and how the interact in it (area ≠ place) • Are there well paid jobs? Is there a smoking culture? What are the social norms? • As individuals, we are all products of our familial, social, and spatial environment (ask yourself why you do, what you do)

6. Why might health vary by area? • 3. Some features of an area might influence health over and above individual characteristics • Pollution, climate, crime, social or health services, violence, social capital etc. • You can be a rich, marathon running, vegan (especially if your friends or family are, or at least don’t mind you being one…), but still get poisoned by air pollution or run over by a joy rider • There are statistical techniques for detecting the balance between ‘individual’ and ‘area’ characteristics in determining health • The consensus is that individual characteristics dominate (90%) • We are rather better at thinking about the relationships between area and health than we are at quantifying them

7. What drives area inequality? • Wealth is far and away the strongest modifiable indicator and manipulator of population health • I’m using wealth as a catch all for money in the bank, economic security etc. • Around 10-15% of variation in mortality between parliamentary constituencies can be ‘accounted for’ by the social class and employment status of resident individuals, (Mitchell, R. Dorling, D., Shaw, M (2000) ) • But N.B. there are many more poor people in non-poor areas, than there are in poor areas.

8. Wealth ↔ Health Mortality rate (45-59 yrs,1996-2001) and economic adversity (1991) in parliamentary constituencies Mortality rate Economic adversity

9. Correlation Or Causation? • Is poverty just correlated with poor health, rather than being a cause? • Longitudinal evidence shows that it is a causal relationship • There are ‘direct’ and ‘indirect’ mechanisms • Too poor to keep warm / lack of control over life is stressful / smoking makes sense if you’re poor • The neighbourhood is an important component in understanding poverty • Brings together individual poverty (folk without money) and environmental disadvantage (opportunities or resources are missing, or folk are unable / less able to take advantage of them) • Can be mutually reinforcing (that ‘place’ thing again)

10. Notions of resilience • Poverty is not always a direct early-death sentence • There are parts of the UK which have all the ingredients for a terrible health record (i.e. long term economic decline) but which have relatively good health • We call these areas ‘resilient’ • We have found some, now we’re trying to explain why they are like that • http://www.ucl.ac.uk/capabilityandresilience/

11. Questions • Area inequalities are, in many ways, the spatial manifestation of social inequalities. • Poorer residents = poorer neighbourhood = poorer health • Are these inequalities inevitable? • Are these inequalities acceptable? • What is an acceptable level of ‘difference’ area to area? • Can area-based policies really ever be effective, or is it better to tackle things at an individual level? • How do we break the intergenerational ‘inheritance’ of neighbourhood-based poverty and adversity?

12. Further information • Richard.Mitchell@ed.ac.uk • Tackling Health Inequalities: Status Report on the Programme for Action, DoH 2005 • Shaw M, Davey Smith G, Dorling D. Health inequalities and New Labour: how the promises compare with real progress. BMJ 2005;330:1016-1021 • Mitchell, R. Dorling, D., Shaw, M (2000) Inequalities in Life and Death: What If Britain Were More Equal? Report for the Joseph Rowntree Foundation, JRF; London, • Wheeler B, Shaw M, Mitchell R, Dorling D. Life in Britain: Using millennial Census data to understand poverty, inequality and place. JRF / The Policy Press; Bristol • http://www.shef.ac.uk/sasi/research/life_in_britain.htm • http://www.ucl.ac.uk/capabilityandresilience/