In both the developed and developing world poverty is linked to poor health, whether biological, psychological or environmental. Economic disadvantage is a cause of poor health (people are deprived of education, resources, or access to healthcare) and a consequence of poor health (good health is an asset upon which livelihoods depend).
The World Health Organization defines poverty using five core dimensions, which incorporate income and work, health and education, empowerment and rights, status and dignity, and security and risk. However, increasingly the harms associated with poverty are being shown to be proportional to the size of the gap between rich and poor, implying it is socioeconomic inequality which drives health harms rather than poverty itself. In other words, the key determinant is the distribution, not the absolute level, of wealth.
At a fundamental level poor environments are less healthy; the urban poor in developed countries have more fast food outlets, more off licences and less green space than their rich friends. As a consequence, people of lower socioeconomic groups have poorer diets, drink more alcohol and exercise less. But the difference in behaviour between the rich and poor cannot simply be explained by their environments; socioeconomic health gradients are found even where health behaviours are free. People of lower socioeconomic positions use less preventative healthcare services and have stronger beliefs in the influence of chance on their health.
Consider the glass ceiling effect of poverty on intelligence. Among those of favourable opportunities, variation in IQ is almost entirely due to genetic differences, among those of less favourable opportunities, variation is almost entirely due to environmental factors. Whether you are a product of nature or nurture depends on whether you are rich or poor. More profound than that, an individual may be both an expression of nature or nurture at different times of the same year. A study by Mani and colleagues found that Indian farmers showed diminished cognitive performance before harvesting their crops (when poor), compared to after harvest (when rich). Their study implies that poverty itself impairs cognitive function; they argue poverty-related issues consume mental resources leaving less for other functions.
I have spent six years (and counting) working on my PhD which sought to understand why people behave in unhealthy ways despite knowing the risks to their long term health. I tried to quantify and interpret various behaviours in an attempt to make sense of seemingly senseless choices. My results indicated that people from socioeconomically disadvantaged environments behaved in unhealthy ways and that such behaviours might make sense given the trade-offs that people face. If you do not have good opportunities for education, employment or secure housing, behaving in a way to maximise your short term pleasures (whether eating unhealthy food, drinking or smoking) might be your best choice, despite the likely long term costs. Poor people have consistently been found to give greater weighting to present over future outcomes.
In public health we spend a lot of time picking up the pieces. We try to help people who are addicted to drugs, who are dependent on alcohol or cigarettes, and we try to make environments healthier and happier. In my day job, I collect and share accident and emergency department data, a major focus of which is preventing violence, whether directed towards oneself or others. A lot of monitoring work is nuanced and complicated but violence prevention work can often be reduced to a simple trend – violence is associated with, and predicted by, poverty. The intervention needs to be here, in this deprived area.
Thankfully violence in the UK is on the decrease but that doesn’t mean the inequality gap is reducing. The number of households that fall below the minimum standard of living has risen from 14% to 33% in the last 30 years, 18 million people currently cannot afford adequate housing, 1.5 million children live in households that cannot afford to heat their homes, half a million children live in families where their parents cannot afford to feed them, those who are poor are typically multiply deprived, and almost half of the working poor work 40 hours a week, meaning full time wages are too low to support families. All the while, the wealth of the richest continues to explode.
While health is high on global and national agendas, it seems very unlikely that we can improve population health without addressing widening inequalities. The key to initiating change is perhaps to inspire others that change is possible, that the status quo does not need to be accepted and that power can be wrestled from the hands of the few and into the hands of the many. This blog was written as we approach a general election in the UK, and at a time when over one million adults are not registered to vote and 34% of those registered did not vote in 2015. I have not written this blog with the election in mind but it seems like an opportune time to consider the health consequences of policies which lead to widening inequalities.