Health inequalities past, present and future

This lecture was recorded on Tuesday, 13 February 2024 at the Whitworth and marked the launch of the Talk 200 lecture and podcast series.

Professor Sir Chris Whitty, Chief Medical Officer for England, the UK government’s Chief Medical Adviser, and head of the public health profession, discusses how as a society we face the hard truth that the more socio-economically disadvantaged someone is, the higher their risk of poor health. The world’s greatest killer is not any one individual disease, but the unequal way in which people are born, grow, live, work and age.

In Greater Manchester, our unique health and social care ecosystem means we can rapidly drive innovation and translate breakthroughs into real-world solutions – which can be scaled-up and replicated across the globe. We have the opportunity to create real and lasting change.

The event also included a question-and-answer session with members of the audience and those joining online, as well as a panel discussion led by the University’s then President and Vice-Chancellor Professor Dame Nancy Rothwell and including Professor of Nursing Dame Nicky Cullum and Jane Pilkington, Director of Population Health NHS Greater Manchester Integrated Care Partnership.

• Find out more about how The University of Manchester is addressing health inequalities – creating fairer healthcare systems and healthier lifestyles.

It's a great honour to be here, and when the President invited me to discuss inequalities, I was very keen to do so because this really is what drives a huge amount of public health.  

I'd like just to start off, because this is a global university, with one slide about the global situation because I think it is stark, and it makes the point very clearly. This is a famous update of a famous slide. Every country in the world is lined up with its income on the bottom axis and the lifespan / life expectancy on the left axis.

Two things really worth highlighting with this, and then one additional encouraging point...

The first is that the line is extremely predictable. Poverty drives poor health outcomes in every country in the world. But, more positively, the great majority of countries in the world not actively at war are moving steadily from the bottom left of this graph to the top right, and the graph scale is not clear on this, but it starts at around 50.

At the point this University started, the lifespan in this city was in the 20s and when the NHS was formed, the lifespan in the UK was roughly where it is in most countries in Africa today.

So, things have improved in every part of the world, but there is a very long way to go.

Now I'm now going to move over to the UK, and specifically England, and again this map I think tells a story that does not need laying out too heavily. The darker on the right the colour, the greater the level of deprivation, this is The Ten Deciles of Deprivation, and on the left, is under 75 mortality in the country. Those maps are essentially identical.  

Poverty and deprivation drives premature mortality with extraordinary predictability.

Now this is true in whichever kinds of infection or non-communicable disease you look at for different reasons, but I also want to highlight another reality of this. And on the left here, I’ve put a map of child mortality under five in the 1850s, and on the right, a map of Covid in its initial period in the UK in this century.

And I think two things, there's a good point and there's a bad point. The good point is child mortality, of course, has massively improved over that time, but the bad point is the areas of deprivation, where premature mortality occurs, are incredibly deep-rooted and have remained the same in this country in many areas, including around Manchester. So, this is something which I think we have to tackle as a matter of national priority.

Some of the reasons for this are relatively easy to explain, and, with will and determination, possible to tackle.

I'm of course going to highlight smoking.

And I’m delighted that the government is aiming for a smoke-free generation. People being addicted to smoking in their childhood, and then suffering for the rest of their lives, something they do not wish to do, a great majority of smokers wish they'd never started and are forced to carry on by addiction, is one of the most appalling situations that leads to avoidable mortality in this country.

On the left, we have deaths from respiratory diseases, particularly chronic obstructive pulmonary disease, but others, and on the right, lung cancer deaths. Smoking drives a very large proportion of the difference that we see here. So, this is a relatively straightforward relationship because the companies that promote smoking essentially do so among the most vulnerable.

But there are also more complex relationships. This, for example, is on the right, liver cancer in the UK. And people often, rather I think simplistically, say well, that's because there's more drinking in people who are living in more deprived socioeconomic areas. That is not true.

In fact, the amount of alcohol and the number of people drinking it is higher in some of the higher socioeconomic groups, but the patterns of drinking are more harmful, so this is a bit more complicated.

The more granular you look at the data for all of these diseases, the starker the differences become, and this has two implications. The negative one is we have an enormous gradient when you look at a granular level between the wealthiest and the least wealthy parts of our society. But on the positive side, from the point of view of what we can do, this tells us where we should go.

There is a very clear concentration of poverty and deprivation related in illness and disability and short lives, and those are the areas we should be concentrating much of our effort.

And this is true at however micro level you go. This is a classic presentation, in this case of Manchester. You can do this for almost any city in the world where there is a ten-year gap in very short distances between more deprived and less deprived parts of the city. And the same would be true in London, Glasgow, or indeed Paris and New York.

Now, the reason the deprivation drives this premature mortality is multifactorial.

Some of the factors are relatively clear, straightforward, and should be addressed through public health. Many of them are much more complex and based on issues around diet, housing, working environment, education, for example education is highly protective against dementia and many other conditions, smoking, as we talked about.

But also importantly, there is something called the inverse care law. Those who need most medical help tend to be those who get it least. And this is a very important mission of the University, in training doctors, nurses, and other health professions, to ensure that we have people to serve those who are in the greatest need.

So, that's one huge driver of inequalities in this country but I want to highlight another one which I think is less discussed.

And that is age. 

And here the maps are very different. In fact, they are to some degree almost mirror images of one another in parts of the country. In the dark blue are the percentage of the population who will be over 75 years old and, as you can see, this is because of the pattern of migration internally in the UK, going to be very heavily in rural, semi-rural and coastal areas. And that is because the pattern of migration in the UK is generally for people to move into cities and towns in their late teens, or early 20s, and to move out typically after two children.

So, this pattern means that the ageing of society is happening in the periphery and the cities are remaining forever young.

And you can see that very clearly in these demographic pyramids on the left, where Manchester, on the left, because of its student population, in large part to which this University contributes, has a very young demographic. But the equation has to balance. And therefore, other parts of the country are ageing extremely rapidly.

And this is leading to a vision of certain forms of disease. So, diseases of young age are concentrating in the cities. I have picked out sexually transmitted infections, I could have chosen many others, this is a disease of youth, by large, not exclusively obviously, and on the right, I've picked out dementia, a disease principally of older age. These are in completely different parts of the country, driven by different risk factors.

So, this separation of diseases, which is actually accelerating or at least progressing very rapidly now, is going to present us with very different problems in the future to those that we face today.

And, of course, most diseases are a combination in terms of their risk factors of age and deprivation.

So, here's coronary heart disease and the two things that drive it are age and deprivation. So coronary heart disease rates are high where there is both age and deprivation around the coastal strip for example, or in any place where there is either a high level of older people or a high level of people living in deprivation. What's spared are the areas of the country that are both affluent and young.

If you superimpose most universities onto that map… I don't need to complete the sentence.

And the same is true for mental health.

For complex reasons, different parts of the lifespan, but obviously a growing concern, already a very major area where our research has been less effective than in some of our other areas of work.

When we look at individual diseases, and I will come on to my views about what we should do next but I'd wanted just to finish describing the issues, some, let's just take cancers, and I've chosen cancers because Manchester University has put…, has over many years contributed so much to our understanding of both epidemiology and the treatment of cancers. Some cancers are very heavily associated with deprivation – obviously lung cancer, head and neck cancer, liver cancer at the top on the left there for men, on the right for women lung, again, stomach cancers, vaginal cancers.

These are very strongly predicated on poverty.

And smoking plays a very major part as I'll come on to.

But many of the cancers have very little gradient. So they will not be driven by deprivation but they will be driven by age, because almost all cancers, not all, are very strongly age-related, so they will go in different directions in different parts of the country.  

And to make this in a sense slightly even more concerning, what I have here this is unpublished data by the Cancer Research UK, who kindly allowed me to show it. On the left-hand of each of these bars, these are all major cancers, is where the ten-year cancer survival was in the 1970s, and on the right is where they are now.

There have been some stunning improvements.

Melanoma, breast cancer, prostate cancer, Hodgkin's lymphoma, these have improved in terms of their survivals immeasurably compared to, measurably but very highly, compared to where they were some decades ago.

At the bottom, however we have a group of cancers, oesophageal cancer, lung cancer, pancreatic cancer and these are the ones in which there is a major socioeconomic gradient, so what we have been doing, and this is not deliberate but it is a reality, is making substantial progress in those cancers where deprivation is not a major driver and making much less progress in those cancers where deprivation is a major driver.

And that is just a reality, that's a fact. You can see on the numbers, not for want of trying, but that is a reality.

And once you then put together large numbers of diseases, you then see a picture which complicates this further.

Most people actually do not, by the time they get near to the end of their life, have a single disease. They usually have multiple diseases – what's sometimes called multimorbidity.

This unsurprisingly increases with age, so age is a major driver of this, but for anyone under the age of 80, it also is very significantly accelerated by deprivation.  

So people living in deprivation will typically get multimorbidity, multiple diseases in one person, making it much harder for them, their families, and for their health care, up to a decade or more earlier than those living in areas of relative affluence. So, this again, has a very major inequality component both on age and on deprivation.

Finally, before I move on to a slightly more cheery part of my talk, but I did want to lay out the problem really clearly, it is important to acknowledge that whilst many things in child health have improved, we are setting up serious problems for ourselves in the future and the biggest one, I think, to highlight at this point, is people living with overweight and obesity.

And the deprivation gradient on this in children is simply shocking. You can see the data on the left, and where this is found in the UK on the right. These people will live with problems which will cause them longer term issues, cardiovascular issues, diabetes, cancers, mechanical problems, for the rest of their lives. They were set up to fail by the system we have in place, and this is driving obesity in areas of deprivation. So, these are the problems that I think we clearly must, as a society, address.

Now, what should we do about it. Well, I think the first thing to say is, I consider this is a largely soluble problem, if we are very serious about it.

And this is both good and bad news. What this slide shows, and this is possibly the single most important slide I would show here, is that those who live in the most deprived areas live for shorter periods, but they also live for a much longer absolute number of years in ill health.

Now, what that tells you – that's a bad thing. But what that also tells you is that, if you can shorten the period of ill health, and you should be able to because biologically they're exactly the same people as the people in the bottom, they may live longer but they'll have less time feeling unwell, they'll have less time in the NHS, they'll have more time with their families, indeed, they'll have more time in economic employment, many of these people are becoming unwell early in their working lives in reality.  

So, shrinking this period of illness, what's called, slightly pompously, compressing morbidity, should, in my view, be the central aim of what we should be trying to do in these groups, and I consider this as achievable because what we need to do is delay disease.

If we all live to 150, we would all get cancers, and dementia, and heart disease, and many other things. But we don't. If we can push diseases off to the right, we will shorten the period people live with them and, indeed, if we can push them off to the right beyond the point that someone naturally will die, because we will all die, then they won't have them at all. So, if you were going to die at 80 and you have your dementia at 85, it's never going be a problem. So, pushing disease off to the right will compress morbidity. It will mean people live longer. But it will also improve their lives and, indeed, reduce the amount of work the NHS has to do to support them.

Why do I think that this is a realistic possibility? Well, because if you look and take the long view of medicine, it has had a stunning achievement in dealing with the diseases to which we have put our minds systematically, scientifically, and politically. So, this is the second half, roughly, of Manchester University's existence. In the first half, infectious diseases disappeared very largely from public view. They were still there just at the beginning of this – they're the dotted line at the bottom.

Then we had a substantial increase in cardiovascular disease in this country, driven principally by smoking, but also by air pollution, working environments, and a variety of other factors, dietary and others, that peaked in around the 1950s. We then had a systematic attempt using primary prevention – stop smoking services and campaigns – all the things that reduced air pollution would be examples of that. Secondary prevention, which came a bit later down that path, where we started reducing blood pressure, dealing with high cholesterol and areas of that kind, and curative services, and the improvements we've seen moving from a situation where roughly one in two people in the UK died of heart disease to roughly one in four, which is where we've sort of moved to now. That has been done by a combination of primary prevention, secondary prevention, and curative services. It can be done, just as we achieved it with infection.

And if you look at the extraordinary improvements in infection over the time that this University has been in existence, we've seen the end of cholera, typhoid, diphtheria, tetanus, TB, very largely, and the bacterial diseases. And I'd just like to highlight, on the right, this sad painting by Lowry from 1935, The Fever Van.

The medical officer of health would arrive, a child who had an infectious disease would be taken from their parents, all their belongings will be destroyed, they'd be taken by the state into isolation, and their parents might never see them again. 

Those kinds of pictures are now not seen because medical science has, by combination of prevention and treatment, de-risked those diseases. So I've just taken cardiovascular disease and infection in their contexts.

And in many of these areas these improvements continue. So, this is from 1970 through to just before the Covid pandemic. This is coronary heart disease in younger people. And again, a stunning improvement over that period, where the difference between men and women has significantly reduced because that was largely driven by much higher smoking rates in men, those have come down, sadly rates in women went up, coming down again now. But public health and curative medicine combined have achieved a  great deal. Scientists here, as elsewhere, have contributed to this.

We could, by the single action of stopping smoking, substantially reduce the cancers which are most prevalent in areas of deprivation.

One in five deaths from cancer in this country are due to smoking, maybe going up to one in four. And a fifth of cancer deaths in the UK are due to lung cancer, the overwhelming majority of which is smoking. So, here is something we know what to do, and it is simply a matter of – do we have the political will to do it?

Then, moving on to some of the issues of older age... As I said earlier on, I think that we now need to think very seriously about what we're going to try and do to support people in older age and to improve their health in a realistic way.

And, if you talk to the average person walking up and down Oxford Road, and say to them: “I can give you two years of life in bad health, or one year of life in good health”, the overwhelming majority will say: “I want the one year of healthy life where I can see my family, see my grandchildren, enjoy my, my existence”. Not all, this should be someone's individual choice.  

As a profession, we have in medicine, we have in science, concentrated for a long, long time on trying to improve longevity, and we have achieved that, to a very large degree. On the bottom of these graphs, what you can see is under-75 mortality, it's been falling for a long time, I’ll come to the caveat of that. Over-90 mortality has hardly moved at all now for a long period of time. And that we should not see as a failure, provided those people are living good lives.

Finally, I'd like to finish with a one bit of cheerfulness, and then one bit of moderately uncheerfulness, and then a summary.

This is what has happened to life expectancy in England over the period that this University has existed. I put the arrow where the University began. And I’m not claiming causality, but there is undoubtedly association, and science has done so much, as have the doctors trained and nurses trained in this University, done so much to contribute to this extraordinary turnaround in mortality.

There's a but to that. If you extend the line further to the end, all of Europe, not just the UK, it's often ascribed to an individual country, all of Europe saw an infection point roughly at the time when the big financial hit occurred. That’s not particularly surprising to anyone in public health. We all know that if you increase wealth, you reduce health. You shouldn't be surprised if the opposite is also true. It is true. You can see it on that graph. This is every country in Europe, big country in Europe. But there are two things you should see with this. The red line is the UK. The dark blue line is the rest of Europe. And we have been drifting down the leaderboard for some time, slowly. It's not one particular issue. And then, of course, Covid had a major hit for everybody in the UK, and elsewhere, and we've got to recover also from that.

So, my summary from all of those points: health inequalities due to deprivation and those due to age are both serious. We need different approaches to them and they are diverging geographically. 

It's no longer going to be realistically possible to only go to areas of deprivation. I think we need to think about both.

We should have as a major aim, shrinking the period of ill health. Because if we do that, longevity will follow as night follows day. But the principle point is that people want to live a good and independent life, shrinking period of illness is the key to that. In my view, this is entirely possible if we aim to at least delay disease and start in the areas of deprivation, which you can see extremely easily if you just map them out. And we should have the same self-confidence to do that as the people who addressed infectious diseases and cardiovascular disease in the last century, where they just said: “we're just going to do this”.

Wider social interventions, non-health interventions are, of course, essential. But we, as a profession, need to target primary and secondary prevention. Primary prevention, we do it to everybody before they get disease, secondary prevention as an individual intervention, when people have got particular risk factors.

And finally, turning to Manchester. Manchester has some of the best scientists, one of the largest medical schools, one of the most important areas of training for nursing. And it has also some of the greatest inequalities in the country. If you wanted to start somewhere, you couldn't start in a better place than Manchester. This is a serious thing we want to tackle. And good luck.