Danny Dorling

The widening gap. Health inequalities and policy in Britain.

Relentlessly, the wide health gap between different groups of people living in Britain continues to get even wider. This book presents new evidence (which was not available to the governments Independent Inquiry into Inequalities in Health) on the size of the gap, and the extent to which the gap is widening. In particular, new geographical data are presented and displayed in striking graphical form. It challenges whether the government is concerned enough about reducing inequalities and highlights the living conditions of the million people living in the least healthy areas in Britain. It presents explanations for the widening health gap, and addresses the implications of this major social problem. In the light of this evidence the authors put forward social policies which will reduce the health gap in the future. The widening gap synthesises all the information available to date and should be read alongside the report of the evidence presented to the Independent Inquiry into Inequalities in Health (Inequalities in health, The Policy Press, 1999) and by all those concerned with reducing health inequalities. Studies in poverty, inequality and social exclusion series

Why are suicide rates rising in young men but falling in the elderly?-- a time-series analysis of trends in England and Wales 1950-1998

Suicide rates doubled in males aged <45 in England and Wales between 1950 and 1998, in contrast rates declined in older males and females of all ages. Explanations for these divergent trends are largely speculative, but social changes are likely to have played an important role. We undertook a time-series analysis using routinely available age- and sex-specific suicide, social, economic and health data, focussing on the two age groups in which trends have diverged most-25-34 and 60+ year olds. Between 1950 and 1998 there were unfavourable trends in many of the risk factors for suicide: rises in divorce, unemployment and substance misuse and declines in births and marriage. Whilst economic prosperity has increased, so too has income inequality. Trends in suicide risk factors were generally similar in both age-sex groups, although the rises in divorce and markers of substance misuse were most marked in 25-34 year olds and young males experienced the lowest rise in antidepressant prescribing. Statistical modelling indicates that no single factor can be identified as underlying recent trends. The factors most consistently associated with the rises in young male suicide are increases in divorce, declines in marriage and increases in income inequality. These changes have had little effect on suicide in young females. This may be because the drugs commonly used in overdose-their favoured method of suicide-have become less toxic or because they are less affected by the factors underlying the rise in male suicide. In older people declines in suicide were associated with increases in gross domestic product, the size of the female workforce, marriage and the prescribing of antidepressants. Recent population trends in suicide appear to be associated with by a range of social and health related factors. It is possible that some of the patterns observed are due to declining levels of social integration, but such effects do not appear to have adversely influenced patterns in older generations.

Ecological study of social fragmentation, poverty, and suicide

Abstract Objectives: To investigate the association between suicide and area based measures of deprivation and social fragmentation. Design: Ecological study. Setting: 633 parliamentary constituencies of Great Britain as defined in 1991. Main outcome measures: Age and sex specific mortality rates for suicide and all other causes for 1981-92. Results: Mortality from suicide and all other causes increased with increasing Townsend deprivation score, social fragmentation score, and abstention from voting in all age and sex groups. Suicide mortality was most strongly related to social fragmentation, whereas deaths from other causes were more closely associated with Townsend score. Constituencies with absolute increases in social fragmentation and Townsend scores between 1981 and 1991 tended to have greater increases in suicide rates over the same period. The relation between change in social fragmentation and suicide was largely independent of Townsend score, whereas the association with Townsend score was generally reduced after adjustment for social fragmentation. Conclusions: Suicide rates are more strongly associated with measures of social fragmentation than with poverty at a constituency level. Key messages Place of residence may affect health, and mortality from most common diseases tends to be higher in areas characterised by low socioeconomic position Research dating back over 100 years suggests that social fragmentation may influence suicide In the 1980s and 1990s, parliamentary constituencies with high levels of social fragmentation had high rates of suicide, independent of deprivation Constituencies with the greatest increases in social fragmentation between 1981 and 1991 also had the greatest increases in suicide rates over the same period Any targeting of suicide prevention may be more effective if aimed at socially fragmented rather than deprived areas

An environmental justice analysis of British air quality

This paper presents the results of the first national study of air quality in Britain to consider the implications of its distribution across over ten thousand local communities in terms of potential environmental injustice. We consider the recent history of the environmental justice debate in Britain, Europe, and the USA and, in the light of this, estimate how one aspect of air pollution, nitrogen dioxide (NO2) levels, affects different population groups differentially across Britain. We also estimate the extent to which people living in each community in Britain contribute towards this pollution, with the aid of information on the characteristics of the vehicles they own. We find that, although community NO x emission and ambient NO2 concentration are strongly related, the communities that have access to fewest cars tend to suffer from the highest levels of air pollution, whereas those in which car ownership is greatest enjoy the cleanest air. Pollution is most concentrated in areas where young children and their parents are more likely to live and least concentrated in areas to which the elderly tend to migrate. Those communities that are most polluted and which also emit the least pollution tend to be amongst the poorest in Britain. There is therefore evidence of environmental injustice in the distribution and production of poor air quality in Britain. However, the spatial distribution of those who produce and receive most of that pollution have to be considered simultaneously to see this injustice clearly.

Geographies of the agenda: public policy, the discipline and its (re)‘turns’

In the 1980s and 1990s, poverty and inequality in Britain increased, yet the discipline of (human) geography was apparently disinterested. This paper poses the question as to why part of the discipline turned its back on public policy and particularly issues of poverty and inequality. The aim of the paper is to encourage students and advocates of geography to think a little about what they are involved in (and to think about the role of academia more generally). Recent publications in a number of geography journals have revealed much angst among prominent geographers concerning the state of human geography and, in particular, its links to contemporary policy debate. However, while geographers discuss the debate, we argue that they are not a significant part of it. We take a critical turn and look at the debate that two geographers – Ron Martin and Doreen Massey – have raised within the light of wider debates on public policy, politics, quantification, academia and the policy agenda. We conclude that for many reasons there is unlikely to be a large shift towards policy-orientated research within human geography.

A nation still dividing: the British census and social polarisation 1971 - 2001

This paper presents an analysis of the degree to which the population of Britain has become more or less geographically polarised as compared with 1991 and earlier censuses. We use the Key Statistics for local authorities from the 2001 Census, released on 13 February 2003 by the census authorities. All of the variables from the 26 Key Statistics tables which can be compared over time with the 1991 Census are examined. The analysis is then extended for a subset of variables that were similarly measured in 1971 and 1981. We conclude that for key aspects of life in Britain, as recorded by the censuses, the nation has continued in the 1990s to divide socially geographically, often at a faster rate than was occurring in the 1980s or 1970s. Where there appears to have been a reduction in polarisation it tends to have been for those aspects of life which are now poorly measured by the census. The paper concludes with speculation about the possible reasons for the continued division of the country into areas now more easily than ever typified as being old and young, settled and migrant, black and white, or rich and poor. Finally the potential for the continued sociospatial polarisation of Britain is discussed. The paper begins with a fictional vignette.

Health inequalities and New Labour: how the promises compare with real progress

Inequalities in health between rich and poor areas of Britain widened in the 1980s and 1990s, and the current government has repeatedly expressed its intention to reduce these inequalities. In this article, however, the authors report that inequalities in life expectancy have continued to widen, alongside widening inequalities in income and wealth, and argue that more potent and redistributive policies are needed

Inequalities in premature mortality in Britain: observational study from 1921 to 2007

Objective To report on the extent of inequality in premature mortality as measured between geographical areas in Britain. Design Observational study of routinely collected mortality data and public records. Population subdivided by age, sex, and geographical area (parliamentary constituencies from 1991 to2007, pre-1974 local authorities over a longer time span). Setting Great Britain. Participants Entire population aged under 75 from 1990 to 2007, and entire population aged under 65 in the periods 1921-39, 1950-3, 1959-63, 1969-73, and 1981-2007. Main outcome measure Relative index of inequality (RII) and ratios of inequality in age-sex standardised mortality ratios under ages 75 and 65. The relative index of inequality is the relative rate of mortality for the hypothetically worst-off compared with the hypothetically best-off person in the population, assuming a linear association between socioeconomic position and risk of mortality. The ratio of inequality is the ratio of the standardised mortality ratio of the most deprived 10% to the least deprived 10%. Results When measured by the relative index of inequality, geographical inequalities in age-sex standardised rates of mortality below age 75 have increased every two years from 1990-1 to 2006-7 without exception. Over this period the relative index of inequality increased from 1.61 (95% confidence interval 1.52 to 1.69) in 1990-1 to 2.14 (2.02 to 2.27) in 2006-7. Simple ratios indicated a brief period around 2001 when a small reduction in inequality was recorded, but this was quickly reversed and inequalities up to the age of 75 have now reached the highest levels reported since at least 1990. Similarly, inequalities in mortality ratios under the age of 65 improved slightly in the early years of this century but the latest figures surpass the most extreme previously reported. Comparison of crudely age-sex standardised rates for those below age 65 from historical records showed that geographical inequalities in mortality are higher in the most recent decade than in any similar time period for which records are available since at least 1921. Conclusions Inequalities in premature mortality between areas of Britain continued to rise steadily during the first decade of the 21st century. The last time in the long economic record that inequalities were almost as high was in the lead up to the economic crash of 1929 and the economic depression of the 1930s. The economic crash of 2008 might precede even greater inequalities in mortality between areas in Britain.

Unemployment and health

Health benefits vary according to the method of reducing unemployment

Urban-rural differences in suicide trends in young adults: England and Wales, 1981-1998

Suicide rates amongst young people, particularly males, have increased in many industrialised countries since the 1960s. There is evidence from some countries that the steepest rises have occurred in rural areas. We have investigated whether similar geographical differences in trends in suicide exist in England and Wales by examining patterns of suicide between 1981 and 1998 in relation to rurality. We used two complementary population-based indices of rurality: (1) population density and (2) population potential (a measure of geographic remoteness from large concentrations of population). We used the electoral ward (n=9264, median population aged 15-44: 1829) as the unit of analysis. To assess whether social and economic factors underlie rural-urban differences in trends we used negative binomial regression models to investigate changes in suicide rates between the years for which detailed national census data were available (1981 and 1991). Over the years studied, the most unfavourable trends in suicide in 15-44-year olds generally occurred in areas remote from the main centres of population; this effect was most marked in 15-24-year-old females. Observed patterns were not explained by changes in age- and sex-specific unemployment, socio-economic deprivation or social fragmentation. The mental health of young adults or other factors influencing suicide risk may have deteriorated more in rural than urban areas in recent years. Explanations for these trends require further investigation.