Fintan O’Toole: Ireland’s well-off live five years longer than its poor

Five years, 60 months, 260 weeks, 1825 days. That’s the amount of extra life you get in Ireland if you are in the top 20 per cent of earners, as opposed to those in the bottom 20 per cent. It’s a long time, time enough to see a grandchild through from birth to school, time to plant a garden, time to do a whole university degree or write a novel or learn a language. An Irish man in the top bracket can now expect to live for 84.4 years. His fellow citizen in the bottom bracket can expect to die at 79.4 years old. For women, the gap is slightly narrower: 4½ years. But for both genders, the relationship between wealth and time moves rigidly in lockstep: the better off you are, the more years you get. At the most extreme end of the spectrum, mortality rates among Traveller males are 3.7 times higher than among the general male population.

If you add up those lost years for the bottom 20 per cent alone, they amount to about 4.8 million years on unlived life in Ireland. The 17th-century English revolutionary Thomas Rainsborough said that “the poorest he that is in England hath a life to live as the greatest he”. But that’s still not true in many countries, including our own. The poorest he and she have less life to lead. The years, the months, the days are not just measures of time – they measure social power.

Lifestyle and genetics

Public health campaigns and TV transformation shows are full of very good advice: don’t smoke, cut down on alcohol, watch the calories, take exercise. It is all perfectly valid. But they leave out the best advice of all: get yourself born in a well-off area. Health is influenced by lifestyle and genetics and sheer dumb luck. But the single biggest influence is social inequality. The evidence in Ireland, as in so many other societies, is overwhelming. Inequality isn’t just an economic and political problem. It is a mass killer.

You can cut this any way you like, using any of the common sense measures of privilege and deprivation. If you want to look at it through jobs, professional people in Ireland have an annual death rate of 494 per 100,000. Unskilled workers die at a rate of 796 per 100,000. Or we can use education as the marker: the mortality rate for those of us with a third level education is 619 per 100,000. It’s 818 per 100,000 if you have just a secondary education and 1,195 if you didn’t get beyond primary level. Or we can see it through the prism of geography. In the least deprived areas of our towns and cities, the death rate is 510 per 100,000, compared to 815 in the most deprived. It even maps on to home ownership. The mortality rate for people who own their own homes is 494 per 100,000. It’s 786 for those who rent their homes from local authorities or voluntary associations.

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And we largely ignore this obvious truth. In Northern Ireland, the department of health publishes an annual comprehensive report on health inequality and how it’s changing. South of the Border, there is no such thing. In the vast apparatus of health service officialdom, the great killer is scarcely present. The Government’s official Healthy Ireland “road map for building a healthier Ireland”is full of good things. And it ostensibly has “reducing health inequalities” as one of its four pillars. But reducing how? Don’t know. By how much? Can’t say. How quickly? We’ll get back to you on that. Ireland remains the only western European country not to have universal health coverage of primary care, so might that not be an obvious place to start? We’ll get around to it sometime.

Revolution

We need a revolution in our conception of health. I chaired a lecture this week at the Royal College of Surgeons in Dublin by the brilliant and passionate doctor David Ansell. As well as being professor of medicine at Rush University Medical Centre in Chicago and a frontline clinician, he is a powerful advocate for just such a conceptual revolution – the need to see inequality as a disease. "Inequality," he says, "triggers so many causes of premature death that we need to treat inequality as a disease and eradicate it, just as we would seek to halt any epidemic. This is bigger than a war on cancer… Inequality is all around us, as are the deaths it causes… Where you live dictates when you will die."  Ansell's work, described in his two books, County: Life, Death and Politics at Chicago's Public Hospital and The Death Gap: How Inequality Kills come out of the American experience, where racial injustice deepens the wounds of social class and where gaps in life expectancy are even worse than those in Ireland. But the US is highly relevant to Ireland's increasingly profit-driven model of healthcare. And Ansell's core argument goes far beyond Chicago.

It is that the differences in mortality are driven by what he calls the “structural violence” of systemic inequality: “Not behaviours. Not biology. Not culture. Not bad luck. But deliberate public and economic policies that have allowed inequality to flourish at the cost of life itself. That is not to reject individual responsibility and accountability for health outcomes. Or to deny that diseases have biological manifestations. But individual behaviours, biology and culture are insufficient explanations for the neighbourhood-to-neighbourhood gaps in illness and life expectancy. And they deflect attention from the social, political, and economic faultlines that create survival gaps.”

Inequality kills

Even at the level of biology, medical research is increasingly uncovering the ways in which inequality kills. If you live in an area of concentrated poverty, you are much more likely to experience psychosocial stress from the womb onwards. The stress activates the body’s “fight or flight” responses which raise heart rates and blood pressure and send inflammatory hormones rushing into the bloodstream. Repeat his process too often and you are much more likely to develop life-limiting and fatal conditions.

We have an odd expression here. We say of unpleasant events that they “would put years on you”. But in fact our society is very good at taking years off people. We tolerate an openly two-tier healthcare system that gives much quicker access to care to those who can afford it than to those who cannot afford it but are more likely to need it. In this way, the health system is itself a vector of disease, another of the markers of inequality that generates illness and premature death. We know that inequality is deadly for the body politic – it is time we recognised that is fatal to the body too.