Inequality Makes People Sick

 

This website mainly focuses on gambling harms arising in disadvataged communities. Let’s remember, though, that a block description such as ‘disadvantaged community’ should never come close to describing the thousands of individuals who live there. Although everyone is affected by their social environment, not everybody is the same by any means. More people in deprived communities suffer from health issues such as obesity, depression, addicitons – but this represents a trend, not a mould for each person. While the odds are stacked unfairly, most people make good lives. ‘Deprived’ communities are far from deprived of such things as caring, mutual aid, resilience and activism towards change.

In the case of gambling harms, and harms generally arising from strong attachment to unhealthy behaviours and substances, nobody anywhere is immune from risk. There are plenty of obese doctors and nurses, for instance which suggests that simply ‘knowing’ about health risks is not sufficient to prevent unhealthy lifestyles. Factors to do with emotional distress or the great pressures of work must play a part. If we drop our stereotypes of ‘a gambler’ we’d be able to see that harms affect middle class people like priests, lawyers, accountants – ‘well-heeled’, respectable folk. We could look too at the harms people run into trying to gamble on the stock markets, an activity described here as a potential addiction. The financial crash of 2008, for which the most disadvantaged are still paying heavily, came about from massive risky ‘investments’ organised by bankers and others gambling in the financial industries.

As said, our main concern is for those best evidenced by the inverse law of care by which those who need most care receive the least. Well educated, financially secure people know their way around various systems including health care and they procure it. Clinics for gambling harms are quite abundant – if you can pay for them. People who work in public services and professions generally are supported by strong policies relating to health including issues arising from dependence or addiction. A consultant surgeon with alcohol dependence syndrome will receive better care and chance of recovery than a homeless person whose main diet consists of cider, sleeping under the arches at Glasgow Central railway station.

All of this is well recognised. The distribution of income, wealth and power is wildly unfair and acts as a major determinant of poor health and risks of harm to those who are most vulnerable. It may be that the values promoted in a culture based upon self-interest, ‘success’, the feverish attempts to ‘consume’ happiness, corrupt the wellbeing of those in society who are materially secure (enough to add them to the one third of the population believed to be addicted to something). There are many millions of citizens working within this context to improve things. From health and care professionals through ancilliary staff, hundreds of charities and other third sector organisations, to community volunteering and activism, in the face of gross injustice and inequality, solutions and practices emerge to improve life for this individual, here, now. In common with other social issues, alongside hard – usually incredibly hard – work to support an individual, there are powerful broad campaigns to raise awareness about ineqaulity, challenge it and put pressures on ‘the powers that be’ to listen and respond.

 

 

Everybody Knows

Everybody knows that the dice are loaded
Everybody rolls with their fingers crossed
Everybody knows the war is over
Everybody knows the good guys lost
Everybody knows the fight was fixed
The poor stay poor, the rich get rich
That’s how it goes
Everybody knows

No News Here

It’s not new. It’s so prevalent, so much part of the atmosphere, seeped into everyday life like stains on concrete. You can lose sight of what’s all around, take everything as just the way things are. Certainly it’s not newsworthy. If a famous person dies that is big news. That people in parts of Glasgow can expect to live twenty years less than those in other parts is a fact. But it’s not news. Reformers and revolutionaries have addressed it for hundred of years. Charles Dickens in Britain and Upton Sinclair in the Unites States brought awareness of it to millions. General Booth, founder of the Salvation Army, or Karl Marx proposed solutions to it. ‘It’ has been in some form a central focus for academia, and, of course, for politics. Thus, communities are identified as deprived, disadvantaged, with poor levels of health, wellbeing, opportunities and happiness.

Many decent, better-off people are aware of the consequences of inequality, injustice and often exploitation, and many do their best to become involved in challenging ‘it’. There is, however, a continuing danger that too much attention to the seemingly intractable social and economic factors behind health and other human inequalities distracts from the more urgent need to bring about the best possible support to this individual, at this time, living under these conditions. It also takes profoundly important attention away from what individuals in communities are doing to adapt as well as possible to conditions.

 

Drumchapel in Glasgow is a few miles from Milngavie in East Dumbartonshire. Male/female life expectancy respectively: 69/74, 80/83. Years of good health and wellbeing are reflected proportionally.

The subject of social inequality is immense in its dimensions. It’s primarily a moral issue. In an ideal world we would all be doing our bit to challenge it, from wherever we are. Here, even a complete overview of gambling harms and inequality is not possible. We simply wish to locate gambling disorders and addiction as serious health problems , particularly mental and emotional distress, as embedded in the social distributions of income, wealth (financial security and beyond) and power. Power relates to social, educational and cultural capitals, and involves the ability to thrive, be involved with society at large, make a difference, have one’s voice heard and so on. Even set against income and wealth indicators, communities and their individuals do have powers to thrive by action, effect change, improve services, lend mutual support and mitigate the many unfair obstacles they face.

We look at community activism elsewhere on the site. Here, we look at some of the issues around health inequalities that intensify gambling harms in communities already suffering from multiple risk factors. At the end of this page we provide some links to work around health inequalities, especially mental health inequalities, with a focus upon Glasgow.

Gambling harm is everybody’s business: A public health approach and call to action

P. Johnstone, M. Regan, Royal Society for Public Health, October 2020

The challenge for policy makers and practitioners is implementing the most effective and cost-effective set of policies at a national and local level. The evidence base to support policy makers and gaps for more research is getting stronger. It is also possible to use lessons learnt from managing harms from other public health threats, such as alcohol, tobacco, obesity and drug use acknowledging the unique characteristics of gambling, such as rapid technological advances and growth of gaming and on-line gambling.

Approaches need to move the focus from ‘personal responsibility’to social, economic and environmental interventionsat the population level. Lessons from other fields show that interventions which target individual behaviour can inadvertentlyincrease inequalities in behaviour, thus it is essential to considerthe broader context in all planning for tackling gambling-related harms. (our emphasis)

We suggest that a public health approach to reduce gambling related harms needs to be multifaceted, combining upstream and downstream approaches applied in a coordinated way, and to include advocacy, information sharing, early intervention andregulation. This should include the following:

 — national and local policy makers adopting a ‘health in all policy’approach and using the best evidence in their future decisions toprevent harm. This will ensure that gambling is seen within its widest context.

 – understanding the prevalence of harmful gambling with insights into the consequences and how individuals, their family and friends, and wider community are affected. To be effective at a local level in addressing gambling harms, it is not just the gambler but affected others who may suffer adverse impact.

- ensuring tackling gambling harms is a key public health commitmentat all levels by including it in strategic plans, with meaningful outcome measures, and communicating this to partners. This will require local agencies to consider gambling as they pull together their plans for action and to develop performance management systems to monitor progress.

 – understanding the assets and resources available in the public,private and voluntary sectors and identifying what actions are underway. By drawing together local assets a coordinated and collaborative local response can be effected.

 – raising awareness and sharing data, developing a compelling narrative and involving people who have been harmed and are willing to share their experience. Many people do not understand gambling as a health harm and developing the narrative,through campaigns will help to raise awareness. (our emphasis)

 – ensuring all regulatory authorities help tackle gambling-related harms under a ‘whole council’ approach. Taking a cross-council approach will enable consideration of gambling within
different contexts such as homelessness, vulnerability, poverty and local regulation.

 – developing a whole systems approach to reducing poverty and health inequalities that incorporates gambling harm within place basedplanning. Understanding how gambling harm is impacting on health inequalities or is linked to inequalities amongst high risk groups will help develop policies and target resources appropriately.

Read the full paper at rsph multi-faceted approach

POWER in its many forms shapes our lives. The power of wealth, for instance, can see decisions made in boardrooms in Asia shut down car production factories in Scotland, throwing thousands out of work, leading to downward spirals of wellbeing in communities. If ships can be built cheaper in India, the shipyards of the Clyde close.

At national level, power involves policy making and resource provision from governments. Governments themselves can only act in the context of global power and the nation’s economy.

Existing power structures ensure that at the top of the triangle power emains concentrated in a relatively few hands. Trickling down, at the base of the triangle we see the human costs of such structures. Interestingly, it’s now widely accepted that what affects people negatively is less to do with income and wealth (except, of course for the 15% or so of the population living in severe poverty) but more to do with inequality itself, the gaps between the powerful and powerless.

At a personal level, many feel powerless. Indeed, Professor Paul Gilbert’s early book about depression was subtitled ‘the evolution of powerlessness‘. When you feel nothing can ever change, that you have no power, things will always be bad, then health, emotional wellbeing, hope may all suffer.

The theme of this page is the belief (based on much evidence) that citizens and their communities have more power than they know. Community health engagement, for instance, not only shows service outcome improvements, but it can also influence power decisions higher up the ‘triangle’. Not only this, the engagement itself is empowering bringing a sense of achievement, growth and noursihing social interactions. It’s not a palliative, a sticking plaster. It can increase personal senses of power, and lead to significant change, while also releasing the flood of energy to challenge injustice and inequality.

Clustering

 

The recommendations from the paper above move towards a nuanced approach aimed at bringing positive change to community health. Instead of waiting for a magic switch to be thrown which will eliminate the unjust determinants of poor health, the ideas are geared to realistic outcomes and involve community activism. This involves ‘whole system’ thinking, awareness in all agencies of the nature and prevalence of gambling harms, integration between services, the active involvement of those harmed by gambling, and an important shift from narratives which locate the ‘problem gambler’, the ‘pathological gambler’ in a context of personal responsibility.

Such an approach to gambling harms may run parallel with a similar framework of thinking about other preventable harms in the community. For instance, we know that bookmakers tend to ‘cluster’ in deprived areas (and harms that arise are greater in such communities independent of relatively small financial losses in absolute terms). A 2018 article in the journal Health and Place concluded:

We observed a greater number of clusters of ‘environmental bad’
outlets (alcohol, fast food, tobacco, and gambling outlets combined)
located within more deprived areas. Additionally when analysed
individually alcohol outlets, tobacco outlets, fast food outlets and
gambling outlets were clustered within deprived areas. Furthermore,
we found a greater number of overlapping clusters in more deprived
neighbourhoods showing evidence of co-location. This research makes
use of a robust technique and novel application of cluster analysis to
detect clusters of outlets and adds to existing evidence that deprived
areas have increased opportunities to access potentially health damaging
and/or addictive goods or services. The findings reported here
may aid authorities to develop policies and planning regulations
appropriate for the areas in greatest need.

Do ‘environmental bads’ such as alcohol, fast food, tobacco, and gambling
outlets cluster and co-locate in more deprived areas in Glasgow City,
Scotland? Full paper at clustering

 

GPs at the Deep End and Community Links Workers

 

General Practioners working at 100 of the most deprived areas of Scotland are part of the Scottish Deep End Project. We’ll see more of their work on this site. The doctors work with academic colleagues, some doctors making academic contributions and research themselves. In recent years, they have come to respect and value community links workers, non-clinicians, non-specialists who work with GPs to deliver individual patient-centred ‘social prescriptions’, address the multiple environmental factors that contribute to poor health and provide the sort of vital support in the community that can make a big positive difference to health. A 2020 report from 12 Deep End General Practioners in Edinburgh and Glasgow includes:

Addressing inequity in health and health care

• Unresolved aspects of health care inequity include the toxic combination in very deprived areas of a time-poor service with lower levels of health literacy; for different reasons patients, practitioners and the system settle for sub-optimal care.
• New partnership is needed within Health and Social Care Partnerships (HSCPs) between general practices dealing with the consequences of longevity and practices serving groups with premature mortality and lower healthy life expectancy.
• Provision of Community Link Workers should be increased from 50% to 100% of Deep End general practices.
• The proven benefits of embedding Financial Advisors in general practice should be recognised and funded as part of the new Scottish Social Security system.
• Most of the new mental health morbidity will present in general practice, below thresholds for referral to mental health services. There is an urgent need to expand the model of embedding mental health workers in general practice.
• New metrics are needed to inform, monitor and evaluate policies to improve health equity.

It may be that in the future there will be a general trend to expand understandings of health in theory and practice, and this would relate to support for gambling harms. Full report: Deep End Report 36

Links to Challenging Health Inequalities

 

Is there a health inequality in gambling related harms? A systematic review (BMC Public Health, 2021) :

….our review strongly suggests that the distribution
of harms in the population is affected by a number
of factors, and presents some key signs to identify
individuals who may be at risk. The type and number of
harms experienced by individuals appears to be
dependent on specific social, demographic and environmental
conditions such as age, cultural background and
socioeconomic status. There is evidence to suggest a
health inequality is present, where some individuals will
suffer more harms than others, despite equivalent exposure
to gambling. With this in mind, Primary Care
Workers will be better equipped to identify those who
are most at risk, or who are showing signs of Gambling
Disorder, and to target prevention and intervention programmes
appropriately.

See health inequality in gambling

What are health inequalities?

Health inequalities are the unfair and avoidable differences in people’s health across social groups and between different population groups.
They represent thousands of unnecessary premature deaths every year in Scotland, and for men in the most deprived areas nearly 24 fewer years spent in ‘good health’.
This is unfair because these health inequalities do not occur randomly or by chance, but are socially determined by circumstances largely beyond an individual’s control. These circumstances disadvantage people and limit their chance to live a longer, healthier life.
Health inequalities are avoidable because they are rooted in political and social decisions. There was a substantial narrowing of health inequalities in the UK and USA between the 1920s and 1970s, the period in which welfare states were constructed and income inequalities declined.

NHS Scotland Health Scotland health-inequalities-what-are-they-how-do-we-reduce-them

From Glasgow Health and Inequality Commission, 2017:

6.2 It is evident that prevention is better than cure. The focus of public sector partners should be as much on maintaining good mental health for our citizens as supporting those with poor mental health. Being able to support people to access the right support and services at the right time will lead to better outcomes.
6.3 Primary care (GPs) have an important role to play, they are well placed to identify mental health issues at an early stage and to help and support patients. Initiatives such as the Scottish Government commitment for additional ‘Link Worker’ roles in GP surgeries offer a real opportunity to allow primary care services to be more routed in the communities they service.
6.4 We believe that GPs in Glasgow are currently not well resourced to deal with the health challenges in our most deprived communities. The current basis for allocating health funding to primary care does not, in our opinion, sufficiently take account of the impact of poverty and deprivation on both physical and mental health in our communities. This is further aggravated by current difficulties in GP recruitment.
6.5 However Primary care and other more specialist mental health services are not always what people need. In the short time we had available, we visited and heard of community projects that play a vital role in tackling loneliness and isolation, promoting social connections and providing mutual support. We believe that ensuring strong social connections is of equal value to promote and maintain good mental health. Communities are essential. People need to be able to be connected locally, have a sense of purpose and belonging and mutual support.

See GCC_Health_Inequality_Commission_Report_for_Executive_October_2017

Health Inequalities in Scotland: a national calamity

a Frontline GP’s view, Dr Catriona Morton

 

The single biggest unaddressed challenge to the Scottish health services is the profound and enduring health inequalities relating to socio-economic status*. The UK ranks second in the EU for income inequality, exceeded only by Lithuania1. Yet it is just these inequalities that determine our nation’s poor health status, and Scotland remains the ‘sick man of Europe’, a shameful failure which not only persists, but is set to grow2. This is despite multiple initiatives over the years, which have largely not delivered sustainable or effective change, resource failing to reach those most at need. This paper is a personal view, albeit of an experienced frontline clinician, and one that may resonate with many GPs who serve deprived populations. It aims to summarise some aspects of Scottish health inequalities, makes proposals about approaches, and offers some pragmatic achievable solutions. Above all it is an appeal to properly formulate what those solutions might be and allow Scottish General Practice to help address the over-riding health issue of our time and country.

See Mortin,C

Professor Emeritus Richard Wilkinson Patron and co-founder of The Equality Trust gave a talk about the relarionships between inequality and impacts on wellbeing. The talk was given in September 2020 as part of a Scottish Alliance for Health and Social Care webinar.

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