“The Social Lens”

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At the risk of blinding you with the science, here’s the science: Inequality kills children of course this is just a summary.


What are they

In the UK, the 5th richest country in the world, 4.2 million children are now living in poverty with almost 2 million going hungry.

The circumstances of birth, work, living conditions and age shape the conditions of daily life, these are social determinants of health which contribute to health inequalities.

For many children skin colour, gender and socioeconomic status may have more impact on their life than the disease that necessitates hospital assessment. Health inequalities and social determinants of health are represented on vertiginous graphs that are regularly produced and which serve to confirm that health outcomes are dependent on socioeconomic status.

How bad are they?

Health inequalities are wide and despite increasing attention, things are not getting better. Life expectancy can differ by decades between different racial and socioeconomic groups not just between countries, but also within them. In London, depending on where you were born along London’s Central Line, a short train ride can knock 20 years off your life expectancy. The numbers are alarming (go to the Library for more) but a focus on the numbers only gets us so far.

Numbers don’t provide an explanation for why Black men were three times more likely to die from COVID-19 than White men the same age. Or why women spend more years of their life in poor health than men even though life expectancy at birth for girls is higher than for boys. Or why the richest people enjoy nearly 20 more years of good health compared to the poorest. The question is not whether health inequalities exist, but why.

What causes them

Biomedical models of healthcare do not explain why health inequalities exist. For that we need to look beyond the medical model, to the wider areas of social sciences, critical humanities and political economy. We need to gaze through ‘the social lens’.

The inability of social structures and institutions to meet basic needs creates health inequalities, and ignoring their shortcomings leads to significant problems.

Health inequalities are not caused by disease, but by the rules that govern the social and economic dimensions of our lives, rules set by those in power, that create our social structures. Thus resulting in an reduced lifespan in the disadvantaged which would not occur in a more equal society, the shortcomings within social structures being accepted as a fact of life


Health Effects: Humans & Systems

Poverty and social factors are root causes of health inequality, and are the most important determinants of child health in the UK, leading to adverse developmental, educational, health and long term social outcomes. Poor children are twice as likely to die, and three times more likely to be injured than rich ones. Poverty pervades all areas of a child’s life, with increased risk of serious morbidity and mortality from diseases such as cardiovascular, diabetes and cancer (RCPCH 2017).
Poverty and social determinants also affect the quality of care children receive. Failure to attend appointments due to lack of and cost of public transport, or extortionate parking costs. Failure to adequately take medication because they cannot read. Lack of interaction with children because of long working hours and inadequate space at home. Evidence shows that health systems and the people they employ, are in danger of making health inequalities worse simply by failing to seethe underlying problems .
As inequalities grow the burden of disease expands with it, health systems having to pick up the pieces of a broken society. Whilst the rules of those in power result in job cuts, wage stagnation and unaffordable healthy food, not even hospitals are safe. Beds, clinical staff, administrative support and allied health services have dwindled to such low levels that every day is a battle to keep one’s head above water. With no where else to go the poor, hungry and homeless are turning up in emergency departments, GP clinics and children’s acute care centres, bringing the already beleaguered NHS to its knees.
The Moral Case

Let’s imagine for a moment that health inequality didn’t kill children: would they still be bad?

Yes, because not everything that matters in life can be summed up in a mortality statistic. Health inequalities matter because of what they signify: the systematic, unfair distribution of material resources and social, economic and political power. Some people consistently have a lot of these things, while the rest of us don’t. Not only does this mean some people are more likely to die or be sicker as a result, but it means that some people are not capable of living lives to their fullest.

How can we live in a world that is OK with most children not being able to reach their potential?

Inequality is the end result of a system where many of our patients are denied the basic ingredients - or capabilities - to live happy, healthy lives. This is an issue of basic human rights. This is an issue of justice. And the issue is critical. It's not a medical emergency, but it is a very social one.
What’s our Role?

As clinicians, we are engaged in the business of life and death; a business that, by its very nature, is deeply moral. Health inequalities are fundamentally an issue of injustice. There is no health problem out there that is not ultimately affected by wider social, economic and environmental factors. And just how those factors affect our patients is down to power: who has it, how it is wielded and to what end.

If we want thing to change we have to equip ourselves to be part of the solution. This means owning our part in existing power imbalances that drive inequality. It also means being critical of how even our best intended actions might just be making health inequalities worse.

For centuries dominant approaches to medicine and public health have woefully mistreated health inequities. Doctors and clinicians have not only ignored the structural causes of health inequalities, but they have also helped to perpetuate unequal social structures.

It is only once we truly see where health inequalities come from - and what our role might be in helping to address them - that we can reframe what our actions ought to be.

It is a basic rule of medical science that if you don’t get to the root of a problem, you’ll never truly solve it. We cannot solve the problems that are created as a side-effect of our processes, by just treating those side-effects. Otherwise we're just treating the fever without treating the underlying infection.

Remember: health inequalities are not just a biological reality; they are a form of social inequality, because they are structured according to unjust power arrangements. Biological and cultural explanations for gaps in health according to race, gender or class merely help to support an unjust social order.

By attributing gaps in health to the innate or cultural traits of socially disadvantaged groups, medical professionals have obscured the very existence of political oppression. e.g. the racial concept of disease that people of different races have different diseases and suffer from common diseases differently.

Just what those actions might be is dealt with here, but the key principle is this: as clinicians our role is to see that health needs social justice. Not only do we have a role in helping patients to be healthy but also in using whatever power we have to ensure the capabilities for a healthy, happy life are available to us all.


This is WHAM’s curated list of select key texts and reports that we think help to encapsulate the most important pieces of evidence and arguments for taking action on the social determinants of health and health inequalities. Feel free to browse through our shelves…

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Of all the forms of inequality, injustice in health is the most shocking and inhuman"

Martin Luther King Jr.