Illustration showing inequalities.

Welcome to the first post in our Inequalities Series, a series of articles that discusses health inequalities and how they relate to cancer, from prevention and early diagnosis to treatment and research.

In this first article, we talk to Professor Sir Michael Marmot, who has stood at the forefront of research into health inequality for decades, to discuss what health inequality actually is, and what we can do to reduce it.

Why do health inequalities exist?

Health inequalities – the fact that some people in society are more likely to suffer worse health than others – have been brought to the fore during a pandemic that has seen a disproportionate impact on more deprived groups, people from ethnic minority backgrounds, and women.

But health inequalities existed before the pandemic struck, affecting all aspects of our health, including our risk of getting and surviving conditions like cancer. A report we produced in 2020 found that over 30,000 extra cases of cancer in the UK each year can be attributed to socio and financial deprivation, and survival is worse for the most deprived groups.

And people’s experience of the healthcare system, and ultimately how likely they are to be successfully diagnosed and treated, varies massively, something we’ll be covering in much more detail in future articles.

So, what’s behind these differences?

“When people think about health, they usually think about healthcare. I’ve lost track of the number of times I’ve been asked to talk about inequalities in healthcare,” says Marmot. “And I have to point out that most of the inequalities in health are not the result of inequalities in access to quality healthcare. Most of them are present before people get sick. It’s the social determinants of health that are most important.”

Marmot describes the social determinants of health as the conditions in which people are born, grow, live, work, and age, and inequalities in power, money, and resources that drive the inequalities in the conditions of daily life.

These factors mean that not everyone has the same pressures and opportunities in life, making it harder for some people to live healthily or increasing barriers to seeking healthcare. For example, people living in more deprived areas are 2.5 times more likely to smoke than those in the least deprived, and find it harder to quit.

The combination of these factors leads to a ‘health gap’ between the most and least deprived in society, with the most deprived more likely to suffer from worse health and have a lower life expectancy.

But, Marmot says, simply seeing it as a gap isn’t the full story.

“The Health Gap was the title I gave to my book on health inequalities, which is accurate, but doesn’t cover the full picture,” says Marmot. “It’s accurate in the sense that, if you look in London, you have something like an 18-year gap in life expectancy between the poorest part of London and the richest. But the real issue exists as a gradient.”

So, those differences in money, power and resources between different groups mean that the lower social and financial position someone finds themselves in, the more likely they are to suffer from worse health, with outcomes getting worse the further they are from the top.

Ultimately, these inequalities are profoundly unfair. But they are also avoidable.

The cost of inaction

Marmot has been doing research into health inequalities and the gradient in health across society for decades, and his work has meant we can see how this has changed over time.

In 2010, Marmot was invited by the Government to write a report on the social determinants of health for England, which gave rise to The Marmot Review. In this, Marmot identified 6 key areas to focus on to reduce health inequalities:

  • Give every child the best start in life
  • Enable all children, young people and adults to maximise their capabilities and have control over their lives
  • Create fair employment and good work for all
  • Ensure healthy standard of living for all
  • Create and develop healthy and sustainable places and communities
  • Strengthen the role and impact of ill health prevention

In February 2020, just as the pandemic was beginning to strike, Marmot published a second report, looking back on The Marmot Review, 10 years on.

Unfortunately, the results were not positive.

“Life expectancy, which had been increasing about one year every four years, for nigh on 100 years, slowed dramatically,” says Marmot. “And the inequality gradient got a bit steeper, so the inequalities got bigger. And third, life expectancy for the poorest 10%, the most deprived, went down.”

When asked why he believed the health gap seemed to be widening, he discussed how the recommendations from his original report weren’t implemented by the Government.

“We said: ‘Here are the 6 key domains that you need to act on’. And they didn’t act on them. And health inequalities got worse.”

Whilst acknowledging that this isn’t proof that inaction on their recommendations is what led to the increase in health inequalities, Marmot believes that it is reasonable speculation, and that these 6 areas are still the areas to focus on if we want to stop the gap widening ever further.

Health and wealth

Marmot says that the link between health and deprivation, including income deprivation, is something that more people need to be made aware of.

“If you ask the general population what concerns them about inequalities, they say inequalities of income and wealth,” says Marmot.

“But if you recognise that inequalities in income and wealth are related to inequalities in health, that means people are concerned about the conditions in which they’re born, grow, live, work and age, even though they may not think of them as being the drivers of ill health.”

Quoting data from The Food Foundation, Marmot gives the example that if people followed government healthy eating advice, those in the bottom 10% of household income in England would have to spend 74% of their disposable income on food.

A healthy diet can reduce the risk of a number of diseases, including cancer, by helping people keep a healthy weight and avoiding foods that can directly affect cancer risk. But when not everyone can afford to eat healthily, this will lead to some groups having a higher risk of diseases. And this is just one example of how lower incomes can lead to worse health.

If you ask people about health, they talk about NHS waiting times. They don’t talk about the fact that there are people who can’t afford to feed their children.

As income inequality in the UK continues to increase, the connection between health and wealth makes it clear that to make a healthy society, action must be taken to improve the conditions in which people live to create a fairer society as well.

But socioeconomic differences are just one of many factors that influence inequality in health and healthcare, including cancer care.

People’s experience of the healthcare system, and ultimately how likely they are to be successfully diagnosed and treated, varies massively. For example, research suggests that people in ethnic minority groups are less likely to attend screening and report more barriers to presenting to primary care with symptoms.

As well as this, there are well known barriers for trans and non-binary people when it comes to cancer screening, which is vital for catching some cancers earlier, when they’re more treatable, or stopping cancers from developing in the first place. And a lack of education for healthcare professionals, as well as discrimination and historical stigma, means that cancer care for the LGBTQ+ community still has progress that needs to be made.

Disparities in who is involved in research, both as researchers and participants in trials and other studies, also affects the kind of work that is done and who benefits most from the advances made.

Change is possible, and necessary

The widening gaps in society’s health, and the variability in people’s experience of the healthcare system, is incredibly troubling.

But inequalities aren’t inevitable. Marmot remains positive that change can be made. He particularly highlights some of the great work that is being made on a regional level by local councils, even as they are hampered by cuts to funding.

Not only does Marmot believe we can make a difference, he believes we have a moral duty to do so.

“The magnitude of health inequalities that we see is not a given. We can do something about it. We can reduce them, and the reason for reducing them is a moral one.

“That’s my takeaway message. That we should try and do something about it, because it’s the right thing to do, and we’ve got the evidence that shows we can.”