Health inequalities and deprivation.

Congratulations on a timely issue on health inequalities and deprivation (BJGP, June 2001). It is arguable that the inequality issue is the medical issue of today. Twenty-one years after the Black Report, followed up by such authors as Blane, Brunner, Davey Smith, Marmot, and Wilkinson, it is clear that we cannot have a healthy society unless it is more equal than the one we live in today. How much more equal, and how this can be achieved in a highly market-driven culture with heavy emphasis on individual freedom and responsibil i ty is not clear. However, the direction in which we need to travel is beyond dispute. All your contributors acknowledge and illustrate the extent to which the health of their populations depends on the structures in society. All of them, except one, nevertheless assert that the profession has a central agency role in trying to redress the damage and disadvantage produced by the societal structures. There is a serious danger here related to the ancient medical self-delusion of megalomania. If doctors take on the role and responsibility of trying to solve problems that are manifestations of end-stage social pathology (e.g. alcoholics, smokers, and other drug abusers; obese diabetics with established vascular disease; people who have already developed cancer or had their first heart attack, etc) the risk is that the patients, the general public, the managers, the government and the polit icians wil l leave it al l to us. Paradoxically, the more successful we are in bailing out these boats with a teaspoon, the more difficult it is to make the political and social changes necessary to generate more upstream health. Observe, for instance, the charmed existence of tobacco companies and their advertising through yet another Queen’s speech, even though for nigh on 50 years we have known that their product is lethal. Notice also that a would-be Prime Minister, Ken Clarke, has been on a trip recently to Vietnam to sell tobacco and thereby kill more Vietnamese than American weaponry ever did. I am a GP on a deprived estate. The surgery has metal shutters and sits within a three-metre-high palisade of iron railings. The NHS gives out care and concern to people who have little elsewhere in their lives. Most other services are poor or non-existent. I am like a prison padre, and as I drive away each evening, the cell door clangs behind me. If the NHS didn’t exist maybe these estates really would explode, so that makes me a kind of jailer as well. ‘Sometimes I think this whole world is one great prison yard; some of us are prisoners, the rest of us are guards’ (Bob Dylan). When I collude in the medicalisation of social and personal problems, it is possible that I am disabling my patients by diverting them from other strategies that may be more useful and effective. I may be confirming them in the sick role and actually contributing to their ill health. I may well make my patients worse. What a thought. This labelling phenomenon is not new and was described years ago by Sackett, Haynes, and Illich, among others. A further consequence is the demoralisation of the workforce as we grapple with intractable, non-amenable problems using inappropriate and ineffective methods. A sense of futility, personal failure, and victim blaming is only a breath away. Clearly we cannot abandon people who are suffering and come to us for help, but we must constantly explore and advocate with them, with each other, and in the larger world, alternative non-medical ways of dealing with the problems. I think it was one Dr Ernesto ‘Che’ Guevara, a middle class asthmatic, who observed, ‘Doctors are the natural advocates of the poor’.