There are high metal fences around both my places of work, at the BMJ, there is a lovely commemorative ornamental railing. At our surgery, a security barrier. Two places far apart both geographically and economically. David Taylor-Robinson (Liverpool), highlighted the socioeconomic differences within the UK in his recent talk at the Centre for Excellence in Public Health, when he showed pictures of two places called Kensington, one in Liverpool and one in London, with a 10 year mortality gap. He needed to add little more to underline the persisting social inequality.
Clinicians find this difficult. The social determinants of health are essentially a public health issue. These are government, economic, and societal issues that are so distant from clinical practice as to be almost intangible. It is difficult for any individual doctor to do anything. With some illnesses, we might not even notice unless someone reminds us of the epidemiology. Public health doctors, who view patients at a distance, can see more clearly the influence of social determinants. Clinicians, in contrast, are much more aware of the social consequences of inequality; how illness penalises people more in lower social strata. Better off people tend not to lose their jobs if they are sick, for example, and are less likely to enter a downward health and economic spiral. The social consequences are clear to see.
The BMJ has always highlighted social inequality and health. We don’t harp on about it but we care deeply. By raising issues, publishing research, and stimulating debate we hope that we may, ultimately, make some small difference to the greater world. We could fill the journal every week with research showing a social class gradient for all cause mortality or disease specific mortality for almost every condition. But, it’s not that exciting and it’s very difficult to find research with a new angle or a new message. To our shame as society, there is little new to say, the health impact of social inequality has changed little. What a dreadful indictment.
General practitioners make a huge difference to the personal world of the patient in front of them and I greatly admire those who spend their career in full time practice helping those in some of the most deprived areas. They change lives. But, we also need people to take a global view. On Tuesdays, I am a real doctor dealing with real people and real problems, and would like to do more. For the rest of the week, as an editor, I hope I do.
Domhnall MacAuley is primary care editor, BMJ