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Some are more equal than others

26 Mar, 09 | by Steven Reid, Evidence-Based Mental Health

With free market capitalism seemingly spinning off into oblivion, despite the best efforts of our Supreme Leader and his G20 disciples, the benefits of globalisation for the world economy are looking a little shaky at the moment. Whilst it has brought an unprecedented increase in prosperity for some, for others low wages and an economy underpinned by massive debt mean that the world seems a more unequal place than ever before. These inequalities are of course not just international but intranational: countries are made up of classes.

In 2004 Michael Marmot charted the impact of inequality on health in The Status Syndrome. This month his text is joined on the shelf by The Spirit Level (Richard Wilkinson and Kate Pickett). Both books marshal an array of epidemiological studies to present a robust bottom line: there is a strong correlation between a country’s level of economic inequality and its social and environmental problems. What’s more, it isn’t just the poorest in the most unequal societies that suffer but the richest too. So according to Wilkinson, “countries such as the US, the UK and Portugal, where the top 20% earn seven, eight or nine times more than the lowest 20%, scored noticeably higher on all social problems at every level of society than in countries such as Sweden and Japan, where the differential is only two or three times higher at the top.” And those social problems range from obesity to big prison populations, from teenage pregnancy rates to, of course, mental illness.

That an unequal society leads to more mental distress may seem self-evident but a study recently published by the World Health Organisation – Mental health, resilience and inequalities – amasses a broad range of evidence to show that mental health problems are not only more pronounced in unequal societies, but that mental health is also key to understanding the impact of inequality on a range of other health outcomes. Dr Lynne Friedli, the report’s author, maintains that the chronic stress of struggling with material disadvantage is intensified by doing so in more unequal societies. In turn chronic stress has a deleterious effect on the neuroendocrine, cardiovascular and immune systems increasing the risk of disorders such as coronary heart disease and metabolic syndrome. Maybe so, although the strength of the evidence is contestable. But what’s to be done? Dr Friedli’s wish list seems rather optimistic:

• social, cultural and economic conditions that support family and community life
• education that equips children to flourish both economically and emotionally
• employment opportunities and workplace pay and conditions that promote and protect mental health
• partnerships between health and other sectors to address social and economic problems that are a catalyst for psychological distress
• reducing policy and environmental barriers to social contact

This sounds too much like ‘motherhood and apple pie’ to me, although a strident call for wealth redistribution would probably be asking a lot of WHO. Of course, the UK government would claim that they have made considerable progress in all of these areas over the last decade. If that is the case, why is there a need to convene a new National Equality Panel to show how your chances in life are influenced by, among other things, ‘how much money you earn’? We are also awaiting another review of Health Inequalities in England to show us the way.

Gordon Brown is busy trumpeting the need for economic and financial reforms ahead of the G20 meeting, or as it has now been rebranded: the London Summit. An opportunity to redress global imbalances? Not bloody likely. I’m more inclined to believe this pithy observation from the Financial Times: “A crisis-torn world is in no mood for the heavy lifting of global rebalancing. Policies are being framed with an aim towards recreating the boom. Washington wants to get credit flowing again to indebted US consumers. And exporters – especially in Asia – would like nothing better than a renewal of demand led by the world’s biggest consumer. It is a recipe for disaster.”

You’ve Never Had it so Good

27 Nov, 08 | by Steven Reid, Evidence-Based Mental Health

That’s not exactly what he said but Andrew Lansley, the Conservative Party’s shadow health secretary, has been slapped down by the party leadership for suggesting that the economic recession may bring health benefits. This is what he did actually say on his blog:
I’ve been reading up on the impact of previous economic downturns on our health. Interestingly on many counts, recession can be good for us. People tend to smoke less, drink less alcohol, eat less rich food and spend more time at home with their families.

You can’t read this now as the post was swiftly removed from the Conservative Party website but to be fair he prefaced his statement by emphasising that for many the everyday reality of recession does mean human misery. Furthermore it certainly is the case, as he reports, that some economists have identified a variety of health indicators that improve during a depression, a notable exception being that of mental health. His comments have caused the inevitable political spat with calls for his head and Mr Lansley has apologised (presumably through gritted teeth).

What does this rumpus have to do with mental health? Well, Lansley was actually trying to highlight the impact of a recession on mental health. He suggests that the recession may lead to a 26% rise in the number of people suffering with mental health disorders by 2010. I’m not sure where those figures come from – they sound rather speculative to me – but what is clear is that debt and mental health are inextricably linked. Seemingly self-evident, it is a point reinforced by good epidemiological data. A study by Rachel Jenkins and colleagues using data from a national cross-sectional survey demonstrated this association, showing that one quarter of people with mental health problems are living with debt or arrears (compared to one tenth of the general population) and 10% have had a domestic utility disconnected. A timely joint initiative has just been launched by the Royal College of Psychiatrists and the First Step Trust. The aim is to provide guidance on supporting patients with debt and mental health problems, an area of ignorance for many health care professionals. The leaflet ‘Final demand – Debt and Mental Health’ can be accessed here and is informative whether you have mental health problems or not. So Mr Lansley’s comments, deemed nonsensical by many, are actually noteworthy. It’s a pity that they will be lost amidst the shrill cacophony emanating from the Westminster village.

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