Thursday, 20 June 2013

The nonsense of health inequalities

The Times has written an editorial (£) about 'health inequalities' which is bound to enrage sociologists, statists and public health types. Banging on about health inequalities is one of many methods used by the Left in the post-Soviet era to campaign for socialism without actually calling it socialism.

It is well known that rich people—on average—tend to live longer, healthier lives than the poor. Life expectancy in Kensington and Chelsea, for example, is an astonishing 89 years (too long, in my opinion). From this, the leftists deduce that the way to get rid of health inequalities is to get rid of income inequalities. By a happy coincidence, economic equality is what they were striving for anyway, but the rhetoric about health makes it sound as if capitalism is killing people.

It's certainly true that people tend to be healthier as they get richer, but that is an argument for making everybody richer rather than addressing inequality per se. That, however, would not fit the politics of envy, so 'health inequalities' it is.

But income is only one factor that influences health outcomes and the relationship between the two is not as simple as is often implied. Poor health will likely lead to low incomes, for example (reverse causation), and the same character traits that lead to unhealthy lifestyles may also lead to poorer job prospects (the third variable). It is the latter point that The Times stresses in its editorial...

It isn’t fat and sugar that kills people so much as fecklessness: a trait that will always be concentrated in the less well-off. Of course there are poor people who eat sensibly and there are wealthy people who smoke, drink and snort their way to oblivion, but the reason that more than twice as many people die before the age of 75 in Manchester, England’s unhealthiest district, than do in Wokingham, the healthiest, is because on the whole people in middle-class commuter towns look after themselves better. The same values that help them to postpone reward to train for jobs and to pay their mortgages help them to refrain from excess at the dining table.

No politician dare risk saying any of this, however. Instead, the tendency of the poor to die early is explained by the vague concept of “deprivation” — without it being clear of what they are supposed to be deprived.

The reason no politician dare say this is that it leads to the conclusion that people have free will and personal responsibility. This goes against the grain of the ludicrous, but widely accepted, sociological consensus that individuals are victims of circumstance whose destiny is decided at birth based on the postcode they were born in and the occupation (if any) of their father.

As Sam Bowman has been saying on Twitter, "fecklessness" is not quite the right word here. People are making a rational choice to prioritise pleasure and enjoyment ahead of health and longevity—a decision that many middle and high earners also make. Recklessness might be a better word, but even that invites moral disapproval.

Public health folk would argue that such choices are not rational (because of hyperbolic discounting and suchlike) and sociologists would argue that they are not free (because accidents of birth make them more likely to choose the unhealthy option). I have little time for such arguments. Accusations of irrational consumption invariably revolve around the moral judgement of the accuser while choices, even if constrained by imperfect information and financial circumstance, are still choices. The fact that the smoking rate is higher in Glasgow than Sevenoaks, for instance, in no way predisposes a Glaswegian to smoke. It is not 'victim-blaming' to point this out.

Insofar as 'lifestyle factors' are a determinant of longevity, they are optional. They are freely entered into with all the costs and benefits borne by the individual. Any serious attempt to get rid of 'health inequalities' must necessarily involve forcing everyone to live the same way. This, as The Times says, is a great threat to liberty...

To have any chance of ironing out “inequalities” a government would have to be ruthless. It would need to deploy health police to close down all takeaways within miles of poor areas and replace them with greengrocers. As for education, it would have to detain poor children at school, in a proper learning environment, and not let them home until bedtime, if at all.

Some of these measures, of course, might be unpalatable from a human rights perspective. We might just have to put up with the inevitability that some social classes will live longer and get better exam grades than others — and stop worrying about it.

The only health inequalities that should concern the government are inequalities in state healthcare provision. So long as the government operates an egalitarian system of nationalised healthcare, it should be of the same standard everywhere. Running the NHS can be seen as a proper function of government; running people's lives cannot.


Simon Cooke said...

...isn't mobility a factor here?

The Mancunian who makes it good doesn't stay in Harpurhey or Moss Side but high tails it to Prestwich or Hale Barns.

...and the struggling person in Altrincham? Aren't they more likely to end up in low rent places - say Harpurhey or Moss Side?

Curmudgeon said...

Isn't it also the case that the top income quartile drink more than the bottom quartile, but manage it better?

Christopher Snowdon said...

Yes to both!

Colonel Shotover said...

"It would need to deploy health police to close down all takeaways within miles of poor areas and replace them with greengrocers. As for education, it would have to detain poor children at school, in a proper learning environment, and not let them home until bedtime, if at all."
Blimey is the Times writing the Labour Party's next manifesto? This is right up Harriet's street.

Eric Crampton said...

If we're REALLY going to start taking health inequalities seriously, we can start by counting the number of functioning kidneys each person has. For those with none, take one from somebody with two.

I don't support such measures. But how different is it in kind from proposals to redistribute income for the purpose of reducing health inequalities (lowering life expectancy a bit at the top in exchange for increasing it a bit at the bottom)?