The only guarantee Covid gives is that things will get worse. Not a hard thing to see, with unemployment racing to match the eighties and mortality figures soaring. This is what pandemics do. Make things bad for many, and end mor lives. This is what we have forgotten, after decades of complacency.

Injustice matters because it’s a core part of what health inequality means. It’s not enough just to observe a health difference, say a 10-year gap in average life span between people living in two geographic areas: health inequality is defined as recognising that difference as both avoidable and unjust. The sense of injustice is easy enough to illustrate: that 10-year gap is real in the city I live in, Birmingham. The two areas are the most deprived and the least deprived. They are 10 miles apart. One year into an earlier grave for every mile. Other comparisons have been made along similar lines: literally along tube lines in London, or between different parts of the country. Look to any depth and you will soon realise that this is not about people behaving badly, and certainly not about virtue and blame. It’s about poverty. Rather, what poverty (or wealth, if you head to the better parts of town) reflects: the physical environment, income, housing quality, social networks, feelings of stress, shame or isolation and yes, some aspects of behaviour. Which are just as much about fending off feelings of stigma and loss of control as they are about risking poorer health. Tell me which of those overarching aspects to reality are avoidable.  Can someone enjoy a spacious house if they’re too poor to even think of making the rent? Can someone feel positive about themselves when they can’t heat their damp, crowded, squalid rooms and need to go to food banks just to feed their kids? All of these are avoidable. All of these are about political choice, far more than the personal. All of them are unjust.

Source: Office for National Statistics

Enter the doctor. It used to be the case, not so many years ago, that healthcare provision was held not to make that big a difference to health inequality, at least not in the UK. We had our NHS. Everyone could get the treatment they needed, when they needed, no matter how poor. But there always was that whisper from a crueller time, that poor areas got the rougher deal. It was called the Inverse Care Law, and was held up as one of the main reasons for the NHS to exist. Doctors went where the money was. Apologies: doctors do not practise medicine to rake in the dosh (well, not those I work with!). It’s just that without free healthcare, that’s what happens.

And it’s coming back. With decades of under-funding, years of austerity, and now Covid, if you’re poor you are increasingly likely not to get timely healthcare, or seek it in the first place. Already burdened with the overarching drivers for inequality, deprived communities are now appreciably more likely to have to do without for longer, maybe too long. The yawning gap of injustice beckons, and it grows wider yet. What do we see, to stop this? Precious little so far. There are instead murmurs of blame, castigating the less fortunate for being a burden: the undeserving sick.

That was how it used to be. Blame the poor and given them even less. Could it get worse?  Everything else is likely to. But it need not be. This is about political choice. We can choose to reverse inequality, to build back better. In the end, this is about lives, and fewer lives lost or wasted. The very core of medicine.

Doctors for the NHS campaigns for the principles underpinning the NHS, which includes opposing any move to end universal free healthcare. We welcome medical students. Because a more equitable future for all needs good people to fight for it.

Alan Taman

Communications Manager, Doctors for the NHS

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