Thanks to all who contributed to this lecture, especially
the Worldmapper group (Graham Allsopp, Anna Barford,
Benjamin Hennig, Mark Newman [University of Michigan],
John Pritchard and Ben Wheeler [University of Cornwall]),
Bethan Thomas and George Davey Smith [University of
Bristol] for the most recent work on inequalities in Britain,
and to Dan Vickers and Dimitris Ballas who helped with
some of the others on the work on inequalities in Sheffield.
Why are inequalities in health greater now
than at any times since the 1920s?
Danny Dorling
Talking Points Lecture,10th February 2010
Medical School Lecture Theatre 2, University of Sheffield
Organized by Yorkshire and Humber Teaching Public Health Network
and co-hosted by the School of Health and Related Research (ScHARR)
Why are inequalities in health greater now
than at any times since the 1920s?
Are they?
Three Parts
Why are they?
What to do?
Answers
Are they?
 they are for Britain by area, since 1930s
Why are they?
 much else polarized
What to do?
 realise how much all are harmed by
rising inequality – from national life
expectancy to local housing, education
and labour markets…
Are they?




Here I will only talk about geographical inequalities –
your chances depending on where you were born and live
– not to whom you were born.
We don’t have enough information to be able to answer
this question worldwide, or for Sheffield, but we can for
Britain.
People migrating in geographically selective ways appears
to matter more now than it did in the 1920s and 1930s
when inequalities were driven most strongly by material
deprivation, occupational and (still) infectious hazards.
Today, in Britain, social inequality itself creates injustice.
Worldwide





It can help to put local experiences in national and
international contexts for perspective;
Inequality in health between countries fell, at least until
the 1980s and then rose;
Superficially the rise could be accounted for by young
deaths due to AIDS;
But worldwide inequalities in income and wealth were
also growing at this time.
Infant mortality rates for my grandparents generation
were as high as in the poorest countries today.
Global Life Expectancy (years)
Dorling, D. et al. BMJ 2006;332:662-664
Global life expectancy slope index of inequality between nation states (in years).
Black triangle shows estimated index in 2000-5 with impact of AIDS removed
Copyright ©2006 BMJ Publishing Group Ltd.
GDP development 1955-2000s

Sustaining postwar growth in rich nations after the 70s
would have required another planet, or redistribution.
60%
1969
50%
Decadal growth rates
(in GDP)
1973
40%
1968
30%
1977
20%
10%
0%
-10%
2000
1995
1990
1985
1980
1975
1970
1965
1960
1955
-20%
Africa
Asia
Americas
Europe
Instead there was a hugely inefficient redistribution of wealth to the richest nations.
A more equal world would have seen far fewer young deaths than now occur.
Age of Death: Infants (aged under 1)

8,142,016 deaths
Age of Death: 1-4

2,556,272 deaths
Age of Death: 5-9

863,022 deaths
Age of Death: 10-14

536,950 deaths
Age of Death: 15-19

870,915 deaths
Age of Death: 20-24

1,273,937 deaths
Age of Death: 25-29

1,496,071 deaths
Age of Death: 30-34

1,606,806 deaths
Age of Death: 35-39

1,652,503 deaths
Age of Death: 40-44

1,788,164 deaths
Age of Death: 45-49

2,098,466 deaths
Age of Death: 50-54

2,412,379 deaths
Age of Death: 55-59

2,802,369 deaths
Age of Death: 60-64

3,615,847 deaths
Age of Death: 65-69

4,548,376 deaths
Age of Death: 70-74

5,416,482 deaths
Age of Death: 75-79

5,410,001 deaths
Age of Death: 80-84

4,381,231 deaths
Age of Death: 85-89

3,144,797 deaths
Age of Death: 90-94

1,563,557 deaths
Age of Death: 95-99

484,416 deaths
Age of Death: 100+

92,585 deaths
Causes of death trends illustrate what is
possible with medical progress and an NHS

Change in Chance of Dying by Cause of Death
in England and Wales 1851-1990
NHS
Source: Very old graph from: A New Social Atlas of Britain (Wiley 1995), page 154: http://sasi.group.shef.ac.uk/publications/new_social_atlas/chapter5.pdf
Sheffield – A tale of two cities
http://www.sasi.group.shef.ac.uk/
research/sheffield/
Now, turn from the
world to a single city
in the middle of
Britain.
How have
inequalities in life
chances changed
here over time and
inequalities in health
responded?
This report was an attempt to collate
most of what we know about spatial
inequalities in Sheffield. And how
they have changed since the
late 1960s, the earliest
date have much
date for.
www.shef.ac.uk/sasi
Unemployment inequalities tell us a lot
Source: A Tale of two Cities. The Sheffield Project. http://www.sasi.group.shef.ac.uk/research/sheffield/
Life Expectancy 1851-1900
by Registration District (years)
1851-60
Sheffield
34
Eccleshall
40
GAP
6
1861-70 1871-80
33
35
40
42
7
7
1881-90 1891- 1900
38
39
43
46
5
7
Data taken from Szreter, S. & Mooney, G. (1998): Urbanization, mortality, and the standard of living debate: new
estimates of the expectation of life at birth in nineteenth-century British cities. Economic History Review, LI, 1
(1998), pp. 84-112.
Average life expectancy in Sheffield

Average life expectancy varies by 20 years at the extreme
(for women) and 16 years (for men) – by very small area
This inequality is slightly higher than in earlier years, but in general inequalities
in health within Sheffield have fallen at times and have not risen as much as
has occurred nationally, despite the huge wealth inequalities within this city.
Inequalities in life expectancy in Britain
Nationally there have been rapid increases in inequality since 2002 by area
 Difference between best and worst-off districts by life expectancy (years)
14
14
Females
Males
13
13
12
12
11
11
10
10
9
9
8
8
7
7
1999 2000 2001 2002 2003 2004 2005 2006
1999 2000 2001 2002 2003 2004 2005 2006
Inequalities in life expectancy in Britain
...and even getting worse in 2007 and 2008
 Difference between best and worst-off districts by life expectancy (years)
14
14
Females
Males
13
13
12
12
11
11
10
10
9
9
8
8
7
7
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008
Poverty, deprivation and health:
the dose-response has been known for many years
250
200
150
SMR <65
100
50
0
0
5
10
15
20
25
30
35
40
45
% Poverty
Scatterplot of standardized mortality ratio for deaths under
65 and % of households living in poverty (Breadline Britain
index), for parliamentary constituencies (Britain (1991-1995)
Source: Modified graph from Shaw, Dorling, Gordon & Smith (1999): The widening gap. Health inequalities and policy in Britain. The Policy Press. Bristol.
Mortality Patterns in Britain 1921-2005
Rates of inequality fell then rose from 1973

Change in SMR by Local Area Poverty Rate (pre 1974 boundaries)
1.2
1.1
1
6
7
8
9
2004-06
2002-04
1999-2001
5
1996-97
4
1993-95
1969-73
3
1990-92
1959-63
2
1986-89
1950-53
1 (most poor)
1981-85
1936-39
1931-35
1926-30
1921-25
0.9
10 (least poor)
Mortality Patterns in Britain 1921-2005
Some more unusual maps are need to see:
Sheffield
Mortality Mosaics: SMR 1921-1925

10:10 ratio of deciles: 2.02
Created by John Pritchard
http://sasi.group.shef.ac.uk/research/mortality_mosaics/
Mortality Mosaics: SMR 1926-1930

10:10 ratio of deciles: 2.41
Created by John Pritchard
http://sasi.group.shef.ac.uk/research/mortality_mosaics/
Mortality Mosaics: SMR 1931-1935

10:10 ratio of deciles: 2.35
Created by John Pritchard
http://sasi.group.shef.ac.uk/research/mortality_mosaics/
Mortality Mosaics: SMR 1936-1939

10:10 ratio of deciles: 2.89
Created by John Pritchard
http://sasi.group.shef.ac.uk/research/mortality_mosaics/
Mortality Mosaics: SMR 1950-1953

10:10 ratio of deciles: 1.96
Created by John Pritchard
http://sasi.group.shef.ac.uk/research/mortality_mosaics/
Mortality Mosaics: SMR 1959-1963

10:10 ratio of deciles: 2.25
Created by John Pritchard
http://sasi.group.shef.ac.uk/research/mortality_mosaics/
Mortality Mosaics: SMR 1969-1973

10:10 ratio of deciles: 1.92
Created by John Pritchard
http://sasi.group.shef.ac.uk/research/mortality_mosaics/
Mortality Mosaics: SMR 1981-1985

10:10 ratio of deciles: 2.12
Created by John Pritchard
http://sasi.group.shef.ac.uk/research/mortality_mosaics/
Mortality Mosaics: SMR 1986-1990

10:10 ratio of deciles: 2.22
Created by John Pritchard
http://sasi.group.shef.ac.uk/research/mortality_mosaics/
Mortality Mosaics: SMR 1991-1995

10:10 ratio of deciles: 2.55
Created by John Pritchard
http://sasi.group.shef.ac.uk/research/mortality_mosaics/
Mortality Mosaics: SMR 1996-2000

10:10 ratio of deciles: 2.83
Created by John Pritchard
http://sasi.group.shef.ac.uk/research/mortality_mosaics/
Mortality Mosaics: SMR 2001-2005

10:10 ratio of deciles: 2.84
Created by John Pritchard
http://sasi.group.shef.ac.uk/research/mortality_mosaics/
Inequalities in premature mortality
here is another way of looking at the rates
Geographical Inequalities in premature mortality (SMR<65) 1921-2006
2.9
2.7
2.5
2.3
2.1
1.9
1.7
1.5
10:10 Ratio
Overall Index of Inequality (RII)
Note that the time periods vary due to data limitations; in particular, there is a large gap between 1939 and 1950. For 1990 (included in 1990-92), 1991 population figures were
used. For 2006 (included in 2004-06), 2005 mid-year estimates (the latest available at small area geography) were used. Note that the final column does not follow on but
overlaps; it is the latest 3 years for which mortality data were available for all of Britain.
Polarisation even for the rarest causes
Poverty and Murder in Britain
Change in SMR for Murder by Ward Poverty, 1981/85-1996/00
Least poor
-4%
Decile 9
-7%
Decile 8
4%
Decile 7
7%
Decile 6
9%
Decile 5
8%
Decile 4
18%
Decile 3
28%
Decile 2
34%
39%
Source: Data from Dorling, Gordon, Hillyard, Pantazis, Pemberton, &Tombs (2008): Criminal obsessions: why harm matters
more than crime. Second Edition. London: Centre for Crime and Justice Studies. http://www.crimeandjustice.org.uk/
Most poor
And it is worth remembering
what the key causes now are:
Main Cause for people dying in Britain (by age)
in the period 1981-2004
Age




0
1-4
5-14
15-34
Cause
Other conditions in the perinatal period
Congenital malformations of heart
Pedestrian and motor vehicle accidents
Other motor vehicle accidents
(driver/passenger/cyclist)

35-95 Heart attack and chronic heart disease
Source: Dorling, D. (2008). Supplementary memorandum from Professor Danny Dorling, pages Ev 323- 324 House of
Commons Transport Committee: Ending the Scandal of Complacency: Road Safety beyond 2010.
Full details given in the preface of Shaw, M. et al., 2008, The Grim Reaper’s Road Map, Bristol: Policy Press.
Underlying inequalities in health is
Income inequality in Britain: the trend
20%
18%
16%
14%
What the richest
1% get
12%
10%
8%
6%
4%
(post tax)
2%
0%
1920 1930 1940 1950 1960 1970 1980 1990 2000

As a result of what first became politically possible and
then, apparently, politically impossible, inequality fell and
then rose. It is hard to believe this trend is unconnected
From this
The most harmful cost of inequality
31%
Inequality in health –
premature mortality
29%
27%
25%
23%
21%
19%
17% Best and worse off area –
15%
differences from average
1920 1930 1940 1950 1960 1970 1980 1990 2000

In more unequal times, and in the aftermath of the shock of mass unemployment, more people in
poorer areas die young as compared to other times and places. The prospects of the wealthy also
move away from those of the average. The line marked by squares shows how much lower the
age-sex standardized under age 65 mortality rate of the best-off 10% by area is as compared to
the average. The line marked by dark diamonds shows how much higher that of the worst-off 30%
is than the average. (Source Dorling and Thomas 2009, derived from Table 4.3 with interpolation
between five year rates in some circumstances)
What to do? - read somebody else’s book!
Inequalities have a direct impact on health, so
they need to be reduced in all areas of life!
Image Source
What to do?
www.polyp.org.uk
Inequalities have a direct impact on health, so
they need to be reduced in all areas of life!
 Health: GPs where they are needed
(like nurses) – it is easier in a time of crisis
(like the NHS after the war).
 20mph speed limit in residential areas
should be a key public health policy.
Source: http://risingtide.org.uk/book/print/269
 Education: In affluent countries with elitist
education all children do worse at school. –
Solutions: Ensure the nearest school to
every child is funded by need, not just
numbers.
 Poverty: NOT means testing – this results
in a JSA of £9 a day.
References



Day, P., Pearce, J., and Dorling, D. (2008). Twelve worlds: A geo-demographic
comparison of global inequalities in mortality. Journal of Epidemiology and
Community Health, 62, 1002-1010
Dorling, D., Shaw, M. and Davey Smith, G. (2006). HIV and global health:
Global inequality of life expectancy due to AIDS. BMJ, 332, 662-664.
Dorling D. and Thomas, B. (2009). Geographical inequalities in health over
the last century, Chapter 1.3 in Graham H. (Ed.) Understanding Health
Inequalities, Open University Press. Pp. 66‐83.
Credits




Mortality mosaic maps by John Pritchard
World maps by the Worldmapper team
Slides created by Benjamin Hennig
Slides available on
http://www.slideshare.net/GeoSaSI
www.polyp.org.uk