Danny Dorling
March 15th 2011
How long before we
see life expectancy
falling in some areas of
the UK?
London School of
Hygiene and Tropical
Medicine,
first given as:
Annual DARE lecture,
NHS National Services Scotland
Faculty of Public Health
Conference, Dunblane,
You have to go back a long
way in time to find falls in life
expectancy (1918, 1854…?)
12th November 2010.
1
How long before we see life expectancy falling in some
areas?
Danny Dorling
University of Sheffield
DARE lecture, NHS National Services Scotland Faculty of
Public Health Conference, Dunblane, 12th November 2010
(apologies for the busy slides – lots to say)
Why should we be concerned that falls are possible?
Because expectancy has hardly been rising in some areas.
How will we first know that they are occurring?
When ONS/GRO(S) release data for a district showing a fall
When will we be sure as to the reasons?
Depends: The reasons, or the reasons underlying the reasons?
Where might life expectancy fall first?
That is not so easy to answer, maybe where it is artificially high?
What should we do to stop it?
Don’t do what they do in affluent countries where there are falls
We need not see falls in areas in our lifetimes. Or the first may be this year
2
I think it is our choice, the key is how well we resist divisive social policies.
With Bethan Thomas
I’ve been working on
a new atlas with a
new map
G la sg o w
E d in b u rg h
N e w c a s tl e
S u n d e r la n d
M id d le s b r o u g h
and with
George Davey Smith
we found that by 2007
inequalities in
Hull
death rates were
higher than any
time since
1921
B ra d fo rd
B l a ck p o o l
Leeds
B o lto n
M anc hester
S h e ffi e ld
L iv e rp o o l
D e rb y
Stoke
N o t tin g h a m
N o rw ic h
L e ic e s te r
C a m b rid g e
B i r m in g h a m
C o v e n tr y
O xf o rd
Sw ans ea
C a r d i ff
S w in d o n
B ri sto l
Ip sw ic h
L u to n
O u te r
London
In n e r
S o u th e n d
See: Thomas, B.,
Dorling, D. and Davey
Smith, G. (2010).
Inequalities in
premature mortality in
Britain: observational
study from 1921 to
2007, BMJ, Friday 23rd
July.
http://www.sasi.group.sh
ef.ac.uk/publications/20
10/ThomasDorlingDave
ySmith_2010_BMJ.pdf
Here are the
major towns
and cities by
built-up area.
You need to
understand this
map to know
what the next
slide is showing
you.
London
3
R e a d in g
Dov er
Budget
cuts to
come.
2010–2011
reduction in
main
revenue
grant
allocations
(%), local
authorities,
England
Reduction in main revenue grant allocations 2010-11 (%)
-2.0
-1.7 – -1.0
-0.9 – -0.8
-0.7
-0.6
-0.5 – -0.1
0.0
This is a
map of the
future of
‘just’
£6 billion
cuts
Claimant count change July 09 - July 10 (%)
-1.5 – -1.1
-1.0 – -0.6
-0.5 – -0.1
0.0 – 0.3
0.4 – 0.7
Recent changes in
unemployment
claimant
geography
This is a
map of the
past (09-10).
Not of the
490,000+
one million
(?) to come
Job
cuts
in
last
4
year
For what I think are the real
reasons behind the reasons,
New Zealand is an ideal place to
look: See Jane Kelsey’s
explanation of how the country
was used as a natural
experiment for policies later
exported to places such as the
UK in: ‘The New Zealand
Experiment (1997 2nd ed.):
She says:
“Ultimately, the people of New
Zealand have to decide what
kind of society they wish to live
in, and work together to create it.
In the meantime, other countries,
governments and peoples who
are being told that they too have
no alternative to the corporate
agenda should learn from New
Zealand's tragic mistake.”
http://www.converge.org.nz/pma/apfail.htm
Take somewhere a long
way away where they
have asked sensible
questions for a long time
in their censuses, such
as where were you living
five years ago and do
you smoke? (in 1981,
1996 and 2006).
Reasons
behind the
reasons
Pearce, J.R. and Dorling, D.
(2010). The Influence of
Selective Migration Patterns
Among Smokers and
Nonsmokers on
Geographical Inequalities in
Health, Annals of the
Association of American
Geographers, First published
on: 18 March 2010.
http://www.sasi.group.shef.ac.uk/publications/
2010/PearceDorling_2010_AnnalsAAG.pdf
5
Pure migrant
contribution
Lived outside Auckland in 1976
(and never smoke by 1981)
12,018
1,587
Lived outside Auckland in 1976
(and smoked in 1981)
(28% immigration)
10,431
Males in Auckland in 1981
Lived Outside NZ in 1976
108,711
3,705
(denominator for -1.17%)
Lived Outside NZ in 1976
3,264
Ex-Smokers
Ignored from herein
27,492
Never Smoked in 1981
Never Smoked:
Lived in Auckland in 1976
Lived Elsewhere in 1981
Smoked:
Lived in Auckland in 1976
Lived Elsewhere in 1981
Smoked in 1981
44,568
41,229
34,584
36,651
Difference
(net increase in never smoked)
3,339
But this is just the men, in one
area, in one of three time periods
with smoking data (the 1981,
1996 and 2006 NZ censuses).
So repeat…. 2 x 3 x 21 times
Less……..
Difference
(net net gain in never smoked over still smoking)
1,272 = -1.17% net
Difference
(net increase in smokers)
2,067
315
Thus this despite
6
Net new male smokers in Auckland
Superficial
Reasons
Areas that loose
smokers tend to
have higher life
expectancy.
This is not
surprising.
But if the
migration patterns
tighten then
expectancies
diverge, as in NZ.
78
Male life expectancy (2001)
Auckland
is the white dot
amongst the 21
district health
boards of NZ
shown here.
79
77
76
75
74
73
72
-3%
-2%
-1%
0%
1%
Sm oking m igration balance (m ale) as a proportion of the
total population 1976-81
7
2%
Underlying reasons – increased social polarisation by area over time.
Take the x axis of the last diagram and compare it over the three time periods
for which we have data on smoking for how more closely net-smoker-migration
patterns now correlate over time. The answer is more strongly in recent years:
2.0%
-2.5%
-2.0%
-1.5%
-1.0%
0.0%
-0.5%
0.0%
2.0%
0.5%
1.0%
1.5%
-10.0%
-8.0%
-6.0%
-4.0%
-2.0%
0.0%
0.0%
2.0%
-2.0%
-2.0%
-4.0%
-4.0%
-6.0%
-6.0%
-8.0%
-8.0%
-10.0%
Internal + immigration
smoking migration
balance 1976-1981
verses 1991-96
-10.0%
-12.0%
Internal + immigration
smoking migration
balance 1991-96 8
verses 2001-06
Back to the UK: when was it last as bad – today the gap between the
very worse and best-off districts for men and women averaged is ‘around’ 12.4
years when men and women’s experiences are combined – when was it last so
wide?
•
Men and women today have a combined averaged life expectancy of 74.3
in Glasgow as compared to 88.7 in the Royal Borough of Kensington and
Chelsea. Therefore the gap between an affluent enclave of London and one
of the most economically run down of cities in Western Europe is now
twelve years, 17% additional years of life, whereas in the 1880s an extra ten
years on top of an expectancy of thirty six was an additional 28% (20072009 data). Over the very long period we cannot compare relative indexes
of inequality – but the extreme gap has tended to follow these recently.
•
We have to go back to the1880s to find greater gaps than those found
today. The lowest life expectancy recorded in the country then was just
thirty-six years in Liverpool. In Bristol it was then ten years higher. [Szreter, S.
and 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, 51,
1, 84-112 (table 1). In Liverpool registration district itself, life expectancy in the 1880s was only 29
years of life, some 19 years lower than the 48 years recorded then in the affluent Clifton district of
Bristol (ibid, table 2). In Glasgow in earlier years similarly low rates as in Liverpool were recorded,
as low as age 27 around 1840 (ibid, table 5). Infant mortality was key to determining these low
overall ages, dragging average life expectancies down as so many died in that first year.
Manchester’s life expectancy for 1801 to 1850 was the lowest I have ever seen, calculated at
25.3 years, affecting a population of 235,000 people in 1841, Ibid: Szreter and Mooney (table 3).]9
Inequalities in health & wealth
•
•
Inequality, in survival chances
to age 65 in Britain, 1918-2005+ [BMJ]
The age-sex standardized mortality
ratios for those under 65 can be
compared by area back to the situation
around 1920 and are found to have
reached a peak then and in the later
1930s which is only being exceeded
today in terms of how much worse off
the chances of those in the areas with
poorest health are compared to the
average and how much better-off the
best-off tenth are.
Income inequality (X axis) verses Health
These geographical changes in
inequalities (Y axis) in Britain, 1918-2005
inequalities in health have tracked
social changes in inequalities in
incomes very closely over the period
1918-2005 except for during the 1930s
when inequalities in income fell but
inequalities in health rose as jobs went.
The very rich then became poorer, but
"1931"
the effect took another decade to be
transferred to health. Each square here
10
is the year of a general election.
32%
30%
28%
26%
24%
22%
20%
18%
16%
0%
2%
4%
6%
8%
10%
12%
14%
16%
18%
20%
Polarisation in politics and income
Income Inequality, share
held by richest 1%, 1918-2005+
Just over half of the reduction in income
inequalities measured from 1918 to
1978 occurred before World War Two.
Since 1978 all that has now been
reversed. The very latest city bonuses
will have taken us back to the early
1920s gilded age maxima inequality.
But back then life expectancy in an
area fell when there were pit disasters,
otherwise there were mostly differential
Electoral Inequality, Segregation Index
improvements everywhere.
of Tory voters, 1918-2005+
Similarly, political polarisation has fallen
from 1918 until October 1974 and has
then risen ever since, including in 2010.
Only a ‘coupon’ election in 2015 could
emulate 1918. (Sources: Dorling, D.,
2010, Injustice, why social inequalities
persists, Bristol: Policy Press).
Sources: ‘Injustice’ Chapter 5
+ New Statesman (2010)
11
When inequalities are high victims are blamed
We reduced inequalities in the past by blaming the system, not victim.
In the future we should expect to continue to see people exercising lifestyle
choices that are harmful, such as going into businesses similar to
advertising cigarettes and finding it easier to target children living in poorer
areas by putting up hoardings just outside the school exclusion zone; or
exercising the lifestyle choice to sell cheap alcohol, the worst of our drugs.
However, I think we will start to curtail such damaging profiteering. People
will become less susceptible to the argument of blaming individuals for the
behaviour that others try to sell them, of seeing differences in smoking,
drinking and diet across the country as some sign of a map of personal
weakness…. rather than these being the target marketing areas of the
wickedly unscrupulous.
12
So, when should we expect to see life expectancy fall in an area?
All the trends appear to be pointing towards that eventuality
“Big variation in life expectancy”
When last year’s “latest figures” were released on 21 October 2009 at 9:30
am, for the first time in many years the BBC chose not to report the rise.
Instead it lead with “Swine flu vaccination under way” and then “Big variation
in life expectancy ”. The ONS press release was titled “Life expectancy
continues to rise”.
In fact, what was reported in the figures that October, just over a year ago,
was an acceleration in recorded health inequalities, and a fall in life
expectancy for men in Glasgow, but not one that was “significant”.
The story was illustrated with the image of a baby.
http://news.bbc.co.uk/1/hi/health/8317986.stm
13
What the BBC should have said is:
“Acceleration in the growth of income inequalities across the
UK”
11.5 years for women
14
14
13
13
Difference between best
and worst-off districts by
life expectancy (years):
People
12.45 years
Difference between best
and worst-off districts by
life expectancy (years):
Females
12
11
10
9
12
8
7
11
6
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008
10
13.6 years for men
9
14
13
Difference between best
and worst-off districts by
life expectancy (years):
Males
12
8
11
10
7
9
8
6
7
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008
6
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008
“Inequalities in health – latest
figures by area (district gap)”
Gap in years
between the
average life
expectancy in
the worse-off
district of Britain
and the best-off,
all, women, men,
Source: ONS
various years
Only recorded ‘fall’
is in Glasgow of 0.1
years – within
confidence limits
(although do not
have too much
confidence in
those!)
14
19 October 2010: ONS release – which should have said: “rapid
deceleration in growth of health inequalities during 2009”
Some 364 days later – a day before the Comprehensive
Spending Review the next set of data is released with
the following interpretation from ONS:
“Life expectancy at birth
Life expectancy results for 2007–09 showed a similar
geographic pattern to previous years, with inequalities
persisting across the UK. The South East, South West
and East of England continued to have the highest life
expectancies at birth”
Source: Life expectancy at birth and at age 65 by local
areas in the United Kingdom, 2007–09;
http://www.statistics.gov.uk/pdfdir/liex1010.pdf
15
Daily Mail headline of October 20 – was it wrong?
“The
gap that cheats Scots out of 13 years; life
expectancy shorter north of the Border”
•
•
Daily Mail (London, England), The, Oct 20, 2010
Byline: Alan Roden Scottish Political Reporter
“THE gap between life expectancy in parts of the West of Scotland and SouthEast England has widened to more than 13 years, according to 'damning'
new figures. A baby boy born today in Glasgow will, on average, live for
71.1 years, compared to 84.4 years in London's Kensington and Chelsea.”
However, this is 13.3 years (84.4-71.1) but the gap for men had been 13.6
years a year earlier (84.3-70.7). So was the gap growing or shrinking?
16
Initially it did appear as if the gap narrowed:
When comparing 2006-2008 with 2007-2009
For the extreme areas, for men then women, respectively, life expectancy rose
from 70.7 to 71.1, 77.2 to 77.5, in Glasgow and from 84.3 to 84.4, and 88.8
to 89.0 in Kensington & Chelsea. We will not know for at least a year
whether this change at the extremes is indicative of wider trends, or remains
(because the data is not disseminated fast). (Glasgow men in 2005-6: 70.8)
For women the gap reduces from 11.6 to 11.5 years.
For men the gap reduces from 13.6 to 13.3
ONS, 2009, Life expectancy at birth and at age 65 by local areas in the United
Kingdom, 2006-08, released 21 October 2009, London: Office of National
Statistics. http://www.statistics.gov.uk/pdfdir/liex1009.pdf.
ONS, 2010, Life expectancy at birth and at age 65 by local areas in the United
Kingdom, 2007-09, realsed 19 October 2010 London: Office of National
Statistics: http://www.statistics.gov.uk/pdfdir/liex1009.pdf
17
But then there is a ‘1984’ style footnote in the latest
figures about past statistics simultaneously being revised :
“Figures for 2000-02 to 2006-08 have been updated due to revisions in the
England and Wales mid-year population estimates for 2002 to 2008
(published by ONS in May 2010)”
Note – no revisions in Scotland – in Glasgow the improvements stands
•
http://www.statistics.gov.uk/StatBase/Product.asp?vlnk=8841
So: For the extreme areas, for men then women, respectively, life expectancy
rose from 70.7 to 71.1, 77.2 to 77.5, in Glasgow and
from 84.1(was .3) to 84.4, and 88.7 (was .8) to 89.0 in Kensington & Chelsea.
For men still a drop from 13.4 to 13.3 – so the Daily Mail was wrong
For women the gap remains at 11.5 years at both periods.
For both sexes simply combined the gap falls from 12.45 to 12.40 years….
18
There were no headlines claiming: “Gordon’s last year his
best!”
The reason was partly the complexity of revisions, but also the sense of failure.
“ Duffy: – but all these eastern Europeans coming in, where are they flocking from?
Brown: A million people come in from Europe, but a million British people have
gone into Europe, you do know there’s a lot of British people staying in Europe as
well. So education, health and helping people, that’s what I’m about.” The Times, 28/4/2010.
The education gap was found earlier in the year to have closed significantly, and, on
the day before the Comprehensive Spending Review came the first ever evidence of
the geographical health gap closing by a fraction.
None of that mattered because Brown did not say: “Eastern Europe, dear Lady”.
Step back and look at non-over lapping time periods 2004-2006 to 2007-2009:
For the extreme areas, for men then women, respectively, life expectancy rose
from 70.5 to 71.1, 77.0 to 77.5, in Glasgow and from 83.1* to 84.4, and
87.2* to 89.0 in Kensington & Chelsea. The gap grows from 11.4 to 12.4
years, the acceleration is removed.
(* now revised to 83.0 and 87.1 apparently so 11.5 to 12.4)
19
What do we see overall rather than just at the extremes?
Life expectancy in years by district, all UK 2004-2006 (x axis) and change to
2007-2009 (y axis) using data from just before the very latest revisions
4.0
Inequalities were slowly rising, although we now
think that may have ended, at least for a moment,
in 2009. It does look as if a hiatus had been reached.
3.0
2.0
1.0
0.0
-1.0
-2.0
68
70
72
74
76
78
80
82
84
20
However, for men – here are the most significant changes
2004-6 to 2007-2009:
Merthyr Tydfil 74.6 (73.7-75.5) was 75.5 (-0.9)
(But, revised down in earlier years to 75.4)
and rises of at least 1.9 years above LCL in:
Westminster 83.4 (82.8-83.9) was 80.2 (+3.2)
South Cambs. 81.6 (81.1-82.2) was 79.2* (+2.4)
Harrow 81.2 (80.8-81.7) was 78.9 (now 79) (+2.3)
(* now 79.4)
21
For women – changes in the same areas which suggests that
the fall is not across the board, but in London the rises were:
Merthyr Tydfil 79.3 (78.4-80.3) was 79.1 (+0.2)
So an improvement where men fell.
And, in comparison to the men:
Westminster 86.5 (86.0-87.0) was 84.0 (+2.5)
South Cambs. 84.5 (84.0-85.0) was 84.2 (+0.3)
Harrow 84.6 (84.1-85.0) was 83.1 (+1.5)
(all 2004-2006 original to 2007-2009)
22
Then came the spending review
October 20th 2010 – we were told how
savings would be made:
•
•
One of the first announcements
was that new tenants of council
and other social housing will now
have to pay at least 80 percent of
market prices in rent. In one
stroke millions of low paid families
are to be excluded from living in
hundreds of towns, cities and
villages where they no longer earn
enough to “deserve” to be.
There are many threats being
made to have to take any job or
be made to “volunteer” for no
pay.
•
Housing benefit will not be paid for
people under the age of 35 who
live alone—this previously applied
only to those under 25.
•
There would be a 10 percent cut
in council tax benefit for those who
cannot afford to live in certain
areas.
•
The immediate question asked
was: Are the few remaining people
living on modest incomes near
affluent suburbs or in
economically successful towns
and villages to be cleansed
away?
23
It could be the greatest threat to health inequalities
•
The best-off fifth of society will
lose just 1 percent of their
entitlements to public services and
spending, the lowest losses of any
group.
•
A million people currently on
employment and support
allowance due to ill health will
each lose £2,000 a year if they
cannot find a job.
•
With the state pension age rising
rapidly to 66 years, only those with
private provision can now retire at
the normal age. Public sector
pensioners will have £1.8 billion
removed from them by 2014-15.
Pension credits will be frozen for
three years.
•
No family on benefits is to receive
more than the income of an
average family in work, no matter
what the circumstances of their
children. If you are poor—or are
made poor when you lose your job
or have a pay cut forced on you—
and have three or more children,
you may need to leave your town
for a new life in a cheaper area,
away from where the remaining
well paid work is.
•
People with worse health will have
to move to poorer areas.
•
This is a recipe to increase
inequalities between areas as fast
as possible. I think it makes
everyone worse off, so is in the
saddest sense ‘fair’, but only in
its likely stupidity of outcome.
24
Conclusion – keep asking
why are 16 or 20 countries better?
Everyone is worse off because there
is less social solidality, more fear:
•
The latest UN report lists those
European countries currently
having a higher life expectancy
than the UK as: Iceland (almost 82
years), Switzerland, Italy, France
(81 years), Sweden, Spain,
Norway, Austria (to almost 80
years), the Netherlands, Germany,
Ireland, Malta, Cyprus, Finland,
Belgium and Luxembourg. People
also live for longer than in Britain
in Australia, Canada and New
Zealand (and especially Japan),
but not in the United States
(where comparable life
expectancy is only 79.1 years)
Of the richest 25 nations in the world
the UK is the 4th most unequal by income
inequality (90:10 ratio UNDP figures).
•
People do live slightly shorter lives
now in Greece (but not by 2010 EU
data), Portugal (more economically
unequal than the UK), Denmark
(where smoking is still very
common) and in Slovenia (78.2
years). All these figures are from
Table H of the most recent UNDP
human development report (2009)
and purport to be for around the
year 2007.
•
Life expectancy is up in the UK, but
increased economic inequality here
would be expected to move our
rank position below one of these
four countries next, to slip from 20th
place to 21st or 22nd out of 25. If that
happens then there will be falls in
life expectancy in some areas.
… we have just moved below
Greece, and the cuts there are far
more equitable than here…
(salaries cut rather than jobs
25
and mostly benefits going…)
•