Health, disease & inequality
As a doctor, I’ve often puzzled over differences in rates of disease, the unequal dispersion of medicine and opportunities for health.
As I walk through my emergency department, a new scatter of patients wait, they murmur to friends and relatives, uneasy amid the bleeps of machines and swish of staff. If I keep walking, out into the ambulance bay, across the forecourt, and tack through the clumps of tourists on Westminster bridge, and if I take the escalator down to the tube and ride the jubilee line east, I know that for each of the next eight stops, the average Londoner loses one year of life expectancy. And if inequality exists here, the country of the NHS, where low income is not usually a barrier to access to healthcare, what could it be like elsewhere? I wanted to find out.
As I pedalled across Asia I stopped off at medical projects, hospitals and clinics to interview patients and staff. I was interested in people on the edge of society: those living in remote areas or those edged out through deforming disease, mental illness, drug addiction; or for social, cultural and economic reasons. I wondered about how people become marginalised, and the impact this can have on their health.
The disparity in the UK has nothing on the global gap. Today, according to the WHO, there is a 36-year difference in life expectancy between countries: 47 years for a child born in Malawi, 83 for a child born in Japan. There are significant rifts in health outcomes within countries, too – rooted in differences in social status, income, ethnicity, gender, disability or sexual orientation. Children from the poorest 20 percent of households are nearly twice as likely to die before their fifth birthday as children in the richest 20 percent. Developing countries account for 99% of annual maternal deaths in the world and around 95% of TB deaths, most of whom are also young. Worldwide, about 150 million people a year face catastrophic health-care costs, quickly draining household resources, driving families into deeper poverty. Even if they could pay, access to doctors would be a challenge. Low-income countries have ten times fewer physicians than high-income countries. The social gradient kills on a grand scale.
As I travelled around the world, the pursuit to uncover the forces behind inequality in health represented another journey, running synchronously with the physical one by bicycle. History, mass migration, tropical rain and drought, political pronouncements, wealth, deserts and mountains, beliefs, habits and traditions – all these things help cut and carve the landscape of health and well-being, they help describe the uneven sprawl of HIV, dengue fever, mental illness and TB; they illuminate the roots of malnutrition, violence and drug addiction. Health is contextual, it’s shaped by circumstance, and to understand the health gap means understanding the details of the environment, of the past, and of people’s lives. For me, cycling brought an appreciation of details that have a bearing on health.
I’m currently writing a book: part travelogue, part investigation into marginalisation and health. “You can’t write about people unless you know what’s on their mantelpiece” journalist and mental health campaigner Marjorie Wallace said recently on Radio Four. Over the six years I spent cycling around the world, I spent around one thousand nights in a tent by the roadside, but I slept as well in the homes of people in more than fifty countries, as well as in countless churches, mosques, hospitals, schools, police and fire stations, temples and army barracks. I shared the fusty air and mosquitoes of a barn with a snortsome, cheesed-off buffalo. I didn’t spot many mantelpieces, but I do see Marjorie’s point.