Prepared: 18:38 on 12 November 2009
2.55 pm
Dr. Howard Stoate (Dartford) (Lab): It is a pleasure to take part in this debate. I am a practising GP and take a great deal of interest in issues around the health of my constituents as well as my patients.
In recent years, the debate on health inequalities has focused almost exclusively on what we eat, drink and do—or, more specifically, what we do not do in terms of physical activity. Hardly any attention has been paid to the physical environment in which we live. It is as if we have collectively decided that with the advent of modern domestic plumbing, central heating, cavity wall insulation and so on we no longer need to spend time worrying about the environment in which we live.
Even though the dragons of poor sanitation and slum housing may largely have been slain in this country, it would be wrong of us to ignore the environment as an important issue. Unquestionably, people’s housing conditions have improved, but the condition of their neighbourhoods leaves a lot to be desired and has not improved to the same extent. Living in badly maintained and badly planned neighbourhoods with inadequate infrastructure and amenities not only restricts people’s ability to live healthy lives, but causes untold damage to their health and mental well-being.
A study published last year in Preventive Medicine found that areas perceived to be safer and more aesthetically pleasing can enhance mental health, while adverse effects were associated with road congestion and urban noise. Rates of psychiatric illness are also greatest in the most deprived areas, and the rates for psychoses map closely those for deprivation. Poorly maintained environments are also a cause of increased levels of stress and a greater susceptibility to heart disease, stroke, cancer and long-term chronic conditions.
Sustrans has reviewed the evidence of links between physical activity, health and social inequality and found that obesity, diabetes and cancer all affect people from deprived communities disproportionately. The link has primarily been made to the environment in which they live.
The recent Royal Commission on Environmental Pollution has also found plenty of evidence to show that living in deprived urban areas increases the risk of poor health outcomes, even after controlling for individual circumstances. So, a bad situation is made to seem much worse by the inevitable contrasts that people in poor neighbourhoods make between their own living conditions and those of richer people living down the road in much better provided and much better maintained areas.
There is plenty of evidence to back up such a view. My particular favourite is the example of Roseto, a blue-collar Italian-American community in Pennsylvania. Puzzled as to why Roseto’s health outcomes were consistently better on average than those of neighbouring towns—despite the fact that Roseto was no wealthier than they—a team of researchers decided to take a closer look. What they found was a town that was different in character and appearance from anything else they had seen in Pennsylvania. Its residents did the same kinds of jobs as those in neighbouring towns; they ate the same diets; they took the same risks with their health; they even had the same disparities in income as the towns nearby. The difference was that it was almost impossible to detect income disparities by looking at the places in which people lived. The houses were the same size, the cars were the same and the clothes that the people wore were similar. It was virtually impossible to distinguish people’s social position just by the appearance of either themselves or their houses. The report states:
“It was difficult to distinguish, on the basis of dress and behaviour, the wealthy from the impecunious in Roseto. Living arrangements—houses and cars—were simple and strikingly similar.”
The researchers attributed that to a strong egalitarian sense of community among Roseto’s residents that precluded ostentatious displays of wealth and frowned on any behaviour that might cause embarrassment or shame to the community’s least affluent members. Clearly, when people’s houses, cars and clothes are uniform across society, it has a beneficial effect on their health outcomes despite the disparities in income.
Sadly—this is the interesting part—it did not last. Once the first generations of primarily Italian-speaking residents died out and were replaced by English-speaking children and grandchildren who had the same cultural and moral values of other Pennsylvanian towns, Roseto’s health outcomes soon began to slip. It is a very instructive example. It reminds me of the rather whimsical essay “The Socialist’s Guide to Camping” by the late Oxford philosopher, GA Cohen. On a camping holiday, Cohen said, “there is no hierarchy” among people. They co-operate, share, generally act in ways that promote the collective good and take great pleasure in doing so. Although some tents may be bigger and brighter than others, or some people may have shinier, more high-tech camping gear than other people, it is much harder to detect the differences in wealth and status between families that mark them out in normal everyday life. So, for a brief, happy, life-affirming and health-enhancing moment, egalitarianism rules and our social differences are forgotten.
In the real world, however, it is not quite so easy to draw a veil over our wealth differences. That is not to say that we should not be trying to do so and indeed there are examples where people have succeeded in doing so. The fact that Britain is becoming more and more segregated geographically by class, age and wealth, as Professor Danny Dorling and his team from Sheffield university have shown, indicates to me that people are trying, consciously or unconsciously, to restrict the degree to which they are exposed to wealthier and supposedly more successful sections of society in their exclusive enclaves.
One way of addressing this issue is to invest more resources in improving the quality of the built environment in our most disadvantaged communities. Over the past 12 years, we have had a number of successes in this respect, but we need to do a lot more. For instance, the new deal for communities has helped to deliver a lot of schemes that have helped to improve the fabric and appearance of many disadvantaged communities, as well as helping to cut crime and improve access to jobs, education and health services. Crucially, local residents in those communities have been closely involved at an early stage in the design and implementation of many of those initiatives. Resident “ownership” is essential if schemes are to be sustainable in the long term and not require further investment at a later stage. The skills and confidence that residents develop as a result of their involvement in those schemes is not only good for their health and well-being but often encourages them to go on and set up further projects of their own. However, we need far more resident-led, area-based initiatives of that kind if we are to reduce health inequalities.
We also need to think much more carefully about health when we are planning new developments. Ever since the public health function was taken away from local authorities back in the 1970s, very few local authorities have spent much time thinking about the health implications of their planning decisions. That has to change if we are to create developments that actively encourage people to pursue healthy lives.
New developments with safe, well-maintained and attractive walking routes, play areas and parks are vital if we are to get people out of their homes and cars, and on to the streets. As with everything in life, it is a matter of motivation. Telling people that they need to take more exercise is easy; getting them to want to take more exercise is altogether more difficult. That is why the built environment is so important. If people look out of their windows and see a grey, badly maintained street scene, clogged with traffic, litter and dereliction, they will stay at home. On the other hand, if they look out of their windows and see trees, grass, nice paths and families out walking their dogs and their children, they will want to take part themselves, because otherwise they will feel left out of what is going on outside. That is a fundamental human condition.
In my area, which is in the Thames Gateway, the new Thames Gateway parkland initiative is a model of the approach that we should be taking. It recognises that creating attractive green spaces that are easily accessible and well integrated with the existing urban grain is a vital aspect of the area’s long-term regeneration. The proposed A2 activity park, the improvements to the Darent valley path and the new Jeskyns community woodland are all good examples of this work in my area. What we need to do now is to extend that programme across other areas in the Thames Gateway. It is clear that many existing communities feel that much of the investment that has been directed at the Thames Gateway has simply passed them by. If we do not address that problem quickly, there is a grave risk that we will not achieve one of the central goals of the Thames Gateway regeneration strategy, which is to improve the quality of life and the life chances of the area’s residents.
In short, if we want to improve people’s sense of well-being and enhance their long-term health prospects, we can do no better than to spend time and money on improving the quality of the built environment in which they live.