HEALTH INEQUALITIES PART 2-BRIDGING THE GAP:TACKLING THE SOCIAL DETERMINANTS OF HEALT

[00:00:00] Stories, labels, Misconceptions NHS remains a blessing Created in 1948 We want it to remain great A podcast where we share our stories Explore solutions in all their glories They say it's broken, but it's not done With your host Val Barett, Dr. Jeremy Anderson

VAL: Welcome to another episode of Stories Labels and Misconceptions with me, Val Barrett. 

DR JEREMY: And I'm Dr Jeremy Anderson 

VAL: and we are continuing the Health Inequality series. And this is. Part two, tackling the social determinants of health.

VAL: we know that health doesn't start in [00:01:00] hospitals. It can start in our homes, our schools, our jobs, and the policies that shape them. In the second episode of our Health Inequality series, we're diving into social determinants of health, the root causes that create health gaps before someone sees a doctor.

VAL: Because inequality isn't inevitable. 

DR JEREMY: Exactly. 

VAL: It's built and we can change it.

Mhm.

DR JEREMY: In the first episode we talked about health and how health is more complicated than just the absence of disease. And there are many different determinants of health.

DR JEREMY: One of the determinants is what we call social determinants of health. That is the social factors that contribute to how healthy you are. And that includes things like education, Economic stability, neighbourhood or the environment you live in, [00:02:00] your access to health care, the amount of community support you have, all of these contribute to how healthy different groups are.

DR JEREMY: There's multiple factors, so obviously not everybody has the same conditions or exactly the same physical or biological makeup, but social and we'll get into psychological factors at some point and, but social and environmental factors play a huge role in how healthy we are. But in terms of the social determinants of health.

VAL: what about systemic? 

DR JEREMY: Systemic yeah, systemic is one of those words that it gets used a lot right now and all it means is that none of us live in a vacuum. We all live within a system. That system is designed in a particular way it may be more or less effective.

DR JEREMY: In working for different groups of people. So for example, the [00:03:00] NHS is a system, designed in a particular way. It works well for some but maybe not as well for others, right? So an example would be if you live in central London. The NHS works relatively well, you have access to multiple hospitals health centers or a GP, but if you live in a small rural town you may have to drive for hours to reach a specialist.

VAL: Do you know how many hospitals? Are in reach of me 

DR JEREMY: from your home. 

VAL: Yeah, five, 

DR JEREMY: is that walking distance driving distance or within 50 minutes ~or ~

VAL: I can reach three. 

DR JEREMY: Three in walking distance. 

VAL: Yeah. 

DR JEREMY: That means. 

VAL: One is a cancer specialist, hospital.

DR JEREMY: That's a clear example of where you live. 

VAL: Yes. 

DR JEREMY: The ease you can access healthcare. 

VAL: Of course. 

DR JEREMY: However our healthcare is designed, we haven't designed it so everyone has access. [00:04:00] That's not how we design the service. I don't know how you would. 

VAL: If you're unfortunate to have cancer, you would want to go to where the specialist care is. And that's at the Royal Marsden, and that's just up the road. But, for some people, hundreds of miles away. 

DR JEREMY: Exactly. 

VAL: Do you see what I mean? 

DR JEREMY: Yeah. 

VAL: I was fortunate when I had my heart attack. 

DR JEREMY: Yes, 

VAL: up the road is one of the country's designated heart attack units. 

DR JEREMY: Yes. 

VAL: So it is about location. It's unfortunate, but to have so many hospitals, there's three on one road here, three.

DR JEREMY: Yeah. 

VAL: Some don't even have one.

VAL: ~They don't. ~

DR JEREMY: ~No. ~It raises an important issue about, infrastructure and [00:05:00] industrialization, you can only do it once as a society, human beings used to congregate together and there was a lot of farming.

DR JEREMY: And then we industrialized and we laid down infrastructure in terms of things like roads and communications lines and public transit and stuff, you do that once, right? You structure the way a city is designed, 

VAL: Yeah 

DR JEREMY: reflects when that happened, 

VAL: right? 

DR JEREMY: If things change, you have to retrofit everything to the existing pattern. 

VAL: Yeah. 

DR JEREMY: And it's the same with the NHS. We have specialist centers in large population centers, and then other more sparsely populated people centers don't have those, and they have to travel if that creates a health inequality, then it's not like we can just, build specialist centers everywhere. So everyone has equal 

VAL: distance. We're not going to do that, 

DR JEREMY: and that's just a function of how. The infrastructure has been laid down originally, so how do we retrofit a [00:06:00] solution there might be several solutions there, it might be, instead of having to travel to see, in this case a cancer specialist a thousand miles away, you do a video call ~like ~

VAL: Not ideal. 

DR JEREMY: Might not be. It might, these are potential solutions, right?

DR JEREMY: Not necessarily ideal, but might be better than now, i'll give an example. One of my patients was considering a stem cell transplant. They needed a stem cell donation from a family member, but the family member lived in a very rural island community.

DR JEREMY: Somewhere in the Caribbean, was that person going to travel all the way to the UK to get a blood test done to, to see if they're a match? 

VAL: If it's just a blood test, that could be done there. 

DR JEREMY: Maybe they do the blood test there. 

VAL: Yeah. 

DR JEREMY: Or, maybe they don't have the facility to test the blood there

DR JEREMY: They send the test to, the nearest regional center, [00:07:00] which might be somewhere in another country. And then they send the results to the UK, it's not as convenient or quick but you adapt, it may not be perfect, but it's better than nothing.

VAL: There used to be many moons ago, little community hospitals. 

DR JEREMY: Oh really? 

VAL: Most of those have gone, I remember when I lived in a different borough and thought, Oh, there used to be one here.

DR JEREMY: So 

VAL: those get taken away and what the government seemed to concentrate on is building like mega hospitals. Now the town where I'm originally from, which is Stafford up the road in Stoke on Trent, they built this massive hospital, it's huge, it's all good having bigger, but it's bigger, always better.

VAL: Do you see what I mean? Because they're always talking about having things on your doorstep. [00:08:00] Realistically that's not going to happen, when you're building bigger. And closing smaller ones, that's an issue. 

DR JEREMY: The Darcy report on a few, podcast episodes now. One of the main points they raised was a lot of money spent in the NHS is, It's being or had been directed towards large hospitals and they were gobbling up a lot of resources. They recommend more services provided in the community.

VAL: Yeah. And 

DR JEREMY: We'll see what this government does, but it seems resources over the next few years are going to be directed towards that. 

VAL: Somewhat 

DR JEREMY: away from hospital care towards meeting people in the 

VAL: community. We know it has to start socially, it's all well and good having these super max hospitals.

DR JEREMY: But if there's nothing to go back to, then people get stuck 

VAL: you've got a massive hospital, but there's no specialism there's no specialized department in any particular thing.

VAL: It's not specialized in [00:09:00] lung disease, heart, cancer, but 50 miles away, there is a cancer specialist. Which would you prefer to go to? 

DR JEREMY: If I have cancer, I want to go to the specialist center. 

VAL: Of course because it gives you that extra confidence certain places, have a professor to that department, which you won't have everywhere, remember when Andre went to great Ormond streets.

VAL: All you have to do is just mention that place. Everybody knows it, and families flying in from other countries going there because it's children, and every, I think every department has a professor. And because it's one of those places you can't just walk in, there's no A& E, you've got to be referred, 

you 

VAL: know, but when we talk about A& E and the government went through this thing where they were closing some down, [00:10:00] especially it might be a local one. They have to travel miles to get to an A& E everybody else is to that A& E. So there needs to be a buffer zone. There needs to be better, saying it again, better what? Social care. 

DR JEREMY: Social care. There's the trade off right? Because to be a specialist really good at something. In medicine you have to perform a lot of those things. If you're a surgeon and you do, I don't know, you do appendectomies, right? You take up people's appendix

VAL: still got mine, 

DR JEREMY: Be good at that. You, wanna do that all the time. 

VAL: Yes.

DR JEREMY: If you have people, getting these procedures done all over the place and there's not as many specialists, the individual specialists don't do the operation as often by closing centers and having everyone go to one place the people there get really good at it. You get good care, but you have to travel 

VAL: yeah. 

DR JEREMY: So then you've 

VAL: Got the traveling [00:11:00] expenses. 

DR JEREMY: Yeah. 

VAL: Nine times outta 10 you've got parking fees. . Government, you still haven't taken away the parking fees. . So you've got parking fees, going up and up. Yeah. Your appointment or what, but you're not going to be there for less than an hour. So you've got to have money to park. You're going to have petrol. You're going to want to eat. I recommend carrying lunch. 

DR JEREMY: Yeah. Very 

VAL: expensive. Yeah. 

DR JEREMY: I was thinking of efforts to reduce. Health inequalities in access to specialist centers. A few years ago in hematology. In blood disorders where I work, so what happened was there were hospitals all over the UK that were performing what they call specialist services. Someone with. Sickle cell disease might need specialist care and would go to their local hospital to try to provide it. But, there's not many people with sickle cell there. So that [00:12:00] hospital almost never provides that service. They're not really highly experienced specialists. They don't have the experience. So people were getting bad outcomes. Energize England restructured the way specialist services are regulated or designated so that it was a pyramid system. At the bottom you had local tertiary care centers. Hospitals that weren't specialist centers, but they have people, In their community that needs specialist care. And then, overseeing them, regional specialist centers and the specialist centers overseen by, coordinating centers.

DR JEREMY: And at the top a national hemoglobinopathy panel. So basically what you have was the most experienced providers the most experienced specialists were able to provide direct supervision and support to the centers down the pyramid. So if a local center, 

VAL: you 

DR JEREMY: know, someone walks in and they need a [00:13:00] specialist procedure but, they only see this, once a year or something like that. And they like, okay, I need some help. They have someone to call, say, okay, what do you recommend I should do here? So it was about connecting these centers together. You can't have a world renowned specialist in every town, but you can connect them

VAL: yeah. 

DR JEREMY: So that's one way of addressing these geographical issues. Should we move on to other social determinants of health?

Mhm.

DR JEREMY: Let's talk about income. Income is considered a social determinant of health, right? So why would that be, we know that. Is it just that, having money in your pocket means you're healthier,

VAL: oh no, of course it doesn't.

DR JEREMY: Otherwise someone could just write you a check. And, cure your illness, right? ~It's right on ~

DR JEREMY: ~the check. ~We know 

DR JEREMY: That's not how it works.

DR JEREMY: When we say certain determinants are linked to health, we're not saying those determinants are directly causing different health outcomes. We're just saying they're related in statistics correlation does not equal [00:14:00] causation. The fact that two things are linked doesn't mean that one thing caused the other, it just means they're late. For example eating ice cream is linked with drowning. 

VAL: Is linked 

DR JEREMY: drowning. 

VAL: When 

DR JEREMY: ice cream sales go up, drowning goes up. 

VAL: Wow. I didn't know that. 

DR JEREMY: Now, is it because eating ice cream causes you to jump in the ocean and drown?

VAL: I wouldn't think no. People are at the beach. 

DR JEREMY: Exactly. When it's summertime people go swimming. They also eat ice cream, you can see factors that are correlated. Happening or changing in the same way 

VAL: yeah. 

DR JEREMY: But there's no direct cause and effect relationship

VAL: I know what you mean. 

DR JEREMY: I think the same thing is with income and health, there isn't a direct connection having money. And having health means there's all these other things happening that contribute to [00:15:00] health.

VAL: You're able to buy, you're able to access resources in the private sector. 

DR JEREMY: You eat better food, right? Healthier, more nutritious food.

VAL: You can choose where to live. 

DR JEREMY: You choose where to live maybe it has, cleaner air access to nature or.

VAL: Better education for children 

DR JEREMY: Education is another social determinant of health. And again, just being smart doesn't make you healthy, but right. Or just having knowledge in your head, being educated isn't what, takes away heart disease. 

VAL: But it might be detected earlier.

DR JEREMY: If you know what to do, you change your behavior and have better health outcomes. 

VAL: They're more likely to go to their private doctors and get an overall checkup. They don't have to feel ill or whatever. They're looking after themselves. They're more likely [00:16:00] to pick up heart disease or whatever it is quicker than poor me.

VAL: You only found out when having said heart attack. I can't afford any private care. I didn't know the heart disease run in my family. Like I said, I see my doctor when I'm not well, why would I go to my doctor when I'm well, you just don't do that in the NHS, unless I'm called in to check my blood pressure to have a blood test.

VAL: If something changes in my body I'll phone my GP and say, this habit has changed. They might say, come in. We'll run some tests. Do you see what I mean? Like you MOT your car, nothing wrong with your car, but you go and you get your car MOT'd.

VAL: So income and social status, you're [00:17:00] able to do those things to prevent you falling into that inequalities box it does make a difference. No, it's not going to stop you from getting any diseases, but it might help detect it a lot earlier. 

DR JEREMY: Yes. 

VAL: That's the difference. 

DR JEREMY: So related to income is employment, right? Employment is indirect. It's not just having a job doesn't make you healthy, but job you do can have a big impact, right?

VAL: I don't think we've got any working mines anymore, but if you imagine way back when there are 

DR JEREMY: no mines in the UK 

VAL: I think they're all closed. I don't know. But if you can imagine, men going down into the mines, how many got ill from whatever, men that worked on buildings when we had asbestos, when we didn't [00:18:00] know what he did, a lot of them went on to have lung conditions.

DR JEREMY: Perfect example, working in as a builder in construction not a bad job. They can be paid reasonably well. Not as much as a CEO it depends on the condition. I do remember, one of my neighbors used to live below me.

DR JEREMY: He was a finishing carpenter. He made way more money than I did. He did custom work for professional sports players. Raking in the dough. He got like that, because of an apprenticeship doing carpentry finishing work inside homes, he was just really good at it.

DR JEREMY: It's possible to make plenty of money in construction, but if you're exposed to chemicals dust and pollutants and things you might be making plenty of money, but it's also something that might be impacting your health. Yeah. So that's one way I think your employment or access to good employment conditions is relevant to your health.[00:19:00] 

VAL: And we've already talked about access to healthcare.

DR JEREMY: social inclusion or non discrimination. Experiences of discrimination and exclusion negatively impact health. How might that work? Here's something indirect.

DR JEREMY: Again, I mentioned in my training, I did a PhD looking at anger and cardiovascular disease and and stress. And I remember a conference where two of the researchers were from the Southern United States and they were looking at cardiovascular disease in African American populations.

DR JEREMY: And specifically they were measuring blood pressure over time. So what normally happens for people is you get up during the day you're running around and your blood pressure is higher. Responding to challenges but at night. When you're sleeping, it drops down. Your blood pressure can go up for a while, but as long as it goes down, as long as it recovers that's not abnormal. It's perfectly healthy. No problem. What they were noticing is that there were African American participants in this research, [00:20:00] specifically in, more deprived communities. In the US at the time the difference between African American neighborhoods and other neighborhoods is stark. People in these neighborhoods, their blood pressure wasn't dropping at night.

DR JEREMY: Their blood pressure was staying high all night long. They attributed that to living in a stressful situation. You're dealing with daily hassles all day and you're not safe at night. 

VAL: Yes. 

DR JEREMY: You don't have a safe community, your blood pressure is always high, you're on alert.

VAL: Yeah. 

DR JEREMY: That was considered a social psychological factor, that is contributing over time, contributing to long term stress and increasing risk of things like heart disease. Yeah. 

VAL: Yeah. Yeah. 

DR JEREMY: So the stressful experiences people have, going through daily life experiencing more hassle direct or indirect experiences of [00:21:00] racism or exclusion or discrimination and you live in a place where constantly feeling under threat.

VAL: Yeah. Your blood pressure stays high. 

DR JEREMY: Yeah, more stressful. 

VAL: I didn't know that. I always just assumed it always came down. 

DR JEREMY: Yeah. 

VAL: What if they were taking blood pressure medication, didn't it bring it down? 

DR JEREMY: Yeah, if you take the tablets, it can bring it down, but that assumes you can afford the tablets. 

VAL: Okay. Yeah. Yeah. 

DR JEREMY: For these communities negative social determinants multiply if you're poor, you can't afford the tablet you need to take because you live in a poor neighborhood and it's more stressful. And if you have a job where it's lower status, lower pay 

VAL: Yeah 

DR JEREMY: you're facing more hassle, less control over your life. These things interact to contribute to a negative health outcome. 

VAL: Okay. What about we need safe housing? 

DR JEREMY: Safe housing. We've talked about housing there was just a [00:22:00] report released by the housing ombudsman. I'm not sure if you saw it where they were saying over the last five years there to the Ombudsman's office has skyrocketed something like five or six times or 547 percent over the last several years. And they mentioned Awaab's law and I can't remember the other one and Grenfell have highlighted these things, but there's still this Failure to, maintain these properties. We talked about this ages ago about the need to fix these properties and deal with things like damp and mold. 

VAL: Yeah. 

DR JEREMY: More people are complaining. And what's interesting about that is, before you get to the ombudsman, you have to raise it with the landlord. So you can't say they're not talking to the landlord. People are bringing ombudsman because they've already brought it to the landlord.

VAL: Awaabs family did it for three years, 

DR JEREMY: precisely. And so what the ombudsman was saying is [00:23:00] the level of dissatisfaction among people living , in social housing there's a significant risk of what he said, social disquiet. Which is a very British euphemistic way of saying we're going to have a revolution on our hands here, right? I don't think people are at the point of, grabbing pitchforks. But that's always the concern at some point, right?

VAL: But I think that goes across the board with everything. If your home isn't safe, that is very before of your. Living in a home where you're catching water through the ceiling with a bucket. You wake up, you open your eyes, the first thing is mould You're not going to be happy. No matter how much money you've got in your bank account, you're not going to be happy. It's your home. 

DR JEREMY: This report talked about people defecating in plastic bags for two years because they didn't have a toilet.

VAL: Is in Brixton, wasn't it?

DR JEREMY: I [00:24:00] don't remember where it was, but that example.

VAL: Read that. And it's What the hell? 

DR JEREMY: Yeah.

VAL: I was shocked when I saw that. Yeah. The basics were not there just was not there, and what is the accountability, perhaps they need to start looking at things like, okay, Thames water have have been fined.

VAL: And so they should, but dumping dump in the water, but then, Is anyone going to prison? I thought we had corporate manslaughter. When Awaab died and I'm sure there's been others. There's another I saw on the news today. Friday, the 30th of May.

VAL: I saw on the news a 15 month old baby died because of the condition they were living in. Awaab will never be the last. 

DR JEREMY: No 

VAL: The government can put whatever legislation they want in place.

VAL: That's all it is. [00:25:00] That's all it is. Unless they start imprisoning people, it might make a change. If you're telling someone for three years, they can't all of a sudden stand up and say we didn't know, they never told us, they can't use that, if someone has died at your hands because of the home you provided they have told you, I would imagine someone from there was being around to look at it, probably said something stupid, like paint it, Like they tell others, 

DR JEREMY: Yeah 

VAL: We know very young children, the elderly, those with , a health condition are more likely. To suffer living in a house with mould than someone who doesn't have one, but they can also suffer. 

DR JEREMY: Yeah. If you have mold no plumbing contaminated water, or fire hazards from that [00:26:00] electrical system, the list goes on that's bad for anyone, if you already have a health condition, it multiplies.

VAL: don't you want a world where all health inequalities are banished?

DR JEREMY: Yeah. 

VAL: There's no such thing. I know we're doing an episode on reports, but I know that. No matter what's written, no matter what's stated, no matter they will not do no matter what plans they have, we're always going to have health inequalities. What I don't like is when it widens, when they say they're putting more money into health. Why then does health inequalities get wider? It's not what we want. We are supposed to narrow it, I know it's not going to be perfect, 

DR JEREMY: Yeah, 

VAL: it's not going to banish, we can't have it getting wider when it's getting wider. It's telling you there's something you're not doing right. It's not just about the money. 

DR JEREMY: Yeah. You're raising a great issue. Close your eyes and imagine the [00:27:00] world you want, so you raise a great question of if you could close your eyes and imagine a society, what kind of society would you want, that was the same question raised by a famous English philosopher, John Rawls. Do you know John Rawls? Have you heard of him?

VAL: No.

DR JEREMY: It's the Rawlsian Veil of Ignorance he proposed exactly what you just did. Imagine you could magically just create a society, right? And you could structure the society any way you wanted, in terms of rich and poor and different outcomes and stuff. But the only thing is you would go into this society, but you would have no say on where you would just randomly get assigned somewhere in this society, what kind of society would you want? And I think when people go through that exercise, they realize they want a relatively flat hierarchy in society. 

VAL: Yeah,

DR JEREMY: you might want some difference in people's status in terms of incentives and whatnot, but you don't really want things to be too bad, [00:28:00] right?

DR JEREMY: You don't want some people to be so high and some people so low if you can't choose where you land. You probably want it a bit flatter, and I think if we could just encourage listeners to do that, to just think about. If you could, how would you want the society to be? Let's how you solve things. You really want people squatting in houses with no toilet, no water. Setting things on fire. 

VAL: I don't think anyone does,

DR JEREMY: Nobody wants that. 

VAL: People being wealthy. Doesn't bother me people inventing things, entrepreneurs, whatever that doesn't bother me. That's a trade off if we could all have health equality. 

DR JEREMY: Yeah. 

VAL: We're going to do an episode I'm, Words that I don't like and educate you on certain words we use here.

DR JEREMY: Yeah. 

VAL: When we start off calling something negative, I think it's downhill from [00:29:00] there. Why don't we flip it and name it where we want it to end 

DR JEREMY: okay. Give me an example. 

VAL: Okay. When they do a health it's just coming out of my head. When they do a health report. They're calling it health inequality, health equality, it's, that's where we want to end up, that's the destination, we already know that is an inequality. We already know, I'm sick and tired of seeing the data. I'm sick and tired of being told I'm likely to suffer X, Y, Z because of my age, ethnicity and gender, that's no way to live. I just don't like it. What I want, I just want a report that just tells me what the hell are you going to do? We can go back to 1980 to Sir Douglas Black, the Black report on health [00:30:00] inequalities. His findings still resonate today. When he handed back that report to the Tory party they dismissed it.

VAL: So imagine a world where we have health equality, where, governments commission reports, by experts. Write recommendations and have to do it. Imagine that. Imagine the findings that came out of Grenfell. Remove all the cladding. Why are we still talking about removing the cladding? That would be nice. Let's start from there. Why have these reports done? If you're not going to pick and choose the things you're going to implement. 

DR JEREMY: Yeah. 

VAL: Makes no sense

DR JEREMY: maybe psychologically, it would make sense to flip the order of the report. Normally we talk about the facts, all the problems, focus on the negative, the inequalities.

VAL: Give me the good first. 

DR JEREMY: [00:31:00] And then the recommendations come at the end, if we flip it around.

VAL: Give me the good stuff first. The juicy stuff first. 

DR JEREMY: The report could be called, here's what we're going to do. The justification can be at the back, focus on the positive. Here are the good things we're going to do. 

VAL: Can you imagine my report, if they commissioned me? Yeah. Do. Your. Job. Done. 

DR JEREMY: Yeah. 

VAL: They've got the black report, the Acheson report, the Marmot review of 2010, 2020. We've got the Lord Darcy report, stop writing reports. We don't need more reports this is the joke. After the black report. He wrote about health inequalities. 

DR JEREMY: Yeah. 

VAL: Health inequalities widened. It got wider. 

DR JEREMY: Yeah. So here's this scenario. I'm just thinking out loud here. So I'm going to propose something. What if we had.

VAL: You're already married.

DR JEREMY: No, I'm not going to propose

VAL: I thought Id break the [00:32:00] tension 

DR JEREMY: What if we have less social housing? 

VAL: Oh, no, I don't think no.

DR JEREMY: What if as an alternative to social housing, that is where the government or the local council, whatever, owns your house and you just, You pay rent when you're able and they're in charge of your house and they do all the repairs and they're responsible.

DR JEREMY: That's what we got now. 

DR JEREMY: That's what if, as an alternative to that, we did something to allow people to actually own and 

VAL: take 

DR JEREMY: care of their own property. 

VAL: We do that now, do we, people buy their homes, 

DR JEREMY: people do buy, 

VAL: that can afford to buy, 

DR JEREMY: exactly. What if we could focus on more people being able to do that?

VAL: I think they, they are trying that, but we've talked about income. 

DR JEREMY: Yeah. I think income is an issue, [00:33:00] but what if, okay, I'm just saying just imagine magically snap our fingers. And what if we lived in a world where people could just have a home that they own? 

VAL: Not everybody might want to own a home.

DR JEREMY: Not everyone might want to, but 

VAL: because you own a home, you got to have money to get things fixed when it breaks down. So there again is income. It's job security, 

DR JEREMY: you gotta pay for the maintenance. That's true, right? But I guess I was thinking in, it struck me when the ombudsman said that we're risking social disquiet.

DR JEREMY: And I was thinking if you own your house and there's something goes wrong with your house and let's say you can't afford to get the roof fixed and you have a bucket. 

VAL: It's 

DR JEREMY: still your house and you're like hold on, but [00:34:00] if you rent a home and the landlord won't fix your roof, you get angry at the landlord, but what you don't get angry at is your country or your government.

DR JEREMY: It doesn't lead to revolution. 

VAL: You're still angry and pissed off that you haven't got the money to fix the roof. 

DR JEREMY: You're angry, but your anger is not directed. 

VAL: But it doesn't matter whether it's directed or not. You're still angry and you're still pissed off. 

DR JEREMY: That 

VAL: roof is not going to get fixed.

VAL: It's still, the anger is still going to be there, irrespective of who owns that house. 

Yeah. 

VAL: Because we're living in a time where there's hardly any job security. Some people are working zero hours Yeah. We're just not as secure as we was when I was growing up. When I was growing up, you had, I remember my friend's [00:35:00] dad, he left school.

VAL: Yeah, and he went through the one job and he retired you hardly get that. Now, places of businesses are closing down. It's not a secure time. So it's not about who just owns the home. It's about the anger. It is about people doing what they are supposed to do. Sure. Even. 

DR JEREMY: Yeah, I'm not suggesting this would be like a cure all for anger but what I'm saying is if you own your house and your roof leaks and you can't afford to get it fixed, you don't grab a pitchfork and want to overthrow the government.

VAL: No, you probably grab a pitchfork and want to do something else, because either way, I'm trying to get it, I'm trying to say either way, you're angry, the roof, because if you own the property. We know that if you want to sell, downsize, or whatever, that roof's still [00:36:00] leaking, that's leaking money. 

Yeah. 

VAL: So you've got another issue there.

VAL: So it's not just so simple as you own a house or whatever. It's a lot of responsibility. It really is. Yes. We all want a home. We need more social housing. But other than the fact that we need more social housing, we need landlords to take care of their homes that they own. That's what we need. There's no point in them keep building and building, buying and buying whatever.

VAL: And they're not taking care of the homes that they've already got. There's a consequence to that. There's a cause and effect to that. So what happens is the cost goes from housing. And it goes straight to the NHS. So if I live in a house that's full of mould, I get sick, I probably can't work, I lose my income, [00:37:00] I go on benefits, I then get very sick with my chest, I'm using the NHS more.

VAL: That's a cost there. So if the landlord had fixed it in the first place, like he should have done, I'd be still working, I'd be happy as Larry, and I'd be able to have my holidays. I wouldn't probably get my lung disease. So it is a cause and effect, as we know, when you live in bad housing, it's more than just an eyesore.

VAL: It's more than just that mold isn't part of the decoration that I desire. It is more than that. It is a potential killer and that's what it does. So if you owned your own home. And you had the mould, and it's a potential killer, and you can't afford to fix it. What are you supposed to do? No, it's about getting these landlords to do what they're supposed to do.

VAL: And the government, whoever, who's in charge of housing, is it Angela [00:38:00] Rayner? I don't know. But they've got to change legislation. But I tell you now, they'll change it soon. They, you see this quiet. 

Yes. 

VAL: I tell you now, the more, the longer you, it's like when you keep something down for so long 

and 

VAL: then you suddenly, a can of pop 

and then you 

VAL: open it and it's it explodes.

VAL: Yeah. These people are going to explode. 

Yeah. They are 

VAL: not going to see it coming because you can't live in a society where the complaints are going up. We're always talking about housing people's homes. These are people's homes. People are dying. People are getting sicker. People want to work. You don't want to be retired at 40.

VAL: You want to work, but you can't work because your lungs are bad and your lungs are bad because your house is bad. No, soon enough the people revolt.

DR JEREMY: I think this ombudsman's report, this social [00:39:00] disquiet, I think that was a very understated way of saying revolution. Yeah. That's a pretty stark warning that they're out together.

DR JEREMY: They can pass legislation and they mentioned AWEB's law. And I guess that then raises the issue of how are they going to pay for it? 

VAL: Yeah. But then we said before cost goes somewhere else. Yeah. 

DR JEREMY: Exactly. 

VAL: Under housing, okay, we can't afford to fix our house. We'll leave it. People lose their job because they're sick.

VAL: It's a cost to DWP to give them benefits. They get money to pay their rent. Cost. They get. Really ill. Social care. Cost. NHS. Cost. Everything's a bloody cost. But [00:40:00] all that cost wouldn't happen if they just fixed a bloody thing in the first place. 

VAL: But they don't, they like to leave it and think, okay this budget is that budget that's over there and that budget is there and that budget is there, but all you're doing is shifting it from one to another, they're just moving the decks on the, what is it? Moving the deck chairs on the deck. 

DR JEREMY: Oh, on the Titanic. Yeah. Yeah. 

VAL: This is all they're doing. Fix people's homes, get them well, get them being able to work, Oh, I'm exasperated. Oh God, I'm depressed now.

DR JEREMY: Yeah. It.

VAL: We make it sound simple, but then what I'm going to say is, why can't it be? Why can't it be? Why do us as humans have to make things so bloody [00:41:00] difficult? Why? If you were bleeding, you'd wash the cut, you'd put a plaster on it. If it was a deep wound, you'd go and get it seen, so you might need some stitches.

VAL: It is. Because if you don't, it's going to get worse, you'll get an infection. You don't take care of that, you lose your finger, 

DR JEREMY: Yeah 

VAL: know, everything with them is just a plaster. 

VAL: You 

VAL: know, it's never the root. They don't go to the root cause and actually look across the board. I think, what housing is part of social care, 

DR JEREMY: Yeah 

VAL: And social care is making people sick.

VAL: It's supposed to be a place where people get better to stay out of A& E, to stay out of acute care. 

DR JEREMY: Yes. 

VAL: Not to get in it because of the place that they live, that makes no sense over [00:42:00] something that can easily be treated. Done.

VAL: It's gonna get worse. People getting sicker because of their homes. We need more doctors. Doctors say they're going on strike. . We need more doctors to be trained. We need more nurses. We need more social care. But they don't want the immigrants to come in and work in social care.

VAL: So we're stuck. Full of fuckery. Yeah. It's shit. 

DR JEREMY: Yeah, 

VAL: it is. But you think about it. I may be here talking a lot of rubbish. I don't know. But this is how I see it. I'm not a clinician. I don't want to be. I'm not a politician. I wouldn't be a good one. All I am is a citizen. I'm a voter. I live in our home and I'm going to see it as simply as possible.

VAL: That's my job. Your job here is to see it from a clinical point of view. 

DR JEREMY: Yeah,

VAL: So I'm going to see it very simple. Get [00:43:00] it done. Get it done, A, to prevent more deaths, B, to prevent people from stopping them. Getting a job. Keep people in work. They keep talking about worklessness.

DR JEREMY: I hadn't heard of that. Usually it's in terms of employment or unemployment, but 

VAL: yeah, they talk about worklessness, 

DR JEREMY: worklessness. Okay. So does worklessness, does that mean something different than unemployment?

VAL: No 

DR JEREMY: mean, sometimes they make distinctions between people who are not working, but who are, who don't want to work, who aren't looking for work. And then there's people who are not working, but they're actively looking for work. So sometimes there's different distinctions to be made. 

VAL: I'm talking about, the people that are living in homes that are making them ill.

VAL: Okay. Thank you. Yeah, where the unable to work, so we did have a few stories, few examples that we can probably read to end this episode. 

DR JEREMY: [00:44:00] Okay. 

VAL: So I think we've explained it well. 

DR JEREMY: I think so. I think, I think it's fairly clear. There's lots of social determinants. And a lot of these things they're outside of, induviduals control yes, it's true. In principle, if you live in a bad neighborhood, you could move, but it's awfully hard, right? It's not necessarily a practical solution to say, go somewhere else. Or, if I dunno, if education is a social determinant, just go get a degree. Yes, it's true. It's true people do those things, but it's not

VAL: Life isn't just about having a degree.

DR JEREMY: No. I guess I just meant in terms of, if you say education is a social determinant of health and you need to be more educated, okay, it's fine to say, go get some education. It's not quite as easy as just signing up. I think

VAL: when we talk [00:45:00] about that, it's not just, it's about young people staying in school and probably staying in college.

VAL: So at least staying in education until they're 18. A lot of them don't, because we know not everybody goes on to university. Unless , you want to do a specific job, that's different, but anyway, talk about housing. So let me give you this story.

VAL: Amir and Joe, they're 36 years old. They're married, live in East London, they don't have any diagnosed illnesses. No hospital visits. They don't have any prescriptions. They're healthy, but their health is being quietly chipped away. Joe works nights in a warehouse. Amir juggles two zero hours cleaning jobs.

VAL: They bring in just enough to survive, but not enough to thrive. [00:46:00] They rent a one bedroom flat in a tower block that's damp and freezing in winter. The landlord won't fix the mould and there's no heating for weeks. their council has a two year wait list for better housing. Every morning, Amir wakes up with a cough.

VAL: Joe barely sleeps during the day because of noise and stress. They argue more. They eat quick, cheat food. They're constantly tired, but there's no time to slow down. So what's the problem? They don't have a medical condition, but they're slowly being pushed towards one. So we know that. Housing that could be affecting their lungs and immune systems.

DR JEREMY: Yeah. 

VAL: And you talked about stress. 

DR JEREMY: Yeah. So they've got health conditions that are under the radar. You can't really see them, but they're just slowly getting worse. 

VAL: Yeah. Yeah. 

DR JEREMY: Yeah. 

VAL: So stress and lack of sleep. Are [00:47:00] raising their risk of heart disease, zero hour contracts mean they can't take time off or get preventative care.

VAL: They can't afford therapy or gym memberships and barely even have time to walk. And you said 

DR JEREMY: they're eating cheap food. Yes. Because they're just barely getting by. 

VAL: Very quick. Yeah. Yeah. So we know that health is not just about disease. We've already talked about that.

VAL: Yeah. It's also about the condition people are forced to live in. So if nothing changes for Amir and Joe, they're likely to experience chronic stress related illness by their forties, end up in A& E. As we said before, for preventative issues, age faster than people in better off post codes. But because we only focus on people after they get sick, we miss the real crisis.

VAL: The thousands of [00:48:00] people like Amir and Joe living in slow, Burn emergencies.

DR JEREMY: Slow burn emergency. That's a great expression. 

VAL: Yeah. And we know that there are probably millions of people like this couple. 

DR JEREMY: Yeah, 

VAL: up and down the country, they don't have an illness, but their home talked about it before a minute ago, the homes is making them sick.

DR JEREMY: And it's all these things, right? It's the zero hour contracts and the shift work. So their income, their occupation, their home, and the things that they're not able to do, all of that interacts together. Do 

VAL: you want to do you want to do a story? 

DR JEREMY: Want to give an example of David. So David is 14 years old, a black British boy growing up in Birmingham. He's bright, loves science and dreams of becoming an engineer. But lately he's been missing school. Not because he doesn't care. [00:49:00] But because he's tired, he's in pain, he's often a bit dizzy.

DR JEREMY: So what do you think is going on with David? David has sickle cell disorder. So his mom works full time as a carer, juggling his hospital visits, raising him with her siblings. Let's say English isn't her first language, and she can struggle to get doctors to really listen. The school doesn't understand David's condition.

DR JEREMY: Teachers assume he's lazy when he's actually fatigued. They don't know or don't care that, or maybe the government won't pay to get it fixed, but they don't know that cold classrooms can trigger a sickle cell crisis. 

VAL: Yeah. 

DR JEREMY: There's no care plan, no adjustments. He just gets detentions and letters home. So one day David has a sickle cell crisis at school from dehydration and he's in severe pain.

DR JEREMY: The ambulance takes 45 minutes to arrive, 45 minutes nowadays would be pretty good.

VAL: But the school 

DR JEREMY: Didn't treat it [00:50:00] as urgent, right? That they don't understand the condition. So at hospital he's he's waiting to get analgesia. Staff are suspicious. They wonder, is he drug seeking, right?

DR JEREMY: Keep in mind, this is a 14 year old boy. So he's waiting and waiting in A& E, and this isn't the first time. So what's going on here? Why is this young man having a problem with his health? It's not just because he's got this blood disorder, right? But it's the people, the teachers, the people around him are not being trained in chronic condition.

DR JEREMY: And there may be different kinds of bias in the way he's treated. It may be some racial bias yeah. Yeah. If he's one of the only people with sickle cell in this community, maybe there isn't a lot of familiarity with the staff, depending on the community he's living in.

DR JEREMY: I would also just add, there is a lot of stigma just towards the illness, just sickle cell in general gets stigmatized. And the school didn't have [00:51:00] a plan for how to deal with when he has symptoms or when he's not able to do certain things. Maybe there isn't language support or interpreters for his mom.

DR JEREMY: And he's dealing with NHS staff who maybe don't know enough about sickle cell disease or how people with sickle cell can present. In hospital, 

VAL: he's in Birmingham, 

DR JEREMY: in Birmingham, 

VAL: Birmingham, we know 

DR JEREMY: there, there are a 

VAL: nation is not in a rural place. 

DR JEREMY: No, I forgot Birmingham, obviously Birmingham, they have specialist centers.

DR JEREMY: I'm not bad mouthing Birmingham in any way. There can be. Individual experiences with hospitals where they're not as familiar with this. So if we let this happen, what happens to David? He's probably not going to do very well at school. He's 14. He's currently, he's trying to, do his GCSEs or prepare for those.

VAL: Remember when we had Alicia and we interviewed her, who's got sickle cell and she said [00:52:00] her education suffered. Yeah, so it would.

DR JEREMY: So it's interfering with education, I think for a lot of the people that I work with. It's not enough to just say I've got this illness. If you don't do well on a test or you don't pass a course for something, you don't say to yourself I'm smart. I've just got this illness. A kid just says, I guess I'm not smart. And they might say I'm not smart because I've got this illness. They don't separate the two.

DR JEREMY: So how does he feel about himself? It feels pretty bad. 

VAL: Yeah. 

DR JEREMY: And so he's not motivated. Education suffers. His sickle crises are not really being addressed or prevented. So he's having more of those. And as he gets older, he just becomes another young man who is being let down by the system.

VAL: Who is not seen or heard. 

DR JEREMY: Yeah, I know 

VAL: that has happened 

DR JEREMY: and he's not seen, he's not heard and his health declines. And that's, it's a good example of how, one's health is not just because of the, even if you have a health [00:53:00] condition, your and how you deal with it is not just a matter of that health condition.

DR JEREMY: It's about the social factors around you. 

VAL: Yeah. Yeah. Okay. Thanks, Dr. Jeremy. 

DR JEREMY: That's okay. Okay. 

VAL: Thanks for that, Dr. Jeremy. 

DR JEREMY: You're welcome. 

VAL: So that's the end of this episode. But before we do close. Thanks Let's go to our labels and misconceptions, stories, labels. 

DR JEREMY: Yeah those are our stories. Yeah. We've had 

VAL: our stories. Yeah. So what's your label?

DR JEREMY: The label? 

VAL: If you could sum it up in one word and you. 

DR JEREMY: Two words, a social disquiet is the label for today, right? I think that's a great label. I think the misconception there is, I think that euphemism, that sort of describing something in this understated way, I think it hides the real threat.

DR JEREMY: I think we need to [00:54:00] take words like social disquiet much more seriously, maybe than we are. 

VAL: True. 

DR JEREMY: It's one step away from the pitchforks. 

VAL: No, we are half a step away from the pitchforks. 

DR JEREMY: Right? 

VAL: What's your misconception? 

DR JEREMY: The misconception was that this is something that we can ignore. I think we can't.

DR JEREMY: I think the euphemism disguises just how serious this is. It's much more serious than I think we're quite giving it credit for. 

VAL: Okay. All right. Yeah. 

DR JEREMY: And you? 

VAL: My label, my one word! 

DR JEREMY: Yeah? 

VAL: I can't use a swear word, a one word neglect. Yeah. Neglect. Because we know when we look at housing, they are being neglected. Yeah, 

DR JEREMY: neglect the maintenance and 

VAL: neglected 

DR JEREMY: it's huge. 

VAL: My misconception is that I think [00:55:00] some people may think

VAL: that health inequalities is just about health, just about you having an illness. 

DR JEREMY: Yeah. The physical or biological part. Yeah. 

VAL: And don't think of the determinants that impact on health inequalities. Like we discussed income, education, housing, environment, blah, blah, blah. So yeah, we've educated you today. 

DR JEREMY: All these wider factors.

DR JEREMY: Yeah. All 

VAL: the wider factors. Yeah. That determined our health, how healthy we're going to be. So you don't have to have an illness. Okay. 

DR JEREMY: Fantastic. 

VAL: Your home can be your killer. Your home.

DR JEREMY: Okay. We knocked that one out of the park, Val. 

VAL: What does that mean? I know, I'm winding you up. Yeah. 

DR JEREMY: We hit a home run. Yeah. I think that was great. 

VAL: Okay, thank you very much. We hope you enjoyed today's episode. We did. 

DR JEREMY: [00:56:00] Great talking to you. 

VAL: And if you have any stories yourselves, and you'd like us to know, please send us a WhatsApp on oh 7 8 1 8 4 3 5 5 7 8 and leave us a voicemail. Yeah, follow us on our socials. We're on Twitter, Facebook. And Instagram. Okay, I'm gonna say goodbye. Okay. Yeah. 

DR JEREMY: Great talking to you this week.

VAL: Are you going to say I miss you? 

DR JEREMY: No, I said, I always miss you Val. You 

VAL: sounded like you were going to say, and I miss. 

DR JEREMY: No, I would say great. Great talking to you. 

VAL: Because I did get a proposal. So wow. But you got to tell the wife. Speak to you soon Jay. 

Okay. See you next week. Bye. 

[00:57:00] You