One of the main echoes that can be heard from Rowntree's work on social evils 100 years ago is the health of the public. But what we hear from that time is distorted by the 100-year distance. There are some similarities but a lot of differences.
Its true that in 2009 health inequalities between the 5% worst off and the 5% best off are still very large – that's a similarity. But over those 100 years the whole distribution curve of the nation's health has shifted very dramatically in the direction of better health. People live longer and have better health. For nearly everyone the destruction of the threat of many infectious diseases through public works and medical technology has changed the nature of the health of the public. That's a difference.
So I have little time for those that say the echo from there to here is in any way 'the same'. It isn't. Rowntree would look at the healthy nature of the population today and marvel. However, there are still some social evil aspects of the health of the public.
East end ill-health: then and now
In London, the map of the Jubilee Line describes a journey between Westminster and Canning Town. If you overlay that on a map of life-expectancy, it shows that a year of life is lost for every stop on the tube eastwards. Rowntree would recognise the gradient of that inequality and would be saddened by it; but he would recognise nothing else about the health of the people in those areas.
Rowntree combined a belief in self-help, alongside that of structural social reform, so he would recognise that one of the aims of social reform has not just been to improve the structures around the disadvantaged but to increase their capacity to gain greater influence over their own lives. Some things can be done to help people improve their health, but it is the capacity and ability to do that with your own life that is key.
Over the past 20 years for many better-off people, concern and activity about our own health has become a behavioural driver. Exercise, better food, less tobacco abuse have all engaged millions more people than ever before. For people like me who have grown to recognise that we can do something about our lives in many areas, improving our health has become one of the signs of our greater control. This doesn't just improve my health, it also gives me a greater say in my life – as does my politics, my ability to earn good money and my ability to confidently question authority in its on terms. My health, like my life, can be influenced by my actions.
'We just aren't very well round here…'
But others do not believe that their actions can affect anything very much. They believe they have not done well at school not because of poor teaching, but because they are not very bright. Their health, like so many other things about their world, is just a given. It is the bad luck of people who live round here. They don't therefore believe that their actions can affect their health. Health, like so much of life, is something that is immutable and a given and done to them.
So the problem for health improvement is the same as for so many other inequality evils: how can more people develop higher aspiration and the capability to work with that aspiration to take more control over their lives? When it is put this way, we know that class and background social issues can never determine social aspiration. We all know of people from a range of ethnicities and disadvantages who have powerful aspirations and the capacity to fulfil them. We need to understand what the triggers are for these people in their lives that provide them with aspiration and capability.
But for very many people, these social factors do curb their capacity to meet health aspirations and, for the health of the nation, this is a disaster. Being fatalistic about health and mortality doesn't just lead to illness-inducing behaviour around smoking, alcohol and exercise, it means that people do not report the pain in their chest or the lump in their breast very early for diagnosis because – 'well, there is nothing you can do!' Inequality in cancer death rates comes from very late presentation caused in part by this fatalism.
Government and the equalisation of aspiration
So what can government do about this? And this is where Rowntree would have had to work through a quandary. If we are trying to create greater aspiration for control over their lives and their health, then telling people what to do and how to live their lives seems a very poor way of helping people have more control. Many government behaviours in public health are aimed at banning activities as the only way of changing behaviour.
That may make government feel it has done something, but being told how to live your life by Whitehall does not increase your capacity to run your own life.
There is also something deeply disturbing in class terms about this. Health improving behaviours are carried out voluntarily by middle-class people. We work it out, how to fit it into our lives and take a little more control on our terms. And then, not knowing what to do for other people who don't live like us, we organise government to tell them what to do. Whatever the morality of that, as I say, this does not induce greater control.
So how can government work with people whose health aspiration has been blocked?
First, it must recognise that it is not good at it. The public does not feel that government can get the subtle messages across that might change health aspiration and capability. In these behavioural terms 'the public' barely exists. But a segmented approach to marketing ideas about aspiration and health improvement is essential. Even if they have the same life-expectancy, treating a 60-year-old Bengali woman the same way as a 60-year-old ex pit man will not work for either. Both may have low health aspiration, but will change in their own ways.
Second, small steps are the most realistic. If you are very overweight, being told that an Olympic athlete is your role model will not work. Such an athlete looks as if they come from another planet. Being told to cook a three-course meal every day is hopeless if you have never cooked vegetables. If we are not careful, improving people's health aspirations can very easily feel like 'make your life like mine!', and the old problem of class imposition of lifestyle re-emerges.
Third, let's link health improvement to other improvements in control. Health is not a separate issue here. Men and women across the country are struggling for greater control over, for example, safety in their community; over getting control of their debt rather than having it control them; over trying to get the school to listen to what they are saying about their child's behaviour and aspirations.
Every day there are millions of moments where people refuse to be socially determined by what goes on around them. Those of us involved in health improvement need to recognise each of those moments as a time and place to say – 'health is like this too'. It is something you can do something about and just like the criminal neighbours, the fear of the credit bill and the non-committal headteacher, you can make a difference to your life.
I think Rowntree would have been good at that.
Paul Corrigan has had four careers. He was a social science academic, a senior manager in local government, a health policy adviser to two secretaries of state and Prime Minister Tony Blair and is now a management consultant and executive coach.
