The past, present and future health costs of inequality
There is a risk factor that triples your risk of heart disease, but it is not hypertension. The same risk factor triples your risk of getting chronic respiratory disease, but it is not smoking. This risk factor increases your risk of type 2 diabetes by four times but it is not diet or obesity. It shortens your lifespan by almost twenty years, but leaves you so ill in the years you live that the costs of treating you exceed the savings bought about by your premature death.
I was taught nothing about it in medical school, yet have faced it every single day in my 21 years of clinical practice. We do not screen for it, rarely ever ask about it, do not treat it or advocate about it.
The risk factor is trauma in childhood. Like any risk factor, smoking for example, many people affected manage to live without serious consequences and we need more research to find out how and why. Like smoking there is a dose response; a little trauma may not cause much harm, but the earlier the trauma starts, the more there is, and the longer it continues, the greater the likelihood of harm.
Evidence is growing that shows how adverse childhood experiences are both correlated and causative risk factors for the development of disease in later life. The effects of stress and fearfulness bought on by being subject to or witnessing abuse, neglect, violence, hunger, abandonment, and criminal behavior in childhood, are both biological and emotional. The biological changes can be seen in neurological, immunological, hormonal and even genetic systems which begin during development in the womb and are most sensitive in the first 3 years of life. Adults who have survived this and flourish nevertheless no more disprove the dangers of adversity than elderly smokers who live without smoking related diseases.
The additional inpatient costs to the NHS of treating the adverse consequences of deprivation are estimated to be £4.8bn a year. But because over ninety percent of NHS interactions happen in primary care, A&E and outpatient settings so the true cost to the NHS is likely to be far, far higher. The psychological consequences include fearfulness and shame – making it hard for people affected to develop trusting relationships and engage with long-term care, but increase their attendance rates in times of crisis.
We need, as a society to take far more seriously the promotion and protection of good health by paying more attention to the risk factors for disease. Trying to prevent diabetes by treating obesity is a typical example of focusing on treatment rather than prevention. The risks of adverse childhood events are cumulative: you might survive emotional neglect, but if you are also exposed to sexual abuse and an alcoholic parent your chances of enjoying good health in adulthood will be slim. The original research that showed the importance of childhood events began in an obesity clinic in the 1980s where doctors discovered the role that comfort-eating played in ameliorating the symptoms of childhood trauma, especially child sexual abuse. The greater the number of adverse events, the greater the chances of obesity and the greater the difficulties losing weight. Bariatric surgery is a poor treatment for trauma.
The chronic diseases the NHS treats today are all too often the end-result of processes that began decades ago. Those who suffered abuse – from deprivation, violence, etc - in the 1970s and 80s are beginning to develop the chronic diseases that are pressuring NHS services today. Because we all contribute to the NHS we are paying for the failure of politicians in the past and will pay for the failure of politicians today.
Further reading:
The Adverse Childhood Experiences Study — the largest, most important public health study you never heard of — began in an obesity clinic.
Caspi A, et. al. Childhood forecasting of a small segment of the population with large economic burden. Nature Human Behaviour. 2016 vol. 1(1) http://www.nature.com/articles/s41562-016-0005
Barnett K, et. al. Epidemiology of multimorbidity and implications for health care, research, and medical education: a cross-sectional study Lancet. 2012 vol: 380 (9836) pp:37-43 http://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(12)60240-2.pdf
Asaria M, Doran R, Cookson R. The costs of inequality: whole-population modelling study of lifetime inpatient hospital costs in the English National Health Service by level of neighbourhood deprivation. Journal of epidemiology and community health 2016 vol. 70 (10) pp: 990-6 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5036206/
Jonathon tweets as @mellojonny. His blog can be found at https://abetternhs.net/
