A Tale of Two Cities: health inequalities in 21st century London

This is a guest contribution from Emma Brooks who is currently a PhD student at UCL Institute of Education researching antenatal care in London.


Piotr appeared to have it all: he worked full-time as a builder and was happily married with two young children. At the beginning of each pre-entry ESOL class he would stop to chat and laugh with the other Polish students, before sitting down to concentrate on the day’s lesson. As he told his classmates, he was eager to improve his English so that he would be able to move to a bigger house. In fact, as Piotr’s English improved, this became a topic of conversation to which he returned, as did his baby’s cough – a respiratory condition which was proving hard to treat. As Christmas beckoned, the informality of the end-of-term party encouraged Piotr to approach me, his teacher, for some advice. He explained how concerned he was about the family’s accommodation and the effect it was having on his very young child. Slightly confused, I asked for more details. Piotr elaborated: he lived in a small terraced house, commonly referred to as a ‘2 up-2 down’, which would have originally been designed to house a nuclear family. Yet, Piotr’s house had 16 people living in it. He and his family lived in one room, and the other three rooms were rented to three different groups. All of them shared one bathroom and one kitchen. The walls were black with damp, which had aggravated his daughter’s asthma to such an extent that she had been hospitalised twice. One of the rooms was also let to intravenous drug users, who often left used needles in the hall. Piotr had tried to speak to the council about his housing several times but they had not understood or addressed his complaint.

A melodramatic introduction? Perhaps. Yet, Piotr’s experience reflects that of thousands of people living in sub-standard accommodation across the UK, in conditions which affect both their mental and physical wellbeing. This sounds like a Dickensian portrait of London past, but in fact it is a contemporary fresco of suburban poverty, masked by paint and compelled by greed. As investors cherry-pick areas ripe for new development, intermittent pockets of wealth spring up in London’s urban peripheries: the slow creep of gentrification, watched remotely by cranes lingering over expectant sites, begins its crawl. The resulting squeeze on the housing market increases rents and prices, and subsequently drives the poorest inhabitants elsewhere: or worse, off the ladder completely, and into the precarity of cramped B&Bs and emergency housing. Communities othered by poverty are also commonly distinguished by ethnicity, linguistic diversity, and class. The housing crisis in our cities stands as a visible reminder of the stark inequalities of 21st century Britain, albeit one that is undeniably easier to perceive than the endemic health disparities that this article hopes to highlight.

Unfortunately, my depiction of a district in south-east London is not unique: it can be seen as a microcosm of a class-bound society, where rich and poor live as neighbours, sharing little experience. With the black and minority ethnic (BME) community predicted to reach 56% by 2020, and the unusually large number of residents who are refugees and asylum seekers, the borough is characterised by its superdiversity. Although more than 50% of the population speak English as an additional language, in 2016 100% of reception children in a local school started with first languages other than English. The significance of these seemingly unrelated statistics lies in the fact that each one of these features is considered to be a social determinant of health. In other words, if you tick more than one of these boxes, there is an increased likelihood of poorer health, and a shorter life expectancy, than a wealthy, white, ‘native’ speaker, living in warm and secure housing. Statistics bear this out- a woman living next to the local hospital, an area marked by poverty and inadequate housing, is likely to die 7 years earlier than a woman living 5 miles away in a relatively wealthy suburb.

Let’s take the example of an asylum seeker: you have no recourse to public funds; you may be housed in temporary accommodation which, due to housing shortages, may or may not meet statutory requirements; although you qualify for a small remittance, you will not be able to work; you may not yet have the language skills needed for day to day encounters, but due to funding cuts and erratic provision in adult education, be unable to access ESOL classes; without English, you may find it difficult to access GP care, therefore exacerbating health needs; without linguistic skills or cultural capital, it may be difficult to enrol your child in a school, meaning that they are placed in one several miles from your house; without money, you are unable to take your child to school etc, etc, etc.

It can be argued that health inequalities are structurally, institutionally, societally and culturally constructed and interlinked, but is also crucial to recognise that factors rarely operate independently. They work as part of systemically unequal system, making it almost impossible to separate, and therefore address, individual issues. However, whilst the abstract notion of health inequalities may be familiar to readers, it is sometimes difficult to conceptualise. The following, distressing, story of a woman I shall call Ayesha*, was related to me by an incredibly passionate Public Health consultant, whose impressive career has been distinguished by her commitment to tackling social determinants of health.

Ayesha and her husband Ali moved to the UK in 2006, in order to join his family. With the promise of a full-time job, the young couple, in their twenties, were hoping for a comfortable future. However, Ayesha was also six months pregnant with their first child and feeling nervous about giving birth in a new country, without her mother and sisters to support her. Even though her husband reassured her that she would soon pick up the language, Ayesha’s fears were compounded by the fact that she did not yet speak any English or attend ESOL classes, as their minimal household income was above the threshold to qualify for free classes. Ali’s employment involved travelling to his cousin’s shop on the other side of London. As he was receiving the minimum wage, Ali couldn’t afford rail fares and had to travel by bus across town. Taking over an hour each way, and sandwiching a 13-hour day, the journey took away precious time from the couple: the days Ayesha spent alone waiting for her husband to return from work were long and lonely. It was a gloomy, November morning, during the eighth month of her pregnancy, while she was busy preparing lunch, that Ayesha felt a sharp pain in her stomach. Although she had visited a midwife in Pakistan, the young woman had been apprehensive about visiting the doctor in the UK, especially without her husband or family to take her. Taking deep breaths and sitting down, Ayesha wondered whether the pains indicated the start of labour. However, as she reached for the phone to call Ali, Ayesha felt a warm gush of liquid – looking down, she was horrified to see blood on her clothes, not water. Ali was quick to take the call from his panicked wife and, as she frantically described her pain and symptoms, he told her to lie as still as possible, as he began the long journey home. At ten past twelve, sixty minutes after the terrifying phone call from his stricken wife, Ali returned to their flat to find Ayesha, and their unborn child, had died.

Neither Ali or Ayesha had known how to contact emergency services, or that the symptoms she was experiencing were potentially life-threatening. Without access to English classes or a social support network, Ayesha experienced an isolation which was entirely avoidable. Her tragic, unnecessary, death triggered an anxious response from local government agencies (Public Health, the hospital, local GPs), and inclusion in an annual enquiry from CMACE (Centre for Maternal and Child enquiries), a body which investigates maternal and infant mortality in the UK. Shockingly, whilst the number of maternal deaths is, thankfully, relatively low in the UK, women from BME backgrounds and those who speak English as an additional language, are disproportionally represented in this group. Therefore, some of the wide-ranging recommendations from the report, included strategies for medical professionals to better engage with migrant communities, as well as improved access to ESOL provision. Whilst one cannot doubt the commitment from professionals working to support vulnerable communities, with NHS funding under constant duress and a persistent reduction in public spending, it would be both naïve and misleading to suggest that recommendations have been adopted uniformly.

This thriving superdiverse landscape of 21st century London, where mosques and temples rub shoulders with Polish churches, phone repair outlets offer the opportunity to transfer money to far-flung lands, and markets advertise African, Afghan and Asian cuisine, can often mask the hidden poverty and pervasive deprivation experienced everyday by its residents. It is only by penetrating the façade of the contemporary that we can reveal the continuance of an alternative reality, incongruent with the notion of modernity and equality.

*Some details of these stories have been changed in order to preserve anonymity. However, they are both genuine tales of lives lived in deprivation.

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