Nada Khan is an Exeter-based GP and clinical academic, and an Associate Editor at the BJGP.
‘”… Mr. Scrooge,” said the gentleman, taking up a pen, “it is more than usually desirable that we should make some slight provision for the poor and destitute, who suffer greatly at the present time. Many thousands are in want of common necessaries; hundreds of thousands are in want of common comforts, sir.”
Charles Dickens, A Christmas Carol
Charles Dickens and his bleak descriptions of destitution in Victorian England highlighted the struggles faced by those experiencing social and economic inequities, often at the hand of the corrupt and the cruel. But are we facing a revival of Dickensian-era diseases?
NHS data obtained from 84 NHS Trusts through freedom of information (FOI) requests shows a ‘shocking’ rise in Victorian maladies including rickets, scurvy, and malnutrition.1 This is not new news, indeed, The Guardian and The Times Health Commission previously conducted equivalent FOI requests in what must be an annual headache for NHS Trust FOI teams, and reported similar increases in hospitalisations for malnutrition and scurvy.2,3 Speaking to Andrew Marr, Sir Michael Marmot described the findings as deeply depressing.4 Why are these diseases seemingly increasing in incidence and what can we do about it?
Food insecurity and disease
“17% of UK households experienced food insecurity in 2023”
Rickets and scurvy are closely interlinked with nutritional deficiencies, and can act as a proxy for malnutrition and poverty. The Food Foundation runs an annual survey measuring food insecurity, asking responders if they have to skip meals, go hungry, or not eat due to difficulties affording or getting access to food. Their survey estimates that 17% of UK households experienced food insecurity in 2023, and the problem is worse in households with children, with 23% of households experiencing food insecurity amid inflationary pressures.5
In Australia, where food insecurity has jumped from 4% (pre-COVID-19) to 21% (July 2022) in the general population, the cost of fresh fruit and vegetables and other ‘healthy’ foods increased by 18% from 2019–2022, while the cost of processed and unhealthy convenience foods ‘only’ increased by 9% over the same time period.6 Increasing costs of living and the higher costs of fresh food and fruit needed to prevent diseases like scurvy are impacting on a household’s ability to afford a healthy diet.
The rise in destitution in the UK
Back to thinking about our society’s slide back through history to Dickensian times. Gordon Brown recently described the UK as ‘haunted by poverty we thought had been consigned to history’, highlighting the ‘moral outrage’ of families unable to afford food, proper clothing, or housing.7
The lack of these fundamental necessities go beyond poverty into a darker definition of destitution, which the Joseph Rowntree Foundation defines as the inability for people to meet basic needs to stay warm, dry, clean, and fed. More specifically, people are defined as destitute if they have lacked, because they cannot afford them, two or more of shelter, food, heating for their home, lighting for their home, appropriate clothing, or basic toiletries.8
“The lack of … fundamental necessities go beyond poverty into a darker definition of destitution … “
The Joseph Rowntree Foundation’s report on destitution in the UK, the fourth in the series dating back to 2015, makes for grim reading. One of the key messages in this report is that the problem is getting worse, with an almost two-thirds increase in households facing destitution in the last 3 years, and almost 1 million children facing destitution in the UK in 2023, nearly three times more than 2017.8
Both Gordon Brown and the Joseph Rowntree Foundation emphasise that Universal Credit and the current value of working-age benefits do not clear even that very-low threshold that recipients need to escape destitution. The rates for Universal Credit are £85 per week for a single person, while the income threshold for destitution is £95 per week, so the system is rigged to make people ‘destitute by design’.8
Stressing the lack of a fair benefits system, and back to that Food Foundation report, half of households receiving Universal Credit experienced food insecurity in 2023.5 To start to tackle destitution requires an overhaul of the benefits system to meet the basic costs of living and prevent that slide into destitution, food insecurity, and poor health, especially among the most vulnerable households with children.
This is not all new. I recommend Marmot’s The Health Gap to anyone and everyone, but not just because it highlights the injustice of health inequalities. What I didn’t expect from this book was hope. I wouldn’t generally describe myself as an optimist, but Marmot certainly seems to be, and tells us that although all of this is deeply depressing, it is a solvable problem.
Action will require fair implementation of national-level policy initiatives, but in his book, Marmot highlights the strength of socially resilient communities taking back control, and actions that doctors can take to tackle the social determinants of health and health inequities.9
Why does it matter to GPs and what do GPs need to know?
“… half of households receiving Universal Credit experienced food insecurity in 2023.”
Poverty is strongly associated with poorer health. And exposure to poverty in childhood, which the Joseph Rowntree Foundation report suggests is increasing, is worrying as it is associated with worse long-term health outcomes, which are even worse for children who persistently live in poverty.10
I’ve written previously about screening for food insecurity and why GPs need to ask and record data about food insecurity before we can act on it.11 Dickens often highlighted the apathy of the rich in providing for the poor. What is our social responsibility as health professionals? If you don’t have time to read Marmot’s The Health Gap, read this, a summary of those five actions that doctors can take in acting on social determinants of health.
With an increase in conditions we may not have seen, or even learned about, clinicians may need to go back and read about common signs and symptoms of scurvy, rickets, other nutritional deficiencies, and how to investigate for them. And, finally, to our own wellbeing. A study recently published in the BJGP looked at the moral distress experienced by GPs caring for patients with health needs related to social inequities.12 When I spoke to Monica Molinaro about this study for a BJGP podcast and asked her what GPs could do about these problems, she cautioned me to remember that GPs working with marginalised patients cannot address the root causes of insufficient resourcing. And while individual wellness and clinician resilience is often promoted in the NHS to combat moral distress and prevent burnout, these measures do not fix the structural and systemic roots of our moral distress.
But before we despair on our society’s slide back into Dickensian levels of destitution and the impact on our patients, try to embody even an sliver of Marmot’s take on ‘evidence-based’ optimism and remember that we can make progress to improve poverty and reduce health inequalities if we try.
References
1. Hand C. Starmer slams ‘shocking’ rise in Victorian era diseases as tens of thousands suffer since Sunak became PM. 2024. https://www.lbc.co.uk/news/starmer-slams-shocking-rise-in-victorian-era-diseases (accessed 22 Feb 2024).
2. Devlin H. Surge in number of people in hospital with nutrient deficiencies, NHS figures show. The Guardian 2023; 21 Dec: https://www.theguardian.com/uk-news/2023/dec/21/surge-in-number-of-people-in-hospital-with-nutrient-deficiencies-nhs-figures-show (accessed 22 Feb 2024).
3. Lambert G. Thousands of people admitted to hospital with malnutrition. Times Health Commission 2023; 10 Jul: https://www.thetimes.co.uk/article/times-health-commission-thousands-of-people-admitted-to-hospital-suffering-from-malnutrition-n23hqgzjr (accessed 22 Feb 2024).
4. LBC. Sir Michael Marmot on ‘grim reality’ of poverty in Britain | LBC. YouTube 2024; 23 Jan: https://www.youtube.com/watch?v=QPKxFZkFQgA (accessed 22 Feb 2024).
5. The Food Foundation. Food insecurity tracking. https://foodfoundation.org.uk/initiatives/food-insecurity-tracking#tabs/Round-13 (accessed 22 Feb 2024).
6. Lewis M, Herron LM, Chatfield MD, et al. Healthy food prices increased more than the prices of unhealthy options during the COVID-19 pandemic and concurrent challenges to the food system. Int J Environ Res Public Health 2023; 20(4): 3146.
7. Butler P. Gordon Brown slams ‘obscene’ levels of destitution in the UK. The Guardian 2024; 8 Feb: https://www.theguardian.com/politics/2024/feb/08/gordon-brown-slams-obscene-levels-of-destitution-in-the-uk (accessed 22 Feb 2024).
8. Fitzpatrick S, Bramley G, Treanor M, et al. Destitution in the UK 2023. 2023. https://www.jrf.org.uk/deep-poverty-and-destitution/destitution-in-the-uk-2023 (accessed 22 Feb 2024).
9. Marmot M. The Health Gap: The Challenge of an Unequal World. London: Bloomsbury, 2015.
10. Lai ETC, Wickham S, Law C, et al. Poverty dynamics and health in late childhood in the UK: evidence from the Millennium Cohort Study. Arch Dis Child 2019; 104(11): 1049–1055.
11. Khan N. The cost of living crisis: how can we tackle fuel poverty and food insecurity in practice? Br J Gen Pract 2022; DOI: https://doi.org/10.3399/bjgp22X719921.
12. Molinaro ML, Shen K, Agarwal G, et al. Family physicians’ moral distress when caring for patients experiencing social inequities: a critical narrative inquiry in primary care. Br J Gen Pract 2024; DOI: https://doi.org/10.3399/BJGP.2023.0193.
