What we can do to protect people from dementia

Like many diseases, it does not strike fairly, writes Michael Marmot. But there are certain things we can address to help people who are more at risk deal with it far more easily, or even hold it off entirely

A new report from Alzheimer’s Research UK shows that dementia risk rises with increasing deprivation (Getty/iStock)

Dementia. The shadow that looms over all of us. But, like so much else to do with health, it casts its shadow unevenly.

Many of us concerned with health inequalities have had a focus on children. A consistent theme of our reports at the UCL Institute of Health Equity is that we must ensure equity from the start, and give every child the best start in life. Hence the alarm when the Joseph Rowntree Foundation recently reported that 1 million children in the UK are living in destitution – a nearly threefold increase between 2017 and 2022.

But what about the 2.8 million people in destitution who are not children? Should we not also care about them? Is it too late to do anything about health and health inequalities after age five, particularly at older ages?

There is a tendency to see death as the great leveller, and the decline in physical and mental functioning that comes before as inevitable. In the fundamental, yet trite, sense that we are all mortal, death is a leveller, but the age at which it happens is strongly influenced by social circumstances. Similarly, life before death is far from equal.

Disease and suffering are also strongly influenced by the conditions in which we are born, grow, live, work and age – the social determinants of health. Inequalities in healthy life expectancy are greater than inequalities in life expectancy. And an important part of those years lived in ill health is dementia.

A new report from Alzheimer’s Research UK shows that dementia risk rises with increasing deprivation, and people living in deprived areas die from dementia at an earlier age than people in more privileged areas. Further, the risk of dementia is increased in Black and south Asian people in the UK, and they die earlier with dementia.

Just as deprivation should not equate to an irreversible sentence of early death, nor should it be one of early dementia. Alzheimer’s Research UK, reviewing the evidence, calls for action in five areas to delay the onset of dementia and reduce inequalities: clean up the air, make smoking obsolete, promote healthy eating, tackle high blood pressure, and identify and treat hearing loss.

The effects of each of these five factors are unequally distributed in the population, to the detriment of people in more deprived areas. They provide ready explanations for the higher risk of dementia in more deprived populations, and for the disadvantage among Black and Asian British people. It is not the whole story, though.

Research from east London confirms a higher dementia risk in the most deprived areas. Taking into account the fact that risk factors – a list that overlaps with the five just listed – are linked to deprivation does not greatly change the picture. Dementia is higher in deprived areas for other reasons in addition to these risks. The authors of the paper – Phazha Bothongo, of Queen Mary University of London, and her colleagues – point to the fact that stressful and traumatic life events influence the risk of dementia, and these may be more common in certain ethnic and deprived groups.

These findings, suggesting that inequalities in dementia risk are to some extent preventable, tap into a different debate: where responsibility lies for action to improve health and reduce health inequalities. It is almost a litmus test for political beliefs. Those to the right of the political spectrum emphasise individual responsibility for health; those to the left call for social action.

I claim that looking at the science of the five actions recommended shows the need for social action. In the case of air pollution, it is clear that individuals can’t reduce it on their own, therefore clean air is a social responsibility. Healthy eating might seem more open to debate. If a politician can claim that sleeping rough is a lifestyle choice, they would have little difficulty in blaming poor people for eating a poor diet.

The evidence shows, of course, that poverty is a cause of unhealthy eating. Progress in smoking reduction has come from social action. Controlling high blood pressure with diet and reduction of alcohol, as well as prompt treatment, entails a mix of individual behaviours and social action.

Until now, it has been possible to believe that the public, too, think that health is a matter of individual responsibility. It is frustrating. If the public believe that ill health results from bad luck or bad choices, it is hardly surprising that politicians predisposed to those beliefs feel no need to change them.

However, recent polling conducted by the Fairness Foundation and Opinium finds that people do recognise the importance of tackling the social determinants of health. Half the population surveyed said their job affected their health, and half said the cost of living did. As to who is responsible for fixing health inequalities, 54 per cent said the government.

If we want our health to improve to the level of our European neighbours, we should have taxation rates and public spending that approach those of our European neighbours. I could never be a politician. It is interesting that the Fairness Foundation survey shows that 52 per cent of Britons support raising taxes to increase spending to reduce health inequalities.

These two reports provide one gloomy and two encouraging messages. It seems quite unfair that along with all the other health misfortunes, people in deprived areas and Black and Asian groups are more likely to suffer dementia. It is enormously encouraging that there is evidence that social policies can make an important difference. It is encouraging, too, that at least half the public recognise and support government action to reduce health inequalities. If not now, when?