All I want is a room somewhere./ Far away from the cold night air …/warm face, warm hands, warm feet. Oh, wouldn’t it be loverly.
To Eliza Doolittle’s lament we can add, not just “loverly”, but healthy, too. George Bernard Shaw, whose play Pygmalion was the source for the film My Fair Lady, was writing about Edwardian London. Yet cold and poor is the reality facing 66% of the population this winter in 21st-century Britain.
Both “cold” and “poor” will contribute to worse health and greater health inequalities. It is a humanitarian crisis. One that will not be solved by tax cuts or removing levies that favour green energy, as seems to be the “solution” proposed by our likely next prime minister. We need to act on the immediate crisis, but we also need to ask how we got here, and what to do to solve the problem of fuel poverty, and its effects on health inequalities, in the longer term.
Fuel poverty has three components: the price of fuel, the quality of housing and ability to pay. The definition used to be having to spend 10% or more of household income to heat your dwelling to an acceptable level. Some variant of that is still used in Wales, Scotland and Northern Ireland. In England, the definition changed, which makes comparisons difficult: a household is fuel poor if the property has a low efficiency rating and the household disposable income, after housing and energy needs, is less than 60% of national median income.
For the cold part of cold and poor, the causal chain is simple. Inflation in general, and the cost of heating, will lead to fuel poverty. Fuel poverty will lead to cold homes. Cold homes will damage mental and physical health. The health effects are considerable, as laid out in our report, Fuel Poverty, Cold Homes and Health Inequalities in the UK, published today by the UCL Institute of Health Equity.
The health effects start in childhood with lungs damaged by cold, but also by mould and damp that tend to accompany cold in substandard housing. Children who live in cold, damp homes have more respiratory illnesses than children who do not. This higher burden of illness is likely to continue through into adulthood.
Cold damages mental health. Children growing up in cold homes have more psychological symptoms than children in warm homes. They also perform less well in school. A combination of days missed through illness, inadequate conditions for study and homework, and the effects of cold on mental health and development all contribute.
One reaction to the finding that cold homes damage mental health and development is disbelief. “In my day,” one senior doctor told me, “when I was a lad, we had ice on the inside of the window. I developed all right.” My thought: think what you might have achieved had you grown up in a warm home. More diplomatically, I said: “When you were a lad, infant mortality was 30 per 1,000 live births, now it is 3.4. The fact that you survived when the rate was nine times higher than it is now, doesn’t mean it was safe or desirable.”
Cold also makes lung problems in adulthood worse. Visits to GPs for respiratory tract infections, asthma attacks, loss of functioning with chronic obstructive pulmonary disease are all linked to cold. Cold affects the heart and blood vessels: the colder the indoor temperature the higher the blood pressure level.
A big issue for the UK is excess winter deaths. In most countries, deaths are higher from December to March than at other times of year. The excess is higher in the UK than in a colder country such as Finland. One possible reason is worse insulation of housing in the UK. It has been estimated that 10% of excess winter deaths can be attributed to fuel poverty and 20% to cold homes.
Cold and poor. Fuel poverty is part of poverty. If the price of energy goes up, people at or below the margin will have less to spend on such frivolities as food, rent and clothing. Because food and energy make up such a high proportion of expenditure in poor households, predicted inflation of 11% in the least deprived fifth of households corresponds to inflation of 17% in the most deprived fifth. To those who doubt that cold could affect children’s development and education, add in going to school without breakfast. Add the effects of parents’ mental health on children’s health and development. Put simply, the struggle to make ends meet increases risk of depression. Mental illness in parents is an adverse childhood experience (ACE). Children who suffer from four or more ACEs have greater risk of mental and physical illness throughout life; they are more likely to drink, smoke and use drugs; and more likely to engage in violent behaviour.
ACEs do not imply that parents are wicked, more that they are poor. ACEs are linked to income and deprivation: the greater the deprivation the greater the frequency of adverse childhood experiences. Inflation and the catastrophic rise in energy prices does not turn people into wicked parents, it means that they are casualties of the struggle to survive.
To ask how we got here, we need to look at all three components of fuel poverty: the price of energy, the quality of housing, and poverty. The price of energy has more to do with our dysfunctional energy market than it has to do with the war in Ukraine. About 36% of Britain’s energy comes from gas, and very little of that gas comes from Russia; nearly 60% of energy comes from nuclear or renewables, so why has the price of energy risen so sharply? The cost of producing energy through nuclear and renewables should not have been affected by the war in Ukraine. People who have studied economics will explain that the price we pay is not related simply to the average cost of producing the energy plus a reasonable profit, but to the marginal cost of supplying the last most expensive unit. If the price of gas goes up, we pay more for energy coming from wind. What? People are going to shiver and go without food this winter because our energy market is crazy.
Second, the quality of housing. Investment in home insulation fell off a cliff in 2013. The government simply took the decision to stop investing in making homes more energy efficient. Third, poverty. We limped into this cost of living crisis with the consequences of a decade of austerity and an economic hit from the pandemic – larger in the UK than in countries that managed the pandemic better. Child poverty, after housing costs, rose from 27% in 2010 to 30% in 2019.
Economists from Paul Krugman to Paul Johnson to Torsten Bell have solutions, going beyond conventional economics, of what we need to do to fix this winter’s looming crisis. Now, though, is also the time to deal with the longer-term problems that led us here in the first place.
Michael Marmot is professor of epidemiology at University College London, director of the UCL Institute of Health Equity, and past president of the World Medical Association
