Hannaliis Jaadla, Alice Reid, Eilidh Garrett and Romola Davenport 

In terms of mortality, the UK currently stands out as one of the most regionally unequal countries in Europe. The divide between local authorities is stark: the gap in life expectancy at birth between the country’s wealthiest and poorest areas is around ten years. These figures reflect broader disparities that go far beyond health, revealing deep-seated structural imbalances in the country’s economic and social fabric.  

Regional health inequalities are not caused by a single factor, but rather a complex web of interrelated issues. Levels of deprivation, child poverty, food insecurity, infrastructure, and the distribution of government resources all play significant roles. Over time, these elements have compounded, shaping unequal opportunities and outcomes across the country. 

The persistence of regional differences is particularly striking. These spatial patterns have deep historical roots, shaped by long-term trends, institutional choices, and persistent policy priorities. Historical legacies and path dependency mean that decisions made decades – or even centuries – ago still influence today’s social and demographic landscape.  

This persistence is particularly marked in Britain. In other European countries, north-south and east-west gradients in life expectancy have seen often dramatic reversals. For example, in France (Figure 1) and Italy, northern more economically developed areas had the highest life expectancies in the early 20th century but lost this advantage to southern areas in the later 20th century.

In Germany, life expectancy in the former GDR, which was much lower than in west Germany, has converged to western levels since reunification. These trends contrast with Britain where inequalities in health and survival have shown much the same regional patterning since at least the mid-19th century.     

Persistent health inequalities in the UK 

In 2021, the Chief Medical Officer for England, Prof Chris Whitty, said: “If you had a map of Covid’s biggest effects now and a map of child deaths in 1850, they look remarkably similar”. The BBC picked this up and produced the maps shown in Figure 2, using data from the interactive website www.PopulationsPast.org, created by researchers at Campop. There are similarities between Covid, an airborne infectious disease, and many of the conditions that children died from in the 19th century, which included measles, whooping cough, scarlet fever and other infectious diseases.  

But the persistence of these regional patterns is more pervasive: the two maps also reflect more general patterns of mortality in their respective time periods. In the 19th century, mortality was dominated by infectious disease and a large proportion of deaths were among infants and children, so a map of overall mortality would look quite similar to the map of child mortality. Today, infectious diseases make no more than a minimal contribution to mortality in the UK: most deaths occur in old age due to non-communicable diseases. Older people with co-morbidities were most vulnerable to Covid, so the second map also reflects more general mortality. 

It is clear that geographical patterns of mortality have persisted over time, despite massive changes in the diseases and conditions that people die from, and in the age structure of deaths. Places where inhabitants had poor health in the 19th century still have people experiencing relatively poor health today.  

There is, of course, a well-established and persistent north-south divide in socio-economic deprivation as well as in health, and to some extent the continued geography of health can be attributed to the continued geography of poverty. For example, a study by Danny Dorling and colleagues in 2000 documented remarkable similarities between geographic patterns of deprivation in London in 1896 and 1991, and found that some forms of mortality in the 1990s were in fact better predicted by deprivation in 1896 than in 1991.  

In 2009, Ian Gregory performed a similar exercise for the whole of England and Wales, comparing not only deprivation in the 1900s and 2000s, but mortality at both times too. This also showed that there were persistent geographic patterns of deprivation. In addition, it demonstrated that mortality in the 2000s was more closely linked to mortality in the 1900s than it was to deprivation in the 1900s, indicating that that the persistence of mortality patterns over time is not simply due to the persistence of deprivation.  

Thus despite considerable population movement, redevelopment, and regeneration, it seems that places find it difficult to shuffle their relative rankings within a mortality hierarchy. The obvious question is then: why does the hierarchy persist? Is it due to the congregation of more vulnerable people into specific places, and if so, what is it about those places which attracts more vulnerable people, or encourages less vulnerable people to leave? One suggestion along these lines might be that such locations have more affordable – or less attractive – housing.  

Such arguments ultimately assume, however, that certain places have higher mortality because they contain more less-well-off people. But of course, there can also be contextual effects of places which can affect health outcomes over and above any effects of family poverty. Work at Campop has indicated that in the early 20th century, the children of professional people living in industrial and mining areas were considerably more likely to have died young than the children of professional people living in leafy suburbs, small towns, or the countryside.  

This contrast might have come about through factors such as differences in street sanitation, air and water pollution, or disease loads in the general environment. While sanitation and infectious disease loads are generally less of an issue today, pollution and a lack of amenities may still have a contextual effect on health. 

Regional variations in fertility 

When we think of regional inequality, health outcomes are far from the only indicator that reveals deep-rooted geographic differences. Fertility, too, tells a fascinating story about how social, economic, and cultural factors shape life across different parts of England and Wales. 

Maps from PopulationsPast highlight that during the late 19th and early 20th century, at the time of the historical fertility decline (when the average number of children that women had across their lives fell from around five to below two), levels of fertility varied considerably from one district to another in England and Wales. Some areas saw steep drops in fertility earlier than others, painting a picture of a country undergoing uneven demographic change. 

While regional differences in fertility today may not be quite as stark, they haven’t disappeared. Fertility still follows distinctive spatial patterns, influenced by a mix of factors including local economies, housing conditions, levels of urbanisation, and sociocultural norms. 

Take London, for example. The city has changed beyond recognition over the last hundred years, but some patterns in how and where particular groups of people live have shown remarkable persistence. One such pattern is the spatial variation in fertility across the capital, where the broad contours of fertility inequality have endured from Edwardian times to today. 

In the early 20th century, London’s fertility differences were sharply divided along an east–west axis. High fertility rates were concentrated in the East End, historically home to working-class communities and recent migrants. In contrast, lower fertility rates, similar to those seen in early 2000s London, were already evident in the more affluent western districts, such as Mayfair, Paddington, and Kensington. These districts were and still are predominantly home to those with wealth and social prestige. 

Fast forward to the 21st century, and the dividing lines have shifted, but not disappeared. Today, the key contrast lies between Inner and Outer London. Fertility rates tend to be higher in suburban Outer London, while central areas – particularly those in Inner London and the historic West End – continue to report significantly lower fertility levels. 

This isn’t just a story of shifting boundaries. Despite demographic, economic, and cultural changes over more than a century, some districts have consistently remained at the low end of the fertility spectrum. The continued clustering of low-fertility areas in Inner London and the West End suggests a deeper structural pattern, shaped by enduring differences in housing, lifestyle, population composition, and economic opportunity. 

Campop interactive atlases

Campop has three interactive, online atlases which allow a wider range of users – from school pupils to university researchers and policy makers – to explore geographic patterns in socio-economic and demographic outcomes. 

PopulationsPast displays a range of demographic outcomes including infant and child mortality, fertility, marriage and migration, with indicators of household structure and age dependency ratios. It also includes socio-economic data including social status distributions, and labour-force participation rates for married, single and widowed women, and for children of both genders. It currently relates to the years 1851‒1911 and provides data at Registration Sub-District level for England and Wales, and at Registration District level for Scotland. More data on mortality and migration will be added shortly, and we hope to add data for 1921 soon too.  

Users can choose which variables to view, zoom in to different geographical resolutions, and compare different maps side by side. For each variable shown there is an explanation of how it is defined and calculated, along with an overview of the national geographical patterns and trends, including a graph showing the trends’ evolution by type of place. Resources for schools including worksheets and podcasts are also provided. 

EconomiesPast is a similar site which enables changing patterns of work from 1600 to 2011 to be explored at parish level. The percentages of men and women in three broad age groups who were working in different occupational groups can be explored. 

The BBCE atlas is the British Business Census of Entrepreneurs, which maps patterns in entrepreneurship, employer/employee status and firm size between 1851 and 1911. 

Further reading

• Bambra, C., Health divides: where you live can kill you (Policy Press, 2016). 
• Bambra, C., Smith, K. E., Nwaru, C., Bennett, N., Albani, V., Kingston, A., and Matthews, F. (2023). Targeting Health Inequalities: Realising the Potential of Targets in Reducing Health Inequalities. 
• Dorling, D., Mitchell, R., Shaw, M., Orford, S., and Smith, G. D., ‘The ghost of Christmas past: health effects of poverty in London in 1896 and 1991.’ BMJ 321:7276 (2000), 1547‒1551. https://www.dannydorling.org/wp-content/files/dannydorling_publication_id0981.pdf 
• Green, M. A., Dorling, D., and Mitchell, R., ‘Updating Edwin Chadwick’s seminal work on geographical inequalities by occupation.’ Social Science & Medicine 197 (2018), 59‒62.  
• Gregory, I. N., ‘Comparisons between geographies of mortality and deprivation from the 1900s and 2001: spatial analysis of census and mortality statistics.’ BMJ 339 (2009).  
• Heblich, S., Trew, A., and Zylberberg, Y., ‘East-side story: Historical pollution and persistent neighborhood sorting.’ Journal of Political Economy 129:5 (2021), 1508‒1552.  
• Jaadla, H., Reid, A., Garrett, E., and Schürer, K., ‘Continuity and change in spatial patterns of fertility: the case of London’, in Hilevych and Kreager, Low Fertility in the Past and Present: Studies in Compositional Demography (OUP, forthcoming). 
• Reid, A., Garrett, E., Jaadla, H., Schürer, K., and Rafferty, S., ‘Fatal Places? Contextual Effects on Infant and Child Mortality in Early Twentieth Century England and Wales.’ Social Science History 47:3 (2023), 397‒424. doi:10.1017/ssh.2023.5 

Tags: demography, fertility, health, inequalities, mortality, north-south divide, regionalism, social history

| This entry was posted on Thursday, July 10th, 2025 at 12:20 am and is filed under Alice Reid, Eilidh Garrett, Hannaliis Jaadla, Romola Davenport. You can follow any responses to this entry through the RSS 2.0 feed. You can skip to the end and leave a response. Pinging is currently not allowed.