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Health Policy 113 (2013) 221–227

Contents lists available at ScienceDirect

Health Policy
journal homepage: www.elsevier.com/locate/healthpol

What (or who) causes health inequalities: Theories, evidence

and implications?
Gerry McCartney a,∗ , Chik Collins b , Mhairi Mackenzie c
a
Public Health Observatory Division, NHS Health Scotland, Elphinstone House, 65 West Regent Street, Glasgow G2 2AF, Scotland, United
Kingdom
b
Politics & Sociology Group, School of Social Sciences, University of West of Scotland, Paisley PA1 2BE, Scotland, United Kingdom
c
Public Policy, Urban Studies, School of Social & Political Sciences/Institute of Health & Wellbeing, University of Glasgow, 27 Bute
Gardens, Glasgow G12 8RS, Scotland, United Kingdom

a r t i c l e i n f o a b s t r a c t

Article history: Health inequalities are the unjust differences in health between groups of people occupying
Received 6 February 2012 different positions in society. Since the Black Report of 1980 there has been considerable
Received in revised form 29 April 2013
effort to understand what causes them, so as to be able to identify actions to reduce them.
Accepted 29 May 2013
This paper revisits and updates the proposed theories, evaluates the evidence in light of
subsequent epidemiological research, and underlines the political and policy ramifications.
Keywords:
The Black Report suggested four theories (artefact, selection, behavioural/cultural and
Health inequalities
Health inequities structural) as to the root causes of health inequalities and suggested that structural the-
Social class ory provided the best explanation. These theories have since been elaborated to include
Theory intelligence and meritocracy as part of selection theory. However, the epidemiological evi-
dence relating to the proposed causal pathways does not support these newer elaborations.
They may provide partial explanations or insights into the mechanisms between cause and
effect, but structural theory remains the best explanation as to the fundamental causes of
health inequalities.
The paper draws out the vitally important political and policy implications of this assess-
ment. Health inequalities cannot be expected to reduce substantially as a result of policy
aimed at changing health behaviours, particularly in the face of wider public policy that
militates against reducing underlying social inequalities. Furthermore, political rhetoric
about the need for ‘cultural change’, without the required changes in the distribution of
power, income, wealth, or in the regulatory frameworks in society, is likely to divert from
necessary action.
© 2013 Elsevier Ireland Ltd. All rights reserved.

1. Introduction [1]. They occur across a range of social dimensions includ-

Health inequalities1 are the, “systematic differences in
the health of people occupying unequal positions in society”
∗ Corresponding author. Tel.: +44 0141 354 2928.
E-mail addresses: gmccartney@nhs.net (G. McCartney),
chik.collins@uws.ac.uk (C. Collins), mhairi.mackenzie@glasgow.ac.uk
(M. Mackenzie).
1
Some authors use inequalities to denote differences between groups
and inequities to denote unjust differences between groups, but this
distinction is not consistently applied across the literature. The more
ing income, social class, deprivation,caste, ethnicity and
geography. Mere variations in health outcomes within a
population do not necessarily represent inequalities; they
do soonly if those variations are patterned by some char-
acteristic of the population which renders the variations
unfair. Populations which have large health inequalities
affecting the majority of the population are likely to have
commonly used term “inequality” has been adopted throughout this arti-
cle to describe unjust differences.

0168-8510/$ – see front matter © 2013 Elsevier Ireland Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.healthpol.2013.05.021
 Author's personal copy
222 G. McCartney et al. / Health Policy 113 (2013) 221–227
large health variations. In contrast, if a health inequal-
ity affects only a small proportion of the population (e.g.
amongst stigmatised benefit recipients or a minority eth-
nic or migrant population) the variation across the whole
population may be small, even when the gap between the
two groups is large.
As with poverty measures, inequalities in health can be
considered in absolute or relative terms. This can be impor-
tant when there are secular trends in the population health
mean (e.g. a downward trend in the mean can increase rel-
ative inequalities even whilst absolute differences remain
stable). Methods of enumerating health inequalities con-
sequently vary depending on which inequality is of most
interest [2,3].
Health inequalities are persistent through time and
have been found in most countries where they have been
investigated [4]. Yet they represent the starkest and most
profound inequalities: the right to life itself is at stake. In
the UK, inequality in health and its causes were investi-
gated in detail in 1980 [5] and have been the explicit focus
of policy since at least 1997. Despite this attention, there is
little or no evidence that these inequalities have narrowed
[6,7].
Theories of health inequalities matter, for the obvious
reason that the successful identification of causes of any
problem is crucial to the elaboration of appropriate meas-
ures to address the problem. The Black Report, published
in 1980, identified four key theories for understanding
how health inequalities arise [5]. These were: artefact;
selection (including natural and social selection); struc-
tural factors; and behaviours (including culture). Since
then, there have been elaborations of these underlying
theories [6,8–11] (including that of MacIntyre which dis-
tinguishes between ‘hard’ and ‘soft’ versions of each)
[12]; different approaches to categorising the under-
lying causal mechanisms [13], and numerous UK and
international reviews of health inequalities tasked with
recommending policy measures to bring about their reduc-
tion [14–18].
In light of empirical developments, the manifest failure
of policy, and a global financial crisis with a near ubiquitous
response of inequality-heightening public expenditure,
and particularly welfare cuts, it seems necessary to revisit
and critically appraise the main theories on how health
inequalities arise, so as to aid clarity in thinking about how
best to address them.
In reviewing these theories we utilise the broad cat-
egorisation employed in the Black Report – which has
had common currency both internationally and over time.
Where some recent contributors have identified more than
the four key theories identified by Black, we have treated
these additional theories as sub-categories within Black’s
four-way categorisation [19,20].
We seek to evaluate the extant theories as to how
and why health inequalities arise, including the most
recent elaborations, using basic epidemiological reason-
ing relating to association, causality and confounding.
In doing this, we help clarify which retain validity, and
in what respects they may do so, and we briefly draw
out the vital political and policy ramifications which
emerge.
2. Health inequalities theory I: the artefact theory
The artefact view proposes that the association between
markers of social status and health outcomes is a statistical
artefact relating to the way in which social status has been
classified over time [5,14].
The theory is gravely undermined by the ubiquitous
demonstration of inequalities in health outcomes [21],
even where different statistical measures of social status
are used (including income, area deprivation, education,
social class and occupational group). In light of this, it is
very difficult to sustain a theory that such outcomes are
unrelated to social status. Consequently, this theory can
confidently be discarded – as indeed it has been since at
least the time of the Black Report. However, this is not
to suggest that improved measures of social status, or,
perhaps better, of the social realities of people’s ‘lived expe-
rience’, could not be found.
3. Health inequalities theory II: selection theory
3.1. ‘Health selection’
The possibility that a health selection effect might
explain inequalities was examined, and quite decisively
rejected, in the Black report. The theory is essentially
that of reverse causation: that poor health causes a social
selection (a ‘social slide’) which leads to the observed
association between ill health and low social status
[5,22].
This ‘health selection’ theory can be tested using lon-
gitudinal studies which measure pre-morbid social status
and test for an association with subsequent morbidity and
mortality. A large number of such longitudinal studies
have subsequently demonstrated that the vast majority
(although not all) of the concentration of ill-health in
lower social groups is explained by pre-morbid social status
rather than any subsequent social slide. Such evidence indi-
cates that this view fails to account for health inequalities
[23–25].
3.2. Intelligence
Despite the rejection of health selection as a major
explanation of health inequalities, an attempt has been
made to reinvigorate selection hypothesis more recently –
in particular by those proposing a role for intelligence [26].
Intelligence and health are closely associated, but this
could be due to:
1. Chance (which can be discounted on the basis of the
cumulative, statistically significant evidence of associ-
ation) [27,28];
2. Reverse causation where the differences in intelligence
are caused by differences in health (a possibility for
measures of intelligence gathered in later life which may
be affected by stroke disease or similar, but which can be
discounted given the association between pre-morbid
intelligence and later health outcomes) [27,28];
 Author's personal copy
G. McCartney et al. / Health Policy 113 (2013) 221–227
a) Socioeconomic status
and early years nurture
(effect modifiers)
Intelligence
Health
derived from
genotype
b)
Socioeconomic Health
status and
early years
nurture Intelligence
Fig. 1. Logical explanations for the association between intelligence,
health and socioeconomic status.
3. Intelligence being due to genetic endowment and this
determining subsequent health (and other correlates
such as social status, education, etc.);
4. Intelligence and health both being caused by another
factor (i.e. a confounder such as socioeconomic status
or early life experiences).
Only 3 and 4 remain plausible (Fig. 1). If intelligence
is a function of genetics, the most common markers of
socioeconomic status (including social class, deprivation
and income) would only be ‘effect modifiers’ in the rela-
tionship between intelligence and health (i.e. if people of
equal social class, deprivation or income were examined,
the variation in intelligence within that group would be
associated with health outcomes) (Fig. 1a).
When the relationship between intelligence and
health is adjusted for markers of socioeconomic sta-
tus, the association with mortality weakens in some
cohorts [29–31] and disappears completely in oth-
ers [32]. In general, residual confounding is common
where only single markers of socioeconomic status
are used in examining associations [23,33–35]. Fur-
thermore, in a study measuring intelligence in early
life, before the full effects of social factors have
become embedded, the independent impact of intelli-
gence on subsequent self-reported health and negative
health behaviours was very small [27,36]. This sug-
gests that the earlier intelligence is measured in life,
the less the independent effect on health outcomes,
a finding which would support the view of intelli-
gence as a consequence of socio-structural influences
(Fig. 1b).
There are two additional issues which challenge the
role of intelligence as the fundamental cause of health
inequalities. The first is the ‘Flynn Effect’ – the secular
increase in measures of intelligence witnessed in various
populations [37,38]. The second is that the differences in
intelligence between populations have varied over time
[39]. Both these features make it less likely that intelligence
is principally genetically determined – since genotype can-
not evolve over a single generation. Rather, socio-economic
and contextual features are more likely to explain the
changing population variation in the measures of intelli-
gence.
223
3.3. Meritocracy
Another relatively recent iteration of selection theory
has been the social mobility – or meritocracy – theorem
[40]. This has arisen in light of findings showing greater
relative health inequalities in Scandinavia, as compared
to southern Europe [4]. The theory is that in Scandina-
vian countries, which are seen to have been more social
democratic and meritocratic than most other countries,
‘more able’ individuals, born into lower socio-economic
groups (characterised as those with higher ‘intelligence’),
rise to a higher socio-economic group in adulthood. On
the other hand, ‘less able’ individuals, born into higher
socio-economic groups, experience a socio-economic slide.
Consequently, there is an accumulation of those at high-
est risk of ill health by adulthood in the lower groups, and
an accumulation of those at lowest risk of ill health in the
higher groups. In less ‘meritocratic’ societies, by contrast,
those with the highest risk of poor health would be spread
between socio-economic groups – since groups at the bot-
tom of the socio-economic gradient would tend less to ‘lose’
their ‘more able’ (and, therefore, healthier) constituents
through upward social mobility, whilst those groups at the
top would tend to be more able to protect their least able
(and least healthy) members from a social slide. This would,
it is argued, inhibit any health inequality gap.
The meritocracy theorem is therefore similar to intel-
ligence theory, with the added insight that nations
characterised as ‘meritocratic’ (those in which ‘intelli-
gence’, ‘ability’, or the confounders that it might actually be
measuring, such as early years’ experience, class or depri-
vation, result in marked social selection and stratification)
would be likely to have greater apparent inequalities in
health.
What does this mean for social mobility as an explana-
tory theory for health inequalities? Similar to the case for
the role of intelligence, it assumes that variation in ‘abil-
ity’ across the population is unrelated to socio-economic
position, early years nurture and the wider social context
in which people grow up. If ‘ability’ is actually a parameter
of this context, then the links are similar to that shown in
Fig. 1b. A further problem with the theory is its somewhat
partial understanding of the Scandinavian welfare systems.
Whilst it is true that social democratic countries are likely
to manifest greater social mobility, they also have stronger
universal welfare systems, more progressive taxation and
higher levels of social solidarity, all of which would mitigate
against the deleterious effects of any ‘social slide’ [41,42].
4. Health inequalities theory III: cultural and
behavioural
4.1. Health behaviours as the cause
Cultural and behavioural theories suggest that differ-
ences in the prevalence of behaviours such as smoking,
alcohol consumption, illicit drug-taking, diet and physi-
cal activity between groups, or differences in the dominant
cultures between groups, are fundamental causes of health
inequalities. For example, many analyses suggest that risk
factors, such as smoking, explain a large proportion of the
 Author's personal copy
224 G. McCartney et al. / Health Policy 113 (2013) 221–227
Socio-economic factors
Differences in the (effect modifiers)
prevalence of
Health inequalies
negave health
behaviours
Fig. 2. The relation between health behaviours, socio-economic factors
and health inequalities in the behavioural theory.
inequality in health outcomes [43]. However, for health
behaviours to be the cause of health inequalities, socio-
economic factors would have to be only an effect modifier
in the relationship as shown in Fig. 2.
It is clear that a whole plethora of unhealthy behaviours
are more prevalent in lower socio-economic groups [23].
However, a simple focus on behaviours as a fundamen-
tal theory of health inequalities has two problems. First,
when populations in different social groups, but with equal
exposure to behavioural risk factors, are compared, mor-
tality remains higher in the lower socio-economic groups
[44]. Second, and more importantly, a simple focus on
behaviours ignores how and why individuals in particu-
lar social groups adopt unhealthy behaviours [45]. When
the patterning of health behaviours has been examined
in adulthood and related to socio-economic exposures
throughout the life-course, the patterning of adult health
behaviours is explained by the earlier socio-economic
exposures [46]. Furthermore, the link between negative
health behaviours and lower social status has almost disap-
peared over time in some populations without a weakening
of the link between lower social status and mortality [47].
Changes over time in the cause-specific mortalities
affecting lower socio-economic groups suggest that remov-
ing one particular exposure (e.g. alcohol abuse) changes
one high cause-specific mortality rate for another [8,48,49].
For example, during the 19th Century in Western Europe
mortality from infectious disease was more common in
lower social groups. During the 20th Century this mech-
anism of death was superseded as a major driver of
inequalities by ischaemic heart disease, cancer and respi-
ratory disease. By the late 20th Century the mechanisms
had again evolved – with violence, drug/alcohol-related
and suicide mortality becoming more important [50]. It
seems, therefore, that while inequalities in mortality have
persisted, the particular mechanisms driving them have
changed. Thus, if a behavioural thesis is to provide a
valid fundamental explanation, it needs to be able to
explain, without reference to the prevailing circumstances
of lower socio-economic groups, how a whole range of
persistently damaging, but specifically different, health
behaviours have arisen in these groups, consistently and
over a very long period. Furthermore, the differentials in
power, income and social circumstances between groups
would have to be explained away as an incidental finding.
All of this seems highly implausible.
4.2. Cultural theories
Closely related to behavioural theory is culturally ori-
entated theory. There have been various expressions of
this over time, including: Durkheim’s theory of ‘anomie’
[51,52], the ‘culture of poverty’ thesis associated with Oscar
Lewis [53], and more recently ‘underclass’/‘dependency
culture’ theory, associated in particular with Charles Mur-
ray [54,55]. The latter two theories are of primary interest
here. Each contends that certain poor populations tend to
develop aberrant cultural patterns which have destructive
and negative implications for social and health out-
comes. For Lewis, such a ‘culture of poverty’ tended to be
self-perpetuating – even when the broader structural envi-
ronment which gave rise to it changed, allowing for better
outcomes. For Murray, on the other hand, the rootedness
of the ‘culture of dependency’ in the structures of gov-
ernment welfare required a new ‘responsibilization’ of the
poor – linked to a substantial withdrawal of state provision.
This is reflected in the current UK Government narrative
of ‘welfare reform’ (and to a lesser degree also in that
of its ‘New Labour’ predecessor). The implication of both
theories is that behaviours reflect cultural patterns which
become inter-generational, entrenched and rather resis-
tant to remediation. Culturally generated and sustained
patterns occasion problems for which individuals and com-
munities themselves must to a substantial degree carry, or
be made to carry, the primary responsibility.
However, the existence of a separate sub-culture within
countries such as the United Kingdom (UK) is disputed
[56,57] and Small, Harding and Lamont cite substantial evi-
dence showing that among the poor in the United States
of America, mainstream values are widely shared and
adopted [58]. Even if it were to be accepted that a dif-
ferent, or somehow more extreme, culture exists in some
contexts, there is no evidence to suggest that such a cul-
ture would somehow precede, or operate without strong
links to, underlying socioeconomic inequalities [58–60].
Indeed, the definition of culture as “the collective adap-
tation to everyday working and living conditions” makes
such links explicit [61]. It is therefore more likely that struc-
tural influences are in fact key. Culture may provide some
helpful explanations as to the mechanisms linking socio-
economic circumstances with health outcomes, allowing
for greater complexity, feedback loops and emergent prop-
erties to be conceptualised. However, the candidacy of
cultural theory as an explanation for the fundamental
cause of inequalities, independent of socioeconomic cir-
cumstances, remains weak.
5. Health inequalities theory IV: structural
Structural theory has provided the dominant frame for
analysis in all of the independent reviews of health inequal-
ities in the UK [5,16–18]. The theory is that differences in
the socioeconomic circumstances of social groups (includ-
ing differences in income, wealth, power, environment
and access), at all stages of the life-course, cause differ-
ences in health outcomes [62]. Structural theorists of health
inequalities see competing explanations as subordinate:
that is, behaviours, culture and intelligence may theorise
potential mechanisms linking structural determinants and
health outcomes, but do not identify the causal roots of
health inequalities [12].
Supporting the above view is evidence that health
inequalities have reduced in periods when structural
inequalities have diminished, and have risen when such
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G. McCartney et al. / Health Policy 113 (2013) 221–227 225

inequalities have increased [63,64]; that the health of com- the distribution of power, income, wealth, or in the regula-
munities has improved when they have been given more tory frameworks in society, are likely to be ineffective – and
resources by chance [65]; and, most convincingly, that the also a diversion from the necessary focus and appropriate
people with the most resources within any society are action. The evidence base to support structural interven-
always the healthiest, regardless of their behaviours [15]. tions in one particular area over another remains patchy
Even where a health condition is clearly attributable to a [77], but those which have the widest implications (such as
genetic mutation (such as cystic fibrosis), inequalities in those which narrow income differentials and those which
mortality by social class are wide and vary depending on democratise power) seem most likely to be effective at
changing contextual factors [66]. reducing inequalities [75,78].
Common to all the dimensions of inequality are power
imbalances [67]. This raises important questions about
7. Conclusion
which systems most perpetrate inequalities, who gains
from inequalities, and what can be done to reduce them
Health inequalities have been, and continue to be, best
[68]. This, in turn, has led to a growing recognition of the
explained from a structural theoretical perspective. The-
importance of the political dimension of broader structural
ories focusing primarily on behaviour and culture can
processes in shaping health outcomes. Some have argued,
provide some insights around the mechanisms through
convincingly, that the proliferation of health inequalities
which such inequalities are generated, but they cannot
is linked to the diminution of broader democratic controls
provide sufficient explanation as to their principal causes.
over the preferred priorities of the rich and powerful. Such
The broader, politically determined social inequali-
growing inequalities of power and health has marked much
ties, which in turn determine health inequalities, are not
of the past 30 years in many nations of the world, but is not,
inevitable: only 40 years ago the gap between rich and poor
as experience in previous decades and in other parts of the
in the UK and in the USA was much narrower than today.
world has shown, inevitable [67,69–71].
Health inequalities have grown in synchrony with income
and power inequalities and are highly likely to diminish if
6. Why the theory of inequalities matters
income and power is redistributed [63,79]. Structural the-
ory indicates that the ‘problem’ we are dealing with here is
Distinguishing between the underlying causes and
not caused by the poor, but is caused more fundamentally
ensuing mechanisms is vitally important if we are to take
by the actions of the rich and powerful [80]. In this light,
appropriate action to eradicate what are, by their very def-
the political dimension is increasingly recognised as vital.
inition, mortal injustices. Policy rhetoric in the UK and
Consequently, in common with other challenges to public
around the world recognises that the contrasting socio-
health, the structural causes of health inequalities become
economic circumstances of people’s lives provide the best
the focus of ‘denialism’. Such denialism entails the selective
explanation as to how health inequalities arise among them
deployment of a range of characteristic tactics and tech-
[15,72]. There is, however, less understanding as to how
niques to undermine the case for interventions which are
these contrasting socioeconomic circumstances are shaped
backed by a legitimate scientific consensus, but which are
and determined by political processes and choices [68,73].
opposed by vested interests [81,82]. There is evidence that
It is clear that health inequalities will persist unless
this has been the approach of various governments over
their actual causes (socioeconomic circumstances and the
time, not least as exemplified by the paradox of rhetorical
political processes and choices which determine them)
commitments to tackling health inequalities alongside the
become the key focus of action. Continued focus on inter-
development of policies that manifestly operate to exacer-
vening mechanisms (whether they be health behaviours or
bate them [83,84].
cultures) can at best contribute to overall (mean) health
As a matter of scientific clarity and intellectual honesty,
improvement. But such a focus has limited potential to
there should be no pretence or illusion that health inequal-
actually reduce inequalities, because, while broader inequal-
ities can be eliminated, or even meaningfully reduced,
ities persist or intensify, alternative mechanisms for the
without a primary focus on structural factors. In the
production of health inequalities are very likely to sub-
absence of this focus, other explanations are insufficient
stitute for those which may successfully be addressed
to understand how inequalities arise, and so the policy foci
[8,48,49]. The overwhelming balance of evidence is that
which emerge from them will in the future, as they have in
interventions which focus on individual behaviours are
the past, lead to wasted effort, a lack of appropriate focus
least likely to prove effective; interventions which utilise
and, most importantly, continuing sustained and unjust
taxation, legislation, regulation and changes in the broader
premature mortality in society.
distribution of income and power in society are much more
likely to do so [11,15,74–76]. Health inequalities are first
and foremost an emergent effect of political decisions, and References
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