Health Inequalities

Health Inequalities
Critical perspectives
Edited by

Katherine E. Smith
Sarah Hill
and
Clare Bambra

1
1
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 Foreword
Debbie Abrahams MP
Chair of the Parliamentary Labour Party Health
Committee

As Frank Dobson (Health Secretary, 1997–2000) said in 1998, ‘Inequality in

health is the worst inequality of all. There is no more serious inequality than
knowing that you’ll die sooner because you’re badly off.’ Despite the strong ef-
forts of the 1997–2010 Labour government to reduce health inequalities, they
persist today. For example, a baby girl born in inner-city Manchester in the
North West of England will live 15 years longer in poor health than a baby girl
born in leafy Richmond-upon-Thames in the South East of England. In some
parts of the UK, even travelling just a few miles can lead to radically different
life chances—with life expectancy gaps of over 15 years in towns like Stockton
on Tees, Liverpool or Glasgow. Within this context, this book is vital: first be-
cause it emphasises the persistence, and importance, of health (and wider so-
cial) inequalities in the UK and elsewhere; second because it offers critical
analysis that goes beyond mere description to suggesting the reasons why
health inequalities persist in rich countries and makes suggestions as to what
more policymakers need to do to tackle them; and third because it argues that
health inequalities researchers seeking to influence policy in this area need to
take the political and democratic aspects of policy-making processes more ser-
iously than many perhaps have. As a policymaker myself I particularly welcome
the latter interjection into the health inequalities debate. As such, the collection
offers food for thought for those in the academy, policy, and practice. It will be
bedside reading for myself and others within the Labour Party, as reducing
health inequalities is a vital part of our programme.
 Foreword
Richard Wilkinson
Emeritus Professor of Social Epidemiology

Even without the benefit of hindsight, it was probably naïve to expect a smooth
transition from research on health inequalities to policies which would solve
the problem. Despite lots of good research, health inequalities have—as this
book shows—not diminished. The message is that we all need to be more active
in policy and politics.
An important part of the background to this picture is that the Black Report
on health inequalities, published in 1980—which kicked off modern research
on health inequalities—coincided with the rise to power of neoliberal econom-
ics under Reagan and Thatcher—as discussed by Collins, McCartney, and Gra-
ham in Chapter 9 of this volume. From then until at least the financial collapse
of 2007–8 the political pendulum swung to the right. Top tax rates were re-
duced, trade unions weakened, utilities were privatized, and income differences
widened dramatically. Indeed, almost all the progress towards greater material
equality which took place from the 1930s till the late 1970s has now been
undone.
In such a hostile context, it is perhaps a tribute to the strength of commitment
to social justice in the public health community that at least research on health
inequalities managed to make substantial progress during those decades, as de-
scribed by Bartley and Blane in Chapter 2, and Raphael and Bryant in Chap-
ter 4. Research has played a crucial role in ensuring health inequality has gained
a growing public recognition.
Since the financial crash the political pendulum has, however, started to
swing back in a more progressive direction. The amount of attention the media
gave to inequality rose dramatically after the Occupy movement. More recently,
world leaders, including the US President Barack Obama, Pope Francis, Ban Ki
Moon, the Secretary General of the UN, and Christine Lagarde, the head of the
IMF, have all made very strong statements about the urgent need to reduce in-
come inequality. As Douglas notes in Chapter 8, a renewed focus on social in-
equality provides an opportunity for public health to return to the root causes
of health inequalities—perhaps using the kinds of research strategies outlined
by Barr, Bambra, and Smith in Chapter 18.
 Foreword vii

So far progress in reducing inequality has been more a matter of lip service
than of real change, but there have been a few policy gains. The OECD has
reached agreement with many of the world’s most important tax havens to share
(but not until 2017) information on bank accounts with the tax authorities in
different countries. Until that is done, the rich can so easily hide their money
away from tax authorities that it is hard to make higher top tax rates stick. The
OECD’s action was apparently not prompted simply by a desire for social justice
or even by a concern for the loss of government revenues: it also reflected a de-
sire to cut terrorist funding and prevent money laundering. Although political
commitment to greater equality has—with the exception of some South Ameri-
can countries—been rare since widening income differences swept across so
many developed countries from around 1980 onwards, countries such as Nor-
way and Finland remind us that it can be a central goal of national policy, as
Dahl and van der Wel discuss in Chapter 3.
As well as slowing the rightward swing of the political pendulum, the finan-
cial crash has also had the perverse effect of justifying cuts in government pub-
lic social expenditure, so shoring up a range of conservative policies under the
rubric of reducing the deficit. The impact of austerity on both health and health
inequality is highlighted by Bambra et al in Chapter 12, while the human mis-
ery caused by ‘deficit reduction’ is compellingly described by McCormack and
Jones in Chapter 17, and by Friedli in Chapter 15. But swings in public opinion
tend to be long and slow, and the current more progressive direction of change
is likely to outlive concern for the deficit. The British Social Attitudes Survey
now shows that over 80% of the population think income differences are too
big—even though they underestimate how large they are. As people have grad-
ually become more aware of the scale of tax avoidance, the bonus culture, and
the continuing tendency for top incomes to rise while other incomes are held
down, it is unlikely that political parties of left or right will be allowed to forget
these issues before they have been effectively addressed.
This sustained shift in public awareness means the future context in which
policies affecting inequalities are developed may be quite different from what
we have been used to in the past. This changing context is not simply a matter
of public opinion; there is also an urgent need to move towards more sustain-
able forms of living, reducing our reliance on fossil fuels and our impacts on the
environment. Pearce et al (Chapter 14) advocate an ‘ecological public health’
perspective, reminding us of the links between social justice and environmental
justice. The United Nations and many think tanks, official bodies, and NGOs
have called for a fundamental transformation in the way our societies’ eco-
nomic systems work. Encouragingly, the post 2015 Sustainable Development
Goals include a clear statement of the need to reduce inequalities both within
viii Foreword

and between countries. As Hanefeld reminds us in Chapter  5, the equality

agenda concerns the distribution of resources for health at a global as well as a
national level and, as Hill says in Chapter 7, ethnic, gender, and socioeconomic
status inequalities all contribute to our social and health divides.
In Chapter 13, Collin and Hill explore the role of large corporations impli-
cated in non-communicable diseases, including the tobacco, alcohol, and pro-
cessed food industries. They cite Nick Freudenberg, whose important book,
Lethal but Legal, shows how these major business sectors—along with the phar-
maceutical, gun, and automobile industries—inflict major damage on public
health. Big corporations act as drivers of inequality, reinforcing the uneven dis-
tribution of the social determinants of health and undermining regulatory ef-
forts to limit the harm they do to public health. The insidious nature of their
power is shown in the extent to which they succeed in packing regulatory com-
mittees so they can defend their profits against attempts to tackle the health
problems they have caused. Another example of the encroachment of corporate
interests into public services is provided in Chapter 11, where Hellowell and
Ralston examine the privatization and marketization of the UK National Health
Service.
But it is not just health which is compromised by corporate interests. They are
the source of the most formidable opposition both to a more egalitarian and to
a more sustainable society. By concentrating wealth and power in the hands of
a few, these transnational corporations effectively undermine democratic polit-
ics. Corporations bigger than many national economies are able to run rings
round national governments which compete to attract inward investment by
offering lower corporation tax and other inducements. The massive economic
and political power of the fossil fuel industry has, as Naomi Klien has recently
documented, subverted effective action on climate change. Nor are such devas-
tatingly anti-social policies confined to the fossil fuel sector. Almost all large
corporations have nominal subsidiaries in tax havens to enable them to avoid
tax payments. The Tax Justice Network estimated that tax havens may handle
(on paper) as much as half of all world trade and banking assets as well as a third
of all foreign investment.
Increasingly, politicians find themselves trying to serve two masters: their
electorate at the ballot box on one side, and the interests of multinational cor-
porations wedded to the frequently anti-social pursuit of profit on the other.
Their weak-kneed attempts to straddle these opposed interests have led inexor-
ably to the discrediting and mistrust of politicians in the public eye. In the long
run, a clash between corporate power and the democratic state looks as in-
escapable and as far reaching as the historical clash between church and state.
What is at stake is the future of democracy itself: without a major rebalancing in
 Foreword ix

favour of democratic forces, the power of elected governments will increasingly

be pushed to the margins.
Reducing carbon emissions is widely regarded as an unwelcome belt-­
tightening exercise. It is seen as if it means making do with a bit less of every-
thing while continuing to cope with our lives as they are now. But life in the rich
world is not an efficient system for ensuring human well-being. Redressing the
balance between private corporations and democratic government, moving to-
wards sustainability, making dramatic reductions in health inequalities, or re-
ducing income differences (even to Scandinavian levels), all require very major
change, but they are central to improving the real quality of life for all of us.
Moving towards greater equity and sustainability is not only an opportunity to
end the sense that we are here to serve the economy rather than it serving us,
but it is also an opportunity to start to address the neglected social needs on
which health and well-being depend.
In Chapter 6 of this book, Smith and Garthwaite discuss contrasting views on
how to address health inequalities. Just as we become aware of the environmen-
tal costs of further economic growth, it has also become evident, first, that
growth no longer improves either health, happiness, or well-being in the rich
countries, and, second, that further improvements in the quality of life now de-
pend on improving the social environment rather than on increases in levels of
material consumption. Though we continue to need technical innovation, we
must turn from growth to address the quality of social and community life.
What has to grow is no longer crude measures of production and consumption,
but well-being.
The good news is that the strength of community life, how cohesive a society
is, levels of violence, and how much people feel they can trust others, are all im-
proved by reducing the scale of income differences between rich and poor. Re-
ducing income differences also makes sustainability easier to achieve. To give
just one example: consumerism is one of the main obstacles to sustainability, yet
research shows that it is driven by status competition which is intensified by
greater inequality—so reining in consumerism means reducing inequality. At
the same time, by reducing status competition, greater equality also strengthens
community life and improves well-being.
As explored in Chapters 19–21 of this book, the role of researchers concerned
with health inequalities must extend beyond the generation of evidence to the
stimulation of public debate and advocacy for change. In Chapter 16, Elliot,
Popay, and Williams suggest that it is time to think imaginatively about the kind
of future society we want and to develop a new vision capable of inspiring the
social movement needed to bring it into existence. Although a Foreword is not
the place for a manifesto for a new society, some key ideas are outlined in a
x Foreword

pamphlet (which can be downloaded for free from the Fabian Society website)
called A convenient truth: a society better for us and the planet, by Wilkinson and
Pickett. We think the road to a more equal society lies through the radical ex-
tension of democracy into the economic sphere—not only through legislation
(as in many EU member countries) for employee representation on company
boards, but also via incentives to expand the sector of the economy made up of
employee-owned companies and cooperatives. Economic democracy not only
reduces income differences within companies: it also redistributes capital and
redirects unearned income. Evaluations suggest that it brings reliable improve-
ments in productivity while at the same time enhancing working relationships
and the experience of work. Greater representation and accountability in the
economic sector is also an important step towards dealing with undemocratic
concentrations of power and wealth in large multinational corporations. Demo-
cratic control has been increased at least within the public health system as
Hunter and Marks outline in Chapter 10, but this is a small change in the con-
text of much wider economic threats to social justice.
What we have to look forward to is a future in which community life starts to
recover from the divisive effects of inequality, and outward wealth ceases to be
the overriding measure of personal worth: a society in which our social needs
are more nearly met, in which the manipulative power of multinationals is re-
duced and the experience of work is less dominated by the extrinsic motivations
of wage labour. As the real quality of social life and relationships improves, we
will increasingly prefer to use greater productivity to give us more leisure, more
time for friends, family, and community—rather than to increase consumerism
and status competition as big business would have us do. In reducing inequality,
we can make a happier, more democratic, and more sustainable society.
 Preface

Health inequalities have long been a cause of both concern and controversy in
British society. The need to reduce inequalities in health contributed to the de-
cision to establish the tax-funded, free-at-the-point-of-delivery National
Health Service (NHS) in 1948. Yet, by the 1970s it was becoming increasingly
evident that free access to health care had not been enough to stem the widen-
ing inequalities in health, and in 1977 the then Secretary of State for Health and
Social Services, David Ennals, faced fresh calls to do something about the issue.
Ennals responded by asking the Chief Scientist Sir Douglas Black to appoint a
working group of experts to investigate the matter and make policy recom-
mendations (see Berridge and Blume 2003 for more detail).
In the resulting report, widely referred to as the Black Report (Black et al 1980),
the authors argued that materialist explanations were likely to play the largest
role in explaining health inequalities and, therefore, that policymakers ought to
prioritize the reduction of differences in material and economic circumstances.
Significantly, the associated policy recommendations, which focused on poverty
alleviation and support for families with children, were wholeheartedly rejected
by the newly elected Conservative government that had come to power between
the commissioning and publication of the Report (Black et al 1980).
Indeed, under the Conservative governments in power from 1979 to 1997,
health inequalities were excluded from the official policy agenda (Berridge and
Blume 2003). Even the term ‘health inequalities’ was discarded and health dif-
ferences between social groups were instead referred to using the less emotive
term ‘health variations’ (which implied that health differences could be ‘natural’
and therefore not something for which policymakers were responsible).
Nevertheless, the Black Report had a significant impact on the research com-
munity, and a mass of research on health inequalities was undertaken and pub-
lished during this period (see Acheson 1998; Bartley et  al 1998; Macintyre
1997). The report remains a seminal document for our understanding of health
inequalities—not only in the UK, but also internationally, having influenced
thinking around health inequalities in the USA (Lynch and Kaplan 2000), Can-
ada (Humphries and van Doorslaer 2000), New Zealand (Davis 1984), and
Australia (Najman et al 1992).
The Black Report also stimulated local efforts to address health inequalities in
the UK. The city of Liverpool was a good example of this: local policymakers
xii Preface

and practitioners worked to produce one of England’s first regional reports on

public health (Ashton 1984), and also forged international links with other re-
gional public health efforts, such as those being undertaken in North Karelia in
Finland (see Hunter et al 2010). There have been subsequent national govern-
ment commissioned reports into health inequalities in 1998 (Acheson Inquiry)
and 2010 (Marmot Review)—both of which had many similar recommenda-
tions to the Black Report (Bambra et al 2011).
Over the past 40 years the UK has become recognized as a global leader in
health inequalities research and policy, with a prominent international expert
describing government-led policy efforts to reduce health inequalities in Eng-
land as ‘historically and internationally unique’ (Mackenbach 2010). Between
1997 and 2010 the UK Labour government introduced a raft of policies to re-
duce health inequalities (Smith and Hellowell 2012), informed by the wealth of
available research (Bambra et al 2011). Despite this sustained political commit-
ment, by most measures the UK’s health inequalities have continued to widen
(Audit Scotland 2012; Mackenbach 2011; National Audit Office 2010). This
failure, whilst largely attributable to the nature of the policies and interventions
employed (see Chapters 6, 8, 9, 12, 15, and 17), has prompted calls for new ap-
proaches to health inequalities research. There is also an increasing consensus
that public health researchers ought to be more actively involved in ‘public
health advocacy’ (e.g. Bambra et  al 2011; Freudenberg 2005; Mackenbach
2011). Yet there is currently no agreement as to what these new research agen-
das should be or what precisely public health egalitarians ought to be advocat-
ing (Horton 2012).
It is against this backdrop that the idea for this book emerged. We wanted to
bring together established and new health inequalities research experts, local
community activists, policymakers, and campaigners, national and local UK
perspectives, and those working on health inequalities beyond the UK, in both
high- and low-income settings. Many of the themes explored in this book
emerged during a cross-sector symposium to explore future directions for
health inequalities research (held in Edinburgh in December 2012). The dis-
cussions at this symposium confirmed our sense that the time was right for a
new edited collection on health inequalities, one which would reflect critically
on research, policy, and practice to date and which would take seriously the
idea that more political activity may be required to achieve greater inroads
into addressing health inequalities. This also comes at a time when academic
researchers are being incentivized to ensure their work has more ‘real world’
impact.
This edited collection draws on research from leading international research-
ers in the field of health inequalities. It is divided into four parts. Part 1 provides­
 Preface xiii

reflections on the UK’s legacy of health inequalities research. C ­ hapter 1 pro-

vides an overview of key concepts to inform the rest of the book. Chapter 2 then
provides a more detailed and personal perspective on the UK’s health inequali-
ties research legacy from the point of view of two of the field’s longest-standing
experts, Mel Bartley and David Blane. In Chapters 3 and 4, Espen Dahl and
Kjetil A. van der Wel, and Dennis Raphael and Toba Bryant, respectively, pro-
vide European and North American perspectives on efforts to develop
­evidence-informed policy approaches to reducing health inequalities, consid-
ering what these experiences suggest about the most fruitful directions for fu-
ture research and policy. Finally, in Chapter 5, Johanna Hanefeld reflects on
international (e.g. World Health Organization) efforts to promote ideas in-
formed by UK health inequalities research to policymakers, practitioners, and
advocates working in low- and middle-income countries (LMICs), highlight-
ing some of the particular difficulties of attempting to reduce health inequalities
in these contexts.
The second part of the book moves on to identify and explore some of the
challenges facing future health inequalities research and policies. This section
starts, in Chapter 6, by drawing on the data from the cross-sector symposium to
comparatively examine what individuals working in different sectors think
about current efforts to research and address health inequalities in the UK, and
where they think health inequalities researchers ought now to be focusing their
efforts. In Chapter 7, Sarah Hill considers how theories of intersectionality may
be useful in moving beyond a conception of health inequalities focused primar-
ily on social class. In Chapter 8, Margaret Douglas, a Public Health Consultant
in NHS Lothian (Scotland), argues that one means of tackling the much-­
discussed ‘lifestyle drift’ in health inequalities research, policy, and practice
may be to move beyond a focus on ‘health’. In Chapter 9, Chik Collins, Gerry
McCartney, and Lisa Garnham examine the political factors implicated in gen-
erating health inequalities, focusing particularly on neoliberalism. In Chap-
ter 10, David J. Hunter and Linda Marks assess different ways of understanding
a ‘public health system’ and the ensuing action (or in-action) to tackle health
inequalities, taking recent changes to the public health system in England as a
case study. In Chapter 11, Mark Hellowell and Maximilian Ralston provide a
detailed examination of contrasting claims about the impact of much debated
English NHS reforms on health inequalities. In Chapter 12, Clare Bambra, Kay-
leigh Garthwaite, Alison Copeland, and Ben Barr examine evidence concern-
ing the actual and potential health impacts of ongoing cuts to welfare provision
in the UK. In Chapter 13, Jeff Collin and Sarah Hill draw on research and policy
concerns with non-communicable diseases to highlight key challenges for pol-
icymakers in engaging with corporations implicated in health inequalities.
xiv Preface

The next four chapters outline some emerging agendas within health inequal-
ities research, many of which aim to address concerns and gaps relating to exist-
ing research. In Chapter  14, Jamie Pearce, Rich Mitchell, and Niamh Shortt
consider the apparent paradox that, whilst area-based interventions have dom-
inated UK policy responses to health inequalities, much of the available research
evidence continues to pay limited attention to the importance of place, context,
and locality for health inequalities. They argue that a more ‘holistic’ interpret-
ation of the environment that recognizes the socio-spatial patterning of a range
of environmental pathogens and salutogens is now needed. In Chapter  15,
Lynne Friedli considers the rise of psychosocial explanations for health inequal-
ities, looking specifically at the growing influence of salutogenesis and
‘­assets-based approaches’ to public health, notably in Scotland. This chapter
considers the social, political, and advocacy implications of ‘assets-based’ ap-
proaches to health inequalities. In Chapter 16, Eva Elliott, Jennie Popay, and
Gareth Williams make the case for a citizen social science that builds knowledge
and understanding about health inequalities, and ideas for policy and social ac-
tion, through ‘narratives of living and being’. In Chapter  17, Jane Jones and
Cathy McCormack reflect on their experiences of working as community activ-
ists trying to change the toxic circumstances in which many people live, drawing
on these understandings to outline what they believe to be the major challenges
currently facing their communities. They go on to consider how researchers
interested in health inequalities might do more to help address these issues.
The third part of the book turns to addressing questions about how best to
ensure health inequalities research is used to support action to tackle health
inequalities. In Chapter 18, Ben Barr, Clare Bambra, and Katherine E. Smith
chart the ascendancy of experimental evaluations of interventions to reduce
health inequalities and systematic reviews of evidence, considering the benefits
and limitations from research and policy perspectives. In Chapter 19, Katherine
E. Smith, Ellen Stewart, Peter Donnelly, and Ben McKendrick reflect on various
efforts to improve the use of health inequalities research in policy and practice,
considering the differences and similarities between ‘knowledge brokerage’, ‘ad-
vocacy’, and ‘lobbying’ in the context of health inequalities. In Chapter 20, Kate
Pickett and Richard Wilkinson, authors of The Spirit Level, one of the most
high-profile books concerning health inequalities to have been published in the
past 20 years (Wilkinson and Pickett 2009), provide some personal reflections
on their experiences of trying to promote health inequalities research to audi-
ences beyond academia. It concludes by suggesting what lessons this case study
might offer other health inequalities researchers.
In the final part of the book, Chapter 21, the editors draw together the ideas
and findings presented in this edited collection, summarizing both the legacy of
 Preface xv

UK health inequalities research to date and critically assessing the various chal-
lenges and emergent research and policy agendas identified by the contributors.
It considers some of the major difficulties facing researchers trying to produce
policy-relevant research and policymakers trying to employ research evidence to
tackle an issue as complex and cross-cutting as health inequalities, outlining what
appear to be the most promising areas for future health inequalities research.

References
Acheson, D. (1998) Independent Inquiry in Health Inequalities: Report. London: The
­Stationery Office.
Ashton, J. (1984) Health in Mersey—A Review: Liverpool. Liverpool: Department of
­Community Health, University Medical School.
Audit Scotland (2012) Health Inequalities in Scotland. Edinburgh: Audit Scotland.
Bambra, C., Smith, K. E., Garthwaite, K., Joyce, K.E. and Hunter, D.J. (2011) A labour of
Sisyphus? Public policy and health inequalities research from the Black and Acheson
­Reports to the Marmot Review. Journal of Epidemiology and Community Health, 65(5):
399–406.
Bartley, M., Blane, D., and Davey Smith, G. (1998) Introduction: Beyond the Black Report.
Sociology of Health and Illness, 20(5): 563–577.
Berridge, V., and Blume, S. (eds) (2003) Poor Health—Social Inequality Before and After
the Black Report. London: Frank Cass.
Black, D., Morris, J. N., Smith, C., Townsend, P. (1980) Inequalities in Health—Report of a
Research Working Group. London: DHSS.
Davis, P. (1984) Health patterns in New Zealand: Class, ethnicity and the impact of eco-
nomic development. Social Science and Medicine, 18(11): 919–925.
Freudenberg, N. (2005) Public health advocacy to change corporate practices: Implications
for health education practice and research. Health Education and Behavior, 32(3): 298–319.
Horton, R. (2012) Offline: Dangerous oligarchies. The Lancet, 379(9827): 1688.
Humphries, K. H., and van Doorslaer, E. (2000) Income-related health inequality in
­Canada. Social Science and Medicine, 50(5): 663–671.
Hunter, D. J., Marks, L., and Smith, K. E. (2010) The Public Health System in England.
­Bristol: Policy Press.
Lynch, J. W., and Kaplan, G. (2000) Socioeconomic position. In L. Berkman and I. Kawachi
(eds), Social Epidemiology. New York: Oxford University Press, pp. 13–35.
Macintyre, S. (1997) The Black Report and beyond: What are the issues? Social Science and
Medicine, 44(6): 723–745.
Mackenbach, J. P. (2010) Has the English strategy to address health inequalities failed?
­Social Science and Medicine, 71(7): 1249–1253.
Mackenbach, J. P. (2011) Can we reduce health inequalities? An analysis of the English
strategy (1997–2010). Journal of Epidemiology and Community Health. 65(7): 568–75.
Marmot, M. (chair) (2010) Strategic Review of Health Inequalities in England post-2010
(2010) Fair Society, Healthy Lives: The Marmot Review. Available at: http://www.
marmotreview.org/AssetLibrary/pdfs/Reports/FairSocietyHealthyLives.pdf accessed
8/7/2015
xvi Preface

Najman, J. M., Bor, W., Morrison, J., Andersen, M., and Williams, G. (1992) Child devel-
opmental delay and socio-economic disadvantage in Australia: A longitudinal study. So-
cial Science and Medicine, 34(8): 829–835.
National Audit Office (2010) Department of Health: Tackling Inequalities in Life Expect-
ancy in Areas with the Worst Health and Deprivation. London: The Stationery Office.
Smith, K. E., and Hellowell, M. (2012) Beyond rhetorical differences: A cohesive account of
post-devolution developments in UK health policy. Social Policy and Administration, 46:
178–198.
Wilkinson, R., and Pickett, K. (2009) The Spirit Level: Why More Equal Societies Almost
­Always Do Better. London: Penguin.
Woolf, S. and Aron, l. (eds.) (2013) US health in International Perspective: Shorter Lives,
Poorer Health (Washington, DC: National Academies Press). Available at: http://
download.nap.edu/cart/download.cgi?&record_id=13497. accessed 8/7/2015
 Acknowledgements

We are grateful to all of the authors who contributed to this book—several of

the individual chapters also have their own acknowledgements. Significant
thanks are also due to Rebecca Hewer, at the University of Edinburgh, for her
help with the final stages of compiling the manuscript. Finally, Kat would like to
thank Nasar Meer for support and feedback on several aspects of the book.
The following grants helped with the production of this book: MRC-ESRC
grant number PTA-037–27–0181, ESRC grant number ES/K001728/1 and a
University of Edinburgh College of Humanities and Social Sciences Challenge
Investment Fund, which was further supported by funding from the Wolfson
Research Institute for Health and Wellbeing, Durham University.
 Contents

List of Acronyms  xxvi

List of Contributors  xxvii

Background and introduction: UK experiences of health

1
inequalities  1
Katherine E. Smith, Clare Bambra, and Sarah Hill
1.1 Health inequalities in the UK  1
1.2 Debates about how health inequalities are conceptualized,
measured, and monitored  2
1.3 Trends in the UK’s health inequalities over the past
30 years  6
1.4 Empirically informed theories for understanding health
inequalities  7
1.5 UK policy responses to health inequalities  13
1.6 Conclusion  16

Reflections on the legacy of British health inequalities

2
research  22
Mel Bartley and David Blane
2.1 Introduction: Social class health differences in Britain  22
2.2 Before and after the Black Report  23
2.3 Policy implications  27
2.4 Research  29
2.5 Summary and conclusions: Future directions for health
inequalities work  30
Nordic health inequalities: Patterns, trends, and policies  33
3
Espen Dahl and Kjetil A. van der Wel
3.1 Introduction to Nordic health inequalities  33
3.2 The Norwegian background  33
3.3 National strategies to reduce health inequalities  34
3.4 The Norwegian strategy in comparative perspective  37
3.5 An appraisal of the Norwegian strategy: How has the Norwegian
strategy been implemented since its inception in 2007?  40
3.6 The Nordic ‘paradox’ revisited  42
3.7 Summary and conclusion  44
xx Contents

Reflections on the UK’s legacy of health inequalities research

4
and policy from a North American perspective  50
Dennis Raphael and Toba Bryant
4.1 Introduction: Reflecting on UK insights from a North American
perspective  50
4.2 Overview of the UK, Canadian, and American health inequalities
scenes  50
4.3 Conceptual contributions  51
4.4 Research contributions  52
4.5 Public policy contributions  53
4.6 Key policy documents in Canada and UK influences  54
4.7 Canadian contributions of interest to UK researchers  55
4.8 The situation in the USA  59
4.9 Conclusion  60

Reflections on the UK legacy of health inequities research,

5
from the perspective of low- and middle-income countries
(LMICs)  69
Johanna Hanefeld
5.1 UK leadership on the social determinants of health  69
5.2 The nature of evidence on health inequities  70
5.3 Addressing health inequities in LMICs  71
5.4 Challenges to addressing health inequities in LMICs  74
5.5 The legacy of UK health inequities research—preventing a
revolution in LMICs?  77
Contrasting views on ways forward for health inequalities
6
research  81
Katherine E. Smith and Kayleigh Garthwaite
6.1 Introduction: Contrasting perspectives on health inequalities  81
6.2 How do different actors understand ‘health inequalities’?  81
6.3 Reflecting on health inequalities research and policy in the UK
so far: What have we learnt?  83
6.4 Where next for health inequalities research?  85
6.5 What should researchers do to improve the impact of health
inequalities research?  88
6.6 Concluding discussion  91

Axes of health inequalities and intersectionality  95

7
Sarah Hill
7.1 Introduction: Intersecting axes of social position  95
7.2 Axes of health inequality  95
 Contents xxi

7.3 Ethnic inequalities in health  96

7.4 Gender inequalities in health  98
7.5 Intersectionality and health inequalities  99
7.6 Inequalities in smoking—‘contours of disadvantage’  100
7.7 Intersectionality and health inequalities: Conceptual and
methodological implications  102
7.8 Conclusion  104

Beyond ‘health’: Why don’t we tackle the cause of health

8
inequalities?  109
Margaret Douglas
8.1 A traditional public health approach?  109
8.2 Fundamental causes  109
8.3 Drifting downstream  110
8.4 Framing health inequalities: Confusion and blame  112
8.5 Trying to paddle upstream  112
8.6 Defining the problem  114
8.7 Mitigate, prevent, and undo  118
8.8 Staying upstream—implications for research and practice  118
8.9 Conclusion  121

Neoliberalism and health inequalities  124

9
Chik Collins, Gerry McCartney, and Lisa Garnham
9.1 Introduction: Neoliberalism and health inequalities  124
9.2 Liberalism(s)  124
9.3 Actually existing neoliberalism(s)  127
9.4 Neoliberalism and health inequalities  130
9.5 Debates: The place of inequality and pathways  133
9.6 Conclusion: Neoliberalism and the challenge to public health  134

Health inequalities in England’s changing public health system  138

10
David J. Hunter and Linda Marks
10.1 Introduction: England’s changing public health system  138
10.2 Background and context to England’s changing public health
system  139
10.3 The public health system across the UK  141
10.4 The new public health system in England  142
10.5 Persistent challenges and new opportunities: Improving health
and tackling health inequalities  145
10.6 An interim assessment of the new arrangements: New dawn or
poisoned chalice?  147
10.7 Conclusion: Testing England’s new public health system  148
xxii Contents

The equity implications of health system change in the UK  151

11
Mark Hellowell and Maximilian Ralston
11.1 Introduction: Health care and health inequalities  151
11.2 Equity in the health system: An international perspective  152
11.3 The UK Conservative–Liberal Democratic Coalition government’s
reforms in context  155
11.4 The NHS: A changing financial context  157
11.5 Conclusion: Why health care is a priority for health inequalities
research  160
All in it together? Health inequalities, austerity, and the ‘Great
12
Recession’  164
Clare Bambra, Kayleigh Garthwaite, Alison Copeland, and Ben Barr
12.1 Introduction: Economic downturns and poor health  164
12.2 Economic downturns and population health  164
12.3 Economic downturns and health inequalities  167
12.4 ‘Austerity’ and health inequalities  169
12.5 Conclusion: A growing health divide?  171

Industrial epidemics and inequalities: The commercial sector as a

13
structural driver of inequalities in non-communicable diseases  177
Jeff Collin and Sarah Hill
13.1 Introduction: Health inequalities and the growing burden of
non-communicable diseases (NCDs)  177
13.2 Industrial epidemics and health inequalities: The commercial sector
as a structural driver of inequalities in NCDs  178
13.3 Towards coherence across NCD policies?  184
13.4 Conclusion: Corporations producing unhealthy commodities as
‘upstream’ drivers of inequalities  185
Place, space, and health inequalities  192
14
Jamie Pearce, Rich Mitchell, and Niamh Shortt
14.1 Introduction: Why is it important to think geographically?  192
14.2 Ecological public health  196
14.3 Life course and place  197
14.4 Resilience, and equigenic environments  199
14.5 Conclusion: The promise of geographical approaches  202

The politics of tackling inequalities: The rise of psychological

15
fundamentalism in public health and welfare reform  206
Lynne Friedli
15.1 Introduction: The rise of psychological explanations
and interventions in public health  206
 Contents xxiii

15.2 Absence of debate  207

15.3 Strengths-based discourse: The power of positive affect  207
15.4 Engaging with the evidence base  208
15.5 Count your assets  209
15.6 Limitations of materialist analysis  210
15.7 Public health and the Glasgow pSoBid study  211
15.8 Workfare  213
15.9 Increasing positive affect  216
15.10 Conclusions  216

Knowledge of the everyday: Confronting the causes of health

16
inequalities  222
Eva Elliott, Jennie Popay, and Gareth Williams
16.1 Introduction: Capitalist ‘wolves’  222
16.2 Understanding health inequalities through knowledge
in everyday life  223
16.3 Towards a theory of transformative action  230
16.4 Conclusion: The battle between evidence and meaning  233

Socio-structural violence against the poor  238

17
Jane Jones and Cathy McCormack
17.1 Introduction: The view from community activism  238
17.2 Socio-structural violence  239
17.3 Housing  240
17.4 Unemployment  240
17.5 Shifting values and the common determination of meaning  242
17.6 Stigmatization  243
17.7 Shifting practices  244
17.8 The new morality  245
17.9 The role of research and dissemination  246
17.10 Transforming private troubles into public issues  247
17.11 Pressure on researchers  248
17.12 Conclusion: Moving health inequalities debates beyond the
academic realm to reclaim our humanity  249
For the good of the cause: Generating evidence to inform social
18
policies that reduce health inequalities  252
Ben Barr, Clare Bambra, and Katherine E. Smith
18.1 Introduction: Using evidence to tackle health inequalities  252
18.2 Beyond ‘hierarchies of evidence’  252
18.3 Experimentation and realism in evaluating the causal impact
of social policies  253
xxiv Contents

18.4 Natural experiments  255

18.5 Systematic reviews and the accumulation of evidence  260
18.6 Conclusion: The need to expand our methodological
toolbox  261
Influencing policy with research—public health advocacy
19
and health inequalities  265
Katherine E. Smith, Ellen Stewart, Peter Donnelly, and Ben McKendrick
19.1 Introduction: Conceptualizing the role of research (and researchers)
in policymaking  265
19.2 What do we already know about the relationship between health
inequalities research and policy?  268
19.3 What is public health ‘advocacy’?  271
19.4 Can tobacco control advocacy successes offer lessons for efforts
to reduce health inequalities?  274
19.5 Who is responsible for advocacy to reduce health inequalities?  275
19.6 Health inequalities researchers as advocates  276
19.7 Conclusion: The specific challenges of working to improve the
influence of health inequalities research  278
The Spirit Level: A case study of the public dissemination
20
of health inequalities research  282
Kate Pickett and Richard Wilkinson
20.1 Introduction: Deciding to do it  282
20.2 Deciding the format  283
20.3 The Equality Trust  284
20.4 Unexpected success  285
20.5 Commitment to dissemination  289
20.6 Not all fun and games  290
20.7 Just what is a ‘public intellectual’?  292
20.8 Moving from research to advocacy and campaigning  292
20.9 Moving on  294

Conclusion—where next for advocates, researchers, and

21
policymakers trying to tackle health inequalities?  297
Katherine E. Smith, Sarah Hill, and Clare Bambra
21.1 The challenge of reducing health inequalities  297
21.2 Using historical and international research to understand
the impact of ‘policy packages’  297
21.3 Broadening our focus and alliances  300
21.4 Emerging research topics for health inequalities  300
21.5 Expanding our methodological toolbox  301
 Contents xxv

21.6 Working with the communities most affected by health

inequalities  301
21.7 Developing an advocacy-coalition to reduce health inequalities  301
21.8 Potential contributions to reducing health inequalities in policy and
practice  302
21.9 Conclusion: Preparing for future ‘policy windows’ to reduce health
inequalities  303

Index  305

 List of Acronyms
ALMP active labour market policies
ASAP Alliance for Sustainability and
Prosperity
CPP Community Planning
Partnership
CSDH Commission on the Social
Determinants of Health
DPH Director of Public Health
DsPH Directors of Public Health
EPH Ecological Public Health
ERA Easthall Residents’ Association
ESRC Economic and Social Research
Council
FCTC Framework Convention on
Tobacco Control
GCPH Glasgow Centre for Population
Health
GDP Gross Domestic Product
GFATM Global Fund to Fight AIDS TB
and Malaria
GIS Geographical Information
Systems
HAZ Health Action Zones
HEA Health Education Authority
HIA Health Impact Assessment
HIIA health inequalities impact
assessment
HR hazard ratio
HWBs Health and Well-being Boards
IMR infant mortality rates
JRCT Joseph Rowntree Charitable
Trust
JSNA Joint Strategic Needs
Assessment
KWS Keynesian Welfare State
LMICs low- and middle-income
countries
MDGs Millennium Development
Goals
MSF Medecins Sans Frontiers
NCDs non-communicable diseases
NDP New Democratic Party
NEF New Economics Foundation
NGO non-governmental
organization
NHS National Health Service
NICE National Institute for Health
and Care Excellence
NIHR National Institute for Health
Research
NS-SEC National Statistics Socio-
Economic Classification
ONS Office for National Statistics
ONS-LS Office for National Statistics
Longitudinal Study
PHE Public Health England
RCTs randomized controlled trials
SARS severe acute respiratory
syndrome
SOA Single Outcome Agreement
SOC sense of coherence
TINA There Is No Alternative
TSA Technical Services Agency
VIA Values in Action
WHO World Health Organization
WTO World Trade Organization
 List of Contributors

Clare Bambra PhD is Professor of Public Health Geography and Director of

the Centre for Health and Inequalities Research, Durham University. Her re-
search focuses on the health effects of labour markets, health and welfare sys-
tems, as well as the role of public policies to reduce health inequalities. She
has published extensively in the field of health inequalities, including books
on Work, Worklessness and the Political Economy of Health (Oxford University
Press 2011), How Politics Makes Us Sick (Palgrave 2015) as well as over 100
book chapters and peer-reviewed journal articles. She contributed to the
Marmot Review (2010), the European Commission’s Health Inequalities in
the EU report (2013), the US National Research Council Report on US
Health in International Perspective (2013), as well as the Public Health Eng-
land commissioned report on health equity in the North of England: Due
North (2014).
Ben Barr is Senior Clinical Lecturer in Applied Public Health Research, Uni-
versity of Liverpool. He studied anthropology as an undergraduate at Univer-
sity College London, trained as a nurse, and undertook postgraduate studies
in public health and epidemiology at LSHTM and the University of Liverpool.
After a number of years working on humanitarian and infectious disease con-
trol programmes in post-conflict countries, he returned to work in applied
public health in the UK for the Health Protection Agency and the NHS. He is
passionate about making a difference to the health of the most disadvantaged.
He was awarded an NIHR doctoral fellowship in 2010, investigating the fac-
tors that influence the employment of people with common mental health
problems and how employment support can be improved. This work is part of
a wider international research collaboration on the differential social conse-
quences of chronic illness with the Karolinska Institute in Sweden, the Univer-
sity of Oslo, the University of Copenhagen, and colleagues at OECD and
Statistics Canada.
Mel Bartley is Professor Emerita of University College London and former dir-
ector (2008–12) of ESRC International Centre for Life Course Studies in Soci-
ety and Health. Her background is in philosophy, sociology, and epidemiology,
and she has researched a number of topics including: unemployment and
health; domestic labour and health; scientific research and social policy; health
inequalities; capability and resilience; and life course effects.
xxviii List of Contributors

David Blane is Professorial Research Associate of University College London, Pro-

fessor Emeritus of Imperial College London, and former deputy director (2008–12)
of ESRC International Centre for Life Course Studies in Society and Health. His
background is in medicine, sociology, and public health, and his research interests
include health inequalities, life course research, and social gerontology.
Toba Bryant PhD is Assistant Professor in the Faculty of Health Sciences at
the University of Ontario Institute of Technology. She has written and re-
searched health inequalities, income and housing as social determinants of
women’s health, and public policy. She is author of the sole-author volume In-
troduction to Health Policy, and co-editor of Staying Alive: Critical Perspectives
on Health, Illness and Health Care.
Jeff Collin PhD is Professor of global health policy at the University of Edin-
burgh. A political scientist, his research focuses on globalization, health gov-
ernance, and corporate strategies to influence public policy. He was a
member of the WHO expert group monitoring tobacco industry influence
on policy, and is a member of the tobacco advisory group of Cancer Re-
search UK, a co-investigator in the UK Centre on Tobacco and Alcohol Stud-
ies, and an expert advisor for the Institute of Alcohol Studies. Recent
publications examine WHO’s Framework Convention on Tobacco Control,
conflict of interest in international health philanthropy, policy coherence in
global health, and UK government support for the global expansion of the
alcohol industry.
Alison Copeland PhD is a lecturer in Human Geography specializing in
Quantitative Methods and Geographic Information Systems (GIS). Her re-
search interests focus on health inequalities, specifically exploring access to
health care for less advantaged groups in the population. She has previously
worked as a nurse in the NHS and in Public Health, and for the Learning Dis-
abilities Observatory as part of the North East Public Health Observatory.
Chik Collins is Reader in Applied Social Science at the University of the West
of Scotland (Paisley). He has written extensively on the role of language in so-
cial change, drawing on the theoretical tradition of Cultural Historical Activ-
ity Theory, and on urban policy and community development. His more
recent research, in collaboration with NHS Health Scotland and the Glasgow
Centre for Population Health, has been on the phenomenon of ‘excess mortal-
ity’ in West Central Scotland, and its relationship to ongoing processes of so-
cial, political, and economic change in the region. He has worked extensively
with Oxfam and its community partners in recent years, and is a co-founder of
the University of the West of Scotland–Oxfam Partnership ‘for a more equit-
able and sustainable Scotland’.
 List of Contributors xxix

Espen Dahl is a Professor at Oslo and Akershus University College in Oslo,

Norway. His research interests are health and social inequalities, social and
health policy, and comparative welfare state research.
Peter Donnelly is President/CEO of and leads Public Health Ontario, an
arm’s-length agency of government providing health protection and health
promotion services to a population of over 13 million in the Canadian prov-
ince of Ontario. He moved to Toronto after six years as Professor of Public
Health at the University of St Andrews, Scotland and is a former Deputy Chief
Medical Officer to the Scottish government. He is a current member of the
technical Board of the New York-based Milbank Memorial Fund, a former
President of the UK Association of Directors of Public Health, and a former
Vice President of the U Faculty of Public Health. He has worked extensively
with the WHO on a variety of public health issues.
Margaret Douglas is Deputy Director of Public Health, NHS Lothian, Edin-
burgh. She has been a Consultant in Public Health in NHS Lothian since 2000
and is currently Deputy Director of Public Health. She is the NHS Lothian
lead on Health Improvement and Health Inequalities. Her main areas of inter-
est are the physical and socio-environmental determinants of health, and ways
to influence these through partnership work with local authorities and other
agencies. She has a long-standing interest in Health Impact Assessment and
chairs the Scottish Health and Inequalities Impact Assessment Network.
Eva Elliott is a lecturer at Cardiff University School of Social Sciences. At the
time of writing she was a co-investigator on two major Connected Communi-
ties projects funded by the Arts and Humanities Research Council (AHRC)
with the Economic and Social Research Council (ESRC). Working with com-
munity and civil society organizations, activists, and members of communi-
ties, both of these aim to rethink and redesign the ways in which underserved,
under-resourced, and otherwise marginalized communities can influence pol-
icy and regulatory practices and create new knowledge spaces about the ways
in poor health and well-being are shaped and experienced unequally.
Lynne Friedli is a freelance researcher, with a special interest in the relation-
ship between mental health and social justice. She is author of a report for
WHO Europe on mental health, resilience, and inequality (http://www.euro.
who.int/document/e92227.pdf) and has contributed to the WHO Europe
Strategy on Mental Health. She is also part of the first residency of The Hub at
Wellcome Collection, exploring the dynamics of rest, noise, tumult, activity,
and work in modern life (http://hubbubgroup.org). She is interested in current
debates about the politics of ‘assets-based approaches’ and the psychologizing
of public health, and is currently researching the (mis)use of psychological ap-
proaches in workfare and other employment programmes.
xxx List of Contributors

Lisa Garnham is a Public Health Research Specialist at the Glasgow Centre for
Population Health. Her research interests centre on spatial and social patterns of
health inequalities, including the ways in which they intersect, and the impact of
‘social’ interventions on reducing them. Her PhD at the University of the West of
Scotland explored the ‘Scottish Effect’ in public health, with a focus on the
socio-political processes that could be understood to underpin its emergence.
Her research often makes use of participatory and creative methods, particularly
when she is working with children and young people.
Kayleigh Garthwaite is a Post-Doctoral Research Associate at the Department
of Geography, Durham University. She has a degree in Sociology, an MA in So-
cial Research Methods (Social Policy), and a PhD in Human Geography (2012),
all from Durham University. Her research interests focus on health inequalities,
welfare-to-work policies, and austerity, with a particular interest in spatial dis-
advantage. She is currently working on an ethnography of health inequalities in
contrasting areas of Stockton-on-Tees. She has published in the fields of social
policy, disability studies, sociology, youth studies, and public health, and is co-
author of Poverty and Insecurity: Life in Low-pay, No-pay Britain (Policy Press,
2012), which won the Peter Townsend Memorial Prize in 2013.
Johanna Hanefeld PhD is Senior Lecturer in Health Systems Economics, An-
thropology, Policy and Politics Group, in the Department of Global Health
and Development, London School of Hygiene and Tropical Medicine. She has
previously worked on social determinants of health at the World Health Or-
ganization’s EURO office and for various public health NGO and advocacy or-
ganisations in a variety of low and middle income settings.
Mark Hellowell is a Senior Lecturer at the Global Public Health Unit, University
of Edinburgh. His research programme focuses on the public/private interface in
health care and health systems, with an emphasis on the equity and efficiency
outcomes from different forms of intersectoral engagement. In addition to pub-
lishing in a diverse array of peer-reviewed journals, he has disseminated his re-
search through a variety of media, including BBC radio and television
documentaries, and newspapers including The Guardian and the Financial
Times. He has acted as special adviser to the House of Commons Treasury Select
Committee, and has advised several multilateral development agencies, including
the World Bank, on the operation of the public–private engagement in areas such
as acute health care, care and control of tuberculosis, and family planning.
Sarah Hill is Director of the Global Public Health Unit in the School of
Social and Political Science at the University of Edinburgh. Her research
focuses on health inequalities and the social determinants of health,
 List of Contributors xxxi

tobacco and health, and global health. She is particularly interested in the
structural drivers of health inequalities, including historical and institu-
tional discrimination and the role of commercial actors in non-communi-
cable disease epidemics. She joined the University of Edinburgh in 2009
having previously worked in research, public health, and medicine in New
Zealand, the USA, West Africa, and the UK.
David J. Hunter is Professor of Health Policy and Management at the Centre
for Public Policy and Health (CPPH), School of Medicine, Pharmacy and
Health, Durham University (www.dur.ac.uk/public.health), and Wolfson Fel-
low in the Wolfson Research Institute for Health and Well-being. He is Deputy
Director of Fuse, the Centre for Translational Research in Public Health
(www.fuse.ac.uk). He is a Non-Executive Director for the National Institute
for Health and Care Excellence (NICE), and advises WHO Europe. CPPH is a
WHO Collaborating Centre on Complex Health Systems Research, Knowl-
edge and Action. David has published extensively on health policy; his books
include The Health Debate (2008), The Public Health System in England (2010)
with Linda Marks and Katherine E. Smith, and Partnership Working in Public
Health (2014) with Neil Perkins (all three published by Policy Press, Bristol).
Jane Jones coordinated the Pilton community health project from 1984 to
1994. Together with Cathy McCormack she was a founder member of the
Scottish Popular Education Forum based on the work of Paulo Freire, the Bra-
zilian educationist. Between 1991 and 1999 she was a member of the Editorial
Advisory Board of the Community Development Journal.
At Edinburgh University she developed the access course ‘Health Issues in
the Community’, which placed community health within a social and political
context. She worked for the Poverty Alliance developing the Communities
Against Poverty (CAP) Scottish network and from 2003 to 2006 she was the
Public Participation Officer for the Scottish Parliament. In 2013 she was in-
vited to deliver the Stephen Maxwell Memorial lecture, ‘The War on the Com-
monweal’. She is a member of the Radical Independence Campaign (RIC).
Gerry McCartney has, since 2010, been Head of the Public Health Observa-
tory at NHS Health Scotland. He was previously a general practitioner and a
public health doctor for NHS Greater Glasgow and Clyde. He trained in medi-
cine at Glasgow University (MBChB 2001, MPH  2006) and has an honours
degree in economics and development (University of London 2007). His MD
thesis (University of Glasgow 2010) was on the anticipated host population
impacts of the 2014 Commonwealth Games. His main research interests and
publications focus on the health impacts of socio-economic, political, and en-
vironmental change, with a particular focus on the ‘excess mortality’ in
xxxii List of Contributors

Scotland as compared to other nations. Views expressed in this chapter are not
necessarily shared by NHS Health Scotland.
Cathy McCormack lives in Easterhouse, Glasgow and since 1982 has been
campaigning on poverty, housing, health, and climate change. Her writings
and broadcasts have received international acclaim, and her biography, The
Wee Yellow Butterfly, was published in 2009. She is also a non-academic com-
munity critical psychologist and has worked with Professor David Fryer,
speaking at conferences all over the world to expose the socio-structural vio-
lence being waged at communities both at home and abroad. In 2013 she ad-
dressed the International Community Psychology Conference at Birzeit
University, Palestine.
In 1994 she was engaged by the World Health Organization as a special ad-
visor at their European Health Policy Conference and in 1995 was an official
representative for the Scottish Environmental Forum at the United Nations
Commission on Sustainable Development.
Ben McKendrick is Chief Executive of the Scottish Youth Parliament, hav-
ing previously worked as Communications and External Affairs Directors
for Myeloma UK. He has worked in and around the devolved institutions in
Scotland since 2000. He initially worked as parliamentary assistant at the
newly formed Scottish Parliament and then as a senior researcher for a pol-
itical parliamentary group. After a period working for a public affairs con-
sultancy, he joined British Heart Foundation (BHF) Scotland as their Senior
Policy and Public Affairs Manager. During that period, he was responsible
for BHF’s tobacco control policy and advocacy work in Scotland and Nor-
thern Ireland, and represented the charity on the high-profile campaigns for
smoke-free public places, for a ban on the display of tobacco at the point of
sale and on the sale of tobacco from vending machines, and for standard-
ized tobacco packaging. He was also responsible for BHF’s policy and advo-
cacy work in Scotland, including on health inequalities and obesity.
Linda Marks is Senior Research Fellow at the Centre for Public Policy and
Health, School of Medicine, Pharmacy and Health, Durham University. With
a background in medical sociology, health policy analysis, and the organiza-
tion of primary care, she has acted as special advisor for WHO Europe’s public
health action plan, as a Non-Executive Director for NHS Darlington, and was
formerly a health policy analyst at the King’s Fund. Her current research inter-
ests include governance, priority-setting and health inequalities, and the im-
pact of the 2012 public health reforms in England. She has published widely
on public health policy and practice, including a recent book, Governance,
Commissioning and Public Health.
 List of Contributors xxxiii

Rich Mitchell is Professor of Health and Environment at the Centre for Re-
search on Environment, Society and Health, and head of the Public Health
Group at the Institute of Health and Well-being, University of Glasgow. He is
also a co-director of the Centre for Research on Environment, Society, and
Health (http://cresh.org.uk), an interdisciplinary and inter-institute centre fo-
cused on exploring how physical and social environments can influence popu-
lation health, for better and for worse. He is an epidemiologist and geographer.
Earlier in his career he focused on monitoring and exploring socio-economic
and geographic inequalities in health. Today, his focus is on the potential for
environments, and natural environments in particular, to positively influence
population health and health inequalities.
Jamie Pearce is Professor of Health Geography at the University of Edin-
burgh, where he is head of the Institute of Geography and Lived Environment,
and co-Director of the Centre for Research on Environment Society and
Health (CRESH). He is Editor-in-Chief of the international journal Health
and Place. His research seeks to understand various social, political, and envir-
onmental mechanisms operating on a range of geographical scales that estab-
lish and perpetuate spatial inequalities in health. Working at the intersection
of human geography, public health, and epidemiology, he has particular inter-
ests in health-related behaviours (e.g. smoking, nutrition, physical activity,
and obesity), environmental justice and health (e.g. air pollution and multiple
environmental deprivation), and macro-level health-related processes (e.g. so-
cial and economic inequality).
Kate Pickett is Professor of Epidemiology at the University of York and a co-
founder of The Equality Trust; her research focuses on the social determinants
of health. She was a UK NIHR Career Scientist from 2007 to 2012 and is a Fel-
low of the RSA and of the UK Faculty of Public Health. She is co-author, with
Richard Wilkinson, of the bestselling The Spirit Level, winner of the 2011 Pub-
lication of the Year from the Political Studies Association and translated into
23 languages. She and Richard were awarded a 2013 Silver Rose Award from
Solidar for championing equality.
Jennie Popay is Professor of Sociology and Public Health at Lancaster Univer-
sity in the UK, Deputy Director of the NIHR School for Public Health Re-
search (SPHR), and Director of Engagement for the NIHR Collaboration for
Leadership in Applied Health Research and Care for the NW Coast (NIHR
CLAHRC NWC). She is also co-Director of the Liverpool and Lancaster Col-
laboration for Public Health Research (LiLaC), one of eight academic mem-
bers of the SPHR. She has worked as a teacher, policymaker, and researcher in
academia and in the public and voluntary sectors in the UK, Africa, and New
xxxiv List of Contributors

Zealand. Her research interests include the social determinants of health and
health equity, the evaluation of complex ‘natural’ policy experiments, com-
munity empowerment, and the sociology of knowledge. She has been in-
volved in a wide range of mixed methods studies, but has particular expertise
in qualitative methods. Her current research includes an evaluation of a
large-scale community empowerment initiative in England and leadership of
a programme of work developing and evaluating local authority approaches
to addressing health inequalities. She has recently completed studies of the
impact on health inequalities and their social determinants of the English
New Deal for Communities regeneration programmes and their approaches
to community engagement. She also led a collaboration undertaking an
MRC-funded study focusing on methods to assess the impact of public in-
volvement in research, which resulted in an online resource for researchers
(piiaf.org.uk). She ran the global Social Exclusion Knowledge Network sup-
porting the WHO Commission on the Social Determinants of Health, and
has held public appointments with the Commission on Health Improvement,
the Commission on Patient and Public Involvement in Health, and the Bevan
Commission in Wales, and is presently chair of the English charity The Peo-
ple’s Health Trust.
Maximilian Ralston is a hospital doctor. He graduated from the University of
Edinburgh’s Medical School in 2015, having previously gained a BMedSci with
Honours in International Public Health Policy in 2012. He has a particular in-
terest in health and public policy, especially in the areas of health economics,
health inequities and social justice, and health care quality improvement.
Dennis Raphael PhD is a Professor of Health Policy and Management at
York University in Toronto. He is editor of Social Determinants of Health:
Canadian Perspectives (2008, Canadian Scholars’ Press), co-editor of Staying
Alive: Critical Perspectives on Health, Illness, and Health Care (2008, Cana-
dian Scholars’ Press), and author of Poverty in Canada: Implications for
Health and Quality of Life (2011, Canadian Scholars’ Press) and About Can-
ada: Health and Illness (2010, Fernwood Publishing). He is also co-author of
Social Determinants of Health: The Canadian Facts (2010, Toronto: York
University School of Health Policy and Management), a primer for the Ca-
nadian public that has been downloaded over 250,000 times from http://
thecanadianfacts.org. His latest edited books are Tackling Health Inequali-
ties: Lessons from International Experiences (2012, Canadian Scholars’ Press)
and Immigration and the Modern Welfare State: Public Policy, Immigrant Ex-
periences, and Health Outcomes (in press, Canadian Scholars’ Press).
 List of Contributors xxxv

Niamh Shortt is a Senior Lecturer in Health Geography at the Centre for En-
vironment, Society, and Health (CRESH), School of Geosciences, University
of Edinburgh. Her research considers how the environment shapes our health,
health behaviours, and resulting health inequalities. She focuses on the effect
of place and in particular the idea of the locale in which various aspects of the
social and natural environment converge to influence health outcomes. Based
on the premise that place matters for health, her research explores a wide
range of area effects and considers the implications for health. Her current
work focuses on alcohol and tobacco environments in Scotland.
Katherine E. Smith PhD is a Reader at the Global Public Health Unit in the
School of Social and Political Science at the University of Edinburgh. Her re-
search focuses on analysing policies affecting public health (especially health
inequalities) and better understanding the relationships between public health
research, policy, advocacy, and lobbying. She recently brought some of this
work together in a book entitled Beyond Evidence-based Policy in Public
Health: The Interplay of Ideas, which is part of a new book series, Palgrave
Studies in Science, Knowledge, and Policy that she co-edits with Professor Rich-
ard Freeman. Between January 2011 and December 2012 she held an MRC-
ESRC Post-Doctoral Fellowship, which was followed, in 2013–2015, by an
ESRC Future Research Leaders award (grant number ES/K001728/1). Both
grants helped support the development of this edited book.
Ellen Stewart holds a Chief Scientist Office Postdoctoral Research Fellowship
in the Centre for Population Health Sciences, University of Edinburgh, re-
searching evidence use and public engagement in hospital closure in the Scot-
tish NHS. She has previously worked at the University of St Andrews and LSE.
Her research interests bridge social policy and politics, with a particular focus
on how health systems negotiate the input of new types of knowledge in the
policy process, including demands for public engagement and evidence-based
policy. Her first monograph, Publics and their Health Systems: Participation
and Beyond, will be published by Palgrave Macmillan in 2015.
Kjetil A. van der Wel PhD is Associate Professor in the Faculty of Social Sci-
ences, Oslo and Akershus University College of Applied Sciences. His research
is on social inequalities in health and health-related worklessness, including
the role of social policies and labour market conditions.
Gareth Williams is Professor of Sociology in the School of Social Sciences
and Director of the Cardiff Institute of Society, Health, and Well-being at Car-
diff University. He previously worked at the University of Manchester and the
University of Salford. He is also Editor-in-Chief of the journal Sociology of
xxxvi List of Contributors

Health and Illness and is a Non-Executive Director on the Board of Public

Health Wales.
Richard Wilkinson is Emeritus Professor of Social Epidemiology at the Uni-
versity of Nottingham, Visiting Professor at the University of York, Honorary
Professor at UCL, and a co-founder of The Equality Trust. He has played a
formative role in international research on the social determinants of health
and on the societal effects of income inequality. He studied economic history at
LSE before training in epidemiology. He is co-author, with Kate Pickett, of the
bestselling The Spirit Level, winner of the 2011 Publication of the Year from the
Political Studies Association and translated into 23 languages. He and Kate
were awarded a 2013 Silver Rose Award from Solidar for championing equality.
 Chapter 1

Background and introduction:

UK experiences of health
inequalities
Katherine E. Smith, Clare Bambra,
and Sarah Hill

1.1  Health inequalities in the UK

In this chapter we introduce key debates in health inequalities research regard-
ing: (i) the best means of conceptualizing, measuring, and monitoring health
inequalities; (ii) trends in the UK’s patterns of health inequalities compared to
other high-income countries; (iii) empirically informed theories to explain
health inequalities; and (iv) the UK’s recent policy efforts to reduce health in-
equalities. The term ‘health inequality’ is usually employed to refer to the sys-
tematic differences in health which exist between different population groups
(e.g. different social classes or ethnic groups). In the UK, discussion of health
inequalities usually focuses on the distribution of health by social class and/or
socioeconomic position. Health inequality may be defined in a purely descrip-
tive way. For example, Kawachi and colleagues refer to health inequality as ‘a
term used to designate differences, variations, and disparities in the health
achievements of individuals and groups’ (Kawachi et al 2002, p647). More com-
monly, however (and in this book), the moral and ethical dimensions of the
term are emphasized: inequalities in health are therefore conceptualized as ‘sys-
tematic differences in the health of people occupying unequal positions in soci-
ety’ (Graham 2009, p 3), with an explicit recognition that such differences are
socially produced and therefore avoidable, unfair, and unjust (Whitehead
2007). In other contexts, slightly different terms may be preferred. For example,
in the USA and Canada, ‘health disparities’ are often employed, and inter-
nationally (e.g. at the World Health Organization (WHO)) and in low- and
middle-­income countries, the preferred term tends to be ‘health inequities’ (as
is evident in Chapter 5 of this book).
2 BACKGROUND & INTRODUCTION: UK EXPERIENCES

1.2  Debates about how health inequalities are

conceptualized, measured, and monitored
This section provides a brief summary of the main ways in which health in-
equalities are conceptualized, particularly in terms of the indicators used to
stratify health. It is by no means a comprehensive account but rather considers
the ways in which researchers focusing on the UK have tended to conceptualize
health inequalities over the past 30 years and some of the key challenges to these
approaches (critiques which are developed later in the book).

1.2.1  Health inequalities research: Data and theory

Health inequalities research relies heavily on empirical data to demonstrate and
explore differences in health status (see Chapter 2). The discipline of epidemi-
ology (the study of patterns of health and disease in human populations using
quantitative methods) has played an important role in this work, and continues
to be vital in describing and monitoring health inequalities within and between
populations. Indeed, the WHO Commission on the Social Determinants of
Health (CSDH), targeted at a global audience, included the need to measure,
understand, and monitor health inequalities as one of its three overarching re-
commendations (CSDH 2008).
The UK’s position as a leading centre for health inequalities research owes
much to its historically strong administrative data systems and to some pion-
eering epidemiologists. As early as the 1840s, researchers such as Edwin Chad-
wick used administrative data to demonstrate that those in manual occupations
died an average of seven years earlier than tradesmen and 20 years earlier than
the gentry (Chadwick 1842). The routine collection of data on mortality and
occupation since the mid-nineteenth century has allowed generations of UK
researchers to continue to examine the association between occupational class
and health (Macintyre 1997), while data relating to residential location have
provided health researchers with a proxy for social class in both the UK (Mac-
intyre 1997) and continental Europe (Susser et al 1985).
While epidemiology has much to offer in describing health inequalities, it has
perhaps been less helpful in understanding the causes of these inequalities. This
partly reflects the quantitative nature of its methods (see also Chapter 18), but
also reflects its links with clinical medicine and an associated tendency to focus
on data relating to the behaviours and lifestyle of individuals rather than the
broader structures and circumstances that shape such behaviours (see Chap-
ter 8). Beaglehole and Bonita (2004), for example, criticize what they describe as
epidemiology’s implicit reliance on a theory of biomedical individualism and its
lack of interest in the social drivers of health and disease. They caution against an
 HOW HEALTH INEQUALITIES ARE CONCEPTUALIZED 3

increasing tendency for epidemiologists to take a mechanistic view of health

while neglecting the population perspective, linking this bias with an ideo-
logical emphasis on individual rather than collective responsibility (Beaglehole
and Bonita 2004, p 145).
These tensions are evident in conflicting explanations for observed health
differences. As Section 1.4 outlines, popular, empirically informed explanations
for health inequalities stress the importance of ‘upstream’ factors, such as the
social and economic context in which behavioural decisions and lifestyle ex-
posures take place. In contrast, much epidemiological research focuses on indi-
vidual factors in seeking to explain patterns of disease, thus emphasizing what
are often regarded as poor, uninformed, or irresponsible lifestyle ‘choices’ on
the part of those with worse health status (see Section 1.4, and Chapters 16 and
17). Such explanations often reflect the underlying (usually unstated) assump-
tions of the researchers, or limitations in available data (as this section con-
siders further), and should therefore be treated cautiously.

1.2.2  Social class, socioeconomic position, and health

Social class, and the concept of ‘general standing in the community based on
occupational skill’ (Bartley 2004, p 1), has a long history in the UK. More re-
cently, health inequalities researchers in the UK have moved to a focus on so-
cioeconomic position as the principal marker of social inequality. This shift
reflects both the difficulties involved in measuring ‘social class’ and its less
widespread use in countries outside of Europe (Bartley 2004; Lynch and Kaplan
2000). However, it has also been criticized as a move away from an explicit focus
on the unequal distribution of power within society.
Various indicators of social class and social position exist, most of which
focus on occupational classifications and/or indicators of income, wealth, or
educational attainment (Galobardes et al 2006). The complexity of social class
and social position means that the indicators employed are inevitably imperfect
proxies and, as Grundy and Holt (2001) point out, the choice of indicator(s)
used is not often adequately reflected on, possibly hampering efforts to under-
stand the underlying mechanisms via which social position affects health.
Scambler and Higgs (1999) argue that a further implication of this tendency is
that ‘class’ is often ‘explained away’ by authors focusing on ‘class-constitutive’ or
‘class-associated’ factors (income, occupation, housing status, etc.) rather than
considering class as a ‘phenomenon in its own right’ (in a more sociological
sense). In a review of the ways in which health is stratified in the UK and the
USA, Krieger and colleagues (1997) argue that health inequalities researchers
necessarily have to focus on these kind of class-associated factors since ‘class’ is
not readily measured or quantified. Nevertheless, the authors note that social
4 BACKGROUND & INTRODUCTION: UK EXPERIENCES

class should be regarded as ‘logically and materially prior to’ socioeconomic

position, which can be seen as the ‘expression’ of social class in terms of the dis-
tribution of material and prestige-based resources across society (Krieger et al
1997, p 346).
Despite the difficulties in pinning down precisely what ‘social class’ is, or how
we might measure such an amorphous concept, there is now a clear consensus
that those positioned higher up the ‘class’ gradient in Britain experience better
health and life expectancy than those further down for many health outcomes
(Bartley 2004; Graham 2009; Marmot 2004). This pattern is evident across the
population, so that ‘even comfortably off people somewhere in the middle tend
to have poorer health than those above them’ (Marmot 2006). Consequently, as
Graham and Kelly (2004) argue, it is important to understand health inequal-
ities as a continual social gradient, rather than as ‘health gaps’ which result from
‘health deprivation’ in poorer communities.

1.2.3  Area and health

An alternative means of conceptualizing health inequalities, and one which also
has a long history in Britain (see Chapter 14), is to consider differences in health
indicators between areas. In many instances, indicators of neighbourhood are
used as another imperfect proxy for social position (see Tunstall and Lupton
2003). Whilst the existence of differences in population health between various
areas of the UK is widely acknowledged, there are also important debates about
how these differences are measured. The choice of scale at which geographically
bounded data are drawn from inevitably influences findings; while compari-
sons of large-scale areas may obscure significant variations in health within
those areas, a focus on health patterns within extremely small-scale areas may
fail to capture variation between larger areas (see Wilkinson 2005). Further, as
Chapter  14 explains, geographical approaches to health inequalities have
tended to ignore the historical and social production of places.

1.2.4  Gender and health

A less common strand of health inequalities research involves considering
health differences from a gendered perspective. Intrinsic to this research is a
distinction between sex, which is biologically defined, and gender, which is so-
cially defined (Annandale and Hunt 2000) and has important implications for
the relative position of men and women in any given society (Ostlin et al 2001).
This is not to say that health differences between women and men can be attrib-
uted proportionally to either the biological or the social; rather, the two elements
interact in their impacts on health such that ‘[b]iological differences between
 HOW HEALTH INEQUALITIES ARE CONCEPTUALIZED 5

the sexes may be in part socially determined, while social differences arising
from gender relations may also have a biological element’ (Ostlin et al 2001,
p 176). In other words, the impact of biologically defined differences (such as
reproductive capacity) will differ depending on socially defined norms and
structures, while differences in the socially defined roles and positions of men
and women may relate to biological differences between them.
As well as considering gender differences in health, there has also been re-
search interest in relation to how health is stratified amongst women, particu-
larly as most of the research on health inequalities in Britain in the 1970s and
1980s tended to focus solely on variations in men’s health (with married women,
where they were included, being categorized according to their husband’s class).
From the late 1980s onwards, researchers began doing more to explore whether
the same kinds of health differences were evident amongst women (e.g. Arber
1991; Bartley et al 1992), whilst also comparing health experiences between
men and women. In most countries (including the UK), such research suggests
that women have a longer life expectancy than men (Salomon et al 2013) but
experience higher levels of many chronic health conditions (Borchers and
Gershwin 2012).

1.2.5  Ethnicity, ‘race’, and health

While health inequalities research in the UK has historically focused on the role
of class and social position, researchers in other English-speaking contexts have
placed greater emphasis on ethnic inequalities in health. This is particularly
true of inequalities research in the USA, but is also an important theme in Can-
ada, New Zealand, and Australia—all former British colonies in which racial
ideology has played an important role in the historical process of colonization
and the establishment of contemporary societal norms and institutions (Armit-
age 1995).
In the US literature, the term ‘race’ is often used where UK researchers would
use ‘ethnicity’ (just as ‘disparities’ is often used in place of ‘inequalities’) (Isaac
2013). The prominence of race within the US partly reflects its historic signifi-
cance in the legal, political, and social development of US society, but also its
long-standing use as a key demographic category (Williams 1997). Some health
researchers in the USA have called for a shift away from the use of ‘race’ to ‘eth-
nic group’, but others argue that a continued focus on race is appropriate in
understanding the important role of racism for health (and other) inequalities
(Thomas 2013; Williams 1997). Ethnicity is a form of collective social identity
that typically includes elements of language, culture, shared history, and com-
mon ancestry (Karlsen and Nazroo 2007; Williams 1997). Ethnic identity is so-
cially constructed by both internal and external group membership; it involves
6 BACKGROUND & INTRODUCTION: UK EXPERIENCES

a complex and dynamic negotiation between those included in a particular eth-

nic grouping and the society in which that grouping has social significance. This
identity is not fixed: on a broad level, the boundaries and terminology used to
define ethnicity change with time and place; and on an individual level, the
same person may identify with different ethnic identities in different social con-
texts and at different points in their life course (though official records often
treat ethnicity as a single category—Aspinall and Song 2013).
The study of health inequalities in relation to ethnicity has historically been
something of a speciality interest in British health research, although it is now
becoming increasingly common (e.g. Chandola 2001; Davey Smith et al 2000;
Nazroo 2006). The research that does exist suggests that most minority ethnic
groups in Britain experience poorer health outcomes for many measures than
their ‘white British’ counterparts (Nazroo 2006). This conclusion in itself can
cause tensions; as Chaturvedi (2001) points out, research which emphasizes
high rates of disease in minority ethnic groups can imply that such disease rates
(and therefore the ethnic groups in question) are a problem.

1.2.6  Intersectionality
Although these various axes of inequalities are often studied in isolation, the
reality of people’s lived experiences involves ongoing intersections across all of
these different axes. The concept of ‘intersectionality’ describes the multiple
intersecting aspects of social identity and structure, particularly those associ-
ated with experiences of exclusion or subordination (Walby et al 2012). Origi-
nating in Black feminist critique, intersectionality is increasingly used in other
areas of research to theorize the experience of simultaneously held identities
with relevance for social position (Meer 2014). In relation to health inequalities,
the concept of intersectionality has not yet been widely employed, but, as Chap-
ter 7 explains, it offers a useful framework for understanding the multiple layers
of advantage and disadvantage that have relevance for health and well-being. It
recognizes that a single person has multiple aspects of identity (including social
class, ethnicity, gender, sexual orientation, ability/disability) which have rele-
vance for their relationships with others and with the structures and systems of
power in society—and, therefore, for their health.

1.3  Trends in the UK’s health inequalities over the past

30 years
Mortality rates in the UK, and across western and central Europe, have been
improving for around 150 years (McCartney et al 2011). However, underlying
the overall improvement in mortality rates, some specific causes of mortality
 Empirically informed theories 7

have increased markedly. For example, alcohol-related mortality increased dra-

matically during the late 1980s and early 1990s in the UK, in contrast to the
improving trends in other parts of Europe (Scott-Samuel et al 2014). Increases
were also evident in drug-related mortality, suicide, and violence over the same
period (Mok et al 2012; Shaw et al 2002; WHO 2012).
Within the UK, mortality rates improved much more slowly in northern and
inner-city areas than in the more affluent southern England (Hacking et al
2011), to the extent that in some areas mortality rates actually worsened (Nor-
man et al 2011). Indeed, for young adults in Scotland there has been no im-
provement over the course of the last 30 years (Whyte and Ajetunmobi 2012).
The rise in spatial inequalities in health since the 1980s is also reflected in a
rapid rise in mortality inequalities by occupational social class in England and
Wales and by area deprivation in Scotland (Leyland 2004). Figure 1.1 shows
that the absolute gap in mortality (as measured by the Slope Index of Inequal-
ity1) between the least and most deprived postcode areas in Scotland remained
high but stable between 1981 and 2001; whilst relative inequalities (as measured
by the Relative Index of Inequality2) increased rapidly, leaving Scotland with
the highest inequalities in western and central Europe (Mackenbach et al 2008;
Popham and Boyle 2010). In England and Wales, life expectancy increased for
all social class groups amongst males and females over time, but the increase
was more rapid amongst the highest social classes (I + II) than in the lowest so-
cial classes (IV + V), such that the inequalities increased.
It has been argued that these trends reflect the neoliberal (small state, free-
market orientated—see Chapters 9 and 12) policies that were adopted in the
UK in this era (see Scott-Samuel et al 2014). This is supported by the fact that
other countries which adopted neoliberal policies in this period also saw rises
in health inequalities, such as the USA and New Zealand (Beckfield and Krieger
2009). These rises in health inequalities were not inevitable: from the 1920s to
the 1970s in both the UK and the USA, inequalities in mortality declined
(Krieger et al 2008; Thomas et al 2007).

1.4  Empirically informed theories for understanding

health inequalities
The government-commissioned Black Report of 1980, which reviewed avail-
able evidence regarding health inequalities, provided a landmark analysis of
social class differences in the health of the population in England and Wales
(Black et al 1980). It remains a seminal document in health inequalities re-
search, not only in the UK but also internationally (e.g. Cutler et al 2006; Lynch
and Kaplan 2000). The Report’s authors ultimately rejected explanations reliant
8 BACKGROUND & INTRODUCTION: UK EXPERIENCES

0.8

0.7 Males
Relative Index of Inequality

0.6

0.5 Females
0.4

0.3

0.2 Relative inequalities in mortality by

Carstairs area deprivation
0.1
(Scotland)
0.0
800

700
Males
Slope Index of Inequality

600

500

400

300 Females

200
Absolute inequalities in mortality by
100 Carstairs area deprivation
(Scotland)
0
80 SC I
SC II
78
SC IIINM
Life expectancy at birth

76 SC IIIM
SC IV
74
SC V
(years)

72

70

68

66 Male life expectancy by social class

(England & Wales)
64
86
SC I
Life expectancy at birth (years)

84 SC II
82 SC IIINM
SC IIIM
80
SC IV
78 SC V

76

74 Female life expectancy by social class

(England & Wales)
72
81
79

93

95

07
97

99

01

05

09
77

83

85

87

89

91

03

11
75

19
19

19

19

20
19

19

20

20

20
19

19

19

19

19

20

20
19

19

Year

Fig. 1.1 Trends in health inequalities in England and Wales 1975–2003 (by occupa-
tional social class) and Scotland 1981–2001 (by Carstairs area deprivation).
Source: Data from National Records for Scotland and Office for National Statistics.
 Empirically informed theories 9

on artefact, biological, behavioural, and cultural factors, and instead focused

their attention on ‘class structure’ and the extent to which this shapes people’s
access to health-promoting resources (Macintyre 1997).
More recently, additional theories of health inequalities have built on the ex-
planations outlined in the Black Report, including psychosocial theories, the
life course approach, and political economy (structural) accounts. The follow-
ing sections briefly outline what appear to be the most popular empirically in-
formed theories for explaining (socioeconomic) health inequalities evident in
contemporary analysis.

1.4.1  Cultural–behavioural
The cultural–behavioural approach asserts that the link between social class
and health is a result of class differences in health-related behaviours (e.g.
smoking, alcohol and drug consumption, diet, physical activity, sexual behav-
iour, and health service usage). The ‘hard’ version of the cultural–behavioural
approach asserts that health differences by socioeconomic class are wholly ac-
counted for by differences in these unhealthy behaviours. The ‘softer’ version
posits that behaviour is a contributory factor to the social gradient, but not the
entire explanation (Macintyre 1997).
Although the Black Report (Black et al 1980) acknowledged that lifestyle be-
haviours contribute to health inequality patterns in the UK, it quickly rejected
this as a sufficient explanation for health inequalities on the basis that lifestyle
behaviours are significantly affected by the socioeconomic contexts in which
people live. The notion that lifestyle behaviours are a symptom, as well as a
cause, of health inequalities remains evident in most contemporary accounts of
health inequalities (e.g. Bartley 2004; Graham 2009).

1.4.2  Materialist
Materialist explanations focus on how wealth and various goods and services
that wealth enables, impact on health. By way of illustration, material wealth
can enable greater access to health care, transport, an adequate diet, good-­
quality education and housing, and opportunities for social participation, all of
which are recognized as promoting health. Material wealth also enables people
to limit their exposures to known risk factors for disease such as physical haz-
ards at work or adverse environmental exposures (such as mould and damp in
housing or proximity to busy roads). However, public policies and services
shape the extent to which key goods and services, such as schools, transport,
and welfare, are dependent on wealth (Bartley 2004).
The materialist perspective was the one most supported by the authors of
the Black Report and it is evident in a great deal of the research on health
10 BACKGROUND & INTRODUCTION: UK EXPERIENCES

inequalities that has been undertaken in the UK since (e.g. Davey Smith et al
2001; Whitehead 1987). Indeed, there now exists a significant consensus that
material determinants of health do affect health and, in this sense, the materi-
alist explanation remains a favoured explanation for health inequalities in the
UK (Graham 2009). However, there have also been some important critiques
of this explanation, one of the most common being that material approaches
fail to fully account for why inequalities in health persist within countries
where the material standard of living has significantly increased, such as the
UK (Mackenbach 2012).

1.4.3  Psychosocial
The ‘income inequalities hypothesis’ suggests that, beyond a certain basic level
of wealth, health is more closely linked to how egalitarian a society is than to
national economic performance or specific levels of poverty. This hypothesis
has contributed to an increasing interest in ‘psychosocial’ explanations of health
inequalities (Wilkinson 2005; Wilkinson and Pickett 2009), which focus on ex-
ploring how social inequality makes people feel and the biological conse-
quences of these feelings for health. For example, feelings of subordination or
inferiority can stimulate stress responses which can have long-term conse-
quences for physical and mental health, especially when they are prolonged
(Bartley 2004). Consequently, addressing material factors alone (see Sec-
tion 1.4.2) may not be sufficient to reduce health inequalities; what matters is
how individuals value themselves in relation to others (i.e. people’s perceived
social status).
Much of the UK empirical research on psychosocial pathways focuses on
the workplace and how a sense of control, security, and esteem influences
health outcomes (e.g. De Vogli et al 2008; Marmot et al 1997). This is largely
as a result of the findings of the highly influential Whitehall civil service co-
hort study, which found that occupational grade is inversely associated with
incidence of coronary heart disease and related conditions (Marmot et al
1991, 1997), all-cause mortality, and non-coronary heart disease mortality
(Marmot and Brunner 2005). Other well-known studies in this genre are in-
formed by cross-national comparisons of indicators of income distribution
(e.g. the Gini co-efficient) and of various health, and other social, outcomes
(e.g. Wilkinson and Pickett 2009). Proponents of this approach argue that it
addresses the key criticism of materialist accounts, helping to explain why
surprisingly poor health outcomes persist in countries where the (overall)
material standard of living has significantly increased (Wilkinson and Pickett
2009). Critics, in contrast, have challenged both the empirical basis of psycho-
social accounts (e.g. Goldthorpe 2009) and the practical implications, arguing
 Empirically informed theories 11

that such approaches can unhelpfully shift policy attention away from the
underlying material causes (e.g. Lynch et al 2000).

1.4.4  Political economy (structural) accounts

Political economy (or structural) accounts of health inequalities draw on ma-
terialist and psychosocial explanations, but highlight that these social deter-
minants of health are themselves shaped by macro-level structural determinants:
politics, the economy, the state, the organization of work, and the labour market
(Bambra 2011; Doyal and Pennell 1979). Politics, and the balance of power be-
tween key political actors/groups, determine whether, for example, states pro-
vide collective interventions to reduce inequalities (as would be expected in a
strong welfare state) and whether policy interventions are individually, envi-
ronmentally, or socially focused. So in this explanation, health inequalities are
politically and economically determined (Bambra et al 2005).
This explanation is supported by comparative research which suggests that
advanced economies with different political and economic macro-policy envir-
onments have different levels of population health (for an overview, see Mun-
taner et al 2011). For example, Coburn’s (2004) research concludes that those
countries which were the least neoliberal in their economic and social policy
orientation (notably the Scandinavian welfare states) had significantly lower
infant mortality rates (IMR), lower overall mortality rates, and less mortality at
younger ages. Similarly, studies by Navarro and colleagues (2003, 2006) indi-
cate that long-term rule by Social Democratic parties results in better health
outcomes than those with more neoliberal governments. There are, however,
ongoing debates about the extent to which these factors help explain patterns of
health inequalities within countries, as well as indicators of overall population
health (see Brennenstuhl et al 2012).

1.4.5  Life course

One approach to understanding health inequalities which has held particular
sway since the 1990s is the life course perspective. This is not, in itself, an aetio-
logical explanation for health inequalities; rather, it is a perspective which sug-
gests that it is essential for theories about the causes of health inequalities to
consider the importance of timing and to think about the whole life course,
rather than just particular points within it. Taking a life course perspective
therefore involves considering the various risks that individuals are exposed to
across their life courses, from foetal development through to old age (Barker
1995; Bartley 2004). This is particularly important for chronic diseases, many of
which are known to have long latency periods (Lynch and Davey Smith 2005).
Health inequalities are therefore understood to result from inequalities in the
12 BACKGROUND & INTRODUCTION: UK EXPERIENCES

accumulation of social, psychological, and biological advantages and disadvan-

tages over time.
Within life course perspectives, the notion of critical social transitions has
been used to explain how certain important changes in social status (e.g. entry
into the labour market or movement between jobs) can have long-term conse-
quences for health and future life chances (Blane 2006). Early childhood has
been identified as a particularly crucial period for health across the life course.
Indeed, using the 1946 birth cohort, Giesinger and colleagues (2014) found that
circumstances in early life accounted for 74% of the subsequent socioeconomic
gradient in mortality.
Longitudinal cohort studies suggest that disadvantage tends to cluster and
accumulate over time (Blane 2006). In this way, individuals who are exposed to
adverse conditions in one respect, for example work, are also more likely to en-
counter disadvantage in others, such as poor and damp housing or exposure to
environmental pollution. Moreover, any disadvantage encountered in the past,
such as unemployment, is likely to increase the chances of accumulating further
disadvantage in the future.

1.4.6  The consensus around the need for ‘upstream’ changes

Health inequalities are a complex phenomenon and, as this section outlines,
whilst research has informed a variety of popular theories concerning the
underlying causes, there is no consensus that any one explanation satisfactorily
explains their persistence over time and across a variety of contexts (Macken-
bach 2012). Indeed, given the complexity of interactions between the multitude
of factors known to impact on health, it seems doubtful that any one theoretical
account could ever be sufficient.
This makes developing policy responses to health inequalities difficult. None-
theless, there is a consensus amongst most researchers that the fundamental
causes of health inequalities lie ‘upstream’, in the social, economic, and political
environments in which we live and work. As such, interventions which aim to
reduce health inequalities by changing people’s lifestyle behaviours (without
also changing the contexts in which they live and/or work) have been widely
criticized by researchers (see Katikireddi et al 2013), not least because, as Lor-
enc and colleagues (2012) demonstrate, such interventions may unintention-
ally widen health inequalities. This happens where mechanisms for change (e.g.
mass media campaigns) rely on individual decision-making, given it is usually
easier to make positive lifestyle-behavioural changes when living in less stress-
ful environments. In addition, as Chapters  15–17 discuss (see also Graham
2012), lifestyle-behavioural interventions can be stigmatizing, unfairly placing
the responsibility for unequal patterns of poor health with those experiencing
 UK policy responses to health inequalities 13

the poorest health. Reflecting this, a recent survey of researchers working on

health inequalities in the UK found the majority believed policies to tackle in-
equalities in income (via taxation and benefits) and social and environmental
contexts (e.g. via public services such as schools) were most likely to reduce
health inequalities (Smith and Kandlik Eltanani 2014).

1.5  UK policy responses to health inequalities

Having considered popular, empirically informed theories of health inequal-
ities, this section moves on to consider how a UK government committed to
reducing health inequalities chose to approach the issue in practice. When a
Labour (left-of-centre) government won the general election in 1997, there was
widespread enthusiasm within public health; not only were health inequalities
firmly on the policy agenda for the first time in nearly two decades, but the gov-
ernment had also committed itself to taking an evidence-based approach to
policymaking (Cabinet Office 1999). Seventeen years after the publication of
the Black Report, ministers seemed keen to emphasize the previous Conserva-
tive government’s failure to implement any of its (largely structural and socio-
economic) recommendations, criticizing the previous administration for
placing an ‘excessive emphasis on lifestyle issues’, and casting the responsibility
for poor health back onto individuals (Department of Health 1997). Soon after
taking office, the new Labour government commissioned an independent in-
quiry into health inequalities (Department of Health 1997) to follow up the
Black Report, promising that the evidence-based conclusions would inform
their new health strategy.
In broad terms, many of the resulting Acheson Report’s 39 recommendations
reflected the conclusions of the earlier Black Report (Acheson 1998): both high-
lighted the need to have a multifaceted approach to health inequalities and both
advocated a reduction in income inequalities, with a particular focus on child
poverty (Bambra et al 2011; Birch 1999). The key difference was that the Ache-
son Report was released in a far more favourable political climate and might,
therefore, have been expected to have more of a policy impact. However, La-
bour had also stipulated that the inquiry’s recommendations should recognize
the government’s fiscal commitments which, at that time, included a two-year
agreement not to increase public spending (discussed further in Chapter 2).
This restriction, Davey Smith and colleagues (1998) argue, led to an
under-representation of structural and socioeconomic determinants in the
emerging policy initiatives which were linked to the Acheson Report.
A wealth of subsequent policy statements referred directly to the Acheson
Report (e.g. Department of Health 1999; Secretary of State for Scotland 1999),
14 BACKGROUND & INTRODUCTION: UK EXPERIENCES

creating the impression that policy decisions had, as promised, been directly
informed by this Report’s assessment of the evidence (see Chapter 2). In reality,
the relationship between evidence and policy is rarely direct or linear, and a
qualitative study exploring the use of health inequalities evidence in policy over
this period found that most of the policy responses to health inequalities that
the Labour government pursued had already been decided upon before the
Acheson Report was published (Smith 2013). Despite this, the ideas outlined in
policies published across the UK between 1997 and 2003 certainly seemed to
reflect some of the research set out in the Black and Acheson Reports (Smith et
al 2009). At this time, there appeared to be a consistency in policy approaches
to health inequalities across the UK, even though political devolution in 1999
had awarded increasing policy responsibilities (including for health) to new
political institutions in Scotland and Wales, creating opportunities for greater
divergence (Smith et al 2009).
Although these approaches did not go as far as addressing the kinds of issues
highlighted in political economy/structural accounts of health inequalities,
policies in England, Northern Ireland, Scotland, and Wales all acknowledged
the need for state intervention to help improve the circumstances in which peo-
ple live and work, placing a particular emphasis on the early years of life (Smith
2013). Area-based policies such as Sure Start in England, for example, aimed to
improve childcare in poorer areas whilst also providing locally relevant forms
of family support, whilst other interventions focused on addressing workless-
ness (see Bambra 2011) and reducing poverty via benefit/taxation reforms and
the introduction of a national minimum wage. Many of these policy changes
were not primarily motivated by an intention to reduce health inequalities, but
they nonetheless reflected aspects of the empirically informed explanations of
health inequalities described in Section 1.4 and might, therefore, have been ex-
pected to contribute to a reduction in health inequalities. Yet, by the time the
UK Labour government left office in 2010, most measures of health inequalities
suggested substantial reductions had not been achieved (National Audit
Office 2010).
There are at least five potential explanations for this. First, despite the devel-
opment of some materially orientated policies in the early years of the new La-
bour government, from 2004 onwards the emphasis of public health policies
across the devolved UK shifted back towards interventions aiming to change
people’s lifestyle behaviours (e.g. through smoking cessation services) and/or
reduce their health risks (via health services and pharmaceutical interventions,
such as statins and beta-blockers) (Smith et al 2009). It is unclear whether this
shift was prompted by a concern to meet the short-term national targets (Bauld
et al 2008; Blackman 2007), or of ministerial changes, media, or public pressure,
 UK policy responses to health inequalities 15

or simply reflected a conceptualization of health inequalities as ‘health gaps’ re-

sulting from ‘health deprivation’ (logically implying the potential for remedi-
ation via targeted interventions—see Section 1.3.1; Graham and Kelly 2004).
Whatever the reason, this shift represented a move away from approaches sup-
ported by the empirically informed theories outlined here to more ‘downstream’
interventions (see Smith et al 2009 for a more detailed analysis of this shift).
From this perspective, the failure to reduce health inequalities is accounted for
simply by the fact that policy responses did not adequately reflect available evi-
dence (Bambra et al 2011). Second, it could be argued that, although (at least
some) policies did reflect (at least some of) the available evidence, they were too
limited in time, reach, scope, or intensity to make a substantial difference. Third,
although many of Labour’s policies aimed to address poverty, they did not expli-
citly seek to reduce key material inequalities, such as income inequalities, which
psychosocial accounts of health inequalities suggest are crucial (Wilkinson and
Pickett 2009). Fourth, the policies intended to reduce health inequalities were
operating in a wider policy, social, and economic context which was unfavour-
able to health inequalities (Smith 2013). Fifth, taking the life course perspective
into account, it might be argued that not enough time has passed to yet be able
to fully assess the impact of Labour’s (1997–2010) efforts to reduce health in-
equalities. All of this serves to highlight the difficulties involved in developing
and implementing evidence-informed responses to health inequalities and in
evaluating their impact. Research remains ongoing, however, and, looking to
the future, it may be that different parts of the devolved UK begin to pursue
more divergent strategies for addressing health inequalities, creating opportun-
ities to learn from ‘natural experiments’ (see Chapter 18).
Shortly before leaving office, the UK Labour government published a new
policy-orientated review of the available evidence on health inequalities (again,
focusing on England), led by Professor Sir Michael Marmot (2010). Although
the Marmot Review followed 13 years of policy efforts to reduce health inequal-
ities and had far more evidence upon which to draw, its policy recommenda-
tions mirror those of the earlier Black and Acheson Reports. This suggests that,
despite the vast quantities of research that was undertaken on health inequal-
ities in the 12-year period between the publication of the Acheson Report and
the Marmot Review, only limited progress was made in developing our under-
standing of health inequalities. It is possible that all of this research is contrib-
uting to longer-term shifts in policy and public health inequalities, which is
how Weiss (1979) suggests research impact most commonly functions. Yet, it is
also possible that the research community needs to alter the focus of its research
and/or do more to ensure that health inequalities research influences changes
in the real world.
16 BACKGROUND & INTRODUCTION: UK EXPERIENCES

1.6  Conclusion
In this chapter we have briefly considered: different ways of thinking about, and
measuring, health inequalities; patterns and trends of health inequalities within
the UK; popular, empirically informed theories that aim to account for these
inequalities; and post-1997 policy responses to health inequalities in the UK.
All of this serves to highlight the complex and deeply political nature of health
inequalities (in both research and policy terms). The remainder of the first part
of this edited collection provides a range of perspectives on these issues from
leading international researchers, further highlighting the limits of the post-
1997 UK strategy and identifying potential ways forward for researchers and
policymakers. In different ways, each of the subsequent parts of this book con-
tributes to imagining what these ways forward might look like.

Notes
1 The slope index of inequality (SII) is a measure of absolute inequality, representing the
absolute difference in a particular health outcome (e.g. mortality) between different
population groups (e.g. people living in different deciles of deprivation). In graphical
terms, the SII can be thought of as the distance (‘height difference’) between the health
outcome in the least advantaged and the most advantaged population groups.
2 The relative index of inequality (RII) is a measure of relative inequality, representing the
relative difference in a particular health outcome (e.g. mortality) between the least advan-
taged and most advantaged population groups (e.g. the highest and lowest deciles of de-
privation). In graphical terms, the RII can be thought of as the percentage difference
(‘height ratio’) between the health outcome in the least advantaged and the most advan-
taged population groups.

References
Acheson, D. C. (1998) Independent Inquiry into Inequalities in Health. London: The Sta-
tionery Office.
Annandale, E., and Hunt, K. (2000) Gender inequalities in health: Research at the cross-
roads. In E. Annandale and K. Hunt (eds), Gender Inequalities in Health. Buckingham:
Open University Press, pp. 1–35.
Arber, S. (1991) Class, paid employment and family roles: Making sense of structural disad-
vantage, gender and health status. Social Science and Medicine, 32(4): 425–436.
Armitage, A. (1995) Comparing the Policy of Aboriginal Assimilation: Australia, Canada
and New Zealand. Vancouver: University of British Columbia Press.
Aspinall, P. J., and Song, M. (2013) Mixed Race Identities. Basingstoke: Palgrave
Macmillan.
Bambra, C. (2011) Work, Worklessness and the Political Economy of Health. Oxford:
­Oxford University Press.
Bambra, C., Fox, D., and Scott-Samuel, A. (2005) Towards a politics of health. Health Pro-
motion International, 20(2): 187–193.
 Conclusion 17

Bambra, C., Smith, K. E., Garthwaite, K., Joyce, K. E., and Hunter D. J. (2011) A labour of
Sisyphus? Public policy and health inequalities research from the Black and Acheson Re-
ports to the Marmot Review. Journal of Epidemiology and Community Health, 65(5):
399–406.
Barker, D. J. P. (1995) Fetal origins of coronary heart disease. British Medical Journal,
311(6998): 171.
Bartley, M. (2004) Health Inequality: An Introduction to Theories, Concepts and Methods.
Cambridge: Polity Press.
Bartley, M., Popay, J., and Plewis, I. (1992) Domestic conditions, paid employment and
women’s experience of ill-health. Sociology of Health and Illness, 14(3): 313–343.
Bauld, L., Day, P., and Judge, K. (2008) Off target: A critical review of setting goals for re-
ducing health inequalities in the United Kingdom. International Journal of Health Ser-
vices: Planning, Administration, Evaluation, 38(3): 439–454.
Beaglehole, R., and Bonita, R. (2004) Public Health at the Crossroads: Achievements and
Prospects (2nd edn). Cambridge: Cambridge University Press.
Beckfield, J., and Krieger, N. (2009) Epi + demos + cracy: Linking political systems and pri-
orities to the magnitude of health inequities—evidence, gaps, and a research agenda. Epi-
demiologic Reviews, 31: 152–177.
Birch, S. (1999) The 39 steps: The mystery of health inequalities in the UK. Health Econom-
ics, 8(4): 301–308.
Black, D., Morris, J. N., Smith, C., and Townsend, P. (1980) Inequalities in Health—Report
of a Research Working Group. London: Department of Health and Social Security.
Blackman, T. (2007) Statins, saving lives, and shibboleths. British Medical Journal,
334(7599): 902.
Blane, D. (2006) The life course, the social gradient, and health. In M. Marmot and
R. Wilkinson (eds), Social Determinants of Health. Oxford: Oxford University Press,
pp. 54–77.
Borchers, A. T., and Gershwin, M. E. (2012) Review: Sociological differences between
women and men. Autoimmunity, 11(6–7): A413–A421.
Brennenstuhl, S., Quesnel-Vallée, A., and McDonough, P. (2012) Welfare regimes, popu-
lation health and health inequalities: A research synthesis. Journal of Epidemiology and
Community Health, 66(5): 397–409.
Cabinet Office (1999) Modernising Government (White Paper). London: The Stationery
Office.
Chadwick, E. (1842) Report of an Enquiry into the Sanitary Conditions of the Labouring
Population of Great Britain. London: Poor Law Commission.
Chandola, T. (2001) Ethnic and class differences in health in relation to British South
Asians: Using the new National Statistics Socio-Economic Classification. Social Science
and Medicine, 52(8): 1285–1296.
Chaturvedi, N. (2001) Ethnicity as an epidemiological determinant—crudely racist or cru-
cially important? International Journal of Epidemiology, 30(5): 925–927.
Coburn, D. (2004) Beyond the income inequality hypothesis: Class, neo-liberalism, and
health inequalities. Social Science and Medicine, 58(1): 41–56.
Commission on the Social Determinants of Health (CSDH) (2008) Closing the Gap in a
Generation: Health Equity through Action on the Social Determinants of Health. Final
18 BACKGROUND & INTRODUCTION: UK EXPERIENCES

Report of the Commission on Social Determinants of Health. Geneva: World Health

Organization.
Cutler, D. M., Deaton, A. S., and Lleras-Muney, A. (2006) The determinants of mortality.
Journal of Economic Perspectives, 20(3): 97–120.
Davey Smith, G., Charsley, K., Lambert, H., Paul, S., Fenton, S., and Ahmad, W. (2000)
Ethnicity, health and the meaning of socio-economic position. In H. Graham (ed.),
Understanding Inequalities in Health. Buckingham: Open University Press, pp. 25–37.
Davey Smith, G., Dorling, D., and Shaw, M. (eds) (2001) Poverty, Inequality and Health in
Britain: 1800–2000—A Reader. Bristol: The Policy Press.
Davey Smith, G., Morris, J. N., and Shaw, M. (1998) The independent inquiry into inequal-
ities in health is welcome, but its recommendations are too cautious and vague. British
Medical Journal, 317(7171): 1465–1466.
Department of Health (1997) Press Release: Public Health Strategy Launched to Tackle the
Root Causes of Ill-health. London: Department of Health.
Department of Health (1999) Reducing Health Inequalities: An Action Report. London: The
Stationery Office.
De Vogli, R., Ferrie, J. E., Chandola, T., Kivimäki, M., and Marmot, M. G. (2008) Unfair-
ness and health: Evidence from the Whitehall II study. Journal of Epidemiology and Com-
munity Health, 61(6): 513–518.
Doyal, L., and Pennell, I. (1979) The Political Economy of Health. London: Pluto Press.
Galobardes, B., Shaw, M., Lawlor, D. A., Lynch, J. W., and Davey Smith, G. (2006) Indica-
tors of socioeconomic position (part 1). Journal of Epidemiology and Community Health,
60(1): 7–12.
Giesinger, I., Goldblatt, P., Howden-Chapman, P., Marmot, M., Kuh, D., and Brunner, E.
(2014) Association of socioeconomic position with smoking and mortality: The contribu-
tion of early life circumstances in the 1946 birth cohort. Journal of Epidemiology and
Community Health, 68(3): 275–279.
Goldthorpe, J. H. (2009) Analysing social inequality: A critique of two recent contributions
from economics and epidemiology. European Sociological Review. doi: 10/1093/esr/
jcp046.
Graham, H. (2009) The challenge of health inequalities. In H. Graham, Understanding
Health Inequalities. Maidenhead: Open University Press, pp. 1–21.
Graham, H. (2012) Smoking, stigma and social class. Journal of Social Policy, 41(1):
83–99.
Graham, H., and Kelly, M. P. (2004) Health Inequalities: Concepts, Frameworks and Policy.
London: HDA.
Grundy, E., and Holt, G. (2001) The socioeconomic status of older adults: How should we
measure it in studies of health inequalities? Journal of Epidemiology and Community
Health, 55(12): 895–904.
Hacking, J. M., Muller, S., and Buchan, I. E. (2011) Trends in mortality from 1965 to 2008
across the English north–south divide: Comparative observational study. British Medical
Journal, 342: d508.
Isaac, L. A. (2013) Defining health and health care disparities and examining disparities
across the lifespan. In T. A. LaVeist and L. A. Isaac (eds), Race, Ethnicity and Health: A
Public Health Reader (2nd edn). San Francisco: Jossey-Bass, pp. 11–31.
 Conclusion 19

Karlsen, S., and Nazroo, J. Y. (2007) Defining and measuring ethnicity and ‘race’: Theoret-
ical and conceptual issues for health and social care research. In J. Nazroo (ed.), Health
and Social Research in Multiethnic Societies. Abingdon: Routledge, pp. 20–38.
Katikireddi, S. V., Higgins, M., Smith, K. E., and Williams, G. (2013) Editorial: Health
­inequalities—the need to move beyond bad behaviours. Journal of Epidemiology and
Community Health, 67(9): 715–716.
Kawachi, I., Subramanian, S. V., and Almeida-Filho, N. (2002) A glossary for health in-
equalities. Journal of Epidemiology and Community Health, 56(9): 647–652.
Krieger, N., Rehkopf, D. H., Chen, J. T., Waterman, P. D., Marcelli, E., and Kennedy, M.
(2008) The fall and rise of US inequities in premature mortality: 1960–2002. PLoS Medi-
cine, 5: e46. doi: 10.1371/journal.pmed.0050046.
Krieger, N., Williams, D. R., and Moss, N. E. (1997) Measuring social class in US public
health research: Concepts, methodologies and guidelines. Annual Review of Public
Health, 18: 341–378.
Leyland, A. H. (2004) Increasing inequalities in premature mortality in Great Britain. Jour-
nal of Epidemiology and Community Health, 58(4): 296–302.
Lorenc, T., Petticrew, M., Welch, V., and Tugwell, P. (2012) What types of interventions
generate inequalities? Evidence from systematic reviews. Journal of Epidemiology and
Community Health. doi: 10.1136/jech–2012–201257.
Lynch, J. W., and Davey Smith, G. (2005) A life course approach to chronic disease epi-
demiology. Annual Review of Public Health, 26: 1–35.
Lynch, J. W., Davey Smith, G., Kaplan, G. A., and House, J. S. (2000) Income inequality
and mortality: Importance to health of individual income, psychosocial environment, or
material conditions? British Medical Journal, 320(7243): 1200–1204.
Lynch, J. W., and Kaplan, G. (2000) Socioeconomic position, Ch 2. In L. Berkman
and I. Kawachi (eds), Social Epidemiology. New York: Oxford University Press,
pp. 13–35.
Macintyre, S. (1997) The Black Report and beyond: What are the issues? Social Science and
Medicine, 44(6): 723–745.
Mackenbach, J. P. (2012) The persistence of health inequalities in modern welfare states:
The explanation of a paradox. Social Science and Medicine, 75(4): 761–769.
Mackenbach, J. P., Stirbu, I., Roskam, A-J. R., Schaap, M. M., Menvielle, G., Leinsalu, M.,
and Kunst, A. E. (2008) Socioeconomic inequalities in health in 22 European countries.
New England Journal of Medicine, 358(23): 2468–2481.
Marmot, M. (2004) The Status Syndrome: How Social Standing Affects Our Health and Lon-
gevity. New York: Times Books.
Marmot, M. (2006) Introduction. In M. Marmot and R. G. Wilkinson (eds), Social Deter-
minants of Health. Oxford: Oxford University Press, pp. 1–5.
Marmot, M. (2010) Strategic Review of Health Inequalities in England Post-2010. Marmot
Review Final Report. London: University College London.
Marmot, M., Bosma, H., Hemingway, H., Brunner, E., and Stansfeld, S. (1997) Contribu-
tion of job control and other risk factors to social variations in coronary heart disease in-
cidence. Lancet, 350(9073): 235–239.
Marmot, M., and Brunner, E. (2005) Cohort profile: The Whitehall II study. International
Journal of Epidemiology, 34(2): 251–256.
20 BACKGROUND & INTRODUCTION: UK EXPERIENCES

Marmot, M., Stansfeld, S., Patel, C., North, F., Head, J., White, I., Brunner, E., and
Feeney, A. (1991) Health inequalities among British civil servants—the Whitehall II
study. Lancet, 337(8754): 1387–1393.
McCartney G., Walsh, D., Whyte, B., and Collins, C. (2011) Has Scotland always been the
‘sick man’ of Europe? An observational study from 1855 to 2006. European Journal of
Public Health, 21(6): 1–5.
Meer, N. (2014) Race and Ethnicity. London: Sage.
Mok, P. L. H., Kapur, N., Windfuhr, K., Leyland, A.H., Appleby, L., Platt, S., and Webb,
R. T. (2012) Trends in national suicide rates for Scotland and for England and Wales,
1960–2008. British Journal of Psychiatry, 200(3): 245–251.
Muntaner, C., Borrell, C., Ng, E., Chung, H., Espelt, A., Rodriguez-Sanz, M., Benach, J.,
and O’Campo, P. (2011) Politics, welfare regimes, and population health: Controversies
and evidence. Sociology of Health and Illness, 33(6): 946–964. doi: 10.1111/j.1467–9566.
2011.01339.x.
National Audit Office (2010) Department of Health: Tackling Inequalities in Life Expect-
ancy in Areas with the Worst Health and Deprivation. London: The Stationery Office.
Navarro, V., Borrell, C., Benach, J., and Muntaner, C. (2003) The importance of the polit-
ical and the social in explaining mortality differentials among the countries of the OECD,
1950–1998. International Journal of Health Services Research, 33(3): 419–494.
Navarro, V., Muntaner, C., Borrell, C., and Benach, J. (2006) Politics and health outcomes.
Lancet, 368(9540): 1033–1037.
Nazroo, J. (2006) Health and Social Research in Multiethnic Societies. London: Routledge.
Norman, P., Boyle, P., Exeter, D., Feng, Z., and Popham, F. (2011) Rising premature mor-
tality in the UK’s persistently deprived areas: Only a Scottish phenomenon? Social Sci-
ence and Medicine, 73(11): 1575–1584.
Ostlin, P., George, A., and Sen, G. (2001) Gender, health, and equity: The intersections. In
T. Evans, M. Whitehead, F. Diderichsen, A. Bhuiya, and M. Wirth (eds), Challenging In-
equities in Health: From Ethics to Action. Oxford: Oxford University Press, pp. 174–189.
Popham, F., and Boyle, P. (2010) Assessing Socio-economic Inequalities in Mortality and
Other Health Outcomes at the Scottish National Level. Edinburgh: Scottish Collaboration
for Public Health Research and Policy.
Salomon, J. A., Wang, H., Freeman, M. K., Vos, T., Flaxman, A. D., Lopez, A. D., and
Murray, C. J. L. (2013) Healthy life expectancy for 187 countries, 1990–2010: A system-
atic analysis for the Global Burden Disease Study 2010. Lancet, 380(9859): 2144–2162.
Scambler, G., and Higgs, P. (1999) Stratification, class and health: Class relations and
health inequalities in high modernity. Sociology, 33(2): 275–296.
Scott-Samuel, A., Bambra, C., Collins, C., Hunter, D. J., McCartney, G., and Smith, K.
(2014) The impact of Thatcherism on health and wellbeing in Britain. International Jour-
nal of Health Services, 44(1): 53–71.
Secretary of State for Scotland (1999) Towards a Healthier Scotland—A White Paper on
Health. London: The Stationery Office.
Shaw, M., Dorling, D., and Davey Smith, G. (2002) Mortality and political climate: How
suicide rates have risen during periods of Conservative government, 1901–2000. Journal
of Epidemiology and Community Health, 56(10): 722–727.
Smith, K. E. (2013) Beyond Evidence-based Policy in Public Health: The Interplay of Ideas.
Basingstoke: Palgrave Macmillan.
 Conclusion 21

Smith, K. E., Hunter, D. J., Blackman, T., Williams, G., McKee, L., Harrington, B., Elliott,
E., Marks, L., and Greene, A. (2009) Divergence or convergence? Health inequalities and
policy in a devolved Britain. Critical Social Policy, 29(2): 216–242.
Smith, K. E., and Kandlik Eltanani, M. (2014) What kinds of policies to reduce health in-
equalities in the UK do researchers support? Journal of Public Health, 37(1): 6–17. Online
first. doi: 10.1093/pubmed/fdu057.
Susser, M., Watson, W., and Hopper, K. (1985) Sociology in Medicine. New York: Oxford
University Press.
Thomas, S. B. (2013) The color line. Ch 2. In T. A. LaVeist and L. A. Isaac (eds), Race, Eth-
nicity and Health: A Public Health Reader (2nd edn). San Francisco: Jossey-Bass,
pp. 35–40.
Thomas, B., Dorling, D., and Davey Smith, G. (2007) Inequalities in premature mortality
in Britain: Observational study from 1921 to 2007. British Medical Journal, 341: c3639.
Tunstall, R., and Lupton, R. (2003) Is Targeting Deprived Areas an Effective Means to Reach
Poor People? An Assessment of One Rationale for Area-based Funding Programmes. Lon-
don: Centre for Analysis of Social Exclusion (CASE), LSE: Paper 37.
Walby, S., Armstrong, S., and Strid, S. (2012) Intersectionality: Multiple inequalities in so-
cial theory. Sociology, 46(2): 224–240.
Weiss, C. (1979) The many meanings of research utilization. Public Administration Review,
39: 426–431.
Whitehead, M. (1987) The Health Divide: Inequalities in Health in the 1980s. London:
Health Education Authority.
Whitehead, M. (2007) A typology of actions to tackle inequalities in health. Journal of Epi-
demiology and Community Health, 61: 473–478.
WHO (World Health Organization) (2012) Health for All Database. Geneva: WHO.
Whyte, B., and Ajetunmobi, T. (2012) Still the ‘Sick Man of Europe’? Scottish Mortality in a
European Context 1950–2010. An Analysis of Comparative Mortality Trends. Glasgow:
Glasgow Centre for Population Health.
Wilkinson, R. (2005) The Impact of Inequality—How to Make Sick Societies Healthier. New
York, USA: The New Press.
Wilkinson, R., and Pickett, K. (2009) The Spirit Level: Why More Equal Societies Almost Al-
ways Do Better. London: Penguin.
Williams, D. R. (1997) Race and health: Basic questions, emerging directions. Annals of
Epidemiology, 7(5): 322–333.
 Chapter 2

Reflections on the legacy

of British health inequalities
research
Mel Bartley and David Blane

2.1  Introduction: Social class health differences

in Britain
The present short chapter is confined largely to social class differences in mor-
tality and rests heavily on decennial supplement and Office for National Statis-
tics Longitudinal Study (ONS-LS) findings; the reader interested in other
aspects of health inequalities research (gender, ethnicity, area, international,
morbidity, health, physiological status, special surveys) is directed to Chapter 7
of this book and, for more detail, to Bartley’s introductory text (Bartley 2003).
Social class differences in mortality are the bedrock of health inequalities re-
search in the UK. These differences in mortality are quite large. Among men of
working age in England and Wales in 2008–10 the mortality rate of the most
disadvantaged social class (NS-SEC 7: routine workers) was 3.6 times higher
than that of the most advantaged social class (NS-SEC 1: higher managerial and
professional workers); NS-SEC social class 7: 458 deaths per 100,000, NS-SEC
social class 1: 128 deaths per 100,000 (ONS 2012, Figure 1). Other characteris-
tics of social class differences in mortality include: (1) being present at all ages
from stillbirths to old age; (2) being found among both women and men; (3)
being found for all but one of the most prevalent causes of death; and (4) being
graded across the whole class structure, with the highest rate among the most
disadvantaged, the lowest rate among the most advantaged, and in-between a
stepwise fall in mortality risk. Two other characteristics are noteworthy: first,
social class differences in mortality have been described in England for some
180 years, having survived the transition from infectious diseases to chronic
degenerative diseases; second, over this period, class differences in mortality
have been maintained against a background of falling population-wide mortal-
ity rates. The mortality rate of the most disadvantaged social class eventually
 Before and after the Black Report 23

falls to the level of the most advantaged class, typically with a lag of some 20 to
30 years, by which time the latter has pulled further ahead.
Such phenomena are difficult to ignore. Early observations include Graunt’s
analyses of Bills of Mortality in the seventeenth century, sixteenth-century de-
scriptions of occupational diseases by Vesalius and Paracelsus, and perhaps,
even earlier, some medieval Danse Macabre. The first explicitly social class ana-
lyses date from the 1840s, when Chadwick (1842) and Engels (1845) compared
gentry and professional persons and their families with tradesmen and farmers
and their families and mechanics, servants, and labourers and their families.
Their finding of sizeable differences in mortality risk between these three social
class groups was challenged on methodological grounds by Neison, who con-
cluded there was no convincing evidence that squalor was harmful to health,
although he did concede it could be aesthetically displeasing (Neison 1844).
Health inequalities research during the second half of the nineteenth century
used as their yardstick healthy areas with the lowest mortality rates, against
which to measure the mortality disadvantage of the rest of the population. It
was not until the early twentieth century that social class re-emerged when the
Registrar General’s classification, assigning occupations to social classes, was
introduced into official statistics including decennial censuses and death regis-
tration (Stevenson 1923). The Registrar General’s classification remained in
use, with some modifications, from the decennial censuses of 1921 to 1991. At
each census a sample of returns was linked to death registration to estimate so-
cial class differences in mortality, which were published, usually several years
after the census, as the decennial supplements on occupational mortality.
At the start of the twenty-first century two innovations were introduced. The
Registrar General’s classification was replaced in official statistics by the Na-
tional Statistics Socio-Economic Classification (NS-SEC), which, unlike its pre-
decessor, has an explicit theoretical basis (employment relations and conditions)
and empirical validity (Rose and Pevalin 2003). Second, social class differences
in mortality increasingly were estimated from the ONS-LS, rather than the pre-
vious method of matching decennial census returns with death registrations
(the ONS-LS is a 1% sample of the population of England and Wales, some half
a million people, linked through their census returns of 1971, 1981, 1991, 2001,
and 2011).

2.2  Before and after the Black Report

Some idea of pre-Black Report thinking about health inequalities can be gained
from Sir John Brotherston’s 1975 Galton Lecture to the Eugenics Society, which
examined five mechanisms contributing to inequalities in health. Only one of
24 LEGACY OF BRITISH HEALTH INEQUALITIES RESEARCH

these involved possible causal pathways (biological effects of deprivation); the

bulk of the lecture was given over to methodological problems and selection
processes (Brotherston 1975). The dominant questions were: what proportion
of social class differences in health are due to measurement artefact; and what
proportion due to reverse causation (selection of healthy people into advan-
taged social classes)?
Such thinking provided part of the scientific context of the Black Report
(Black et al 1980); others were the concurrent preparation of the 1971 census’
decennial supplement on occupational mortality (Office for Population Cen-
suses and Surveys (OPCS) 1978) and the membership of the research working
group tasked by the Secretary of State for Health and Social Security to report
on health inequalities. Of particular importance scientifically was the member-
ship of a distinguished epidemiologist and public health physician (Morris) and
a distinguished sociologist and social policy analyst (Townsend), who were
supported formally by an early career sociologist (Hart 1978) and informally by
the decennial supplement’s author.
The Report had two main effects: first, it drew public attention to inequalities
in health; and second, it provided a conceptual framework to guide subsequent
research. The first of these was the result of poor handling by a new government
which used standard techniques to minimize the Report’s impact, without giv-
ing due weight to both the social policy skills of one of the Report’s members
and the unpopularity of a government de-industrializing Britain (see Chap-
ter 9). Government attempts to suppress the Black Report became a political
scandal, with reducing health inequalities adopted as a policy by the main op-
position political party and the nation’s trade union movement. A few years
later, with similar motives but somewhat greater finesse, the same government
buried the 1981 decennial supplement by publishing it as microfiche tables,
with a dismissive assessment of any findings based on the Registrar General’s
classification.
The Black Report suggested four possible explanations of the relationship be-
tween social class and health (artefact, natural or social selection, materialist or
structural, and cultural–behavioural), thereby providing a framework for fu-
ture research. The results of this follow-up research were clear-cut. The relation-
ship was real, with little evidence of it being produced by measurement artefact.
The direction of the relationship was primarily from social class to health, with
little evidence of it being created by health selection into advantaged social
classes. In other words, the relationship was primarily causal, through social
class differences in either material circumstances or behaviours (Fox et al 1985;
Goldblatt 1990; Wilkinson 1986). Also important scientifically were concurrent
updatings (Goldblatt 1989; Whitehead 1987) and regional reports (Crofton
 Before and after the Black Report 25

1988; Phillimore 1989). The remaining explanations, and more recent develop-
ments, are briefly outlined in Chapter 1.

2.2.1  The Acheson Report

Such evidence continued to accumulate into the early 1990s (Filakti and Fox
1995; Harding 1995; Kuh and Wadsworth 1993; Phillimore et al 1994). Al-
though nothing was said on record, the Department of Health behaved as
though it had started contingency planning for the election of a Labour govern-
ment which, among other things, would want to reduce inequalities in health.
Sir Donald Acheson, a former Chief Medical Officer for England, attached him-
self to a medical charity working on policies to reduce health inequalities (Ben-
zeval et al 1995). One of the Department’s senior civil servants consulted
academic researchers about possible policy initiatives (DoH 1995), and the De-
partment’s reviews unit in York investigated the effectiveness of relevant policy
interventions (Arblaster et al 1995). As a result, when a Labour government was
formed after the 1997 general election, the Department of Health had in place a
feasible mechanism for implementing the new government’s policy commit-
ment to reducing health inequalities.
Sir Donald Acheson was invited to chair the independent inquiry into in-
equalities in health (see also Chapter 1). His work benefited from scientific re-
search during the nearly two decades since the Black Report, work which
showed he should concentrate on causation (i.e. assessing how social class af-
fects health rather than considering the possibilities that artefact or social selec-
tion might explain patterns of health inequalities). It benefited also from the
concurrent publication of the 1991 census decennial supplement which, with
considerable originality, documented the multifaceted nature of health in-
equalities (Drever and Whitehead 1997). Acheson’s briefing included advice
that his report should not include financial costings, on the grounds that the
cost of implementing its recommendations probably would have forced a re-
elected Labour government in 1979 to also reject the Black Report. Acheson
selected as members of his inquiry team mostly academics with distinguished
records in the areas of, respectively, birth weight, clinical services, gender, psy-
chosocial factors, and public health, plus three high-quality support staff. Nu-
merous researchers were invited to submit written evidence on a specified topic
and answer the inquiry’s questions. Later, after publication of the Acheson Re-
port (Acheson et al 1998), these submissions were published independently
(Gordon et al 1999).
Acheson consulted with government departments about any suggestions
deemed plausible, in order to eliminate the impractical and unacceptable. One
of the present authors (David Blane) was involved in one such consultation at
26 LEGACY OF BRITISH HEALTH INEQUALITIES RESEARCH

which the Department for Transport responded to the suggestion from Ache-
son, supported by the Royal Society for the Prevention of Accidents, that com-
mercial vehicle use of the public highway should be subject to health and safety
legislation. The argument was simple: roads are one of the few places where the
worlds of work and domesticity mingle on an unregulated basis; most serious
road accidents are industrial accidents, although not recognized as such, be-
cause most victims are pedestrians, cyclists, and motorcyclists, who predomin-
antly are workers hit by apparently commercial vehicles; and applying health
and safety legislation to commercial vehicles offers the possibility of a quick
reduction in health inequalities. The Department for Transport found the sug-
gestion unacceptable on the basis that it would hamper business; equally un-
acceptable was an interim compromise proposal that the police record whether
a serious traffic accident involved a commercial vehicle (the response was that
‘the police are too busy’).
At the end of these consultations, the Acheson Report made 39 main recom-
mendations to reduce health inequalities at all stages of the life course (with 143
sub-recommendations). There were three over-arching recommendations
(covering health inequality impact assessment, the health of families and chil-
dren, and income inequality) and a general suggestion that effective action
would require inter-departmental co-operation across government (health in-
equalities are not due significantly to variation in access to medical care, so they
are not solely or even primarily the responsibility of the Department of Health).
As advised, the recommendations were not costed.
The government welcomed the Acheson Report and established a cabinet
sub-committee to coordinate cross-government initiatives which, perhaps
ominously, acted administratively via the Department of Health (DoH
1999). Acheson responded to criticism of the absence from his report of
costings (Black et al 1999) by saying he would monitor government delivery.
Among other things, he obtained from government a commitment to meet
specific targets for inequality reductions in infant mortality and life expect-
ancy (initially considered over-modest, in the context of the difficulties in
meeting them, these targets are now often described as aspirational), and,
from the Joseph Rowntree Foundation, funding to monitor implementation
and progress.
The then Chancellor of the Exchequer, Gordon Brown, supported Acheson
with a budget whose balance of tax and benefits was designed to counteract the
health inequality gradient, by funding Sure Start centres for mothers and chil-
dren in deprived areas (see Chapter 1), and by encouraging initiatives in other
government departments (HM Treasury 2002). Within a year, every spending
department in Whitehall was able to give the Joseph Rowntree researcher
 Policy implications 27

v­ oluminous documentation of its ideas for contributing to a reduction of in-

equalities in health (Exworthy et al 2003).
A range of reforms followed including: free bus travel for retired people, to
enhance resilience against the adversities of ageing by maintaining social net-
works and social participation; working tax credits, to address financial depriv-
ation among the families of low-paid workers; and financial benefits, to enable
working-class adolescents to remain in full-time education beyond the min-
imum school leaving age. The Marmot Review (Marmot et al 2010; see Chap-
ter 1), with its core policy that everyone should have the minimum income for
healthy living, built on these improvements and consolidated support for them.
The subsequent failure of social class difference in mortality to narrow (ONS
2012; White et al 2007), despite unusually favourable circumstances post-­
Acheson, suggests that health inequalities require long-term consistent policies
and recognition of countervailing influences. The Report’s first over-arching
recommendation was never implemented. Sure Start’s initial focus on finan-
cially deprived areas was diluted subsequently with its spread into more affluent
areas. Many targeted benefits were reduced by post-2008 austerity. The counter-
gradient budgets were no match for growing inequality of pre-tax incomes. Job
security, insecure employment, and wages and salaries all deteriorated with
growing austerity. Where health is concerned, apart from preventing accidents,
it seems there are no quick fixes—as a life course perspective (see Chapter 1)
would suggest.

2.3  Policy implications

The preceding brief chronology prompts a few thoughts, the first being the im-
portance to public health of cumulative innovation. The creation of a national
system of death registration in 1837, the creation of a method of assigning oc-
cupations to social classes in 1911, and the creation of a large, nationally repre-
sentative linked-register longitudinal study in 1971 provided the infrastructure
for the study of social class difference in mortality. These are public health’s
equivalent of the microbiologist’s microscope, dyes, and petri dishes: tools that
give sight of things which are too small or too large for the human eye.
Each component evolved over time. The registration of deaths became more
complete during its first two decades. The Registrar General’s classification was
modified repeatedly, to take account of occupational change, and replaced at
the 2001 census by a theoretically based and empirically validated scheme (NS-
SEC)—sadly, the promised dual coding (to link the new approach with the pre-
vious ones) never materialized, thereby breaking a unique historical series (the
decision to publish electronically, without a printed decennial supplement, had
28 LEGACY OF BRITISH HEALTH INEQUALITIES RESEARCH

a similar effect). Contemporary threats to the decennial census, and thereby the
ONS-LS, if implemented, would blind public health to one of the main struc-
tural influences on mortality.
Second, it is noticeable that in both the late 1970s and the late 1990s two ap-
parently independent events occurred close together: publication of a decen-
nial supplement on occupational mortality and publication of the report of an
inquiry into inequalities in health. The schedule for publication of decennial
supplements is long established, but is it a coincidence that on both occasions a
Labour government commissioned an inquiry to report around the same time?
It is often assumed that people tend to equate health with health services and
that the social determinants of health are of minor interest to most people. In
future, rather than accepting this assumption, perhaps the processes which
produce it should be investigated.
Third, perhaps the Acheson Report was the result of the poor handling of the
Black Report, in the same way that the Second World War was the result of the
poor peace treaty at the end of the First World War. Certainly the civil service
seems to have been more involved. Unlike Sir Douglas Black, who was a mem-
ber of an independent profession and president of a royal college smarting from
loss of teaching hospital funds under the resource allocation working party for-
mula, Donald Acheson was a civil service insider who had received a crash
course in health inequalities and two NHS reviews before being invited to chair
the inquiry. None of Black’s working party was a member of Acheson’s inquiry,
who, with one possible exception, lacked Peter Townsend’s social policy experi-
ence and expertise. Unlike Black’s recommendations, which were few and
costed, Acheson’s resulted from extensive consultations with government, so
their different reception was unsurprising.
In the absence of civil service guidance, how might health inequality re-
searchers proceed? One possibility is to collaborate with social policy analysts
to gain better understanding of the social policy process (as discussed in Chap-
ter 19). In retrospect, most of the researchers who gave evidence to the Acheson
Inquiry had probably never heard of a ‘policy window’ (see Chapter 19)—cer-
tainly they failed to recognize and make best use of the one which opened in
1997—nor were they prepared for how quickly such windows close. How often
is a new government elected that is committed through circumstances and
choice to reducing health inequalities, with a cabinet sub-committee to drive
cross-government initiatives and a Chancellor of the Exchequer who is sup-
portive, despite budget constraints? Maybe once or twice in a lifetime? The evi-
dence submitted to the Acheson Inquiry, as published (Gordon et al 1999),
indicates that researchers gave evidence based on their own and close collabo-
rators’ work, mostly without consulting their wider research community. There
 Research 29

was no evidence that health inequality researchers collectively had reached a

scientific consensus around a small number of changes which could be de-
livered in circumstances of budget constraint (see Chapter 1). Equally, there
was no evidence that researchers were conscious that the impact of their work
would be enhanced through alliances with relevant Third Sector organizations
and media personnel (see Chapter 19).
Many health inequality researchers belatedly realized their mistake, the most
energetic of whom turned seriously to mobilizing non-academic public sup-
port. Richard Wilkinson and Kate Pickett founded The Equality Trust to draw
attention to the health, educational, and wider social effects of increasing in-
come inequality (see Chapter 20 for their personal reflections on stepping out-
side of academic to develop this initiative). And Sir Michael Marmot led a series
of reviews worldwide to document the ways in which social fairness and justice
enhance population good health, gathering support for a programme of pol-
icies to eliminate disadvantage in the social determinants of health (e.g. Mar-
mot et al 2010).

2.4  Research
Research challenges to be addressed also remain. As mentioned earlier, health
inequalities research might benefit from taking a more life course perspective
(see Chapter 1). If health inequalities result from accumulation and interaction
across the life course of a succession of biologically plausible hazards, each with
a modest impact on its own, then the cause of health inequalities is the social
structure’s tendency to ensure that an individual is exposed to either a succes-
sion of health hazards or a succession of health benefits. This explanatory model
raises a number of questions, including: is it true? and how can it be tested?. It is
possible to demonstrate from existing datasets that social advantages or disad-
vantages tend to accumulate over the life course when the accumulation in
these datasets occurs at the level of social categories like social class, manual
employment, or family structure, rather than biologically plausible hazards
such as a cold residence, asbestos dust exposure, or family conflict.
So one research challenge is how to bring together social and biological plausi-
bility in longitudinal studies. Three things might be worth considering. First,
bring together biology and social history in the interpretation of birth cohort
study data to identify the prevailing social conditions in which each biological
stage of that cohort’s life course was lived, including the extent to which these
social conditions varied by social class. Second, give greater attention to the re-
lationship between health inequalities and secular change in longevity: how did
health inequalities during the past century-and-a-half survive the transition
30 LEGACY OF BRITISH HEALTH INEQUALITIES RESEARCH

from infectious to chronic disease?; which social processes drive the 20–30-year
lag between the mortality rates of the most and least socially advantaged?; are
inequalities in health created by the same social processes which have delivered
a fall of two-thirds in middle-age mortality since 1970, with a proportionately
similar reduction in all of the most prevalent causes of death? Third, make better
analytic use of international comparisons (see also Chapter 6): an increasing
number of countries are developing longitudinal studies, but these studies are
an under-used resource in health inequalities research (Banks et al 2006 is a not-
able exception); the choice of which countries to compare can be made analyti-
cally, by welfare state regime (Harding et al 2013) or cultural differences free of
confounding by differences in standard of living (Sekine et al 2011).
Public health is the poorer for neglecting such opportunities (see also Chap-
ter 8). Professor J. N. Morris always was puzzled by the failure of public health
to make a significant and independent contribution to debates about the level of
the national minimum wage, which was why, in his nineties, he started a new
programme of research to calculate the minimum income for healthy living.
His reasoning was simple: 50 years of research worldwide had identified the
components required to sustain health, and in the absence of an income which
could buy those components at current prices, it was inappropriate to tell peo-
ple how to live healthily (see Chapters 8, 16, and 17). As an example of research
challenges, a method of estimating the proportion of the life course spent below
the minimum income for healthy living is needed, in order to investigate how it
relates to mortality risk and to social class differences in health.

2.5  Summary and conclusions: Future directions

for health inequalities work
Reflecting on the legacy to date of health inequalities research in the UK suggests
a number of promising lines of future work. Health inequality researchers might
well benefit from building links within the university to departments of social
policy and outside the university to policymakers, third-sector (civil society)
organizations, and media personnel (as discussed further in Chapter  19). In
terms of traditional research, health inequality researchers might benefit from
greater inter-disciplinarity, through building links with biologists, social histori-
ans, and quantitative analysts of national and international longitudinal studies.

References
Acheson, D., Barker, D., Chambers, J., Graham, H., Marmot, M., and Whitehead, M.
(1998) Independent Inquiry into Inequalities in Health (Acheson Report). London: The
Stationery Office.
 FUTURE DIRECTIONS FOR HEALTH INEQUALITIES WORK 31

Arblaster, L., Entwistle, V., Lambert, M., Forster, M., Sheldon, T., and Watt, I. (1995) Re-
view of the Research on the Effectiveness of Health Service Interventions to Reduce Varia-
tions in Health. York: University of York, NHS Centre for Reviews and Disseminations.
Banks, J., Marmot, M., Oldfield, Z., and Smith, J. (2006) Disease and disadvantage in the
United States and England. Journal of the American Medical Association, 295(17):
2037–2045.
Bartley, M. (2003) Health Inequalities: Concepts, Methods, Findings. Bristol: Polity Press.
Benzeval, M., Judge, K., and Whitehead, M. (eds) Tackling Inequalities in Health: An
Agenda for Action. London: King’s Fund.
Black, D., Morris, J. N., Smith, C., and Townsend, P. (1980) Inequalities in Health: Report
of a Research Working Group (Black Report). London: Department of Health and Social
Security.
Black, D., Morris, J. N., Smith, C., and Townsend, P. (1999) Better benefits for health: Plan
to implement the central recommendation of the Acheson Report. British Medical Jour-
nal, 318: 724–727.
Brotherston, J. (1976) The Galton Lecture 1975: Inequality, is it inevitable? In C. Carter
and J. Peel (eds), Equalities and Inequalities in Health. London: Academic Press,
pp. 73–104.
Chadwick, E. (1965) (ed. M. Flinn) Report on the Sanitary Condition of the Labouring Popu-
lation of Great Britain 1842. Edinburgh: Edinburgh University Press.
Crofton, J. (ed.) (1988) Health Promotion in Areas of Multiple Deprivation. Edinburgh:
Scottish Health Education Group.
Department of Health (DoH) (1995) Variations in Health: What Can the Department of
Health and the NHS Do? (Metters Report). London: Department of Health.
Department of Health (DoH) (1999) Reducing Health Inequalities: An Action Plan. Lon-
don: Department of Health.
Drever, F. and Whitehead, M. (eds) (1997) Health Inequalities: Decennial Supplement.
London: The Stationery Office.
Engels, F. (1845) The Condition of the Working Class in England 1844. London: Granada.
Exworthy, M., Stuart, M., Blane, D., and Marmot, M. (2003) Tackling Health Inequalities
since the Acheson Inquiry. Bristol: Policy Press.
Filakti, H. and Fox, J. (1995) Differences in mortality by housing tenure and by car access
from the OPCS Longitudinal Study. Population Trends, 81: 27–30.
Fox, J., Goldblatt, P., and Jones, D. (1985) Social class mortality differentials: Artefact, se-
lection or life circumstances? Journal of Epidemiology and Community Health, 39: 1–8.
Goldblatt, P. (1989) Mortality by social class 1971–1985. Population Trends, 56: 6–15.
Goldblatt, P. (1990) Mortality and Social Organisation, Longitudinal Study 1971–1981. LS
series no. 6. London: HMSO.
Gordon, D., Shaw, M., Dorling, D., and Davey Smith, G. (1999) Inequalities in Health: Evi-
dence Presented to the Independent Inquiry into Inequalities in Health, Chaired by Sir
Donald Acheson. Bristol: Policy Press.
Harding, S. (1995) Social class differences in mortality of men: Recent evidence from the
OPCS Longitudinal Study. Population Trends, 80: 31–37.
Harding, S., Lenguerrand, E., Costa, G., d’Errico, A., Martikainen, P., Tarkiainen, L.,
Blane, D., Akinwale, B., and Bartley, M. (2013) Trends in mortality by labour market
32 LEGACY OF BRITISH HEALTH INEQUALITIES RESEARCH

position around retirement ages in three European countries with different welfare re-
gimes. International Journal of Public Health, 58: 99–108.
Hart, N. (1978) Health and Inequality. Essex: University of Essex, Department of Sociology.
HM Treasury (2002) Tackling Health Inequalities: Summary of the 2002 Cross-cutting Re-
view. London: Department of Health.
Kuh, D. and Wadsworth, M. (1993) Physical health status at 36 years in a British national
birth cohort. Social Science and Medicine, 37: 905–916.
Marmot, M., Allen, J., Goldblatt, P., Boyce, T., McNeish, D., Grady, M., and Geddes, I.
(2010) Fair Society, Healthy Lives. London: The Marmot Review.
Neison, F. (1844) On the method recently proposed for conducting inquiries into the com-
parative sanitary conditions of various districts, with illustrations derived from numer-
ous places in Great Britain at the period of the last census. Quarterly Journal of the
Statistical Society of London, 7: 40–68.
Office for National Statistics (ONS) (2012) Intercensal mortality rates by NS-SEC 2001–2010.
ONS Statistical Bulletin, available at: http://www.ons.gov.uk.
Office for Population Censuses and Surveys (OPCS) (1978) Occupational Mortality Decen-
nial Supplement, England and Wales 1970–1972. London: HMSO.
Phillimore, P. (1989) Shortened Lives: Premature Death in North Tyneside. Bristol: Univer-
sity of Bristol, Department of Applied Social Studies.
Phillimore, P., Beattie, A., and Townsend, P. (1994) Widening inequality of health in
northern England, 1981–1991. British Medical Journal, 308: 1125–1128.
Rose, D. and Pevalin, D. (2003) A Researcher’s Guide to the National Statistics Socio-­
Economic Classification. London: Sage.
Sekine, M., Tatsuse, T., Kagamimori, S., Chandola, T., Cable, N., Marmot, M., Marti-
kainen, P., Lallukka, T., Rahkonen, O., and Lahelma, E. (2011) Sex inequality of phys-
ical and mental functioning of British, Finnish and Japanese civil servants: Role of job
demand, control and work hours. Social Science and Medicine, 73: 595–603.
Stevenson, T. (1923) The social distribution of mortality from different causes in England
and Wales, 1910–1912. Biometrika, XV: 382–400.
White, C., Glickman, M., Johnson, B., and Corbin, T. (2007) Social inequalities in adult
male mortality by the National Statistics Socio-Economic Classification, England and
Wales, 2001–2003. Health Statistics Quarterly, 36: 6–22.
Whitehead, M. (1987) The Health Divide: Inequalities in Health in the 1980s. London:
Health Education Council.
Wilkinson, R. (ed.) (1986) Class and Health: Research and Longitudinal Data. London:
Tavistock.
 Chapter 3

Nordic health inequalities:

Patterns, trends, and policies
Espen Dahl and Kjetil A. van der Wel

3.1  Introduction to Nordic health inequalities

Norway, along with the other Nordic countries, has health inequalities compar-
able with other West European countries (Lundberg et al 2012). Although poli-
ticians knew this already in the 1990s (Dahl 2002, p. 70) after Mackenbach and
collaborators (1997) published their influential paper,1 the topic did not receive
substantial political attention in Norway until 2002. Five years later, in 2007, the
so-called ‘Red/Green’ Government led by the social-democratic Labour Party
introduced a comprehensive strategy to reduce social inequalities in health.
Since then, Norway has had a quite ambitious policy in place to tackle health
inequalities. Partly as a result of the Rio declaration on social determinants of
health, which was also signed by Norway, a Norwegian version of the ‘Marmot
Review’ (see Chapters 1 and 2) was launched in March 2014 (Dahl et al 2014).
Among other things, the Norwegian review assessed the national strategy to
reduce health inequalities. In this chapter, we present and discuss the Norwe-
gian strategy and compare it to the strategies of Sweden, Denmark, Finland,
and England.

3.2  The Norwegian background

In comparative perspective, Norway is a rather egalitarian society, characterized
by limited social inequalities and generous and universally provided welfare ar-
rangements (Esping-Andersen 1990). Generous out-of-work benefits also mute
inequalities in wages because they allocate bargaining power to low-paid work-
ers (Barth and Moene 2009). Free education and accessible and cheap childcare,
health services, elderly care, and other family services justify labels such as the
‘social service state’. Further support for such a notion is the extensive use of dif-
ferent forms of expensive training and activation regimes, known as active
­labour market policies (ALMP), to (re)integrate public benefit recipients into
the labour market. Although many welfare reforms have been carried out
34 Nordic health inequalities

over the last 25 years, the level of welfare provision has not yet been actively cut
back and services have expanded steadily (Halvorsen and Stjernø 2008, p. 24).
In terms of achieving welfare for its citizens, Norway seems to be doing reason-
ably well. In comparative perspective, poverty rates and unemployment rates are
persistently low (Fritzell et al 2012; Hussain et al 2012). Yet income inequality, as
measured by the Gini-index, rose from the 1990s until mid-2000 to remain stable
around 0.24 up to now.2 Social participation and employment is high (Saltkjel
et al 2013; van der Wel et al 2011), and particularly so among women, the elderly,
and low education groups and those who report long-standing limiting illnesses
(van der Wel et al 2012). Recent studies also document that working conditions
in general, particularly psychosocial indicators, are favourable (Bambra 2011a).
The Black Report, the Acheson Report, and the Marmot Review all advocate
policy responses to health inequalities that should imply that the Norwegian
society would perform quite well also in the domain of health inequalities. Such
advice includes abolishing poverty (the Black Report), reducing income in-
equality (the Acheson and Marmot Reports), and implementing progressive
taxation (the Marmot Review) (Bambra et al 2011, p. 104). All three reports also
emphasize early years and preschool childcare, areas in which social policy in
Norway has been in place for more than three decades. Important examples are
the generous parental leave schemes and subsidized childcare for children aged
1 to 6 years, although ‘full’ coverage was only obtained recently. Even if Norway
did not adopt an explicit policy for the reduction of health inequalities until
2007, for many years, at least judged by the advice of the three British reports on
health inequality, it had apparently been doing the ‘right thing’.
Yet, inequalities in mortality have been rising ever since the 1960s (Stein-
grímsdóttir et al 2012) (see Figure 3.1), and have remained at a rather average
level in European comparisons (Lundberg et al 2012). Because it might be in-
ferred from the social determinant of health perspective that increased wealth
and the expansion of the welfare state would imply a reduction in health in-
equality and smaller health inequalities in Norway than elsewhere, this has
come to be known as a ‘paradox’ (Mackenbach 2012) or a ‘public health puzzle’
(Bambra 2011b). In our concluding discussion, we will return to this issue re-
garding the situation in Norway, questioning whether we have in fact been
doing the ‘right thing’.

3.3  National strategies to reduce health inequalities

As discussed in Section  3.2, Norway was a laggard in developing a political
strategy to address health inequalities. Key policy documents through the
1990s seldom mentioned health inequalities and never addressed them directly
 Men

52

50

48

46

44

42

40
Years

38
19

19

19

19

19

19

19

19

19

20

20

20
19

65

69

73

77

81

85

89

93

97

01

05

09
61

Primary education Secondary education

Tertiary education

Women

52

50

48

46

44

42

40
Years

38
19

19

19

19

19

19

19

19

19

20

20

20
19

65

69

73

77

81

85

89

93

97

01

05

09
61

Primary education Secondary education

Tertiary education
Fig. 3.1 Life expectancy at age 35 by educational level. Men and women.
Reproduced from Steingrímsdóttir, O.A. et al, Trends in life expectancy by education in Norway
1961–2009, European Journal of Epidemiology, Volume 27, Issue 3, pp. 163–171, Copyright ©
2012 Springer + Business Media B. V. 2012, with kind permission from Springer Science and Busi-
ness Media.
36 Nordic health inequalities

by policy measures (Dahl 2002). Often, health inequality was reduced to a

problem of marginalization and poverty (Dahl 2002, p. 73), i.e. perceived as a
dichotomy rather than a gradient. It was not before 2002 that the topic became
a high-priority political issue (Norwegian Ministry of Health 2003). That year,
the non-socialist coalition government, which came into power in 2001,
launched a white paper that explicitly set the reduction of social inequalities in
health as a goal for public health policy. The white paper also clearly acknow-
ledged health disparities as a social phenomenon, rather than something dom-
inantly individual (p.  43) that needed to be addressed by social policy and
health policy. The white paper declared:
It is a matter of unfairness when people from low social positions with few advan-
tages and resources also bear a heavier burden of pain and disease, and have lower
functioning and shorter life expectancy. Social inequalities in health must also be
taken seriously because health is a central precondition for participation in society
as well as social participation more broadly.
Reproduced from Norwegian Ministry of Health 2003, Resept for et sunnere
Norge: Folkehelsepolitikken, Statens forvaltningstjeneste, Oslo,
Norway, © 2003, Statens forvaltningstjeneste

Although the white paper had a rather limited action plan regarding health in-
equalities, it sketched out a number of potential areas for policy interventions,
such as improving conditions for children in deprived areas, free school meals
and fruit, cheaper child care, and improving working conditions.
However, only after a new coalition government headed by the Labour Party
came into office in 2005 was an elaborate strategic plan for reducing health in-
equalities eventually produced. At the time of the release of the strategy (Nor-
wegian Ministry of Health and Care Services 2007), then Minister of Health
stated in a press release:
We have to acknowledge that we live in a stratified society, where the most privil-
eged people, in economic terms, have the best health. These inequalities in health
are socially determined, unfair and modifiable. The government has therefore de-
cided to initiate a broad, long-term strategy to reduce social inequalities in
health. . . . A fair distribution is good public health policy. The Norwegian policy
will continue to build on the Nordic tradition of general welfare schemes and at the
same time implement special measures to help the people with the most
problems.
Reproduced from Report 20 (2006–2007) to the Storting, ‘National strategy
to reduce social inequalities in health’, Norwegian Ministry of Health
and Care Services, 2007

As indicated by this statement, the white paper advocated a long-term (i.e. ten
years) comprehensive strategy to reduce inequalities in health. Compared with
 NORWEGIAN STRATEGY - COMPARATIVE PERSPECTIVE 37

earlier policy documents on public health, the strategy adopted in the white
paper had a sharper focus on the gradient, on structural forces, and on the need
for cross-sectoral action. The 2006–7 white paper applied a gradient perspective
on the policy to reduce social inequalities in health, stating that social inequal-
ities in health affect all social layers in society, not only the disadvantaged. As
Chapter 1 notes, this perspective influences the choice of measures to reduce
inequalities in health. Given that inequalities are most obvious in groups with
low income and little education, the government noted the importance of giv-
ing these groups priority. However, it is also argued that tailored measures tar-
geted at specific population groups are not always the most effective instruments.
General welfare schemes were preferred, because they were considered less stig-
matizing to vulnerable groups, more effective in preventing people from ending
up in high-risk situations, and at the same time capable of protecting the most
vulnerable. In contrast, targeted approaches only have the latter advantage.
The national strategy identified four priority areas: (1) reducing social in-
equalities that contribute to inequalities in health—that is, in income, child-
hood conditions, and work–life factors; (2) reducing social inequalities in
health-­related behaviours and use of health services; (3) targeted initiatives to
promote social inclusion, in particular among vulnerable groups; and (4) devel-
opment of knowledge and cross-sectoral tools. The government’s ambition was
to ensure that the health inequality perspective would be integrated into future
policies in a variety of policy areas and anchored in different ministries.
The national strategy thus embraced the ‘social determinants of health’ per-
spective, as applied for instance in the report from the WHO Commission on
Social Determinants of Health (CSDH 2008). This orientation was accompan-
ied by the formulation of clear goals and an overarching and long-term strategy,
including specific means to reduce health inequalities. Over the past decade,
the problem definition in Norway changed from one of individualization with
a focus on health behaviours to a structural understanding that emphasizes the
problem of the gradient and the ‘upstream’ social determinants of health.

3.4  The Norwegian strategy in comparative perspective

Based on the brief review in the previous section, the Norwegian strategy to
reduce health inequalities has the following key characteristics: it focuses on the
gradient; it addresses social determinants; it emphasizes universal solutions (al-
though not exclusively); and it has a long-term and comprehensive cross-
sectoral approach. In this section, we discuss and compare the Norwegian
strategy to existing analyses of governments’ plans to reduce health inequalities
in Denmark, Finland, Sweden, and England.
38 Nordic health inequalities

Vallgårda (2008) has studied the process of problematization of the issue of

health inequality policies in four countries—Sweden, Denmark, Norway, and
England—as a way of exercising power by setting the political agenda. She
addressed two dimensions in particular: whether the problem was conceptu-
alized as a dichotomy or as a gradient, and whether the solution was framed
within a universalistic or a targeted approach. According to her analysis, the
Norwegian strategy differed from those adopted in England and Denmark,
but resembled the strategy adopted in Sweden by the then social democratic
government. Vallgårda (2008, p. 74) argues that the English strategy has been
sliding from an explicit focus on the gradient in the initial policy documents
towards a dichotomized understanding. All the empirical indicators chosen
to monitor the effects of the action programme measure dichotomies, e.g.
manual groups, as opposed to the whole population. Graham (2004, p. 126),
on the other hand, in her analysis of the English policies rather finds a move-
ment from a narrow focus to a broader orientation in terms of health gradi-
ents. However, Judge et al (2005) and, more recently, Smith and Hellowell
(2012) seem to agree with Vallgårda, both finding that the English approach
to health inequalities (like other countries considered in each analysis) failed
to adopt any explicit targets relating to the social gradient and the distribution
of health across the entire population. This is despite the emphasis placed on
a social gradient approach by one of the most high-profile advisors on health
inequalities to the English government, Professor Sir Michael Marmot (e.g.
Marmot 2010).
The Danish programme shared many similarities to the English approach by,
for example, defining the problem as a dichotomy. The Danish definition is
somewhat peculiar, as the group of disadvantaged is defined by both social and
health characteristics. Denmark has, however, seen a development over recent
years in which the gradient perspective has occupied a more important pos-
ition. For instance, in a new publication from the Danish Ministry of Health,
reducing social inequalities in health is the first of seven new goals for Danish
health policy (Danish Ministry of Health 2014). The aim is phrased in a way
that acknowledges the gradient:

Life expectancy (. . .) for all levels of education shall, as a minimum, increase at the same
pace as the life expectancy for the population as a whole (. . .). Simultaneously people
with low education shall experience the largest improvements . . . (Danish Ministry of
Health 2014, p. 6).

Since 1984, the Swedish approach to health inequalities has had a gradient per-
spective. With a liberal government in office from 2006, however, Swedish
health policy abandoned the concept of ‘social inequalities’ for a narrower focus
 NORWEGIAN STRATEGY - COMPARATIVE PERSPECTIVE 39

on ‘social exclusion’, hence moving towards a dichotomized understanding of

health inequalities (Vallgårda 2010).
The Norwegian and Swedish programmes more often than the others state
that responsibility for reducing inequalities is political, not individual. As the
statement from the former Minister of Health testifies, the Norwegian govern-
ment was explicit on this point. In England, in contrast, whilst some of the
policy documents published between 1997 and 2003 accepted political respon-
sibility, documents published from 2004 onwards increasingly shifted responsi-
bility back to the individual (see Chapter 1 and Smith et al 2009).
The Danish approach presented the least comprehensive view on causes of
health inequalities, as it addressed almost exclusively the behaviour of the
disadvantaged (Vallgårda 2010). Although the gradient perspective is now
more widely acknowledged in Denmark, the Danish approach seems also
very ‘downstream’-oriented, as all main measures are directed to health-­
related behaviours (Danish Ministry of Health 2014). Vallgårda (2010, p. 496)
states that the current ‘Danish strategy is a high risk strategy; it could poten-
tially become a never-ending story as no efforts are directed towards prevent-
ing people from ending up in the few-resources category’. The Norwegian and
the Swedish understandings of the causes, and to a lesser extent the English,
have a broader scope, encompassing behaviour and social relations as well as
social structure.
It seems that the political solutions suggested are consistent with how the
problem appears to be perceived in the different countries. Denmark and Eng-
land have put forward mostly selectivist or targeted solutions, whereas Sweden,
at least up until recently, and Norway clearly favour universal approaches com-
bined with targeted ones (Vallgårda 2008).
Equity goals and policies to reduce health inequalities have been in place in
Finland during the past 30 years and have been emphasized in central policy
documents like the 2001 national public health programme and the later action
plan to reduce inequalities in health (Mikkonen 2012). Finnish authorities have
typically seen health challenges as socio-political problems as well as problems
related to health behaviour or inequity in health care services. Finland has been
an advocate of the Health in All Policies agenda, which stresses cross-sectoral
actions based on the social determinants of health perspective (Melkas 2013).
The Finnish strategy has a gradient approach: indeed, the aforementioned ac-
tion plan’s main objective is to reduce social inequalities in health by levelling
up (Mikkonen 2012, p. 163). Nevertheless, the ambition to reduce health in-
equalities seems to have lower priority than other policy objectives such as mar-
ket liberalization and economic growth (Melkas 2013; Mikkonen 2012).
Mikkonen (2012) argues that reducing health inequalities requires a strong
40 Nordic health inequalities

­ olitical commitment and that a sharper focus should be placed on the imple-
p
mentation and monitoring of relevant Finnish policy measures and
programmes.
In conclusion, Vallgårda (2008, p. 80) states: ‘There is more variation among
the Scandinavian countries than between Scandinavia and England. Universal-
ism which is often claimed to be the hallmark of the [Nordic welfare] model is
not on the Danish agenda in this policy field’. In her 2010 comment, the conclu-
sion is that governments in Sweden and Denmark both:
adhere to a liberal policy where social inequalities are dealt with by targeting the
excluded or disadvantaged (. . .). The Danish government concentrates on chan-
ging behaviours, whereas the Swedish government wishes to reduce exclusion too.
The Norwegian and Finnish governments propose universal measures addressing
the whole population as well as targeting the most disadvantaged and wish to deal
both with behaviours and living conditions – more in accordance with social lib-
eral or social democratic policy.
Reproduced from Journal of Epidemiology & Community Health,
Signild Vallgårda, 64(6), p. 496 © 2010, BMJ Publishing Group.
With permission from BMJ Publishing Group Ltd.

The current analyses of political documents from the five countries give a rather
dynamic picture. The countries appear to be on somewhat different paths. It
seems that the position of universal strategies to combat social inequalities in
health has weakened in Sweden and England. Finland and Norway seem, at
least to a higher degree, to endorse to universal measures, whereas Denmark
seems to be on a path towards a gradient perspective and ensuing universal pol-
icies. Further, in England and Sweden the problem of social inequalities in
health is now more often understood as a problem of the few rather than the
many. In Denmark the development is in the opposite direction, but here the
focus is very much on health-related behaviour. All this suggests that the devel-
opment of public health policies in the inequality realm is not linear, as the
model proposed by Whitehead (1998, p. 471) seems to imply. The overall devel-
opment is not one of policy evolving from simple to more comprehensive and
complex policy forms; rather, it seems, the development of policies to reduce
health inequalities runs in both directions.

3.5  An appraisal of the Norwegian strategy: How has

the Norwegian strategy been implemented since its
inception in 2007?
In an assessment of the Norwegian strategy, it is important to note that the Red/
Green Government that launched the white paper in 2007 had already taken steps
 An appraisal of the Norwegian strategy 41

to realize a broadly defined programme for reducing social inequalities. This

means that a number of ministries and governmental bodies were committed to
an egalitarian project and that plans were underway to further equality in many of
the domains of the social determinants of health, even before the strategy to re-
duce health inequalities was released.
In a report produced for the Norwegian review of health inequalities, Giæver
(2013) has described and evaluated the national strategy to reduce health in-
equalities. The report, which is in Norwegian, describes all the areas of the strat-
egy as listed here. Linked to each domain, such as early childhood conditions,
education, income, work, health-related behaviour, inequality in health care,
disadvantaged groups, etc., were sets of aims, measures, and empirical indica-
tors (with some exceptions).
Giæver (2013) has provided assessments of the degree to which the measures
have been implemented across domains. Note that whether measures actually
have led to smaller inequalities in the distribution of the social determinants is
a different question, which we will not address in this chapter due to space limi-
tations. The former Red/Green Government fulfilled many of the plans and
promises it put forward in the 2007 white paper. Some prominent examples are
equalizing tax reforms, strongly subsidized preschool for ‘all’, an array of re-
forms and local initiatives in basic education, and measures to prevent
­dropping-out from high school. One may of course ask whether all these initia-
tives were properly designed for or had the capacity to reduce inequalities in the
determinants in question, but such in-depth analysis is beyond the scope of this
chapter.
There is some incoherence in the Norwegian equity strategy. First, targets and
indicators are still lacking for some domains, in particular in the health care
domain. Second, although the strategy is explicit in its aim to reduce the social
gradient, several of the targets are formulated as shares rather than inequalities.
For example, there are targets to reduce the share of pupils enrolled in elemen-
tary school with unsatisfactory language skills, to reduce the share of students
who drop out of high school, and to increase the share of people on long-term
sick leave who return to work within a year (Giæver 2013, p. 2). Changes in
shares of problematic social categories may or may not be accompanied by re-
duced social inequalities and, if one measures the wrong thing, there is a risk
that one pursues the wrong ends. Besides, if a disadvantaged group gets smaller,
it is possible that the composition changes and therefore that inequalities in
health between this group and the rest become larger, as is shown for long-term
recipients of social assistance in Norway (Naper et al 2008).
In one policy domain, however, little has been done: health care.3 In the na-
tional strategy for equity in health, measures in the national health services
42 Nordic health inequalities

were primarily linked to provision of new research-based knowledge, analysis

of consequences of reforms, and evaluation of new programmes. In all these
respects and areas there has been little progress. We still know very little about
equity in health care, whether important health care reforms have impacted on
social groups in different ways, to which degree user fees have detrimental ef-
fects among low-income groups, whether there are social inequalities in use of
and gain from medical assistance, and so on (for an analysis of the likely impact
of these kinds of reforms in the UK context, see Chapter 11). The knowledge
base in this area has only improved marginally since 2007. Comprehensive
policy initiatives like the Work and Welfare Administration reform (Askim et al
2010), the Coordination reform (Romøren et al 2011), and the Inclusive Work-
ing Life Agreement (Hagelund and Bryngelson 2014) were never designed to
level out social inequalities, and were never evaluated in terms of their potential
effects on health inequalities. These are questions about differential use and ef-
fects, quality, implementation, and allocation of services and resources.
It should also be mentioned that the Public Health Act, made effective in
2012, positions reducing health inequalities as a high-priority aim. In the Act,
the municipalities4 are granted a significant role in identifying and monitoring
both health indicators and social determinants of health, and are expected to
take action to reduce health inequalities if they find it necessary (see Chapter 10
for an overview and analysis of a similar kind of ‘localism’ being implemented
within public health in England). It is, however, far too early to draw any con-
clusions as to how successful this Act has been in reducing health inequalities.

3.6  The Nordic ‘paradox’ revisited

Bambra (2011b) and Mackenbach (2012) have respectively used the words
‘puzzle’ and ‘paradox’ to describe the situation that health inequalities in the
Nordic countries are no narrower than in other Western European countries,
despite the egalitarian legacy and redistributive social policies pursued in these
countries. This situation is unexpected from a ‘social determinants of health’
perspective, given the mounting evidence linking social inequality in various
living conditions to health inequalities. As Mackenbach himself acknowledges,
however, although the Nordic countries have an egalitarian legacy, social in-
equality is not eradicated and neither has the intention ever been to do so. Ra-
ther, the term ‘just inequality’ has been used to describe the social-democratic
notion of inequality (Halvorsen 2014).
In our own literature review (Dahl et al 2014), we point out that develop-
ments in health inequalities in Norway throughout the past two decades coin-
cide with remarkable stability in the distribution of material (e.g. income and
 The Nordic ‘paradox’ revisited 43

0.33
0.31
0.29
0.27
0.25
0.23
0.21
0.19
0.17
0.15
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
Annual income Income, 3-year average
Fig. 3.2 Income inequality after taxes measured by the Gini-coefficient. Household
equivalent income (EU-scale) excluding student households. The spike in the trend is
most likely due to some temporary changes in taxation.
Reproduced with permission from Pedersen, A. W., Inntekt og helse: Underlagsrapport til
Kunnskapsoversikt om sosial ulikhet ihelse, p.14, Copyright ©2013, available from www.hioa.no/
helseulikhet.

work environment) and immaterial (e.g. education, credentials, and skills) re-
sources. Figure 3.2 displays trends in income inequalities in Norway between
1986 and 2011, and shows a stable trend in the last decade.
In principle, the extensive welfare arrangements in Norway—both in cash and
in kind—have a significant potential for redistribution of money and goods.
However, more detailed and in-depth analysis of specific programmes, such as
use of preschools, programmes to prevent high-school dropout, help to do home-
work, and use of after-school programmes shows that the levelling effects are
often disappointing. Figure 3.3 shows the proportion of pupils that completes
secondary education within five years by the educational level of their parents.
Clearly, there has not been a reduction in social inequalities. Hence, the funda-
mental sources of inequality have not become more favourable, and some im-
portant policy interventions appear to have had no effect on furthering equality.
The social determinants of health are not only about conditions within reach
of welfare policies; Norway has an utterly skewed distribution in smoking be-
haviour. The fact that Norwegian inequalities in smoking behaviour (as meas-
ured by education) are among the largest in Europe (Eikemo et al 2014) may be
explained by the differential evolution of the smoking epidemic in different
countries (see Lopez et al 1994). Norway is assumed to be at a more mature
44 Nordic health inequalities

90
80
70
60
50
40
30
20
10
0
1994 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

Master degree Bachelor degree Secondary school

Elementary school Unknown education
Fig. 3.3 The proportion of pupils who completes secondary education within five years
by parental educational level.
Source: Data from Statistics Norway, Statistikkbanken, table 09,254, https://www.ssb.no/statistik
kbanken/SelectVarVal/Define.asp?MainTable=GjennVGOFullForel&KortNavnWeb=vgogjen&
PLanguage=0&checked=true Last Accessed 8th March 2015.

stage of this epidemic, a stage where inequalities are particularly large as people
in high socioeconomic groups are far more inclined to quit than people in lower
socioeconomic positions. The latest statistical trend on smoking in Norway,
starting in 2007, even indicates that the educational inequalities (absolute) in
smoking are about to decline.
As can be seen from Figure 3.1, educational differences in life expectancy
among men have not continued to grow during the last decade. Furthermore,
detailed studies of cause-specific mortality trends suggest that increases in
mortality inequalities observed between the 1970s and 1990s can largely be ex-
plained by smoking-related diseases, particularly among women (Strand et al
2010). It is therefore not unlikely that a reduction of social inequalities in smok-
ing will contribute to reducing social inequalities in health in the future.

3.7  Summary and conclusion

Since 2007, Norway has had a rather ambitious programme for reducing social
inequalities in health. The health equity strategy has four distinctive features: it
focuses on the gradient; it addresses the social determinants (e.g. childhood
conditions, education, work, and income) as well as health-related behaviours;
it emphasizes universal solutions (although not exclusively); and it has a ten-
year cross-sectoral design. The strategy has been part of a broader equity
 Summary and conclusion 45

initiative taken by the Red/Green Government led by the Social-Democrats

that held office from 2005 until 2013. Comparisons of public health policy
documents from Sweden, Denmark, Finland, England, and Norway point to a
mixed and dynamic picture. The position of universal strategies to combat so-
cial inequalities in health has weakened within some Nordic countries, but not
in Norway. The problem of social inequalities in health is now more often
understood as a problem of the few, rather than the many, in both England and
Sweden. Recent policy developments in Denmark, however, indicate that there
is now a heightened awareness of the social gradient in health.
Since the 1960s, educational inequalities in mortality in Norway have been
increasing steadily among men and women in absolute and relative terms. At
the same time, educational inequalities in mortality have repeatedly been
shown to be at the same level in Norway (and in the other Nordic countries) as
in other Western European countries considered less egalitarian. This has been
dubbed the Nordic ‘puzzle’ or ‘paradox’ (Bambra 2011b; Mackenbach 2012).
However, the distribution of many social determinants of health—both up-
stream and down-stream, and their developments in Norway over the past
­decades—shows that there is (as in many countries) a fundamental structure of
inequality in Norwegian society. In some respects, and in some groups, in-
equalities have increased, whilst in others they have remained stable. Educa-
tional inequalities in smoking behaviour have increased over the past decades
and are larger in Norway than elsewhere, but at the same time overall smoking
rates have dropped. These patterns are consistent with the observed increasing
educational inequalities in mortality that we have witnessed since the 1960s, as
well as the phenomenon that inequalities in mortality and other health out-
comes are at approximately the same level in Norway as in other Western Euro-
pean countries. This narrative is not new and aligns with one of the
interpretations put forward by Mackenbach (2012). All this suggests that the
Norwegian case may not be such a paradox after all.
In Norway, for the first time in 40 years, there is now no increase in absolute
educational inequalities in mortality among men (reductions in deaths from car-
diovascular disease have played a crucial role in this) and a reduction is evident in
absolute educational inequalities in smoking (Dahl et al 2014). What role public
health policy has had in these promising trends is, however, less clear. The devel-
opment should therefore be closely investigated and monitored in the future.

Acknowledgements
We are grateful for valuable help from Finnish colleagues Eero Lahelma and
Hannele Palosuo for providing useful comments and important documents for
this chapter.
46 Nordic health inequalities

Notes
1 The paper was one of the first truly comparative studies of health inequalities, and docu-
mented socioeconomic morbidity and mortality patterns in 11 countries.
2 In comparison, UK had a Gini-coefficient of 0.30 in 2013, very close to the EU average.
3 Like the UK, Norway has a universal tax-funded health service. All legal residents have an
equal right to use the health services. Health services are quite accessible, as patient
charges are relatively modest. Dental services, however, although with some exceptions,
are only free for children and youth up to the age of 18. The health care system is based
on a decentralized model of provision. The state is responsible for policy design, budget-
ing, quality of health care, and legislation. The state also runs the hospitals through own-
ership of the regional health authorities, which are separate legal entities. The
municipalities are responsible for primary health care, such as school health services,
local health centres, midwife services, and institutional and domestic nursing. Every citi-
zen is assigned or can choose a state-subsidized general practitioner (see Halvorsen and
Stjernø 2008).
4 The municipality in Norway is the lowest democratic level in the Norwegian structure of
government. The municipalities have traditionally enjoyed a high level of autonomy, but
they are also obliged by the state to fulfil a number of services to their populations. The
‘welfare municipality’ is the prime provider of welfare services; primary school, social as-
sistance, and employment agencies, health care and school health services, integration of
immigrants, etc. The municipality is also responsible for crucial infrastructure such as
water, sewage and renovation, and local roads. Norway has 428 municipalities with an
average size of about 12,000 inhabitants (see Halvorsen and Stjernø 2008).

References
Askim, J., Christensen, T., Fimreite, A. L., and Laegreid, P. (2010) How to assess adminis-
trative reform? Investigating the adoption and preliminary impacts of the Norwegian
welfare administration reform. Public Administration, 88(1): 232–246.
Bambra, C. (2011a) Work, Worklessness and the Political Economy of Health. Oxford:
­Oxford University Press.
Bambra, C. (2011b) Health inequalities and welfare state regimes: Theoretical insights on
a public health ‘puzzle’. Journal of Epidemiology and Community Health, 65(9):
740–745.
Bambra, C., Smith, K. E., Garthwaite, K., Joyce, K. E., and Hunter, D. J. (2011) A labour of
Sisyphus? Public policy and health inequalities research from the Black and Acheson Re-
ports to the Marmot Review. Journal of Epidemiology and Community Health, 65(5):
399–406.
Barth, E., and Moene, K. O. (2009) The Equality Multiplier (working paper no. 15076).
Cambridge, MA: National Bureau of Economic Research.
CSDH (2008) Closing the Gap in a Generation: Health Equity through Action on the Social
Determinants of Health. Final report, executive summary, Geneva.
Dahl, E. (2002) Health inequalities and health policy: The Norwegian case. Norsk Epidemi-
ology, 12(1): 69–75.
Dahl, E., Bergsli H., van der Wel, K. A. (2014) Sosial ulikhet i helse. En norsk kunnskapso-
versikt. Oslo: HiOA.
 Summary and conclusion 47

Danish Ministry of Health (2014) Healthier lives for all—national goals for the health of
Danes the next 10 years [Sundere liv for alle—Nationale mål for danskernes sundhed de
neste 10 år]. Copenhagen: Ministeriet for sundhed og forebyggelde.
Eikemo, T. A., Hoffmann, R., Kulik, M. C., Kulhánová, I., Toch-Marquardt, M., Men-
vielle, G., Looman, C., Jasilionis, D., Martikainen, P., Lundberg, O., and Mackenbach,
J.P. for the EURO-GBD-SE consortium (2014) How can inequalities in mortality be re-
duced? A quantitative analysis of 6 risk factors in 21 European populations. PLoS ONE,
9(11): e110952. doi: 10.1371/journal.pone.0110952.
Esping-Andersen, G. (1990) The Three Worlds of Welfare Capitalism. Cambridge: Polity
Press.
Fritzell, J., Bäckman, O., and Ritakallio, V. M. (2012) Income inequality and poverty: Do
the Nordic countries still constitute a family of their own? In J. Kvist, J. Fritzell, B. Hvin-
den, and O. Kangas (eds), Changing Social Equality. The Nordic Welfare State in the 21st
Century. Bristol: The Policy Press, pp. 165–186.
Giæver, Ø. (2013) Nasjonal strategi for å utjevne sosiale helseforskjeller. Underlagsrapport til
Kunnskapsoversikt om sosial ulikhet i helse. Oslo: Oslo and Akershus University of Ap-
plied Sciences.
Graham, H. (2004) Tackling inequalities in health in England: Remedying health disadvan-
tages, narrowing health gaps or reducing health gradients? Journal of Social Policy, 33(1):
115–131.
Hagelund, A., and Bryngelson, A. (2013) Change and resilience in welfare state policy. The
politics of sickness insurance in Norway and Sweden. Social Policy and Administration,
48(3): 300–318.
Halvorsen, K. (2014) Velferd. Fra ide til politikk for et godt samfunn. Oslo: Cappelen
Damm Akademisk.
Halvorsen, K., and Stjernø, S. (2008) Work, Oil and Welfare. The Welfare State in Norway.
Oslo: Universitetsforlaget.
Hussain, M. A., Kangas, O., and Kvist, J. (2012) Welfare state institutions, unemployment
and poverty: Comparative analysis of unemployment benefits and labour market partici-
pation in 15 European countries. In J. Kvist, J. Fritzell, B. Hvinden, and O. Kangas (eds),
Changing Social Equality. The Nordic Welfare State in the 21st Century. Bristol: The Pol-
icy Press, pp. 165–186.
Judge, K., Platt, S., Costongs, C., and Jurczak, K. (2005) Health Inequalities: A Challenge
for Europe. London: UK Presidency of the EU.
Lopez, A., Collishaw, N., and Piha, T. (1994) A descriptive model of the cigarette epidemic
in developed countries. Tobacco Control, 3(3): 242–247.
Lundberg, O., Östergren, O., Menvielle, G., Kulhánová, I., Eikemo, T. A., Mackenbach,
J. P., and the EUROGBD-SE Consortium (2012) Inequalities in mortality across Europe:
An international comparative study. In T. A. Eikemo and J. P. Mackenbach (eds), EURO
GBD SE. The Potential for Reduction of Health Inequalities in Europe. Final report. Rot-
terdam: Erasmus MC.
Mackenbach, J. P. (2012) The persistence of health inequalities in modern welfare states:
The explanation of a paradox. Social Science and Medicine, 75(4): 761–769.
Mackenbach, J. P., Kunst, A. E., Cavelaars, A. E., Groenhof, F., Geurts, J. J., and the EU
Working Group on Socioeconomic Inequalities in Health (1997) Socioeconomic inequal-
ities in morbidity and mortality in Western Europe. The Lancet, 349(9066): 1655–1659.
48 Nordic health inequalities

Marmot, M. (2010) Strategic Review of Health Inequalities in England post-2010. Marmot

Review Final Report. London: University College London.
Melkas, T. (2013) Health in all policies as a priority in Finnish health policy: A case study
on national health policy development. Scandinavian Journal of Public Health, 41(Suppl.
11): 3–28.
Mikkonen, J. (2012) Finnish experiences. In D. Raphael (ed.), Tackling Health Inequal-
ities: Lessons from International Experiences. Toronto: Canadian Scholars Press,
pp. 155–184.
Naper, S. O., van der Wel, K., and Halvorsen, K. (2008) Arbeidsmarginalisering og fattig-
dom blant langtidsmottakere av sosialhjelp. I. I. Harsløf and S. og Seim (eds), Fattigdom-
mens dynamikk. Perspektiver på marginalisering i det norske samfunnet. Oslo:
Universitetsforlaget.
Norwegian Ministry of Health (2003) Report No. 16 (2002–3) to the Storting: Prescription
for a Healthier Norway. [St. meld. nr. 16. (2002–3) Resept for et sunnere Norge]. Oslo:
Statens forvaltningstjeneste.
Norwegian Ministry of Health and Care Services (2007) Report No. 20 (2006–7) to the
Storting: National strategy to reduce social inequalities in health [St. meld. nr. 20. Nas-
jonal strategi for å utjevne sosiale helseforskjeller]. Oslo: Departementenes servicesenter
(English version available at: http://ec.europa.eu/health/ph_determinants/socio_
economics/documents/norway_rd01_en.pdf).
Romøren, T. I., Torjesen, D. O., and Landmark, B. (2011) Promoting coordination in
Norwegian health care. International Journal of Integrated Care, 11(Special 10th Anni-
versary Edition): e127.
Saltkjel, T., Dahl, E., and van der Wel, K. A. (2013) Health related social exclusion in Eur-
ope: A multilevel study of the role of welfare generosity. International Journal for Equity
in Health, 12(1): 1–11.
Smith, K. E., and Hellowell, M. (2012) Beyond rhetorical differences: A cohesive account of
post-devolution developments in UK health policy. Social Policy and Administration,
46(2): 178–198.
Smith, K. E., Hunter, D. J., Blackman, T., Williams, G., McKee, L., Harrington, B., Elliott,
E., Marks, L., and Greene, A. (2009) Divergence or convergence? Health inequalities and
policy in a devolved Britain. Critical Social Policy, 29(2): 216–242.
Steingrímsdóttir, O. A., Næss, Ø., Moe, J. O., Groholt, E. K., Thelle, D. S., Strand, B. H.,
and Baevre, K. (2012) Trends in life expectancy by education in Norway 1961–2009.
European Journal of Epidemiology, 27(3): 163–171.
Strand, B. H., Groholt, E. K., Steingrímsdóttir, O. A., Blakely, T., Graff-Iversen, S., and
Næss, O. (2010) Educational inequalities in mortality over four decades in Norway: Pro-
spective study of middle-aged men and women followed for cause specific mortality,
1960–2000. British Medical Journal, 340: c654. doi: http://dx.doi.org/10.1136/bmj.c654.
Vallgårda, S. (2008) Social inequality in health: Dichotomy or gradient? A comparative
study of problematizations in national public health programmes. Health Policy, 85(1):
71–82.
Vallgårda, S. (2010) Tackling social inequalities in health in the Nordic countries: Target-
ing a residuum or the whole population? Journal of Epidemiology and Community
Health, 64(6): 495–496.
 Summary and conclusion 49

van der Wel, K. A., Dahl, E., and Thielen, K. (2011) Social inequalities in ‘sickness’: Euro-
pean welfare states and non-employment among chronically ill. Social Science and Medi-
cine, 73(11): 1608–1617.
van der Wel, K. A., Dahl, E., and og Halvorsen, K. (2012) Arbeidsinkludering og ar-
beidsmotivasjon i komparativt perspektiv. Sluttrapport til FARVE. Oslo: Oslo and Aker-
shus University of Applied Sciences.
Whitehead, M. (1998) Diffusion of ideas on social inequalities in health: A European per-
spective. Milbank Quarterly, 76(3): 469–492.
 Chapter 4

Reflections on the UK’s legacy of

health inequalities research and
policy from a North American
perspective
Dennis Raphael and Toba Bryant

4.1  Introduction: Reflecting on UK insights from a North

American perspective
In this chapter we reflect on the insights UK research and policy experiences
have offered those working to address health inequalities in Canada and the
USA. We conclude that the UK has provided researchers and policymakers
with numerous insights into how to conceptualize, research, and act to reduce
health inequalities. If and when North American authorities choose to address
health inequalities, these insights will prove invaluable.

4.2  Overview of the UK, Canadian, and American health

inequalities scenes
The UK has a long tradition of concern with health inequalities and the social
inequalities that spawn them, as Chapters 1 and 2 reflect. Our personal libraries
are chock-full of UK work and in this chapter we acknowledge our debt to these
contributions. These contributions include means of identifying and measuring
health inequalities, conceptualizing their causes, and identifying and imple-
menting ways of reducing health inequalities.
In Canada, resurgence of interest in health inequalities was stimulated by the
1996 publication of Richard Wilkinson’s Unhealthy Societies: The Afflictions of
Inequality. The book resonated with Canadian researchers and policy analysts,
as this was the time of the neoliberal resurgence by governments that led to re-
trenchment of the Canadian welfare state services and programmes (Banting
et al 1997; Langille 2009; Teeple 2000). These policy changes led to significant
increases in income and wealth inequalities and the deepening of poverty (The
Caledon Institute 2001).
 Conceptual contributions 51

4.3  Conceptual contributions

To our minds, the development of the materialist explanation for health has
been one of the UK’s greatest contributions to the health inequalities literature
(see Table  4.1). Building upon key UK reports, including the Black Report

Table 4.1  UK concepts that have influenced Canadian research on health inequalities

Concept Examples of Contributions

Comparative analysis of health inequalities
and the social determinants of health
Conceptualizing poverty and its health
effects
Conceptualizing health
Conceptualizing health inequalities and
health inequities
Conceptualizing social determinants of
health and their distribution
Conceptualizing social exclusion
Employment and health
Gender and health inequalities
Geography of health inequalities
Health impact assessment
Housing and health
Impact of living conditions on health
Income inequality and health
Life-course approaches to health inequalities
Lived experiences of health inequalities
Mapping health inequalities
Mechanisms causing health inequalities
Political economy of health
Politics of health
Race and health inequalities
Welfare state analysis and impacts on health
inequalities
Bambra 2005b, 2006
Gordon 2010; Pantazis et al 2006;
Townsend 1993
Aggleton 1990; Blaxter 2010
Benzeval et al 1995; Dahlgren and
Whitehead 1992; Whitehead 1985
Graham 2007; Marmot and
Wilkinson 2006
Levitas 2005
Bambra 2011b; Bartley and Plewis 2002
Doyal 1995; Pollard and Brin Hyatt 1999
Mitchell et al 2000
Scott-Samuel et al 2001
Shaw 2004
Acheson 1998; Black and Smith 1992;
Engels 1845/1987; Whitehead 1992
Wilkinson 1996; Wilkinson and Pickett 2009
Davey Smith 2003; Kuh et al 2004
Williams and Popay 1997
Mitchell et al 2000
Brunner and Marmot 2006; Marmot 2004;
Shaw et al 1999; Townsend et al 1992;
Wilkinson 1996, 2001; Wilkinson and
Pickett 2009
Bambra 2007, 2009; Eikemo and
Bambra 2008
Bambra et al 2005
Riste et al 2001
Bambra 2005a, 2005b, 2006, 2011a
52 REFLECTIONS ON THE UK FROM NORTH AMERICA

(Black et al 1980; see Chapters 1 and 2), The Health Divide (Whitehead 1987),
and the Independent Inquiry (Acheson 1998—see Chapters 1 and 2), the ‘Bristol
Group’ of UK researchers carefully explicated the materialist argument in the
Widening Gap (Shaw et al 1999).
UK conceptual developments to the health inequalities literature also include
the explication of the life-course approach to understanding health inequalities
(see Chapters 1 and 2; Ben-Shlomo and Kuh 2002; Davey Smith 2003; Kuh et al
2004), buttressed by an extensive empirical literature that documents the effects
of material conditions of life upon health across the life span (see Chapter 1;
Benzeval et al 1995; Davey Smith 2003; Graham 2001). Brunner and Marmot’s
(2006) work on biological mechanisms mediating the effects of living condi-
tions on health provided a spur to our own research on the social determinants
of type II diabetes (Raphael et al 2012).
The extensive UK literature on poverty and health that conceptualizes the
meaning of poverty and how it comes to have such an important influence on
health is valuable (Gordon and Townsend 2000; Lister 2004; Pantazis et  al
2006). The social exclusion work from the UK has also gained traction in Can-
ada (Levitas 2005) and stimulated Canadian thinking about its role in creating
health inequalities (Galabuzi 2005; Guildford 2000; Labonte 2004). Additional
conceptual work that we have found useful is detailed in Table 1. This includes
seminal work on definitions of health (Aggleton 1990; Blaxter 2010), the social
determinants of health and their public policy implications (Dahlgren and
Whitehead 1992; Whitehead 1985), the distinction between the social deter-
minants of health and the distribution of the social determinants of health
(Graham 2004a, b), means of conceptualizing and remedying health inequal-
ities (Graham 2007), the relationship between welfare theory and health in-
equalities (Bambra 2007; Eikemo and Bambra 2008), and the politics of health
(Bambra et  al 2005). Methodologically, the work by Popay and Williams
(1994) has impressed upon us the importance of examining people’s lived ex-
periences as part of addressing the health inequalities agenda (see also Chap-
ter 16 of this book). Health Impact Assessment by Scott-Samuel and colleagues
(2001) provides a potential means of edging government authorities towards
consideration of how public policies shape the extent of health inequalities
amongst Canadians.

4.4  Research contributions

UK research contributions include concern with health inequalities in general
and more specific social determinants of health, such as income (Wilkinson
1996), housing (Marsh at al. 1999; Shaw 2001, 2004), employment and working
 Public policy contributions 53

conditions (Bambra 2011; Bartley and Plewis 2002), ethnicity and race (Riste
et al 2001; Templeton et al 2003), and gender (Doyal 1995; Pollard et al 1999).
The geography and mapping work on health inequalities has, alongside the pro-
motion of policy tools such as health impact assessment, pointed towards the
importance of making concrete their effects (Boyle et al 2000; Mitchell et al
2000; Scott-Samuel et al 2001; Shaw et al 2002).

4.5  Public policy contributions

The efforts that began to address health inequalities in the UK through public
policy from 1997 onwards are extensive and well documented (see Chapter 1
and 2; and Smith and Bambra 2012; Whitehead 2009). There have been numer-
ous evaluations of available health inequalities evidence in the UK (e.g. Asthana
and Halliday 2006) and of efforts to achieve greater levels of equality more
broadly in the UK (e.g. Hills et al 2009; Hills and Stewart 2005). These have
stimulated Canadian work on inter-sectorality as a means of addressing health
inequalities (Health Council of Canada 2010b; Public Health Agency of Canada
and Health Systems Knowledge Network 2007). Table  4.2 summarizes these
contributions.

Table 4.2  UK concepts that have influenced Canadian work on responses to health

inequalities

Concept Examples of Contributions

Conceptualizing responses to health
inequalities
Evaluating governmental responses to
health inequalities
Governmental responses to health
inequalities
Health impact assessment
Mechanisms mediating policy responses to
health inequalities
Public health responses to health
inequalities
Responding to social exclusion
Welfare state analysis and responses to
health inequalities
Graham 2004a, b; Smith 2007; Smith and
Bambra 2012
Hills et al 2009; Hills and Stewart 2005
Asthana and Halliday 2006; Dahlgren and
Whitehead 2006; Whitehead and
Dahlgren 2006
Scott-Samuel et al 2001
Petticrew et al 2004; Whitehead et al 2004
Benzeval et al 1995; Marmot et al 2010;
Scottish Executive 2004; Welsh Assembly
Government 2004
Levitas 2005; Social Exclusion Unit 2001
Bambra 2009; Joyce and Bambra 2010
54 REFLECTIONS ON THE UK FROM NORTH AMERICA

4.6  Key policy documents in Canada and UK influences

Canada has been prolific in producing reports on addressing health inequali-
ties, but government action on addressing health inequalities has, however,
lagged far behind the UK. Nonetheless, Canadian thinking continues to be in-
fluenced by research and policy initiatives in the UK and this section examines
some of these efforts.

4.6.1  The
Chief Health Officer’s report: Health inequalities
in Canada
As a result of the SARS (severe acute respiratory syndrome) epidemic—not a
concern with addressing health inequalities—the Liberal government estab-
lished the Public Health Agency of Canada in 2007, headed up by a Chief Public
Health Officer of Canada. The first report entitled Addressing Inequalities in
Health (Butler-Jones 2008) contains many references to health inequalities,
making specific reference to UK (see Chapters 1 and 2) and Nordic (see Chap-
ter 3) policy approaches:
While socio-economic conditions and specific health problems vary globally, all coun-
tries have portions of their population at higher risk of health challenges. Some, how-
ever, have moved from concern to concerted action by establishing a commitment to
reducing health inequalities. In particular, the Nordic countries and the United King-
dom have identified health inequalities as a priority and conducted audits of the roles
that government departments can and do play in reducing social and health inequali-
ties. The UK has set specific goals, objectives and targets to reduce inequalities, with
implications across a number of sectors, and they have committed to measuring impact
and reporting on progress.
© All rights reserved. The Chief Public Health Officer’s Report on the State
of Public Health in Canada. Public Health Agency of Canada, 2008. Reproduced
with permission from the Minister of Health, 2014

4.6.2  The
Health Council of Canada report: Stepping
it up: Moving the focus from health care in Canada
to a healthier Canada
The Health Council of Canada was a federally funded, arms-length agency
charged with monitoring the operation of the health care system in Canada. As
part of its analysis of the importance of addressing health inequalities through
action on the ‘determinants of health’, it repeatedly cited UK experiences as
models for Canadian action (Health Council of Canada 2010b), notably the
government-commissioned Independent Inquiry into Inequalities in Health
(also known as the Acheson Inquiry—see Chapters 1 and 2) and the English
national targets for reducing health inequalities by 2010.
 Canadian contributions 55

4.6.3  Canadian Senate reports on population health

The Canadian Senate is modelled on the UK’s House of Lords. In 2008 Standing
Senate Committee on Social Affairs, Science and Technology established a Sub-
committee on Population Health and was provided with terms of reference that
included:
That the Committee be authorized to study international examples of population
health initiatives undertaken either by individual countries, or by multilateral inter-
national bodies such as (but not limited to) the World Health Organization. (Subcom-
mittee on Population Health of the Standing Senate Committee on Social Affairs 2008)

The subcommittee produced no fewer than five reports on these issues (Senate
Subcommittee on Population Health 2008). Its report A Healthy, Productive
Canada: A Determinants of Health Approach (Senate Subcommittee on Popula-
tion Health 2008) concluded that:
Internationally, Canada is lagging behind other jurisdictions in this regard. We can
learn from our own successful examples and those in other countries, notably Sweden
and the United Kingdom, to find the optimal mix of top-down and bottom-up policy
models, balancing local flexibility with national accountability. (Senate Subcommittee
on Population Health 2008, p. 38)

One of the reports, Population Health Policy: International Perspectives (Sub-

committee on Population Health of the Standing Senate Committee on Social
Affairs 2008), noted that England has a long history of pioneering a national
approach to population health, being the first, if not the only, country with a
whole-of-government policy for addressing health inequalities and improv-
ing overall population health (for some reflections on this approach, see
Chapters 1–3).

4.7  Canadian contributions of interest to UK

researchers
Canadian contributions to health promotion, population health, and healthy
cities have been documented in many venues (Raphael 2008; Restrepo 2000).
It has also been documented that these concepts have seen their application
primarily outside Canada, such that Canada can best be seen as a ‘health pro-
motion document powerhouse’ (Raphael 2008, p. 484). As a result of the in-
ability of these issues to gain traction in Canada, significant efforts have been
undertaken to make sense of why this might be the case (Bryant 2002, 2010;
Raphael 2010).
These analyses may be useful to UK readers. These include an explication of
various discourses of the social determinants of health and their implications
56 REFLECTIONS ON THE UK FROM NORTH AMERICA

for health promotion and public policy change (Raphael 2012), analysis of the
role of the mainstream media in addressing or ignoring the social determinants
of health (Raphael 2011), and a number of articles that document the failure,
and the reasons for such failure, of Canadian authorities to address the issue of
health inequalities (Collins and Hayes 2007; Hancock 2011; Low and Therault
2008; Raphael 2008). Essentially, willingness to address health inequalities runs
up against the dominant biomedical and lifestyle discourses on health deter-
minants, complicated by co-existing and contested concepts of health equity, all
of which are shaped by the general unwillingness of the liberal welfare state to
interfere in the operation of the unbridled market economy.
Another contribution is in the Health Council of Canada’s (2010a) Stepping it
Up report, which provides an analysis of what is needed for governments to ad-
dress the ‘determinants of health’ through what is called ‘a whole-­of-government’
approach. The Checklist for Whole-of-Government or Intersectoral Work speci-
fies the values, information, and government infrastructure that is needed to
address health inequalities and is presented as Appendix 1. It is useful for detail-
ing what led to the UK addressing health inequalities during the 1997–2010
Labour party reign, as well as what is occurring at present.
A Canadian edited collection, based on an analysis of international experi-
ences that included the UK, applies a political economy analysis to willingness
to address health inequalities (Raphael 2012; see also Chapter 1). Figure 4.1
recognizes some of the more specific structures and forces that shape the extent
of health inequalities in a nation as well as the inclination (or not) to tackle
them. Factors that have worked in favour of the UK addressing health inequal-
ities include a central governance structure (although this is changing with de-
volution) and the long-standing presence of a significant ‘social-democratic’
political party. There are many factors working against the UK addressing
health inequalities: the UK being a liberal welfare state, working under the
Westminster ‘first past the post’ electoral process that usually limits ongoing
power of the left, a weak trade union movement, and a frail civil society sector
(see Chapter  19). Based on this analysis, Bryant (2012) summarizes the UK
situation as follows (see also Chapters 1–3 of this book):
By the time of the election of the Labour government in 1997, the growth of social and
health inequalities had become a widespread public concern and tackling these were a
part of Labour’s election platform. The newly elected government undertook a variety
of initiatives, but these were embedded with the ongoing operation of the UK’s political
and economic system, which is associated with rather higher income and wealth ine-
qualities. There was also a general reluctance to undertake governmental interventions
in the marketplace associated with the UK’s liberal welfare state. Critiques of the
government’s approach toward tackling health inequalities have focused on the
 Power Relations
• Electoral Behaviour
• Trade Union Strength
- Union Density
- Collective Agreement
Coverage
• Civil Society Coalitions

The State Extent of Social Inequalities

• Liberal vs. Social Democratic Health Inequalities
Extent • Poverty Rates
Welfare Regime • Extent of Health Inequalities
of • Income Inequality
• Proportional Representation Decommodification • Tackling of Health Inequalities
• Developmental Inequalities
• Central vs. Federal System
• Workplace Inequalities

SDOH-Related Public Policy

• Disability Policy
• Family Policy

Canadian contributions
• Health Policy
• Income and Taxation Policy
• Labour Policy
• Pension Policy

Fig. 4.1 Factors contributing to the extent of health inequalities and willingness to tackle them.
Adapted from models provided by V. Navarro et al, The importance of the political and the social in explaining mortality differentials among the countries of the OECD,
1950–1998, in V. Navarro (Ed.), The political and social contexts of health (pp. 11–86) (Amityville: Baywood Press, 2004), and informed by the work of D. Brady, Rich
democracies, poor people: How politics explain poverty (New York: Oxford University Press, 2009) and D. Coburn, Beyond the income inequality hypothesis: Globaliza-
tion, neo-liberalism, and health inequalities, Social Science & Medicine, 58(2004), 41–56.

57
58 REFLECTIONS ON THE UK FROM NORTH AMERICA

unwillingness to address broad issues of income and wealth inequality by concentrat-

ing on the needs of the most disadvantaged.
Reproduced from T. Bryant, ‘Applying the Lessons from International Experiences’,
In: D. Raphael (Ed.), Tackling Health Inequalities: Lessons from International
Experiences, p. 274, Canadian Scholars’ Press Incorporated, Toronto, Canada.
Copyright © 2012, Canadian Scholars’ Press Incorporated

Bryant (2012) also specifies how different models of public policy change can be
applied in the service of placing health inequalities on the agenda of nations that
differ in their form of the welfare state. She concludes that a political economy
analysis—that places power and influence as key influences upon public policy-
making—is especially relevant to the situation in liberal political economies such
as Canada and the UK, where the business and corporate sectors dominate.
Even these developments are now threatened by the election of a
Conservative–­Liberal Democratic Coalition government in 2010, which at-
tempted to implementing significant cuts to publicly funded services and to
welfare support, having vowed to cut government expenditures by 40% and the
most recent 2015 election which saw a Conservative majority elected. Even so,
the situation in the UK regarding continued commitments to tackling health
inequalities should be cause for envy among those concerned with these issues
in Canada and the USA (pp. 274–275).
Another Canadian contribution is the potential value of grass-roots activities
that aims to place the issue of health inequalities on the public policy agenda.
On the public health front, a local public health unit in Ontario created a video
animation entitled Let’s Start a Conversation about Health and Not Talk about
Health Care at All (Sudbury and District Health Unit 2011). It has been adapted
by no less than 20 other public health units in Ontario (out of the total of 36),
numerous others across Canada, and in jurisdictions in the USA and Australia.
Its aim is to shift the thinking of policymakers and the public towards a broader
perspective on health (see Chapters 1, 2, 19, and 20 for further discussion about
the importance of this kind of advocacy work for health inequalities).
In a similar vein, Mikkonen and Raphael (2010) created a public primer en-
titled Social Determinants of Health: The Canadian Facts that has been down-
loaded over 300,000 times since April 2010; 85% of these downloads appear to
have been by Canadians. A new organization, entitled Upstream, is also aiming
to create a movement to build a healthy society through dissemination to the
public of evidence-based, people-centred ideas (Upstream 2013). Other useful
Canadian contributions come from analyses of how early child development
shapes health (Hertzman and Frank 2006; Hertzman and Power 2003), efforts
to theorize social inequalities, (Grabb 2007), analyses of how multiculturalism
shapes the welfare state (Banting 2005), and reflections on neoliberalism and
 The situation in the USA 59

the welfare state (Leys 2001; Teeple 2000), globalization and health (Labonte
and Schrecker 2007a, b, c), and how the human rights perspective provides a
moral imperative for addressing health inequalities (Rioux 2010; Teeple 2005).
These works provide insights into the significant barriers that make addressing
health inequalities difficult in the Anglo-Saxon liberal welfare state as well as
means of overcoming them.

4.8  The situation in the USA

Action on health inequalities in USA is much less developed than in Canada. Bez-
ruchka (2012) notes that, in various agency reports, health inequalities are usually
seen as originating in lack of access to health care or the adoption of health-threat-
ening behaviours, such as tobacco use, sedentary behaviour, or ill-chosen diets.
There appears to be a common perception that drawing on developments in the
UK would have little if any value for assisting the agenda in the USA. A prominent
policy analyst who works on Capitol Hill communicated to us that she had been
told, ‘While international data and experiences are interesting, they would have
no value in trying to persuade American policymakers to address these issues.’
This is consistent with ‘American Exceptionalism’, a concept discussed later.
A similar conclusion can be drawn from a series of analyses undertaken by
the Robert Wood Johnson Foundation (the largest US philanthropy devoted
solely to public health issues), on how to communicate with Americans on is-
sues of health inequalities and the social determinants of health (Robert Wood
Johnson Foundation 2010). They provided Americans in numerous focus
groups with the following statement:
America leads the world in medical research and medical care, and for all we spend on
health care, we should be the healthiest people on Earth. Yet on some of the most im-
portant indicators, like how long we live, we’re not even in the top 25, behind countries
like Bosnia and Jordan.
Reproduced from Robert Wood Johnson Foundation, A New Way to
Talk About the Social Determinants of Health, p. 41 © 2010, Robert Wood
Johnson Foundation

The authors of the report note that they tested several versions of this statement,
changing only the countries used as comparators (combinations of 25 different
countries were used) They note that when nations familiar to ­respondents—
such as France and Spain—were used as comparators, ‘respondents rejected
them outright and refused to believe them’ (Robert Wood Johnson Foundation
2010, p. 10). It can be assumed that the UK was one such country. Overall there
is not a single reference to the UK or its experiences addressing health inequali-
ties in the entire report. This is also the case in the Foundation’s two flagship
60 REFLECTIONS ON THE UK FROM NORTH AMERICA

reports on health inequalities (Robert Wood Johnson Foundation 2008, 2013).

This particular form of ‘American Exceptionalism’ or even xenophobia is com-
mon across a wide range of areas (Lipset 1997). It is therefore unsurprising that
UK work has been much more positively received in Canada, a nation with
stronger UK-related traditions and ties compared to the USA.
Researchers working in the USA have developed innovative means of map-
ping health inequalities over time (Bezruchka 2012), and Braveman’s health
equity work (e.g. Braveman and Gruskin 2003) and Navarro’s analyses of the
political economy of health inequalities (Navarro 2009) can help move these
inequalities back onto the public policy agenda in both Canada and the UK.
Hofrichter’s analysis of how local public health units across the USA can ad-
dress issues of health inequalities, and health inequalities can aid these efforts
(Hofrichter 2006). Finally, the pioneering efforts of California Newsreel in pro-
ducing the series Unnatural Causes: Is Inequality Making us Sick? provides a
model of how issues of health inequalities can be communicated to the general
public (Adelman 2008).

4.9  Conclusion
We have been privileged as Canadians in that there is significant interest—if not
action—in Canada on the insights that research and policy activities concern-
ing health inequalities in the UK have provided. Labour’s election in 1997 pro-
vided an impetus for UK action consistent with analysis that social-democratic
parties are more receptive to, and successful at, implementing public policies
that reduce social inequalities and health inequalities (Brady 2009). The recent
2011 elevation of the social-democratic New Democratic Party (NDP) in Can-
ada to the Official Opposition in Ottawa is a positive development, and indica-
tions are that the NDP will raise the issue of the social determinants of health
and health equity in its next election campaign in 2015 (New Democratic Party
of Canada 2013). If this optimistic scenario plays out, and Canada begins to
place health inequalities on the public policy agenda, it will be due in large part
to the contributions provided by the UK. Thank you.

References
Acheson, D. (1998) Independent Inquiry into Inequalities in Health. London: The Stationery
Office.
Adelman, L. (2008) Unnatural Causes: Is Inequality Making us Sick? San Francisco: Califor-
nia Newsreel.
Aggleton, P. (1990) Health. London, UK: Routledge.
Asthana, A., and Halliday, J. (2006) What Works in Tackling Health Inequalities: Pathways,
Politics and Practice through the Lifecourse. Bristol, UK: Policy Press.
 Conclusion 61

Bambra, C. (2005a) Worlds of welfare and the health care discrepancy. Social Policy and So-
ciety, 4(1): 31–41.
Bambra, C. (2005b) Cash versus services: Worlds of welfare’ and the decommodification of
cash benefits and health care. Journal of Social Policy, 34(2): 195–213.
Bambra, C. (2006) Health status and the worlds of welfare. Social Policy and Society, 5(1):
53–62.
Bambra, C. (2007) Going beyond The three worlds of welfare capitalism: Regime theory and
public health research. Journal of Epidemiology and Community Health, 61(12):
1098–1102.
Bambra, C. (2009) Welfare state regimes and the political economy of health. Humanity
and Society, 33(1 and 2): 99–117.
Bambra, C. (2011a) Work, Worklessness and the Political Economy of Health. Oxford:
­Oxford University Press.
Bambra, C. (2011b) Health inequalities and welfare state regimes: Theoretical insights on
a public health ‘puzzle’. Journal of Epidemiology and Community Health, 65(9):
740–745.
Bambra, C., Fox, D., and Scott-Samuel, A. (2005) Towards a politics of health. Health Pro-
motion International, 20(2): 187–193.
Banting, K. (2005) The multicultural welfare state: International experience and North
American narratives. Social Policy and Administration, 39(2): 98–115.
Banting, K., Hoberg, G., and Simeon, R. (eds) (1997) Degrees of Freedom: Canada and the
United States in a Changing World. Montreal, Canada: Queens McGill University Press.
Bartley, M., and Plewis, I. (2002) Accumulated Labour market disadvantage and limiting
long-term illness: Data from the 1971–1992 Office for National Statistics Longitudinal
Study. International Journal of Epidemiology, 31(2): 336–341.
Ben-Shlomo, Y., and Kuh, D. (2002) A life course approach to chronic disease epidemiol-
ogy: Conceptual models, empirical challenges and interdisciplinary perspectives. Inter-
national Journal of Epidemiology, 31(2): 285–293.
Benzeval, M., Judge, K., and Whitehead, M. (1995) Tackling Inequalities in Health: An
Agenda for Action. London: King’s Fund.
Bezruchka, S. (2012) American experiences. In D. Raphael (ed.), Tackling Inequalities in
Health: Lessons from International Experiences. Toronto: Canadian Scholars’ Press,
pp. 33–62.
Black, D., Morris, J., Smith, C., and Townsend, P. (1980) Inequalities in Health. Report of a
Research Working Group. London: Department of Health and Social Security.
Black, D., and Smith, C. (1992) The Black Report. In P. Townsend, N. Davidson, and M.
Whitehead (eds), Inequalities in Health: The Black Report and the Health Divide. New
York: Penguin.
Blaxter, M. (2010) Health (2nd edn). Cambridge, UK: Polity Press.
Boyle, P., Curtis, S., Gatrell, A., Graham, E., and Moore, E. (eds) (2000) The Geography of
Health Inequalities in the Developed World. Ashgate: Aldershot.
Brady, D. (2009) Rich Democracies, Poor People: How Politics Explain Poverty. New York:
Oxford University Press.
Braveman, P., and Gruskin, S. (2003) Defining equity in health. Journal of Epidemiology
and Community Health, 57(4): 254–258.
62 REFLECTIONS ON THE UK FROM NORTH AMERICA

Brunner, E., and Marmot, M. (2006) Social organization, stress, and health. In M. Marmot
and R. G. Wilkinson (eds), Social Determinants of Health (2nd edn). Oxford: Oxford
University Press.
Bryant, T. (2002) The role of knowledge in progressive social policy development and im-
plementation. Canadian Review of Social Policy, 49(50): 5–24.
Bryant, T. (2010) Politics, public policy, and health inequalities. In D. Raphael, T. Bryant,
and M. H. Rioux, (eds), Staying Alive: Critical Perspectives on Health, Illness, and Health
Care (2nd edn). Toronto: Canadian Scholars’ Press, pp. 239–263.
Bryant, T. (2012) Applying the lessons from international experiences. In D. Raphael (ed.),
Tackling Health Inequalities: Lessons from International Experiences. Toronto: Canadian
Scholars’ Press Inc.
Butler-Jones, D. (2008) Report on the State of Public Health in Canada 2008: Addressing
Health Inequalities. Ottawa: Public Health Agency of Canada.
Coburn, D. (2004) Beyond the income inequality hypothesis: Globalization, neo-liberalism,
and health inequalities. Social Science & Medicine, 58(1): 41–56.
Collins, P., and Hayes, M. (2007) Twenty years since Ottawa and Epp: Researchers’ reflec-
tions on challenges, gains, and future prospects for reducing health inequities in Canada.
Health Promotion International, 22(4): 337–345.
Dahlgren, G., and Whitehead, M. (1992) Policies and Strategies to Promote Equity in
Health. Copenhagen, Denmark: World Health Organization, Regional Office for
Europe.
Dahlgren, G., and Whitehead, M. (2006) Levelling Up (Part 2): A Discussion Paper on Euro-
pean Strategies for Tackling Social Inequities in Health. Liverpool, UK: WHO Collaborat-
ing Centre for Policy Research on Social Determinants of Health, University of
Liverpool.
Davey Smith, G. (ed.) (2003) Inequalities in Health: Life Course Perspectives. Bristol, UK:
Policy Press.
Doyal, L. (1995) What Makes Women Sick: Gender and the Political Economy of Health.
New Brunswick, NJ: Rutgers University Press.
Eikemo, T. A., and Bambra, C. (2008) The welfare state: A glossary for public health. Jour-
nal of Epidemiology and Community Health, 62(1): 3–6.
Engels, F. (1845) Die Lage der arbeitenden Klasse in England. Leipzig: Otto Wigand, pub-
lished in translation as Engels, F. (1993) The Condition of the Working Class in England.
Oxford: Oxford University Press.
Galabuzi, G. E. (2005) Canada’s economic apartheid: The social exclusion of racialized
groups in the new century. Toronto: Canadian Scholars’ Press.
Gordon, D. (2010) Health inequalities in developing nations. Social Alternatives, 29(2):
28–33.
Gordon, D., and Townsend, P. (eds) (2000) Breadline Europe: The Measurement of Poverty.
Bristol, UK: The Policy Press.
Grabb, E. (2007) Theories of Social Inequality (5th edn). Toronto: Harcourt Canada.
Graham, H. (ed.) (2001) Understanding Health Inequalities. Buckingham, UK: Open Uni-
versity Press.
Graham, H. (2004a) Social determinants and their unequal distribution: Clarifying policy
understandings. Milbank Quarterly, 82(1): 101–124.
 Conclusion 63

Graham, H. (2004b) Tackling health inequalities in health in England: Remedying health

disadvantages, narrowing health gaps or reducing health gradients? Journal of Social Pol-
icy, 33(1): 115–131.
Graham, H. (2007) Unequal Lives: Health and Socioeconomic Inequalities. New York: Open
University Press.
Guildford, J. (2000) Making the Case for Social and Economic Inclusion. Population Public
Health Branch, Atlantic Regional Office, Halifax: Health Canada.
Hancock, T. (2011) Health promotion in Canada: 25 years of unfulfilled promise. Health
Promotion International, 26(Suppl. 2): ii263–ii267.
Health Council of Canada (2010a) Stepping It Up: Appendix A: Selected Provincial, Territo-
rial and Federal Horizontal Initiatives: Intersectoral and Whole-of-Government Ap-
proaches to Improve Population Health and Reduce Inequities. Toronto: Health Council
of Canada.
Health Council of Canada (2010b) Stepping It Up: Moving the Focus from Health Care in
Canada to a Healthier Canada. Toronto: Health Council of Canada.
Hertzman, C., and Frank, J. (2006) Biological pathways linking the social environment, de-
velopment, and health. In J. Heymann, C. Hertzman, M. Barer, and R. G. Evans (eds),
Healthier Societies: From Analysis to Action. Toronto: Oxford University Press,
pp. 35–57.
Hertzman, C., and Power, C. (2003) Health and human development: Understandings
from life-course research. Developmental Neuropsychology, 24(2 and 3): 719–744.
Hills, J., Sefton, T., and Stewart, K. (eds) (2009) Towards a More Equal Society? Poverty, In-
equality, and Policy Since 1997. Bristol, UK: Policy Press.
Hills, J., and Stewart, K. (eds) (2005) A More Equal Society? New Labour, Poverty, Inequal-
ity and Exclusion. Bristol, UK: Policy Press.
Hofrichter, R. (ed.) (2006) Tackling Health Inequalities through Public Health Practice.
Washington, DC and Lansing, MI: The National Association of County and City Health
Officials and the Ingham County Health Department.
Joyce, K., and Bambra, C. (2010) Health inequalities in developed nations. Social Alterna-
tives, 29(2): 21–27.
Kuh, D., Ben Shlomo, Y., and Susser, E. (eds) (2004) A Life Course Approach to Chronic
Disease Epidemiology (2nd edn). Oxford, UK: Oxford University Press.
Labonte, R. (2004) Social inclusion/exclusion and health: Dancing the dialectic. In D.
Raphael (ed.), Social Determinants of Health: Canadian Perspectives. Toronto: Canadian
Scholars’ Press.
Labonte, R., and Schrecker, T. (2007a) Globalization and social determinants of health: In-
troduction and methodological background. Part 1 of 3. Globalization and Health, 3(5).
Labonte, R., and Schrecker, T. (2007b) Globalization and social determinants of health:
Promoting health equity in global governance. Part 2 of 3. Globalization and Health,
3(6).
Labonte, R., and Schrecker, T. (2007c) Globalization and social determinants of health: The
role of the global marketplace. Part 3 of 3. Globalization and Health, 3(7).
Langille, D. (2009) Follow the money: How business and politics shape our health. In D.
Raphael (ed.), Social Determinants of Health: Canadian Perspectives (2nd edn). Toronto:
Canadian Scholars’ Press, pp. 305–317.
64 REFLECTIONS ON THE UK FROM NORTH AMERICA

Levitas, R. (2005) The Inclusive Society: Social Exclusion and New Labour. Houndmills, Bas-
ingstoke, Hampshire: Palgrave.
Leys, C. (2001) Market-Driven Politics. London, UK: Verso.
Lipset, M. (1997) American Exceptionalism: A Double-Edged Sword. New York: W. W. Nor-
ton and Company.
Lister, R. (2004) Poverty. Cambridge, UK: Polity Press.
Marmot, M. (2004) Status Syndrome: How Your Social Standing Directly Affects Your
Health and Life Expectancy. London, UK: Bloomsbury.
Marmot, M., and Wilkinson, R. (2006) Social Determinants of Health (2nd edn). Oxford,
UK: Oxford University Press.
Marmot, M., Allen, J., Goldblatt, P., Boyce, T., McNeish, D., Grady, M., and Geddes, I.
(2010) Fair Society, Healthy Lives: Strategic Review of Health Inequalities in England Post
2010 (The Marmot Review). London, UK: UCL Institute of Health Equity.
Low, J., and Therault, L. (2008) Health promotion policy in Canada: Lessons forgotten, les-
sons still to learn. Health Promotion International, 23(2): 200–206.
Marsh, A., Gordon, D., Pantazis, C., and Heslop, P. (1999) Home Sweet Home? The Impact
of Poor Housing on Health. Bristol, UK: Policy Press.
Mikkonen, J., and Raphael, D. (2010) Social Determinants of Health: The Canadian Facts.
Retrieved 28 June 2011, from http://thecanadianfacts.org.
Mitchell, R., Dorling, D., and Shaw, M. (2000) Inequalities in Life and Death. What if Brit-
ain Were More Equal? Bristol, UK: The Policy Press.
Navarro, V. (2009) What we mean by social determinants of health. Global Health Promo-
tion, 16(1), 5–16.
Navarro, V., Borrell, C., Benach, J., Muntaner, C., Quiroga, A., Rodrigues-Sanz, M.,
­Vergés, R., Gumá, J., and Pesarín, M. I. (2004) The importance of the political and the
social in explaining mortality differentials among the countries of the OECD, 1950–1998.
In V. Navarro (ed.), The Political and Social Contexts of Health. Amityville, NY: Baywood
Press, pp. 11–86.
New Democratic Party of Canada (2013) Disease Prevention. Retrieved 22 October 2014
from http://www.ndp.ca/health/disease-prevention.
Pantazis, C., Gordon, D., and Levitas, R. (eds) (2006) Poverty and Social Exclusion in Brit-
ain: The Millennium Study. Bristol, UK: Policy Press.
Petticrew, M., Whitehead, M., Macintyre, S. J., Graham, H., and Egan, M. (2004) Evidence
for public health policy on inequalities: 1: The reality according to policymakers. Journal
of Epidemiology and Community Health, 58(10): 811–816.
Pollard, T. M., and Brin Hyatt, S. (eds) (1999) Sex, Gender and Health. New York: Cam-
bridge University Press.
Popay, J., and Williams, G. H. (eds) (1994) Researching the People’s Health. London, UK:
Routledge.
Public Health Agency of Canada and Health Systems Knowledge Network (2007) Crossing
Sectors: Experiences in Intersectoral Action, Public Policy and Health. Ottawa: Public
Health Agency of Canada and Health Systems Knowledge Network.
Raphael, D. (2008) Grasping at straws: A recent history of health promotion in Canada.
Critical Public Health, 18(4): 483–495.
 Conclusion 65

Raphael, D. (2010) Bridging the gap between research findings and public policy. In
D. Raphael (ed.), Health Promotion and Quality of Life in Canada: Essential Readings.
­Toronto: Canadian Scholars’ Press, pp. 139–147.
Raphael, D. (2011) Mainstream media and the social determinants of health in Canada: Is it
time to call it a day? Health Promotion International, 26(2): 220–229.
Raphael, D. (2012) An analysis of international experiences in tackling health inequalities.
In D. Raphael (ed.), Tackling Health Inequalities: Lessons from International Experiences.
Toronto: Canadian Scholars’ Press, pp. 229–264.
Raphael, D., Daiski, I., Pilkington, B., Bryant, T., Dinca-Panaitescu, M., and Dinca-­
Panaitescu, S. (2012) A toxic combination of poor social policies and programmes, un-
fair economic arrangements and bad politics: The experiences of poor Canadians with
Type 2 diabetes. Critical Public Health, 22(2): 127–145.
Restrepo, H. E. (2000) Health promotion: An anthology. In H. E. Restrepo (ed.), (pp. ix–xi).
Washington, DC: Pan American Health Organization.
Rioux, M. (2010) The right to health: Human rights approaches to health. In D. Raphael, T.
Bryant, and M. Rioux (eds), Staying Alive: Critical Perspectives on Health, Illness, and
Health Care. Toronto: Canadian Scholars’ Press Inc.
Riste, L., Khan, F., and Cruickshank, K. (2001) High prevalence of type 2 diabetes in all
ethnic groups, including Europeans, in a British inner city. Relative poverty, history, in-
activity, or 21st-century Europe? Diabetes Care, 24(8): 1377–1383.
Robert Wood Johnson Foundation (2008) Overcoming Obstacles to Health. Princeton:
Robert Wood Johnson Foundation.
Robert Wood Johnson Foundation (2010) A New Way to Talk about the Social Determin-
ants of Health. Princeton: Robert Wood Johnson Foundation. Retrieved 6 February 2012
from http://www.rwjf.org/vulnerablepopulations/product.jsp?id=66428.
Robert Wood Johnson Foundation (2013) Overcoming Obstacles to Health in 2013 and Be-
yond. Princeton: Robert Wood Johnson Foundation.
Scott-Samuel, A., Birley, M., and Ardern, K. (2001) The Merseyside Guidelines for Health
Impact Assessment. Liverpool: International Health Impact Assessment Consortium.
Senate Subcommittee on Population Health (2008) A Healthy, Productive Canada: A De-
terminant of Health Approach. Ottawa: Government of Canada.
Shaw, M. (2001) Health and housing: A lasting relationship. Journal of Epidemiology and
Community Health, 55(5): 291–296.
Shaw, M. (2004) Housing and public health. Annual Review of Public Health, 25: 397–418.
Shaw, M., Dorling, D., Gordon, D., and Smith, G. D. (1999) The Widening Gap: Health In-
equalities and Policy in Britain. Bristol, UK: The Policy Press.
Shaw, M., Dorling, D., and Mitchell, R. (2002) Health, Place and Society. Harlow, UK:
Prentice Hall.
Smith, K. E. (2007) Health inequalities in Scotland and England: The contrasting journeys
of ideas from research into policy. Social Science and Medicine, 64(7): 1438–1449.
Smith, K., and Bambra, C. (2012) British and Northern Irish experiences. In D. Raphael
(ed.), Tackling Health Inequalities: Lessons from International Experiences. Toronto: Ca-
nadian Scholars’ Press, pp. 93–121.
Social Exclusion Unit (2001) Preventing Social Exclusion. London: Social Exclusion Unit.
66 REFLECTIONS ON THE UK FROM NORTH AMERICA

Subcommittee on Population Health of the Standing Senate Committee on Social Affairs,

S. a. T. (2008) Population Health Policy: Issues and Options, from http://www.parl.gc.ca/
Content/SEN/Committee/392/soci/rep/rep10apr08-e.htm.
Sudbury and District Health Unit (2011) Let’s Start a Conversation about Health . . . and
Not Talk about Health Care at All. Retrieved 25 June 2011, from http://tinyurl.
com/7t8476f.
Teeple, G. (2000) Globalization and the Decline of Social Reform: Into the Twenty-First Cen-
tury. Aurora, Ontario: Garamond Press.
Teeple, G. (2005) Riddle of Human Rights. Aurora Ontario: Garamond.
Templeton, L., Velleman, R., Persaud, A., and Milner, P. (2003) The experiences of post-
natal depression in women from black and minority ethnic communities in Wiltshire,
UK. Ethnicity and Health, 8(3): 207–221.
The Caledon Institute (2001) The Harris record. In R. Cohen (ed.), Alien Invasion: Ontario
Politics and Government 1995–2003. Toronto: Insomniac Press.
Townsend, P., Davidson, N., and Whitehead, M. (eds) (1992) Inequalities in Health: The
Black Report and the Health Divide. New York: Penguin.
Townsend, P. (1993) The International Analysis of Poverty. Milton Keynes: Harvester
Wheatsheaf.
Upstream (2013) Upstream is a Movement to Create a Healthy Society through Evidence-
Based, People-Centred Ideas, from http://www.thinkupstream.net/.
Welsh Assembly Government (2004) Health Challenge Wales. Cardiff, UK: Welch Assem-
bly Government.
Whitehead, M. (1985) The Concepts and Principles of Equity and Health. Copenhagen:
WHO Regional Office for Europe.
Whitehead, M. (1987) The Health Divide: Inequalities in Health in the 1980s. London:
Health Education Authority.
Whitehead, M. (1992) The health divide. In P. Townsend, N. Davidson, and M. Whitehead
(eds), Inequalities in Health: The Black Report and the Health Divide. New York: Penguin,
pp. 215–281.
Whitehead, M., Petticrew, M., Graham, H., Macintyre, S. J., Bambra, C., and Egan, M.
(2004) Evidence for public health policy on inequalities: 2: Assembling the evidence jig-
saw. Journal of Epidemiology and Community Health, 58(10): 817–821.
Whitehead, M. (2009) England. In C. Hogstedt, H. Moberg, B. Lundgren, and M. Backhans
(eds), Health for All? A Critical Analysis of Public Health Policies in Eight European Na-
tions. Stockholm: Swedish National Institute for Public Health, pp. 89–120.
Whitehead, M., and Dahlgren, G. (2006) Levelling Up (Part 1): A Discussion Paper on Con-
cepts and Principles for Tackling Social Inequities in Health. Liverpool, UK: WHO Collab-
orating Centre for Policy Research on Social Determinants of Health, University of
Liverpool.
Wilkinson, R. G. (1996) Unhealthy Societies: The Afflictions of Inequality. New York:
Routledge.
Wilkinson, R. (2001) Mind the Gap: Hierarchies, Health and Human Evolution. London:
Weidenfeld and Nicolson.
Wilkinson, R. G., and Pickett, K. (2009) The Spirit Level—Why More Equal Societies Al-
most Always Do Better. London, UK: Allen Lane.
 A Checklist for Whole-of-Government or Inter-Sectoral Approach 67

Williams, G., and Popay, J. (1997) Social science and the future of population health. In L.
Jones and M. Sidell (eds), The Challenge of Promoting Health. London, UK: The Open
University, pp. 260–273.

Appendix I  A Checklist for Whole-of-Government

or Inter-Sectoral Approach
The checklist on this page synthesizes key pieces of information from Canadian
and international reports and documents about implementing inter-sectoral
and whole-of-government approaches; our consultants’ experience working
with Canadian governments, agencies, and organizations; and the information
we gathered from our interviews with officials from across Canada.
Values and commitment:
◆ An overriding philosophy that health initiatives will be viewed through a
population health lens.
◆ Leadership at the top from the prime minister, premiers, ministers, cabinet
secretaries, and others.
◆ Recognition and awareness among elected representatives of the import-
ance of the determinants of health for promoting population health and re-
ducing health inequities.
◆ Recognition that it may take years, even decades, for benefits to materialize.
◆ Willingness to name the difficult problems and barriers that exist, and to
provide the resources necessary to transcend them.
◆ Commitment of civil servants to undertake a broader approach to address-
ing population health and reducing health inequities.
◆ Willingness and commitment to ensure a structural approach to placing
health projects on the public policy agenda.
◆ Allocation of significant funding that allows for governmental commission-
ing of research, analysis, and policy implementation.
Information and data:
◆ Decisions should be made and actions taken based on available evidence
without necessarily waiting for conclusive evidence.
◆ Information and evidence on the state of population health and the presence
of health inequities is presented in a government-instigated integrative re-
port or statement.
◆ Development of clear, identifiable, and measurable goals and targets.
◆ Focusing on explicit concrete objectives and visible results. Ensuring trans-
parency in governmental efforts and activities.
68 REFLECTIONS ON THE UK FROM NORTH AMERICA

◆ Messaging to the public, including media support, about the importance of

dealing with population health and reducing health inequities through ac-
tion on the determinants of health.
◆ Development of practical models, tools, and mechanisms, such as health
impact assessment, to support the implementation.
◆ Setting of realistic timelines.
◆ Support for academic and agency researchers who provide data and
evaluation.
◆ Provision of ongoing public reports that document successes and
challenges.
Governmental infrastructure:
◆ Governments must establish the means for society’s participation in the
initiatives.
◆ Establishment of an independent authority within government that will be
responsible for coordinating activity across ministries and departments.
◆ Cross-ministry structures and processes that provide a basis for these kinds
of whole-of-government or inter-sectoral approaches.
◆ Contacting and drawing support from various external organizations that
would be responsive to governmental action on the determinants of health.
◆ Government civil servants’ capacity to carry out the task.
◆ Ensuring that leadership, accountability, and rewards are shared among
partners.
◆ Provision of adequate resources to sustain activities beyond the tenure of the
present governing authority.
◆ Establishment of a balance between central direction and discretion of local
authorities to implement goals and objectives.
◆ Establishment of accountability and evaluation frameworks.
◆ Building of stable teams of people who work well together, with appropriate
support systems.
Reproduced with permission from Health Council of Canada, Stepping it Up: Moving the Focus from
Health Care in Canada to a Healthier Canada, p. 25, Health Council of Canada, Toronto, Canada,
Copyright © 2010, available from http://www.healthcouncilcanada.ca/tree/2.40-
HCCpromoDec2010.pdf.
 Chapter 5

Reflections on the UK legacy

of health inequities research,
from the perspective of low-
and middle-income countries
(LMICs)
Johanna Hanefeld

5.1  UK leadership on the social determinants of health

Although the socially determined nature of health has been emphasized in glo-
bal policy commitments on health, including in the WHO constitution in
1948, the Alma Ata Declaration on primary health care in 1978 (which expli-
citly acknowledged the need for a focus on ‘social, economic and political
causes of poor health’) and the Health for All Movement in 1988, concerted
policy action on social determinants of health is a more recent phenomenon
(Irwin and Scali 2010). As Chapters 1 and 2 outline, the UK has a particularly
rich legacy of research on health inequities and their social determinants. As a
consequence, the UK is seen as a global and European leader, both in terms of
research on and policy awareness about health inequities (Mackenbach and
Bakker 2003). Along with Sweden, Norway (see Chapter 3), and the Nether-
lands, the UK is considered amongst the first European countries to work to
translate policy commitments to reducing health inequities and addressing the
social determinants of health into practice (see Chapters 1–4). Emblematic of
the UK research communities’ leadership in health inequities research is the
chairing of the WHO’s Commission on Social Determinants of Health by a UK
academic, Professor Sir Michael Marmot. This chapter reflects on the impact
and legacy of UK health inequities research from the perspective of low- and
middle-income countries (LMICs) by examining the nature and evidence base
on health inequities and how responses to health inequities globally have
changed over time.
70 LOW- AND MIDDLE-INCOME COUNTRY PERSPECTIVES

5.2  The nature of evidence on health inequities

Policy action, or the lack thereof, on health inequities links closely to the nature
and function of evidence. The public health community (in policy, research,
and practice settings) is largely committed to the idea that health policy ought
to be evidence-informed (Smith 2013). Research on health inequities is difficult
as it involves examining determinants of health, which often lie outside of
health, are relatively upstream, and are often themselves subject to a complex
set of political decisions (see Chapters 8 and 16). A specific challenge of this
work is to establish direct causality. Reflecting this, the WHO Commission on
Social Determinants of Health remarked that:
By their nature many of the social determinants considered by the Commission are
relatively distant, spatially and temporally from individuals and health experience. This
is challenging, both conceptually and empirically, when trying to attribute causality
and demonstrate effectiveness of action on health equity. (Commission on Social De-
terminants of Health (CSDH), 2008, p. 42)

Thus, much evidence in the field of social determinants of health has focused on
measurement of burden by different social groups in an attempt to ascertain the
aetiological pathways linking specific determinants to health effects. This type
of research has drawn largely on methods from the field of social epidemiology
(see Chapters 1, 6, and 16–18 for some critical perspectives on this). Adding to
the complexity for research addressing health inequities is the fact that depriv-
ation and exclusion inherently create vulnerability to ill-health and negative
health outcomes at population level, complicating further the attribution of in-
dividual factors that in turn would allow for policies and strategies to redress
ill-health even in comparative poverty (Bernard et al. 2007). These characteris-
tics, taken together, mean that health inequities are difficult to measure and that
identifying and addressing their causes is complex. At the same time, given the
relatively recent nature of policy interventions aimed at addressing health in-
equities in high-income countries (roughly over the past 25 years), evaluation
of policies and interventions to address the causes of health inequities remains
comparatively limited (Macintyre et al. 2001; Mackenbach 2010).
Despite these challenges in evidence creation and the complexity of causal
pathways, the link between overall country development and health is widely
recognized. This is evident in major, international policy initiatives, such as the
Millennium Development Goals (MDGs), which clearly recognize the import-
ance of health to achieving wider development outcomes. However, the MDGs,
which shaped much of the development agenda and determined funding to
LMICs, have been criticized for their lack of attention to equity (Irwin and Scali
2010; Waage et  al.  2010). The extent to which LMICs have linked health
 ADDRESSING HEALTH INEQUITIES IN LMICs 71

policies to the attainment of the MDGs may in fact have been a contributing fac-
tor for the limited attention paid to health inequities in LMICs to date. A large
extent of policy attention and financing, including by international donors and
aid agencies, has focused on achieving the eight headline goals and the targets
defined within these. For example, the reduction in maternal and child mortality,
as well as in the number of people living with HIV, has focused on total numerical
indicators per country. Successes by countries in reaching these targets overall
have in many cases masked uneven progress, with those with better income, for
example, benefiting more from improvements in health (Wagstaff et al. 2014).
Moreover, detailed research at country level has in the past revealed that in some
cases where overall national indicators have improved, these have actually wors-
ened amongst sections of the population facing marginalization. For example,
rates of maternal mortality have often been persistently high amongst indigenous
women in central American countries like Peru (International 2007).

5.3  Addressing health inequities in LMICs

5.3.1  Research
Research on health inequities in LMICs has differed from the (many more)
studies focusing on high-income countries, such as the United Kingdom, Swe-
den, and the Netherlands. In the latter, research has tended to focus on factors
producing socioeconomic gradients in morbidity and mortality which cut
across all social and income groups in society. This has resulted in identifying a
differential burden of disease (e.g. cardiovascular diseases), risk factors (such as
tobacco and alcohol), and wider determinants (including education and in-
come). On the other hand, health inequities research in LMICs has, for much of
the two decades preceding 2000, focused on addressing health inequities
through policies and financing aimed at increasing access to health services
(Leon 2001). This is partly because access to services has posed such a great
challenge to population health in many LMICs, given the high burden resulting
from communicable disease. Research on and action to address inequities in
health have therefore often focused more on health systems or the developmen-
tal barriers (including poverty) to accessing health services that face different
groups (Travis et al. 2004). As a consequence, health inequities in LMICs have,
in the past, often been associated and researched in the context of a lack of ac-
cess to health services, or challenges to accessing health services. For example,
maternal mortality has been seen mainly in terms of physical barriers of access
(Belaid and Ridde 2012; International 2007) and many of the large-scale inter-
ventions to expand HIV treatment to patients in LMICs initially focused
72 LOW- AND MIDDLE-INCOME COUNTRY PERSPECTIVES

narrowly on the provision of treatment rather than on more systemic issues

(Hanefeld 2010).

5.3.2  The Commission on Social Determinants of Health

Recently, however, approaches to thinking about health inequities in LMICs
have started to change, as population health is increasingly challenged by the
rise of non-communicable diseases (NCDs) (Alwan and MacLean 2009; Irwin
et al. 2006). As in high-income countries, the causes of NCDs lie outside of the
health sector (Irwin, Valentine et al. 2006). The CSDH, convened by the WHO
in 2005, marked a milestone in the development of research on health inequi-
ties, as it brought together practitioners and researchers who had previously
approached health inequities from these contrasting (i.e. high- versus LMICs)
perspectives. While the CSDH was shaped around the work of nine knowledge
networks, it was chaired by Sir Michael Marmot, a UK social epidemiologist
whose background included the famous Whitehall Study (Marmot et al. 1991),
a longitudinal study of British civil servants which identified clear, socially
graded inequalities in the health of civil servants (see Chapter 1). This research
is firmly positioned in the tradition of health inequities research in high-­income
countries, with the concomitant focus on interventions aimed at addressing
variations in risky behaviours and broader, upstream determinants of such be-
haviours. In other words, the CSDH was led by someone whose work had fo-
cused on this, rather than a developmental, approach to health inequities.
The CSDH produced its final report and associated recommendations in
2008. These were broad and ‘upstream’ in nature:
1 improve daily living conditions;
2 tackle the inequitable distribution of power money and resources; and
3 measure and understand the problem and assess the impact of action.
Despite the significant resources invested in the CSDH, little is known about
how the outputs or processes have been informed or interpreted by national
and local actors in LMICs.

5.3.2.1  Growing policy interest in health inequities in LMICs

There is growing evidence that LMICs are increasingly adopting strategies to ad-
dress health inequities (Marmot et al. 2012). There may be several reasons for this.
In part this may be as a result of growing attention to inequities in LMICs. This in-
cludes in countries developing and transitioning from low- to middle-income sta-
tus, such as Zambia, and the ‘rising powers’, including the BRICS countries (Brazil,
Russia, India, China and South Africa), which hold an increasing amount of the
world’s wealth but which, nonetheless, face numerous population challenges,
 ADDRESSING HEALTH INEQUITIES IN LMICs 73

including health inequities. This is increasingly leading to health inequities being

raised as a domestic policy issue, with dissatisfaction becoming more evident
amongst poorer sections of the population as demonstrated, for example, by the
recent demonstrations of Chinese citizens against air pollution (Davison 2014).
Health inequities in emerging economies have also received greater attention
in recent years from donor agencies, posing new challenges for donor coun-
tries. Traditionally most international development assistance is provided from
donor countries either bilaterally to the government or civil society organiza-
tions of another country. Alternatively, development assistance is channelled
through multilateral organizations such as United Nations or the WHO. Since
the 2000s this has also included an increasing channelling of aid through civil
society organizations, including non-governmental organizations such as Me-
decins Sans Frontiers (MSF), or public–private partnerships such as the Global
Fund to Fight AIDS TB and Malaria (GFATM) (Buse et al. 2009).
In the past, when the vast majority of people in LMICs were living in poverty,
a model where aid was given on a country basis seemed unproblematic. How-
ever, as many countries develop, but develop unevenly, the majority of the
world’s poorest people are increasingly living in middle- and high-income
countries. This makes a model of aid, where one government gives to another,
harder to justify. For example, the UK government announced it was ceasing
aid to India by 2015, as the Indian government itself is seen as wealthy enough
to look after the majority of its citizens (BBC 2012). Yet, a large number of peo-
ple in India still are amongst the world’s poorest (400 million according to
World Bank estimates in 2010). This example highlights the challenges of exist-
ing aid modalities in a world where the majority of poor people live in middle-
and high-income countries. In this context, the question of how to address
health inequities is gaining importance within the field of development and
global health. This is already reflected in the calls for greater emphasis on equity
in the post-MDGs (Alleyne et al. 2013; Stuckler et al. 2010).
Second, as noted already, the growing burden of NCDs in LMICs, which in-
variably require greater focus on prevention, is also likely to be stimulating the
greater focus on health inequities in these settings. By 2013, NCDs had caused
35 million of the 53 million annual deaths worldwide and more than three-
quarters of these occurred in low- and middle-income countries (Alleyne
et al. 2013). While less is known about the health inequities within LMICs, re-
searchers working on NCDs have highlighted that, to address the challenge of
NCDs requires further research on within-country health differences in LMICs
(Di Cesare et al. 2013). In effect, the changing burden of disease also necessi-
tates a shift in research focus from access to health services and absolute pov-
erty to better understanding upstream factors and interventions addressing the
74 LOW- AND MIDDLE-INCOME COUNTRY PERSPECTIVES

determinants of health and their distribution (i.e. to a research agenda more

similar to the type of research conducted in the UK over the past 30 years).
Third, the greater focus on health inequities in LMICs may in part result from
the momentum generated by the CSDH and the resulting World Health Assem-
bly Resolution 62.14, Reducing health inequities through action on the social de-
terminants of health, which committed Member States to adopting and enacting
policies based on recommendations and findings of the CSDH (2008). A World
Conference on Social Determinants on Health was held by the WHO in Brazil
in 2011, discussing progress towards the implementation of recommendations
by the CSDH. This resulted in a political declaration (2011) indicating coun-
tries’ support for the agenda of addressing health inequities.

5.4  Challenges to addressing health inequities in LMICs

5.4.1  Long-term interventions
Addressing health inequities in LMICs poses several challenges which may be
specific to these settings, or at least more pronounced than in high-income set-
tings. It is well recognized that for policies and strategies addressing health in-
equities via upstream social determinants to demonstrate effect requires a long
timeframe. This has been observed by several commentators and advanced as
an explanation for failures of past policy efforts to achieve reductions in inequi-
ties, including in the UK (Leon 2001; Mackenbach 2011). This is likely to be
particularly problematic for low-income countries, which remain heavily reli-
ant on aid as a source of revenue (Grepin and Sridhar 2012). Commentators on
the English health inequalities strategy have argued that a period of longer than
the 13 years that Labour were in power may be required to deliver substantial
reductions in health inequities in the Western democratic context, but it is hard
to imagine how this might be enabled in democracies (Mackenbach 2011).
This may be even more difficult to imagine in low-income settings that are de-
pendent on aid, given the documented volatility and short-term nature of de-
velopment aid (Grépin and Sridhar 2012). The need for long-term sustained
investments to achieve changes in the social determinants and health inequi-
ties mean that these processes will have to be led by civil society and other dis-
parate actors within these countries working to hold their governments to
account on equity targets.

5.4.2  Measurement of social determinants

and of health inequities
Measurement of health inequities within countries was identified as a priority
by the CSDH and continues to be highlighted as a challenge within the literature
 CHALLENGES IN LMICs 75

(CSDH 2008). While this remains a challenge even in the high-income settings
(Marmot and Goldblatt 2013; and see Chapter 2), limited and often poor-­quality
data make this a particular challenge in LMICs. A policy appraisal focusing on
social inclusion policies in six sub-Saharan African countries, for example,
identified the lack of measurement of inequities as a key challenge (Rispel
et al. 2009). Research examining health inequities drawing on household sur-
veys in South Africa also highlighted concerns and weaknesses with these data
(Ataguba et al. 2011), despite South Africa having some of the stronger datasets
and research capacity amongst LMICs.
Ongoing research by the author, currently in the inception phase, aims to ex-
plore approaches to health inequities in Chile and Venezuela and in Ethiopia
and Kenya. An initial review of secondary data to compare trends in health in-
equities over time underscored the lack of comparable data. Specifically, a focus
on MDG indicators on maternal and child mortality, nutrition, and immuniza-
tion revealed that such data was available by income quintile for Ethiopia and
Kenya, but not for Chile or Venezuela.

5.4.3  Research and policy capacity

Closely linked to the monitoring and measurement of data are issues relating to
research capacity and, importantly, capacity amongst those charged with im-
plementing policies and interventions (e.g. health information systems to
monitor health inequities). While there is now a very strong and rapidly grow-
ing social science and global health research community in many LMICs, par-
ticularly in Asia and sub-Saharan Africa, gaps in capacity remain, especially
amongst those charged with implementing policies (e.g. in the public sector)
(Samb et al. 2010).
To implement routine monitoring of health outcomes by social status and
enable cross-referencing of, for example, mortality data by education, age, em-
ployment status, gender, and income levels, requires significant investment in
public-sector human resources, including career structures, to provide incen-
tives for the retention of highly educated and skilled workers. For such efforts to
be worthwhile, a policy process which is responsive to findings and adjusts
policy measures on the basis of data collected is also required. Findings from
policy analysis of health reform processes in LMICs highlight the importance
of human resources and implementers in this context, and provide a sense of
the likely challenges involved in operationalizing this (e.g. Lee et al 2002). Qual-
itative research on the challenges front-line health workers in LMICs highlight
the existing challenges faced at clinic level, in terms of resources, staffing, and
management (Topp et al. 2015). It is in this context that further equity-sensitive
monitoring will have to be implemented.
76 LOW- AND MIDDLE-INCOME COUNTRY PERSPECTIVES

5.4.4  Accountability
Measurement of inequities and implementation capacity relate directly to is-
sues of accountability, which have proven critical to addressing health inequi-
ties in high-income settings. Again, research by the CSDH focusing on the
possibility of policy transfer from one country to another identified the lack of
participation by civil society and relevant communities in policy design and
implementation, resulting in a lack of accountability, as a key challenge to suc-
cessful implementation (Rispel et al. 2009). This seems a critical issue: while
there are many social movements in LMICs, including around health (e.g. the
Treatment Action Campaign in South Africa, ActUP, and others), these have so
far tended to focus on questions of access to medicines and health systems, ra-
ther than on issues relating to equity and social determinants, for the reasons
set out earlier. Some research and activist organizations based in LMICs such as
the People’s Health Movement (which has an explicit equity focus and was con-
sulted during the CSDH), the Equity Gauge in South Africa, and Equinet Africa
(Equinet Africa 2014) are undertaking important work. However, this has not
yet developed into more widespread social mobilization around social deter-
minants or health inequities. The recent resonance and uptake of the 99%
movement in LMICs showed some greater attention to the issue of inequities,
including in health (Sharma 2011). However, just as health inequities research
in the UK and other high-income countries has been championed by medics
and academic researchers, its broader application in LMICs will require domes-
tic champions, leadership, and policy entrepreneurs. Given the differences in
context, whereas champions in many high-income countries, including in the
Nordic region and the UK (see Chapters 1–3), have come from the academic
medical sectors, such leadership may depend on other kinds of communities in
low-­income countries.

5.4.5  Health
as a starting point for addressing social
determinants may not be the best strategy
In addition to potentially different sources of leadership, it is likely that strat-
egies to address health inequities may need to be articulated in a different way
in LMICs. Evidence shows that factors and policies lying out of the domain of
health, such as employment and education, have far-reaching consequences for
health. Recommendations from the field of health inequities and social deter-
minants, including the CSDH and the more recent Political Rio Declaration
(CSDH 2008, 2011), highlight the need for the health sector to work with others
through intersectoral action. Concepts such as ‘governance for global health’
(Kickbusch and Szabo 2014) draw attention to the role of other sectors and the
 UK LEGACY—PREVENTING A REVOLUTION IN LMICs? 77

critical role for health as a brokering concept in making these connections. If we

take together the magnitude of inequities and challenges faced by LMICs with
the overwhelming evidence of upstream determinants and their effects on
health, it is possible that ‘health’ may not be the best entry point to address
health inequities (as, indeed, Chapter 8 argues in relation to high-income set-
tings). The kind of radical change required, as the CSDH itself formulated, to
‘tackle the inequitable distribution of power, money and resources’ will likely
require more radical approaches and champions to policymaking than the field
of health inequities and social determinants of health has so far produced. In
fact, it may be more effective to work with labour movements, or the business
and education sectors, than through ‘health’ coalitions. A possible limitation of
current attempts to translate research findings from high-income settings, such
as the UK, into policy recommendations in LMICs may be that it prevents more
radical articulation of a health inequities movement. It may, for example, be
more likely that the pressure to introduce policies and actions to address social
determinants of health and their unequal distribution in LMICs is better en-
abled via broader social justice frames and movements, such as the ‘We are the
99%’ movement, than it can be via evidence-based health inequities debates.

5.5  The legacy of UK health inequities r­ esearch—

preventing a revolution in LMICs?
In sum, addressing health inequities in LMICs is an emerging field of re-
search, policy, and advocacy. Research into, and responses to, health inequi-
ties have, internationally, been informed by the strong research tradition in
this field in the UK and other northern European countries. This tradition, as
Chapters 1–4 of this book outline, focuses on social differences of health re-
lating to indicators of health outcomes, related lifestyle behaviours, and the
wider contexts that shape these behaviours and directly inform patterns of
health inequity. In contrast, as this chapter outlines, inequities in health in
LMICs have (where they have been a focus of discussion at all) been primar-
ily articulated as inequities in access to health services and/or treatments.
Both approaches make sense, given the historical, disease-specific context of
these different settings. However, this is now changing with the international
spread of NCDs (see also Chapter 13), which requires efforts to address social
determinants that go far beyond (whilst still including) access to health ser-
vices and treatments.
There are many challenges to addressing health inequities in LMICs, includ-
ing those relating to data availability, resources, skills capacity, and policy ac-
countability. In low-income settings where health and other social systems
78 LOW- AND MIDDLE-INCOME COUNTRY PERSPECTIVES

are, in large part, dependent on donor funding, this extends responsibility for
addressing health inequities and their social determinants to the donors who
provide funding. Yet, to date, there is little evidence that major funders in
LMICs (e.g. the Bill and Melinda Gates Foundation and the GFATM) are able
to support the more complex interventions which address some of the up-
stream interventions that are required.
These challenges to addressing health inequities in LMICs may not be best
served by exporting research, ideas, and interventions from high-income coun-
tries. Indeed, the challenges of inequities in health in LMICs may be more effect-
ively tackled by being articulated by other sectors or by more justice-based
responses to those developed in stable social democracies with functioning wel-
fare states. Here, examples of such therapeutic citizenship evident in Brazil and
the more radical efforts by HIV treatment access movements in South Africa and
elsewhere highlight types of approaches that seem very different to those fostered
by the health inequalities movement, which grew mainly out of the tradition of
public health and social medicine (see Chapters 1 and 2). Clinicians and health
workers are powerful and much-needed advocates against inequities, and ‘health’
often has a tremendous convening power (Yach and Bettcher 1998). At the same
time, however, medical and other health actors should not been seen as the sole
leaders or custodians of a movement to tackle health inequities and their social
determinants, but rather as one part of efforts to enable wider, indigenous efforts
to generate and express populist responses to health inequities in new ways. Key
to this will be research to explore what is actually happening in LMICs, compar-
ing, for example, those that have taken an e­ vidence-informed CSDH approach
with those that have experienced more political, social justice based movements.

Acknowledgements
This research was supported by a small grant from the Wellcome Trust (grant
number WT103441FR).

References
Alleyne, G., Binagwaho, A. Haines, A., Jahan, S., Nugent, R., Rojhani, A., and Stuckler, D.
(2013) Embedding non-communicable diseases in the post-2015 development agenda.
The Lancet, 381(9866): 566–574.
Alwan, A. and MacLean, D. R. (2009) A review of non-communicable disease in low- and
middle-income countries. International Health, 1(1): 3–9.
Ataguba, J. E., Akazili, J., and McIntyre, D. (2011). Socioeconomic-related health inequal-
ity in South Africa: evidence from General Household Surveys. International Journal of
Equity in Health 10(1): 48. doi:10.1186/1475-9276-10-48
BBC (2012) UK to end financial aid to India by 2015. Retrieved 23 January 2014 from
http://www.bbc.co.uk/news/uk-politics-20265583.
 UK LEGACY—PREVENTING A REVOLUTION IN LMICs? 79

Belaid, L. and Ridde, V. (2012) An implementation evaluation of a policy aiming to im-

prove financial access to maternal health care in Djibo district, Burkina Faso. BMC Preg-
nancy and Childbirth, 12(1): 143.
Bernard, P., Charafeddine, R., Frohlich, K. L., Daniel, M., Kestens, Y., and Potvin, L.
(2007) Health inequalities and place: A theoretical conception of neighbourhood. Social
Science and Medicine, 65(9): 1839–1852.
Buse, K., Hein, W., and Drager, N. (eds) (2009) Making Sense of Global Health
­Governance—A Policy Perspective. London: Palgrave Macmillan.
CSDH (2008) Closing the Gap in a Generation: Health Equity through Action on the Social
Determinants of Health. Final Report of the Commission on the Social Determinants of
Health. Geneva: World Health Organization.
Davison, N. (2014) Environmental protest in China—volatile atmosphere, 4 April. London:
The Economist Group.
Di Cesare, M., Khang, Y.-H., Asaria, P., Blakely, T., Cowan, M. J., Farzadfar, F., Guerrero,
R., Ikeda, N., Kyobutungi, C., Msyamboza, K. P., Oum, S., Lynch, J. W., Marmot,
M. G., and Ezzati, M. (2013) Inequalities in non-communicable diseases and effective
­responses. The Lancet, 381(9866): 585–597.
Equinet Africa (2014). Equinet Africa website. Accessed 23 January 2014 from http://www.
equinetafrica.org.
Grépin, K. A. and Sridhar, D. (2012) Multi-bi aid and effects of the 2008–10 economic
­crisis on voluntary development assistance for health contributions: A time series
­analysis. The Lancet, 380(Suppl. 2): S3.
Hanefeld, J. (2010) The impact of Global Health Initiatives at national and sub-national
level—a policy analysis of their role in implementation processes of antiretroviral treat-
ment (ART) roll-out in Zambia and South Africa. AIDS Care, 22(Suppl. 1): 93–102.
International, A. (2007) Fatal flaws—barriers to maternal mortality in Peru. London.
Irwin, A., and Scali, E. (2010) Action on the Social Determinants of Health: Learning from
Previous Experiences. Geneva: WHO.
Irwin, A., Valentine, N., Brown, C., Loewenson, R., Solar, O., Brown, H., Koller, T., and
Vega, J. (2006) The Commission on Social Determinants of Health: Tackling the social
roots of health inequities. PLoS Medicine, 3(6): e106.
Kickbusch, I., and Szabo, M. C. (2014) A new governance space for health. Global Health
Action, 7. doi:http://dx.doi.org/10.3402/gha.v7.23507.
Lee, K., Buse, K., Fustukian, S (Eds). (2002). Health Policy in a Globalising World. Cam-
bridge: Cambridge University Press.
Leon, D. A. W., and Ed., G. (2001) Poverty, Inequality, and Health: an International Per-
spective. Oxford: Oxford University Press.
Macintyre, S., Chalmers, I., Horton, R., and Smith, R. (2001) Using evidence to inform
health policy: Case study. British Medical Journal, 322(7280): 222–225.
Mackenbach, J. P. (2010) Has the English strategy to reduce health inequalities failed?
­Social Science Medicine, 71(7): 1249–1253.
Mackenbach, J. P. (2011) The English strategy to reduce health inequalities. The Lancet,
377(9782): 1986–1988.
Mackenbach, J. P. and Bakker, M. J. (2003) Tackling socioeconomic inequalities in health:
Analysis of European experiences. The Lancet, 362(9393): 1409–1414.
80 LOW- AND MIDDLE-INCOME COUNTRY PERSPECTIVES

Marmot, M., Allen, J., Bell, R., and Goldblatt, P. (2012) Building of the global movement
for health equity: From Santiago to Rio and beyond. The Lancet, 379(9811): 181–188.
Marmot, M. G., Smith, G. D., Stansfeld, S., Patel, C., North, F., Head, J., White, I.,
­Brunner, E., and Feeney, A. (1991) Health inequalities among British civil servants: The
Whitehall II study. The Lancet, 337(8754): 1387–1393.
Rispel, L. C., de Sousa, C. A., and Molomo, B. G. (2009) Can social inclusion policies re-
duce health inequalities in sub-Saharan Africa? A rapid policy appraisal. Journal of
Health, Population, and Nutrition, 27(4): 492–504.
Samb, B., Desai, N., Nishtar, S., Mendis, S., Bekedam, H., Wright, A., Hsu, J.,
­Martiniuk, A., Celletti, F., Patel, K., Adshead, F., McKee, M., Evans, T., Alwan, A., and
Etienne, C. (2010) Prevention and management of chronic disease: A litmus test for
health-systems strengthening in low-income and middle-income countries. The Lancet,
376(9754): 1785–1797.
Sanjay, S. (2011) Indian ‘Occupy Wall Street’ movement takes rootshape (19 December),
Times of India.
Smith, K. E. (2013) Understanding the influence of evidence in public health policy: What
can we learn from the ‘Tobacco Wars’? Social Policy and Administration, 47(4): 382–398.
Stuckler, D., Basu, S., and McKee, M. (2010) Drivers of inequality in Millennium Develop-
ment Goal progress: A statistical analysis. PLoS Medicine, 7(3): e1000241.
Topp, S. M., Chipukuma, J. M., and Hanefeld, J. (2015) Understanding the dynamic inter-
actions driving Zambian health centre performance: A case-based health systems ana-
lysis. Health Policy and Planning, 30(4), 485–499.
Travis, P., Bennett, S., Haines, A., Pang, T., Bhutta, Z., Hyder, A. A., Pielemeier, N. R.,
Mills, A., and Evans, T. (2004) Overcoming health-systems constraints to achieve the
Millennium Development Goals. The Lancet, 364(9437): 900–906.
Waage, J., Banerji, R., Campbell, O., Chirwa, E., Collender, G., Dieltiens, V., Dorward,
A., Godfrey-Faussett, P., Hanvoravongchai, P., Kingdon, G., Little, A., Mills, A.,
­Mulholland, K., Mwinga, A., North, A., Patcharanarumol, W., Poulton, C.,
­Tangcharoensathien, V., and Unterhalter, E. (2010) The Millennium Development
Goals: A cross-sectoral analysis and principles for goal setting after 2015. The Lancet,
376(9745): 991–1023.
Wagstaff, A., Bredenkamp, C, and Buisman, L. R. (2014) Progress toward the Health
MDGs. Are the Poor Being Left Behind? Washington DC: World Bank.
Walker, L., and Gilson, L. (2004) ‘We are bitter but we are satisfied’: Nurses as street-level
bureaucrats in South Africa. Social Science and Medicine,59(6): 1251–1261.
WHO (2009) Reducing health inequities through action on the social determinants of
health. WHA 62.14. Geneva: World Health Organization.
WHO (2011) Rio political declaration on social determinants of health. Geneva: World
Health Organization.
Yach, D., and Bettcher, D. (1998) The globalization of public health, I: Threats and oppor-
tunities. American Journal of Public Health, 88(5): 735–738.
 Chapter 6

Contrasting views on ways

forward for health inequalities
research
Katherine E. Smith and Kayleigh Garthwaite

6.1  Introduction: Contrasting perspectives

on health inequalities
Drawing on over a hundred interviews and 14 focus groups with individuals in-
volved in health inequalities research, policy, practice, and advocacy,1 this chap-
ter considers these actors’ contrasting perspectives on emergent health
inequalities research agendas. It examines variations within and between actors
working in different professional settings, but concludes that the most import-
ant differences appear to result from interviewees’ contrasting disciplinary, ide-
ological, and epistemological positions, rather than their professional location.
The chapter starts by exploring different perspectives on the meaning of
health inequalities, before considering emerging research topics, many of
which point to the need to do more to situate health inequalities, and policy
responses to these inequalities, within broader social, economic, and political
systems. Finally, the chapter considers how interviewees thought research
could (and should) be used to promote more effective action to reduce health
inequalities, highlighting the notable divide between those favouring the in-
volvement of researchers in more advocacy-orientated approaches and those
cautioning against such an approach. Many of the subsequent chapters in this
book expand on the suggestions outlined in this chapter.

6.2  How do different actors understand ‘health

inequalities’?
As a term, ‘health inequalities’ is broad and accommodating and can be used to
refer to differences in health outcomes between a variety of population groups
(see Section 1.3 in Chapter 1). As Chapter 1 notes, health inequalities are gen-
erally deemed to be preventable. Reflecting this, many of the individuals we
82 CONTRASTING VIEWS ON FUTURE RESEARCH

spoke to (working in both research and policy settings) framed health inequal-
ities as a moral issue around which urgent action is required. However, for oth-
ers, health inequalities appear to be more of an empirical puzzle, an issue which
requires further research to enable us to better understand both the processes
underlying their production and the potential means of achieving their reduc-
tion. Table 6.1 illustrates these contrasting perspectives.
As the following sections explain, these contrasting ways of thinking about
health inequalities are linked with differing perspectives on: (i) what we have
(and have not) achieved in health inequalities research to date in the UK; (ii)
where those interested in researching health inequalities ought to be focusing

Table 6.1  Contrasting perspectives on ‘health inequalities’ in the UK

Perspective Illustrative quotations from researchers Illustrative quotations from

A moral Senior academic: ‘I think that health
issue inequalities are [. . .] the most
fundamental abuse of human rights in
the developed world. [I]f you imagine
locking up a substantial proportion of
your population for the last five or ten
years of their life without any justification
at all, well actually this is worse than that,
it’s like executing them arbitrarily. [. . .]
And when people don’t know about it, in
a sense it’s not a moral issue, but as we
come to know about these differences
and get a clear idea of how they could be
remedied, if we then fail to act, it is
morally culpable.’
An empirical Senior academic: ‘We [don’t yet] have a
puzzle comprehensive model such that we could
advise a local authority [. . .] exactly
where the levers are and, particularly in
the era of scarce resources, “what would
give the best bang for the buck?” in order
to reduce health inequalities.’
policy actors
Advocate: ‘It’s a crisis at the
moment, it’s a genuine crisis,
and at times of crisis I do think
the research community has
to kind of find common cause
now with people who are
experiencing this. It’s not a
joke anymore; I mean it’s just
awful. [. . .] I think it’s quite
important [for researchers] to
really see themselves as on
the side of people who are
experiencing inequalities . . .’
Policymaker: ‘I think we need
to be really clear, I hate the
word legacy, but about what
we’ve learned [about health
inequalities] over the past 15
years, and what we’re
confident about and what we
don’t know about. [. . .] It’s
always great to look at
something with new eyes, but
I feel that I would like [health
inequalities researchers] to be
really confident about what
has worked and what we’re
not sure about.’
 WHAT HAVE WE LEARNT? 83

future efforts; and (iii) how researchers might best support the use of health in-
equalities research in policy and practice.

6.3  Reflecting on health inequalities research

and policy in the UK so far: What have we learnt?
As the quotations in the final row of Table 6.1 begin to illustrate, there seems
to be widespread concern amongst researchers, practitioners, policymakers,
and advocates about a perceived failure to adequately learn from the multiple
policies and interventions intended to reduce health inequalities in the post-
1997 UK context. The vast majority of researchers, policymakers, practition-
ers, and advocates we spoke to indicated that they felt efforts to tackle health
inequalities in the UK had been less successful than people had hoped. There
were varying perspectives on why this is the case and, as Table 6.2 illustrates,
these can be broadly categorized into those focusing on the limitations of the
available evidence and those focusing on more political explanations. This
split does not (as might have been expected) map onto a division between in-
dividuals involved in research and those whose jobs focused more on political
and policy debates. Rather, as Table 6.2 demonstrates, actors working across a
range of professional settings suggested that health inequalities researchers

Table 6.2  Illustrative quotations reflecting contrasting explanations for the failure to

substantially reduce health inequalities in the UK in the post-1997 era

Group Perceived explanation for the failure to make further progress in reducing UK
health inequalities
Evidence-focused explanations
(i) Limited evidence on what works in
reducing health inequalities
Senior civil servant (Wales): ‘I think
sadly a lot of research evidence is
relatively weak and it’s been one of
my concerns, actually, that public
Civil servants
Political explanations
(ii) Public health researchers and
advocates were ‘out-lobbied’
Senior civil servant (Wales): ‘I think
that it’s hard for . . . a public health
community with relatively limited
resources to confront an industry. I

health research and helping people
like me advise ministers about what
would be effective is relatively weak.’
mean the BMA estimated two years
ago the alcohol industry was
spending £800 million on advertising
in the UK [. . .] and you see what’s
happening with the Olympics, with
McDonalds and Coca Cola, and then
you realise that the resources that we
have at our command just don’t stack
up against these big beasts.’
84 CONTRASTING VIEWS ON FUTURE RESEARCH
Table 6.2  (continued) Illustrative quotations reflecting contrasting explanations for
the failure to substantially reduce health inequalities in the UK in the post-1997 era
Group Perceived explanation for the failure to make further progress in reducing UK
health inequalities
Evidence-focused explanations
(iii) Researchers did not focus
sufficiently on developing evidence-
informed recommendations
Senior academic: ‘We’ve spent [too
Academic researchers
much] time since the Black Report
knocking down all the criticisms of
what we were doing. We haven’t
been developing our own agenda, so
I think we want to forget about being
defensive and we want to say, well,
these are the things which the
government, if it’s serious, could do.’
(v) Researchers have not translated
evidence into issues advocates can
easily campaign on
Politicians, policy advisors and advocates
Health advocate/campaigner: ‘It
seems like there’s a vast array of
evidence on the links between health
inequalities and social determinants
[. . .] [But] we have to justify ourselves
in terms of the particular conditions
on which we work [in a specific
health charity]. [. . .] It would be
useful to have researchers bear that
in mind so that perhaps there could
be better links [between health
inequalities research findings] and
[implications for] particular
conditions . . . ’
could do more to improve the impact of health inequalities research on future
policies. However, many explicitly argued that the UK’s failure to reduce health
inequalities was not a reflection of the limitations of the available evidence.
These two perspectives were not always mutually exclusive, with some individ-
uals articulating both perspectives within the same interview/focus group
discussion.
Political explanations
(iv) The economic and political
context prevented policy responses
that reflected the available evidence
Senior academic: ‘There are . . . a
whole range of potential
interventions around redistribution of
wealth that might . . . actually be
really quite effective [in reducing
health inequalities] [. . .] but when
those . . . obvious policy implications
are pulled out of research . . . they’re
then placed within the context of a
particular political economy and . . .
they cannot be implemented within
that context.’
(vi) There was a lack of serious
political commitment to reducing
health inequalities
MP: ‘[Labour] were embarrassed
about [health inequalities]. [. . .]
There is not a good evidence base
that choice helps tackle . . . inequity
and yet they worshiped this mantra
[. . .] So I never took it seriously. It was
just all spin! Do you not see that they
just felt [. . .] “Well we’re Labour, we
ought to tackle health inequality.
We’ll have a target”? I don’t blame
them. If I were them, with not much
in the way of policy, I would have
some targets and aspirations and deal
with the failure to tackle it later.’
 Where next for health inequalities research? 85

Several of the civil servants and researchers we spoke to were keen to point out
that the Labour government that was elected in 1997 did at least appear to be
interested in the available health inequalities evidence, commissioning an inde-
pendent inquiry into health inequalities within three months of taking office
(this inquiry, which became known as the Acheson Report, is discussed in more
detail in Chapters 1 and 2). Yet, despite this review and the huge investments that
have been made in health inequalities research since this time, many of the re-
searchers, policymakers, practitioners, and advocates we spoke to argued that
the evidence base for developing specific policy recommendations remains
weak, particularly around the social determinants of health (see Bambra et al
2010). Reflecting on this, there appears to be a great deal of support for the idea
that researchers ought to do more to develop coherent policy advice based on
their work. Yet, as Sections 6.4 and 6.5 discuss, there is a lack of consensus re-
garding the type of work that needs to be undertaken to develop this kind of
clarity for tackling health inequalities; whilst some individuals we spoke to sug-
gested more sophisticated, experimental approaches to research were required,
others argued researchers ought to be focusing their efforts on persuading pub-
lic, media, and political actors to take action based on existing understandings.

6.4  Where next for health inequalities research?

Table 6.3 summarizes the most popular suggestions made by researchers, poli-
cymakers, practitioners, and advocates for future health inequalities research.
Three of these suggestions (i–iii) were widely supported across professional
groups and echo the findings of earlier studies (Petticrew et al 2004; Smith 2013;
Whitehead et al 2004), reflecting the desire among potential users of health in-
equalities research for more evidence about how to tackle these inequalities.
Our interviews and focus group discussions suggest more specific proposals
for future research agendas vary (to some extent) by professional group. As
might be expected, individuals working at a local level place more emphasis on
the opportunities to learn from local variations, while those working at a na-
tional level place more emphasis on the need to evaluate national policy changes
and undertake comparative work on an international scale. There does not ap-
pear to be a distinctive difference in the types of research favoured by individ-
uals working in research and those working in other settings, with an evident
consensus around the need for health inequalities research to shift towards
work focusing on evaluation, effectiveness, and cost-effectiveness (Petticrew
et al 2004; Research Councils UK 2010; Wanless 2004). There was, however, a
stronger methodological focus to many of the suggestions put forward by re-
searchers, particularly when discussing how to improve our understanding of
what might be effective in reducing health inequalities.
86 CONTRASTING VIEWS ON FUTURE RESEARCH

Table 6.3  Desirable future health inequalities research agendas

Suggestions Illustrative quotation

(i) More evidence Advocacy focus group participant: ‘Nobody was interested in the
relating to the cost of conditions that we were living in because they had been
the problem and/or brainwashed to think it was our own fault. It wasn’t until we
the cost-effectiveness actually put a price on it—how much did it cost to treat the
of potential solutions symptoms? [. . .] That’s what people listened to.’
(ii) Evidence Senior academic: ‘I think one of the things that’s really important
concerning the impact [. . .] is the absolute reality that the impact of public sector cuts
of ‘upstream’, macro- and the welfare cuts which are utterly savage, I mean savage, in
level policy changes on [. . .] Wales, the North East, parts of Scotland etc. And we ain’t
health inequalities, seen nothing yet. That’s the reality and I think, as researchers
including current within public health [. . .] that’s a really important issue to take
welfare reforms on-board . . . morally.’
(iii) Predictive/solution- MP (England): ‘Evidence around interventions—I think that is
oriented research, where our gaps are [. . .] I know we have the recommendations
including modelling from Marmot as well, but let’s unpick that in a bit more detail
and . . . I’d love to do some scenario modelling and . . . get some
evidence about what the potential impacts on inequalities would
be . . . ’
(iv) More evidence Policy advisor (Wales): ‘We’ve got to put more effort into
about effectively particular groups and into particular communities just in that one
targeting particular area where we are trying to intervene [. . .] [so] that we are clear
social groups or confident about what we need to do differently . . . ’
(v) More people/ Former senior civil servant (Scotland): ‘I would go for this more
community-centred people-centred approach so [. . .] I would say, let’s invest a bit
research on people’s more time trying to understand how these lives are lived and why
lived experiences people end up doing what they’re doing . . . ’
(vi) Improving Civil servant (Scotland): ‘I think they certainly should be looking at
evaluation (e.g. ways of . . . evaluating the impact on health inequalities of those
assessing clusters of non-health sector . . . interventions using natural experimental
policies and processes as best they can.’
interventions)
(vii) More comparative Ex-civil servant (England): ‘I think we’ll get some learning [. . .]
research and analyses from the natural experiment around much more localism in
of ‘natural England. [. . .] I think the academic community [. . .] needs to get
experiments’ out there . . . and do some more comparative analysis.’
(viii) More research to Head of a large campaigning organisation: ‘We firmly believe that
understand who is the area of public health that’s been neglected is around the
influencing policy and commercial determinants of health and public health’s been very
how, including studies slow at engaging that agenda. It’s seen to be a radical fringe,
of corporate influence which it isn’t—it’s mainstream public health [. . .]. So I don’t think
the public health community’s embraced that agenda enough and
I don’t think the advocacy is all that well informed at times. [. . .]
[T]he literature’s still pretty thin around things like corporatology
and [. . .] how that relates to inequalities . . . ’
 Where next for health inequalities research? 87

Table 6.3  (continued) Desirable future health inequalities research agendas

Suggestions Illustrative quotation

(ix) Research taking an ‘Policy and practice’ focus group: ‘I think a lot of the health
‘assets’/‘salutogenesis’ inequalities research [. . .] there is a lot of description of the
approach (or at least problem [. . .] I prefer that whole salutogenic model about how do
moving away from a we create good health in populations, about how do we create
‘deficit’ model of good social circumstances? It is about the social determinants and
health inequalities) about people’s resilience.’

In addition to suggestions for how we might improve our understanding of

‘what works’ in tackling health inequalities, Table 6.3 also illustrates that many
researchers, policymakers, practitioners, and advocates are interested in other,
potentially less well-recognized avenues of research. These include: (i) ethno-
graphic, people-centred research, which provides information about people’s
life experiences and decision-making processes, as well as their perspectives on
health inequalities and potential policy responses (see Chapters 16 and 17); and
(ii) research exploring the policy influence of non-health actors who shape and
inform the policies and activities that impact on health (e.g. research examining
the role of business interests in health inequalities—see Chapter 13).
There is relatively little research exploring public experiences and percep-
tions of health inequalities (Parry et al 2007; Popay et al 2003) and even less
exploring public perspectives on potential responses (see Lundell et al 2013 for
one, US-focused, exception). The desire for more community-based, ethno-
graphic research seems to stem from a view that health inequalities researchers
have not been particularly good at listening to the perspectives of the commu-
nities on whose behalf they often claim to be undertaking research, as the fol-
lowing focus group extract reflects:
Researcher: ‘How good [. . .] is the research community at knowing and understanding
communities and working with communities, quite genuinely listening to them? [. . .]
None of us do actually really listen. [. . .] It’s about actually listening to people about
what it’s [. . .] like for [them] where they’re living and what are the challenges they face
on a daily basis—which will often be different from what we think they are, because we
don’t know, because we’re all middle class.’

However, alongside this view, some of the individuals we spoke to cautioned

that a particular focus on deprived communities can shift the focus away from
the need for population level change and unintentionally stigmatize people liv-
ing in communities labelled as ‘deprived’:
Researcher: ‘We do tend to conceptualize health inequalities as [being] about particu-
lar, well-defined communities, and of course it’s all about the gradient. It’s not only
88 CONTRASTING VIEWS ON FUTURE RESEARCH

about the people in those communities. And sometimes I think we do harm by focus-
ing so much on the deprived communities and calling them ‘deprived communities’.
[. . .] Sometimes you make the stigma worse [. . .] because you’ve defined them as de-
prived communities and all your documents say, “we’re focusing on people in these
deprived communities.” [. . .] And I see the faces, sometimes, of the admin staff with
some of the things that I write, where we say we’re going to prioritise these deprived
communities, and they live there! And they say, “but wait a minute, actually we’re not
deprived, we live there—it’s a perfectly good community”. And I think we need to be a
bit careful about saying there are some people who suffer from health inequalities and
they’re the deprived folk, then there’s everybody else . . . ’

Thus, it appears there is a dilemma facing health inequalities researchers: whilst

it may well be helpful to have more in-depth insights into people’s everyday ex-
periences of living in difficult circumstances (and there was certainly some de-
sire for such research amongst policy actors as well as researchers), there is also
a concern around the potentially stigmatizing consequences of this kind of re-
search. George (1976) argues that poorer communities already understand the
difficulties and problems in their lives and suggests that researchers should in-
stead focus on examining richer, more powerful groups, an idea with some sup-
port among the individuals we spoke to (see row (viii) in Table  6.3 and
Chapter 13). This is a strand of research that has so far been relatively under-
explored within health inequalities, although Scambler has drawn attention to
the issue via his ‘greedy bastards hypothesis’ (Scambler 2007), which states that
Britain’s widening health inequalities can be seen ‘as a largely unintended conse-
quence of the voracious, “strategic” appetites of ’ capitalist power elites (Scambler
2012, p. 137).

6.5  What should researchers do to improve the impact

of health inequalities research?
There is a consensus that more could, and should, be done to improve the links
between health inequalities research, policy, and practice, although specific
suggestions as to how to improve these links vary with different understand-
ings of the relationships between research, policy, and practice. Table 6.4 sum-
marizes the types of suggestions made by the researchers, policymakers,
practitioners, and advocates with whom we spoke, categorizing these accord-
ing to the (implicit) underlying conceptualization of the role that evidence
plays in policy and practice (see Chapter 20 for an overview of these contrast-
ing conceptualizations).
The suggestions outlined in rows (i) and (ii) of Table 6.4 reflect reviews of the
available evidence regarding what appears to be effective in increasing (albeit
not necessarily improving) the use of research evidence in decision-making
 WHAT SHOULD RESEARCHERS DO TO IMPROVE IMPACT? 89

Table 6.4  Suggestions for improving the impact of health inequalities research

Conceptualization of the Specific suggestions relating to this

role of evidence in policy conceptualization
and practice
(i) Rational, instrumental - Synthesize multiple research studies with policy audiences
suggestions in mind (rather than promoting single studies)

Suggestions in this
category reflect the idea
that knowledge can/should
directly shape decisions in
policy and practice
(ii) ‘Bridging’ approaches
Suggestions in this category
focus on overcoming
perceived communicative,
cultural, and institutional
‘gaps’ between researchers
and policy actors which are
perceived to ‘block’
knowledge translation
(iii) Strategic, advocacy-
orientated suggestions
Suggestions in this
category reflect a more
political, interest-driven
vision of policymaking in
which policy change is
largely attributed to the
influence of external actors
(lobbyists, campaigners,
and local communities)
seeking to influence
policies.
- Help develop and promote tools to support the use of
evidence in decision-making (e.g. impact assessments)
- Ensure that evidence being promoted to policy, practice,
and advocacy audiences is rigorous and credible
- Develop and evaluate knowledge translation interventions
- Invest in people with experience of working in multiple
contexts
- Provide appropriate incentive structures for cross-sector
engagement
- Support secondments between research and policy
- Engage in co-produced research
- Researchers should focus on developing ‘soft-skills’ and
long-term relationships with appropriate decision-makers
- Achieve cross-sector clarity about policy objectives
- Work to place and maintain issues on public and political
agendas
- Reframe issues to the benefit of public health
- Discredit public health opponents/misleading claims
- Engage wide ranges of relevant actors from beyond
research and policy
- Employ evidence accurately but persuasively, developing
analogies, metaphors, etc.
- Be strategic and opportunist

(see, for example, Contandriopoulos et al 2010; Innvær et al 2002; Mitton et al
2007; Nutley et al 2007; Walter et al 2005). Most of these suggestions are uncon-
troversial and were widely supported by the civil servants and academic re-
searchers we spoke to (this was particularly true for the suggestions categorized
as reflecting a rational, instrumental conceptualization of the role of evidence
in decision-making). Yet, at the same time, researchers, policymakers, practi-
tioners, and advocates all also frequently highlighted the limited impact that
these kinds of approaches have had in practice so far.
90 CONTRASTING VIEWS ON FUTURE RESEARCH

Some of the individuals we spoke to suggested that the impact of the kinds of
activities outlined in row (i) of Table 6.4 could be improved by efforts to over-
come perceived communicative, institutional, and/or cultural gaps between re-
searchers and decision-makers (see Caplan 1979). These suggestions rely on the
idea that stronger, ongoing, collaborative relationships between researchers
and potential users will increase levels of trust and mutual understanding and
that this, in turn, will increase the relevance and impact of research. These kinds
of approaches were primarily advanced by academics, civil servants, and indi-
viduals working in local policy and practice, and not by individuals working in
more political/campaigning contexts, such as politicians and advocates, who
tended to favour the more strategic, advocacy-orientated kind of approaches to
achieving research impact that are illustrated in row (iii) of Table 6.4.
The suggestions illustrated in the final row of Table 6.4 represent a move away
from traditional, instrumental accounts of public health knowledge translation,
towards the need for more ‘advcoacy’ to tackle health inequalities (as already
mooted by Mackenbach 2011 and Smith 2013). Overall, there was a great deal of
support for the need to increase advocacy to reduce health inequalities amongst
the individuals we spoke to. However, it was also evident that it remains unclear
who, exactly, ought to be undertaking this kind of work, with opinions appear-
ing particularly divided around questions of whether researchers ought to be
involved. Whilst some participants strongly supported the idea of researchers
getting more involved in advocacy-orientated work, others seemed deeply un-
comfortable with this suggestion. This division (which is explored in more de-
tail in Chapters  19 and 20) highlights that closer relationships between
academics and activists/advocates in public health are not necessarily straight-
forward. This may be particularly true for health inequalities due to the dearth
of groups/campaigners specifically focusing on this issue (see Smith 2013) and
the conflicting preferences of the multiple advocates and campaigners who
might reasonably be expected to have an interest in health inequalities. For ex-
ample, our conversations suggested health advocates working in organizations
focusing on particular health conditions/risks (e.g. heart disease and cancer
charities, and organizations campaigning to improve tobacco and alcohol con-
trol) feel that health inequalities researchers should do more to emphasize links
between their work and these specific conditions/risks, whilst individuals work-
ing in local communities, policy, and practice often favoured an entirely ‘non-
health’ frame which instead stresses the importance of widening social and
economic inequalities. Exploring whether and how researchers might engage
with more strategic, advocacy-orientated approaches to promoting evidence-
informed responses to health inequalities therefore appears to be an area war-
ranting further examination and debate (see also Chapters 19 and 20).
 Concluding discussion 91

6.6  Concluding discussion

Studies exploring policy actors’ and researchers’ perspectives on health in-
equalities research, and their advice on improving the relationship between re-
search and policy, have largely focused on the views of senior academics and
civil servants. This chapter complements these studies by additionally consider-
ing the perspectives of those working to influence and/or implement policies
impacting on health inequalities. This approach reflects theories of policy
change which point to the importance of ‘advocacy coalitions’ (Sabatier and
Jenkins-Smith 1999) and/or ‘policy entrepreneurs’ (Kingdon 1995 [1984]). Ap-
plying this kind of wider lens to policymaking debates surrounding health in-
equalities potentially draws attention to the democratic and interest-informed
nature of policy and to the crucial links between evidence, public preferences
(or, at least, political and policy perceptions of these preferences), and wider
social, policy, and political debates.
Indeed, policy actors with an interest in reducing health inequalities have fre-
quently focused on the need for researchers to better understand policymakers’
needs. This reflects David Blunkett’s (2000) suggestion that, to become more rel-
evant to policy, researchers ought to focus on providing advice on which interven-
tions are likely to be most effective and why (preferably on the basis of quantifiable,
experimental data). However, others overtly reject the prioritization of issues on
the basis that they can be measured and assessed (see Kisby 2011). For example,
many of the individuals we spoke to articulated a desire for more research explor-
ing the everyday lives of people in communities which experience worse health,
whilst others highlighted the need for better evidence about the actors and pro-
cesses influencing policies impacting on health inequalities (including corpora-
tions producing unhealthy commodities, as discussed in Chapter 13).
Overall, our interviews and focus group discussions suggest there may be
three, distinct kinds of health inequalities researcher, each of whom has differ-
ent preferences regarding the future direction of health inequalities research
and the best means of improving the impact of this research: (i) policy-focused
positivists; (ii) empathetic ethnographers; and (iii) critical materialists (see
Garthwaite et al, in press). Further, whilst there is an identifiable distinction
between the researchers’ and policy actors’ priorities for future research agen-
das (with researchers placing more emphasis on methodological develop-
ments), epistemological and disciplinary boundaries may be more important
than distinctions between who is a ‘researcher’ and who a ‘policy actor’ (see
Smith and Joyce 2012). Hence, support for each of these three approaches to
studying health inequalities can be found amongst at least some individuals
working in advocacy, policy, and practice settings.
92 CONTRASTING VIEWS ON FUTURE RESEARCH

Our interviews and focus group discussions clearly demonstrate that policy
actors’ recommendations for improving the influence of health inequalities re-
search go beyond well-rehearsed suggestions for increasing the instrumental
use of evidence in policy and practice. Rather, many of the individuals we spoke
to put forward suggestions which map directly onto Chapman’s (2007) account
of ‘public health advocacy’: being strategic, political, and opportunist. However,
the question as to who, exactly, ought to be undertaking advocacy to reduce
health inequalities remains contested amongst both policy actors and re-
searchers; whilst some individuals are clearly persuaded that sufficient evidence
exists to morally require researchers to engage in advocacy, others remain hesi-
tant about both the ability of researchers to undertake this kind of work and the
appropriateness of them doing so (Smith and Stewart, 2014).
Overall, this chapter draws attention to what Kisby (2011) has referred to as
the ‘illusion’ that the use of evidence in policy can be an essentially neutral,
technical matter. This is partly because, as Kisby (2011) and Oliver (2006) point
out, only some issues make it on to the policy agenda in the first place, but also
because ‘the acquirement of facts on a policy issue does not in itself suggest
what policy response ought to be adopted’ (Kisby 2011, p. 111). Hence, as many
of the individuals we spoke to highlighted, it seems important for researchers to
both engage with how and why particular issues make it on to policy agendas
and to try to provide evidence-informed recommendations for addressing con-
cerns that are already on policy agendas.
However one views the role of research and researchers in public health ‘ad-
vocacy’, if we accept that political and social factors inform how policy actors,
and wider members of the public, engage with problems (Oliver 2006), and that
decisions and claims made in policy debates are necessarily based on values and
interpretations (Kisby 2011), then we are recognizing the need for ‘political ar-
gument’ (Kisby 2011, p. 124) involving both members of the public and particu-
lar interests. Whilst, as Kisby (2011) notes, political and policy debates are
rarely resolved by reference to facts and evidence alone, this is not the same as
arguing that evidence does not play an important role in such debates. In this
context, the importance of considering how advocates and campaigners might
mediate the translation of evidence-informed ideas into policy seems undeni-
able, as Chapter 19 goes on to explore.

Acknowledgements
The focus group data and analysis drawn on in this chapter was supported by
funding from the University of Edinburgh and Durham University. The inter-
view data, and the lead author, were supported via two ESRC grants (grant
numbers PTA-037–27–0181 and ES/K001728/1). The views presented in the
 Concluding discussion 93

chapter are those of the authors or participants and not necessarily of the
funders. We particularly wish to thank the participants who gave up their time
to take part in the focus groups (held at a symposium in Edinburgh in Decem-
ber 2012) and Heide Weishaar and other members of the steering group (Clare
Bambra, Sarah Hill, David Hunter, Jamie Pearce, Steve Platt, and Niamh Shortt)
for assisting with the organization of the symposium and for providing feed-
back on the analysis.

Note
1 The methods employed in this study are fully detailed in Garthwaite et al, in press.

References
Bambra, C., Gibson, M., Sowden, A., Wright, K., Whitehead, M., and Petticrew, M.
(2010) Tackling the wider social determinants of health and health inequalities: Evidence
from systematic reviews. Journal of Epidemiology and Community Health, 64(4):
284–291.
Blunkett, D. (2000) Influence or irrelevance: Can social research improve government?
­Research Intelligence, 71( Spring). London: British Educational Research Association.
Caplan, N. (1979) The two-communities theory and knowledge utilization. American
­Behavioral Scientist, 22(3): 459–470.
Chapman, S. (2007) Public Health Advocacy and Tobacco Control—Making Smoking His-
tory. Oxford: Blackwell.
Contandriopoulos, D., Lemire, M., Denis, J.-L., and Tremblay, É. (2010) Knowledge
­exchange processes in organizations and policy arenas: A narrative systematic review of
the literature. Milbank Quarterly, 88(4): 444–483.
Garthwaite, K., Smith, K. E., Bambra, C., and Pearce, J. (in press) Desperately ­seeking re-
ductions in health inequalities: Perspectives of UK researchers on past, present and fu-
ture directions in health inequalities research. Sociology of Health and Illness.
George, S. (1976) How the Other Half Dies: The Real Reasons for World Hunger. London:
Penguin Books.
Innvær, S., Vist, G., Trommald, M., and Oxman, A. (2002) Health policy-makers’ percep-
tions of their use of evidence: A systematic review. Journal of Health Services Research
and Policy, 7(4): 239–244.
Kingdon, J. W. (1995 [1984]) Agendas, Alternatives, and Public Policies (2nd edn). New
York: HarperCollins College Publishers.
Kisby, B. (2011) Interpreting facts, verifying interpretations: Public policy, truth and
­evidence. Public Policy and Administration, 26(1): 107–127.
Lundell, H., Niederdeppe, J., and Clarke, C. (2013) Public views about health causation, attribu-
tions of responsibility, and inequality. Journal of Health Communication, 18(9): 1116–1130.
Mackenbach, J. P. (2011) Can we reduce health inequalities? An analysis of the English
strategy (1997–2010). Journal of Epidemiology and Community Health, 65(7): 568–575.
Mitton, C., Adair, C. E., McKenzie, E., Patten, S. B., and Waye Perry, B. (2007) Knowledge
transfer and exchange: Review and synthesis of the literature. The Milbank Quarterly,
85(4): 729–768.
94 CONTRASTING VIEWS ON FUTURE RESEARCH

Nutley, S., Walter, I. C., and Davies, H. T. O. (2007) Using Evidence: How Research Can
­Inform Public Services. Bristol: Policy Press.
Oliver, T. R. (2006) The politics of public health policy. Annual Review of Public Health, 27:
195–233.
Parry, J., Mathers, J., Laburn-Peart, C., Orford, J., and Dalton, S. (2007) Improving health
in deprived communities: What can residents teach us? Critical Public Health, 17(2):
123–136.
Petticrew, M., Whitehead, M., Macintyre, S. J., Graham, H., and Egan, M. (2004) Evidence
for public health policy on inequalities: 1: The reality according to policymakers. Journal
of Epidemiology and Community Health, 58(10): 811–816.
Popay, J., Bennett, S., Thomas, C., Williams, G., Gatrell, A., and Bostock, L. (2003)
­Beyond ‘beer, fags, egg and chips’? Exploring lay understandings of social inequalities in
health. Sociology of Health and Illness, 25(1): 1–23.
Research Councils UK (2010) Memorandum from Research Councils UK (RCUK) to the
House of Lords Science and Technology Select Committee in response to its call for
­evidence on behaviour change (October 2010), http://www.esrc.ac.uk/_images/esrc-­
submission-behaviour-change-travel-mode-choice_tcm8-19573.pdf.
Sabatier, P. A., and Jenkins-Smith, H. C. (1999) The advocacy coalition framework: An as-
sessment. In P. A. Sabatier (ed.), Theories of the Policy Process. Oxford: Westview Press.
pp. 117–166.
Scambler, G. (2007) Social structure and the production, reproduction and durability of
health inequalities. Social Theory and Health, 5(4): 297–315.
Scambler, G. (2012) Review article: Health inequalities. Sociology of Health and Illness,
34(1): 130–146.
Smith, K. E. (2013) Beyond Evidence-Based Policy in Public Health: The Interplay of Ideas.
Basingstoke: Palgrave Macmillan.
Smith, K. E., and Joyce, K. E. (2012) Capturing complex realities—understanding efforts to
achieve evidence-based policy and practice in public health. Evidence and Policy, 8(1):
59–80.
Smith, K. E., and Stewart, E. (2014) Influencing policy - public health advocacy and health
inequalities. Journal of the Royal College of Physicians of Edinburgh, 44(4): 316–321.
Walter, I., Nutley, S., and Davis, H. (2005) What works to promote evidence-based
­practice? Evidence and Policy, 1(3): 335–363.
Wanless, D. (2004) Securing Good Health for the Whole Population [final report].
Norwich: HMSO.
Whitehead, M., Petticrew, M., Graham, H., Macintyre, S., Bambra, C., and Egan, M.
(2004) Evidence for public health policy on inequalities 2: Assembling the evidence
­jigsaw. Journal of Epidemiology and Community Health, 58(10): 817–821.
 Chapter 7

Axes of health inequalities

and intersectionality
Sarah Hill

7.1  Introduction: Intersecting axes of social position

Health inequalities research in the UK has focused predominantly on social
class or socioeconomic status as the primary axis of social inequity. This chapter
examines health inequalities in relation to other important aspects of social
position, particularly ethnicity and gender. It critiques the view that socioeco-
nomic gradients are the primary driver of health inequalities and, drawing on
the concept of intersectionality, argues for a more complex understanding of
identity, social position, and inequality.
The chapter outlines key axes of social position that have formed the focus of
health inequalities research in various contexts, exploring different aetiological
perspectives on ethnic and gender inequalities in health. As with socioeco-
nomic inequalities, such explanations range in focus from ‘downstream’ (indi-
vidual) causes such as lifestyle, ‘culture’, and biological factors, to ‘upstream’ (or
structural) drivers including differential access to education and secure
employment.
The concept of intersectionality is examined as a way of understanding the
relationships between different axes of social position and their relevance for
health inequalities. The example of smoking is used to illustrate the relevance of
these axes—including their intersection with one another—and to compare ex-
planations advanced to account for related health inequalities. An intersec-
tional approach encourages researchers and policymakers to focus on the
structural drivers of health inequalities, pointing to a shared understanding of
their fundamental causes via a political analysis of power relations.

7.2  Axes of health inequality

As noted in Chapter 1, health inequalities (or inequities) generally refer to sys-
tematic differences in the health of people occupying unequal positions in soci-
ety (Graham 2009). Research in the UK has largely focused on social class or
96 AXES OF HEALTH INEQUALITIES & INTERSECTIONALITY

socio-
labour
economic
market
position
environment
gender disease, ill-health
education & &
system impairment disability

ethnicity behaviour
welfare
benefits
system sexuality

social
structure social position intermediary factors health outcomes
(examples) (examples)

Fig. 7.1 Model of the social determinants of health, including different axes of ­social
position.
Reproduced from Graham H, Unequal Lives: Health and Socioeconomic Inequalities, Open Univer-
sity Press, Maidenhead, UK, Copyright © 2007, reproduced with the kind permission of Open
University Press. All rights reserved.

socioeconomic status as the key indicator of social position, and health inequal-
ities have therefore been described primarily in relation to these concepts. But
other aspects of social position are important for health and health inequalities,
reflected in Graham’s (2007) model of the social determinants of health (Fig-
ure 7.1). These include ethnicity, gender, sexual orientation, and other aspects of
identity, with significance ‘for a person’s relationship with other people . . . [and
with] the social and economic structures of society’ (Link and Phelan 1995, p. 81).
Researchers typically focus on the aspect(s) of social position they see as most
significant for a person’s relationship with the society in which they live. This
varies for different societies, for particular individuals, and over time. Thus
health inequalities researchers in the USA have focused largely on ethnicity or
race, while those in Canada, Australia, and New Zealand are also concerned
with indigenous status. Research on the role of gender-related health inequal-
ities is often conducted by those concerned with the status of women in society,
and has gained greater prominence in recent decades (Annandale and Hunt
2000). The significance of sexual orientation is only now emerging as a priority
for health inequalities research (Institute of Medicine 2011).

7.3  Ethnic inequalities in health

Ethnicity is a form of collective social identity that typically includes elements
of language, culture, shared history, and common ancestry (Karlsen and
 Ethnic inequalities in health 97

Nazroo 2006; Williams 1997). Ethnic identity is socially constructed by both

internal and external group membership; it involves a complex and dynamic
negotiation between those included in a particular ethnic grouping and the so-
ciety in which that grouping has social significance. This identity is not fixed: on
a broad level, the boundaries and terminology used to define ethnicity change
with time and place; and on an individual level, the same person may identify
with different ethnic identities in different social contexts and at different points
in their life course.
In many countries, disparities in the health status of different ethnic groups
are comparable in magnitude to socioeconomic health inequalities. The gap in
life expectancy between indigenous and non-indigenous populations is seven
years in New Zealand (SNZ 2013) and 10–12 years in Australia (AIHW 2011).
In the USA, African Americans have a life expectancy five years lower than that
of White Americans (Arias et al 2010).
Diverse explanations are presented or assumed to account for such differ-
ences. As with socioeconomic inequalities, these tend to locate along a spec-
trum from an individual to a structural focus. The persistence of biological
(including genetic) explanations for ethnic differences in health emphasizes the
extent to which these explanations are theoretically driven, or how ‘[obsolete]
ideas can endure and be made to seem real if they have social and political-
economic utility’ (Goodman 2013, p. 50).
Several authors have described the origins and decline of a biological con-
cept of race, noting how ideas of distinct racial categories predated a modern
understanding of genetic theories and are undermined by recent develop-
ments in genetic research (Frank 2007; Williams 1997). Rather than compris-
ing discrete biological sub-categories, the human population has been shown
to exhibit continuous (and continuously evolving) genetic variation. While
genetic similarities are associated with geographic proximity (Kittles and
Weiss 2003; Templeton 1998), there are no clear divisions between ‘groups’ of
people and different genetically determined traits that have overlapping and
incongruous geographic distribution (Goodman 2013). Biological explan-
ations for ethnic differences in health are conceptually flawed since they treat
ethnic or racial groups as fixed, empirical categories rather than socio-political
constructs. This misconception becomes apparent in reflecting on the dynamic
and context-specific nature of ethnic categories. An individual identifying as
‘Samoan’ in the New Zealand census would be classed as ‘Asian or Pacific Is-
lander’ in the US and ‘Other’ in the UK; the English census classed people of
Chinese origin as ‘Other’ until 2011, when they officially became ‘Asian / Asian
British’ (ONS 2012); and the US government once regarded Irish as ‘non-
White’ (Thomas 2013).
98 AXES OF HEALTH INEQUALITIES & INTERSECTIONALITY

A less biological view of ethnicity links health differences to ‘cultural’ vari-

ation in diet, drug use, and other health-related practices. UK data suggest
some minority ethnic groups have lower alcohol and tobacco consumption as
well as different dietary preferences (Davey Smith et al 2000). While these fac-
tors affect the risk of specific diseases, cultural practices are depicted as more
important for the health of ethnic minorities than for the ethnic majority
(whose culturally specific behaviours are less visible and are regarded as
‘normal’).
Many researchers have focused on the common correlation of minority eth-
nic status and lower socioeconomic position (Davey Smith 2000). Some regard
socioeconomic differences as the primary explanation for ethnic inequalities in
health, with race even being used as a proxy for socioeconomic status in the US
(Davey Smith 2000; Kawachi et al 2005). While an association between socio-
economic status and ethnicity is clearly a contributing factor, it is simplistic to
assume that differences in socioeconomic position ‘explain’ ethnic health in-
equalities. Such a framing cannot account for why ethnic minority groups are
more likely to be disadvantaged in terms of occupation and income, nor explain
the significant ethnic disparities that persist among those with comparable in-
come, education, or occupational status (Nazroo 2003).
Racism is increasingly recognized as an important—and perhaps
­fundamental—cause of ethnic inequalities in health (Davey Smith 2000; Jones
2000; Williams 1997). Members of ethnic minority groups are more likely to
experience racially motivated discrimination, with the experience of such dis-
crimination linked to poorer health (Williams and Mohammed 2009). Along-
side this personally mediated racism, ‘institutional racism’ connotes ways in
which social structures and institutions systematically privilege some ethnic
groups while disadvantaging others (Jones 2000). This includes the tendency
for ethnic minorities to gain less benefit from mainstream education, labour
market, and health systems, impacting on their access to the social determin-
ants of health.

7.4  Gender inequalities in health

While ‘sex’ refers to biological differences between women/girls and men/boys,
‘gender’ captures the social construction of sex-related roles and ­relationships—
or ‘how we are perceived and expected to act as women and men because of the
way society is organized’ (WHO 1998, p. 10).
Ostlin et al (2001) describe gender health inequalities as reflecting the un-
equal position of men and women in society, thus encompassing two (linked)
conceptions: (i) that men and women occupy different social, economic, and
 Intersectionality and health inequalities 99

political positions within society; and (ii) that these disparities in social pos-
ition give rise to health differences which are socially based, avoidable, and
(therefore) unjust. The distinction between sex and gender is therefore intrinsic
to the study of gender inequalities, although health differences between women
and men cannot be attributed proportionally to the biological or the social. Ra-
ther, the two elements interact in their impacts on health such that ‘[b]iological
differences between the sexes may be in part socially determined, while social
differences arising from gender relations may also have a biological element’
(Ostlin et al 2001, p. 176). The impact of biologically defined differences (such
as reproductive capacity) will vary according to socially defined norms and
structures, while disparities in the socially defined roles and positions of men
and women may relate to their distinct biology.
The study of gender-based inequalities in health therefore necessarily as-
sumes the importance of the social. Research that privileges biological causes
tends not to refer to ‘gender’, focusing instead on specific conditions unique to
women or men. For example, Shiffmann and del Valle (2006) note that main-
stream research into inequalities in maternal mortality tends to focus on clin-
ical factors associated with pregnancy and childbirth while ignoring social and
political factors.
Because gender research assumes the importance of social identity, explan-
ations for ‘gender inequalities in health’ emphasize social rather than bio-
logical factors—although this emphasis may still range from the individual
(personal identity) to the societal (social norms and institutions). This con-
trasts with studies of ethnic inequalities, where differences in biology, culture,
or socioeconomic status are still presented as ‘explaining’ health disparities.
Research into gender inequalities has more commonly examined the intersec-
tion between gender and other aspects of social position (Annandale and
Hunt 2000). Gendered research has sought to acknowledge multiple elements
of identity to explore how gender interacts with other axes of social position.
For example, socioeconomic position is an important determinant of health
for both men and women living in Canada, but differences in income appear
to have a greater impact on the health of women compared with men (Denton
and Walters 1999).

7.5  Intersectionality and health inequalities

‘Intersectionality’ emerged in social science to describe multiple intersecting
aspects of social identity and structure, particularly those associated with ex-
periences of exclusion or subordination (Walby et al 2012). Originating in
Black feminist critiques, intersectionality is increasingly used to theorize the
100 AXES OF HEALTH INEQUALITIES & INTERSECTIONALITY

experience of simultaneously held identities relevant to social position (Meer

2014). The individual and structural elements of intersectionality are evident in
Davis’s definition of ‘the interaction between gender, race, and other categories
of difference in individual lives, social practices, institutional arrangements,
and cultural ideologies and the outcomes of these interactions in terms of
power’ (2008, p. 68).
Intersectionality offers a useful framework for understanding the multiple
layers of advantage and disadvantage relevant for health and well-being. It rec-
ognizes that any individual has multiple aspects of identity with relevance for
their relationships with others and with the structures and systems of p­ ower—
and, therefore, for their health.

7.6  Inequalities in smoking—‘contours of disadvantage’

The practice of smoking provides a case study of how different aspects of social
identity and position may interact, with implications for health. As well as being
a significant risk factor for many diseases, smoking is a socially embedded be-
haviour which shows a complex distribution across multiple axes of identity
and is associated with social disadvantage or marginalization, following ‘the
contours of disadvantage within as well as between groups’ (Graham 1995,
p. 510).
There is a strong relationship between smoking and socioeconomic disad-
vantage in countries at an advanced stage of the tobacco epidemic (Corsi et al
2013; Lopez et al 1994; Mackenbach et al 2008). In the latter half of the twenti-
eth century, growing awareness of the damaging consequences of tobacco use
and initiatives to reduce consumption produced a decline in overall smoking
prevalence alongside the emergence of a marked social gradient (Giskes et al
2005; Jarvis and Wardle 2003). Smoking levels in the UK have halved since the
1970s, declining most rapidly in advantaged socioeconomic groups—resulting
in a four-fold difference in smoking prevalence across the socioeconomic gra-
dient (Hiscock et al 2012).
Smoking is often more common in minority ethnic groups. Prevalence is par-
ticularly high among indigenous populations in the USA, Canada, Australia,
and New Zealand (Freemantle et al 2007). While smoking prevalence in US
adults is similar for White and African Americans (and slightly lower for His-
panic groups) (Garrett et al 2011), the average duration of smoking is longer for
African Americans (Siapush et al 2009), suggesting different life-course pat-
terns of tobacco use.
Smoking in New Zealand is associated with both socioeconomic disadvan-
tage and minority ethnic status (Hill et al 2003). Prevalence is highest in the
 Inequalities in smoking 101

indigenous Maori population at 45%—more than twice that amongst

­Europeans—while Pacific New Zealanders have intermediate levels (NZMoH
2010). Socioeconomic smoking gradients are evident within each ethnic group,
but their steepness varies; thus, socioeconomic status is a stronger predictor of
tobacco use for Europeans than Maori or Pacific peoples (Salmond et al 2012).
Smoking also shows complex patterns by gender. Maori women are more likely
to smoke than any other group (with prevalence approaching 50%), while
smoking is less common among Pacific and European women compared with
men in the same ethnic groups and is particularly rare among South East Asian
women (NZMoH 2010). While Maori and European women display a socioec-
onomic gradient in tobacco use, no gradient is evident for Pacific women (Sal-
mond et al 2012), who, until recently, showed an inverse gradient with higher
smoking levels in those with higher education and income (Hill et al 2003).
Complex patterns of smoking by class, ethnicity, and gender are also ob-
served in other populations. In the UK and USA, the latter part of the twentieth
century saw a more rapid decline in smoking among men compared with
women, narrowing the historic gender gap (Graham 1995; USDHHS 2001).
Social processes involved in smoking initiation appear to differ for girls, with
uptake particularly pronounced in girls from disadvantaged social backgrounds
(USDHHS 2001). In the UK, social relationships and negotiation of gender
roles appear to be particularly significant for smoking behaviour in women
(Graham 1995; Michelle and Amos 1997). The relationship between smoking
and socioeconomic position appears stronger for White girls and women than
for those from minority ethnic groups (Graham 1995; Wallace et al 2009), sug-
gesting that material disadvantage may have particular significance for women
in the majority ethnic group.
While other aspects of health may reveal different patterns of intersectional-
ity, these complex patterns of smoking behaviour demonstrate how focusing on
one aspect of social identity gives an incomplete picture of health risk. Re-
searchers need to consider how the effect of any one social factor (such as socio-
economic position) is modified by other important aspects of social identity
(such as ethnicity and gender). The relevance of intersecting social identities is
also suggested by the ways in which tobacco companies promote their products
to specific population groups. The tobacco industry has exploited changing
gender norms in marketing cigarettes to women (Amos and Haglund 2001),
including strategies targeting working-class women (Barbeau et al 2004a), and
has similarly tailored and promoted products to increase their appeal and ac-
cessibility for particular ethnic minorities (Primack et al 2007; Yerger et al
2007). Such strategies highlight the policy salience of understanding intersect-
ing social identities.
102 AXES OF HEALTH INEQUALITIES & INTERSECTIONALITY

7.7  Intersectionality and health inequalities:

Conceptual and methodological implications
Intersectionality offers two useful principles for examining the complex rela-
tionship between social identity, social position, and health: first, it acknow-
ledges that social identity is multifaceted, with each person simultaneously
occupying multiple identities relevant to their relationship with others and
their position within society; second, intersectionality directs attention away
from explanations of health and health behaviour focused on individual fac-
tors, encouraging consideration of axes of power that shape the relative privil-
ege or disadvantage experienced by particular communities (see also Chapters 8,
9, 16, and 17).

7.7.1  Social position is multifaceted

Health researchers often focus on one particular aspect of social identity in
order to better understand its significance for a particular social context and a
particular health outcome. Yet our understanding of the links between social
position and health will remain incomplete if we focus on only one aspect of
social identity/position in isolation.
One practical implication of this insight is the need to collect data on multiple
aspects of social identity, so that researchers have the tools to examine their dif-
ferent effects and interactions (Karlsen and Nazroo 2007). Recognizing this
multiplicity is essential in moving beyond a crude categorization that treats any
one social group as homogeneous. A retired Bangladeshi housewife living with
her daughter in Tower Hamlets may have a very different life experience to a
Punjabi lawyer living with her partner in Notting Hill—yet surveys often place
these individuals in the same category, making it difficult to explore how differ-
ent aspects of social identity affect these women’s lives. It is important for re-
searchers to take a ‘both/and’ rather than an ‘either/or’ approach to studying the
effect of social class, ethnicity, and gender on health: ‘[N]one of these social
constructs is a stand-in for any other, and all are necessary for generating ad-
equate depictions of social inequalities in health’ (Barbeau et al 2004b, p. 273).
Additionally, many common indicators of social position are best suited for
dominant groups within society, and may not accurately capture the experi-
ences of minority or less advantaged groups. This is evident in relation to class
and gender, where indicators such as occupation and employment status often
function less well for women, but it is also an important limitation in studying
the relationship between social class and health for minority ethnic groups,
people with disabilities, and sexual minorities (Graham 2007, pp. 50–51). The
non-equivalence of indicators across diverse groups creates challenges in
 CONCEPTUAL AND METHODOLOGICAL IMPLICATIONS 103

interpreting differential patterns between these groups, since it is difficult to

tease apart the methodological limitations of our research tools from genuine
interactions between various aspects of social position.
The multifaceted nature of social position also has implications for policy ef-
forts to reduce health inequalities. Policies directed at one aspect of social
­inequality—such as socioeconomic inequality—may be less effective for some
population groups. Thus, interventions targeting income inequalities may fail
to address ethnic inequalities, despite an over-representation of ethnic minor-
ities among those on low incomes. In ensuring that policies are widely effective,
policymakers must consider the needs of particular groups and how experi-
ences of socioeconomic position may differ from that of the dominant group.
This requires a more sophisticated evidence base that highlights how different
social groups may experience disadvantage in distinct ways.

7.7.2  Intersectionality and shared understandings

Intersectionality also facilitates a shared understanding of the underlying
causes of health inequalities. This may seem paradoxical, given how intersec-
tionality encourages us to consider multiple diverse aspects of social identity.
But there is also a sense of commonality across these different facets of social
experience, in that each of them reflects patterns of dominance and subordin-
ation. Bowleg (2012, p. 1267) describes how ‘multiple social identities such as
race, gender, sexual orientation, SES, and disability intersect at the micro level
of individual experience to reflect interlocking systems of privilege and oppres-
sion (i.e. racism, sexism, heterosexism, classism) at the macro social-structural
level.’ An intersectoral understanding of health inequalities requires us to
examine underlying axes of power that shape experiences of privilege and dis-
advantage within society.
Explanations for health inequalities that focus on individual attributes (such
as genetic predisposition, ‘culture’, or individual choice) ignore the ways in
which social position is co-constructed through the interaction of individual
self-identification and externally generated social categorization. In contrast,
explanations focusing on the ‘upstream’ drivers of social inequality highlight
ways in which social structures and ideology create a power imbalance across
these social categories. Thus, a person’s social identity (in terms of class, ethni-
city, gender, and other attributes) carries implications for access to socially gov-
erned resources, including different forms of ‘capital’ (Bourdieu 1986) relevant
to health.
This point is illustrated in the different explanations offered for socioeco-
nomic, ethnic, and gender disparities in tobacco use. The idea that certain
104 AXES OF HEALTH INEQUALITIES & INTERSECTIONALITY

population groups are genetically predisposed to nicotine addiction persists

and (somewhat inconsistently) has been advanced to explain both higher
(Bierut 2009) and lower (Lea et al 2005) smoking rates in Europeans compared
with other population groups. Apart from conceptual limitations, empirical
evidence refutes claims that ethnic minority and socially disadvantaged groups
develop stronger nicotine addictions (Scragg et al 2014). Similarly, the depic-
tion of smoking and quitting as reflecting individual choice directs attention
away from social patterns in smoking, and may even implicitly blame those
experiencing social disadvantage—thus stigmatizing marginalized population
groups and exacerbating health inequalities (Graham 2012).
The above case study demonstrates the intersecting nature of social position
and its influence on health. Recognition of intersectionality can help shift our
focus away from the behaviours of those occupying a less powerful position in
the social hierarchy and towards those actors with greater privilege and status.
This encourages consideration of how powerful actors, such as tobacco com-
panies, shape the social structures and processes responsible for the axes of
advantage and disadvantage that underlie health inequalities (see Chapters 9
and 13).

7.8  Conclusion
This chapter has examined how social inequalities in health extend beyond
those associated with social class. Research in New Zealand and the USA has
emphasized ethnicity as a marker of social advantage and disadvantage, while
researchers in many countries have increasingly acknowledged the role of gen-
der in health. While the importance of social class for health inequalities re-
mains indisputable, our understanding of the links between social position and
health remains incomplete if we do not also acknowledge the influence of other
aspects of social identity/position.
Intersectionality offers a way of understanding multiple intersecting aspects
of social identity and structure. For health inequalities researchers, this encour-
ages us to examine patterns of health in relation to multiple markers of social
position and to consider the heterogeneous experiences of groups defined by
any one social category. Thus, it is important to include multiple measures of
social position wherever possible, and to recognize that these capture distinct
aspects of social experience rather than being proxies for one another.
An understanding of intersectionality also encourages examination of the
role of power in health inequalities. While many different aspects of social iden-
tity have relevance for health, a common theme in health inequalities research
is the extent to which poorer health is experienced by less advantaged social
 Conclusion 105

groups—whether defined in relation to social class, ethnicity, gender, sexual

minority status, or other markers of social disadvantage. This commonality
points towards a political analysis of the causes of health inequalities, focusing
on the ideological norms (see Chapters 9 and 17), social structures (see Chap-
ters 16 and 17), and political activities (see Chapter 13) that reinforce dominant
patterns of privileging and subordination. Social stratification is intrinsically
exploitative, with the advantage experienced by one group reflecting the disad-
vantage experienced by other groups (Krieger et al 1997).
A political analysis of health inequalities has implications for the focus of
health inequalities research. The study of health inequalities cannot be detached
from an examination of the structures and processes producing social inequal-
ities (Graham 2007, p. 50). Researchers need to move beyond merely describing
health inequalities to examining the social processes and structures that rein-
force power inequalities, ‘so that bringing the agency of the disadvantaged into
focus does not leave the actions of the powerful out of sight’ (Walby et  al
2012, p. 228). In doing so it is important not only to focus on the experience of
the less powerful, but also to examine the basis of privilege and power within
society.

References
AIHW (2011) The Health and Welfare of Australia’s Aboriginal and Torres Strait Islander
People: An Overview. Canberra: Australian Institute of Health and Welfare.
Amos, A., and Haglund, M. (2001) From social taboo to ‘torch of freedom’: The marketing
of cigarettes to women. Tobacco Control, 9(1): 3–8.
Annandale, E., and Hunt, K. (2000) Gender inequalities in health: Research at the cross-
roads.’ Ch. 1. In E. Annandale and K. Hunt (eds), Gender Inequalities in Health. Bucking-
ham: Open University Press, pp. 1–35.
Arias, E., Rostron, B. L., Tejada-Vera, B. (2010) United States Life Tables, 2005. National
Vital Statistics Reports, 58(10): 1–132.
Barbeau, E. M., Leavy-Sperounis, A., and Balbach, E. D. (2004a) Smoking, social class, and
gender: What can public health learn from the tobacco industry about disparities in
smoking? Tobacco Control, 13(2): 115–120.
Barbeau, E. M., Krieger, N., and Soobader, M. J. (2004b) Working class matters: Socioeco-
nomic disadvantage, race/ethnicity, gender, and smoking in NHIS 2000. American Jour-
nal of Public Health, 94(2): 269–278.
Bierut, L. J. (2009) Nicotine dependence and genetic variation in the nicotinic receptors.
Drug and Alcohol Dependence, 104S: S64–S69.
Bourdieu, P. (1986) The forms of capital. In I. Szeman and T. Kaposy (eds) (2011), Cultural
Theory: An Anthology. Wiley-Blackwell, Chichester, pp. 81–93.
Bowleg, L. (2012) The problem with the phrase Women and Minorities: Intersectionality—
an important theoretical framework for public health. American Journal of Public Health,
102(7): 1276–1273.
106 AXES OF HEALTH INEQUALITIES & INTERSECTIONALITY

Corsi, D. J., Lear, S. A., Chow, C. K., Subramanian, S., Boyle, M. H., Teo, K. K. (2013) So-
cioeconomic and geographic patterning of smoking behaviour in Canada: A cross-­
sectional multilevel analysis. PLoS ONE, 8(2): e57646.
Davey Smith, G. (2000) Learning to live with complexity: Ethnicity, socioeconomic pos-
ition, and health in Britain and the United States. American Journal of Public Health,
90(11): 1694–1698.
Davey Smith, G., Chaturvedi, N., Harding, S., Nazroo, J., and Williams, R. (2000) Ethnic
inequalities in health: A review of UK epidemiological evidence. Critical Public Health,
10(4): 375–408.
Davis, K. (2008) Intersectionality as buzzword. Feminist Theory, 9(1): 67–85.
Denton, M., and Walters, V. (1999) Gender differences in structural and behavioural deter-
minants of health: An analysis of the social production of health. Social Science and Medi-
cine, 48(9): 1221–1235.
Frank, R. (2007) What to make of it? The (re)emergence of a biological conceptualization of
race in health disparities research. Social Science and Medicine, 64(10): 1977–1983.
Freemantle, J., Officer, K., McAullay, D., and Anderson, I. (2007) Australian Indigenous
Health—Within an International Context. Darwin: Cooperative Research Centre for
Aboriginal Health.
Garrett, B. E., Dube, S. R., Trosclair, A., Caraballo, R. S., and Pechacek, T. F. (2011) Cig-
arette smoking—United States, 1965–2008. Morbidity and Mortality Weekly Report,
60(Suppl.): 109–113.
Giskes, K., Kunst, A., Benach, J., Borrell, C., Costa, G., Dahl, E., Dalstra, J. A. A., Feder-
ico, B., Helmert, U., Judge, K., Lahelma, E., Moussa, K., Ostergren, P. O., Platt, S., Prat-
tala, R., Rasmussen, N. K., and Mackenbach, J. P (2005) Trends in smoking behaviour
between 1985 and 2000 in nine European countries by education. Journal of Epidemiol-
ogy and Community Health, 59(5): 395–401.
Goodman, A. H. (2013) Why genes don’t count (for racial differences in health). Ch. 4. In
T. A. LaVeist and L. A. Isaac (eds), Race, Ethnicity and Health: A Public Health Reader
(2nd edn). San Francisco: Jossey-Bass, pp. 49–56.
Graham, H. (1995) Cigarette smoking: A light on gender and class inequality in Britain?
Journal of Social Policy, 24(4): 509–527.
Graham, H. (2007) Unequal Lives: Health and Socioeconomic Inequalities. Maidenhead:
Open University Press.
Graham, H. (2009) The challenge of health inequalities. In H. Graham, Understanding
Health Inequalities. Maidenhead: Open University Press, pp. 1–21.
Graham, H. (2012) Smoking, stigma and social class. Journal of Social Policy, 41(1): 83–99.
Hill, S., Blakely, T., and Howden-Chapman, P. (2003) Smoking inequalities: Policies and
patterns of tobacco use in New Zealand, 1982–1996. Public Health Monograph Series
No. 11. Wellington: Department of Public Health, University of Otago.
Hiscock, R., Bauld, L., Amos, A., and Platt, S. (2012) Smoking and socioeconomic status in
England: The rise of the never smoker and the disadvantaged smoker. Journal of Public
Health, 34(3): 390–396.
Institute of Medicine (2011) The Health of Lesbian, Gay, Bisexual, and Transgender People:
Building a Foundation for Better Understanding. Washington, DC: National Academies
Press.
 Conclusion 107

Jarvis, M., and Wardle, J. (2003) Social patterning of individual health behaviours: The case
of cigarette smoking. Ch. 11. In M. Marmot and R. Wilkinson (eds), Social Determinants
of Health (2nd edn). Oxford: Oxford University Press, pp. 224–237.
Jones, C. P. (2000) Levels of racism: A theoretical framework and a gardener’s tale. Ameri-
can Journal of Public Health, 90(8): 1212–1215.
Karlsen, S., and Nazroo, J. Y. (2006) Defining and measuring ethnicity and ‘race’: Theoret-
ical and conceptual issues for health and social care research. Ch. 2. In J. Nazroo (ed.),
Health and Social Research in Multiethnic Societies. Abingdon: Routledge, pp. 20–38.
Kawachi, I., Daniels, N., and Robinson, D. E. (2005) Health disparities by race and class:
Why both matter. Health Affairs, 24(2): 343–352.
Kittles, R., and Weiss, K. (2003) Race, ancestry and genes: Implications for defining disease
risk. Annual Review of Genomics and Human Genetics, 4: 33–67.
Krieger, N., Williams, D. R., and Moss, N. E. (1997) Measuring social class in US public
health research: Concepts, methodologies and guidelines. Annual Review of Public
Health, 18: 341–378.
Lea, R., Benowitz, N., Green, M., Fowles, J., Vishvanath, A., Dickson, S., Lea, M. G.,
Woodward, A., Chambers, G. K., and Phillips, D. (2005) Ethnic differences in nico-
tine metabolic rate among New Zealanders. New Zealand Medical Journal, 118(1227):
1773.
Link, B. G., and Phelan, J. (1995) Social conditions as fundamental causes of disease. Jour-
nal of Health and Social Behavior, 35(1): 80–94.
Lopez, A., Collishaw, N., and Piha, T. (1994) A descriptive model of the cigarette epidemic
in developed countries. Tobacco Control, 3(3): 242–247.
Mackenbach, J. P., Stirbu, I., Roskam, A. J. R., Schaap, M. M., Menvielle, G., Leinsalu, M.,
and Kunst, A. E. (2008) Socioeconomic inequalities in health in 22 European countries.
New England Journal of Medicine, 358(23): 2468–2481.
Meer, N. (2014) Key Concepts in Race and Ethnicity. London: Sage.
Michelle, L., and Amos, A. (1997) Girls, pecking order and smoking. Social Science and
Medicine, 44(12): 1861–1869.
Nazroo, J. Y. (2003) The structuring of ethnic inequalities in health: Economic position, ra-
cial discrimination, and racism. American Journal of Public Health, 93(2): 277–284.
NZMoH (2010) Tobacco Use in New Zealand: Key Findings from the 2009 New Zealand To-
bacco Use Survey. Wellington: New Zealand Ministry of Health.
ONS (2012) Ethnicity and National Identity in England and Wales 2011. London: Office of
National Statistics.
Ostlin, P., George, A., and Sen, G. (2001) Gender, health, and equity: The intersections.
Ch. 13. In T. Evans, M. Whitehead, F. Diderichsen, A. Bhuiya, M. Wirth, and M. White-
head (eds), Challenging Inequities in Health: From Ethics to Action. Oxford: Oxford Uni-
versity Press, pp. 174–189.
Primack, B. A., Bost, J. E., Land, S. R., and Fine, M. J. (2007) Volume of tobacco advertis-
ing in African American markets: Systematic review and meta-analysis. Public Health Re-
ports, 122(5): 607–615.
Salmond, C., Crampton, P., Atkinson, J., and Edwards, R. (2012) A decade of tobacco con-
trol efforts in New Zealand (1996–2006): Impacts on inequalities in census-derived
smoking prevalence. Nicotine and Tobacco Research, 14(6): 664–673.
108 AXES OF HEALTH INEQUALITIES & INTERSECTIONALITY

Scragg, R., DiFranza, J. R., Youdan, B., and Laugesen, G. M. (2014) Ethnicity and socioec-
onomic status as risk factors for rapid onset of tobacco addiction. Australian and New
Zealand Journal of Public Health, 38(2): 194–195.
Shiffman, J., and del Valle, G. A. L. (2006) Political history and disparities in safe mother-
hood between Guatemala and Honduras. Population and Development Review, 32(1):
53–80.
Siapush, M., Singh, G. K., Jone, P. R., and Timsina, L. R. (2009) Racial/ethnic and socioec-
onomic variations in duration of smoking: Results from 2003, 2006 and 2007 Tobacco
Use Supplement of the Current Population Survey. Journal of Public Health, 32(2):
210–218.
SNZ (2013) New Zealand Period Life Tables 2010–2012. Wellington: Statistics New Zealand.
Templeton, A. (1998) Human races: A genetic and evolutionary perspective. American An-
thropologist, 100(3): 632–650.
Thomas, S. B. (2013) The color line. Ch. 2. In T. A. LaVeist and L. A. Isaac (eds), Race, Eth-
nicity and Health: A Public Health Reader (2nd edn). San Francisco: Jossey-Bass,
pp. 35–40.
USDHHS (2001) Women and smoking: A report of the Surgeon General. Washington, DC:
US Department of Health and Human Services.
Walby, S., Armstrong, S., and Strid, S. (2012) Intersectionality: Multiple inequalities in so-
cial theory. Sociology, 46(2): 224–240.
Wallace, J. M., Vaughn, M. G., Bachman, J. G., O’Malley, P. M., Johnston, L. D., and
Schulenberg, J. E. (2009) Race/ethnicity, socioeconomic factors, and smoking among
early adolescent girls in the United States. Drug and Alcohol Dependence, 104S: S42–S49.
WHO (1998) Gender and Health: Technical Paper. Geneva: World Health Organization.
Williams, D. R. (1997) Race and health: Basic questions, emerging directions. Annals of Ep-
idemiology, 7(5): 322–333.
Williams, D. R., and Mohammed, S. A. (2009) Discrimination and racial disparities in
health: Evidence and needed research. Journal of Behavioral Medicine, 32(1): 20–47.
Yerger, V., Przewoznik, J., and Malone, R. (2007) Racialized geography, corporate activity,
and health disparities: Tobacco industry targeting of inner cities. Journal of Health Care
for the Poor and Underserved, 18(4 Suppl.): 10–38.
 Chapter 8

Beyond ‘health’: Why don’t

we tackle the cause of health
inequalities?
Margaret Douglas

8.1  A traditional public health approach?

When John Snow’s investigations led him to conclude that contaminated water
from the Broad Street pump was spreading cholera, he famously had the pump
handle removed to prevent further exposure (Hempel 2006). When research
demonstrated the strong association between smoking, lung cancer, and many
other diseases, the public health community began researching and imple-
menting interventions to reduce the prevalence of smoking (Royal College of
Physicians and ASH 2002). This is the traditional public health approach: iden-
tify determinants of poor health, then direct efforts towards reducing the popu-
lation’s exposure to them.
Nowadays we have growing evidence that inequalities in income, wealth,
power, and status lead to poorer health. Yet social inequality is rarely con-
sidered or addressed as a health determinant in itself. Rather than asking how
to reduce exposure to social inequality, we appear to drift perpetually down-
stream. We accept social inequality as a given and ask how we can direct health
services and health promotion interventions to the groups of people who are
most disadvantaged.

8.2  Fundamental causes

The idea that health inequalities are caused by social inequalities, rather than
more proximate risk factors, is now well accepted (see Chapters 1–4). Policy
reviews from the Black Report onwards have identified the need for a multi-
sectoral approach that goes beyond individually focused health interventions
to address underlying social forces (see Chapter 1). The WHO’s Commission
on the Social Determinants of Health (CSDH 2008, p. 8) made this very expli-
cit, stating, ‘Social injustice is killing people on a grand scale’, and as one of its
110 Beyond ‘health’

three over-arching recommendations it called for action to ‘tackle the inequit-

able distribution of power, money and resources’. Similarly, Fair Society,
Healthy Lives said, ‘Social and economic differences in health status reflect,
and are caused by, social and economic inequalities in society’ (Marmot et al
2010, p. 16).
This relates to the ‘fundamental causes’ theory of health inequalities, first
described by Link and Phelan (1995). They demonstrate that the risk factors
mediating the association between socioeconomic position and health have
changed, but the association remains. They argue that fundamental social
causes influence access to resources like money, knowledge, power, pres-
tige, and beneficial social connections. People who can command more of
these resources are better able to avoid risks, disease, and consequences of
disease. Thus, whatever the current disease profile, the people who are most
affected are those of lower social position with least access to resources.
Empirical support for the ‘fundamental causes’ theory includes findings
that, as socioeconomic gradients reduce in some conditions, gradients
emerge in new conditions (Scott et al 2013). As knowledge increases about
how to prevent particular conditions, the socioeconomic gradients increase
(Phelan et al 2004).
This suggests that addressing proximate risk factors, even if targeted at the
most vulnerable people, will not address the underlying fundamental causes
and, unless fundamental causes are addressed, health inequalities will persist.
As Link and Phelan (1995, p. 88) state, ‘to address fundamental social causes,
the interventions must address inequalities in the resources that fundamental
causes entail’.
While Link and Phelan identify access to resources as the main mediator, oth-
ers have demonstrated that psychosocial stress related to low social position
leads to poor health (Bartley 2012; Wilkinson and Pickett 2009). There is some-
times debate about whether lack of material resources or psychosocial stress is
the most important factor causing poor health. But in either case, the under-
lying determinant—or fundamental cause—of health inequalities is inequal-
ities in social position. To reduce health inequalities, we must reduce social
inequalities.

8.3  Drifting downstream

As Chapter 1 outlines, many UK government policy documents on health in-
equalities have identified that health inequalities are determined by differences in
social circumstances. Their recommendations include reducing poverty, improv-
ing living standards, and prioritizing children to prevent inequalities persisting
 Drifting downstream 111

through generations. Yet repeatedly the focus shifts to more proximate behav-
ioural and medical risk factors.
For example, the English government developed ambitious targets to reduce
health inequalities with a Programme for Action in 2003 (Department of Health
2003). This referenced the Acheson Report, followed a ‘cross-cutting review’ to
identify the role of every government department, and frequently noted ‘under-
lying determinants’ of health inequalities. It identified the importance of early
years support, improved social housing, improved educational attainment, im-
proved access to public services, reduced unemployment, and improved income
among the poorest. Yet the interventions that were thought likely to have most
impact on the short-term targets were reducing smoking; managing risks such as
poor diet, obesity, physical inactivity, and hypertension; improved housing; im-
proved antenatal care and early years support; and preventing teenage preg-
nancy. This shifted the focus towards clinical and behavioural risk factors in
individuals living in disadvantaged communities. This might deliver some short-
term benefits, but is unlikely to impact on the underlying social inequalities.
Similarly, in Scotland, Equally Well (Scottish Government 2008) recognized
that health inequalities required a multi-sectoral response and needed ‘joined
up’ working across policy areas. Yet, in practice, the actions focused on more
proximate clinical and behavioural factors. A review of Equally Well concluded
that it is seen as a health and well-being initiative, with limited spread into other
policy areas (Beeston et al 2014). An example of this shift is the report’s recom-
mendation to develop ‘integrated impact assessment for public policies and
programmes’ in which ‘health inequalities is a clear component’ (Scottish Gov-
ernment 2008, p. 55). I was tasked with leading the development of ‘health in-
equalities impact assessment’ (HIIA) to consider impacts of policy decisions on
health, equality, and human rights. Following a successful pilot, HIIA is now
promoted and supported by NHS Health Scotland (Douglas and Palmer 2011).
Those of us involved in developing HIIA intended it to be used to identify and
improve the impacts that any policy can have on health inequalities. A range of
policies in Scottish Government health directorates and NHS Boards have been
subjected to HIIA, but, despite multiple attempts, it has so far proved impos-
sible to persuade colleagues in other policy areas to use it—health inequalities
is perceived by colleagues as only relevant to health policies.
This ‘lifestyle drift’ is commonly described (Braveman 2012a; Mackenbach
2011; Whitehead 2012). In jurisdictions without universal health care the ap-
proach to health inequalities often focuses on improved access to health care
(see Chapter 5). Of course health care is important to mitigate the effects, but
this approach conflates health with health care and cannot address the under-
lying causes of health inequalities.
112 Beyond ‘health’

8.4  Framing health inequalities: Confusion and blame

Although most health inequalities researchers agree that social inequalities
underpin health inequalities, there is heated debate about mediating pathways
and preferred interventions (see Chapter 20). A huge volume of literature de-
tails the extent of health inequalities, but there is much less evidence on the ef-
fectiveness of interventions and most evaluative research focuses on short-term
outcomes of downstream interventions addressing clinical or behavioural risk
factors (Pons-Vigues et al 2014).
Among public health practitioners, similarly there is often conflict and con-
fusion about what constitutes a health inequalities intervention. Any health-
related intervention targeting any disadvantaged population can be considered
to be addressing health inequalities. The range of approaches and interventions
that this potentially includes can make it difficult to prioritize and serves to em-
phasize downstream actions. In my own work I frequently observe confusion
about the difference between ‘health improvement’ initiatives to improve the
population’s health and ‘health inequalities’ initiatives to reduce the gap and/or
gradient.
The framing of health inequalities in the media is also confused (Aubrun et al
2007; Baum and Fisher 2013), reflecting the lifestyle drift apparent in govern-
ment policies. This of course also reflects the predominant understanding of
health more generally, as an individual rather than societal issue.
Across the UK, responses have targeted geographical areas deemed the ‘most
deprived’ (see Chapter 1). This is despite evidence that many people in poverty
do not live in these areas and that health inequalities occur across the social
gradient (Graham and Kelly 2004). This emphasis on particular neighbour-
hoods and the drift towards individual rather than structural actions implicitly
situate the problem with individuals and communities who are seen to have
poor lifestyles or lack psychosocial ‘assets’ (see Chapters 15 and 17), rather than
with wider societal patterns. This means the real fundamental causes remain
unchanged and any reductions in health inequalities are likely to be short-lived.
This approach may also directly cause harm—by stigmatizing particular com-
munities (see Chapters 16 and 17). As one resident said at a public meeting
about poverty and inequalities in Edinburgh, ‘who wants to live in a deprived
area?’.

8.5  Trying to paddle upstream

My own personal experience illustrates some of these issues at a local level. For
several years I have been the lead for health improvement and health inequal-
ities for NHS Lothian, a Scottish health authority covering a population of
 Trying to paddle upstream 113

around 800,000 people. Our population lives across four local authority areas.
Each of these has a Community Planning Partnership (CPP) that brings to-
gether public, private, and third sector organizations to jointly plan services
and programmes. Each CPP sets out a Single Outcome Agreement (SOA) de-
tailing priority outcomes, including indicators and targets through which pro-
gress will be monitored. The Lothian CPPs all have a multi-agency Health
Improvement Group or Alliance—I chair or attend all four of these. These
groups aim both to improve population health and to reduce health inequal-
ities. They lead a programme of health improvement activities, and have sub-
groups working on topics such as physical activity, food and nutrition, and
sexual health. This work is targeted towards the most deprived neighbourhoods
in each area, but is clearly not addressing the underlying structural causes of
health inequalities. The SOAs include targets to improve health and reduce
health inequalities—commonly life expectancy and the gap in life expectancy
between affluent and deprived areas, plus indicators relating to behavioural de-
terminants like smoking prevalence, physical activity levels, etc. The Health Im-
provement Groups are expected to monitor these targets and report to the CPP,
but changes in life expectancy reflect a much wider set of determinants than
those that our own action plans can address.
The CPPs also have other groups working on issues including housing, em-
ployment, and community safety and the SOAs include indicators relating to
affordable housing, employment, poverty, etc. These are health determinants,
but they are rarely seen as ‘health’ indicators, in contrast to behavioural risk fac-
tors like smoking prevalence and physical activity levels. The Health Improve-
ment Groups have sought to engage with the groups working on economic
development, housing, transport, and other policy areas that affect health de-
terminants with varying levels of success. Just as Equally Well failed to spread
into other policy areas at a national level, we have struggled to move beyond
obvious ‘health’ responses to tackle health inequalities at a local level.
In an attempt to shift our focus upstream in Edinburgh, we developed a
Health Inequalities Framework that made explicit the need to address wider
determinants of health, including social inequalities. Subsequently, the CPP de-
veloped a vision of a city in which ‘all forms of inequality and deprivation are
reduced’ (Edinburgh Partnership 2013, p. 1). It set up a new group to identify
how to reduce poverty and inequality in the city, which developed a set of ac-
tions that will feed into the work plans of all the groups that form part of the
CPP structure. It has involved a wide range of sectors and, in doing so, has cer-
tainly increased their understanding of and involvement in ways to reduce pov-
erty and inequalities in the city. However, this is not generally considered to be
health inequalities work. Whereas all of my colleagues in the local authority,
114 Beyond ‘health’

other local agencies, and the NHS readily recognize smoking and physical ac-
tivity as legitimate interests for public health, many do not perceive poverty and
social inequality as health determinants. Health inequalities work is limited to
‘health’ topics—targeted health care and/or health improvement focusing on
behavioural risks—rather than addressing the underlying social inequality.
‘Health’ inequalities are seen as being different to social inequalities and to re-
quire a different response.
The Edinburgh work also highlighted the difficulty of addressing—or even
talking about—social inequalities. There is widespread support and commit-
ment to reduce poverty, which is most often understood to mean targeting sup-
port and services to people considered to be vulnerable in some way. Challenging
inequalities is more difficult. It implies that the people who are relatively power-
ful and affluent must give up some of their status, power, or resource to allow
less well-off people to have relatively more. This is difficult even to articulate,
let alone do (see chapter 20). So the focus remains on the geographical areas
considered to be ‘most deprived’. As noted, this situates the issue with deprived
people, is stigmatizing, and avoids any consideration of the underlying social
structures that cause them to be deprived (see chapters 16 and 17).

8.6  Defining the problem

So why is it so difficult to shift the focus from downstream ‘health’ interventions
towards the structural causes of health inequalities? Why is it so difficult for us
to have, and share, an understanding of social inequality as a health determin-
ant that is as legitimate for us to try to address as smoking or contaminated
water? In the next section I suggest some reasons for this difficulty.

8.6.1  Health is an individual issue

One reason is the current prevalent understanding of health as an individual
issue, determined by individuals’ genetic make-up and individual choices. This
chimes with societal values emphasizing personal independence, free choice,
and individual autonomy. Yet we have no problem understanding that environ-
mental factors, like air quality, are health determinants and these are also
shared. Understanding our social structure as a health determinant seems to be
more challenging than applying this understanding to our physical
environment.

8.6.2  Powerful interests

Another reason is that, by definition, any challenge to the existence and main-
tenance of social inequalities means challenging powerful interests, who are
 Defining the problem 115

likely to oppose this (see chapters 9 and 13). Sometimes this is very explicit,
such as the reaction of the incoming Conservative government that sought to
suppress the Black Report in 1980 (see chapter 12). Other governments have
used terms like ‘variations’ and ‘disparities’ rather than ‘equity’ or ‘inequalities’
to frame health inequalities as inevitable, rather than something that could be
shaped by their decisions (Braveman 2012a; Wilkinson 1995).

8.6.3  Not in our own interests?

Most researchers and professionals working on health inequalities are in rela-
tively well-paid and well-respected posts. Many of us have titles like ‘Doctor’ or
‘Professor’, reinforcing our own power and status. The people who are the most
influential opinion leaders speaking publicly about health inequalities tend, by
definition, to have high status and often also high incomes. It can feel very un-
comfortable for us to think that, individually, we might benefit from the social
structures that cause health inequalities. This cognitive dissonance might lead
some to focus on downstream determinants and actions—challenging the up-
stream causes is challenging our own position (see chapter 6).

8.6.4  Social inequality seen as inevitable

In recent years, health inequalities have become a priority in the UK and every
political party claims to want to reduce them. But the same does not apply to
other forms of social inequality. As Iona Heath (2007) comments, ‘governments
can be shamed so much more readily by inequalities in health than wealth’. Part
of the reason is that inequalities in wealth are considered to be an inevitable by-
product of the economic system, and even desirable to drive the economy.
Many health inequalities researchers and professionals may also believe that
social inequality is inevitable and we should direct efforts to mitigating its ef-
fects rather than changing the underlying cause (see chapter 6). But there is
evidence that these inequalities are not inevitable, at least not to the extent we
see in the UK today. Both income and health inequalities have been lower in
other times and in other countries (see chapter 9). John Snow did not accept
contaminated water as a given and look for ways to mitigate the effects of drink-
ing it. Richard Doll did not accept smoking as a given and look for ways to miti-
gate the carcinogenic effects of tobacco smoke on alveoli. Neither must we
accept social inequality as inevitable and focus simply on mitigating its effects.

8.6.5  ‘Too political’

Many researchers and professionals working on health inequalities may feel
that, while they can legitimately lead downstream interventions to support
116 Beyond ‘health’

disadvantaged individuals, challenging social inequality is too overtly political

and not legitimate ‘health’ work (see chapter 20). As one researcher said at a
seminar I attended, ‘I don’t want to be seen as just another socialist’. But ad-
dressing many public health issues involves direct challenges to powerful insti-
tutional and commercial interests (see chapter 13). John Snow’s removal of the
Broad Street pump handle was a direct challenge to the Southwark and Vaux-
hall Waterworks company. Similarly, tobacco control, reducing harmful drink-
ing, and reducing obesity all involve direct challenges to commercial interests.
Public health work is often unpopular and politically difficult (see chapter 20).

8.6.6  ‘Not my bag’

Researchers and professionals working on health inequalities tend to be epi-
demiologists and clinicians. They may feel that understanding and addressing
social inequality is not part of their skill set. It might seem better to focus on
what we can do rather than on things beyond our sphere of knowledge and in-
fluence. But again, many other public health issues require actions beyond the
delivery of ‘health’ interventions and require partnership with other disciplines.
Preventing exposure to contaminated water required engineering measures to
develop a safe sanitation system. Reducing exposure to smoking has required
close working with marketing professionals to understand and challenge the
marketing tactics of tobacco companies. Improving levels of physical activity
requires work with spatial planners and transport professionals to encourage a
modal shift from cars to active travel.

8.6.7  Institutional responsibilities

Similarly, the institutions responsible for health inequalities are government
health departments and NHS Boards. The areas they can control directly are
health care delivery and health improvement programmes (Smith 2013). Both
the review of Equally Well and my own experiences discussed earlier demon-
strate the difficulty of getting other sectors to ‘own’ health inequalities. Yet it is
possible to gain support from other departments and other sectors for other pub-
lic health priorities. For example, the groups in Lothian that lead on health topics
such as physical activity, food and nutrition, sexual health, etc. are all multi-
agency, as these are understood to be issues that the NHS cannot address alone.

8.6.8  Short timescales

Governments often want to see outcomes in a short timescale—‘quick wins’
(Blackman et  al 2009). Actions to address underlying structural causes are
likely to take longer than actions addressing proximate factors. This is apparent
 Defining the problem 117

in the aforementioned 2003 English Programme for Action, which identified

actions addressing social determinants as being likely to be most effective in the
long term. But as noted previously, the programme focused on the actions
thought most likely to meet the short-term target, which were predominately
health care and behavioural interventions.

8.6.9  Evidence is downstream

As already noted, most of the effectiveness evidence on ways to tackle health
inequalities evaluates downstream interventions. This reflects all the issues
mentioned here—researchers’ disciplines, the kinds of research that health in-
stitutions commission, and the kinds of interventions that can be evaluated in a
short timescale (see chapter  6). If the evidence only considers downstream
interventions, it becomes self-perpetuating.

8.6.10  Equality legislation ignores socioeconomic inequality

In the UK, the approach to socioeconomic inequality contrasts sharply with the
approach to inequality related to other characteristics like race, gender, or age.
Disadvantage related to these characteristics is understood to relate to equality,
fairness, and human rights. The Equality Act 2010 prevents discrimination
against people with defined ‘protected characteristics’—which include race,
age, disability, gender, faith, and sexual orientation, but not socioeconomic sta-
tus (Government Equalities Office 2013). Public organizations must eliminate
discrimination, promote equality of opportunities, and foster good relations
between people who share a protected characteristic and those who do not. The
Equality and Human Rights Commission has legal powers to enforce these du-
ties. This has resulted in a different approach to socioeconomic inequalities
compared to inequality related to the protected characteristics. There is an
understanding that racial and gender inequalities in health are underpinned by
stigma and discrimination, which should be addressed. Socioeconomic health
inequalities are not generally understood to be caused by stigma, discrimin-
ation, or lack of opportunity related to socioeconomic status. So responses to
socioeconomic health inequalities are less likely to challenge these issues.

8.6.11  It’s a wicked issue

Finally, another reason for the neglect of structural causes is that health in-
equalities are a complex, ‘wicked’ issue that cannot be resolved by a single sim-
ple solution (Blackman et al 2006). Here I have argued that there is too much
focus on mitigating the health consequences of underlying social inequalities.
But it is also true that there is a need for these mitigation measures, and that
118 Beyond ‘health’

these encompass a broad range of health interventions targeting the needs of

many different populations. There is a host of separate interests involved in pro-
moting and supporting these interventions, and often conflict about how they
should be prioritized. The complexity of the many actions required to mitigate
the health consequences helps to cloud the lack of action to address the under-
lying social inequalities.

8.7  Mitigate, prevent, and undo

As health inequalities require a multifaceted response, it is helpful to have a
framework that articulates the main elements of a comprehensive approach.
NHS Health Scotland, the Scottish national health improvement organization,
has a corporate strategy that prioritizes health inequalities. The organization
recently produced a Health Inequalities Action Framework (Craig 2013) that
identifies the need for actions at the following three levels (based on a frame-
work first suggested by Geronimus (2000)):
◆ Actions to mitigate the health consequences of social inequalities—targeting
of health and social care
◆ Actions to prevent social inequality impacting on health outcomes—­
targeting of health improvement actions
◆ Actions to undo the policies and social processes that cause social
­inequality—requiring fiscal, cultural, and legislative change.
This framework makes it clear that all three kinds of action are needed to ad-
dress the complex issue of health inequalities. They are all legitimate elements
of a strategy to tackle health inequalities, and all three are needed to form a
comprehensive approach. It also highlights that, despite the rhetoric about so-
cial determinants, most of the action to date has focused on mitigation, or at
best prevention. We have not even defined the actions needed to undo social
inequality, let alone implemented them.

8.8  Staying upstream—implications for research

and practice
Developing and implementing actions to undo—not just mitigate—social in-
equality implies a significant shift in focus for health inequalities researchers,
policymakers, and professionals.

8.8.1  Define the key inequalities and pathways

First, we need to define the aspects of social inequality that are most important
for health. Although there is agreement that health inequalities are caused by
 Staying upstream—implications 119

social inequalities, the latter are usually described and understood rather
vaguely. We have few theories and even less empirical evidence that shows how
social inequalities lead to health outcomes. What is most important—­inequality
of income, wealth, power, or status? These overlap, but are not the same. Redis-
tribution of income is often proposed as a policy solution and is very important,
but is unlikely to be enough on its own, for several reasons (Starfield and Birn
2007). One is that policies to redistribute income may not reduce inequalities in
wealth, which are greater than income inequalities. Redistribution of income or
wealth also may not reduce existing inequalities in power, in status, and in the
ability to access and use other resources like knowledge and social connections.
Inequalities between different groups of people have been maintained over gen-
erations. People and groups who historically have received better education, or
benefited from higher prestige employment or more affluent social networks,
are likely to retain these advantages. More equitable income distribution may
improve distribution of these other resources over time, but be insufficient on
its own. There is an important research agenda to determine what aspects of
social inequality are most important for health, and the pathways through
which they lead to health outcomes.

8.8.2  Measures of inequality

Having defined the key aspects of social inequality, we need to establish meas-
ures of them to assess progress. These should be seen as health indicators to the
same extent as indicators such as smoking prevalence, physical activity levels,
and air quality. So they must be based on robust theory and research evidence
demonstrating a causal association with health outcomes. They must include
measures of inequality across the whole population, not only measures of pov-
erty or that relate only to the ‘most deprived’ populations. Some, such as meas-
ures of income inequality, may already exist. Measures of other aspects of social
inequality may need to be developed. They would have several purposes. Re-
searchers need outcome measures to evaluate the effectiveness of interventions.
Policymakers and practitioners could use them for performance monitoring of
the effect of plans and strategies. Their use in performance frameworks could
also help prioritize efforts towards ‘undoing’ social inequalities.

8.8.3  Interventions to reduce inequality

A new research agenda is needed that develops and evaluates interventions and
policies to reduce inequalities in the fundamental causes—inequalities in in-
come, wealth, power, knowledge, and beneficial social connections (see chap-
ter 6). This research would consider questions such as: What interventions can
120 Beyond ‘health’

reduce inequalities in income, wealth, power, and status between different

groups of people? How effective are they? What other negative and positive ef-
fects do these interventions have on health and other outcomes? This evaluative
research should be informed by the research discussed here to determine and
define the most significant aspects of social inequality and pathways by which
they affect health.

8.8.4  Inequality as the outcome

Currently, evaluative health inequalities research usually assesses the impact of
an intervention on health outcomes, not the impact on social inequality. In con-
trast, research on interventions to reduce smoking prevalence or increase phys-
ical activity evaluates their impact on smoking or physical activity. If they are
successful in achieving these outcomes, it is not deemed necessary to demon-
strate that this leads to reduced heart disease or increased life expectancy. It is
understood that demonstrating an impact on health outcomes would require
longer follow-up than demonstrating change in the determinants the interven-
tion targets. Similarly, if we have robust evidence of a causal association be-
tween identified aspects of social inequality and health, then we should be able
to use measures of social inequality as the primary outcome for evaluative
health inequalities research.

8.8.5  The
causes of inequality—from local practice
to national policy
Reducing social inequalities requires researchers, policymakers, and practi-
tioners to understand and challenge the people, structures, and institutions that
create and maintain these inequalities. There is a significant research agenda to
explore the ways in which social inequalities are maintained. One likely impli-
cation for practice is that the response to health inequalities should focus more
on national policy and legislation. Currently, the emphasis is on local-level
interventions and the responsibility for addressing health inequalities is often
placed with local government and health authorities. They in turn focus on tar-
geted interventions in deprived neighbourhoods. This may mitigate the conse-
quences, but cannot challenge or address the underlying cause of health
inequalities.

8.8.6  New approaches

Addressing fundamental causes will require us to influence non-health policy
and practice. We need a range of ways to do so. One approach currently being
used to engage with proposals in other sectors is Health Impact Assessment
 Conclusion 121

(HIA). Guidance on HIA stresses the need to identify differential impacts to

consider how a proposal may increase or reduce health inequalities. But to ad-
dress fundamental causes, HIAs could more explicitly identify the ways in
which a proposal may affect inequalities in income, power, and status.

8.8.7  New partners

All of this will require health inequalities researchers, policymakers, and prac-
titioners to develop new partnerships with sociologists, political scientists,
economists, and others. Some of these may be willing partners and perceive
health and other inequalities as a priority issue. Others may have different val-
ues and be hostile towards efforts to reduce social inequalities. But this is not
really a new challenge. There is a long public health tradition of working with
colleagues in many other sectors and disciplines, and challenging individuals
and institutions whose actions are bad for health.

8.9  Conclusion
Paula Braveman summarized it very succinctly when she said, ‘We are failing
on health equity because we are failing on equity’ (Braveman 2012b). Although
tackling health inequalities has been a priority across the UK and elsewhere for
many years, these inequalities persist. In this chapter I have argued that this is
largely because we have focused on ‘health’—usually understood to mean
health care and behavioural interventions—rather than ‘inequality’. In order to
make a real impact on health inequalities we need to start addressing the under-
lying cause—which is social inequality. To do that, we need to perceive social
inequality as a health determinant and direct efforts towards the cause rather
than the outcome (as we already do for other health determinants). There is
broad consensus that social inequality is a health determinant—so let’s start to
act on it.

References
Aubrun, A., Brown, A., and Grady, J. (2007) External factors v right choices: Findings from
cognitive elicitations and media analysis on health disparities and inequities in Louisville,
Kentucky. Louisville: Centre for Health Equity.
Bartley, M. (2012) Explaining health inequality: Evidence from the UK. Social Science and
Medicine, 74(5): 658–660.
Baum, F., and Fisher, M. (2013) Why behavioural health promotion endures despite its
failure to reduce health inequities. Sociology of Health and Illness, 36(2): 213–225.
Beeston, C., McCartney, G., Ford, J., Wimbush, E., Beck, S., MacDonald, W., and Fraser,
A. (2014) Health inequalities policy review for the Scottish Ministerial Task Force on
Health Inequalities. Edinburgh: NHS Health Scotland, http://www.healthscotland.com/
documents/23047.aspx.
122 Beyond ‘health’

Blackman, T., Elliott, E., Greene, A., Harrington, B., Hunter, D., Marks, L., McKee,
L., Smith, K., and Williams, G. (2009) Tackling health inequalities in post-devolution
Britain: Do targets matter? Public Administration, 87(4): 762–778.
Blackman, T., Greene, A., Hunter, D. J., McKee, L., Elliott, E., Harrington, B., Marks, L.,
and Williams, G. (2006) Performance assessment and wicked problems: The case of
health inequalities. Public Policy and Administration, 21(2): 66–80.
Braveman, P. (2012a) Health inequalities by class and race in the US: What can we learn
from the patterns? Social Science and Medicine, 74(5): 665–667.
Braveman, P. (2012b) We are failing on health equity because we are failing on equity. Aus-
tralian and New Zealand Journal of Public Health, 36(6): 515.
Commission on the Social Determinants of Health (2008) Closing the gap in a generation:
Health equity through action on the social determinants of health. Final Report of the
Commission on Social Determinants of Health. Geneva, World Health Organization,
http://whqlibdoc.who.int/publications/2008/9789241563703_eng.pdf?ua=1.
Craig, P. (2013) Health Inequalities Action Framework. Edinburgh: NHS Health Scotland,
http://www.healthscotland.com/documents/22627.aspx.
Department of Health (2003) Tackling health inequalities: A programme for action. Lon-
don: Department of Health, http://webarchive.nationalarchives.gov.uk/20130107105354/
http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/
digitalasset/dh_4019362.pdf.
Douglas, M., and Palmer, S. (2011) Health Inequalities Impact Assessment—an approach
to fair and effective policy making: Guidance, tools and templates. Edinburgh: NHS
Health Scotland.
Edinburgh Partnership (2013) The Edinburgh Partnership Community Plan 2013–2016.
Edinburgh: Edinburgh Partnership.
Geronimus, A. (2000) To mitigate, resist, or undo: Addressing structural influences on the
health of urban populations. American Journal of Public Health, 90(6): 867–872.
Government Equalities Office (2013) Equality Act 2010: Guidance. London: Government
Equalities Office. Crown Copyright, https://www.gov.uk/equality-act-2010-guidance.
Graham, H., and Kelly, M. P. (2004) Health Inequalities: Concepts, Frameworks and Policy.
London: Health Development Agency.
Heath, I. (2007) Life and death: Let’s get tough on the causes of health inequality. British
Medical Journal, 334(7607): 1301.
Hempel, S. (2006) The Medical Detective—John Snow, Cholera and the Mystery of the Broad
Street Pump. London: Granta Publications.
Link, B. C., and Phelan, J. (1995) Social conditions as fundamental causes of disease, Jour-
nal of Health and Social Behaviour, (extra issue): 80–94.
Mackenbach, J. P. (2011) Can we reduce health inequalities? An analysis of the English
strategy (1997–2010). Journal of Epidemiology and Community Health, 65(7): 568–575.
Marmot, M., Allen, J., Goldblatt, P., Boyce, T., McNeish, D., Grady, M., and Geddes, I.
(2010) Fair Society, Healthy Lives: A Strategic Review of Health Inequalities in England
Post-2010 (The Marmot Review). London, UK: UCL Institute of Health Equity.
Phelan, J., Link, B.C., Diez-Roux, A., Kawachi, I., and Levin, B. (2004) Fundamental
causes of social inequalities in mortality: A test of the theory. Journal of Health and Social
Behaviour, 45: 265–285.
 Conclusion 123

Pons-Vigues, M., Diez, E., Morrison, J., Salas-Nicás, S., Hoffmann, R., Burstrom, B.,
van Dijk, J.P., and Borrell, C. (2014) Social and health policies or interventions to tackle
health inequalities in European cities: A scoping review. BMC Public Health, 14(1): 198.
Royal College of Physicians, ASH (2002) Forty fatal years: A review of the 40 years since
the publication of the 1962 report of the Royal College of Physicians on smoking and
health. London: Royal College of Physicians, https://www.rcplondon.ac.uk/sites/default/
files/documents/fortyfatalyears.pdf.
Scott, S., Curnock, E., Mitchell, R., Robinson, M., Taulbut, M., Tod, E., and McCartney,
G. (2013) What Would It Take to Eradicate Health Inequalities? Testing the Fundamental
Causes Theory of Health Inequalities in Scotland. Glasgow: NHS Health Scotland.
Scottish Government (2008) Equally well: Report of the Ministerial Task Force on Health
Inequalities. Edinburgh: Scottish Government, http://www.gov.scot/resource/doc/
229649/0062206.pdf.
Smith, K. E. (2013) Institutional filters: The translation and re-circulation of ideas about
health inequalities within policy. Policy and Politics, 41(1): 81–100.
Starfield, B., and Birn, A.-E. (2007) Income redistribution is not enough: Income inequal-
ity, social welfare programs, and achieving equity in health. Journal of Epidemiology and
Community Health, 61: 1038–1041.
Whitehead, M. (2012) Waving or drowning? A view of health equity from Europe. Austral-
ian and New Zealand Journal of Public Health, 36(6): 523.
Wilkinson, R. (1995) ‘Variations’ in health. British Medical Journal, 311(7014): 1177.
Wilkinson, R., and Pickett, K. (2009) How inequality gets under the skin. In R. Wilkinson
and K. Pickett, The Spirit Level. London: Penguin.
 Chapter 9

Neoliberalism and health

inequalities
Chik Collins, Gerry McCartney,
and Lisa Garnham

9.1  Introduction: Neoliberalism and health inequalities

In this chapter we use the term ‘health inequalities’ to refer to unfair differences
in health outcomes between social groups (differences which in other countries
are often referred to as ‘health inequities’—see Chapters 1 and 5). The chapter
deals particularly with neoliberalism and its impacts in terms of inequalities in
general, and health inequalities in particular. It is presented as follows. Section
one deals with the development of liberalism, with particular reference to Brit-
ain, describing its market, social and neoliberal (or anti-social) forms; and it
positions these in relation to both ‘one nation’ conservatism and social democ-
racy. In section two, some of the issues arising in applying the concept of neo-
liberalism are discussed and some of the main connections between
neoliberalism and inequality, both in theory and in practice, are outlined. Sec-
tion three summarizes relevant research on neoliberalism and inequalities in
health specifically. In section four, two of the key debates around theorizing the
connection between neoliberalism and health are discussed. In conclusion,
what the authors see as the implications and challenges arising for those en-
gaged with the field of public health are identified.

9.2  Liberalism(s)
Neoliberalism, in Britain and also more widely, is strongly associated with the
persona of Margaret Thatcher who, as UK Prime Minister between 1979 and
1990, pioneered the application of a neoliberal policy agenda in an industrially
developed society. This entailed forcing deindustrialization as part of a broader
‘political attack’ on the social democratic welfare state and the organized work-
ing class, and promoting privatization of public goods and services, together
with deregulation of banking and finance, thereby shifting the distribution of
 Liberalism(s) 125

income and wealth, and opportunities for social mobility, back towards what
had typified the early decades of the twentieth century. There are, of course,
strongly opposing views as to Thatcher’s contribution to the development of the
UK in general terms, but in terms of health inequalities there is strong evidence
of a very negative impact (Scott-Samuel et al 2014).
But why would a leader of the Conservative Party be so strongly associated
with neoliberalism? In the early years of her government, Thatcher faced oppos-
ition within her own Party. Her opponents saw her policies as destructive and
divisive, threatening the ‘one nation’ in which ‘true Conservatives’, following
their pragmatic later nineteenth-century leader Benjamin Disraeli, had come to
believe. To them, Thatcher was not really a Conservative at all, but a ‘Manches-
ter Liberal’ (Gilmour 1992).
In the nineteenth century, prior to the creation of the social-democratic La-
bour Party, liberalism, in Britain and beyond, radically challenged traditional
conservatism, asserting limited government, individual liberty, free markets,
and economic growth. Disraeli’s ‘one nation’ conservatism was a response to
this challenge. Disraeli articulated anxieties about the results of liberalism in
practice—and perhaps nowhere were these results more clearly exhibited than
in Manchester, where spectacular economic growth brought mass human mis-
ery (Engels 1845). This was the era of ‘market liberalism’, a period which saw
what Karl Polanyi (1934) described as a stark ‘utopian experiment’, entailing the
attempt to subordinate both economy and society to the self-governing mech-
anism of the market.
Later nineteenth-century currents within liberalism, recognizing the de-
structive impacts of such market liberalism, took a ‘social liberal’ direction. For
the social liberals, there was little appealing about the ‘freedom to starve’ or to
otherwise live a miserable life. Consequently, the state could, and should, take
positive steps to support people to live decent lives and enjoy meaningful free-
doms. This development was reflected in the ‘Liberal Reforms’ in the UK be-
tween 1906 and 1914, providing what were to become the building blocks for
the welfare state—an anathema to classical and later neoliberals (such social
liberalism informs the distinctive use of the term ‘liberal’ in the USA, to indi-
cate support for ‘big government’). However, in the inter-war period, the em-
phasis very clearly returned to market liberal precepts—fostering reckless
financial speculation and then, after the 1929 crash, a decade of unemployment,
hunger, and depression, which was alleviated only by preparations for the Sec-
ond World War.
The experience of this war was to lay the basis for an overwhelming rejection
of market liberalism, and a new popular consensus around the ‘Keynesian Wel-
fare State’ (KWS). In the case of the UK, this KWS was in fact principally
126 Neoliberalism and health inequalities

mapped out by two social liberals, John Maynard Keynes and William Bever-
idge, but implemented in practice by a ‘social-democratic’ Labour Party, linked
to the broader labour and trade union movement, and committed to much
greater social equality.
This marriage of economic management to ensure growth and employment,
together with public services to promote citizen well-being ‘from the cradle to
the grave’ (to ensure adequate income, health care, housing, and education),
provided the key reference point for the view of Thatcher’s Conservative op-
ponents. For them, ‘Thatcherism’ dogmatically refused to learn from the ex-
perience of market liberalism, which had been so deeply implicated in colossal,
and avoidable, human suffering in the nineteenth and earlier twentieth
centuries.
In the early post-war period, those who remained committed to ‘anti-social
liberalism’ and ‘market fundamentalism’ were marginal. Foremost amongst these
was the ‘Austrian School’, led by Hayek. For Hayek, the Keynesian welfare state
was to be seen as The Road to Serfdom. Social justice was to be seen as a meaning-
less ‘mirage’, the pursuit of which would, nonetheless, radically undermine indi-
vidual freedom (understood simply as ‘the absence of coercion’) and responsibility.
Inequality, from this perspective, was a simple fact of human life, and the relief of
poverty and suffering in extreme cases was better left to the charitable instincts of
successful wealth creators. This was the birth of ‘neoliberalism’.
From the 1960s, such thinking was presented in a more populist manner by
Milton Friedman and his ‘Chicago School of Economics’, which equated capit-
alism with freedom and choice, and sought to provide a blueprint for the re-
assertion of market principles across both economy and society.
But how did these initially marginal ideological currents enter the main-
stream? They did so in the context of a developing crisis in Western societies
from the later 1960s, particularly after the dramatic increase in world oil prices
in the early 1970s. The ensuing scenario of economic stagnation and inflation
(or ‘stagflation’), together with industrial conflict around the issue of who was
to ‘pay’ for the crisis—in terms of unemployment, real wages, spending cuts,
and so on—was constructed by what was then called ‘the new right’ as a crisis of
profitability and of ‘ungovernability’ in Western societies. For such commenta-
tors, the ‘rising expectations’ as to standards of living across such societies, and
amongst the working class in particular, posed a profound challenge to the con-
tinuation of capitalist accumulation. Neoliberalism was seen to provide both
viable ideological legitimation and specific practical guidelines for breaking
such expectations, restoring ‘governability’, and returning the division of the
proceeds of wealth creation between classes to a pattern more characteristic of
the late nineteenth and early twentieth centuries.
 Actually existing neoliberalism(s) 127

Such a project would, of course, meet opposition, and this, it was increasingly
understood, would need to be met with some ‘conviction’—in the form of
‘shock treatment’ (Klein 2007). The organized working class and wider social
movements were to be dealt with through mass unemployment and carefully
planned political action. After an initial and abortive attempt—seen to be lack-
ing in conviction—by Edward Heath’s (Conservative) UK government, elected
in 1970, it was implemented more forcefully in Chile from 1973, with input
from the Chicago School, under the dictatorship of General Pinochet. There-
after, the project progressed to Uruguay and Argentina—producing what one
Argentinian called ‘planned misery’ (see Klein 2007, pp. 95–96).
Simultaneously, neoliberal precepts were propounded with increasing force
in the UK and the USA, preparing the way for the election of Thatcher in 1979
and Ronald Reagan in 1980. Sustained attacks on the KWS and the ‘rising ex-
pectations’ of the working classes ensued. Here too, as contemporary docu-
ments were later to show, mass immiseration was fully anticipated (Collins and
McCartney 2011).

9.3  Actually existing neoliberalism(s)

As indicated, the political forces projecting neoliberalism in the 1970s and early
1980s were referred to as ‘the new right’. However, by the end of the 1980s par-
ties beyond the political right were displaying a clear neoliberal bent—­including
many previously centrist and leftist parties (for example, the ‘New Democrats’
in the USA and ‘New Labour’ in the UK).
As Boyle and his co-authors (2008) observe, by this time neoliberalism had
proved to be ‘a tenacious animal’ (Boyle et al 2008, p. 322). It had effectively col-
onized large parts of the planet—in Europe, Latin America, the former Soviet
Union, and South Africa—and global institutions and inter-governmental or-
ganizations (including the IMF, the World Bank, and the EU). And all of this was
not only in spite of the recurring crises produced by neoliberalism in practice,
but also frequently as a result of the active exploitation of such (see Klein 2007).
These developments, for Coburn (2000, 2004), reflected how processes of
globalization had seen transnational corporations substantially escape the pre-
vious forms of control exerted at nation state level. With this, Coburn argued,
came a sharp decline in the ‘legitimation’, as opposed to the ‘accumulation’,
function of the state, and in turn the more effective subordination of the state to
international business interests (see Chapter 13). However, for Navarro (2009),
such an emphasis on ‘globalization’ obscures the continuing power of nation
states, and their capture by quite narrow class interests. In this light, such a ‘glo-
balization’ perspective can, unwittingly, provide an alibi for these interests.
128 Neoliberalism and health inequalities

In all of this there was an increasing reliance in critical academic analyses on

a singular term (neoliberalism) to traverse an increasingly wide set of contexts
and experiences. One concern arising was that abstract neoliberal precepts had
in practice to be adapted to pre-existing realities already ‘on the ground’ across
all of these diverse contexts, such that, as Boyle and colleagues (2008) put it, the
precepts became ‘hybridized’ and ‘crystallized into complex and mutant “actu-
ally existing forms”’ of neoliberalism (consequently, the situation in New Zea-
land is very different from Argentina, which is very different from Russia, etc.).
Moreover, ‘[t]hese forms often contradict the principles from which they derive
and in any event run in parallel with other ideologies and programmes of re-
form’ (Boyle et al 2008, p. 313). In this light, some had concluded: ‘A removal of
the term [neoliberalism] from the academic vocabulary seems the only way to
overcome glib and fruitless characterizations of contemporary political econ-
omy’ (Boyle et al 2008, p. 313).
This discussion usefully highlights the need to avoid simplistic understand-
ings of the process of ‘neoliberalization’ across diverse contexts, and to engage
concretely with the complex ways in which it has been adopted in distinct con-
texts to produce, not a one-dimensional translation of precepts into practice,
but widely varying forms of ‘actually existing neoliberalism’. Nonetheless, as
Boyle and his co-authors themselves conclude, the term remains fundamen-
tally important in critically orientating our understandings of policies and
practices across diverse contexts.
An important insight into the broad development of neoliberalism in the
more advanced capitalist nations is provided by Peck and Tickell (2002) in their
distinction between the ‘roll back’ neoliberalism of the 1980s and the ‘roll out’
neoliberalism of the 1990s. Across the 1980s, neoliberal governments in the
USA and UK forced deindustrialization in order to use the brute force of mass
unemployment to contain trade unionism. Through deregulation and privat-
ization these governments unleashed massive speculation. And in all of this
they deepened existing, and fostered new, social and spatial divisions. By the
end of the decade it was apparent that this ‘roll back’ approach was not sustain-
able and created unnecessary and undesirable effects even for those committed
to the neoliberal project (e.g. in the UK in the later 1980s, rampant financial and
property speculation, overt ideological and political divisions and conflict, and
social breakdown and ‘social exclusion’ with attendant costs in terms of welfare,
policing, and incarceration). Thereafter, something new, and in its own way de-
velopmental and regulatory, came to the fore, seeking greater stability and look-
ing to manage such undesirable outcomes. This was ‘roll out’ neoliberalism,
exemplified best by the Clinton and Blair administrations, in which the state
looked proactively to regulate the relationships between the state and the
 Actually existing neoliberalism(s) 129

market on terms which were ultimately of greatest benefit to the private sector.
This marked the transition from ‘government’ to ‘governance’.
‘Actually existing neoliberalism’, then, is a complex and diverse p
­­ henomenon—
or set of phenomena—which has evolved in significant ways over a number of
decades. Its exponents are not averse to contradicting and indeed inverting its
basic precepts. This reflects that neoliberalism is not, first and foremost, a ‘pol-
itical ideology’ which is slavishly adhered to, but rather an ongoing practical
project serving particular social interests (Harvey 2007).
Nonetheless, there are certain key features which can be seen quite clearly to
follow both (ideo)logically, and also in practice across diverse contexts, from
the application of neoliberalism, in relation to both inequality in general and, as
we shall see in the next section, health inequalities in particular (see also Co-
burn 2000, 2004).
Neoliberalism actively embraces inequality, and either refutes the concept of
social justice, or equates justice with what a supposedly ‘free’ market will produce
(and in practice, states that have trumpeted ‘free market’ policies have actually
funnelled huge public resources to an increasingly dependent private sector). It
rejects ideas of solidarity—and indeed at times the idea of ‘society’ itself—and
looks to undermine, if not actually to destroy, social institutions based on such
ideas. One might call these ‘equalizing institutions’—trade unions, social security,
and public provision of vital resources like housing, health care, and utilities.
In practice, this has all found fairly consistent expression across the contexts
of ‘actually existing neoliberalism’, with, for instance:
◆ Restructuring (particularly in the UK and USA) of economies away from
heavier industries and manufacturing, and towards finance and services in
order to undermine the basis of organized labour, creating unemployment
and poverty, particularly in deindustrialized areas;
◆ A pronounced centralization of power and removal of vital considerations
about the nature and purpose of economic and social life from the sphere of
democracy (under the slogan ‘There Is No Alternative’ (TINA)), and the in-
creasing colonization of the political process by business interests (see
Chapter 13);
◆ Privatization and deregulation, fostering what Harvey (2004) has called ‘ac-
cumulation by dispossession’—the transfer of public assets into private
hands through privatization, ‘financialization’, management and manipula-
tion of crises, and state redistribution;
◆ Massively widening inequalities in income and wealth—driven less by gen-
eration of new wealth than by its redistribution in favour of the rich
(Harvey 2007);
130 Neoliberalism and health inequalities

◆ Ongoing attacks on public welfare provision which, in a context of historic-

ally heightened levels of unemployment and ‘worklessness’, increase, inten-
sify, and spatially concentrate poverty;
◆ The emergence, more recently, of a series of highly focused interventions
designed to ‘incentivize’ individuals to reconstruct themselves in the model
of ideal subjects for the ‘flexible labour market’—most obviously through
overtly coercive conditionalities for the receipt of meagre welfare benefits,
which have most recently seen large numbers in rich nations reduced to des-
titution and reliance on food banks (see Chapters 12 and 17).

9.4  Neoliberalism and health inequalities

All of these aspects of neoliberalism figure amongst what are known to be social
determinants of health and, consequently, the effects of this ‘return to liberal-
ism’ can be seen very clearly playing out in the health and inequality data cover-
ing the past 100 years. Thus, following the World Wars and the associated
influenza pandemic, average life expectancy across most high income countries
rose rapidly for some 40 years, resuming the pattern of improvement witnessed
from the 1850s to 1910 (McCartney et al 2012). Following the Second World
War and the building of the KWS in the UK, this increase in average life expect-
ancy was also associated with a large and rapid decline in spatial inequalities in
income and health (Leigh 2007; Thomas et al 2010). A pattern of positive state
intervention and democratization on the one hand, and consequent decline in
poverty, income inequality, and mortality on the other, can be seen across many
high-income nations during this period (Caminada and Goudswaard 2001;
Mackenbach 2013).
However, these positive trends started to falter, or indeed reverse, in many
nations during the last 20 years of the twentieth century. In New Zealand, neo-
liberal reforms under Minister of Finance, Roger Douglas (1984–8), led to
sharp increases in poverty and income inequality, and consequent rapid rises in
mortality inequalities across income groups and between Maori and non-Maori
populations (Blakely et al 2004, 2008). In the USA, a very similar phenomenon
was witnessed, when a radical change in political direction towards neoliberal-
ism under Reagan led to both a slowing in the improvement of the average
health of the population (McCartney et al 2012) and a rapid rise in health in-
equalities between income groups and ethnic groups (Krieger et al 2008). In the
UK, the election of the Thatcher government in 1979, as indicated earlier, her-
alded a sharp change in political direction, leading to mass unemployment and
rapidly rising income inequality (Collins and McCartney 2011; Scott-Samuel
 Neoliberalism and health inequalities 131

et al 2014; Smith 1985). The health consequences of this were profound, with
those who benefited most continuing to enjoy the greatest improvements in
health, whilst those in the most deprived areas, and those who suffered most
from unemployment and deindustrialization, seeing comparatively little, no,
and in the very worst cases negative, improvement (Collins and McCartney
2011; Norman et al 2011). The net result was a massive increase in health
­inequalities—an increase that took back all of the progress in reducing them
over the preceding century (Thomas et al 2010), as Figure 9.1 illustrates.
Eastern Europe has provided a particularly distressing example of a disas-
trous adoption of ‘brute’ neoliberalism. The health of the population of Rus-
sia, together with that of the other constituent states of the USSR and those
in its wider sphere of influence, improved quickly in the post-war decades,
such that, until around 1980, it was catching up with the life expectancy of
Western and Central Europe. There was then a gradual move within these
societies towards ‘restructuring’, which accelerated with the changes intro-
duced under Soviet leader Mikhail Gorbachev. This development coincided
with a gradual decline in life expectancy across the USSR (Mackenbach
2013). However, it was the 1989 revolution and rapid application thereafter
of the neoliberal ‘shock doctrine’ (Klein 2007) that resulted in a drop of some
eight years in average life expectancy in Russia, and also drops in other parts
of Eastern Europe. Much of this was occasioned through alcohol and ex-
treme poverty. Although there has subsequently been some rebuilding of
state welfare provision and a moderate subsequent recovery in life expect-
ancy, health inequalities and average mortality rates remain worse in Eastern
Europe than elsewhere: a deadly legacy of a political experiment which bene-
fited some massively, but proved utterly disastrous for many others (Stuckler
et al 2008).
The associations between neoliberal politics, rising income inequality, and
increases in health inequality are therefore—notwithstanding the diversity of
‘actually existing forms’ of neoliberalism—clear, well known, and causal. They
have been witnessed around the world in a variety of countries in a consistent
and well-characterized pattern (Beckfield and Krieger 2009). What is more
controversial is the suggestion that neoliberalism might impact negatively on
entire populations, irrespective of the economic benefits accruing for some in-
dividuals, or as reflected in Gross Domestic Product (GDP). Also controversial
is the suggestion that the impacts of neoliberalism and inequalities in income
can be dissociated from any impact on health inequalities, and connected in-
stead to other, more ‘proximal’ determinants, such as smoking or alcohol con-
sumption. It is to these debates that we now turn.
132 Neoliberalism and health inequalities

Mortality ratio in best to worst local authority 2.5 0.5

Great Britain

Income inequality (Gini coefficient)

2 0.4
Mortality ratio

1.5 0.3
deciles

Income inequality
1 0.2

0.5 0.1
Election of Thatcher

0 0
2 0.4
USA

Income inequality (Gini coefficient)

Mortality ratio between income

1.6
Mortality ratio 0.3
quintiles 1 and 5

1.2
Income inequality 0.2
0.8

0.1
0.4
Election of Reagan
0 0
10
19 0

19 0

20 0
19 0

19 0

19 0

19 0

19 0
65

19 5

85

95

05
19 5

45

55
19 5

0
3

7
7
3
2

19

20

20
19

19

19
19

Year
Fig. 9.1 Trends in health and income inequalities in Great Britain and the USA.
Source: Data from Thomas, B. et al., Inequalities in premature mortality in Britain: observational
study from 1921 to 2007, British Medical Journal, Volume 341, Issue 3639, 2010; Krieger, N.
et al., The fall and rise of US inequities in premature mortality: 1960–2002, PLoS Medicine/Public
Library of Science, Volume 5, e46, 2008; and Institute of Fiscal Studies, Luxembourg Income
Study.
 DEBATES: INEQUALITY AND PATHWAYS 133

9.5  Debates: The place of inequality and pathways

Wilkinson and Pickett (2009) have argued that, amongst high-income coun-
tries where absolute poverty has been relatively rare (though it is clearly far
more evident in many high-income countries in recent times), relative inequal-
ities (as measured by income inequality) are causally associated with worse
average health across populations, and also a broader range of negative social
outcomes (including crime, family breakdown, and care of the environment).
Perhaps most convincingly, their systematic review of the literature found that
the association was consistent across time and place and was identified by dif-
ferent research groups who investigated the relationship (Wilkinson and Pick-
ett 2006). However, they have suggested that the impact specifically on health
inequalities is minor (Wilkinson and Pickett 2008).
The central debate around their contribution is about how far income in-
equality impacts on the health of the whole population by reducing the cohe-
siveness and efficient functioning of society overall (via psychosocial
pathways—see Chapter  1), and how far income inequality is simply a proxy
measure of relative poverty which impacts most profoundly on the poorest
groups (via material and structural pathways—again, see Chapter 1), and which
in turn reduces average population health (Lynch et al 2000). What has clearly
been missing from much of this debate has been a political contextualization of
the contemporary causes of income inequalities and poverty, given the likely
importance of both in explaining health outcomes, although some have sought
to redress this b­ alance—some in rather abstract terms (Marmot et al 2010), and
others in clearer and more explicit ways (Beckfield and Krieger 2009; Birn 2009;
Coburn 2000, 2004; Navarro 2009).
Perhaps the most lively debate in the health inequalities literature has been
around the various attempts to explain why health inequalities arise, by explor-
ing the pathways and mechanisms linking markers of socioeconomic status to
health outcomes (Macintyre 1997; see Chapter 1). Some of this work has simply
set out to list the various hypothesized pathways without sufficient critical ap-
praisal of the strength of evidence related to them, and the likelihood of some
exposures being confounded by others. This has led to unhelpful suggestions
that all pathways are more or less valid and that interventions focused on all of
them are therefore worth pursuing (Benzeval et al 2014). Others have used ob-
servational evidence to suggest that removal of a particular exposure (e.g.
smoking) would reduce health inequalities (Gruer et al 2009).
These kinds of contributions can be seen as problematic for three main rea-
sons. First, there is very limited evidence for some of the pathways (such as
health selection, where poor health is said to cause low socioeconomic status
134 Neoliberalism and health inequalities

rather than the other way round) and a focus on such explanations has the po-
tential to mislead public health interventions (McCartney et al 2013). Second,
all of the pathways are entirely contingent on inequalities in socioeconomic
status, and the evidence is clear that only a narrowing of the inequalities in in-
come, power, and resources is likely to reduce health inequalities—not least
because action on any particular behavioural pathway would, on the basis of
past experience, be likely to reveal other pathways that would in turn emerge to
drive health inequalities (Link and Phelan 1995; Mackenbach 2011; McCartney
et al 2013; Scott et al 2013). Finally, and particularly pertinent in the context of
this chapter, a number of authors have highlighted how much of the theorizing
and research undertaken thus far ignores, or is reluctant to adequately engage
with, the political determinants of inequalities in income, power, and
­resources—thereby failing to identify the key actors and actions responsible for
health inequalities, and by implication, the substantive practical steps which
would be required to address them (Coburn 2000; Krieger 1994; Krieger et al
2008; McCartney et al 2013; Navarro 2008, 2009; see Chapters 1, 8, and 17).

9.6  Conclusion: Neoliberalism and the challenge

to public health
Liberalism has a long history. It evolved through its earlier market form, via so-
cial liberalism, and then, in reacting against that, neoliberals laid the ideological
basis for its current, dominant (anti-social) form. At its core, neoliberalism, as
revealed by what its exponents do in practice, is a fundamentally political project
which is legitimated by, much more than it is driven by, ideological adherence. As
Harvey (2007) has shown, it has been much less successful in achieving eco-
nomic growth than was Keynesianism in the post-war decades, and indeed,
since Harvey made this case, global events have highlighted how illusory many
of the claims about the economic success of neoliberalism have been. However,
neoliberalism has impacted dramatically by attacking and weakening the organ-
izations of the working class, and redistributing income and wealth in favour of
an increasingly small minority of beneficiaries—who bear a striking resem-
blance to what was in the past often referred to as a capitalist class (on the vital
necessity of the concept of class, and the reasons why it became ‘unfashionable’,
see Navarro 2009). This has involved a pronounced diminution of democracy,
with the great majorities within societies increasingly separated from meaning-
ful influence over the decisions affecting their lives, not least by the adaptation of
almost all major political parties to the purposes of neoliberalism.
The particular forms generated by the projection of neoliberalism have varied
between countries, and over time, reflecting the particularities of their specific
 THE NEOLIBERAL CHALLENGE TO PUBLIC HEALTH 135

histories, contexts, and political alignments, and indeed in some countries, par-
ticularly in South America, there have been notable movements away from
neoliberalism (on Argentina, for instance, see Novick et al 2009); but its com-
mon features have been associated with increased inequality in income, power,
and access to resources within countries and a dismantling of universal welfare
provision. As a result, neoliberalism has been found to be a causal force in ex-
acerbating health inequalities and, although perhaps somewhat more tenta-
tively, producing average health worse than it would otherwise be.
Much of the academic work (with notable exceptions) within public health
has, unfortunately, failed to grasp, or failed to address, the very clear links be-
tween such politics and policy, on the one hand, and health inequalities on the
other (see Chapters 8 and 17). As a result, this work has often failed to identify
the key actors and actions responsible for these inequalities. Moreover, a lack of
sufficient critical appraisal of some prominent theories has led to an unjustified
focus on those (such as selection and cultural–behavioural ­theories—see Chap-
ter 1) which have little prospect of explaining, or catalysing action to reduce,
health inequalities (Baum and Fisher 2014). The net result of these deficiencies
in public health research has been a failure to identify the most important
causes and potentially effective solutions to health inequalities, whilst those
most severely affected continue to suffer ill health and die prematurely.
Public health built its reputation, and obtained public support, through the
willingness of key figures to grasp the challenges of power, political doctrine,
and inequality in a world ravaged not so much by the ‘hidden injuries of class’
(Sennett and Cobb 1977) as by its very overt injuries. In recent decades, how-
ever, public health contributors have, on the whole, been reluctant to show
similar willingness in a world in which, increasingly, those injuries seem once
again as overt, and their causation just as clear, as in the early period of the
twentieth century. In this context, one is led to consider whether the reputation
of public health, and its wider social support, may in some sense be, in a round-
about way, another casualty of the neoliberal project.

References
Baum, F., and Fisher, M. (2014) Why behavioural health promotion endures despite its
failure to reduce health inequities. Sociology of Health and Illness, 36(2): 213–225.
Beckfield, J., and Krieger, N. (2009) Epi + demos + cracy: Linking political systems and pri-
orities to the magnitude of health inequities—evidence, gaps, and a research agenda. Epi-
demiologic Reviews, 31: 152–177.
Benzeval, M., Bond, L., Campbell, M., Egan, M., Lorenc, T., Petticrew, M., and Popham,
F. (2014) How does Money Influence Health? York: Joseph Rowntree Foundation.
Birn, A.-E. (2009) Making it politic(al): Closing the gap in a generation: Health equity
through action on the social determinants of health. Social Medicine, 4(3): 166–182.
136 Neoliberalism and health inequalities

Blakely, T., Ajwani, S., Robson, B., Tobias, M., and Bonne, M. 2004. Decades of disparity:
Widening ethnic mortality gaps from 1980 to 1999. New Zealand Medical Journal,
117(1199): U995.
Blakely, T., Tobias, M., and Atkinson, J. (2008) Inequalities in mortality during and after
restructuring of the New Zealand economy: Repeated cohort studies. British Medical
Journal, 336(7640): 371–375.
Boyle, M., McWilliams, C., and Rice, G. (2008) The spatialities of actually existing neo-
liberalism in Glasgow, 1977 to present. Geografiska Annaler, Series B: Human Geography,
90(4): 313–325.
Caminada, K., and Goudswaard, K. (2001) International trends in income inequality and
social policy. International Tax and Public Finance, 8(4): 395–415.
Coburn, D. (2000) Income inequality, social cohesion and the health status of populations:
The role of neo-liberalism (statistical data included). Social Science and Medicine, 51(1):
135–146.
Coburn, D. (2004) Beyond the income inequality hypothesis: Class, neo-liberalism, and
health inequalities. Social Science and Medicine, 58(1): 41–56.
Collins, C., and McCartney, G. (2011) The impact of neoliberal ‘political attack’ on health:
The case of the ‘Scottish Effect’. International Journal of Health Services, 41(3): 501–523.
Engels, F. (1845) Die Lage der arbeitenden Klasse in England. Leipzig: Otto Wigand, pub-
lished in translation as Engels, F. (1993) The Condition of the Working Class in England.
Oxford: Oxford University Press.
Gilmour, I. (1992) Dancing with Dogma: Britain under Thatcherism. London: Simon and
Schuster.
Gruer, L., Hart, C. L., Gordon, D. S., and Watt, G. C. M. (2009) Effect of tobacco smoking
on survival of men and women by social position: A 28-year cohort study. British Medical
Journal (Clinical Research Ed.), 338: doi: http://dx.doi.org/10.1136/bmj.b480.
Harvey, D. (2004) The ‘New’ Imperialism: Accumulation by dispossession. Socialist Regis-
ter, 40: 63–87.
Harvey, D. (2007) Neoliberalism as creative destruction. The ANNALS of the American
Academy of Political and Social Science, 610(1): 22–44.
Klein, N. (2007) The Shock Doctrine: The Rise of Disaster Capitalism. London: Penguin.
Krieger, N. (1994) Epidemiology and the web of causation: Has anyone seen the spider? So-
cial Science and Medicine, 39(7): 887–903.
Krieger, N., Rehkopf, D. H., Chen, J. T., Waterman, P. D., Marcelli, E., and Kennedy, M.
(2008) The fall and rise of US inequities in premature mortality: 1960–2002. PLoS Medi-
cine/Public Library of Science, 5(2): e46.
Leigh, A. (2007) How closely do top income shares track other measures of inequality? Eco-
nomic Journal, 117(542): F619–F633.
Link, B. G., and Phelan, J. C. (1995) Social conditions as fundamental causes of disease. The
Journal of Health and Social Behavior, 35(Extra Issue): 80–94.
Lynch, J. W., Davey Smith, G., Kaplan, G. A., and House, J. S. (2000) Income inequality
and mortality: Importance to health of individual income, psychosocial environment, or
material conditions. British Medical Journal, 320(7243): 1200–1204.
Macintyre, S. (1997) The Black Report and beyond: What are the issues? Social Science and
Medicine (1982), 44(6): 723–745.
 THE NEOLIBERAL CHALLENGE TO PUBLIC HEALTH 137

Mackenbach, J. P. (2011) What would happen to health inequalities if smoking were elimi-
nated? They would persist at a lower level because obesity would fill part of the gap. Brit-
ish Medical Journal, 342: d3460. doi: http://dx.doi.org/10.1136/bmj.d3460.
Mackenbach, J. P. (2013) Political conditions and life expectancy in Europe, 1900–2008.
­Social Science and Medicine, 82(1): 134–146.
Marmot, M. F. S. (2010) Healthy lives. The Marmot Review Executive Summary. London:
The Marmot Review.
McCartney, G., Collins, C., and MacKenzie, M. (2013) What (or who) causes health in-
equalities: Theories, evidence and implications? Health Policy, 113(3): 221–227.
McCartney, G., Walsh, D., Whyte, B., and Collins, C. (2012) Has Scotland always been the
‘sick man’ of Europe? An observational study from 1855 to 2006. European Journal of
Public Health, 22(6): 756–760.
Navarro, V. (2008) Politics and health: A neglected area of research. European Journal of
Public Health, 18(4): 354–355.
Navarro, V. (2009) What we mean by social determinants of health. International Journal
of Health Services, 39(3): 423–441.
Norman, P., Boyle, P., Exeter, D., Feng, Z., and Popham, F. (2011) Rising premature mor-
tality in the UK’s persistently deprived areas: Only a Scottish phenomenon? Social Sci-
ence and Medicine, 73(11): 1575–1584.
Novick, M., Lengyel, M., and Sarabia, M. (2009) From social protection to vulnerability
Argentina’s neo-liberal reforms of the 1990s. International Labour Review, 148(3):
235–252.
Peck, J., and Tickell, A. (2002) Neoliberalizing space. Antipode, 34(3): 380–403.
Polanyi, K. (1934) The Great Transformation. Boston: Beacon Books.
Scott, S., Curnock, E., Mitchell, R., Robinson, M., Taulbut, M., Tod, E., and McCartney,
G. (2013) What Would it Take to Eradicate Health Inequalities? Testing the Fundamental
Causes Theory of Health Inequalities in Scotland. Glasgow: NHS Health Scotland.
Scott-Samuel, A., Bambra, C., Collins, C., Hunter, D. J., McCartney, G., and Smith, K.
(2014) The impact of Thatcherism on health and well-being in Britain. International
Journal of Health Services, 44(1): 53–71.
Sennett, R., and Cobb, J. (1977) The Hidden Injuries of Class. Cambridge: Cambridge Uni-
versity Press.
Smith, R. (1985) ‘Bitterness, shame, emptiness, waste’: An introduction to unemployment
and health. British Medical Journal, 291(6501): 1024–1027.
Stuckler, D., King, L., and McKee, M. (2008) Mass privatisation and the post-communist
mortality crisis: A cross-national analysis. The Lancet, 372: 1–9.
Thomas, B., Dorling, D., and Davey Smith, G. (2010) Inequalities in premature mortality
in Britain: Observational study from 1921 to 2007. British Medical Journal, 341: c3639.
doi: http://dx.doi.org/10.1136/bmj.c3639.
Wilkinson, R. G., and Pickett, K. E. (2006) Income inequality and population health: A re-
view and explanation of the evidence. Social Science and Medicine, 62(7): 1768–1784.
Wilkinson, R. G., and Pickett, K. E. (2008) Income inequality and socioeconomic gradients
in mortality. American Journal of Public Health, 98(4): 699–704.
Wilkinson, R., and Pickett, K. (2009) The Spirit Level: Why More Equal Societies Almost Al-
ways Do Better. London: Allen Lane.
 Chapter 10

Health inequalities in England’s

changing public health system
David J. Hunter and Linda Marks

10.1  Introduction: England’s changing public

health system
In April 2013 the public health system in England underwent what, by all ac-
counts, was the most significant change in its history for over 40 years. Whereas
between 1974 and 2013 lead responsibility for public health lay with the NHS,
this role now rests with 152 upper-tier local authorities. In many ways, the move
represents a return of public health to local government because local author-
ities held responsibility for the function prior to 1974. For many in local govern-
ment, the changes introduced by the Health and Social Care Act 2012 therefore
represent a ‘coming home’ and have been widely welcomed. But for many of
those whose public health careers have been spent in the NHS, the changes have
given rise to considerable scepticism, verging on hostility, not helped by having
gone through a lengthy and traumatic period of uncertainty and transition.
Quite apart from the physical dislocation involved in moving from one struc-
ture to another, the culture shock has perhaps provoked the greatest unease and
anxiety. The intensely political nature of local authorities, where elected mem-
bers are the leaders, is very different from how business is conducted in the
NHS. For those familiar with marshalling and using evidence as the basis for
making decisions, there is a perception that local government does not regard,
or use, evidence in the same way, relying to a greater extent on local mandates
and priorities, for example, and the experiential or tacit knowledge of elected
members and officers. The need to understand and familiarize themselves with
a new culture and ways of working has proved difficult for many.
In this chapter, drawing on our research over the past 25 years or so aimed at
exploring the workings of the public health function, and the public health sys-
tem in England in particular (Hunter et al 2010), and knowledge acquired from
running leadership programmes for public health practitioners since 2006, we
briefly review the history of the public health system in England and how it has
 ENGLAND’S CHANGING PUBLIC HEALTH SYSTEM 139

changed. We then consider to what extent the public health arrangements in

England are different, or distinctive, from those elsewhere in the UK. In review-
ing how public health has evolved, and the policy imperatives with which it has
to wrestle, we consider some of the criticisms that have been levelled at practi-
tioners. Notable among these are the undue focus on individual behavioural
change to the exclusion of the wider social determinants of health which need
to be addressed if the aim of narrowing of health inequalities is to succeed; and
the failure of practitioners to provide effective political advocacy in the face of
powerful corporate interests engaged in shaping policies with an impact on
population health (see Chapter 8 for a discussion of these issues from the per-
spective of a practitioner working in Scotland). We go on to assess whether the
move of public health back to local government is likely to enable inroads to be
made into reducing health inequalities in a way that, for the most part, did not
prove possible under the NHS. Finally, we conclude the chapter with an interim
assessment of the impact of the public health reforms in England, over a year
after their introduction.

10.2  Background and context to England’s changing

public health system
Between 1974 and 2013, most major public health responsibilities rested with
the NHS across the UK. Environmental health remained with local govern-
ment, but no other major public health functions. In addition, from 2002 to
2010 the NHS was responsible for narrowing the health gap, as reflected through
two national health inequalities targets, described as ‘arguably the toughest
anywhere in the world’ (House of Commons Health Committee 2009, p. 6).
This was despite the recognition that health inequalities largely arose from the
unequal distribution of the social determinants of health, such as income and
housing, areas which fall well outside the remit of a health care system. During
this period, and in recognition of the fact that achieving health equity requires
multi-sectoral action, numerous efforts were made to ensure that joint respon-
sibility for health between the NHS and local government took root. These
moves were combined with others designed to develop a multidisciplinary
workforce to embrace notions of public health that went beyond the epidemio-
logical training of public health specialists with a medical background (Wright
et al 2014). Nevertheless, health was often perceived as ‘NHS business’, which
served to distract attention from the wider determinants of health and health
equity (see also Chapter 8).
While most of those working in public health were content to be located in the
NHS, there was unease in some quarters arising from the downstream focus of
140 ENGLAND’S CHANGING PUBLIC HEALTH SYSTEM

much of their work. This emphasis became associated with needing to reflect the
evidence base for public health interventions, which was itself skewed towards
control of lifestyle factors (see Chapters 1 and 16), and to demonstrate results
over the shorter term, particularly given the pressure to meet the relatively
short-term health inequalities targets (see also Chapter 8). But others accepted
a more downstream focus than was desirable as the price to be paid for securing
a seat at the top table within the NHS when it came to deciding how resources
should be allocated and priorities agreed (Holland and Stewart 1998). These
tensions reflected a deeper problem concerning the ‘lack of a firm philosophy to
guide [public health] in approaching health problems’ (Lewis 1986, p. 3). Such a
state of affairs has persisted to this day, with notions of influences on health and
health inequalities oscillating between a focus on controlling risky behaviours
and a concern with the structural determinants and the idea of ‘health in all pol-
icies’ (Leppo et al 2013). These differing conceptions of public health are re-
flected in professional concerns about who should be doing public health and
what the requisite skills required for the task involve. These debates have argu-
ably impeded progress in establishing and sustaining a vigorous public health
community. It is certainly not a new issue—the continuing fragility and vulner-
ability of the public health profession has been a consistent feature since 1974-
prompting Frenk to argue that ‘public health is experiencing a severe identity
crisis, as well as a crisis of organisation and accomplishment’ (Frenk 1992, p. 68).
The move to a multidisciplinary public health workforce has not been with-
out its problems and tensions since it challenged the hegemony of a speciality
led by medically qualified professionals (Evans and Knight 2006). Despite at-
tempts to open up the public health profession to those without a clinical quali-
fication during the 1990s, there remains a power imbalance between clinical
and non-clinical specialists in England, evident in status and remuneration dif-
ferences. Debate about the appropriate composition of, and skills required for,
the workforce has been linked to discussions about its location. A growing be-
lief that it made little sense to maintain the location of the majority of public
health specialists within the NHS when most of the major levers for achieving
public health’s aims lay beyond the reach of the NHS led, initially, to the idea of
joint posts. Supporting such posts, the first joint Director of Public Health
(DPH), giving evidence to the House of Commons Health Committee in 2001,
considered it to be ‘irrational that most of the interest, skills and resources to
improve public health are outside the NHS while the DPH is locked into it’. His
solution was to ease the DPH ‘out of the NHS box’ (House of Commons Health
Committee 2001, p. 442). Unexpectedly, that is precisely what happened with
the passage of the Health and Social Care Act in 2012. However, as the following
section outlines, this shift applied only to England.
 The public health system across the UK 141

10.3  The public health system across the UK

Up until political devolution in 1999, the nature of the public health workforce,
the policy context, and structural setting differed only marginally across the
UK. But since 1999 there is evidence of growing policy divergence and differ-
ences in the structures within which public health practitioners operate. Per-
haps the most significant difference is that Scotland, Wales, and Northern
Ireland have not been subjected to the same degree of policy and organizational
turbulence as England. Whereas the health system in England, including public
health, has undergone almost continuous policy and structural change since
the late 1990s, none of this has greatly affected the rest of the UK although a
review of the public health function is nearing completion in Scotland.
The public health workforce remains similar across the UK in terms of its con-
figuration, training, and skills. The professional bodies, notably the Faculty of
Public Health and the Royal Society of Public Health, cover the UK, as does the
UK Public Health Register, which was established in 2003 to accredit and quality-
assure those who are non-medically qualified. Moreover, the key public health
challenges, including widening health inequalities, are a feature of all parts of the
UK. How they are being tackled may be subject to different approaches and, al-
though initial analysis suggested that the rhetoric differed more than the reality
(Smith et al 2009), recent changes point to greater divergence. Wales and Scot-
land have eschewed the formal shift of public health from the NHS back to local
government, preferring instead to strengthen community health partnerships
and networks and to regard the health system as a single ‘whole of government’
and ‘whole of society’ entity embracing all facets of the public’s health.
In terms of policy, in England, there is a greater emphasis on individual life-
styles at the national policy level, represented by initiatives like the ‘nudge’ unit,
initially located in the Cabinet Office and now operating as an independent
social enterprise, and the system of responsibility deals introduced by the De-
partment of Health under the Coalition government in 2010, which brought
together relevant stakeholder interests in key lifestyle concerns, including com-
mercial interests (see Chapter 17). Little of this type of thinking is evident in the
Welsh or Northern Ireland Assemblies or Scottish Government, although simi-
lar approaches exist at some levels. For example, an early pioneer of incentives
to alter behaviour, NHS Tayside in Scotland, has sought to nudge the behaviour
of pregnant mothers who smoke by offering them shopping vouchers if they
give up the habit for the duration of their pregnancy (NHS Health
Scotland 2009).
There is something of a policy paradox given that most advocates of tackling
health inequalities believe that local government is better suited to adopting a
142 ENGLAND’S CHANGING PUBLIC HEALTH SYSTEM

social determinants of health approach than the NHS (Elson 1999). Yet only
England, in which the overall policy and political context seems more hostile to
a social determinants approach (despite the Coalition government’s ostensible
support for the 2010 Marmot review), has experienced the shift of public health
into local government.

10.4  The new public health system in England

Those welcoming the return of public health to local government in England
are under no illusions that it represents a panacea to the challenges ahead. The
prevailing financial and policy environments are hardly favourable, with local
government (and particularly authorities in the most deprived areas) being es-
pecially hard-hit when it comes to public spending cuts. This is in direct con-
trast to the increased funding provided by the last Labour government for the
fifth most deprived areas in England to help address health inequalities. The fi-
nancial climate has an impact across the range of health and local authority
services through increases in poverty, family stress, domestic violence, unem-
ployment, and alcohol problems (Stuckler and Basu 2013; and see Chapter 12).
It also reduces the capacity of the NHS and local authorities to focus on any-
thing other than immediate demands and statutory responsibilities. The gov-
ernment’s reasoning for transferring public health to local government derives
from a belief that, having ‘taken on the key role in promoting economic, social
and environmental wellbeing at the local level, it is ideally placed to adopt a
wider wellbeing role’ (Department of Health 2011). In so doing, local authori-
ties will be working with a wide range of partners across civil society and the
principal mechanism for this is the Health and Wellbeing Board  (HWB), a
statutory committee of the local authority.
Some of the public health functions transferred to local government are man-
datory, including the NHS health check programme and access to sexual health
services, while others, such as lifestyle services, are non-prescribed. Chief
among the changes introduced in 2013 has been the relocation of the Directors
of Public Health (DsPH) and their teams, who have become the employees of
local authorities and accountable to elected members for the discharge of their
responsibilities. Possibly the most significant change facing DsPH in the new
system is working in a political environment that is very different from the
NHS. It has proved to be a source of considerable anxiety for many DsPH who
acknowledge that working successfully in their new environment will require
different, and possibly new, skills. Working with elected members and influen-
cing a wide range of partners, within the local authority and beyond, is becom-
ing the essence of a DPH’s remit.
 The new public health system in England 143

Ironically, DsPH find themselves in an environment which has not been the
target of systematic research, evidence, and knowledge exchange activities in
relation to public health and health inequalities (which were largely directed to
the NHS). A publication from the Economic and Social Research Council
(ESRC) - funded Local Government Knowledge Navigator, What local govern-
ment needs to know about public health, underlines the existence of this knowl-
edge gap (South et al 2014). There is therefore an urgent need to redirect these
resources and to reinterpret and reshape them to fit a local authority context.
Examples of this include initiatives such as the National Institute for Health and
Care Excellence (NICE) briefings for local authorities and members of HWBs,
a resource guide for local authorities published by the King’s Fund (Buck and
Gregory 2013), opinion pieces on local actions to reduce health inequalities
commissioned from the British Academy (2014), and joint publications from
the Local Government Association and Public Health England (2014). Focus-
ing on evidence-based and practical interventions that local authorities could
implement to address health inequalities, for example, Greig et al (2014) iden-
tify their role in restricting fast food outlets, creating 20 mph zones, providing
accessible welfare rights advice, improving internal housing conditions, and
adopting a ‘health first’ case management approach to reducing worklessness
among those on long-term incapacity benefit.
Possibly until 2016, DsPH and their teams will preside over a ring-fenced
public health budget as a way of affording some protection to public health re-
sources and preventing budget raids. Views are sharply divided on the merits or
otherwise of ring-fenced budgets (Iacobucci 2014). Support comes from public
health practitioners who fear that, without ring-fencing, essential services will
be vulnerable to cuts, but critics allege that public health practitioners will make
themselves unpopular by having a protected budget that is denied to other local
services, especially during a period of deep cuts. Moreover, if it is accepted that
virtually all local government functions and services impact on public health in
one way or another, and if relocating public health to local government was in
part intended to encourage the adoption of a wider perspective that embraces
the social determinants of health, then ring-fenced public health budgets seem
difficult to justify. In keeping with such a view is the encouragement being given
to introducing community or place-based budgeting (House of Commons
Communities and Local Government Committee 2013a).
Perhaps the most important piece of new machinery locally is the HWB.
These boards will for the most part replace previous partnership arrangements
designed to enable the NHS and local government to collaborate more effec-
tively. HWBs have no executive powers—their impact must be achieved
through influence and persuasion. Their main role is the production of a health
144 ENGLAND’S CHANGING PUBLIC HEALTH SYSTEM

and wellbeing strategy informed by a joint strategic needs assessment. HWBs

have been widely welcomed, although their value has yet to be fully tested. Ex-
pectations are running high, possibly unreasonably so. The House of Commons
Communities and Local Government Committee concluded that HWBs have a
pivotal role and their success ‘is crucial to the new arrangements’. However, it
also warned of the dangers of HWBs repeating history and becoming little
more than ‘expensive talking shops’ (House of Commons Communities and
Local Government Committee 2013b, p. 14). An early assessment of shadow
HWBs (NHS Confederation 2012) showed that membership which reflected
the wider determinants of health seemed underdeveloped.
There are of course limits to what local authorities themselves can do to tackle
many of the root causes of socially patterned premature mortality and avoid-
able morbidity. Action locally, when most of the pressures on public health are
national or global (see Chapters 13 and 17), seems neither adequate nor appro-
priate. Tackling transnational corporate food and drink companies, for exam-
ple, requires action on a bigger stage (see Chapter 13). In the case of obesity, for
instance, local government has an important role in reshaping what has been
termed an ‘obesogenic environment’ (Butland et al 2007), but it cannot succeed
by its own efforts alone; other measures are required at higher levels of govern-
ment. Acknowledging that it cannot be left to localism to resolve many modern
public health issues, Lang and Rayner (2012) call upon public health leaders
working locally to ‘be noisy and to build alliances’. There is, therefore, an im-
portant advocacy role for local authorities under the post-2013 arrangements.
Above all, they need to be ‘change agents, building and supporting movements
with agencies above and beyond the local’ (Lang and Rayner 2012; see also
Chapter 21).
It falls to Public Health England (PHE), set up independently of the Depart-
ment of Health as an arm’s-length executive agency in 2013, to provide national
leadership for public health. PHE is responsible for health protection, emer-
gency preparedness, and the provision of public health information and evi-
dence. A considerable part of PHE’s role entails working closely with local
government to achieve what is termed ‘sector-led improvement’, although the
various parties are still exploring how this relationship can function to provide
development and support, rather than regulation and inspection (Department
of Health 2011). PHE’s independence and ability to act as an advocate for public
health also remains in question. Indeed, following an inquiry into the operation
of PHE in November 2013, the House of Commons Health Committee stated
that PHE must demonstrate unequivocally that it is able to, and regularly does,
‘speak truth unto power’ (House of Commons Health Committee 2014). In its
response to the Committee’s report, the government argued that ‘PHE has to be
 PERSISTENT CHALLENGES AND NEW OPPORTUNITIES 145

part of government, but operationally autonomous’, as well as ‘credible and au-

thoritative’ (Department of Health 2014).

10.5  Persistent challenges and new opportunities:

Improving health and tackling health inequalities
Local authorities inevitably face many of the same challenges as did the NHS in
addressing health inequalities (and the NHS continues to face these challenges
in other parts of the UK—see Chapter 8). Differences in life expectancy be-
tween rich and poor areas are dramatic and increasing; a ‘segment tool’ showing
the causes of death which drive health inequalities between wards within a local
authority and across local boroughs (Public Health England 2014) showed that
across London, for example, the life expectancy gap between affluent and de-
prived wards is estimated to be almost 25 years. The two overarching indicators
in the public health outcomes framework (Department of Health 2012)—to
increase overall healthy life expectancy and to reduce differences in life expect-
ancy and healthy life expectancy between communities—are backed by com-
parative data on premature deaths by local authority, which have been provided
in an accessible form in order to promote local debate and action, as well as to
help prioritize and target local interventions (Public Health England 2013). In
some areas at least, local authorities can build on established joint initiatives
while being better placed than NHS organizations to engage with local commu-
nities in identifying underserved groups and in providing community-­sensitive
services in convenient locations.
In addition to narrowing the gap between wards, local authorities will also
need to address preventable morbidity and premature mortality by acting pro-
portionately across the social gradient, as recommended in Fair Society, Healthy
Lives (Marmot et al 2010). While local authorities are well placed to adopt a
life-course perspective, taking account of critical periods of influence (such as
early years development), or the cumulative impact of disadvantage across the
life course, prioritizing and targeting preventive activities accordingly, the de-
cline in local authority control of key services, such as education, means that
‘place-based’ approaches across the life course risk becoming increasingly
fragmented.
The public health outcomes framework also emphasizes the importance of
more rapid improvements in disadvantaged communities if the health inequal-
ities gap is to be narrowed. As NICE (2014) guidance reiterates, people who do
not routinely access services are diverse, including homeless people, vulnerable
migrants, and those whose first language is not English, and, as part of their
new responsibilities, local authorities are expected to draw on knowledge of
146 ENGLAND’S CHANGING PUBLIC HEALTH SYSTEM

local communities to develop services which are acceptable to the groups in-
volved. Local authorities can also develop innovative approaches to the deploy-
ment of the public health budget, combining, targeting, and remodelling
preventive services, addressing social conditions that foster health damaging
behaviour, and ensuring that delivery of NHS health checks and associated life-
style interventions, for example, reach those who are least likely to access rou-
tine services. They can also potentially coordinate action on complex public
health challenges so that, for example, alcohol strategies incorporate lifestyle
interventions at one end of the local intervention spectrum and licensing re-
strictions at the other (Local Government Association 2014).
There are a number of potential reasons for the widening gap and one of
these, the association of economic disadvantage with the polarization of risky
behaviours (smoking, drinking, lack of exercise and poor nutrition). This, has
clear implications for intervention strategies. The King’s Fund pointed out that,
in 2008, those with no qualifications were more than five times more likely to
have all four unhealthy behaviours than those with the highest level of qualifi-
cations (compared with only three times as likely in 2003), thus contributing to
a widening gap (Buck and Frosini 2012, p. 1). This underlines the complexity of
the task facing local authorities—the need to work across different areas of in-
fluence simultaneously and to avoid overreliance on simplistic and downstream
influences. It also means recognizing that the increasing concentration of social
disadvantage and risky behaviours requires solutions which do not view such
behaviours in isolation either from each other or from the social factors associ-
ated with them and which accumulate over the life course.
While there is a growing evidence base for the effectiveness of public health
interventions (Owen et al 2012), a basket of such interventions forms only part
of the picture. The longer-term potential of the new public health system in Eng-
land is likely to lie in adopting an approach to commissioning across the range
of local authority directorates which incorporates health and health equity im-
pact assessment (see Chapter 8) as a matter of course. As argued by Phelan et al
(2004), fundamental causes (such as income, wealth, and power) influence mul-
tiple outcomes and work through many different mechanisms. Socioeconomic
gradients in avoidable causes of mortality therefore persist over time, although
the specific reasons for this gradient differ by country and context.
A key issue, therefore, is the extent to which a concern with fairness and so-
cial justice permeates commissioning, decision-making, and priority-setting
across the range of local authority departments and committees, including the
HWBs. This might include, for example, an equity-orientated Joint Strategic
Needs Assessment (JSNA) to inform strategy development and decision-­
making. However, social justice and fairness across a local area have not been a
 AN INTERIM ASSESSMENT OF THE NEW ARRANGEMENTS 147

traditional starting point of JSNAs, whereas a growing number of Independent

Fairness Commissions are explicitly intended to promote equality and fairness
across a local area. Starting with an initiative in the London borough of Isling-
ton in 2010, a number of Commissions have been set up, making far-reaching
recommendations across council and other services to improve equality (see
also Chapter 20).
Despite these more promising opportunities, the experience of the NHS in
trying to address local health inequalities provides some warnings. Just as some
of the former Primary Care Trusts interpreted an agenda for health and well-
being as being the sum of current NHS activities (Marks 2014), so local author-
ities may equate their public health responsibilities with statutory local authority
services. This seems particularly likely where resources available for additional
and innovative initiatives are reduced, as is currently the case. Short-term pri-
orities may predominate over the longer-term approach needed to address the
fundamental causes of health inequalities. In order for health inequalities to be
addressed in the new system, there needs to be a fresh commitment to health
and health equity across the range of local government policies, reflected
through processes for priority-setting and decision-making.

10.6  An interim assessment of the new arrangements:

New dawn or poisoned chalice?
With the public health changes just over a year old at the time of writing, it is far
too early to pass judgement on the consequences for public health (McKee et al
2011). The changes have been both extensive and complex, and will inevitably
take time to settle as new relationships form. Early evidence from the Local
Government Association is encouraging, but is, inevitably, largely anecdotal.
Other bodies, such as the Association of Directors of Public Health and the
Royal Society of Public Health, are more wary about reaching positive conclu-
sions just yet. Instead, they prefer to draw attention to some of the weaknesses
and concerns being expressed by public health practitioners who feel insecure
in their new setting and unsure quite what the future will bring. Research is
underway, commissioned by the Department of Health and the National Insti-
tute for Health Research (NIHR), to establish how the new public health system
is operating, but it will be some time before studies yield useful findings.
HWBs are seen by some observers as occupying pole position in terms of
making the changes work; others query whether they are up to the job (Bentley
2013). Issues of governance and accountability seem confused and unclear.
Merely acting as a strategic forum is likely to add little of value if there is no
mechanism for being clear about what has changed as a result of HWB decisions
148 ENGLAND’S CHANGING PUBLIC HEALTH SYSTEM

or if organizations cannot be held to account by the HWB. HWBs are expected

to perform a critical role in regard to integrated care, one that has assumed even
greater importance with the introduction of the Better Care Fund, which in-
volves the transfer of £3.8 billion from the NHS to local government to invest in
social care. But there is also a danger lurking here as far as the public health
agenda is concerned. If HWBs become preoccupied with the health and social
care conundrum, which has both preoccupied and defeated policymakers for
the past 50 years or so, then their impact on public health could be dissipated or
lost altogether. The risk of HWBs being captured by the integrated care agenda
was noted by the House of Commons Communities and Local Government
Committee (2013b, p. 16), which stressed the need ‘to maintain a strategic and
balanced outlook on their new responsibilities, focusing on promoting the
health of their local population, rather than becoming exclusively preoccupied
with the detail of health and social care commissioning and integration’.

10.7  Conclusion: Testing England’s new public

health system
The test of the new public health system in England will be the degree to which
local government displays confidence in using the many levers available to it for
improving health in its widest sense, including education, housing, and trans-
port (Hicks 2013). Putting health improvement and the narrowing of health
inequalities at the core of its work would more than justify relocating public
health to local government. But while there is a general determination to suc-
ceed, there remain significant risks, notably the pessimistic public spending
outlook. The public policy landscape and the future of public services in a con-
text where choice, markets, and privatization continue to be heavily promoted
as the solution to problems of demand and quality pose particular difficulties
and challenges for public health.

References
Bentley, C. (2013) Public health and local authorities. Written submission. In House of
Commons Communities and Local Government Committee. The Role of Local Author-
ities in Health Issues, Eighth Report of Session 2012–13, HC 694, Ev 152–165. London:
The Stationery Office.
British Academy (2014) ‘If You Could Do One Thing . . . ’. Nine Local Actions to Reduce
Health Inequalities. London: The British Academy.
Buck, D., and Frosini, F. (2012) Clustering of Unhealthy Behaviours Over Time: Implica-
tions for Policy and Practice. London: King’s Fund.
Buck, D., and Gregory, S. (2013) Improving the Public’s Health. A Resource Guide for Local
Authorities. London: King’s Fund.
 TESTING ENGLAND’S NEW PUBLIC HEALTH SYSTEM 149

Butland, B., Jebb, S., Kopelman, P., McPherson K., Thomas, S., Mardell, J., Parry, V.
(2007) Tackling Obesities: Future Choices—Project Report. Commissioned by the UK
Government’s Foresight Programme, Government Office for Science, London: Depart-
ment of Innovation, Universities and Skills.
Department of Health (2011) Public Health in Local Government Factsheets. London: De-
partment of Health.
Department of Health (2012) Improving Outcomes and Supporting Transparency, Part 1A:
A Public Health Outcomes Framework for England, 2013–2016. London: Department of
Health.
Department of Health (2014) Government Response to the House of Commons Health
­Committee Report on Public Health England, Eighth Report of Session 2013–14. Cm 8881.
London: HMSO.
Elson, T. (1999) Public health and local government. In S. Griffiths and D. J. Hunter (eds),
Perspectives in Public Health. Oxford: Radcliffe Medical Press, pp. 192–197.
Evans, D., and Knight, T. (2006) ‘There Was No Plan!’: The Origins and Development of
Multi-disciplinary Public Health in the UK. Witness seminar. Bristol: University of the
West of England.
Frenk, J. (1992) The new public health. In Pan American Health Organization (PAHO), The
Crisis of Public Health: Reflections for Debate. Washington, DC: PAHO/WHO.
Greig, G., Garthwaite, K., and Bambra, C. (2014) Addressing health inequalities: Five
practical approaches for local authorities. Perspectives in Public Health, 134(3):
132–134.
Hicks, N. (2013) Oral Evidence Taken before the House of Commons Communities and Local
Government Committee, 26 November 2012. HC 694. London: The Stationery Office.
Holland, W., and Stewart, S. (1998) Public Health: The Vision and the Challenge. London:
Nuffield Trust.
House of Commons Communities and Local Government Committee (2013a)
­Community Budgets, Third Report of Session 2013–14, HC 163. London: The Stationery
Office.
House of Commons Communities and Local Government Committee (2013b) The Role of
Local Authorities in Health Issues, Eighth Report of Session 2012–13, HC 694. London:
The Stationery Office.
House of Commons Health Committee (2001) Public Health, Second Report Session
2000–1. HC 30. London: The Stationery Office.
House of Commons Health Committee (2009) Health Inequalities, Third Report of Session
2008–9, vol. 1, HC 286–281. London: The Stationery Office.
House of Commons Health Committee (2014) Public Expenditure on Health and Social
Care, Seventh Report of Session 2013–14. HC 793. London: The Stationery Office.
House of Commons Health Committee (2014b) Public Health England, Eighth Report of
Session 2013–14, HC 840. London: The Stationery Office.
Hunter, D. J., Marks, L., and Smith, K. E. (2010) The Public Health System in England. Bris-
tol: Policy Press.
Iacobucci, G. (2014) Raiding the public health budget. British Medical Journal, 348: g2274.
Lang, T., and Rayner, G. (2012) Ecological public health: The 21st century’s big idea? Brit-
ish Medical Journal, 345: e5466.
150 ENGLAND’S CHANGING PUBLIC HEALTH SYSTEM

Leppo, K., Ollila, E., Pena, S., Wismar, M., and Cook, S. Eds. (2013) Health in All Policies:
Seizing Opportunities, Implementing Policies. Helsinki: Ministry of Social Affairs and
Health of Finland and European Observatory on Health Systems and Policies.
Lewis, J. (1986) What Price Community Medicine? The Philosophy, Practice and Politics of
Public Health Since 1919. Brighton: Wheatsheaf.
Local Government Association and Public Health England (2014) Public Health Transfor-
mation Nine Months On: Bedding In and Reaching Out. London: Local Government
Association.
Marks, L. (2014) Governance, Commissioning and Public Health. Bristol: The Policy Press.
McKee, M., Hurst, L., Aldridge, R. W., Raine, R., Mindell, J. S., Wolfe, I., and Holland, W.
W. (2011) Public health in England: An option for the way forward? The Lancet, 378:
536–539.
Marmot, M., Allen, J., Goldblatt, P., Boyce, T., McNeish, D., Grady, M., and Geddes, I.
(2010) Fair Society, Healthy Lives: Strategic Review of Health Inequalities in England Post-
2010 (The Marmot Review). London, UK: UCL Institute of Health Equity.
NHS Health Scotland (2009) Scottish Social Marketing Toolkit: Give it Up for ­Baby—
smoking cessation intervention for pregnant women in Dundee, Scotland. Dundee: NHS
Tayside, http://www.scottishsocialmarketinghub.org.uk/sites/default/files/casestudy/
files/Give_it_up_for_baby2.pdf.
NHS Confederation (2012) Making a Local Difference: State of Play and Challenges Ahead
for Health and Wellbeing Boards. London: The NHS Confederation.
National Institute for Health and Care Excellence (NICE) (2014) Improving Access to
Health and Social Care Services for People Who do Not Routinely Use Them. NICE Local
Government Briefings (LGB 14). London: NICE.
Owen, L., Morgan, A., Fischer, A., Ellis, S., Hoy, A., and Kelly, M. P. (2012) The cost-­
effectiveness of public health interventions. Journal of Public Health, 34(1): 37–45.
Phelan, J. C., Link, B. G., Diez‐Roux, A., Kawachi, I., and Levin B. (2004) Fundamental
causes of social inequalities in mortality: A test of the theory. Journal of Health and Social
Behaviour, 45(3): 265–285.
Public Health England Knowledge and Intelligence Teams (London and East Midlands)
(2014) The segment tool—segmenting life expectancy gaps by cause of death. London:
London Health Observatory, http://www.lho.org.uk/LHO_Topics/Analytic_Tools/
Segment/TheSegmentTool.aspx.
Public Health England (2013) Longer lives website. London: Public Health England, http://
longerlives.phe.org.uk/.
Smith, K. E., Hunter, D. J., Blackman, T., Elliott, E., Greene, A., Harrington, B. E., Marks,
L., McKee, L., and Williams, G. H. (2009) Divergence or convergence? Health inequal-
ities and policy in a devolved Britain. Critical Social Policy, 29(2): 216–242.
South, J., Hunter, D. J., and Gamsu, M. (2014) What Local Government Needs to Know
About Public Health. A Local Government Knowledge Navigator Evidence Review. Need
to Know Review Number Two. London: Local Government Association.
Stuckler, D., and Basu, S. (2013) The Body Economic: Why Austerity Kills. London:
Allen Lane.
Wright, J., Sim, F., and Wright, K. (2014) Multidisciplinary Public Health: Understanding
the Development of the Modern Workforce. Bristol: Policy Press.
 Chapter 11

The equity implications of health

system change in the UK
Mark Hellowell and Maximilian Ralston

11.1  Introduction: Health care and health inequalities

The NHS was created in 1948 with the aim of ensuring that access to health care
would depend on need and not ability to pay. ‘The essence of a satisfactory
health service’, wrote the Minister of Health Aneurin Bevan, ‘is that the rich and
the poor are treated alike, that poverty is not a disability, and wealth is not ad-
vantaged’ (Webster 2002). Since then, the NHS has provided a globally promi-
nent example of how socioeconomic inequalities in access to health care can be
reduced through progressive tax-based financing and government stewardship
(Dixon et al 2003; van Doorslaer and Wagstaff 1992; Wagstaff et al 1999).
Of course, the availability of health care—of goods, services, and activities that
maintain or improve health—is only one of a complex array of factors that deter-
mine health. For this reason, some health inequalities researchers (particularly
those working in contexts in which medical treatments are free-at-the-point-of-
need, such as the UK) have tended to regard a focus on health care as a distraction
from a more appropriate emphasis on the social determinants of health (Marmot
et al 2010). However, studies of the relationship between institutions and cultural
values show that institutions that embody values of fairness and social justice can
help to elicit and sustain such values in wider society (Svallfors 2010). The com-
mitment to social justice embodied in the NHS is likely to play a central role in
marshalling the societal efforts required to address health inequalities in the UK.
Recent changes in the structure of the NHS have raised questions about its
ability to continue to meet social justice objectives. Some of these relate to delib-
erate adjustments by policymakers to the way the NHS is organised, including
reforms to modes of governance and resource allocation, particularly in Eng-
land.1 Others relate to external factors (political, demographic, and macroeco-
nomic) that are present to some degree across the UK. To a large extent the
marginalization of health care in the inequalities literature has arisen in a con-
text in which the socioeconomic gradient in health care access has been limited
152 The equity implications of health system change

due to state intervention (van Doorslaer and Wagstaff 1992). Literature con-
cerning health inequalities in contexts where this is less true, such as the USA
and many developing countries, have tended to place a much stronger emphasis
on health care, as Chapters 4 and 5 note. If, as seems likely, inequalities in health
status are combined with an increasing degree of inequity in coverage and access
in England, and perhaps in the rest of the UK, the health care system is likely to
become a more salient topic for health inequalities researchers in future.
This chapter draws on the international health systems literature to assess the
significance of the two most prominent categories of change in the NHS policy
context from an equity perspective. To provide a foundation for subsequent anal-
ysis and discussion of these changes, Section 11.2 reviews how the principle of
equity in health care is conceptualized by scholars and operationalized by policy-
makers. Section 11.3 provides an analysis of the current phase of structural reform
in the NHS. This has been the focus of substantial policy debate and academic
criticism—with one article describing the reforms as ‘paving the way for the intro-
duction of a US-style health system by eroding entitlement to equality of health
care provision’ (Pollock et al 2012, p. 387). However, we explain in Section 11.4
how the international health systems literature directs our attention to the central
importance of funding constraints, as distinct from structural change. We argue
that this latter category of change poses a major threat to the mechanisms of pro-
gressive revenue collection and risk pooling—institutions that, to paraphrase An-
eurin Bevan, comprise the central pillars of an equitable health service.

11.2  Equity in the health system: An international

perspective
This section provides an overview of the principles of equity in health care sys-
tems as a foundation for subsequent analysis and discussion of systemic change.

11.2.1  Equity in health care

In the health care system, equity concerns the fair and socially just distribution
of health services. Markets in health care will fail to meet this requirement, as
they allocate goods and services on the basis of the demand for these ­things—a
person’s ability and willingness to pay—and not on the need for them. Low-­
income members of society lack ‘demand’ because they are unable to afford the
market price of health care. This observation underlies the well-known inverse
care law, which states that the availability of good medical care tends to vary
inversely with the need for it in the population served. This law operates more
completely where medical care is most exposed to market forces, and less so
where such exposure is reduced (Tudor-Hart 1971).
 Equity in the health system 153

How the equity requirement should be put into operation through policy ac-
tion is the subject of intense and persistent debate within normative economic
analysis. Olsen and Rogers (1991) suggest the appropriate objective of policy is
to ensure equality of access, in which case everyone in society is equally able to
obtain or make use of health care. Others point out that it is not access to health
care itself that is of concern, but equal access to needed services—i.e. services that
are effective (and perhaps cost-effective) in attaining a higher state of health
(Culyer 1989). In contrast, Culyer and Wagstaff (1993) observe that the norma-
tive basis for equity in health care resides in its ability to promote health, and
that the appropriate equity goal is therefore to generate equality of health.
Different notions of equity are also evident at the policy level in terms of how the
commitment to equity is put into operation through the allocation of resources to
different geographies (Bevan 2009). For example, different ­population-based re-
source allocation models are employed by each of the four NHS jurisdictions in
the UK (Carr-Hill and Dixon 2006). We also observe important differences over
time within the four NHS jurisdictions (Barr et al 2014). The traditional NHS ap-
proach has been ‘to secure through resource allocation equal opportunity of ac-
cess for people at equal risk’ (Department of Health and Social Security 1976, p. 7),
which is roughly consistent with Culyer’s (1989) principle of equal access to
needed services, and remains at the core of the capitation approaches in Scotland,
Wales, and Northern Ireland. However, the Labour government of 1997–2010
sought to use the capitation formula to contribute to a reduction in avoidable
health inequalities in England by targeting more resources in deprived areas.
This may be regarded as a move towards an ‘extra-welfarist’ approach and a
focus on the equal distribution of health.2
Notwithstanding this diversity in normative/policy frameworks, it is notable
that in each case there is an emphasis on distribution of services according to
need and health status and not ability to pay, such that there is (broadly) equal
access to needed care by all individuals in society.

11.2.2  Safeguarding equity in the health care system

Unpredictability in the need for medical care generates an important role for
insurance—either public or private—in the health care system (Arrow 1963).
Where insurance institutions are effective, individuals are able to pool the fi-
nancial risks associated with health care, and those who fall ill are able to obtain
the health care they need. Unlike most goods and services, the production of
insurance is an inherently collective activity. It is impossible for a single individ-
ual to produce insurance, except in the limited sense of self-insurance: main-
taining a fund to pay for future health care costs through saving (Ehrlich and
154 The equity implications of health system change

Becker 1972). An individual can produce insurance only by joining together

with others, even if this is through market-based transactions, to form a risk
pool. In a well-functioning market system, it is possible to equalize risk between
the sick and the well in this way. However, in order to additionally equalize risk
between different socioeconomic strata, government intervention is necessary.
A system of private insurance markets is unable to provide the broadly equal
access to needed care that is called for in the previous section of this chapter. As
noted, markets allocate goods and services on the basis of demand—a person’s
ability and willingness to pay. Low-income members of society lack ‘demand’
because they are unable to afford the market price of insurance.3 This is particu-
larly so given the inverse relationship between socioeconomic status and health
status, which makes premiums in a private market higher for those with fewer
economic resources (and normally greater need).
When insurance markets form risk pools by voluntary enrolment, inequities
are exacerbated by information asymmetries between providers and purchasers
of insurance (Hurley 2001). Risk-selection arises when suppliers of insurance
selectively enrol low-risk individuals (cream-skimming) or when high-risk
consumers seek out more generous insurance (adverse selection). The former
type of risk selection leads directly to inequities, as high-risk members of soci-
ety are unable to buy insurance. The latter type of risk selection also reduces the
breadth of coverage, since even people who are willing to buy insurance at a
premium that reflects their risk status may be unable to do so.
For these reasons, significant public financing is a necessary condition for achiev-
ing distributional equity in terms of coverage and access. This will work most effect-
ively in equity terms when the level of coverage is perceived to be adequate by
better-off groups, thus ameliorating demand for private health insurance (which
contributes to inequities in coverage and access). In the absence of coverage, people
are likely to face high financial barriers to accessing the health care they need.
A sufficient condition is that the organization and delivery of services also sup-
port distributional goals. The extent to which these conditions are achieved has
been termed effective coverage (Kutzin 2013). No country succeeds in completely
eliminating shortfalls in effective coverage; gaps exist because not all individuals
in a society can be aware of all of their needs for services. In addition, new and
more expensive diagnostic and therapeutic technologies continuously emerge,
which generate new need (in the sense that there are individuals in society who
may secure health benefits from them) that cannot be immediately satisfied. In
addition, empirical evidence has shown that there is also a socioeconomic dimen-
sion to this shortfall in coverage, even in countries such as the UK that have largely
been successful in attaining universal financial protection (Cookson et al 2012).
It may therefore be more useful to think of equitable access and coverage as a
direction rather than a destination. The international health systems literature
 THE UK GOVERNMENT’S REFORMS IN CONTEXT 155

indicates that the following policy actions are likely to move health systems
away from achieving equity goals (van Doorslaer et al 2000): (i) a reduction in
the proportion of revenues for health that come from compulsory prepaid
funds (Wagstaff et al 1999); (ii) a reduction in the extent to which the budgets
of health care providers and purchasing agencies reflect the risk status of the
populations they serve (Kutzin 2001); and (iii) a reduction in pooling, which
compromises the redistributive capacity of prepaid funds (Kutzin 2013),
thereby enabling a lower level of financial protection and equity in the distribu-
tion of resources from a given level of resources.
In addition, the pattern of income redistribution associated with public fi-
nancing through progressive taxation is likely to serve wider equity objectives.
Private insurance with risk-rated premiums provides no ex ante redistribution
of income (though, ex post, there is redistribution from the well to the sick
within the pool). In contrast, public financing embodies ex ante redistribution
from the wealthy to the poor (who have on average worse health) as well as ex
post redistribution from the healthy to the sick (van Doorslaer and
Wagstaff 1992).

11.3  The UK Conservative–Liberal Democratic Coalition

government’s reforms in context
The NHS has seen regular structural reorganizations since the Thatcher era.
An important change occurred in 1991 when integrated NHS organizations
were disaggregated into geographically defined entities (district health au-
thorities, primary care groups, primary care trusts), which provided pri-
mary health care to the local population and contracted with local hospital
organizations (NHS Trusts and, later, Foundation Trusts) to deliver acute
care services. That structure has, broadly, been maintained in England,
Wales, and Northern Ireland, whereas Scottish NHS services were reinte-
grated on a regional basis in 2003. Additionally, since 2003 a small propor-
tion of NHS acute services have, in England and Scotland, been delivered by
private sector providers, often in Independent Sector Treatment Centres,
which provide diagnostic and elective health care under contracts with
government.
The nature of structural reform in England has been consistently market-
oriented since 2002. One important component of reform was a change in the
basis of payments to hospital organizations under contracts with local health
care commissioners. Prior to 2002, payments were made to hospitals on the
basis of prospective global budgets, which were set according to the estimated
costs of the treatments to be provided. In 2002 a prospective case-based
system—­‘Payment by Results’—was introduced, in which providers are paid a
156 The equity implications of health system change

fixed price per ‘finished treatment episode’, with this price designed to approxi-
mate the average cost of delivering the treatment across the NHS (Hellowell and
Pollock 2007). As referral decisions are to some degree made according to the
choices that patients (and GPs) make, hospitals have an incentive to attract pa-
tients from competitors, at least where the associated treatments are likely to
generate surpluses-or, in the case of some private providers, profits.
Since the prices in this NHS market are fixed under the Payment by Results re-
gime, the surpluses of provider organizations can be maximized by: (i) reducing
the cost of treatments (i.e. increasing technical efficiency); (ii) increasing the de-
mand for services by enhancing patients’ perceptions of service quality (i.e. en-
hancing clinical quality and/or other aspects of quality such as hotel services); and/
or (iii) favouring access for patients for whom the cost of treatment is lower than
the price (i.e. increasing inequity through ‘cream-skimming’) (Propper et al 2006).
Under the 2012 Act, all 152 primary care trusts in England were abolished
and replaced by groups of commissioning organizations led by GPs and other
clinicians, who are in turn accountable to a central NHS commissioning board.
The intended effect is to amplify the emphasis on choice and competition, espe-
cially in relation to hospital care, with patients and GPs able to choose to be
treated by any accredited provider in the public or private sector. Providers are
subject to EU competition law and the scrutiny of an economic regulator,
­Monitor—which was previously the financial regulator of Foundation Trusts,
but now has powers similar to those held by regulators of the privatized utilities
such as water, energy, and telecoms. Under the Competition Act, Monitor has
powers to prevent ‘anti-competitive behaviour in the provision of health care
services for the purposes of the NHS which is against the interests of people
who use such services’ (Department of Health 2012, p. 36).
The central motif of these reforms is marketization—i.e. a shift from bureau-
cratic planning and cost-based resource allocation to a model in which funding
is allocated to health care providers according to their ability to attract patients
within a competitive market. They also involve a degree of privatization—i.e. a
change in the ownership of health care assets as non-state actors expand their
production of health care. This is currently of some significance; it is estimated
that about 5% of NHS expenditure in England is spent on health care services
supplied by private companies and voluntary organizations, about twice that in
Scotland (Laing and Buisson 2013).
However, it is important also to highlight what the reforms do not do. They do
not involve a change in the way money is raised to pay for care, and they leave
in place the principle that resources should continue to be allocated on the basis
of population need. The policy actions outlined above as likely to compromise
equity are absent. Concerns have been raised that the market-oriented reforms
 The NHS: A changing financial context 157

may increase inequity, as providers select patients according to the cost of treat-
ment (which may be associated with socioeconomic factors) (Hunter 2009).
However, evidence suggests this has not happened in practice (Cookson et al
2012; Cooper et al 2009). Although the combination of markets, private owner-
ship, progressive tax-financing, and needs-based planning certainly make the
‘new’ NHS in England highly distinctive in a global context, the components of
the system that are crucial to achieve equity have been retained.

11.4  The NHS: A changing financial context

The capacity of any health system to provide comprehensive health care free at
the point of use depends on the level of public funding it receives. This is limited
by a country’s macroeconomic performance, a government’s fiscal policy deci-
sions, and how a government allocates its budget to different areas of expendi-
ture. For reasons explored in more detail later, the demand for NHS services has
risen over time despite consistent increases in real prices. As a result, public
expenditure on the NHS increased in real terms by an average of 4% annually
between 1950 and 2011 (Office of Health Economics 2012). NHS spending also
increased as a share of GDP, from 3.5% in 1950 to 7.7% in 2011.
Historically, periods of fiscal contraction have led to a decrease in coverage
for, and hence access to health care—i.e. an increase in the extent to which sup-
ply is rationed. For example, in the five years from 1950/51, the NHS experi-
enced an average real-terms budget cut of 2.4% per year, resulting in the
introduction of charges for prescriptions, dental services, and spectacles (and
one high-profile ­resignation—that of Aneurin Bevan as Minister of Health). In
1975/76 to 1979/80, the NHS budget grew by an average of just 1.3% a year in
real terms. In the context of rising demand and higher relative prices, this
prompted the onset of a long period in which waiting times for hospital services
increased, a trend that intensified through the period of Conservative govern-
ment between 1979 and 1997 (in which real-terms NHS spending grew below
the trend, at 3.3%) and was not reversed until 2003 (Appleby et al 2009).
During the 2000s, NHS spending grew at its fastest ever rate, at an average of
6.6% per year between 2000 and 2008. Along with the reduction in waiting lists
and decreased waiting times, these additional resources led to higher levels of
activity in hospitals and primary care and better health outcomes, including
improved survival and improvements in the control of chronic conditions
(Bojke et al 2013).
Given the historic record, what do current and projected levels of NHS
spending tell us about the likely future level of supply? The 2010 Spending Re-
view outlined cash spending plans for the period 2011/12 to 2014/15 that were
158 The equity implications of health system change

just sufficient to freeze NHS spending in real terms (Office for National Statis-
tics 2014). The current NHS England planning framework assumes that public-
sector health expenditure in 2020/21 will fall, as a proportion of GDP, from a
peak of 7.7% in 2010/11 to 6% in 2020/21—equivalent to the level last seen in
2003 (NHS England 2013).4
Assuming these plans are implemented, they will require a level of cost con-
tainment that has neither historical precedent nor international parallel. Al-
ready, there is growing evidence of financial pressures building in the NHS and
an emphasis on rationing-through-waiting as a means of managing demand
(Appleby et al 2014). Of course, the level of NHS spending is ultimately a result
of political choices, which are impossible to predict. But the choice is con-
strained by the fiscal planning framework, which all three political parties cur-
rently support (at least in terms of current spending). It is estimated that this
requires an average annual real reduction in departmental spending of 3.7% to
the end of 2018/19 (Institute for Fiscal Studies 2014). It therefore remains un-
clear if the relative protection from cuts that the NHS has experienced since
2010 can or will be sustained over this period. The Labour Party’s plan for a
‘zero-based review’ of public budgets that covers ‘all areas of public spending,
including those that have been protected in the current Spending Review such
as health’ (Labour Party 2014), suggests that a change in government is unlikely
to ease the current budgetary constraints on the health care system.
However budgets are restricted, demand for health care is certain to grow.
Estimates of the impact of the various drivers of health spending vary (Cutler
1995; Newhouse 1993; Oliveira et al 2006), but there is a general view that real
growth of 3% to 6% a year is required to allow the NHS to meet the growth in
demand. On this basis, NHS England has attempted to model the level of pro-
ductivity improvements required to close the funding gap in the context of a
real-terms freeze in funding. This calls for productivity growth of £20bn be-
tween 2011/12 and 2014/15—equivalent to average annual productivity growth
of around 5% a year (NHS England 2013). Reflecting this, if the NHS continues
with the expected levels of funding, savings of £20bn will leave a funding gap of
£30bn between 2013/14 and 2020/21; and the gap will increase from then on-
wards (Department of Health 2013).
Setting aside the uncertainties over projections of health care demand, there
are reasons to believe that the expected shortfall is an underestimate. As the
only major purchaser of health care in the UK, the NHS has considerable mar-
ket power relative to providers (health care organizations and the health care
workforce). Current progress towards the productivity target has been driven
by means of a sector-wide pay freeze that has been made possible by the mo-
nopsony status of the NHS. In the long term, productivity improvements will be
 The NHS: A changing financial context 159

more difficult to achieve. All developed world health care systems have been
shown to be subject to what the economist William Baumol has called the ‘cost
disease’ (Baumol et al 2012). Because health services rely on a significant ‘hand-
icraft’ component, it is hard to replace labour with capital, and the rate of pro-
ductivity growth is therefore lower than the average in the economy. It follows
that prices will rise faster in the health sector compared to the economy as a
whole. Between 1974/5 and 2007/8, pay and prices in the NHS in England rose
by around 1,000%—nearly twice the increase in the GDP deflator, the main
measure of inflation in the economy (Appleby et al 2014). Higher relative prices
imply that health spending must grow relative to inflation if population need
for care is to be met.

11.4.1  Howwill the NHS seek to address the funding gap,

and what are the implications for equity? The expansion
of rationing by waiting
As already noted, the traditional response to funding constraints has been to
intensify the degree of rationing. In a market system, price is the factor that bal-
ances supply and demand, providing signals to production and consumption. A
higher price rations demand and stimulates supply so that in equilibrium bal-
ance is achieved. Where public financing and provision of health care remove
the monetary price to the consumer, other balancing factors are needed. In rela-
tion to the NHS, Klein describes the existence of an implicit ‘bargain between
the State and the medical profession’, in which ‘[p]oliticians in the Cabinet
made the decisions about how much to spend; doctors made the decisions
about which patient should get what kind of treatment’ (Klein 2010, p. 61).
The prominent problem of rationing by waiting has been part of the manage-
ment of demand in the NHS since 1948 (Bevan 2009).5 As NHS finances have
become increasingly constrained, waiting times have once again begun to grow.
In April 2014 the number of people waiting more than 18 weeks for an opera-
tion reached 3 million, the highest number for six years (NHS England 2014).
In May 2014 the emblematic cancer treatment target was missed for the first
time since it was introduced in 2009 (Department of Health 2014).

11.4.2  An expanded role for private insurance

It seems reasonable to assume that the lower the capacity of the NHS to address
health care needs, the greater the scope for a private health care sector to exist.
The econometric evidence highlights the significance of waiting times in par-
ticular as a factor in determining the demand for private health care (and, con-
sequently, private health insurance) in the UK. Besley and colleagues (1999)
160 The equity implications of health system change

matched survey data with administrative data at health authority level in Eng-
land over the period 1986–91, and found that an increase by one person per
1,000 in the proportion of patients that had to wait more than 12 months in-
creased the probability of buying private health insurance by 2%. Similarly,
King and Mossialos (2005) used survey data over the period 1997–2000 and
found a significant positive effect of inpatient and outpatient waiting times on
the demand for private insurance. It is therefore likely that the role of private
insurance will increase in the coming years due to the constraints on NHS
funding and supply, and, for the reasons outlined in 11.2 (above), a health sys-
tem in which private insurance plays a more prominent role will lead to inequi-
ties, with comprehensive coverage for members of society with the ability and
willingness to pay, and more restricted coverage for low-income members and
individuals with lower health status (and greater need). This is a context in
which the health care system itself is likely to become a more salient topic for
health inequalities research in the future.

11.5  Conclusion: Why health care is a priority for health

inequalities research
There is a clear asymmetry in the degree of scholarly attention afforded to the reform
of the health system in England relative to the problems likely to emerge from public
financial constraints (which apply across the UK). To a degree, this is unsurprising:
deliberate policy actions often receive greater public attention than external factors,
even when the latter may have far greater influence on social and economic out-
comes (Easterly 2014). However, policy inaction is all that is required to create a fi-
nancial crisis in the NHS that will weaken its ability to provide comprehensive free
health care in the near future. As Richard Smith, a former editor of the British Med-
ical Journal, observed (1999): ‘Most institutions on the scale of the NHS end not with
a bang but with a whimper . . . one possible endgame is that the middle classes lose
confidence in the service and begin to make other arrangements.’ This chapter ar-
gues that this possibility is worthy of greater study and reflection by advocates of
equity in health. If their voices are not heard in debates around how to respond to the
growing financial crisis in the NHS, in order to safeguard its social justice mission
then the view of others­—with far less interest in equity—are likely to dominate.

Notes
1 Since devolution in 1999, there have been four separate health care administrations in the
UK—one for each of England, Scotland, Wales, and Northern Ireland. There has also
been some divergence in the policies of these administrations (especially between Eng-
land and the rest) in terms of the emphasis placed on competition between health care
providers as a means of improving the efficiency and quality of services.
 A PRIORITY FOR HEALTH INEQUALITIES RESEARCH 161

2 After a review of allocations policy in 2013, NHS England implemented a new formula
that gives less weight to deprived areas. This has been the subject of criticism by health
inequalities scholars (Barr et al 2014).
3 Due to the high cost of medical care, the actuarially fair price of insurance is likely to be
too high for low-income members. Due to various categories of market failure (includ-
ing, at a minimum, adverse selection, moral hazard, monopoly, and transaction costs),
the market price is also likely to be higher than this fair price.
4 Although these estimates relate to England only, they are relevant for all four health care
jurisdictions, as these determine the NHS component of the block grant paid by the HM
Treasury to the devolved administrations.
5 Although, during the 2000s, there were two key developments that changed the ways in
which the NHS in England rations care. First, the Labour government’s overriding objec-
tive of the increases in funding the NHS in England in the 2000s was to end crude ration-
ing by waiting. The government’s targets for the time patients had to wait from seeing a
GP to being admitted to hospital for an elective operation were reduced from over two
years (in 2000) to 18 weeks (in 2005) (Thorlby and Maybin, 2010). This was achieved by
regimes of performance management (based on command and control strategies of ‘tar-
gets and terror’). These approaches were not introduced in the NHSs in Scotland, Wales,
and Northern Ireland where, although each too had similar increases in funding, there
was less progress in reducing waiting times (Connolly et al 2010).

References
Appleby, J., Crawford, R., and Emmerson, C. (2009) How Cold Will it Be? Prospects for
NHS Funding: 2011–17. London: King’s Fund.
Appleby, J., Galea, A., and Murray, R. (2014) The NHS Productivity Challenge: Experience
from the Front Line. London: King’s Fund.
Arrow, K. (1963) Uncertainty and the welfare economics of medical care. American
­Economic Review, 53(5): 941–973.
Barr, B., Bambra, C., and Whitehead, M. (2014) The impact of NHS resource allocation
policy on health inequalities in England 2001–11: Longitudinal ecological study. British
Medical Journal, 348: g3231. doi: 10.1136/bmj.g3231.
Baumol, W., de Ferranti, D., Malach, M., Pablos-Méndez, A., Tabish, H., and Wu, L. G.
(2012) The Cost Disease: Why Computers Get Cheaper and Health Care Doesn’t. New
Haven, CT: Yale University Press.
Besley, T., Hall, J., and Preston, H. (1999) The demand for private health insurance: Do
waiting lists matter? Journal of Public Economics, 72(2): 155–181.
Bevan, G. (2009) The search for a proportionate care law by formula funding in the English
NHS. Financial Accountability and Management, 25(4), November: 391–410.
Bojke, C., Castelli, A., Grasic, K., Street, A., Ward, P. (2013) NHS Productivity from 2004/5
to 2010/11. York: Centre for Health Economics, University of York.
Carr-Hill, R., and Dixon, P. (2006) Review of the Resource Allocation Adjustment for
Healthcare Needs Due to Morbidity and Life Circumstances and Other Factors. NHS
­Scotland Resource Allocation Committee, Technical Report D.
Connolly S., Bevan, G., and Mays, N. (2010) Funding and Performance of Healthcare Sys-
tems in the Four Countries of the UK Before and After Devolution. London: Nuffield Trust.
162 The equity implications of health system change

Cookson, R., Laudicella, M., Li Donni, P., and Dusheiko, M. (2012) Effects of the Blair/
Brown NHS reforms on socioeconomic equity in health care. Journal of Health Services
Research and Policy, 17(Suppl. 1): 55–63.
Cooper Z., McGuire, A., Jones, S., Le Grand, J. (2009) Equity, waiting times and NHS
­reforms: Retrospective study. British Medical Journal, 339: b3264.
Culyer, A. J. (1989) The normative economics of health care finance and provision. Oxford
Review of Economic Policy, 5(1): 34–58.
Culyer, A. J., and Wagstaff, A. (1993) Equity and equality in health and health care. Journal
of Health Economics, 12(4): 431–457.
Cutler, D. M. (1995), Technology, Health Costs, and the NIH. Paper prepared for the
­National Institutes of Health Roundtable on the Economics of Biomedical Research.
Cambridge, MA: Harvard University and the National Bureau of Economic Research.
Department of Health and Social Security (1976) Sharing Resources for Health in England.
Report of the Resource Allocation Working Party (The RAWP Report). London: HMSO.
Department of Health (2012) The Health and Social Care Act 2012. London: The Stationery
Office.
Department of Health (2013) Annual Report and Accounts 2012–13 (For the period ended
31 March 2013). HC 46. London: The Stationery Office.
Department of Health (2014) Provider-based Cancer Waiting Times for Q4 2013–14.
­London: NHS England.
Dixon, A., Le Grand, J., Henderson, J., Murray, R., and Poteliakhoff, E. (2003) Is the NHS
equitable? A review of the evidence. LSE Health and Social Care Discussion Paper Num-
ber 11.
Easterly, W. (2014) The Tyranny of Experts: Economists, Dictators, and the Forgotten Rights
of the Poor. New York: Basic Civitas Books.
Ehrlich, I., and Becker, G. (1972) Market insurance, self-insurance, and self-protection.
Journal of Political Economy, 80(4): 623–648.
Hellowell, M., and Pollock, A. (2007) Private Finance, Public Deficits: A Report on the Cost
of PFI and its Impact on Health Services in England. Edinburgh: Centre for International
Public Health Policy.
Hunter, D. (2009) The case against choice and competition. Health Economics, Policy and
Law, 4(4): 489–501.
Hurley, J. (2001) Ethics, economics, and public financing of health care. Journal of Medical
Ethics, 27(4): 234–239.
Institute for Fiscal Studies (2014) Green Budget. London: Institute for Fiscal Studies.
King, D., and Mossialos, E. (2005) The determinants of private medical insurance preva-
lence in England, 1997–2000. Health Services Research, 40(1): 195–212.
Klein, R. (2010) The New Politics of the NHS: From Creation to Reinvention (6th edn).
­London: Radcliffe.
Kutzin, J. (2001) A descriptive framework for country-level analysis of health care financ-
ing arrangements. Health Policy, 56(3): 171–204.
Kutzin, J. (2013) Health financing for universal coverage and health system performance:
Concepts and implications for policy. Bulletin of the World Health Organization, 91(8):
602–611.
Labour Party (2014) Labour’s Zero-Based Review. London: The Labour Party.
 A PRIORITY FOR HEALTH INEQUALITIES RESEARCH 163

Laing and Buisson (2013) Healthcare Market Review 2013. London: Laing and Buisson.
Marmot, M., Allen, J., Goldblatt, P., Boyce, T., McNeish, D., Grady, M., and Geddes, I.
(2010) Fair Society, Healthy Lives: Strategic Review of Health Inequalities in England Post-
2010 (The Marmot Review). London. UK: UCL Institute of Health Equity.
Newhouse, J. P. (1993) An iconoclastic view of health cost containment. Health Affairs,
12(Suppl.): 152–171.
NHS England (2013) Everyone Counts: Planning for Patients 2014/15 to 2018/19. London:
NHS England.
NHS England (2014) Monthly hospital activity data. London: NHS England. Accessed on 8
August 2014 from http://www.england.nhs.uk/statistics/statistical-work-areas/hospital-
activity/monthly-hospital-activity/mar-data/.
Office of Health Economics (2012) NHS Spending 2011/12 to 2014/15. London: Office of
Health Economics.
Oliveira M., de la Maisonneuve, C., and Bjørnerud, S. (2006) Projecting OECD health and
long-term care expenditures: What are the main drivers? Economics Department Work-
ing Paper No. 477. Paris: Organisation for Economic Co-operation and Development.
Olsen, E., and Rogers, D. (1991) The welfare economics of equal access. Journal of Public
Economics, 45(1): 91–106.
Pollock, A., Price, D., Roderick, P., Treuherz, T., McCoy, D., McKee, M., and Reynolds, L.
(2012) How the Health and Social Care Bill 2011 would end entitlement to comprehen-
sive health care in England. The Lancet, 379(9814): 387–389.
Propper, C., Wilson, D., and Burgess, S. (2006) Extending choice in English health care:
The implications of the economic evidence. Journal of Social Policy, 35(4): 537–557.
Smith, R. (1999) The NHS: Possibilities for the endgame. British Medical Journal,
318(7178): 209–210.
Svallfors, S. (2010) Policy feedback, generational replacement, and attitudes to state inter-
vention: Eastern and Western Germany, 1990–2006. European Political Science Review,
2(1): 119–135.
Thorlby, R., and Maybin, J. (2010) A High Performing NHS? A Review of Progress 1997–
2010. London: King’s Fund.
Tudor-Hart, J. (1971) The Inverse Care Law. The Lancet, 297(7696): 405–412.
van Doorslaer, E., and Wagstaff, A. (1992) Equity in the delivery of health care: Some
international comparisons. Journal of Health Economics, 11(4): 389–411.
van Doorslaer E., Wagstaff, A., van der Burg, H., Christiansen, T., De Graeve, D., Duch-
esne, I., Gerdtham, UG., Gerfin, M., Geurts, J., Gross, L., Häkkinen, U., John, J., Kla-
vus, J., Leu, RE., Nolan, B., O’Donnell, O., Propper, C., Puffer, F., Schellhorn, M.,
Sundberg, G., Winkelhake, O (2000) Equity in the delivery of health care in Europe and
the US. Journal of Health Economics, 19(5): 553–583.
Wagstaff, A., van Doorslaer, E., van der Burg, H., Christiansen, T., De Graeve, D.,
­Duchesne, Gerdtham, U., Gerfin, M., Geurts, J., Gross, L., Häkkinen, U., John, J.,
­Klavus, J., Leu, R. E., Nolan, B., O’Donnell, O., Propper, C., Puffer, F., Schellhorn, M.,
Sundberg, G., and Winkelhake, O. (1999) Equity in the finance of health care: Some fur-
ther international comparisons. Journal of Health Economics, 18(5): 263–290.
Webster, C. (2002) The National Health Services: A Political History (2nd edn). Oxford:
­Oxford University Press.
 Chapter 12

All in it together? Health

inequalities, austerity, and the
‘Great Recession’
Clare Bambra, Kayleigh Garthwaite,
Alison Copeland, and Ben Barr

12.1  Introduction: Economic downturns and poor health

This chapter examines the effects of economic downturns on health
­inequalities—how sudden economic change can exacerbate the large health dif-
ferences that exist between social groups in virtually all countries (WHO 2008).
Using international research evidence, we argue that inequalities in health be-
tween social groups have increased during past downturns—in some countries
but not in others. The chapter reflects on how this is related to different inter-
national social security systems, some of which are better at protecting vulner-
able groups in times of hardship. It will then reflect on the potentially negative
health impacts of ‘austerity’ and conclude by arguing that the ‘Great Recession’
since 2008—in which the economic downturn has been accompanied by the
pursuit of austerity in the UK—will only serve to divide our nation’s health fur-
ther. We are not ‘all in it together’.

12.2  Economic downturns and population health

National economic wealth (i.e. GDP) has long been considered as the major
global determinant of population health, with the vast differences in mortality
between high- and low-income countries traditionally accounted for in terms
of differences in economic growth (Brenner, 2005). Changes in the economy
therefore potentially have important implications for population health and in-
equalities in health.
Recessions are defined as two successive quarters of negative growth in GDP
(Oxford Dictionaries 2012). They are characterized by instability (in terms of
inflation and interest rates) and sudden reductions in production and con-
sumption, with corresponding increases in unemployment. For example, recent
 Economic downturns and population health 165

economic experiences have been characterized by unemployment rates of

around 8.5% in the UK and the USA, 10% in France, and more than 20% in
Spain. This post-2008 economic downturn is popularly referred to as the ‘Great
Recession’, as it has been longer, wider, and deeper than any previous economic
downturns, including the ‘Great Depression’ of the 1930s.
Evidence suggests that economic recessions have detrimental health effects
for those losing jobs or in fear of losing their jobs (Neumayer 2004). More gen-
erally though, the epidemiological literature suggests that the short-term popu-
lation health effects of recessions are mixed (Bambra 2011), with the majority of
international studies concluding that all-cause mortality, deaths from cardio-
vascular disease, motor vehicle accidents, and hazardous health behaviours de-
crease during economic downturns, whilst deaths from suicides, rates of mental
ill health, and chronic illnesses increase in some—but not all—countries (Stuck-
ler and Basu 2013).
Unemployment increases during recessions and it is strongly associated with
greater morbidity and mortality (Bambra 2011), particularly mental health
problems such as depression and stress (Hagquist et al 2000; Janlert 1997), sui-
cide and parasuicide (Lewis and Sloggett 1998; Newman and Bland 2007; Platt
1986), sleep difficulties, and psychosomatic complaints (Hyyppä et al 1997;
McKee-Ryan et al 2005). There is also evidence of unemployment and social
hardship having a negative effect on the mental health of children (Mistry et al
2002; Solantaus et al 2004). Unemployment has been shown to be associated
with an increase in health-related behaviour risks such as smoking and exces-
sive alcohol consumption (Eliason and Storrie 2009; Kriegbaum et al 2011;
Montgomery et al 1999). Evidence also suggests that unemployment is associ-
ated with increased physical health problems, including higher rates of self-­
reported limiting long-term illness (Bambra and Eikemo 2009; Bartley and
Plewis 2002; Popham and Bambra 2010) and longer recovery times from illness
(Bartley et al 2004; Dorling 2009). For example, a study looking at the US and
five European countries (van Lenthe et al 2005) found all-cause mortality rates
increased following job loss. Death from cardiovascular disease was also found
to be associated with unemployment in Scotland (Brenner 1987) and in Sweden
(Sundquist et al 2006). In the longer term, Burstrom et al (2010) observe how,
in Sweden, delayed and differential impacts of austerity and recession can influ-
ence health and the employment prospects of people with chronic illness.
Recessions are also characterized by an increase in job insecurity and ‘precar-
ious’ employment, with increasing numbers of people working on either tem-
porary contracts or no contracts, with limited or no employment or welfare
rights. Precarious employment is associated with stress, fatigue, backache, and
muscular pains, job dissatisfaction and absenteeism (Benavides et al 2000),
166 All in it together?

poor occupational health outcomes (Quinlan et al 2001), psychiatric morbidity

and health-related behaviours (Ferrie et al 2002), and mortality (Kivimäki et al
2003). Kivimäki and colleagues’ (2003) analysis of Finnish longitudinal data
found that overall mortality was shown to be more than 20% higher in tempor-
ary employees when compared with those employees on a permanent contract.
Further, mortality from alcohol-related causes was increased for both men and
women temporary workers when compared with permanent workers (men
hazard ratio [HR] = 2.0, 95% CI 1.4 to 2.9; women HR = 1.7, 95% CI 1.1 to 2.5).
Beyond the job insecurity and unemployment literature, research into the
wider effects of recessions on health appears to show conflicting results. A num-
ber of researchers have found that health deteriorates during periods of reces-
sion. For instance, Katikireddi et al’s (2012) recent study using the Health
Survey for England found that the self-reported mental health of men in Eng-
land, measured by the General Health Questionnaire (GHQ12) scores, deteri-
orated over the two years following recession, though the same was not seen for
women. Mental health problems such as stress and depression were also found
to increase during periods of recession in studies in Spain (Gili et al 2013),
Greece (Economou et al 2011), and Northern Ireland (Houdmont et al 2012).
In a number of studies this was found to lead to an increase in mortality rates
during periods of recession, particularly from suicide (Barr et al 2012; Chang et
al 2009; Economou et al 2008, 2011; Hopkins 2006). However, it is not just the
mental health of individuals that is affected by recessions; Gerdtham and Jo-
hannesson (2005) found all-cause mortality increased significantly during pe-
riods of recession for Swedish men (although the findings were not replicated
for Swedish women), and a number of studies worldwide found the self-related
health status of individuals worsened during times of recession (Kondo et al
2008; Zavras et al 2013).
Conversely, there are also a number of studies contradicting these findings
and suggesting that recessions are in fact ‘good for health’. For instance, Ger-
dtham and Ruhm’s (2006) study of 23 Organisation for Economic Cooperation
and Development (OECD) countries from 1960 to 1997 found mortality rates
rose during periods of economic growth. Tapia Granados’s (2005) study of
mortality trends in the USA found that the overall decline in mortality rates in
the twentieth century actually reversed during periods of recession. One poten-
tial explanation for this inverse relationship between mortality rates and reces-
sion is given by Adams (1981), who suggests higher unemployment rates lead
to a decrease in business activity and therefore a reduction in work-related
deaths, combined with a reduction in alcohol and tobacco consumption as in-
comes reduce, resulting in a reduction in mortality risks. A number of studies
also found road traffic accidents decreased during periods of recession, as
 Economic downturns and health inequalities 167

people have less need to—and are less able to afford to—drive (Ruhm 1995,
2000; Tapia Granados 2005). The majority of studies finding a positive associ-
ation between health and recessions are based on country or state-level aggre-
gate data and investigate in-year average population effects. It seems likely that
recessions have differential and potentially divergent effects across subgroups
within a population and that these effects will occur over the medium to long
term, accumulating over time. These factors will not be captured in the studies
investigating annual changes in aggregate country-level data (Suhrcke and
Stuckler 2012).
Studies have found that there are important national policy variations in the
effects of recessions and economic downturns on population health. For ex-
ample, Stuckler and Basu (2013) found that the population health effects of re-
cessions vary significantly by policy context with those countries (such as
Iceland and the USA) which responded to the financial crisis of 2007 with an
economic stimulus, faring much better—particularly in terms of mental health
and suicides—than those countries (e.g. Spain, Greece, and the UK) which
chose to pursue a policy of austerity (public expenditure cuts to reduce govern-
ment debt). Similarly, Hopkins (2006) found that in Thailand and Indonesia,
where social welfare spending decreased during the Asian recession of the late
1990s, mortality rates increased. However, in Malaysia, where no cutbacks oc-
curred, mortality rates were unchanged (Hopkins 2006). Similarly, Stuckler et
al’s (2009) study of 26 European countries concluded that greater spending on
social welfare could considerably reduce suicide rates during periods of eco-
nomic downturn.

12.3  Economic downturns and health inequalities

In many ways it is still too early to be conclusive about the effects of the current
‘Great Recession’ on health inequalities, as few studies have been conducted to
date and because it will take time to see the longer-term health impacts (e.g. on
mortality). We therefore have to look back on data from past economic down-
turns to gain insights into what to expect and also draw on qualitative data that
captures people’s everyday lived experiences (Garthwaite 2013; Garthwaite et al
forthcoming; Shildrick et al 2012—also see Chapters 16 and 17).
There were post-war economic downturns in the 1970s, 1980s, and 1990s in
the UK and other Western countries. Studies of these events suggest that the
health effects of economic downturns are unequally distributed across the
population, thereby exacerbating health inequalities—in some countries but
not others (Kondo et al 2008). For example, a study of the Japanese working-age
population found that economic downturn increased inequalities in self-rated
168 All in it together?

health amongst men (Kondo et al 2008), whilst a Finnish study found that the
economic downturn slowed down the trend towards increased inequalities in
mortality (Valkonen et al 2000). Similarly, a comparative study of working age
(16–64 years) morbidity conducted in Finland (Manderbacka et al 2001), Nor-
way (Dahl and Elstad 2001), Sweden (Lundberg et al 2001), and Denmark (La-
helma et al 2002) found that inequalities in self-reported health remained stable
during the 1980s and 1990s. A more recent comparative study of self-reported
health from 1991 to 2010 found that there was a more negative impact on the
health of the most vulnerable in England than in Sweden during recessions
(Copeland et al 2015). These findings are supported by a study of inequalities in
preterm births in the Scandinavian countries, which remained broadly stable
from 1981 to 2000, despite economic downturns (Petersen et al 2009).
Few studies examine whether the health effects of recessions vary by gender
and the results vary of those that do exist. For example, Gerdtham and Johan-
nesson (2005) found that recessions increased all-cause mortality in Swedish
men, but there was no significant increase among Swedish women. However, a
study of young adults in Japan and Sweden found that women suffered worse
self-reported health than men during recessions (Novo et al 2001). Copeland
and colleagues’ (2015) study of health inequalities in England and Sweden
found that, whilst recessions had a significant positive effect on the health of
women overall—but not men—in both England and Sweden, in England this
improvement was only enjoyed by the most educated women, whilst the health
of less-educated women declined during recession. In contrast, in Sweden the
health of all women improved significantly during recession, regardless of their
educational status, although the most educated benefited the most.
The health inequalities effects of recessions may well therefore be experi-
enced quite differently by otherwise similar individuals and communities due
to national policy variation (Burstrom et al 2010; Whitehead et al 2000), with
more generous welfare systems protecting the health of the population and es-
pecially the most vulnerable (Copeland et al 2015). This may be because com-
paratively strong social safety nets provide a buffer against the structural
pressures towards widening health inequalities (Lahelma et al 2002). The wel-
fare states of the social-democratic countries—in contrast to others—seem to
protect the health of the most vulnerable during economic downturns. These
findings are also in keeping with the wider political economy literature, which
has shown that population health indicators (including self-reported health,
life expectancy, and infant mortality rates) vary by welfare state type (Bambra
2007; Chung and Muntaner 2007; Dahl et al 2006), with the more generous and
encompassing Scandinavian welfare states enhancing population health (espe-
cially in terms of reducing infant mortality rates).
 ‘Austerity’ and health inequalities 169

12.4  ‘Austerity’ and health inequalities

In economics, ‘austerity’ refers to reducing budget deficits in economic down-
turns by decreasing public expenditure, particularly on welfare, and/or increas-
ing taxes. In the UK, since 2010, this has been characterized by the former with
large-scale cuts to central and local government budgets, NHS privatization,
and associated cuts in welfare services and benefits. Cuts to local government
budgets have hit the poorest parts of the country hardest (Taylor-Robinson et al
2013) and the effect of tax and benefit reforms has largely been regressive, with
low-income households of working age losing the most (Browne and Levell
2010). Office for National Statistics (ONS) data shows that the gap in healthy
life expectancy (the number of years people are expected to live in ‘good’ health
and are disability-free) between people living in the most deprived (52 years for
men) and most affluent (71 years for men) areas of England equates to almost
20 years (ONS 2014). Whilst this is part of a long-term trend in which area
health inequalities have risen almost every year since the 1980s—indeed the
UK has the highest regional inequalities in health in Europe—it seems likely
that the UK’s programme of austerity will worsen existing inequalities.
Indeed, previous studies of the effects of welfare state expansion and contrac-
tion on health inequalities suggest that, whilst overall population health is
largely unaffected, inequalities in both mortality and morbidity increase when
welfare services are cut. For example, a US study found that, whilst premature
mortality (deaths under age 75) and infant mortality rates (deaths before age 1)
declined overall in all income quintiles from 1960 to 2002, inequalities by in-
come and ethnicity decreased only between 1966 and 1980, and then increased
between 1980 and 2002 (Krieger et al 2008). The reductions in inequalities
(1966–80) occurred during a period of welfare expansion in the USA (the ‘War
on Poverty’) and the enactment of civil rights legislation which increased access
to welfare state services. The increases in health inequalities occurred during
the Reagan–Bush period of ‘austerity’, when public welfare services (including
health care insurance coverage) were cut, funding of social assistance was re-
duced, the minimum wage was frozen, and the tax base was shifted from the
rich to the poor, leading to increased income polarization.
These findings are mirrored in studies of welfare state restrictions in New
Zealand (Blakely et al 2008; Shaw et al 2005), which found that, whilst general
mortality rates declined, inequalities amongst men, women, and children in
all-cause mortality increased in the 1980s and the 1990s, then stabilized in the
early 2000s. The increases occurred during a period in which New Zealand
underwent major structural reform, including a less redistributive tax system,
increased targeting of social benefits, the introduction of a regressive tax on
170 All in it together?

consumption, privatization of major utilities and public housing, the introduc-

tion of user charges for welfare services, and a more deregulated labour market.
The stabilization of inequalities in mortality in the late 1990s and early 2000s
was during a period in which the economy improved and there were some im-
provements in services (e.g. better access to social housing, more generous so-
cial assistance, and a decrease in health care costs). So as with the US study, this
suggests that cuts to welfare services have detrimental effects on the health of
the poorest.
Research into the health effects of Thatcherism (1979–90) has also concluded
that neoliberalism, the large-scale dismantling of the UK’s social democratic
institutions, and the early pursuit of ‘austerity-style’ policies increased health
inequalities (see also Chapter 9). The combination of policies associated with
‘Thatcherism’ included the de-regulation of labour and financial markets, pri-
vatization of utilities and state enterprises, restrictions on social housing, cur-
tailments of trade union rights, marketization of the public sector, and
significant cuts to the social wage resulting from welfare state retrenchment,
mass unemployment, and large tax cuts for the business sector and the most
affluent (Scott-Samuel et al 2014). In this period, whilst life expectancy in-
creased and mortality rates decreased for all social groups, the increases were
greater and more rapid amongst the highest social groups so that inequalities
increased (Scott-Samuel et al 2014). These rises were not inevitable, as in the
UK—like the USA and New Zealand—inequalities in mortality declined from
the 1920s to the 1970s due to a reduction in income inequalities as the welfare
state expanded (Thomas et al 2010).
The lived reality of experiencing the sharp end of austerity in the UK has also
been demonstrated through qualitative research. Research with long-term sick-
ness benefits recipients explored the narratives of those facing austerity meas-
ures in the north-east of England (Garthwaite 2013) found that the increasing
stigma associated with claiming benefits can deter people from accessing the
support they need, leading to under-claiming and the risk of amplified financial
strain and hardship. The rising cost of living, together with unemployment, pre-
carious, part-time, and poorly paid employment, changes to social security, and
debt mean that everyday insecurity is now a common experience. There is a
growing prevalence of precarious working conditions, zero-hours and tempor-
ary contracts, underemployment, and low wages (Shildrick et al 2012). As a re-
sult, many are caught in a ‘low pay, no pay’ cycle, oscillating between short spells
of poorly paid employment and unemployment. Benefits and tax credits are be-
coming less generous, more conditional, and increasingly punitive, and this is
accompanied by a divisive rhetoric of ‘strivers versus skivers’, which demonizes
people who are unable to work (Garthwaite 2011). There are growing risks of
 Conclusion: A growing health divide? 171

food and fuel poverty, homelessness, and indebtedness. The importance of wel-
fare reform and its link to food bank use is explored in ongoing longitudinal
research by Garthwaite and Bambra, which explores how residents in deprived
areas of Stockton-on-Tees are accessing food banks for emergency food provi-
sion as a result of benefit delays, benefit changes, and sanctions. Food bank users
report the detrimental mental health effects of the stresses and strains of such
food insecurity. Indeed, subsequent chapters in this volume argue a need for an
understanding of health inequalities through ‘narratives of living and being’ (see
Chapter 16) and from a community activism perspective (see Chapter 17).
In summary then, the existing quantitative and qualitative research literature
suggests three things about the likely effects of the ‘Great Recession’ and auster-
ity on health inequalities in the UK. First, social safety nets are important in
mitigating health inequalities during economic downturns. Insights from the
research reviewed here suggest that austerity may exacerbate health inequalities
in countries like the UK because they have inadequate social safety nets. Sec-
ond, austerity is likely to increase inequalities. Following Stuckler and Basu
(2013), it is not economic downturns per se that matter for health inequalities,
but rather the austerity and welfare ‘reform’ that may follow: i.e. that ‘austerity
kills’ and, as we argue here, it particularly ‘kills’ those in lower socioeconomic
positions. Finally, the UK’s pursuit of austerity during the ‘Great Recession’
could be doubly problematic. The UK government has chosen to pursue a pol-
icy of austerity during a time of unprecedented economic downturn; it seems
very likely that our nation’s health will be divided further as a consequence of
this policy decision. Therefore, despite political claims to the contrary, we are
not ‘all in it together’ (Osborne 2009); rather, the health effects of the ‘Great Re-
cession’ are being felt more by some in our society than others.

12.5  Conclusion: A growing health divide?

This chapter has critically discussed the actual and potential impacts of eco-
nomic downturns, recessions, and austerity on health and health inequalities.
The chapter drew on international evidence to illustrate how inequalities in
health between social groups have increased during past downturns in some
countries but not in others. It has highlighted the importance of social safety
nets, and concluded by arguing that the current economic downturn, coupled
with the pursuit of ‘austerity’ in the UK, will only serve to divide health further.

Acknowledgements
This chapter is based upon the essay Bambra, C. (2013) ‘All in it together’?
Health inequalities, austerity and the ‘Great Recession’. In C. Wood (ed.), Health
172 All in it together?

and Austerity. London: Demos. Clare Bambra and Kayleigh Garthwaite are
funded by a Leverhulme Trust Research Leadership grant on health inequalities
and austerity(RL-2012–006). Ben Barr is funded by an NIHR fellowship on
health inequalities.

References
Adams, O. (1981) Health and Economic Activity: A Time-Series Analysis of Canadian Mor-
tality and Unemployment Rates. Ottawa: Health Division, Statistics Canada.
Bambra, C. (2007) Going beyond the three worlds: Regime theory and public health re-
search. Journal of Epidemiology and Community Health, 61: 1098–1102.
Bambra, C. (2011) Work, Worklessness and the Political Economy of Health. Oxford:
­Oxford University Press.
Bambra, C. (2013) ‘All in it together’? Health inequalities, austerity and the ‘Great Reces-
sion’. In C. Wood (ed.), Health and Austerity. London: Demos.
Bambra, C., and Eikemo, T. (2009) Welfare state regimes, unemployment and health:
A comparative study of the relationship between unemployment and self-reported health
in 23 European countries. Journal of Epidemiology and Community Health, 63: 92–98.
Barr, B., Taylor-Robinson, D., Scott-Samuel, A., McKee, M., and Stuckler, D. (2012)
­Suicides associated with the 2008–10 economic recession in England: Time trend
­analysis. British Medical Journal, 345 e5142.
Bartley, M., and Plewis, I. (2002) Accumulated labour market disadvantage and limiting
long-term illness: Data from the 1971–1991 ONS longitudinal study. International Jour-
nal of Epidemiology, 31: 336–341.
Bartley, M., Sacker, A., and Clarke, P. (2004) Employment status, employment conditions,
and limiting illness: Prospective evidence from the British household panel survey
1991–2001. Journal of Epidemiology and Community Health, 58(6): 501–506.
Benavides, F. G., Benach, J., Diez-Roux, A. V., and Roman, C. (2000) How do types of
­employment relate to health indicators? Findings from the Second European Survey on
Working Conditions. Journal of Epidemiology and Community Health, 54: 494–501.
Blakely, T., Tobias, M., and Atkinson, J. (2008) Inequalities in mortality during and after
restructuring of the New Zealand economy: Repeated cohort studies. British Medical
Journal, 336: 371–375.
Brenner, M. H. (1987) Relation of economic change to Swedish health and social wellbeing,
1950–1980. Social Science and Medicine, 25: 183–195.
Brenner, M. (2005). “Commentary: Economic growth is the basis of mortality rate decline
in the 20th century—experience of the United States 1901–2000.” Int J Epidemiol 34:
1214–1221.
Browne, J., and Levell, P. (2010) The Distributional Effect of Tax and Benefit Reforms to Be
Introduced between June 2010 and April 2014: A Revised Assessment. London: Institute
for Fiscal Studies.
Burstrom, B., Whitehead, M., Clayton, S., Fritzell, S., Vannoni, F., and Costa, G. (2010)
Health inequalities between lone and couple mothers and policy under different welfare
regimes: The example of Italy, Sweden and Britain. Social Science and Medicine, 70(6):
912–920.
 Conclusion: A growing health divide? 173

Chang, S. S., Gunnell, D., Sterne, J. A., Lu, T. H., and Cheng, A. T. (2009) Was the
­economic crisis 1997–1998 responsible for rising suicide rates in East/Southeast Asia?
A time-trend analysis for Japan, Hong Kong, South Korea, Taiwan, Singapore and
­Thailand. Social Science and Medicine, 68(7): 1322–1331.
Chung, H., and Muntaner, C. (2007) Welfare state matters: A typological multilevel ana-
lysis of wealthy countries. Health Policy, 80: 328–339.
Copeland, A., Bambra, C., Nylen, L., Kasim, A.S., Riva, M., Curtis, S., and Burstrom, B.
(2015) All in it together? The effects of recession on population health and health in-
equalities in England and Sweden, 1991 to 2010. International Journal of Health Services,
45: 3–24.
Dahl, E., and Elstad, J. I. (2000) Recent changes in social structure and health inequalities
in Norway. Scandinavian Journal of Public Health (Suppl.), 55: 7–17.
Dahl, E., Fritzell, J., Lahelma, E., Martikainen, P., Kunst, A. E., and Mackenbach, J. P.
(2006) Welfare state regimes and health inequalities. In J. Siegrist and M. Marmot (eds),
Social Inequalities in Health. Oxford: Oxford University Press, pp. 193–222.
Dorling, D. (2009) Unemployment and health: Health benefits vary according to the
method of reducing unemployment. British Medical Journal, 338: 1087.
Economou, M., Madianos, M., Theleritis, C., Peppou, L., and Stefanis, C. (2011) Increased
suicidality amid economic crisis in Greece. The Lancet, 378: 1459.
Economou, A., Nikolaou, A., and Theodossiou, I. (2008) Are recessions harmful to
health after all? Evidence from the European Union. Journal of Economic Studies, 35:
368–384.
Eliason, M., and Storrie, D. (2009) Does job loss shorten life? Journal of Human Resources,
44(2): 277–302.
Ferrie, J. E., Shipley, M. J., Stansfeld, S. A., and Marmot, M. G. (2002) Effects of chronic
job insecurity and change in job security on self-reported health, minor psychiatric mor-
bidity, physiological measures, and health-related behaviours in British civil servants:
The Whitehall II study. Journal of Epidemiology and Community Health, 56: 450–454.
Garthwaite, K. (2011) ‘The language of shirkers and scroungers?’ Talking about illness, dis-
ability and coalition welfare reform. Disability and Society, 26(3): 369–372.
Garthwaite, K. (2013) Fear of the brown envelope: Exploring welfare reform with long-
term sickness benefits recipients. Social Policy and Administration, 48: 782–7981.
Garthwaite, K., Bambra, C., and Collins, P. (2015) Food for thought: exploring health in
austerity through an ethnographic study of an English food bank, Social Science and
Medicine, 132: 38–44.
Gerdtham, U., and Johannesson, M. (2005) Business cycles and mortality: Results from
Swedish microdata. Social Science and Medicine, 60: 205–218.
Gerdtham, U., and Ruhm, C. (2006) Deaths rise in good economic times: Evidence from
the OECD. Economics and Human Biology, 4: 298–316.
Gili, M., Roca, M., Basu, S., McKee, M., and Stuckler, D. (2013) The mental health risks of
economic crisis in Spain: Evidence from primary care centres, 2006 and 2010. The Euro-
pean Journal of Public Health, 23(1): 103–108.
Hagquist, C., Silburn, S. R., Zurbrick, S. R., Lindberg, G., and Ringbäck, W. G. (2000)
­Suicide and mental health problems among Swedish youth in the wake of the 1990s
­recession. International Journal of Social Welfare, 9: 211–219.
174 All in it together?

Hopkins, S. (2006) Economic stability and health status: Evidence from East Asia before
and after the 1990s economic crisis. Health Policy, 75: 347–357.
Houdmont, J., Kerr, R., and Addley, K. (2012) Psychosocial factors and economic reces-
sion: The Stormont Study. Occupational Medicine, 62(2): 98–104.
Hyyppä, M. T., Erkki, K., and Alanen, E. (1997) Quality of sleep during economic reces-
sion in Finland: A longitudinal cohort study. Social Science and Medicine, 45: 731–738.
Janlert, U. (1997) Unemployment as a disease and diseases of the unemployed. Scandi-
navian Journal of Work, Environment and Health, 23 Suppl 3: 79–83.
Katikireddi, S. V., Niedzwiedz, C. L., and Popham, F. (2012) Trends in population mental
health before and after the 2008 recession: A repeat cross-sectional analysis of the 1991–
2010 Health Surveys of England. British Medical Journal, 2(5).
Kivimäki, M., Vahtera, J., Virtanen, M., Elovainio, M., Pentti, J., and Ferrie, J. E. (2003)
Temporary employment and risk of overall and cause-specific mortality. American Jour-
nal of Epidemiology, 158: 663–668.
Kondo, N., Subramanian, S., Kawachi, I., Takeda, Y., and Yamagata, Z. (2008) Economic
recession and health inequalities in Japan: Analysis with a national sample, 1986–2001.
Journal of Epidemiology and Community Health, 62: 869–875.
Kriegbaum, C., Persson, M., Haldager, M., Alpizar-Alpizar, L., Jacobsen, W.,
­Gardsvoll, B., and Ploug, M. (2011) Rational targeting of the urokinase receptor
(uPAR): Development of antagonists and non-invasive imaging probes. Current Drug
Targets, 12(12): 1711–1728.
Krieger, N., Rehkopf, D. H., Chen, J. T., Waterman, P. D., Marcelli, E., and Kennedy, M.
(2008) The fall and rise of US inequities in premature mortality: 1960–2002. PLoS Medi-
cine, 5: 227–241.
Lahelma, E., Kivelä, K., Roos, E., Tuominen, T., Dahl, E., Diderichsen, F., and Yngwe,
M. Å. (2002) Analysing changes of health inequalities in the Nordic welfare states. Social
Science and Medicine, 55(4): 609–625.
Lewis, G., and Sloggett, A. (1998) Suicide, deprivation and unemployment: Record linkage
study. British Medical Journal, 317: 1283–1286.
Lundberg, O., Diderichsen, F., and Yngwe, M. Å. (2001) Changing health inequalities in a
changing society? Sweden in the mid-1980s and mid-1990s. Scandinavian Journal of Pub-
lic Health, 29: 31–39.
Manderbacka, K., Lahelma, E., and Rahkonen, O. (2001) Structural changes and social in-
equalities in health in Finland, 1986–1994. Scandinavian Journal of Public Health, 29:
41–54.
McKee-Ryan, F. M., Song, Z., Wanberg, C. R., and Kinicki, A. J. (2005) Psychological and
physical well-being during unemployment: A meta-analytic study. Journal of Applied
Psychology, 90: 53–76.
Mistry, R. S., Vandewater, E. A., Huston, A. C., and McLoyd, V. C. (2002) Economic well-
being and children’s social adjustment: The role of family process in an ethnically diverse
Low-income sample. Child Development, 73(3): 935–951.
Montgomery, S. M., Cook, D. G., Bartley, M., and Wadsworth, M. E. (1999b) Unemploy-
ment, cigarette smoking, alcohol consumption and body weight in young British men.
European Journal of Public Health, 8: 21–27.
Neumayer, E. (2004) Recessions lower (some) mortality rates: Evidence from Germany.
­Social Science and Medicine, 58: 1037–1047.
 Conclusion: A growing health divide? 175

Newman, S. C., and Bland, R. C. (2007) Case-control study of unemployment and parasui-
cide. Comprehensive Psychiatry, 48(6): 511–515.
Novo, M., Hammerstrom, A., and Janlert, U. (2001) Do high levels of unemployment in-
fluence the health of those who are not unemployed? A gendered comparison of young
men and women during boom and recession. Social Science and Medicine, 53: 293–303.
Office for National Statistics (2014) Life expectancy at birth and at age 65 for local areas in
England and Wales, 2010–2012.
Osborne, G. (2009) ‘We will lead this economy out of crisis’. Speech to Conservative Party
Conference, 6 October 2009.
Oxford Dictionaries (2012) The Oxford English Dictionary.
Petersen, C. B., Mortensen, L. H., Morgen, C. S., Madsen, M., Schnor, O., Arntzen, A.,
Gissler, M., Cnattingius, S., and Nybo Andersen, A. (2009) Socio-economic inequality
in preterm birth: A comparative study of the Nordic countries from 1981 to 2000. Paedi-
atric and Perinatal Epidemiology, 23(1): 66–75.
Platt, S. (1986) Parasuicide and unemployment. British Journal of Psychiatry, 149: 401–405.
Popham, F., and Bambra, C. (2010) Evidence from the 2001 English Census on the contri-
bution of employment status to the social gradient in self-rated health. Journal of Epide-
miology and Community Health, 64: 277–280.
Quinlan, M., Mayhew, C., and Bohle, P. (2001) The global expansion of precarious em-
ployment, work disorganisation, and consequences for occupational health: A review of
recent research. International Journal of Health Services, 31: 335–414.
Ruhm, C. J. (1995) Economic conditions and alcohol problems. Journal of Health Econom-
ics, 14: 583–603.
Ruhm, C. J. (2000) Are recessions good for your health? Quarterly Journal of Economics, 14:
617–650.
Scott-Samuel, A., Bambra, C., Collins, C., Hunter, D. J., McCartney, G., and Smith, K. E.
(2014) The impact of Thatcherism on health and wellbeing in Britain. International Jour-
nal of Health Services, 44: 53–72.
Shaw, C., Blakely, T., Atkinson, J., and Crampton, P. (2005) Do social and economic re-
forms change socioeconomic inequalities in child mortality? A case study: New Zealand
1981–1999. Journal of Epidemiology and Community Health, 59(8): 638–644.
Shildrick, T., MacDonald, R., Webster, C., and Garthwaite, K. (2012) Poverty and Insecur-
ity: Life in ‘Low-pay, No-pay’ Britain. Bristol: Policy Press.
Solantaus, T., Leinonen, J., and Punamaki, R. (2004) Children’s mental health in times of
economic recession: Replication and extension of the family economic stress model in
Finland. Developmental Psychology, 40: 412–429.
Stuckler, D., and Basu, S. (2013) The Body Economic: Why Austerity Kills. London:
Allan Lane.
Stuckler, D., Basu, S., Suhrcke, M., Coutts, A., and McKee, M. (2009) The public health
­effect of economic crises and alternative policy responses in Europe: An empirical ana-
lysis. The Lancet, 374: 315–323.
Suhrcke, M., and Stuckler, D. (2012) Will the recession be bad for our health? It depends.
Social Science and Medicine, 74(5): 647–653.
Sundquist, J., Johansson, S. E., Yang, M., and Sundquist, K. (2006) Low linking social cap-
ital as a predictor of coronary heart disease in Sweden: A cohort study of 2.8 million peo-
ple. Social Science and Medicine, 62(4): 954–963.
176 All in it together?

Tapia Granados, J. A. (2005) Increasing mortality during the expansions of the US econ-
omy, 1900–1996. International Journal of Epidemiology, 34: 1194–1202.
Taylor-Robinson, D., Gosling, R., Harrison, D., Khan, M., and Barr, B. (2013) Austerity
measures hit the sickest hardest. British Medical Journal, 347: f4208.
Thomas, B., Dorling, D., and Smith, G. D. (2010) Inequalities in premature mortality in
Britain: Observational study from 1921 to 2007. British Medical Journal, 341:c3639
Valkonen, T., Martikainen, P., Jalovaara, M., Koskinen, S., Martelin, T., and Makela, P.
(2000) Changes in socioeconomic inequalities in mortality during an economic boom
and recession among middle-aged men and women in Finland. European Journal of Pub-
lic Health, 10: 274–280.
Van Lenthe, F. J., Brug, J., and Mackenbach, J. P. (2005) Neighbourhood inequalities in
physical inactivity: The role of neighbourhood attractiveness, proximity to local facilities
and safety in the Netherlands. Social Science and Medicine, 60(4): 763–775.
Whitehead, M., Burström, B., and Diderichsen, F. (2000) Social policies and the pathways
to inequalities in health: A comparative analysis of lone mothers in Britain and Sweden.
Social Science and Medicine, 50(2): 255–270.
World Health Organization (2008) Closing the Gap in a Generation: Health Equity through
Action on the Social Determinants of Health; Report of the WHO Commission on the
­Social Determinants of Health. Geneva: World Health Organization.
Zavras, D., Tsiantou, V., Pavi, E., Mylona, K., and Kyriopoulos, J. (2013) Impact of eco-
nomic crisis and other demographic and socio-economic factors on self-rated health in
Greece. The European Journal of Public Health, 23(2): 206–210.
 Chapter 13

Industrial epidemics
and inequalities: The commercial
sector as a structural driver
of inequalities in non-
communicable diseases
Jeff Collin and Sarah Hill

13.1  Introduction: Health inequalities and the growing

burden of non-communicable diseases (NCDs)
The last century witnessed a marked rise in the prevalence of NCDs, with con-
ditions such as heart disease, stroke, cancer, chronic respiratory disease, and
diabetes now accounting for over 60% of all deaths globally (Lozano et al 2012).
Traditionally identified as ‘diseases of affluence’, the NCD burden has increas-
ingly shifted onto disadvantaged populations (Ezzati et al 2005). Over 80% of
NCD deaths occur in low- and middle-income countries (WHO 2011), a bur-
den predicted to rise as global shifts in trade and marketing expose these popu-
lations to higher levels of unhealthy consumption (Ezzati et  al 2005). In
high-income countries, cardiovascular disease, cancer, respiratory disease, and
diabetes are concentrated in less advantaged population groups and collectively
account for 45–75% of the mortality difference between working-age adults in
the lowest and highest socioeconomic groups (Di Cesare et al 2013). These in-
equalities reflect the uneven distribution of smoking, harmful drinking, and
obesity, all of which are substantially more common among lower socioeco-
nomic groups (Marmot et al 2010).
NCDs are directly linked with consumption patterns of tobacco and alcohol
and with unhealthy diets (Lim et al 2012), recognition of which has given rise
to the concept of ‘industrial epidemics’ (Jahiel and Barbor 2007)—used here to
denote epidemics that are driven by the producers of commodities that are
harmful to health. This concept was first applied to tobacco-related diseases,
and later extended to diseases associated with other ‘unhealthy commodities’
178 Industrial epidemics and inequalities

such as alcohol and processed foods (Moodie et al 2013). This suggests a basic
policy tension between public health objectives and the economic interests of
multiple business sectors. Efforts to address industrial epidemics might be ex-
pected, therefore, to be characterized by policy conflict in which ‘public health-
oriented policies run the risk of being opposed by industrial corporations’
(Jahiel and Babor 2007, p. 1335).
Such adversarialism has come to characterize tobacco control, with wide-
spread recognition that tobacco companies should be excluded from the devel-
opment of health policy—a principle enshrined in Article 5.3 of the WHO
Framework Convention on Tobacco Control (FCTC) (WHO 2003), the first
international health treaty negotiated by the WHO. Yet this exclusion contrasts
starkly with the approach taken to alcohol and processed food industries, which
in many cases continue to enjoy privileged status in national and global health
policy initiatives (e.g. Department of Health 2011; UN 2011). Rather than hav-
ing their activities regulated, to control what the industrial epidemics frame
identifies as important ‘vectors’ of NCDs, food and alcohol companies are more
typically viewed by policymakers as ‘partners’.
This chapter explores the significance of such tensions for policies intended
to reduce health inequalities associated with NCDs. First, it outlines the role of
unhealthy commodity industries as structural drivers of health inequalities via
the profound influence they exert on ‘upstream’ causes of inequalities in NCDs.
Our analysis demonstrates how these industries contribute to health inequal-
ities by shaping preferences, affecting physical and social environments, and
influencing public policy development. The chapter then considers the implica-
tions of such an understanding for prevailing models of health governance,
questioning both a long-standing presumption in favour of partnership with
key commercial stakeholders in addressing NCDs and the extent to which the
tobacco industry and tobacco control have been treated as exceptional (Collin
2012). It concludes by outlining emergent pressures towards a more coherent
approach across tobacco, alcohol, and food policies, considering the implica-
tions of such coherence for policy and health inequalities research.

13.2  Industrial epidemics and health inequalities: The

commercial sector as a structural driver of inequalities
in NCDs
The activities and global expansion of the unhealthy commodity industries not
only increase the overall burden of NCDs, but also directly contribute to in-
equalities in NCDs. Less advantaged population groups are more vulnerable to
industry pricing tactics, less able to exercise choice in their consumption
 Industrial epidemics and health inequalities 179

patterns, less likely to benefit from public health interventions, and (in global
terms) more likely to be disadvantaged by the global movement of goods and
capital. Thus, in terms of the social determinants of health, corporations may be
seen as structural drivers of inequality (Freudenberg 2012).

13.2.1  Targeting disadvantaged groups

Tobacco, alcohol, and processed food companies have all made use of targeted
marketing strategies to enhance and protect sales among disadvantaged popu-
lation groups. Such actors have been adept at exploiting cultural capital and
social movements in marketing their products to particular groups within soci-
ety (Nestle 2002). In this way the tobacco and ultra-processed food industries
have directly contributed to inequalities in smoking and diet, while the alcohol
industry is expanding its market into populations that have traditionally had
very low alcohol consumption (Collin et al 2014).
In high-income countries at an advanced stage of the tobacco epidemic
(Lopez et al 1994), industry efforts often focus on recruiting and maintaining
smokers among disadvantaged socioeconomic and ethnic minority groups
(Barbeau et al 2004). The promotion of cigarettes (including via point-of-sale
displays) in the US has become concentrated in areas with a higher proportion
of low-income and ethnic minority individuals (Luke et al 2000; Yerger et al
2007). Comparable tactics have been utilized by the alcohol and processed food
industries. Researchers in England and Scotland have noted that McDonald’s
and other fast-food chains concentrate their outlets in more deprived neigh-
bourhoods (Cummins et al 2005; Macdonald et al 2007). Similar patterns have
been observed in other high-income countries (Fraser et al 2010; Pearce et al
2007; Smoyer-Tomic et al 2008) and, increasingly, in relation to alcohol outlets
(Schneider and Gruber 2013).
In seeking to increase sales to women in high-income countries during the
twentieth century, the tobacco industry sought to reframe smoking as a sign of
emancipation, with advertisements exploiting ideas of female liberation and in-
dependence in order to transform the cigarette ‘[f]rom social taboo to “torch of
freedom”’ (Amos and Hagland 2000, p. 3). Given historically low rates of smok-
ing prevalence among women in many developing countries, increasing the ap-
peal of tobacco products arguably constitutes ‘the greatest product-­marketing
opportunity in the world’ (Kaufman and Nichter 2001). Major alcohol produ-
cers are similarly seeking to attract new consumers among women in low- and
middle-income countries. Companies are developing and marketing brands
specifically targeted at women in Asia, Africa, and Latin America (Diageo 2012;
Fletcher 2012), with a leading drinks producer noting the ‘opportunity to unlock
180 Industrial epidemics and inequalities

significant growth from female consumers across the world’ (Diageo 2012) and
one industry analyst describing the female market as ‘the holy grail for the alco-
hol industry’ (Spiros Malandrakis, quoted in Fletcher 2012).

13.2.2  Manipulating price and ‘choice’

While ideas of ‘quality’ appeal to high-income consumers, low-income groups
are likely to respond better to low-cost, ‘value’ products, which may be less
healthy (Freudenberg 2012). For example, those on lower incomes show greater
price-sensitivity in purchasing food (Powell and Chaloupka 2009) and are
therefore more likely to buy low-cost processed foods that are typically high in
fats, sugars, and salt (Drewnowski 2009). Research from Scotland shows that
pre-school children eat fewer fruit and vegetables and more crisps and sweets
when their families experience a decline in financial security (Skafida and Trea-
nor 2014). Among those who drink alcohol (Robinson and Harris 2011), pur-
chasing patterns are similarly sensitive to price (Gruenewald et al 2006), with
cheaper products appealing to those on limited incomes.
It has been argued that ‘[s]elling inexpensive, low-quality products does not
hurt the poor (as long as they understand any tradeoffs related to safety)’ (Kar-
nani 2007, p. 102), but there are critical flaws in this assumption of rational
agency in health-related consumption. First, such groups may be financially
excluded from choosing healthier options. For example, low-income mothers
in Scotland had sound knowledge of what comprises a healthy diet for their
children, but were limited in their food choices by their financial circumstances
(Harden 2013). In such cases, poor groups may incur a double burden, reflect-
ing the material impact of less-healthy consumption and the psychological im-
pact of necessarily consuming what they know to be less healthy products.
Second, the degree of ‘choice’ available to consumers of addictive products
(such as nicotine, alcohol, and—arguably—ultra-processed foods) is substan-
tially limited by the presence of physical and/or psychological dependence, and
low-income smokers often find it more difficult to quit compared with high-
income smokers (Hill et al 2014), again highlighting the ‘double burden’ experi-
enced by those in less advantaged circumstances.
Adams (2013) notes that industries manufacturing addictive products derive
a substantial proportion of their profits from excessive consumption. While a
minority of consumers are addicted, ‘they invest more heavily and, accord-
ingly, contribute far more to profits’ (Adams 2013, e1). This creates a direct link
between population harms and industry profitability, which Adams (2013)
terms ‘addiction surpluses’. Consequently, producers of addictive products
have a vested interest in the continuation of harmful consumption patterns.
 Industrial epidemics and health inequalities 181

For example, three-quarters of all alcohol sold in the UK is consumed by peo-

ple who drink at levels exceeding health guidelines, and a third of all alcohol
sales are consumed by just 7% of the population (Department of Health 2008,
p. 12). Just as the tobacco industry manipulated the content of cigarettes to
make them more addictive (Bates et al 1999), there is evidence that manufac-
turers of processed food deliberately manipulate their composition to boost
the neuropsychological ‘reward’ they elicit, thus increasing customer demand
(Gearhardt et al 2012).

13.2.3  Promoting ineffective health policies

Unhealthy commodity industries have sought to influence public policy in
order to divert attention from measures most likely to protect the health of
these groups, reflecting fears that such measures would negatively impact on
profits. Such tactics have been most extensively documented across the tobacco
industry (WHO 2008a), and more recent research suggests the alcohol and pro-
cessed food industries are seeking to avoid effective regulation using similar
strategies (Miller and Harkins 2010; Moodie et al 2013).
A growing body of evidence indicates that policy interventions aimed at ‘up-
stream’ drivers of ill-health (such as economic and social conditions, and living
and working environments) are more effective than those targeting ‘down-
stream’ factors (such as health behaviours) (see Chapters 1, 3, 4, 8, 9, and 17).
This is particularly evident in relation to health inequalities: preventive inter-
ventions directed at ‘downstream’ drivers of NCDs may actually increase health
inequalities (Hill et al 2014; Lorenc et al 2013). Since tobacco, alcohol, and food
industries consistently favour voluntary measures to address health issues asso-
ciated with their products, their influence on public policy is likely to increase
inequalities in NCDs by discouraging policymakers from adopting measures
most likely to be effective (particularly in relation to inequalities), while en-
couraging approaches likely to have their greatest impact on better-resourced
population groups.
This pattern is illustrated by the role of the UK alcohol industry in promoting
educational campaigns, known to be ineffectual (McCambridge et  al 2014),
while pressuring policymakers to abandon more effective measures for reducing
alcohol-related harm (Gornall 2013). Indeed, food and alcohol companies have
followed the tobacco industry playbook in promoting the role of individual
choice and responsibility as the primary drivers of NCDs and arguing against
government regulation (Miller and Harkins 2010), often advocating these views
via front-groups posing as ‘grass-roots’ organizations (Yanamadala et al 2012).
Moodie and colleagues (2013) describe how alcohol, food, and sugared beverage
182 Industrial epidemics and inequalities

industries in the US spend millions of dollars lobbying Congress and supporting

‘pro-business’ candidates for federal office in order to minimize regulation.
Alcohol companies have also sought to undermine public health legislation
in low- and middle-income countries. For example, Bakke and Endal (2010)
describe how SABMiller (a UK-based alcohol company) and the International
Center for Alcohol Policies (an industry-funded organization) effectively wrote
the national alcohol policies for several countries in sub-Saharan Africa, thus
imitating the tobacco industry’s direct involvement in policy formulation (Patel
et  al 2007). Alcohol companies in high-income countries have used World
Trade Organization (WTO) rules to challenge public health measures in coun-
tries such as Thailand (O’Brien 2013), potentially undermining the capacity of
states to protect their populations from alcohol-related health risks.

13.2.4  Industry engagement in health policy

As described in the previous section, manufacturers of unhealthy commodities
are key drivers of the rising burden of NCDs. Despite growing evidence of this
role, and with the striking exception of tobacco, such companies are widely re-
garded by policymakers as legitimate stakeholders in the development or im-
plementation of health policies (Department of Health 2011). In many contexts,
governments and health agencies have committed to strategies of active en-
gagement with relevant industries. Such strategies reflect a widespread pre-
sumption that partnership working is required to tackle complex public health
problems (Buse and Harmer 2007), despite the inadequacies of the evidence-
base regarding such approaches (Basu et al 2012).
The curious prominence of partnership approaches within initiatives to re-
duce inequalities is typified by the public health strategy of the UK Coalition
government since 2010. This centres on a ‘Public Health Responsibility Deal’ in
which businesses voluntarily sign up to various health-related ‘pledges’ (De-
partment of Health 2011)—including commitments to promote physical activ-
ity in the workplace, encourage consumption of fruit and vegetables, and
support the alcohol industry-sponsored ‘Drinkaware’ campaign. The contrast
between the voluntary nature of these pledges (focused on downstream factors)
and the largely unregulated power of these industries in shaping health-related
environments has raised widespread concern in the public health community
(Gilmore et al 2011).
International NCD strategies are characterized by stark divergence in policy
approaches to tobacco compared with food and alcohol producers. The FCTC
gives unprecedented recognition to a fundamental conflict of interest between
public health and tobacco company interests, being described by the WHO as
 Industrial epidemics and health inequalities 183

‘the only international convention to explicitly address the dangers of an indus-

try subverting (its) object and purpose’ (WHO 2014). In stark contrast (and
despite aggressive lobbying by the sugar industry to undermine its
­development—see Waxman 2004), the WHO’s Global Strategy on Diet, Physical
Activity and Health envisages the food industry playing an important role
among ‘advocates for healthy lifestyles’ (WHO 2004). In a similar vein, develop-
ment of the recent Global Strategy to Reduce Harmful Use of Alcohol included a
consultation with ‘economic operators’ (WHO 2008b). While the resulting
strategy stops short of treating alcohol manufacturers as partners, it does en-
courage such actors ‘to consider effective ways to prevent and reduce harmful
use of alcohol within their core roles’ (WHO 2010).
Within tobacco control, such exhortations to good conduct and corporate
social responsibility to achieve health objectives have long been rejected as in-
adequate. The resulting lack of coherence across NCD policies is especially not-
able in initiatives to increase the prominence of NCDs on the post-2015
development agenda (Collin 2012). The political declaration emerging from the
2011 UN High Level meeting on NCDs emphasized the need for further imple-
mentation of the FCTC and explicitly precluded involvement of the tobacco
industry, yet its approach to the obesity and alcohol epidemics centred on vol-
untarism and partnership (UN General Assembly 2011).
There are signs of an emergent challenge to this dominant paradigm of part-
nership, particularly in relation to obesity. Under Mayor Michael Bloomberg,
New York’s success in adopting smoke-free policies spurred a radical pro-
gramme of interventions to combat NCDs, including mandatory calorie labels
for chain restaurants and a ban on trans-fats (Alcorn 2012). Analysis of Den-
mark’s short-lived tax on saturated fat in food products (introduced in 2011 and
abandoned one year later) showed around 10–15% reduction in consumption
of butter, blends, margarine, and oils (Jensen and Smed 2013). Perhaps most
interestingly, Mexico is confronting the serious public health challenge of its
obesity epidemic via a distinctive combination of voluntary partnerships with
the food industry and innovative regulation that challenges the economic inter-
ests of key actors (Martinez Valle 2013). In April 2013 Mexico’s government
launched a ‘National Crusade Against Hunger’ in collaboration with major
food companies including PepsiCo, Walmart, and Nestlé, raising civil society
concerns about conflict of interests (for example, in Nestlé’s sponsorship of a
network offering nutritional advice and selling products in poor communities)
(IBFAN 2013). Such partnerships have typically served as an alternative to gov-
ernmental regulation, but in September 2013 the Mexican government an-
nounced a tax on sugary drinks, despite strong lobbying on behalf of leading
manufacturers (Economist 2013).
184 Industrial epidemics and inequalities

13.3  Towards coherence across NCD policies?

An exclusionary approach to tobacco policy has been justified with reference to
the absence of safe tobacco products or usage, the enormity of their health im-
pacts, and the tobacco industry’s established record of distorting science and
policy (Collin 2012). An emphasis on the exceptional nature of tobacco has
been an important strategy within the international advance of tobacco control;
this was evident, for example, in the WHO’s assurances that the FCTC’s com-
mitment to strong regulation of industry conduct was not part of a broader
anti-corporate stance (Yach and von Schirnding 2014). Yet framing tobacco as
exceptional is challenged by a broader understanding of NCDs as industrial
epidemics driven by economic actors. With this perspective, the broader ap-
plicability of the tobacco control experience requires more detailed examin-
ation by advocates, policymakers, and researchers. This challenges the broad
presumption in favour of public–private partnerships as a preferred means of
addressing the economic and social policy goals described earlier.
The scale of the political challenge implied in committing to tackle the eco-
nomic interests that drive NCDs should not be underestimated and is evident
in the strategic ambiguity characterizing the WHO Director General’s recent
interventions in policy debates. When addressing the Global Conference on
Health Promotion in June 2013, Margaret Chan identified the need to counter
corporate threats to effective policy beyond tobacco, depicting public health as
also having to contend with ‘Big Food, Big Soda, and Big Alcohol’, arguing that
‘the formulation of health policies must be protected from distortion by com-
mercial or vested interests’ (Chan 2013b). Yet in the more politically sensitive
context of the World Health Assembly, only one month earlier, Chan drew a
clear distinction between a pariah tobacco industry and ‘other industries that
have a role to play in reducing the risks for NCDs’, for which she did not exclude
cooperation on the grounds that ‘there are healthier foods and beverages, and
in some cultures, alcohol can be consumed at levels that do not harm health’
(Chan 2013a).
Maintaining starkly divergent approaches across tobacco, alcohol, and obes-
ity policies may prove unsustainable in the longer term. The increased political
salience of NCDs within global health and development agendas creates pres-
sure for greater policy coherence, as do organizational responses such as the
integration of the WHO’s Tobacco Free Initiative into the Department of Pre-
vention of NCDs. Public health’s terms of engagement with the commercial
sector are becoming increasingly contentious, as demonstrated by health advo-
cates withdrawing from the UK government’s responsibility deals (Limb 2013),
and the emergence of the Conflict of Interest Coalition amid concerns about
 CORPORATIONS - UPSTREAM DRIVERS OF INEQUALITIES 185

the inclusion of alcohol and food companies in the 2011 UN High Level Meet-
ing on NCDs (Lincoln et al 2011). Other areas of public health have shown
strong interest in adopting or adapting, via soft law, the framework convention
approach to strengthening global health governance (Gostin 2014; Taylor and
Dhillon 2013). This is evident in calls for an exclusionary approach to health
governance by the Lancet NCD Action Group (Moodie et al 2013) and the UN
Special Rapporteur on the Right to Food (De Schutter 2014).
Such increasing interest notwithstanding, policymakers and states more
broadly continue to display a general preference for partnership approaches.
Changing the terms of engagement with non-state actors has proved to be the
most protracted and divisive element of the WHO’s ongoing reforms (Richter
2012). While civil society and some developing countries have questioned the
adequacy of safeguards against undue corporate influence, the institutional re-
sponse has been limited. The WHO reform process has maintained a narrow
interpretation of the principle of not engaging ‘with industries that make prod-
ucts that directly harm human health’, applying this only to the tobacco and
arms industries while rejecting any differentiation between appropriate roles
for business-interest and public-interest NGOs (WHO 2013). The withdrawal
of Denmark’s ‘fat tax’ initiative amid concerted industry opposition (Nestle
2012) and the eventual defeat, via legal challenges, of New York’s introduction
of limits on large sugary drinks (Grynbaum 2014) indicate the scale of the on-
going political challenge associated with developing innovative approaches that
are perceived as threatening key economic interests. Indeed, pressures towards
partnership might mean that policy coherence across NCDs is more likely to be
attained by the erosion of tobacco control’s distinctive model of health govern-
ance than by its extension to other health issues, particularly in light of the to-
bacco industry’s strategic adoption of the harm reduction agenda amid
investments in the burgeoning e-cigarette market (Clifford et al 2013).

13.4  Conclusion: Corporations producing unhealthy

commodities as ‘upstream’ drivers of inequalities
In this chapter we have presented the case for why corporations producing un-
healthy commodities should be regarded as structural or ‘upstream’ drivers of
inequalities in NCDs, both within populations and at a global level. We argue
that public health policy has to date paid insufficient attention to conflicting
interests between the economic imperative for business and the public health
mandate to protect population health and reduce health inequalities. Recogni-
tion of such conflicts has important implications for how those involved in
186 Industrial epidemics and inequalities

health policy, global governance, and health research should interact with these
corporations.
The comparative success of tobacco control suggests that placing the man-
agement of conflict of interest and the regulation of corporate conduct at the
centre of NCD policy may hold broader promise from a health inequalities
perspective. Indeed, such an approach may offer a potentially significant
route towards countering public health’s inherent tendency towards ‘lifestyle
drift’ (see Chapter 8). While many tobacco control interventions, and par-
ticularly an emphasis on smoking cessation services, might be seen as epit-
omizing such drift, an alternative reading of the tobacco control experience
emphasizes the significance of measures intended to address the upstream
drivers of these behaviours, including marketing, social and physical envir-
onments, and industry engagement in trade and policy. Indeed, the WHO
CSDH highlighted the FCTC as an example of an effective governance frame-
work combining individual and population-wide interventions, including ap-
propriate attention to the effects of trade liberalization on health inequalities
(CSDH 2008).
Building on this precedent poses a major challenge to global health govern-
ance. While agencies such as the WHO were established primarily to address
the threat of infectious diseases, the growing burden of NCDs means we now
face a different set of health challenges, often in the form of harmful or excessive
patterns of consumption, driven by actors with substantial economic and polit-
ical power. These challenges require radical new ways of conceptualizing and
researching the causes of ill-health, and the policy approaches needed to tackle
these will entail innovation and coordination across national and global levels.

References
Adams, P. J. (2013) Addiction industry studies: Understanding how proconsumption influ-
ences block effective interventions. American Journal of Public Health, 103(4): e35–e38.
Alcorn, T. (2012) Redefining public health in New York City. The Lancet, 379(9831):
2037–2038.
Amos, A., and Haglund, M. (2000) From social taboo to ‘torch of freedom’: The marketing
of cigarettes to women. Tobacco Control, 9(1): 3–8.
Bakke, O., and Endal, D. (2010) Vested interests in addiction research and policy. Alcohol
policies out of context: Drinks industry supplanting government role in alcohol policies
in sub-Saharan Africa. Addiction, 105(1): 22–28.
Barbeau, E., Leavy-Sperounis, A., and Balbach, E. (2004) Smoking, social class, and gen-
der: What can public health learn from the tobacco industry about disparities in smok-
ing? Tobacco Control, 13(2): 115–120.
Basu, S., Andrews, J., Kishore, S., Panjabi, R., and Stuckler, D. (2012) Comparative per-
formance of private and public healthcare systems in low- and middle-income countries:
A systematic review. PLoS Medicine, 9(6): e1001244.
 CORPORATIONS - UPSTREAM DRIVERS OF INEQUALITIES 187

Bates, C., Connoly, G. N., and Jarvis, M. (1999) Tobacco Additives: Cigarette Engineering
and Nicotine Addiction. London: ASH and Imperial Cancer Research Fund.
Buse, K., and Harmer, A. (2007) The seven habits of highly effective global health partner-
ships: Practice and potential. Social Science and Medicine, 64(2): 259–271.
Chan, M. (2013a) WHO Director-General addresses the sixty-sixth World Health Assem-
bly. Geneva, Switzerland, 20 May, http://www.who.int/dg/speeches/2013/world_health_
assembly_20130520/en/.
Chan, M. (2013b) WHO Director-General addresses health promotion conference. Hel-
sinki, Finland, 10 June, http://www.who.int/dg/speeches/2013/health_
promotion_20130610/en/.
Clifford, D., Hill, S., and Collin, J. (2013) Seeking out ‘easy targets’? Tobacco companies,
health inequalities and public policy. Tobacco Control. doi: 10.1136/
tobaccocontrol–2013–051050.
Collin, J. (2012) Tobacco control, global health policy and development: Towards policy
coherence in global governance. Tobacco Control, 21(2): 274–280.
Collin, J., Johnson, E., and Hill, S. (2014) Government support for alcohol industry:
­Promoting exports, jeopardising global health? British Medical Journal, 348: g3648.
CSDH (2008) Closing the Gap in a Generation: Health Equity through Action on the Social
Determinants of Health. Final Report of the Commission on the Social Determinants of
Health. Geneva: World Health Organization.
Cummins, S. C., McKay, L., and Macintyre, S. (2005) McDonald’s restaurants and neigh-
borhood deprivation in Scotland and England. American Journal of Preventive Medicine,
29(4): 308–310.
Department of Health (2008) Safe, Sensible, Social—Consultation on Further Action.
­London: Department of Health.
Department of Health (2011) The Public Health Responsibility Deal. London: Department
of Health.
De Schutter, O. (2014) Unhealthy diets greater threat to health than tobacco; UN expert
calls for global regulation. Press Release, 10 May, http://www.srfood.org/en/
unhealthy-diets-greater-threat-to-health-than-tobacco-un-expert-calls-for-global-
regulation.
Diageo (2012) Presentation by Paul Walsh (CEO Diageo) to the Consumer Analyst Group
of New York, 12 February 2012. Presentation script accessed from http://www.diageo.
com/Lists/Resources/Attachments/1228/Diageo%20at%20CAGNY%20Presentation%
20Script.pdf on 3 July 2014.
Di Cesare, M., Khang, Y., Asaria, P., Blakely, T, Cowan, M.J., Farzadfar, F., Guerrero,
R., Ikeda, N., Kyobutungi, C., Msyamboza, K.P., Oum, S., Lynch, J.W., Marmot, M.G.,
Ezzati, M., on behalf of The Lancet NCD Action Group (2013) Inequalities in non-­
communicable diseases and effective responses. The Lancet, 381(9866): 585–597.
Drewnowski, A. (2009) Obesity, diets, and social inequalities. Nutrition Reviews, 67(S1):
S36–S39.
Economist (2013) Soft drinks in Mexico: Fizzing with rage. 19 October.
Ezzati, M., Vander Hoorn, S., Lawes, C. M., Leach, R., James, W. P. T., Lopez, A. D.,
Rodgers, A., and Murray, C. J. et al (2005) Rethinking the ‘diseases of affluence’ para-
digm: Global patterns of nutritional risks in relation to economic development. PLoS
Medicine, 2(5): e133.
188 Industrial epidemics and inequalities

Fletcher, C. (2012) Snapp, if you don’t want a beer. Bloomberg Businessweek, 21 June 2012,
New York: Bloomberg LP. Accessed from http://www.bloomberg.com/bw/articles/
2012–06-21/snapp-if-you-dont-want-a-beer on 3 July 2014.
Fraser, L. K., Edwards, K. L., Cade, J., and Clarke, G. P. (2010) The geography of fast food
outlets: A review. International Journal of Environmental Research and Public Health,
7(5): 2290–2308.
Freudenberg, N. (2012) The manufacture of lifestyle: The role of corporations in unhealthy
living. Journal of Public Health Policy, 33(2): 244–256.
Gearhardt, A., Bragg, M. A., Pearl, R. L., Schvey, N. A., Roberto, C. A., and Brownell,
K. D. (2012) Obesity and public policy. Annual Review of Clinical Psychology, 8: 405–430.
Gilmore, A. B., Savell, E., and Collin, J. (2011) Public health, corporations and the New
­Responsibility Deal: Promoting partnerships with vectors of disease? Journal of Public
Health, 33(1): 2–4.
Gornall, J. (2013) Under the influence. British Medical Journal, 348: f76.46.
Gostin, L. (2014) Healthy living needs global governance. Nature, 511 (7508): 147–149.
Gruenewald, P. J., Ponicki, W. R., Holder, H. D., and Romesjo, A. (2006) Alcohol prices,
beverage quality, and the demand for alcohol: Quality substitutions and price elasticities.
Alcoholism: Clinical and Experimental Research, 30(1): 96–105.
Grynbaum, M. (2014) New York’s ban on big sodas is rejected by final court. New York
Times, 26 June.
Harden, J. (2013) Food and finance: Mothers’ food practices with young children, on a low
income. Scottish School of Public Health Research Briefing 4, August 2013. Edinburgh:
Scottish School of Public Health. Available from http://ssphr.files.wordpress.
com/2013/08/ssphr_briefing_4.pdf.
Hill, S., Amos, A., Clifford, D., and Platt, S. (2014) Impact of tobacco control interventions
on socioeconomic inequalities in smoking: Review of the evidence. Tobacco Control.
23(e2): e89-e97.
IBFAN (International Baby Food Action Network) (2013) Conflicts of interest threaten
Mexico’s hunger project. Press Release, 9 April, http://www.babymilkaction.org/
archives/493.
Jahiel, R. I., and Babor, T. F. (2007) Industrial epidemics, public health advocacy and the
alcohol industry: Lessons from other fields. Addiction, 102(9): 1335–1339.
Jensen, J. D., and Smed, S. (2013) The Danish tax on saturated fat: Short run effects on con-
sumption, substitution patterns and consumer prices of fats. Food Policy, 42(1): 18–31.
Karnani, A. (2007) The mirage of marketing to the bottom of the pyramid: How the private
sector can help alleviate poverty. California Management Review, 49(4): 90–111.
Kaufman, N. J., and Nichter, M. (2001) The marketing of tobacco to women: Global per-
spectives. In Samet, J.M., and Yoon, S.Y. (eds), Women and the Tobacco Epidemic: Chal-
lenges for the 21st Century. Geneva: World Health Organization, pp. 69–98.
Lim, S. S., Vos, T., Flaxman, A. D., Danaei, G., Shibuya, K.,Adair-Rohani, H., AlMazroa,
M.A., Amann, M., Anderson, H.R., Andrews, K.G., Aryee, M., Atkinson, C., Bacchus,
L.J. Bahalim A.N., Balakrishnan, K., Balmes, J., Barker-Collo, S., Baxter, A., Bell, M.L.,
and Blore, J.D.(2012) A comparative risk assessment of burden of disease and injury at-
tributable to 67 risk factors and risk factor clusters in 21 regions, 1990–2010: A system-
atic analysis for the Global Burden of Disease Study 2010. The Lancet, 380(9859):
2224–2260.
 CORPORATIONS - UPSTREAM DRIVERS OF INEQUALITIES 189

Limb, M. (2013) Public health body quits responsibility deal over government’s failure to
act on tobacco and alcohol. British Medical Journal, 347: f4590.
Lincoln, P., Rundall, P., Jeffery, B., Kellett, G., Lobstein, T., Lhotska, L., Allen, K., and
Gupta, A. (2011) Conflicts of interest and the UN high-level meeting on non-­
communicable diseases. The Lancet, 378(9804): e6.
Lopez, A. D., Collishaw, N. E., and Piha, T. (1994) A descriptive model of the cigarette epi-
demic in developed countries. Tobacco Control, 3(3): 242–247.
Lorenc, T., Petticrew, M., Welch, V., and Tugwell, P. (2013) What types of interventions
generate inequalities? Evidence from systematic reviews. Journal of Epidemiology and
Community Health, 67(2): 190–193.
Lozano, R., Naghavi, M., Foreman, K., Lim, S., Shibuya, K., Aboyans, V., Abraham, J.,
Adair, T., Aggarwal, R., Ahn, S. Y., AlMazroa, M.A., Alvarado, M., Anderson, H.R.,
Anderson, L. M., Andrews, K.G., Atkinson, C., Baddour, L.M., Barker-Collo, S.,
­Bartels, D.H., Bell, M.L., and Benjamin, E.J. (2012) Global and regional mortality from
235 causes of death for 20 age groups in 1990 and 2010: A systematic analysis for the
­Global Burden of Disease Study 2010. The Lancet, 380(9859): 2095–2128.
Luke, D., Esmundo, E., and Bloom, Y. (2000) Smoke signs: Patterns of tobacco billboard
advertising in a metropolitan region. Tobacco Control, 9(1): 16–23.
Macdonald, L., Cummins, S., and Macintyre, S. (2007) Neighbourhood fast food environ-
ment and area deprivation—substitution or concentration? Appetite, 49(1): 251–254.
Marmot, M. G., Allen, J., Goldblatt, P., Boyce, T., McNeish, D., Grady, M., and Geddes, I.
(2010) Fair society, healthy lives: Strategic review of health inequalities in England post-
2010. UCL Institute of Health Equity.
Martinez Valle, A. (2013) Addressing social determinants of health through intersectoral
work: Five public policy cases from Mexico. Social Determinants of Health Discussion.
Paper Series 6 (Case Studies). Geneva: World Health Organization.
McCambridge, J., Kypri, K., Miller, P., Hawkins, B., and Hastings, G. (2014) Be aware of
Drinkaware. Addiction, 109(4): 519–524.
Miller, D., and Harkins, C. (2010) Corporate strategy, corporate capture: Food and alcohol
industry lobbying and public health. Critical Social Policy, 30(4): 564–589.
Moodie, R., Stuckler, D., Monteiro, C., Sheron, N., Neal, B., Thamarangsi, T., Lincoln, P.,
Casswell, S., and the Lancet NCD Action Group (2013) Profits and pandemics: Preven-
tion of harmful effects of tobacco, alcohol and ultra-processed food and drink industries.
The Lancet, 381(9867): 670–679.
Nestle, M. (2002) Food Politics: How the Food Industry Influences Nutrition and Health.
Berkeley: University of California Press.
Nestle, M. (2012) Fighting the flab means fighting makers of fatty foods. New Scientist, 2892
26 November.
O’Brien, P. (2013) Australia’s double standard on Thailand’s alcohol warning labels. Drug
and Alcohol Review, 32(1): 5–10.
Patel, P., Collin, J., and Gilmore, A. B. (2007) The law was actually drafted by us but the
Government is to be congratulated on its wise actions: British American Tobacco and
public policy in Kenya. Tobacco Control, 16(1): e1 doi:10.1136/tc.2006.016071
Pearce, J., Blakely, T., Witten, K., and Bartie, P. (2007) Neighborhood deprivation and
­access to fast-food retailing: A national study. American Journal of Preventive Medicine,
32(5): 375–382
190 Industrial epidemics and inequalities

Powell, L. M., and Chaloupka, F. J. (2009) Food prices and obesity: Evidence and policy
implications for taxes and subsidies. Milbank Quarterly, 87(1): 229–257.
Richter, J. (2012) WHO Reform and Public Interest Safeguards: An historical perspective,
Social Medicine, 6(3): 141–150.
Robinson, S., and Harris, H. (2011) Smoking and drinking among adults, 2009: A report
on the 2009 General Lifestyle Survey. Newport: Office for National Statistics.
Schneider, S., and Gruber, J. (2013) Neighbourhood deprivation and outlet density for to-
bacco, alcohol and fast food: First hints of obesogenic and addictive environments in
Germany. Public Health Nutrition, 16(7): 1168–1177.
Skafida, V., and Treanor, M. C. (2014) Do changes in objective and subjective family in-
come predict change in children’s diets over time? Unique insights using a longitudinal
cohort study and fixed effects analysis. Journal of Epidemiology and Community Health,
68(6): 534–541.
Smoyer-Tomic, K. E., Spence, J. C., Raine, K. D., Amrhein, C., Cameron, N.,
­Yasenovskiy, V., Cutumisu, N., Hemphill, E., and Healy, J. (2008) The association
­between neighborhood socioeconomic status and exposure to supermarkets and fast
food outlets. Health and Place, 14(4): 740–754.
Taylor, A. L., and Dhillon, I. S. (2013) An international legal strategy for alcohol control:
Not a framework convention—at least not yet. Addiction, 108(3): 450–455.
UN (2011) List of civil society representatives to be invited to participate in the High-level
Meeting on the Prevention and Control of Non-communicable Diseases, to be convened
on 19 and 20 September 2011. United Nations: New York.
UN General Assembly (2011) Political declaration of the High-level Meeting of the General
Assembly on the Prevention and Control of Non-communicable Diseases, A/66/L.1,
New York: United Nations. http://www.who.int/nmh/events/un_ncd_summit2011/
political_declaration_en.pdf.
Waxman, A. (2004) The WHO Global Strategy on Diet, Physical Activity and Health: The
controversy on sugar. Development, 47(2): 75–82.
WHO (2003) WHO Framework Convention on Tobacco Control. Geneva: World Health
Organization.
WHO (2004) WHO Global Strategy on Diet, Physical Activity and Health. Geneva: World
Health Organization.
WHO (2008a) Tobacco Industry Interference with Tobacco Control. Geneva: World Health
Organization.
WHO (2008b) Report from a roundtable meeting with economic operators on harmful use
of alcohol, 6 November, Geneva. Geneva: World Health Organization, http://www.who.
int/substance_abuse/activities/msbeoreport.pdf.
WHO (2010) Global Strategy to Reduce the Harmful Use of Alcohol. Geneva: World Health
Organization.
WHO (2011) Global Status Report on Noncommunicable Diseases 2010. Geneva: World
Health Organization.
WHO (2013) WHO governance reform: Report by the Secretariat. Executive Board 133rd
session, provisional agenda item 5. EB133/16, 17 May 2013. Geneva: World Health
Organization. Accessed from http://apps.who.int/gb/ebwha/pdf_files/EB133/B133_16-
­

en.pdf on 23 October 2013.

 CORPORATIONS - UPSTREAM DRIVERS OF INEQUALITIES 191

WHO (2014) WHO Tobacco Laboratory Network (TobLabNet) participation and conflict-
of-interest requirements. Geneva: World Health Organization. Accessed from http://
www.who.int/tobacco/global_interaction/toblabnet/conflict_of_interest/en/index.html.
Yach, D., and von Schirnding, Y. (2014) Public health lives: Gro Harlem Brundtland.
­Public Health, 128(2): 148–150.
Yanamadala, S., Bragg, M. A., Roberto, C. A., and Brownell, K. D. (2012) Food industry
front groups and conflicts of interest: The case of Americans against Food Taxes. Public
Health Nutrition, 15(8): 1331–1332.
Yerger, V., Przewoznik, J., and Malone, R. (2007) Racialized geography, corporate activity,
and health disparities: Tobacco industry targeting of inner cities. Journal of Health Care
for the Poor and Underserved, 18(4 Suppl.): 10–38.
 Chapter 14

Place, space, and health

inequalities
Jamie Pearce, Rich Mitchell,
and Niamh Shortt

14.1  Introduction: Why is it important to think

geographically?
International evidence demonstrates strong, and rising, geographical inequal-
ities in health on a range of spatial scales, from between countries to across
neighbourhoods in the same city. In the UK, the socio-spatial patterning in
health outcomes has been documented for over 150 years, beginning with the
work of nineteenth-century social scientists, political theorists, and social re-
formers such as Engels, Chadwick, and Rowntree (Pearce and Dorling 2009).
Geographical inequalities in health across parliamentary constituencies fell
during the period from the early 1920s to early 1970s (Thomas et al 2010), but
since the 1970s there has been a sharp increase in spatial inequalities in health
in the UK; by 2007 health inequalities were as substantial as any time since the
economic depression of the 1930s. The difference between the highest and low-
est life expectancy across local authorities in the UK is around 14 years (Fig-
ure  14.1). Examining the geographical patterning of health is likely to be
productive, as it can help to reveal societal, political, and environmental ante-
cedents for health inequalities.

14.1.1  Researching geographical inequalities in health

Much has been written on health inequalities by academics from geography,
sociology, epidemiology, and public health, and some of this work has
adopted a spatial framework to consider geographical explanations for the
ubiquitous rise in health inequalities. In the broadest sense, within the field
of health inequalities, three interrelated areas of geographical scholarship can
be identified.
 WHY IS IT IMPORTANT TO THINK GEOGRAPHICALLY? 193

Years
No data available
71.6 –77.0
77.1 –78.1
78.2 –79.2
79.3 – 80.2
80.3 – 85.1

Km
0 50 100
Fig. 14.1 Male life expectancy at birth (years) by UK local authorities 2008–2010.
Source: Data from Life expectancy at birth and at age 65 by local areas in the United Kingdom,
2006–08 to 2010–12, Office of National Statistics, 2014.
194 Place, space, and health inequalities

First, the neighbourhoods and health literature emphasizes that local circum-
stances can be important in understanding residents’ health. Drawing on socio-
ecological theory, it is argued that where you live, work, and play, as well as who
you are, matters for your health, and that ‘place’ explains a component of this
socio-spatial arrangement. Galster (2011) suggests neighbourhood influences
can be split into four broad rubrics: social interactive mechanisms (social pro-
cesses such as the collective norms or networks and cohesion between residents);
environmental mechanisms (physical attributes such as the public infrastructure,
and exposure to toxic substances); geographical mechanisms (particularities of
areas relating to macro-level political and economic factors, such as limited local
tax base or restricted job opportunities); and institutional mechanisms (actions
of those external to the neighbourhood which may result in place-based stigma-
tization or unequal public and private investment). A large body of work, often
using multilevel modelling, distinguishes between ‘contextual’ and ‘composi-
tional’ accounts for geographical variations in health. It is argued that place exerts
an influence on a range of health outcomes (e.g. mortality, cancer incidence) and
related behaviours (e.g. smoking, nutrition, and alcohol consumption).
However, neighbourhood explanations of health inequalities have been criti-
cized for providing a partial account for inequalities in health across local areas
(Pearce 2013). Most studies rely on cross-sectional associations, and there are
few attempts to develop longitudinal study designs which are better suited to
identifying causal processes (see Chapter 2). As the human geography literature
has long recognized, neighbourhoods are fluid and non-bounded, and their
make-up partially reflects broader macro-level social and economic processes
that have accumulated over many years and decades (Wacquant 2008). Few
studies have tracked and explained the historical development of neighbour-
hoods, and then considered the repercussions for local health and well-being.
This approach offers opportunities not only to identify causal relationships, but
also to better understand the ways in which local neighbourhoods can mediate
between structural drivers (social, political, and environmental factors) and in-
equalities in health.
Second, work on environmental justice and health inequalities has been help-
ful in emphasizing that place and environment are socially produced and that
there are material effects of these arrangements, including health (Rosenberg
2014). Environmental and social differences are inextricably connected. From a
health inequalities perspective, this work has demonstrated that the social and
spatial distribution of environmental ‘goods’ and ‘bads’ affects the socio-spatial
distribution of health and well-being. For instance, socially disadvantaged
neighbourhoods often suffer from the ‘triple jeopardy’ of poor environmental
quality (e.g. higher levels of ambient air pollution levels), high mortality and
 WHY IS IT IMPORTANT TO THINK GEOGRAPHICALLY? 195

morbidity levels, as well as the many aspects of multiple deprivation (Pearce

et al 2010). Importantly, environmental justice framing encourages researchers
to identify the social and political processes underlying this geographical ar-
rangement, as well as the implications for health and well-being.
Third, work on mobility and migration has been instructive (Gatrell 2011). In
particular, the work on health-selective movements of people within and be-
tween countries, and the socio-political drivers of these processes, have demon-
strated a tendency for ‘healthy’ populations to migrate to similar places (e.g.
from the north to south of the UK). These movements can therefore partially
explain the unequal geographies of health at various spatial scales. For instance,
New Zealand research demonstrated that the differential migration of smokers
and non-smokers since the 1970s has strongly affected the country’s increas-
ingly uneven social geographies of health (Pearce and Dorling 2010). Other
migration–health inequalities work has pointed to the effects of migration on
stress and mental health (of those that move and those remaining behind), mi-
gration as a vector for spreading disease, the implications of large-scale migra-
tion streams for health care provision, and monitoring the long-term
implications of moving between highly distinct societies (e.g. adopting local
risk factors and health profiles).
These three approaches have helped to explicate a number of geographical
processes that are significant in understanding socio-spatial inequalities in
health, but there is scope for further work using geographical frameworks to
reveal how environmental processes combine with social and political concerns
to establish and perpetuate health inequalities. We identify three areas in par-
ticular. First, geographical accounts of health inequalities have tended not to
consider environmental concerns that have been typically examined outside
the public health sphere. Yet human health emerges from complex systems and
is affected by broader ecosystems that include multiple ecologies. These con-
cerns are especially salient during a period of anthropogenic-driven environ-
mental change. Second, whilst it is well recognized that spatial context matters
for health, the historical context that is critical to understanding contemporary
geographical processes (i.e. time) is rarely considered in public health work.
Third, few studies have examined how social and physical environments can
support good health and narrow health inequalities. It is plausible that environ-
mental processes can disrupt the well-established links between material fac-
tors, health, and inequalities. The rest of this chapter uses a geographical
framework to explore these three emergent, and interrelated, research areas
that offer promise in understanding socio-spatial inequalities in health, moving
us beyond the limitations of current approaches to studying health inequalities
(see Chapters 6–9, 13, and 16–17).
196 Place, space, and health inequalities

14.2  Ecological public health

Whilst public health was historically developed on the ideology of a social
model of health, more recently there has been a policy shift towards a ‘new’
public health, with agency/the individual and behavioural change at the centre.
Policy now appears to focus less on ‘public’ health and more on ‘individual’
health (Katikireddi et al 2013). This places us in the middle of what has been
termed a ‘lifestyle drift’ (see Chapter 8). This drift has been in direct response to
changing risks and health problems, for example a rise in lifestyle-related risks
such as tobacco and alcohol consumption, coupled with health outcomes such
as cancer and cardiovascular disease. Individuals do not exist in isolation, but
rather in particular places and environments. Whilst such interventions recog-
nize changing risks at the individual level, they fail to recognize parallel changes
to risk within the environment. Furthermore, working within such linear sys-
tems of cause and effect fails to acknowledge the complex causal processes oc-
curring ‘in the real world’ (Dean 1993, p. 29).
The challenges we now face, including increasing health inequalities and glo-
bal environmental change, have been referred to as ‘wicked issues’ (Hunter
2009) due to their innate complexity (with tangled webs of interconnected
nodes and pathways) and the consequent lack of simple, linear solutions. From
a complex systems perspective, this means we need to be alert to the possibility
that the impacts of particular changes may be nonlinear, unpredictable, and
‘messy’. Within health inequalities research, complexity thinking has so far
been lacking (Dean 1993), but it can help to move us beyond simple linear mod-
els of health outcomes (e.g. change behaviours to improve health and reduce
health inequalities) towards seeing such outcomes as situated within dynamic
systems, driven by a multitude of factors.
Addressing the challenge of complexity, Rayner and Lang (2012) present a
model of Ecological Public Health (EPH). EPH emerged in the 1980s, respond-
ing to broader environmental risks for public health such as climate change
and environmental hazards. Recognizing that people coexist with the natural
environment, the concept focuses on the complex processes, environmental
and social, that create and shape health. Individuals are not separated from
their environment; human health is instead seen as part of a broader ecosystem
that includes four environmental dimensions: material, biological, cultural,
and social. EPH is currently being proposed as a ‘new wave’ of public health
(Hanlon et al 2011), though EPH in itself may not offer anything new to public
health researchers who have engaged with similar broader socio-­ecological
theories, such as those proposed by Bronfenbrenner (1979) and Dahlgren and
Whitehead (1991). EPH does, however, remind us of the importance of the
 Life course and place 197

environment at a time of great environmental change. It also pushes us to

explore not only the environmental determinants of health inequalities, but
also the underlying mechanisms that drive these determinants. Such mech-
anisms illustrate the interrelationships between the broader macro-level
social and economic processes highlighted earlier. In this context, whilst
not new, EPH offers a framework for researchers to engage with these chal-
lenges that moves us beyond a bio-reductionist approach (Rayner 2009).
Exploring the interactions between all elements of the system, individual
and environmental, will help us to understand the complexities and inter-
relationships of multiple variables ‘viewing health as a process nested in
contexts rather than as a static attribute of individuals’ (McLaren and Hawe
2005, p. 9).
Reflecting these temporal and spatial concerns, the environmental determi-
nants of health inequalities are diverse, including factors from each of the four
broad EPH dimensions. These environmental determinants of health inequali-
ties have become increasingly complex in an age of globalization and environ-
mental change. Given this complexity, it is unsurprising that interventions that
focus on changing individual behaviours have been shown, paradoxically, to
increase the very same health inequalities they aim to reduce; a phenomenon
known as the ‘inequality paradox’ (Buck and Frosini 2012). It is the explicit
recognition of these environmental determinants of health inequalities in
EPH that could encourage public health researchers to broaden their scope
and better integrate, research, and data, across both proximal and distal
environments.

14.3  Life course and place

As Chapter 1 outlines, life course perspectives have made an important contri-
bution to health inequalities research over the past 20 years. However, those
with an interest in place and health inequalities have tended not to use longitu-
dinal study designs to incorporate a life course perspective and have instead
largely relied on contemporaneous analysis using cross-sectional data. This is
problematic because we know that people move between places over time (to
places more or less supportive for good health), particularly earlier and later in
life, which is likely to affect subsequent health outcomes. Places also evolve in
response to macro-level processes such as industrial restructuring, land use
changes, urban expansion, redevelopment and regeneration initiatives, or gen-
trification. Local particularities also mediate relations through the local re-
sources, rules, and practices, which in turn can reinforce and rework place-based
characteristics. People make places as much as places make people. The few
198 Place, space, and health inequalities

studies that have incorporated area-level constructs into life course accounts of
health have tended to use measures of neighbourhood socioeconomic disad-
vantage, usually obtained from past censuses (Curtis 2004; Murray et al 2012).
This work has been instructive in demonstrating that neighbourhood-level so-
cioeconomic conditions in childhood and early life affect health and health in-
equalities later in life. Yet, the reliance on census-based measures has been
insufficient to capture the multiple pathways through which place can influence
health inequalities (which, as outlined in the discussion of complexity, seems
increasingly necessary).
It is therefore clear that integrating longitudinal environmental information
with population data, which identifies health and socioeconomic information,
as well as geographical location, is likely to offer important insights into place–
health relations, including a more sophisticated understanding of the way in
which places affect health inequalities. One of the key challenges to incorporat-
ing a temporal dimension is the significant exertion required in obtaining
place-based or environmental data over time. It is rare that long-term area-level
environmental data, such as on housing, green space, community resources, or
pollution levels, are collected and archived, especially in a digital format. None-
theless, we contend that the extent of recoverable historical data for small areas
has not been fully appreciated. Our investigations suggest that there may be a
vast cache of small area data that might enable the reconstruction of past urban
environments for use in work on life course, place, and health inequalities.
Linking meaningful area-level information and cohort data remains an import-
ant research need that offers considerable analytical possibilities.
Work in the field of ‘Historical Geographical Information Systems (GIS)’ of-
fers the possibility of recreating neighbourhood environments over time. GIS
software and geospatial methods have already been adopted to contribute to
aspects of historical scholarship. For instance, it is possible to collect place-
based data from various historical sources to capture environmental character-
istics that potentially affect health, and incorporate this information into a GIS.
Once integrated into a GIS it is feasible to develop neighbourhood measures of
the health-related environment at particular time points. A recent pilot project
in the Edinburgh region of Scotland examined a range of historical data sources
including censuses, paper maps, aerial photographs, tabular land use data, city
plans, and others to consider the feasibility of developing a series of
­neighbourhood-level health-related measures at different time points over the
past 100 years. The Edinburgh region was selected because it coincided with the
geographical extent of the Lothian Birth Cohorts of 1921 and 1936 (Deary et al
2012); the intention for the future is to append small area longitudinal data to
the cohort. The pilot work demonstrated the feasibility of obtaining a number
 Resilience, and equigenic environments 199

of measures of the local environment relating to the physical features of neigh-

bourhoods and the resources within them (e.g. public parks). Extracting his-
torical information relating to the experiential environment (e.g. social
cohesion) was more challenging. Once the data had been digitally captured and
incorporated into a GIS, it was possible to operationalize small area measures of
the health-related environment over time, and to build up a ‘life course of place’.
In summary, collaboration between geographers, public health researchers,
and those with interests in historical GIS offers potential for understanding the
significance of place-based factors for health inequalities. The use of archival
material for estimating environmental exposure over the life course offers ana-
lytical promise. In addition, prospective cohort data collection strategies could
usefully consider routinely collecting place-based data that establish the geo-
graphical contexts in which people live, work, and play throughout their lives.
The diminishing technical and ethical concerns regarding the linking of routine
data from various sources (e.g. medical records, census returns, educational
reports, social surveys) emphasizes the potential of this approach. In the UK,
and elsewhere, there is growing interest amongst researchers, funders, and pol-
icymakers in the analytical possibilities offered by utilizing large and complex
datasets collected by government departments, the private sector, and other
organizations (see for example the ESRC’s Big Data Network). Further, pro-
spective cohort studies could usefully examine the opportunities for routinely
including environmental data. The integration of longitudinal environmental
and health data offers new opportunities for enhancing our understanding of
geographical factors that may assist in explaining the establishment of health
inequalities over the life course.

14.4  Resilience, and equigenic environments

How can thinking about health and place offer both hope for narrowing health
inequalities and directions for future research? We know that social and physical
environmental characteristics affect health (CSDH 2008), but we have for too
long focused solely on which of these characteristics are harmful, how they are
harmful, and who is more likely to be exposed to them. There is an alternative.
Rather than ask, ‘who is at greater risk of being sick and why?’, we can ask, ‘who
seems to stay well, and how do they do that?’. A focus on the positive aspects of
health takes many different forms, some with greater relevance to, and evidence
from, geographical studies than others. The umbrella of ‘positive health’ ideas
includes notions of salutogenesis (Antonovsky 1979, 1996), positive deviance
(Marsh et al 2004), resilience (Bartley 2006; Mitchell 2014; Werner 1996), and
assets-based approaches (Morgan and Ziglio 2007), whilst acknowledging that
200 Place, space, and health inequalities

each of these terms has its own focus, history, and definition (see also Chap-
ter 15). This focus on how people stay well can be an inspiration for thinking
about how health inequalities might be minimized and what the role of place
might be. Much of the existing perspectives are focused on socioeconomic ine-
qualities in health, and we consider these first and foremost later in the chapter.
The underlying concept is that some environments, or environmental char-
acteristics, could disrupt the usual conversion of adversity to poor health. Pear-
son and colleagues (2013) propose a useful framework for considering how this
might work. They note that both the neo-material path and the psychosocial
path to health inequalities could be affected by environmental characteristics.
Places might either reduce exposure to health-damaging things or increase ex-
posure to health-promoting things. Examples of health-promoting social en-
vironments could include those which are socially cohesive and supportive,
with little or no social segregation and with good and equally accessible health
services. Examples of health-promoting physical environments could include
those that promote physical activity, that have low levels of pollution, and that
offer and promote access to nature. The multiple aspects of environmental in-
fluence on health support the ecological public health perspective.
Wealthier people often use their material advantage to buy access to environ-
ments which minimize health-related harms or maximize health-related bene-
fits. Yet, it is important to recognize that their wealth is not directly paying for
the environmental characteristics they enjoy. They do not, as individuals, pay
for their clean air, their walkable street network, their park, or their active social
interaction. Affluence buys them residence and participation in places which
already have those characteristics (though their presence and influence as resi-
dents may then reinforce and protect these characteristics). Where such envir-
onmental characteristics are available to less advantaged people, their health
can benefit too. Indeed, there is evidence to suggest that some salutogenic en-
vironmental characteristics are of greater health benefit to less advantaged peo-
ple than to their more advantaged neighbours (Lachowycz and Jones 2014). It
thus becomes possible that features of the social, physical, or service environ-
ments could act to create health equality within the confines of existing material
inequality. We call this equigenesis (Mitchell 2013). Equigenic environments
could reduce inequalities between places, and/or within them.
A small number of studies have explored these ideas. Studies have, for ex-
ample, shown that health inequalities are narrower in areas with ready access to
urban green spaces, and that the benefits of contact with nature appear stronger
for more deprived populations than for more affluent (Mitchell and Popham
2008). Focusing on geographical research, a larger number of studies has looked
for ‘resilient’ areas, defined as having relatively good health given a high level of
 Resilience, and equigenic environments 201

socioeconomic deprivation (Cairns et al 2012; Mitchell et al 2009; Pearson et al

2013; Tunstall et al 2007; van Hooijdonk et al 2007). These studies have found
geographically defined populations which face long-term socioeconomic de-
privation, yet appear to have significantly better health outcomes than their
economic or environmental peers. Mixed methods research, for example, sug-
gests that strong local social cohesion, demographic stability, local housing
policies, and physical environments were all implicated in their apparent resili-
ence (Leipert and Reutter 2005; Mitchell et al 2009).
It is important to recognize though, that resilient places are, by definition,
rare. Some studies also suggest that, whilst health in these places may be better
than in other places facing similar kinds of adversity, it is still often worse than
in places not facing adversity at all (Tunstall et al 2007). It also appears that what
is a recipe for resilience in one place does not always work in another. Pearson
et  al note ‘some factors may be associated with positive health outcomes in
some neighbourhoods, but not in other areas. These findings highlight the im-
portance of the interactions between people and their neighbourhoods, rather
than simply the presence of certain factors. . . . Simply altering environments
may not actually change behaviours or outcomes’ (2013, p. 244). Other studies
have argued that passive ‘receipt’ of health advantage does not simply stem from
residence in a resilient area.
Research has also looked at resilience as a process, though this work has
tended to focus on individuals more than places (Canvin et al 2009; Massey
et al 1998; Schoon 2006). Such studies are in contrast to those which simply
look for places that have achieved a particular ‘outcome’, like a relatively good
mortality rate, despite facing adversity. Studies of process are able to explore
the strategies used to mitigate the impacts of adversity, without a need to de-
fine a ‘successful’ outcome. This work (usually qualitative) is often far more
nuanced than the outcome studies and reveals the complex trajectories which
people living in poverty experience. As Batty and Cole argue: ‘It is more useful
to see resilience as a process of meeting successive challenges—in which some
people are able to make incremental gains that extend the opportunities open
to them despite the relentlessness of the financial challenges they face’ (2010,
p. 47). There are also longitudinal mixed methods and quantitative studies of
individuals who face adversity, which have been able to explore the processes
by which resilience manifests itself (or not) (see, for example, Conger and
Conger 2002, and Werner 1996), but we note a general lack of such studies
about places or communities. Such studies might better explore how the char-
acteristics of places help or hinder positive outcomes from adverse situations.
The idea of focusing on how some people stay well is controversial (Harrison
2013; MacKinnon and Derickson 2013). A key criticism is that focusing on how
202 Place, space, and health inequalities

to mitigate the conversion of economic adversity to poor health, rather than on

eliminating economic adversity itself, might implicitly condone economic in-
equality (for an overview of this perspective, see Chapter 15). Such arguments
about the potential political misuse of positive perspectives on health are well
made, but the position in which they leave those of us concerned about health
inequalities seems perverse. Whilst the structural causes of inequality are clear,
progress in reducing it is demonstrably poor. Radical action is not supported by
the electorate, which continues to hold a paradoxical opinion on income in-
equalities and redistribution. About 80% of the population believe that the in-
come gap between the richest and poorest is too large (Park et al 2013). However,
only 40% say they would actually like income to be redistributed and just 5%
agree that extra spending on welfare benefits (a key lever for reducing poverty)
is a high priority for government (Park et al 2013). To argue that reducing ma-
terial inequalities is the only way to tackle health inequalities is akin to only
prescribing a medicine which is not really available. There must be room for
alternative agendas.
We should also note that economic situation is far from being the only source
of adversity which places face now, and will in the future. The ecological public
health perspective reminds us of the risks posed by environmental change and
degradation. It is likely that less advantaged places and people will be most at
risk from these threats in the future, but all humans are potentially vulnerable
(McMichael et al 2008). Understanding how best to foster resilience to these
kinds of adversities will be important if we are to avoid the creation of new en-
vironmentally based axes of health inequality in the future.
In summary, evidence about the extent to which characteristics of places
might disrupt the pathways between poverty and poor health is beginning to
emerge from a variety of disciplines. It is currently comparatively sparse, but it
holds the promise of something which might actually work to narrow inequal-
ities in health. Searching for equigenic environments should not lead us, or
policymakers, to abandon the drive for narrowing material inequalities or pre-
venting ecological catastrophe, but whilst that struggle continues we must
examine the possibility that where we live and work might contribute to achiev-
ing greater health equality now and in the future.

14.5  Conclusion: The promise of geographical

approaches
This chapter has argued that geographical approaches have been important in
identifying social, political, and environmental drivers of health inequalities. The
places in which we live, work, and play throughout our lives, and the geographical
 Conclusion: The promise of geographical approaches 203

processes operating through these spaces, are integral to a comprehensive under-

standing of health inequalities. Using a geographical framing, three nascent and
interrelated themes that offer promise in understanding health inequalities have
been considered. First, the utility of the concept of EPH was considered. EPH
links environmental change to health, and more broadly to a consideration of all
aspects of the environment, their interactions, and the casual pathways between
the environment and health inequalities. Second, the use of historical data sources
to recreate health-related place-based measures over time offers analytical prom-
ise. Appending these historical data with cohort information will enable re-
searchers to better understand how environmental factors affect health inequalities
over the life course. Finally, the chapter has offered a cautious welcome to the
comparatively new idea that some aspects of social and physical environment
might, in themselves, play a part in reducing health inequalities by disrupting the
usual conversion of socioeconomic adversity to poor health. Whilst, like others in
this book (Chapter 15), we are concerned that such a focus could legitimize re-
ductions in effort to tackle socioeconomic inequalities themselves, we believe that
the potential of equigenic environments must be explored.

References
Antonovsky, A. (1979) Health, Stress and Coping. San Francisco: Jossey-Bass.
Antonovsky, A. (1996) The salutogenic model as a theory to guide health promotion.
Health Promotion International, 11(1): 11–18.
Bartley, M. (ed.) (2006) Capability and resilience: Beating the odds. London: UCL.
Batty, E., and Cole, I. (2010) Resilience and the Recession in Six Deprived Communities: Pre-
paring for Worse to Come. York: Joseph Rowntree Foundation.
Brofenbrenner, U. (1979) The Ecology of Human Development. Cambridge, MA: Harvard
University Press.
Buck, D., and Frosini, F. (2012) Clustering of Unhealthy Behaviours Over Time: Implica-
tions for Policy and Practice. London: King’s Fund.
Cairns, J. M., Curtis, S. E., and Bambra, C. (2012) Defying deprivation: A cross-sectional
analysis of area level health resilience in England. Health and Place, 18(4): 928–933.
Canvin, K., Marttila, A., Burstrom, B., and Whitehead, M. (2009) Tales of the unexpected?
Hidden resilience in poor households in Britain. Social Science and Medicine, 69(2):
238–245.
CSDH (2008) Closing the gap in a generation: Health equity through action on the social
determinants of health. Final report of the CSDH. Geneva: WHO.
Conger, R. D., and Conger, K. J. (2002) Resilience in Midwestern families: Selected find-
ings from the first decade of a prospective, longitudinal study. Journal of Marriage and
Family, 64(2): 361–373.
Curtis, S. (2004) Health and Inequality: Geographical Perspectives. London and Thousand
Oaks, CA: Sage.
Dahlgren, G., and Whitehead, M. (1991) Policies and Strategies to Promote Social Equity in
Health. Stockholm: Institute of Futures Studies.
204 Place, space, and health inequalities

Dean, K. (1993) Integrating theory and methods in population health research. In K. Dean
(ed.), Population Health Research: Linking Theory and Methods. London: Sage
Publications.
Deary, I. J., Gow, A. J., Pattie, A., and Starr, J. M. (2012) Cohort profile: The Lothian Birth
Cohorts of 1921 and 1936. International Journal of Epidemiology, 41(6): 1576–1584.
Galster, G. C. (2011) The mechanism(s) of neighbourhood effects: Theory, evidence, and
policy implications. In M. Van Ham, D. Manley, N. Bailey, L. Simpson, and D. Maclen-
nan (eds), Neighbourhood Effects Research: New Perspectives. New York: Springer.
Gatrell, A. C. (2011) Mobilities and Health. Farnham, Surrey and Burlington, VT: Ashgate.
Hanlon, P., Carlisle, S., Hannah, M., Reilly, D., and Lyon, A. (2011) Making the case for a
‘fifth wave’ in public health. Public Health, 125(1): 30–36.
Harrison, E. (2013) Bouncing back? Recession, resilience and everyday lives. Critical Social
Policy, 33(1): 97–113.
Hunter, D. J. (2009) Leading for health and wellbeing: The need for a new paradigm. Jour-
nal of Public Health, 31(2): 202–204.
Katikireddi, S. V., Higgins, M., Smith, K. E., and Williams, G. (2013) Health inequalities:
The need to move beyond bad behaviours. Journal of Epidemiology and Community
Health, 67(9): 715–716.
Lachowycz, K., and Jones, A. P. (2014) Does walking explain associations between access to
greenspace and lower mortality? Social Science and Medicine, 107(1): 9–17.
Leipert, B. D., and Reutter, L. (2005) Developing resilience: How women maintain their
health in northern geographically isolated settings. Qualitative Health Research, 15(1):
49–65.
MacKinnon, D., and Derickson, K. D. (2013) From resilience to resourcefulness: A critique
of resilience policy and activism. Progress in Human Geography, 37(2): 253–270.
Marsh, D. R., Schroeder, D. G., Dearden, K. A., Sternin, J., and Sternin, M. (2004) The
power of positive deviance. British Medical Journal, 329(7475): 1177–1179.
Massey, S., Cameron, A., Ouellette, S., and Fine, M. (1998) Qualitative approaches to the
study of thriving: What can be learned? Journal of Social Issues, 54(2): 337–355.
McLaren, L., and Hawe, P. (2005) Ecological perspectives in health research. Journal of Epi-
demiology and Community Health, 59(1): 6–14.
McMichael, A. J., Friel, S., Nyong, A., and Corvalan, C. (2008) Global environmental
change and health: Impacts, inequalities, and the health sector. British Medical Journal,
336(7637): 191–194.
Mitchell, R. (2013) What is equigenesis and how might it help narrow health inequalities?
[Online]. Edinburgh: Centre for Research on Environment, Society and Health. Avail-
able from http://cresh.org.uk/2013/11/08/what-­is-equigenesis-and-how-might
-it-help-narrow-health-inequalities/ (accessed on 9 June 2014).
Mitchell, R. (2014) Population resilience. The Wiley Blackwell Encyclopedia of Health, Ill-
ness, Behavior, and Society. John Wiley and Sons, Ltd.
Mitchell, R., Gibbs, J., Tunstall, H., Platt, S., and Dorling, D. (2009) Factors which nurture
geographical resilience in Britain: A mixed methods study. Journal of Epidemiology and
Community Health, 63(1): 18–23.
Mitchell, R., and Popham, F. (2008) Effect of exposure to natural environment on health
inequalities: An observational population study. The Lancet, 372: 1655–1660.
 Conclusion: The promise of geographical approaches 205

Morgan, A., and Ziglio, E. (2007) Revitalising the evidence base for public health: An assets
model. Global Health Promotion, 14(1): 17–22.
Murray, E. T., Southall, H., Aucott, P., Tilling, K., Kuh, D., Hardy, R., and Ben-Shlomo,
Y. (2012) Challenges in examining area effects across the life course on physical capabil-
ity in mid-life: Findings from the 1946 British Birth Cohort. Health and Place, 18(2):
366–374.
Park, A., Bryson, C., Clery, E., Curtice, J., and Phillips, M. (2013) British Social Attitudes:
The 30th Report. London: National Centre of Social Research.
Pearce, J. (2013) An environmental justice framework for understanding neighbourhood
inequalities in health and well-being. In D. Manley, M. van Ham, N. Bailey, L. Simpson,
and D. Maclennan (eds), Neighbourhood Effects of Neighbourhood-based Problems? A
Policy Context. Dordrecht: Springer Press, pp. 89–112.
Pearce, J., and Dorling, D. (2009) Tackling global health inequalities: Closing the health
gap in a generation. Environment and Planning A, 41(1): 1–6.
Pearce, J., and Dorling, D. (2010) The influence of the selective migration patterns of
smokers and non-smokers on geographical inequalities in health. Annals of the Associa-
tion of American Geographers, 100(2): 393–408.
Pearce, J., Richardson, E., Mitchell, R., and Shortt, N. (2010) Environmental justice and
health: The implications of the socio-spatial distribution of multiple environmental de-
privation for health inequalities in the United Kingdom. Transactions of the Institute of
British Geographers, 35(4): 522–539.
Pearson, A. L., Pearce, J., and Kingham, S. (2013) Deprived yet healthy: Neighbourhood-
level resilience in New Zealand. Social Science and Medicine, 91: 238–245.
Rayner, G. (2009) Conventional and ecological public health. Public Health, 123(9):
587–591.
Rayner, G., and Lang, T. (2012) Ecological Public Health: Reshaping the Conditions for
Good Health. Oxon: Routledge.
Rosenberg, M. (2014) Social justice, idealist theory, health and health care. Progress in
Human Geography, 38(3): 466–475.
Schoon, I. (2006) Risk and Resilience: Adaptations in Changing Times. Cambridge Univer-
sity Press.
Thomas, B., Dorling, D., and Smith, G. D. (2010) Inequalities in premature mortality in
Britain: Observational study from 1921 to 2007. British Medical Journal, 341: c3639.
Tunstall, H., Mitchell, R., Gibbs, J., Platt, S., and Dorling, D. (2007) Is economic adversity
always a killer? Disadvantaged areas with relatively low mortality rates. Journal of Epide-
miology and Community Health, 61(4): 337–343.
Van Hooijdonk, C., Droomers, M., Van Loon, J. A. M., Van der Lucht, F., and Kunst,
A. E. (2007) Exceptions to the rule: Healthy deprived areas and unhealthy wealthy areas.
Social Science and Medicine, 64(6): 1326–1342.
Wacquant, L. J. D. (2008) Urban Outcasts: A Comparative Sociology of Advanced Marginal-
ity. Cambridge: Polity Press.
Werner, E. E. (1996) Vulnerable but invincible: High risk children from birth to adulthood.
European Child and Adolescent Psychiatry, 5(Suppl. 1): 47–51.
 Chapter 15

The politics of tackling

inequalities: The rise
of psychological fundamentalism
in public health and welfare
reform
Lynne Friedli

Negativity enacts the dissent without which politics disappears.

Negativity, in this sense, is inseparable from the struggles of
subordinated persons to resist the social conditions of their
devaluation.
Berlant and Edelman 2014, p. xii
“Preface,” in Sex, or the Unbearable, Lauren Berlant, Lee Edelman, Eds.,
pp. vii-xvii. Copyright, 2014, Duke University Press. All rights reserved.
Republished by permission of the copyright holder. www.dukeupres.edu

15.1  Introduction: The rise of psychological

explanations and interventions in public health
This chapter1 is concerned with the growing influence of non-material explana-
tions for inequalities and a corresponding emphasis on psychological interven-
tions, which aim to modify cognitive function or emotional disposition/affect
(Friedli 2013, 2014). These developments intersect with and are reinforced by the
parallel rise in brain science, which correlates a range of outcomes (crime, addic-
tion, health behaviour, educational attainment) with brain structure (Katz 2013;
Rose 2013). As a recent editorial in the British Medical Journal observes:
There is great interest in whether the structure and function of brain circuits can be changed
to optimise the operation of the executive control system (Marteau and Hall 2013, p. 6750)

In public health, the psychological attributes and dispositions of individuals

and communities (the ostensible presence or absence of optimism, aspiration,
self-efficacy, conscientiousness, sense of coherence, etc.) are being used to
 Strengths-based discourse 207

explain patterns of health and health behaviour and to account for the impact
of material deprivation, in a twin process of psychologizing and biologizing
poverty (Edwards et al 2014). Deprivation is understood less and less in relation
to issues of equity, power, and justice and more and more in terms of the impact
of the ‘environment’ on brain function.

15.2  Absence of debate

Of course there is an important debate to be had about the relative contribution
of psychological factors to the social gradient in health and other outcomes, but
the growing authority of Whitehead’s ‘emerging cartel of psychocrats’ (White-
head et al 2011, p. 2830) is rarely challenged.
The absence of critical academic assessment of assets-based approaches has been
discussed elsewhere (Friedli 2013), but there has also been a marked silence about
the use and misuse of psychology in public policy. The Cabinet Office Behavioural
Insights Unit (recently privatised) is simply the most visible manifestation of the
(mis)‘application of behavioural science and psychology to public policy’ (Behav-
ioural Insights Team 2013). What is less visible, and less remarked upon, are the
implications of psycho-policy for the disadvantaged and excluded populations who
are its primary targets, and the coercive and punitive nature of many psycho-policy
interventions (Friedli and Stearn 2013; Howell and Veronka 2012).

15.3  Strengths-based discourse: The power

of positive affect
Of particular note is the proliferation of ‘strengths-based’ approaches, which
play an important normative role. Sometimes referred to as ‘assets based’, these
approaches validate a very specific set of attributes that are classified as adap-
tive, as predictive of positive health and social outcomes (both for individuals
and for communities), and are promoted via a range of psycho-interventions.
The idea that personality and outlook can be abstracted to explain health is
pervasive (Morgan et al 2012; Muntaner 2004). A particular version of
­psychology—avowedly non-materialist, influenced by positive psychology and
health behaviourism—is now so prevalent that it barely attracts comment. It
has become axiomatic that self-esteem, optimism, confidence, hopefulness,
sense of coherence, aspiration, coping abilities, and other markers of cheerful
self-sufficiency and resilience produce health and are fundamental indicators of
well-being. Their absence is routinely implicated in every health and social
problem from obesity and chronic pain to inappropriate use of services and
long-term unemployment. Psychology is increasingly achieving the status of
‘first cause’ and/or primary intervening variable.
208 The politics of tackling inequalities

15.4  Engaging with the evidence base

These developments are of special significance in respect to health and un-
employment, where psychology is contributing to the ‘sidelining by stealth’ of
material explanations (Friedli 2014). I say ‘by stealth’ because psychology has
not been required to defend itself in relation to an extensive body of research
evidence on the social determinants of health—the conditions in which people
are born, grow, live, work, and age and their political antecedents (Birn 2009;
Krieger 2011; Scott et al 2013). Nor has psychology had to engage with critiques
of ‘supply side’ economics, which call into question the effectiveness (and there-
fore the ethics) of addressing unemployment by attempting to modify those
who are unemployed (Webster 2005).
The rise and fall of specific causes of mortality and the strong social gradient
for avoidable causes of death raise challenging questions about the most effect-
ive approaches to reducing inequalities, notably approaches concerned with
addressing individual attributes (McCartney et al 2013). Although interpret-
ation of the roots of, and remedies for, inequalities is inevitably politically
driven, the strength of the case for the ‘fundamental causes’ of health inequal-
ities is striking (see Chapters 1, 8, 9, and 16). In a major revisiting of the evi-
dence, the CSDH has demonstrated where attention should be focused: health
inequalities are a symptom, an outcome, of inequalities in power, money, and
resources (CSDH 2008).2 These structural and material inequalities result in
unequal exposure, by social position, to a range of health risks and advantages
(Phelan et al 2010; Scott et al 2013; Thomas et al 2010). As causes of death and
disease are socially patterned, the removal of one risk factor (e.g. smoking) will
simply be replaced by another (e.g. obesity), unless material inequalities are
addressed (Scott-Samuel 2011). The absence of evidence that knowledge, atti-
tudes, and motivation have any significant impact on ‘health behaviour’ in
comparison with structural factors further undermines the case for focusing
on ‘reducing individual risk and increasing individual assets’ (Mackenbach
2012; Scott et al 2013):

Looking at trends over time, the KAM [knowledge, attitudes and motivation] survey
consistently found a lack of association between behaviour change and levels of know-
ledge and motivation in all health behaviours which were explored. (Rutherford and
Reid 2013)

The wealth of evidence on the health impact of the distribution of money and
power, and the lack of evidence on abstracted ‘health behaviour’, raises serious
questions about psychological approaches. Nevertheless, ‘resources to act on
health messages’ are routinely understood as non-material: levels of mental
 Count your assets 209

capital or ‘psychological barriers’ to people’s ability to act on information. In

public health, psychological resources have become a de facto substitute for in-
come and security.

15.5  Count your assets

We believe that sustainable improvements in people’s life chances are most likely to be
achieved by identifying and supporting the development of their own capabilities to
manage their way out of poverty. (Scottish Government 2011, p. 9)

Assets-based approaches are essentially about recognizing and making the

most of people’s strengths, to ‘redress the balance between meeting needs and
nurturing the strengths and resources of people and communities’ (McLean
2011, p. 2), with a corresponding shift in focus from the determinants of illness
to the determinants of health (salutogenesis). Although assets can include ma-
terial resources—land, buildings, and income—in public health the primary
focus is on valuing individual and collective psychosocial attributes (Friedli
2013). These include the familiar roll-call of self-esteem, aspiration, confidence,
optimism, sense of coherence (SOC), meaning and purpose, the so-called in-
tangible assets such as knowledge, skills, wisdom, and culture, and key features
of social capital: social networks, reciprocity, mutual aid, and collective efficacy
(Lindstrom and Eriksson 2010).
Assets-based approaches draw on positive psychology and the work of An-
tonovsky on SOC (Antonovsky 1987), as well as on traditions of community
development (McKnight 1995) and health activism, notably in the disability
rights, user/survivor, and recovery movements (Duffy 2010). Based on empir-
ical studies of psychological resilience in the face of profound adversity, An-
tonovsky argues that the presence or absence of SOC is fundamental to
understanding life outcomes, notwithstanding the experience of trauma. Indi-
viduals who experience life as structured, predictable, and explicable, who are
confident that they have the resources to meet demands, and who believe that
such demands are challenges worthy of investment and engagement are thus
said to be consistently more likely to have positive health (Lindstrom and Eriks-
son 2010).
Despite the evangelical zeal that assets-based approaches have generated,
notably in Scotland, where they have enjoyed strong support from Professor Sir
Harry Burns (Chief Medical Officer in Scotland 2005–14), there is no evidence
that SOC can explain health inequalities, or that assets approaches can reverse
the main avoidable causes of morbidity and mortality. A recent analysis of data
from a cross-sectional survey of the populations of Glasgow, Liverpool, and
Manchester did not support either a lower SOC or psychological outlook
210 The politics of tackling inequalities

(optimism, aspirations, hedonism, individualism) as plausible factors in ex-

plaining Glasgow’s excess mortality and poor health (Walsh et al 2013).
In the absence of evidence and critical debate, the function of assets-based
approaches is purely ideological. They are being used:
◆ to reinforce the view that the way in which poor people make use of welfare
benefits (income and services) is morally flawed and unaffordable;
◆ to perpetuate the idea that ‘a culture of poverty’ produces psychological
traits that trap people (and their children) in ‘lives of destitution’ and de-
pendency; and
◆ to suggest that ‘cycles of dependency and need’ are characteristic not of the
rich, currently enjoying unprecedented levels of fiscal privilege and state
benefits, but of the poor.
As Mark Steel has observed, ‘it takes a trained mind to understand that the
people who are robbing us are the poor’ (Steel 2013).

15.6  Limitations of materialist analysis

Assets-based approaches are strongly associated with a non-materialist
­position—money does not matter as much as relationships, sense of meaning
and belonging, opportunities to contribute, and autonomy. Like the wider well-
being debates (Friedli 2009; ONS 2011), they address some limitations of ma-
terialist accounts:
They speak to the resistance of deprived communities to being pathologised, criminal-
ised, ostracised; to being described in public health reports in terms of multiple deficits
and disorders: chaotic, unengaged, and disaffected. (Friedli 2011, p. 29)

Strengths-based discourse has been an important element in resistance to the

imposition of psychiatric labels and diagnostic categories and to public health
attempts to pathologize those who are poor. The capabilities approach in the
work of Sen, Nussbaum, and others is part of wider international efforts to rec-
ognize and address the non-material dimensions of poverty and deprivation,
which feature so strongly in narrative testimonies of citizens living in poverty
and other excluded groups (Nussbaum 2011). What is at stake is the social,
emotional, and spiritual impact of poverty and inequality, as well as the view
that well-being does not depend solely upon economic assets (Sen 1992).
The problem with the assets-based literature is that respect for people’s capac-
ity for resistance (generally described as ‘resilience’) is abstracted from any
analysis of social injustice or the causes of inequalities: ‘naming who and what
are the forces and institutions creating and perpetuating inequitable conditions
in the first place’ (Birn 2009, p. 168).
 PUBLIC HEALTH AND THE GLASGOW pSoBID STUDY 211

15.7  Public health and the Glasgow pSoBid study

Strengths-based discourse also dominates public health as part of an ostensibly
scientific psychological model that validates the health-giving properties of cer-
tain attributes: ‘the right kind of affect’ and ‘unimpaired cognitive function’.3 A
cheerful disposition, in combination with a thankful heart and highly devel-
oped ‘executive control’, are so widely celebrated in public health literature that
the politics (and epidemiology) of this reification is rarely questioned. In this
brave new world, people who are poor constitute clusters of impaired brains,
targets for novel and exciting new interventions:
Although the number of children born into poverty in the UK and elsewhere is
high and may be rising, a broadening array of findings from brain and behavioural
sciences suggest novel targets for intervention to reduce the strength of association
between ‘demography and destiny  .  .  . ’ Together with interventions that target
brains, those that target environments could reduce the double hit faced by those
born into poverty: living in environments that contain more cues for unhealthier
behaviours, coupled with a reduced capacity to inhibit responses to those cues
(emphasis added).
Reproduced from The British Medical Journal, Theresa M Marteau,
Peter A Hall, Breadlines, brains, and behaviour, 347, p. 6750,
doi: http://dx.doi.org/10.1136/bmj.f6750, Copyright © 2013,
The BMJ Publishing Group Ltd. With permission from the
BMJ Publishing Group Ltd.

In other words, notwithstanding rising levels of poverty, brain and behavioural

science can solve the problem of poor people’s inability to resist unhealthy be-
haviour. The objectification of ‘those born into poverty’ in this paper (and many
other papers) and the casual fatalism regarding poverty, are a reminder of the
growing social, emotional, and moral distance between people who design
public health interventions and those who experience them (see Chapters 6, 16,
and 17). A reminder too, of public health’s contribution to social abjection: stig-
matizing the behaviour and existence of the poorest citizens (Tyler 2013).
A potent example of these trends is a series of papers linking personality
characteristics to health behaviour that forms part of the Glasgow Centre for
Population Health pSoBid study (GCPH 2013), which aims to ‘examine the
pathways between people’s social circumstances, mental wellbeing, and bio-
logical markers of disease’ (Millar et al 2013; Packard et al 2012; Velupillai et
al 2008). The pSoBid research is concerned with an important question: can
a deeper understanding of psychological factors (the domain of the psycho-
social) deepen our understanding of health inequalities, notably Glasgow’s
‘excess mortality’? (Walsh et al 2013). In practice, however, the pSoBid proto-
col for examining questions such as ‘do deprived groups differ from affluent
212 The politics of tackling inequalities

ones in psychological profile (affective state and cognition)?’ (Velupillai et al

2008, p. 3) reinforces certain messages about people living in deprived areas
(with their ‘impaired cognitive function’ and ‘altered (negative) mental out-
look’). This framing both justifies and promotes (psychological) interven-
tions that target the health behaviour of people who are poor:
From a public health perspective it is important to establish if those who need to
take on board messages advocating lifestyle change (weight loss, physical activity)
are in a position affectively and intellectually to receive them. Equally, certain per-
sonality and other individual difference factors modify responses to stress and
challenge, conferring both vulnerability and protection, and must be accounted
for as moderating variables.
Reprinted from Yoga N Velupillai, Chris J Packard, G David Batty,
Vladimir Bezlyak, Harry Burns, Jonathan Cavanagh, Kevin Deans, Ian Ford,
Agnes McGinty, Keith Millar, Naveed Sattar, Paul Shiels, and Carol Tannahill,
Psychological, social and biological determinants of ill health (pSoBid):
Study Protocol of a population-based study, BMC Public Health 8, p.126
doi:10.1186/1471–2458–8–126 © 2008 Velupillai et al; licensee
BioMed Central Ltd. This quote is licensed under the terms
of the Creative Commons Attribution License

Just as in assets-based discourse, the underlying message here is that resili-

ence to ‘stress and challenge’ flows from psychological rather than material
resources.
Papers by Packard and colleagues (2012) and Millar and colleagues (2013)
show that the pSoBid study’s actual concern is ‘the identification of individuals
whose personality styles render them vulnerable to particular health risks’
(Millar et al 2013, p. 8) on the basis that ‘individuals who display certain per-
sonality characteristics are more likely to indulge in harmful health behaviours
and to have increased risk of morbidity and mortality’ (Millar et al 2013, p. 1).
The use of the term ‘indulge’ in reference to harmful health behaviours signals
a familiar normative message; concepts like ‘pessimistic worry’ and ‘low consci-
entiousness’ encode a moral framework that locates poor health in attributes
defined as psychological deficits. The caveat that certain personality character-
istics are ‘associated with low SES’ does nothing to prompt questions about the
usefulness of the constructs or to subvert notions of ‘harmful health behaviour’
as a determinant of health. On the contrary, it confirms the original ­­hypothesis—
that deprived groups differ from affluent ones in ‘psychological profile’—and
invites and authorizes ever-more intrusive psycho-interventions targeted at
disadvantaged populations:
A strategy of adapting interventions to the behaviours and beliefs that characterise par-
ticular personality types may improve the implementation of intervention pro-
grammes. (Millar et al 2013, p. 8; see also Packard et al 2012, p. 8)
 Workfare 213

Although there is robust evidence that interventions focusing on health behav-

iour are likely to increase health inequalities (see McCartney et al 2013; and
Chapters 1, 2, 8, and 9), in the pSoBid studies, psychology functions to distract
attention from the established and primary relationship between material de-
privation and poor health. In a curious sleight of hand, psychology assumes a
special importance for those who are most deprived:
Personality traits and mental wellbeing are more important determinants of health be-
haviours within areas of high socioeconomic deprivation . . . no personality trait or
aspect of mental wellbeing appeared to predict this health behaviour in the more afflu-
ent group. (Packard et al 2012, p. 9)

Other research in the pSoBid series examines the ‘association between neigh-
bourhood level deprivation and brain network structure’. This apparently dem-
onstrates ‘a structural organization that is consistent with a [brain] system that
is less robust and less efficient in information processing. These findings pro-
vide some evidence of the relationship between socioeconomic deprivation and
brain network topology’ (Krishnadas et al 2013). So there we have it. Deprived
Glaswegians may defy claims that they lack a ‘sense of coherence’ (Walsh et al
2013), but there is a marked deficit in their ‘brain power’.
Although ostensibly concerned with the impact of deprivation, these papers
serve to obscure the fundamental drivers of health inequalities: inequalities in
power, privilege, and resources. In Packard et al’s conclusion, in what amounts
to a specification for social marketing (NSMC 2013), the social determinants of
health are entirely absent:
Persistence of a social divide in health may be related to interactions between person-
ality, mental wellbeing and the adoption of good health behaviours in deprived areas.
Effectiveness of health messages may be enhanced by accommodating the variation in
the levels of extraversion, neuroticism, hopelessness and sense of coherence. (Packard
et al 2012, p. 1)

As has been noted, what is also absent is any reference to the contested nature
of constructs such as personality and mental well-being, their ideological un-
derpinnings, and the processes through which specific characteristics acquire
both social value and economic reward. In other words, the political nature of
these issues is evaded.

15.8  Workfare
While notions of psychological failure are implied in public health discourse,
they are explicit in welfare reform interventions targeting social security claim-
ants (Friedli and Stearn 2013; Friedli and Stearn 2015). Eligibility for both out-
of-work and in-work benefits is contingent not only on certain behaviours, but
214 The politics of tackling inequalities

Box 15.1 Workfare
Workfare is any activity that a person in receipt of social security payments
is obliged to do in order to continue to receive those payments, and which
they carry out under the threat of sanctions. Often, workfare is forced, un-
paid work for a business, charity, or social enterprise, or mandatory partici-
pation in training.
Sanctions are the cessation of payment of one or more benefit, in whole or
in part, for a period of time. They are the threat which ensures people engage
in workfare. Typically, sanctions involve a 100% decrease in the amount
paid; for Jobseeker’s Allowance, they can last from 4 weeks to 3 years.
Source: Data from L. Friedli and R. Stearn Whistle while you work (for nothing):
positive affect as coercive strategy—the case of workfare, 2013. Retrieved from
http://medicalhumanities.wordpress.com/2013/12/10/whistle-while-you-work-
for-nothing-positive-affect-as-coercive-strategy-the-case-of-workfare/ and D.
Webster, Independent review of Jobseeker’s Allowance (JSA) sanctions for claimants
failing to take part in back to work schemes, 2014. Retrieved from http://www.cpag.
org.uk/sites/default/files/uploads/CPAG-David-Webster-submissio
n-Oakley-review-Jan-14_0.pdf.

also on possession of positive affect. ‘Employability’ is now less a set of skills

than a mindset. Psycho-compulsions familiar from the ‘recovery agenda’ (How-
ell and Voronka 2012) are key features in ‘workfare’—the central plank in the
management and governance of a wide range of ‘unproductive’ or failing citi-
zens, i.e. those who are out of work, not working enough, not earning enough,
and/or failing to seek work with sufficient application (see Box 15.1).
The use of positive affect in the delivery of workfare has far-ranging conse-
quences for people who are unemployed, sick, disabled, or in ‘in-work’ poverty.
These include mandatory participation in ‘positive psychology’ courses and the
use of psychological referral as punishment for non-compliance with the new
regimes of welfare conditionality to which people claiming out-of-work benefits
(or, in future, universal credit) are subject (Citizens Advice Bureau 2013). This
means that those currently claiming benefits, and those who could be at risk of
doing so, are regularly subjected to the blandishments of positive thinking. As we
have seen, this includes positive affect as a substitute for income and security.
These developments mean that—in the lives of those who are poor—positive
psychology is now as significant a feature of conditionality as going to church
once was, and they share a common evangelical language: ‘something within
the spirit of individuals living within deprived communities that needs healed’
 Workfare 215

(SCDC 2011, p. 3). Unfortunately, the compulsions of positive affect are not
confined to Sundays.

I am shy and have difficulty speaking to people and I will not do play acting in front
of a group of people I am very uncomfortable with. . . . I was told I would be sanc-
tioned if I didn’t take part, so I said I would get up, but I am not speaking. . . . After
that, we had to fill out yet another ‘benefits of being assertive’ sheet.
Reproduced from K. Day, How Work Programme Makes me Feel,
Sunday 18th August 2013, http://soisthismylifenow.blogspot.co.uk/2013/08/
how-work-programme-makes-me-feel.html. Accessed 12th February 2015
© 2013 K. Day, with permission

Compulsory positive affect and psychological authority are being applied in

workfare for three reasons:
◆ to identify ostensible psychological barriers to gaining employment;
◆ to punish people for non-compliance (through conditionality and benefit
sanctions); and
◆ to inculcate attributes and attitudes said to increase employability.
The consistent failure of Work Programme interventions to improve work out-
comes has resulted in a much greater focus on psychological or ‘soft outcomes’,
said to ‘move people closer to work’:

Evidence from this evaluation suggests that while there was no significant diffe-
rence in job outcomes at the end of the programme, [it was] successful in achiev-
ing soft outcomes such as increases in motivation, confidence, job-seeking
behaviour and a positive change in attitudes to work. These softer impacts may
yet translate into job outcomes and sign off from JSA.
Reprinted from Nilufer Rahim, Mehul Kotecha, Jenny Chanfreau,
Sue Arthur, Martin Mitchell, Colin Payne and Sarah Haywood, Evaluation of
Support for the Very Long-Term Unemployed Trailblazer, p.4 © 2012
Department of Work and Pensions. This quote is licensed under the terms
of the Open Government License, v.3. Emphasis added

Efforts to achieve these ‘soft outcomes’ are evident in the course content of
mandatory training programmes run by major workfare contractors like A4e
and Ingeus. The A4e Engage Module states that ‘students will learn how to de-
velop the right mindset which will appeal to employers’ (other elements of this
module are assertiveness, confidence, benefits of work, motivation, and en-
hance your mood). One of the criteria for being sent on Community Work
Placements (DWP 2013) is ‘lack of motivation’, regarded in the policy literature
as a significant impediment to gaining employment, although never precisely
defined.
216 The politics of tackling inequalities

15.9  Increasing positive affect

In addition to mandatory training informed by positive psychology, claimants
may be subjected to strengths-based interventions, including online psychomet-
ric testing, and ‘failure to comply may result in loss of benefits’ (SKwawkbox 2013).
As Cromby and Willis have noted, every aspect of the Values in Action (VIA)
‘Inventory of Signature Strengths’ test recently imposed on claimants contra-
vened the British Psychological Society’s ethical code (Cromby and Willis 2013).
Positive affect as it is now deployed constitutes a more and more arduous and
demeaning array of tasks whose insufficient performance is a sanctionable of-
fence. Working on these deficits becomes the full-time, unpaid labour of mil-
lions of people, which, together with mandatory job search activities, ensures
that these days, people who are poor have no money, no time, and no place:
Basically what I’m saying in short is that I feel there is no place in society for a quiet,
shy, creative person like me. And now I feel I don’t even deserve to call myself cre-
ative, because I don’t even do that anymore, because I am too depressed.
Reproduced from K. Day, How Work Programme Makes me Feel,
Sunday 18th August 2013, http://soisthismylifenow.blogspot.co.uk/2013/08/
how-work-programme-makes-me-feel.html. Accessed 12th February 2015
© 2013 K. Day, with permission

15.10  Conclusions
[T]he voices of resistance against the abjectifying logic of neo-liberal governmentality
are growing louder. (Tyler 2013, p. 2)

The participation of psychology (and by implication, psychologists) in the de-

livery of coercive goals in health and in welfare reform clearly raises ethical
questions. The discourse of assets, the psychological determinism of the Glas-
gow pSoBid study, and the psycho-compulsions of workfare all demonstrate, to
varying degrees, the coercive use of positive affect. Public health’s preoccupa-
tion with a ‘tiny proportion of variables’ (Lewis 2014) involves increasing levels
of abstraction: the brain is abstracted from the person; personality, disposition,
and behaviour are abstracted from context, history, and political struggle.
Whether in health or in employment, psychology is implicated in what amounts
to a ‘substitution of outcomes’, where the modification of psychological attrib-
utes stands in for delivering actual improvements in health or increasing the
availability of real paid work. Choosing psycho-analysis over economic analysis
has serious consequences for how public health explains and responds to issues
of social justice. The discourse of ‘assets’ and ‘resilience’ is entirely consistent
with the erosion of universal services, the dismantling of social security, and
new configurations of the deserving and undeserving poor.
 Conclusions 217

Psychology now plays a central and formative role in stigmatizing the ‘exist-
ence and behaviour of various categories of poor citizens’ (Slater 2013). Manda-
tory work activity and ‘supported job searches’ involve tasks experienced as
humiliating and pointless by job seekers (Day 2013a): the ‘grotesque daily prac-
tices of condemnation and disenfranchisement’ that contribute to the social
abjection of the most socially and economically disadvantaged citizens (Tyler
2013, pp.  170–171). There is no evidence that work programme psycho-­
interventions increase the likelihood of gaining decent paid work. In perpetu-
ating notions of psychological failure, they shift attention away from the social
patterning of poor health and unemployment and from wider trends: market
failure, the rise of in-work poverty, the cost-of-living crisis, and the scale of in-
come inequalities (Shildrick et al 2012; Whittaker and Hurrell 2013).
Psychology is the origin of the term psychosocial and the linking of the social
patterning of psychological stressors to disease distribution (Krieger 2011,
p. 193). If inequalities in health are a matter of social justice—a consequence of
inequalities in power, wealth, and income—then psychology and those engaged
in psychosocial research have a shared responsibility to ask and to address the
political question: who and what is responsible for the generation and pattern-
ing of psychosocial stressors? As things stand, such questions are largely absent
from public health, which is becoming more and more enmeshed in the cult of
the ‘ideal’ personality. Even so, these questions are being asked elsewhere, in the
bubbling-up of multiple forms of resistance to neoliberal definitions of value
and worth and to the erosion of the hard-won rights of social citizenship.

Notes
1 This work now contributes to Lynne Friedli’s collaboration with Hubbub, an interdiscip-
linary exploration of rest and its opposites funded by the Wellcome Trust (see: http://
hubbubgroup.org/). Research for the sections of this chapter on workfare was funded by
the Wellcome Trust, grant number 103817. LF is a member of Boycott Workfare, an or-
ganisation campaigning to abolish workfare.
Earlier versions of some of the ideas in this chapter were presented (with Robert
Stearn) at the Critical Medical Humanities Symposium, 4/5 November 2013, http://
medicalhumanities.wordpress.com/2013/10/31/­critical-medical-humanities-symposium-
final-programme-and-invitation-to-follow-critmh-debate-on-twitter/ and appear in
Friedli and Stearn (2013), Friedli and Stearn (2015), and Midlands Psychology Group
and Friedli (forthcoming). The analysis of ­assets-based approaches previously appeared
in Friedli (2013).
2 Health 2020, a new public health policy being developed by WHO Regional Office for
Europe, will also focus on equity and social determinants, http://www.euro.who.int/en/
what-we-do/event/first-meeting-of-the-european-health-policy-forum/health-2020.
3 My thanks to Robert Stearn (personal communication) for the apt description ‘the right
affect’.
218 The politics of tackling inequalities

References
Antonovsky, A. (1987) Unravelling the Mystery of Health: How People Manage Stress and
Stay Well. San Francisco: Jossey-Bass.
Behavioural Insights Team (2013) What we do. Retrieved from https://www.gov.uk/
government/organisations/behavioural-insights-team.
Berlant, L., and Edelman, L. (2014) Sex, Or the Unbearable. Durham and London: Duke
University Press.
Birn, A. (2009) Making it politic(al): Closing the gap in a generation. Health Equity through
Action on the Social Determinants of Health Social Medicine, 4: 166–182.
Citizens’ Advice Bureau (2013) What is universal credit?: The claimant’s commitment,
http://www.adviceguide.org.uk/england/benefits_e/benefits_welfare_benefits_reform_e/
benefits_uc_universal_credit_new/benefits_uc_claiming_universal_credit/uc95_uc_the_
claimant_commitment.htm.
Commission on the Social Determinants of Health (2008) Closing the gap in a gener-
ation: Health equity through action on the Social Determinants of Health Final Report
of the Commission on Social Determinants of Health. Geneva: World Health
Organization
Cromby, J., and Willis, M. E. H. (2013) Nudging into subjectification: Governmentality
and psychometrics. Critical Social Policy, 34(2): 241–259.
Day, K. (2013a) Patronising teamwork exercise number 5,348 (or something), Friday 16
August. Retrieved from http://soisthismylifenow.blogspot.co.uk/2013/08/patronising-
teamwork-excersise-number.html.
Day, K. (2013b) How work programme makes me feel. Retrieved from http://
soisthismylifenow.blogspot.co.uk/2013/08/how-work-programme-makes-me-feel.html.
Department for Work and Pensions (2013) European Social Fund: Community work place-
ments. Retrieved from http://www.dwp.gov.uk/esf/news/community-work-placements.
shtml.
Duffy, S. (2010) The citizenship theory of social justice: Exploring the meaning of personal-
isation for social workers. Journal of Social Work Practice, 24(3): 253–267.
Edwards, R., Gillies, V., and Horsley, N. (2014) The biologisation of poverty: Policy and
practice in early years intervention. Retrieved from http://www.discoversociety.org/
policy-briefing-the-biologisation-of-poverty-policy-and-practice-in-early-years-
intervention/.
Friedli, L. (2009) Mental health, resilience and inequalities—a report for WHO Europe and
the Mental Health Foundation. London/Copenhagen: Mental Health Foundation and
WHO Europe.
Friedli, L. 2011. Reasons to be Cheerful: The Count Your Assets Approach to Public Health.
Perspectives Magazine of Scotland’s Democratic Left: Issue 30: 29–32
Friedli, L. (2013) What we’ve tried hasn’t worked: The politics of asset-based public health.
Critical Public Health, 23(2): 131–145.
Friedli, L. (2014) The ethics of psycho-policy: Reflections on the role of psychology in pub-
lic health and workfare. Clinical Psychology Forum, 256: 11–16.
Friedli, L., and Stearn, R. (2013) Whistle while you work (for nothing): Positive affect as
coercive strategy—the case of workfare. Retrieved from http://medicalhumanities.
wordpress.com/2013/12/10/whistle-while-you-work-for-nothing-positive-affect-as-coercive-
strategy-the-case-of-workfare/.
 Conclusions 219

Friedli, L., and Stearn, R. (2015) Positive affect as coercive strategy: conditionality, activa-
tion and the role of psychology in UK government workfare programmes Med Humani-
ties; 41:40–47
Glasgow Centre for Population Health (2013) Psychological, social and biological deter-
minants of ill health (pSoBid): Study protocol of a population-based study. Retrieved
from http://www.gcph.co.uk/work_themes/additional_work/psobid.
Howell, A., and Voronka, J. (2012) The politics of resilience and recovery in mental health
care studies. Social Justice, 6(1): 1–7.
Katz, M. B. (2013) The biological inferiority of the undeserving poor. Social Work and Soci-
ety (international online journal), 11: 1.
Krieger, N. (2011) Epidemiology and the People’s Health: Theory and Context. Oxford:
­Oxford University Press.
Krishnadas, R., Kim, J., McLean, J., Batty, G. D., McLean, J. S., Millar, K., Packard, C. J.,
and Cavanagh, J. (2013) The envirome and the connectome: Exploring the structural
noise in the human brain associated with socioeconomic deprivation. Frontiers in Human
Neuroscience, 7: 722.
Lewis, B. (2014) The art of medicine: Taking a narrative turn in psychiatry. The Lancet, 383:
22–23.
Lindstrom, B., and Eriksson, M. (2010) A salutogenic approach to tackling health inequal-
ities in health assets. In A. Morgan, M. Davies, and E. Ziglio (eds), A Global ­Context—
Theory, Methods, Action. London: Springer.
Mackenbach, J. P. (2012) The persistence of health inequalities in modern welfare states:
The explanation of a paradox. Social Science and Medicine, 75(4): 761–769.
Marteau, T. M., and Hall, P. A. (2013) Breadlines, brains, and behaviour. British Medical
Journal, 347: f6750.
McCartney, G., Collins, C., and Mackenzie, M. (2013) What (or who) causes health in-
equalities?: Theories, evidence and implications. Health Policy, 113(3): 221–227.
McKnight, J. (1995) The Careless Society: Community and its Counterfeits. New York: Basic
Books.
McLean, J. (2011) Asset-Based Approaches to Health Improvement: Redressing the Balance.
Briefing Paper 9. Glasgow: Glasgow Centre for Population Health
Midlands Psychology Group and Friedli L (forthcoming) Midlands Psychology Group
Reply to Packard et al (2012). Interaction of personality traits with social deprivation
in determining mental wellbeing and health behaviours.
Millar, K., Lloyd, S. M., McLean, J. S., Batty, G. D., Burns, H., Cavanagh, J., Deans, K. A.,
Ford, I., McConnachie, A., McGinty, A., Mõttus, R., Packard, C. J., Sattar, N., Shiels, P. G.,
Velupillai, Y. N., and Tannahill, C. (2013) Personality, socio-economic status and inflam-
mation: Cross-sectional, population-based study. PLoS ONE, 8(3).
Morgan, A., Davies, M., and Ziglio, E. (eds) (2012) Health Assets in a Global Context—­
Theory, Methods, Action. London: Springer.
Muntaner, C. (2004) Social capital, social class and the slow progress of psychosocial epide-
miology. International Journal of Epidemiology, 33: 674–680.
NSMC (National Social Marketing Centre) (2013) What is social marketing? Retrieved
from http://www.thensmc.com/content/what-social-marketing-1.
Nussbaum, M. (2011) Creating Capabilities—The Human Development Approach. Cam-
bridge, MA: Harvard University Press.
220 The politics of tackling inequalities

Office for National Statistics (2011) Measuring What Matters: National Statistician’s Re-
flections on the National Debate on Measuring National Well-Being. London: ONS.
Packard, C., Cavanagh, J., McLean, J. S., McConnachie, A., Messow, C. A., HYPERLINK
“http://eprints.gla.ac.uk/view/author/4445.html” Batty, G. D., Burns, H., Deans, K. A.,
HYPERLINK “http://eprints.gla.ac.uk/view/author/10313.html” Sattar, N., HYPERLINK
“http://eprints.gla.ac.uk/view/author/10327.html” Shiels, P. G., HYPERLINK “http://
eprints.gla.ac.uk/view/author/12871.html” Velupillai, Y. N., Tannahill, C., and HYPER-
LINK “http://eprints.gla.ac.uk/view/author/7899.html” Millar, K. (2012) Interaction of
personality traits with social deprivation in determining mental wellbeing and health be-
haviours. Journal of Public Health, 34(4): 615–624.
Phelan, J. C., Link, B. G., and Tehranifar, P. (2010) Social conditions as fundamental
causes of health inequalities: Theory, evidence, and policy implications. Journal of Health
and Social Behaviour, 51(Suppl): S28–40.
Rahim, N., Kotecha, M., Chanfreau J., Arthur S., Mitchell M., Payne C. and Haywood S.
(2012) Evaluation of support for the very long-term unemployed trailblazer report: Re-
search summary, https://www.gov.uk/government/publications/
evaluation-of-support-for-the-very-long-term-unemployed-trailblazer-rr824.
Rose, S. (2013) Beware ‘brain-based learning’. Times Higher Education, 12 December.
Rutherford, L., and Reid, S. (2013) Knowledge, Attitudes and Motivations to Health, 2008–
11. Glasgow: NHS Health Scotland.
Scott, S., Curnock, E., Mitchell, R. et al (2013) What Would it Take to Eradicate Health In-
equalities? Testing the Fundamental Causes Theory of Health Inequalities in Scotland.
Glasgow: NHS Health Scotland.
Scott-Samuel, A. (2011) Further evidence that effective interventions on health inequalities must
tackle the root causes, British Medical Journal, Rapid Response, http://tinyurl.com/7j7wx7c.
Scottish Community Development Centre. 2011. Asset Alliance Scotland Event Report. Glas-
gow: SCDC. (Accessed June 23, 2012) http://www.scdc.org.uk/assets-alliance-scotland/
Scottish Government (2011) Child Poverty Strategy for Scotland. Edinburgh: Scottish
Government.
Sen, A. (1992) Inequality Re-examined. Cambridge, MA: Harvard University Press.
Shildrick, T., MacDonald, R., Webster, C., and Garthwaite, K. (2012) Poverty and Insecu-
rity: Life in Low Pay, No Pay Britain. Bristol: Policy Press.
Slater, T. (2013) Review of Imogen Tyler revolting subjects Antipode A radical journal of ge-
ography pp. 1–9, http://radicalantipode.files.wordpress.com/2013/09/book-review_slater-
on-tyler.pdf.
Steel, M. (2013) The poor spend all the money. Isn’t it obvious? The Independent, 25 August.
The Skwawkbox (2013) DWP: Fake psych ‘test’ training given by unqualified ‘experts’, The
Skwawkbox blog, 4 July. Retrieved from http://skwalker1964.wordpress.
com/2013/07/04/dwp-fake-psych-test-training-given-by-unqualified-experts/.
Thomas, B., Dorling, D., and Davey Smith, G. (2010) Inequalities in premature mortality
in Britain: Observational study from 1921 to 2007. British Medical Journal, 363: 9.
Tyler, I. (2013) Revolting Subjects: Social Abjection and Resistance in Neoliberal Britain.
London: Zed Books.
Velupillai, Y. N., Packard, C. J., Batty, G .D., Bezlyak, V., Burns, H., Cavanagh, J., Deans,
K., Ford, I., McGinty, A., Millar, K., Sattar, N., Shiels, P., and Tannahill, C. (2008) Psy-
chological, social and biological determinants of ill health (pSoBid): Study protocol of a
population-based study. BMC Public Health, 8: 126.
 Conclusions 221

Walsh, D., McCartney, G., McCullough, S., van der Pol, M., Jones R. (2013) Exploring Po-
tential Reasons for Glasgow’s ‘Excess’ Mortality: Results of a Three-city Survey of Glasgow,
Liverpool and Manchester. Glasgow: GCPH.
Webster, D. (2005) Long-term unemployment, the invention of ‘hysteresis’ and the misdi-
agnosis of structural unemployment in the UK. Cambridge Journal of Economics, 29(6):
975–995.
Webster, D. (2014) Independent review of Jobseeker’s Allowance (JSA) sanctions for claim-
ants failing to take part in back-to-work schemes, http://www.cpag.org.uk/sites/default/
files/uploads/CPAG-David-Webster-submission-Oakley-review-Jan-14_0.pdf.
Whitehead, M., Jones, R., and Pykett, J. (2011) Governing irrationality, or a more than
­rational government? Reflections on the rescientisation of decision making in British
public policy. Environment and Planning A, 43: 2819–2837.
Whittaker, M., and Hurrell, A. (2013) Low Pay Britain. London: Resolution Foundation.
 Chapter 16

Knowledge of the everyday:

Confronting the causes of health
inequalities
Eva Elliott, Jennie Popay, and Gareth Williams

Freedom for the wolves has often meant death to the sheep.
This material was originally published in Four Essays on Liberty by Isaiah
Berlin, and has been reproduced by permission of Oxford University Press,
http://ukcatalogue.oup.com/. For permission to reuse this material, please
visit http://www.oup.co.uk/academic/rights/permissions

16.1  Introduction: Capitalist ‘wolves’

Isaiah Berlin occupies an interesting position in the history of political thought.
A liberal, he was stung by left-wing critics of what was seen as his overemphasis
on the malign power of the State into making the unequivocal and beautifully
expressed statement with which we open this chapter: the power of ‘unre-
strained capitalist competition’ (xlv) is potentially as damaging to liberty as the
harsh excesses of authoritarian regimes. Liberty was his theme, but in making
his argument he clearly sets out the case for greater equality. His times are not
our times, of course. But there is something happy about encountering an old
liberal who understood the profound dangers of what we would nowadays call
‘neoliberalism’ (see Chapter 9).
Yet, in these post-recessional times of austerity, as social and health inequal-
ities widen in the UK and internationally (Dorling and Thomas 2011), there are
few who publicly use phrases such as ‘unrestrained capitalist competition’ when
discussing the causes or consequences of the current situation. And those who
do are too often ridiculed as ‘idealistic’ or ‘utopian’, and roundly abused by the
organs and institutions of political and economic power and the over-­privileged,
greedy wolves who populate them.
What makes the current situation even more objectionable from a standpoint
of equality or social justice is that the wolves then turn around, eyes wide with
sardonic indignation, and insist that the injuries and premature deaths of the
‘sheep’ are self-inflicted—it is their lifestyle choices! And they claim, with some
 UNDERSTANDING THROUGH EVERYDAY LIFE 223

justification given the behavioural bias in current health inequalities research

(Popay and Williams 2009; Popay et al 2010; Whitehead and Popay 2010), to
have strong evidence for this point of view. It is surely time for health inequal-
ities researchers to address this bias (see also Chapters 6 and 17).
In this chapter we make a two-fold case, normative and analytical, for a shift
towards more qualitative ‘ways of knowing’ about health inequalities and a
greater emphasis on the social and the political in this research field. First, we
argue (in common with the authors of Chapter 17) that, from both a democratic
and theoretical perspective, health inequalities researchers need to pay more
attention to the voices, and the silences, of those whose health is most severely
affected by inequalities in power and resources. Second, we will demonstrate
how the analysis of the causal pathways generating and sustaining health in-
equalities could be enhanced through the more sophisticated application of so-
cial theories that help draw attention to the politics of health inequalities and the
policies that shape these inequalities. Third, we will highlight the need to iden-
tify the resources for, and barriers to, solidarity and collective action (as opposed
to lifestyle choice or self-regulation) as strategies to reduce health inequalities
(Popay et al 2010). The chapter concludes by arguing for health inequalities re-
searchers to work harder at helping the voices of those bearing the ‘weight of the
world’ (Bourdieu et al 1999) to be heard and creating dialogical spaces through
which they will be taken seriously: creating a citizen social science that builds
knowledge and understanding about health inequalities through ‘narratives of
living and being’ (Chapter 17 then attempts to do precisely this).

16.2  Understanding health inequalities through

knowledge in everyday life
‘Evidence-based’ approaches to understanding inequality and developing policy
downplay knowledge that is about the ‘everyday’. Trahair (2014, p. 6), for exam-
ple, asks whether it is possible to create a map of inequality, ‘an intricate tracery
of exclusion and privilege within which we could locate ourselves and the places
in which we live’. Notwithstanding her failure to reference the long history of
doing just that (Dorling 2011; Dorling and Thomas 2011), Trahair insightfully
answers her own question by arguing that any map of inequality will be partial
because ‘there are experiences of hardship, subjugation and alienation which
cannot easily be captured and weighed via ratios, metrics and indices’ (Trahair
2014, p. 6). Experiences of, and ideas about, dissent, resistance, and the reclaim-
ing of assets, which inform counter-representations of inequality, are equally
difficult to measure. This does not mean that we should dismiss measurement,
but rather that we should not feel compelled to translate into measures social
phenomena—observations, actions, features of everyday ­life—which are better,
224 Knowledge of the everyday

more richly represented as shouts, stories, pictures, murals, banners, poems,

songs, or dramas.
There is an absence of class analysis from much epidemiological literature on
health inequalities (Veenstra 2006). This is matched by the failure of research in
this area adequately to engage with qualitative explorations of the ‘life worlds’
(Schutz 1972) of the subjects of these inequalities (see also Chapter 6). As we
have previously argued, ‘the articulation of these meanings—which we refer to
as “lay knowledge”—in narrative form could provide invaluable insights into
the dynamic relationships between human agency and wider social structures
that underpin inequalities in health’ (Popay et al 1998, p. 636).
Without research into these ‘knowledgeable narratives’ about the everyday
(Williams 2000), we reduce the people whose health is being unequally affected
to unthinking bearers of various assets, deficits, and risks (see Chapter 15) and
hollow out the ‘evidence’ needed to understand and reduce health inequalities.
Wilkinson and Pickett (2010) point to the importance of these ‘social mean-
ings’. The emotional experiences they describe as ‘psychosocial’ processes, link-
ing structural inequality, societal breakdown, and health inequalities, are
experiences (e.g. humiliation, rejection, and disrespect) about which people
themselves have points of view (see Sennett and Cobb 1973, on the ‘hidden in-
juries of class’). These bodies of knowledge inform people’s assessment of the
impact of these experiences upon them, and what action they feel able to take.
Qualitative studies can highlight the contribution these social meanings can
make to our understanding of the causes of health inequalities, and actions to
reduce them. However, attempts by health inequalities researchers to undertake
these qualitative explorations remain limited (see Chapter 6).
In the mid-1990s the Health Education Authority (HEA) commissioned a
review of qualitative research relevant to health inequalities (Rogers et al 1997).
Initial database searches predictably generated thousands of hits, but the appli-
cation of inclusion criteria identified just 68 English language articles using
qualitative approaches to explore smoking, accidents, diet, risk, control, social
support, and lifestyles—a behavioural orientation partly reflecting the continu-
ing preoccupation with lifestyle in health inequalities research, policy, and
practice (see Chapters 1, 8, and 17).
A more recent, much less systematic review conducted to inform this chapter
searched Medline and Primo Central Index for 1995–2014, using similar terms.
It generated more than 4,000 citations, which, because of time constraints, were
ordered by relevance, and abstracts for the first 600 were read. The same inclu-
sion criteria identified 29 English language journal articles plus two qualitative
studies of health inequalities policymaking and a book reporting qualitative
research on the environmental health movement in the USA (see Box 16.1).
 UNDERSTANDING THROUGH EVERYDAY LIFE 225

Box 16.1  Key references identified in recent review

of qualitative research on health inequalities (not all
referenced in text)

Lay perceptions of nature and causes of health

inequalities
Backett-Milburn, K, Cunningham-Burley, S, Davis, J, (2003), Contrasting lives, con-
trasting views? Understandings of health inequalities from children in differing social
circumstances, Social Science & Medicine 57 (2003) 613–623.
Davidson, R, Mitchell, R, Hunt, K, (2007), Location, location, location: The role of
­experience of disadvantage in lay perceptions of area inequalities in health, Health &
Place 14 (2008) 167–181.
Davidson, R, Kitzinger, J, Hunt, K, (2005), The wealthy get healthy, the poor get poorly?
Lay perceptions of health inequalities, Social Science & Medicine 62 (2006)
2171–2182.
Hodgetts, D. J., & Chamberlain, K. (2000) The social negotiation of people’s views on
the causes of illness; Journal of Health Psychology, 5(3), 325–336.
Putland, C, Baum, F.E, Ziersch, A.M, (2011), From causes to solutions—insights from
lay knowledge about health inequalities, BMC Public Health 2011, 11: 67.

Behaviour, e.g. smoking, eating/diet

Alexander, S.A,C, Frohlich, K.L, Poland, B.D, Haines, R.J, Maule, C, (2010), I’m a
young student, I’m a girl . . . and for some reason they are hard on me for smoking: The
role of gender and social context for smoking behaviour, Critical Public Health, 20: 3,
323–338.
Backett-Milburn, K.C, Wills, W.J, Gregory, S, Lawton, J, (2006), Making sense of
­eating, weight and risk in the early teenage years: Views and concerns of parents in
poorer socio-economic circumstances, Social Science & Medicine 63 (2006) 624–635.
Bancroft, A, Wiltshire, S, Parry, O, Amos, A, (2002), ‘“It’s like an addiction first
thing . . . afterwards it’s like a habit”’: daily smoking behaviour among people living in
areas of deprivation, Social Science & Medicine 56 (2003) 1261–1267.
Devine, C.M, Jastran, M, Jabs, J, Wethington, E, Farell, T.J, Bisogni, C.A, (2006),
‘ “A lot of sacrifices:”’ Work–family spillover and the food choice coping strategies of
low-wage employed parents, Social Science & Medicine 63 (2006) 2591–2603.
Ritchie, D, Amos, A, Martin, C, (2009), Public places after smoke-free—A qualitative
­exploration of the changes in smoking behaviour, Health & Place 16 (2010)
461–469.
Robinson, J, Kirkcaldy, A.J, (2007) ‘You think that I’m smoking and they’re not’: Why
mothers still smoke in the home, Social Science & Medicine 65 (2007) 641–652.
Robinson, J, Ritchie, D, Amos, A, Cunningham-Burley, S, Greaves, L, Martin, C,
(2010), ‘Waiting until they got home’: Gender, smoking and tobacco exposure in house-
holds in Scotland, Social Science & Medicine 71 (2010) 884–890.
226 Knowledge of the everyday

Box 16.1  Key references identified in recent review of qualitative research on

health inequalities (not all referenced in text) (continued)

Place and health

Airey, L, (2003), ‘“Nae as nice a scheme as it used to be”’: lay accounts of neighbourhood
incivilities and well-being, Health & Place 9 (2003) 129–137.
Bolam, B, Murphy, S, Gleeson, K, (2006) Place-identity and geographical inequalities in
health: A qualitative study, Psychology & Health, 21: 3, 399–420.
Bush, J, Moffatt, S, Dunn, C, (2000), `Even the birds round here cough’: stigma, air pol-
lution and health in Teesside, Health & Place 7 (2001) 47–56.
Bustos Castro, P, Lindbladh, E, (2003), Place, discourse and vulnerability—a qualitative
study of young adults living in a Swedish urban poverty zone, Health & Place 10 (2004)
259–272.
Dutta, M.J, and Dutta, U, (2012), Voices of the Poor From the Margins of Bengal: Struc-
tural Inequities and Health, Qualitative Health Research 23(1) 14–25.
Keene, D.E, Padilla, M.B, (2010), Race, class and the stigma of place: Moving to ‘“oppor-
tunity”’ in Eastern Iowa, Health & Place 16 (2010) 1216–1223.
Kelaher, M, Warr, D.J, Feldman, P, Tacticos, T, (2009), Living in ‘Birdsville’: Exploring
the impact of neighbourhood stigma on health, Health & Place 16 (2010) 381–388.
Pearce, J, (2012), The ‘blemish of place’: Stigma, geography and health inequalities. A com-
mentary on Tabuchi, Fukuhara & Iso, Social Science & Medicine 75 (2012) 1921–1924.
Ruston, A, (2009), Isolation: A threat and means of spatial control. Living with risk in a
deprived neighbourhood, Health, Risk & Society, 11:3, 257–268.
Smith, S.J, Easterlow, D, (2004) The strange geography of health inequalities, Trans Inst
Br Geogr NS 30 173–190 2005
Stead, M, MacAskilla, S, MacKintosh, A-M, Jane Reece, J, Eadie, D, (2001), ‘“It’s as if
you’re locked in”’: qualitative explanations for area effects on smoking in disadvan-
taged communities, Health & Place 7 (2001) 333–343.
Warr, D.J, Tacticos. T, Kelaherb, M, Klein, H, (2006) ‘Money, stress, jobs’: Residents’
perceptions of health-impairing factors in ‘poor’ neighbourhoods, Health & Place 13
(2007) 743–756.

Specific group experiences of disadvantage

Graham, H, McDermott, E, (2006). Qualitative Research and the Evidence Base of Pol-
icy: Insights from Studies of Teenage Mothers in the UK. Journal of Social Policy, 35,
pp 21–37.
Hodgins, M, Millar, M, Barry, M.M, (2005) ‘“it’s all the same no matter how much fruit
or vegetables or fresh air we get”’: Traveller women’s perceptions of illness causation
and health inequalities, Social Science & Medicine 62 (2006) 1978–1990.
Laliberté, A, Haswell, M, and Tsey, K, (2012), Promoting the health of Aboriginal Aus-
tralians through empowerment: eliciting the components of the Family well-being em-
powerment and leadership programme, Global Health Promotion 2012 19: 29.
McManus, V, Abel, S, McCreanor, T, Tipene-Leach, D, (2010), Narratives of depriv-
ation: Women’s life stories around Maori sudden infant death syndrome, Social Sci-
ence and Medicine 71 (2010), 643–649.
 UNDERSTANDING THROUGH EVERYDAY LIFE 227

Box 16.1  Key references identified in recent review of qualitative research on

health inequalities (not all referenced in text) (continued)

Class identity and health inequalities

Bolam, B, Murphy, S, Gleeson, K, 2004, Individualisation and inequalities in health: a
qualitative study of class identity and health, Social Science & Medicine 59 (2004)
1355–1365.

Ethnographic study of policymaking in Whitehall

Qureshi, K, (2013) It’s not just pills and potions? Depoliticising health inequalities policy
in England, Anthropology & Medicine, 20: 1, 1–12.
Smith, K. (2007) Health inequalities in Scotland and England: The contrasting journey
of ideas from research into policy. Social Science and Medicine 64 1438–1449.

Book
Brown, P (2007) Toxic Exposure: Contested Illnesses and the Environmental Health
Movement, Columbia University Press, New York

This small sample suggests that, while studies of specific behaviours, notably
smoking and diet, remain prominent (seven papers), the direct experience of
social inequalities is a more explicit focus of recent qualitative research. There
were 12 papers reporting on studies of the experience of health inequalities in
disadvantaged places, four focused on the experience of inequality and disad-
vantage amongst specific groups, and five focused on lay people’s understand-
ing of health inequalities and their causes. Most studies were conducted in the
UK, but there were also papers from Sweden, Australia, New Zealand, the USA,
and Bangladesh, and a systematic review of qualitative research on teenage
mothers’ experiences.
These studies reveal the interconnectedness of ‘knowledgeable narratives’. As
people talk of the everyday, they weave accounts of personal experience and
biography with the material, social, normative, and ‘macro’-political processes
generating inequalities. They also reveal the salience of social context for under-
standing individual agency. What some professionals and/or researchers see as
fatalism or a low locus of control are revealed as realistic assessments of the
limited opportunities people have to control their lives. This is illustrated by a
quote drawn from a recent study of social cohesion in South Wales (Elliott et al
2011) from a young man who tries to describe his struggle to develop skills and
find employment:
I’m only 21. I shouldn’t really be going through what I’ve gone through and I
should, I should be out there having a life really, like, do you know what I mean . . .
228 Knowledge of the everyday

like, it’s like I always wanted to go college, I always wanted to go university. I had a
good head on me in school like, do you know what I mean but now I’ve been out of
school five, six years and haven’t had no . . . do you know what I mean, it’s like I’m
losing it sort of thing. I can read, write but it’s just you lose; you’ll end up losing it.
Reproduced from Elliott, E. Burgess, S. Fone, D. Williams, G. and Lynch, R,
Neighbourhood, social deprivation and mental health: the mediating role
of social cohesion. Ref: ReF06/2/229, © 2011, Wales Office of Research
and Development for Health and Social Care.

Embedded in this quote is a fundamental challenge for all research—that for

some people the experience of inequality may be an ‘apophatic’ reality (Robin-
son 2012)—a reality that eludes words. Perhaps because of the depth of concern
and the strength of emotions—sadness, anger, anxiety—people sometimes find
it difficult to express what they feel and/or say what they think. As Sayer puts it,
‘We know so much more than we can tell’ (2011, p. 74). This young man’s use of
repeated refrains is more than a personal habit or linguistic tic. It is filling the
gaps of the unsayable because what is happening is just too big, too important
to place within a wider framework of meaning. It is a way of trying to get us to
understand what it was, with all the contradictions of despair and hope within
the interview, that made life difficult in the here and now and in imagining a
future which he could control and create. In making this attempt at understand-
ing, our respondent is reminding us of the importance of what Levitas (2013,
p. 4), following the playwright Dennis Potter, refers to as ‘looking for the blue’,
looking to the future in a way that may start with an existential quest but move
into ‘imagining transformation’ through art or music or other forms of co-
operative activity that may enable the communal or collective reworking of in-
stitutions and practices (Unger 2004). Needless to say, for many this is not
possible under present conditions of neoliberalism (see Chapters 9 and 17), and
like our respondent, they struggle to articulate any sense of a meaningful
future.
Qualitative research can also reveal the strategies people develop to cope with
or control the experiences and exposures that threaten them. The decision-
making processes informing these strategies are shaped by unequal access to
material resources, cultural norms, and social relationships of power and con-
trol. They involve complex risk assessments: mothers leaving children un-
attended rather than risking carrying them and baskets down flights of stairs to
hang out washing (Roberts 1993); smoking to maintain social relationships
with peers (Stead et al 2001); or not breast feeding because it disrupts everyday
activities and increases the risk of social exclusion (Stewart-Knox et al 2003).
Central to many of these coping strategies is the purposeful development
and/or maintenance of valued social identities in situations that threaten to
 UNDERSTANDING THROUGH EVERYDAY LIFE 229

undermine moral worth. For example, Graham and McDermott (2006) argued
that their synthesis of multiple qualitative studies demonstrated how teenagers
with children pursued resilient mothering practices as a pathway into a valued
adult identity in the face of significant constraints imposed by material disad-
vantage and social stigma.
The pursuit of socially valued identities also emerges as a key factor in studies
of how people manage lives in stigmatized places. In the early 1990s qualitative
research in Glasgow (MacIntyre et al 2002) highlighted how the influence of
neighbourhood reputation on people’s self-esteem was linked to the extent to
which people identified with the places in which they lived. Our own research
in the mid-1990s (Popay et al 2003a) similarly found that a positive identity
with place operated as an ontological resource, helping protect people from
some of the negative impacts of living in difficult places. More recent research
has elaborated these processes. For example, Airey (2003, p. 135) argues that
women living in a low-income neighbourhood in Scotland constructed spatial
hierarchies which emphasized moral boundaries between themselves and
‘problematic others’ in an active attempt ‘to protect their personal identities
from the stigma associated with the social environment in Kirkhead’. For em-
pathetic qualitative researchers this recognition of stigma can be a double bind,
as acknowledging the impact of deprivation, disadvantage, and exclusion is po-
tentially to reinforce an identity that people may be trying to resist (see
Chapter 6).
The small but growing body of qualitative research into lay perceptions about
the causes of health inequalities reveals an apparent disagreement, with some
studies reporting that disadvantaged people are less likely to point to wider
structural causes (Putland et al 2010) and others which find no such reluctance
(Davidson et al 2006; Hodgetts and Chamberlain 2000; Popay et al 2003b).
Whilst part of the explanation for these divergent findings may be methodo-
logical, they also signal more profound processes. As Popay et al (2003b) dem-
onstrate, people living in disadvantaged circumstances appear to acknowledge
the differential impact of social and economic circumstances on health. How-
ever, at the same time, they stress the importance of individual strength of char-
acter as a mechanism to overcome these impacts, so resisting the moral
judgements implied by the dominant lifestyle discourse. Bolam’s study of class
identity and explanations for health inequalities throws more light on this issue.
Resistance to class explanations was more common amongst Bolam’s working-
class respondents and acceptance was more common amongst middle-class re-
spondents. However, while all participants recognized and mobilized both
types of explanations, the key difference was the use to which different explan-
ations were put: ‘class talk could be mobilised when speaking about the health
230 Knowledge of the everyday

of others, as opposed to self; and when considering health as a socio-political

issue’ (Bolam et al 2004, p. 1362).
Qualitative research also highlights fault lines between lay and professional
understandings of health inequalities. For example, whilst lay accounts of
health and illness are grounded in personal experience, biography and material,
social and cultural context, professionals (and many researchers) tend to frag-
ment experiences, looking at specific behaviours out of context or, more re-
cently, clusters of (bad) behaviours in individuals over time (Buck and Frosini
2012). Additionally, lay people and professionals may share ‘values’ but inter-
pret the implications for action differently. For instance, Roberts et al (1993)
reported a shared acceptance of parental responsibility for keeping children
safe by mothers and professionals, but while professionals emphasized their
educational role, parents emphasized the responsibility for child safety of a
range of institutions and people, including local authorities and private-sector
building firms. More recently, Graham and McDermott (2006) have argued
that the acceptance of the middle-class linear trajectory to adulthood, via edu-
cation and employment, as the norm makes it difficult for professionals to see
the positive values and identities affirmed through teenage motherhood: for
teenagers with children ‘it emerges as an act of social inclusion’ (p. 21), while
professionals construct it as a pathway to social exclusion and life-long
disadvantage.

16.3  Towards a theory of transformative action

As Sayer has argued, too much sociology, and social science more generally,
‘tends to produce bland accounts of social life, in which it is difficult to assess
the import of things for people’ (2011, p. 6). We have argued that qualitative re-
search can provide an understanding of these private troubles as public issues,
in the way C. Wright Mills suggested ought to be the hallmark of the ‘socio-
logical imagination’ (1970; see also Burawoy 2005 on ‘public sociology’). Ad-
ditionally, these understandings remind us that health inequalities are also
matters of ethical and political concern that require action. Yet most health in-
equalities research, regardless of the methodological paradigm, falls short of
developing a theory of transformative action. Theories based on social capital,
social cohesion, resilience, community assets, etc. are prominent influences on
contemporary public health research, policy, and practice (see Chapter  15).
However, though they may be useful for describing the way things are, and sug-
gest interventions that help people weather the continual assaults on their emo-
tional and material resources (see Chapter 17), they offer limited insight into
how to overcome the threats themselves.
 Towards a theory of transformative action 231

Theories used to support ideas about transformation require critical atten-

tion to the sources of, and control over, the transformatory powers that are
being evoked. A recent review of theories, concepts, and interventions relating
to community-level strengths and their impact on health and well-being con-
firm that, whilst there is a wealth of concepts that describe different ways of
understanding ‘communities’, and theories that could explain the production of
social benefits, these are often portrayed relatively narrowly and uncritically
(Elliott et al 2011). Furthermore, changing relationships between citizens and
the State also shape the ways in which ideas such as resilience, social capital, and
co-production are interpreted and used by different interest groups and at dif-
ferent historical moments in government policy (see Chapter 15). It could be
argued they have become symbolic prizes for social justice in a battle for polit-
ical ownership.
Perhaps as a consequence, and despite the rise in popularity of community
concepts in public health, the quality of evaluations of community-oriented
interventions and perhaps the interventions themselves is often poor. The
term ‘transformation’ is often used to suggest a dramatic change in personal or
collective capacities, powers, or resources. However, the changes described
might better be understood as affirmative: the benefits generally relate to the
personal rewards of social support or friendship. These changes may be trans-
formative for the individuals themselves, but the types of transformation
claimed in some community interventions refer to the acquisition of social or
political power. Most interventions considered in the recent review (Elliott et
al 2011) fell far short of this and no interventions suggested a transformation
of collective powers. This highlights the need for more research into how com-
munities can best mobilize internal and external resources to achieve the so-
cial, economic, and political transformations required to reduce health
inequalities.
The literature on the concept of control may contribute to a theory of action
for health inequalities. Control is usually conceptualized at the individual level
(especially in social psychology—e.g. Siegrist 1996). In contrast, the concept of
cultural continuity, which Chandler and Lalonde (1998, 2009) have used to ex-
plain differential rates of suicide in British Columbia’s First Nations groups, is
operationalized in terms of measures of collective control over ‘civic lives’. In the
First Nations context, this includes: securing ownership of traditional lands;
community control over educational services, police and fire protection ser-
vices, and health care; having dedicated ‘cultural facilities’ to preserve and en-
rich cultural lives; women’s participation in local governance; community
control over child custody and child protection services; and reductions in the
proportion of children removed from parental care.
232 Knowledge of the everyday

The ability of Canada’s First Nations to have collective control over their des-
tiny has been undermined by colonial forces, including ‘unrestrained capital-
ism’ (to return to our opening theme). Similar forces are vividly described in
Kai Erikson’s research on the 1972 Buffalo Creek disaster in the Appalachian
Mountains (where the collapse of a poorly maintained dam killed 123 people,
injured 1,000, and left 4,000 homeless). Erikson argued that the disaster caused
collective trauma, telling the reader that the fear, apathy, and demoralization
one encounters along the entire length of the hollow are derived from the shock
of being ripped out of a meaningful community setting, as well as the shock of
meeting that cruel black water. Erikson goes on to link the scale of this trauma
to wider political and economic forces, explaining that whatever one knows
about economic theory, wherever one stands on matters of political ideology,
one still must conclude that the men and women of Appalachia are among the
most truly exploited people to be found anywhere. In the beginning, they had
rights to good land. In the course of a few decades, however, dating from the last
years of the nineteenth century, almost all of those valuable resources were cut
or scraped or gouged away.
This analysis would not be lost on the people of Aberfan in south Wales as
they approach, in 2016, the fiftieth anniversary of their collective trauma; a
trauma caused not only by the death of 144 children and their teachers at Pant
Glas Primary School when a coal tip collapsed, but also by the callous self-­
interest of key members of the power élite and the abject failure of all the organ-
izations that should have protected the public interest both before and after the
disaster (McLean and Johnes 2000).
These arguments are also relevant to the more recent experience of disadvan-
taged places and people around the world. As the authors of the ‘Kilburn Mani-
festo’ argue:
It is the reassertion of the powers of capital that has produced the neoliberal world as
we know it today . . . The widening of inequalities is the main launch-pad of this restor-
ation bid . . . Countervailing values—equality, democracy and citizenship—have been
circumvented, and dissenting social forces fragmented and dispersed. (Hall et al 2013)

Emerging work by the New Economics Foundation (NEF) opening up a discus-

sion of ‘solidarity’ may be useful in articulating a theory of change that reinte-
grates the social forces that neoliberal policies have fragmented and dispersed.
The authors of the NEF discussion paper (Coote and Angel 2014) argue that,
unlike concepts such as social capital and social cohesion, which are about ‘the
glue’ that holds people together (or not), ‘solidarity’ concerns ‘momentum’ and
the conditions for change. It both locates the sources of transformative action in
civil society and recognizes that moments for change arise from popular under-
standing of the structures and processes that reproduce inequalities.
 THE BATTLE BETWEEN EVIDENCE AND MEANING 233

Qualitative research has revealed how the strategies people develop to man-
age their lives in difficult places, their individual agency, can undermine their
capacity to develop collective control or solidarity. In our own work in the
north-west of England, for example, we argue that one response to the social
and economic inequalities generated by deindustrialization is an increasing
privatization of everyday life and a withdrawal from the public sphere (Popay et
al 2003a). Similarly, Rushton (2008) reported that, in response to the dangers
they perceived around them (which resulted in feelings of physical and social
isolation threatening their well-being), people living in low-income neighbour-
hoods in London resorted to distancing strategies of avoidance, surveillance,
and fortification, further reinforcing their isolation (see also Bustos Castro et al
2004 on similar findings in a Swedish context). As Airey (2003, p. 267) con-
cludes, ‘not only are risks experienced individually but also the ways in which
residents of deprived areas identified, managed and live with risk suggest that
collective partnership approaches will have limited success’.
We have argued elsewhere (Popay et al 2003a) that shared narratives and
meanings, and respect based on mutual understanding, are prerequisites for
collective action for change. More inclusive knowledge spaces (Elliott and Wil-
liams 2008) can support the development of such shared narratives through
dialogue and debate. These spaces are not characterized by a dichotomy be-
tween lay and scientific, but rather explore the fissures and overlaps between
forms of knowledge conventionally understood as scientific, experiential, pro-
fessional, regulatory, and political. Such debates have the potential to generate
new collective intelligence to inform policy and practice. Health inequalities
researchers can play a facilitative role in these processes, helping to reduce in-
equalities between diverse forms of knowledge to enable alternative under-
standings of the issues and appropriate actions to address them to emerge (see
suggestions in Chapter 17).

16.4  Conclusion: The battle between evidence

and meaning
The battlefield between evidence and meaning is reflected in what Armstrong
(2001), amongst others, has said about the separation of two ways of under-
standing the world: ‘mythos’ and ‘logos’. Logos concerns the rational world—
how we might understand how the world works, how we solve problems and
grasp causal processes. It is mundane and concerns both logical argument and
the accumulation of facts. Mythos, on the other hand, is concerned with mean-
ing: it is what gives life its telos or purpose. It is often expressed in different
forms, through metaphor, poetry, or visual arts: resources commonly used to
234 Knowledge of the everyday

express the emotional life and our relationships to others (Richards 2011). The
point is not that one ‘way of knowing’ is better than the other, but rather that
knowledge itself has become impoverished through this separation, often un-
wittingly, because of the narrow disciplinary confines in which people work and
their assumption that their expertise marks them out as separate from the
everyday.
Qualitative data are important therefore, because they give us access to what
might be going on, causally speaking, inside the ‘black box’ of social epidemiol-
ogy’s models of the determinants of health inequalities. More than this, they
open up understanding of what Sayer (2011) has termed ‘lay normativity’: what
things mean to people and what matters to them, what concerns them, what
drives them to act (or not) in the situations they are in.
Much research on health inequalities deals with individuals, aggregated and
disaggregated, framed and discussed in ways that lose all sense of the particu-
lars of their situation and the knowledge they develop to deal with their experi-
ences. The earlier discussion of key themes in qualitative research on health
inequalities illustrates that these are particulars from which we can make theor-
etical connections to more general structures and processes. It is also in these
particulars that people may have the opportunity to move from the given facts
of inequality to generating mechanisms for personal and collective change,
through new forms of solidarity.
Health researchers have recently begun to think of more creative ways in
which to engage with and represent the experiences of people and communities
by, for example, working more closely with people in the arts and humanities.
These kinds of initiatives are asking us to think more creatively about what cul-
tural representations of inequality might look like, beyond the graph and the
quote. They are not easy to pursue in the face of the overwhelming scientific,
‘scientistic’, evidence-based self-image of the age (see Chapter 6), but they do
suggest ways in which health inequalities research might be carried out so as to
do justice to the knowledge and concerns of local publics (Burawoy 2005).
Evidence-based policy really does descend into policy-based evidence unless
it engages with politics. It is Navarro’s view that ‘[t]here is a deliberate policy to
avoid “politics” in public health circles’ (2011, p. 313). Politics arise from the
relationship between structure and agency within particular contexts, shaped
by large economic and social forces (see Chapters 9 and 13). Working inside the
fabric of everyday life can reveal the effects of these processes more clearly, illu-
minating the limits of behaviour change and demonstrating the knowledge and
concern about the texture of everyday life. This surely offers the hope of health
inequalities research with a stronger connection to, and relevance for, broader
social and political action in a relentlessly unequal, unjust society.
 THE BATTLE BETWEEN EVIDENCE AND MEANING 235

References
Armstrong, K. (2001) The Battle for God: Fundamentalism in Judaism, Christianity and
Islam. London: Harper Collins.
Berlin, I. (1969) Four Essays on Liberty. Oxford: Oxford University Press.
Bolam, B., Murphy, S., and Gleeson, K. (2004) Individualisation and inequalities in health:
A qualitative study of class identity and health. Social Science and Medicine, 59:
1355–1365.
Bourdieu, P. (ed.) (1999) The Weight of the World: Social Suffering in Contemporary Society.
Cambridge: Polity Press.
Buck, D., and Frosini, F. (2012) Clustering of Unhealthy Behaviours Over Time: Implica-
tions for Policy and Practice. London: King’s Fund.
Burawoy, M. (2005) 2004 American Sociological Association presidential address: For pub-
lic sociology. The British Journal of Sociology, 56(2): 259–294.
Chandler, M. J., and Lalonde, C. E. (1998) Cultural continuity as a hedge against suicide in
Canada’s First Nations. Transcultural Psychiatry, 35(2): 191–219.
Chandler, M., and Lalonde, E. (2009) Cultural continuity as a moderator of suicide risk
among Canada’s First Nations. In L. Kirmayer and G. Valaskakis (eds), The Mental
Health of Canadian Aboriginal Peoples: Transformations, Identity, and Community. Van-
couver: University of British Columbia Press, pp. 221–247.
Coote, A., and Angel, J. (2014) Social Solidarity: Why it Matters for a New Social Settlement.
New Economics Foundation. http://b.3cdn.net/nefoundation/207c255d8a0c04cba0_
sum6b1yy7.pdf
Davidson, R., Kitzinger, J., and Hunt, K. (2006) The wealthy get healthy, the poor get
poorly? Lay perceptions of health inequalities. Social Science and Medicine, 62(2006):
2171–2182.
Dorling, D. (2011) So You Think You Know about Britain? London: Constable.
Dorling, D., and Thomas B. (2011) Bankrupt Britain: A Post-recession Atlas. Bristol: Policy
Press.
Elliott, E., Byrne, E., Shirani, F., Gong, Y., Henwood, K., Morgan, H., Shepherd, M.,
Palmer, S., and Williams, G. (2011) A review of theories, concepts and interventions re-
lating to community-level strengths and their impact on health and well-being, Arts and
Humanities Research Council, https://policynutshell.files.wordpress.com/2011/12/a-
review-of-theories-concepts-and-interventions.pdf
Elliott, E., Burgess, S., Fone, D., Williams, G., and Lynch, R. (2011) Neighbourhood, Social
Deprivation and Mental Health: The Mediating Role of Social Cohesion. Ref: ReF06/2/229.
Cardiff: Wales Office of Research and Development for Health and Social Care.
Elliott, E., and Williams G. H. (2008) Developing public sociology through health impact
assessment. Sociology of Health and Illness, 30(7): 1101–1116.
Erikson, K. (1976) Everything In its Path: Destruction of Buffalo Creek. New York: Simon
and Schuster.
Hall, S., Massey, D., and Rustin, M. (2013) After neoliberalism: the Kilburn Manifesto,
http://www.lwbooks.co.uk/journals/soundings/manifesto.html.
Hodgetts, D. J., and Chamberlain, K. (2000) The social negotiation of people’s views on the
causes of illness. Journal of Health Psychology, 5(3): 325–336.
236 Knowledge of the everyday

Levitas, R. (2013) Utopia as Method: The Imaginary Reconstitution of Society. Basingstoke:

Palgrave Macmillan.
Macintyre, S., Ellaway, A., and Cummins, S., (2002) Place effects on health: How do we
conceptualise, operationalise and measure them? Social Science and Medicine, 55 (1):
125–139.
McLean, I., and Johnes, M. (2000) Aberfan: Government and Disasters. Cardiff: Welsh Aca-
demic Press.
Mills, C. W. (1970) The Sociological Imagination. Harmondsworth: Penguin.
Navarro, V. (2011) The importance of politics in policy. Australian and New Zealand Jour-
nal of Public Health, 35(4): 313.
Popay, J., Whitehead, M., and Hunter, D. (2010) Injustice is killing people on a large
scale—but what is to be done about it? Journal of Public Health, 32(2): 148–149. doi:
10.1093/pubmed/fdq029.
Popay, J., Bennett, S., Thomas, C., Williams, G., Gatrell, A., and Bostock, L. (2003b)
­Beyond beer, fags, egg and chips? Exploring lay understandings of social inequalities in
health. Sociology of Health and Illness, 25(1): 1–23.
Popay, J., Thomas, C., Williams, G., Bennett, S., Gatrell, A., and Bostock, L. (2003a)
A proper place to live: Health inequalities, agency and the normative dimensions of
space. Social Science and Medicine, 57(1): 55–69.
Popay, J., and Williams, G. (2009) Equalizing the people’s health: A sociological perspec-
tive. In J. Gabe and M. Calnan (eds), The New Sociology of the Health Service: Sociological
Perspectives on Health Policy and Health Care, Sociology of Health and Illness Monograph.
London: Routledge, pp. 222–243.
Popay, J. Williams, G. Thomas, C, Gatrell, A. (1998) Theorising Inequalities in Health: The
Place of Lay Knowledge. Sociology of Health & Illness, 20(5) 619–644.
Putland, C., Baum, F. E, and Ziersch, A. M. (2011) From causes to solutions—insights
from lay knowledge about health inequalities. BMC Public Health, 11: 67.
Richards, G. (2011) Psychology, Religion and the Nature of the Soul: A Historical Entangle-
ment. New York: Springer
Robinson, M. (2012) When I Was a Child I Read Books. London: Virago.
Roberts, H., Smith, S., and Bryce, C. (1993) Prevention is better . . . Sociology of Health and
Illness, 15(4): 447–463.
Rogers, A., Popay, J., Williams, G., and Latham, M. (1997) Health Inequalities and Health
Promotion: Insights from the Qualitative Literature. London: Health Education
Authority.
Sayer, A. (2011) Why Things Matter to People: Social Sciences, Values and Ethical Life.
­Cambridge: Cambridge University Press.
Schutz, A. (1972) The Phenomenology of the Social World. Evanston: Northwestern Univer-
sity Press.
Sennett, R., and Cobb, J. (1973) The Hidden Injuries of Class. New York: Vintage.
Siegrist, J. (1996) Adverse health effects of high-effort/low-reward conditions. Journal of
Occupational Health Psychology, 1(1): 27–41.
Stead, M., MacAskilla, S., MacKintosh, A.-M., Jane Reece, J., and Eadie, D. (2001)‘It’s as if
you’re locked in’: Qualitative explanations for area effects on smoking in disadvantaged
communities. Health and Place, 7(4): (2001): 333–343.
 THE BATTLE BETWEEN EVIDENCE AND MEANING 237

Stewart-Knox, B., Gardiner, K., and Wright, M. (2003) What is the problem with breast-
feeding?: A qualitative analysis of infant feeding perceptions. Journal of Human Nutrition
and Dietetics, 16(4): 265–273.
Trahair, E. (2014) Editorial. Planet: The Welsh Internationalist, 213(Spring): 6–9.
Unger, R. (2004) False Necessity: Anti-Necessitarian Social Theory in the Service of Radical
Democracy. London: Verso.
Veenstra, G. (2006) Neo-Marxist class position and socio-economic status: Distinct or
complementary determinants of health. Critical Public Health, 16 (2): 111–129.
Whitehead, M., and Popay, J. (2010) Swimming upstream? Taking action on the social de-
terminants of health inequalities. Social Science and Medicine, 71(7): 1234–1236.
Wilkinson, R., and Pickett, K. (2010) The Spirit Level: Why Equality is Better for Everyone.
London: Penguin.
Williams, G. (2000) Knowledgeable narratives. Anthropology and Medicine, 7 (1): 135–140.
 Chapter 17

Socio-structural violence against

the poor
Jane Jones and Cathy McCormack

17.1  Introduction: The view from community activism

The two authors approach this chapter from the critical perspective of commu-
nity activism and popular education, with which they have been involved at
local, national, and international level. For over 30 years they have worked in
community campaigns addressing the social, environmental, psychological,
and political determinants of health inequalities. The chapter is also informed
by their working relationships, both fruitful and contentious, with researchers,
health professionals, politicians, policymakers, and voluntary sector organiza-
tions, at local and national levels.
What we have experienced and witnessed through our work is the misery
consequent on what are referred to as ‘health inequalities’. We have come to
understand how deeply these ‘inequalities’ are embedded in the way society
functions: in economic policy, in health policy, and in the ways in which profes-
sionals understand and construe their roles.
Moreover, the ways in which language is used to describe and analyse these in-
equalities and the people who suffer them play a profound part in creating and
maintaining them. While the language used in the media and in political discourse
ranges from the sober to the virulent—the virulence being directed against those
who suffer most—the language of research is nearly always dispassionate (see
Chapters 6 and 20 for reflections on this tension from researchers’ perspectives).
This tends to efface the reality of the lived experience (see also Chapter 16).
In this chapter, we try to communicate some of that experience. Much of the
language we use, and the analysis we present, speaks explicitly of violence
against the poor. By violence, we mean the knowing and deliberate inflicting of
harm. It is beyond doubt that harm is being inflicted, and that it is consequent
on economic and social policies pursued in the full knowledge that such harm
will result. It may not be the primary purpose of the policies, but collateral dam-
age is no less violent for those affected. Furthermore, the rhetoric used to justify
 Socio-structural violence 239

policy seeks to turn the victims into being responsible for their own injury, pre-
paring the ground for further punitive policies; and the violence then becomes
more explicitly targeted. This is a ‘war without bullets’ against ­working-class
people (Fryer and McCormack 2012). The chapter will examine the concept of
socio-structural violence, drawing from our experience in the 1980s as a tenant
activist and as a community development worker involved in the housing and
health campaigns in Easthall, Glasgow and Pilton, Edinburgh. We will conclude
by discussing the implications of this for inequalities and health research. Spe-
cific personal contributions will be indicated in the text.

17.2  Socio-structural violence

The term ‘socio-structural violence’ captures the systematic ways in which so-
cial, political, economic, and cultural practices combine to cause early and
avoidable death, harm, disadvantage, fear, insecurity, and marginality for par-
ticular groups of people. Some authors have broadened the concept to include
that which violates basic needs, rights, and the individual’s intrinsic dignity as,
for instance, enumerated in the United Nations Universal Declaration of
Human Rights of 1948 (Fryer and McCormack 2012; Galtung 1990).
The more visible aspects of socio-structural violence are to be found embed-
ded in the economic and social policies pursued by the UK government. The
rejection of the Black Report recommendations in the 1980s, such as increasing
the maternity grant and child benefit as a means to reduce inequalities in health,
signalled the start of a harsher, uncompromising government who were deter-
mined to cut public expenditure (see Chapters 1 and 2). In a defining moment,
seven years later, Margaret Thatcher deregulated the City of London in an en-
thusiastic embrace of neoliberalism: ‘it was, in every sense a revolution. It was
messy and there was blood all over the place. Unlike most revolutions, it was
imposed top down’ (Agius 2011).
The tsunami of neoliberalism that began to wreck working-class communities
was even more messy and cruel (see also Chapter 9). It was clear that integral to
the policies that began to flow from this government was a blatant disregard for
the suffering of the poorest section of society. It was our first realization that in
order to fulfil her government’s election pledges to reduce taxation, Thatcher
was going to be snatching more than milk from children (the policy described as
‘the meanest and most unworthy thing he had seen in twenty years in parlia-
ment’, by Edward Short, the Labour education spokesman at the time).
Instead of examining the root causes of health inequality, the increasing em-
phasis on individual behaviour and personal responsibility shifted the public
discourse around social and economic conditions.
240 Socio-structural violence against the poor

17.3  Housing
In the 1970s, Greater Easterhouse in Glasgow, which included the community
of Easthall, had a population of 70,000. It was the largest public post-war hous-
ing scheme in Europe, built as ‘houses for heroes’, ironically, to accommodate
the massive slum clearance of the inner city, and thereby to address Glasgow’s
appalling health record. By the 1980s this social housing was in a poor state. The
substandard structures created massive issues of internal dampness and high
heating costs for tenants.
Cathy: ‘I became really depressed because no matter how much I loved my children or
tried to take care of them, I could neither keep the doctor at bay, or the fungus that was
destroying everything that it came into contact with . . . I was continually having to
throw out mouldy furniture, clothes, and toys and found myself having to choose be-
tween feeding my hungry children or hungry fuel meters which kept demanding more
and more money. My doctor offered me a course of anti-depressants and it occurred to
me that he was only employed to treat the symptoms of our health problems in the same
way as our landlord . . . I asked him for a prescription for a warm, dry home and he
laughed. I refused the tablets and I joined the city wide anti-dampness campaign
instead.’

The same picture was evident in Pilton, Edinburgh. Tenants complaining to the
housing department of the Council were told that the cause of the dampness
was a result of boiling too many kettles and hanging up wet washing. The official
view implied that their poor health was a result of eating too many fish suppers
and not taking enough exercise.
We complained to the housing department and people would come down and
­say—well you’ve got to keep the house warm . . . but that was quite difficult because
there wasn’t any heating in the rooms . . . and the cost of running a fire, if there had
been space, [was too high]. You just felt caught in a trap and there was nothing you
could do . . . my daughter was prone to coughs and colds and she ended up getting
pneumonia.
Reproduced from J. Jones, Private Troubles and Public Issues—a community
development approach to health © 1999 Community Learning Scotland.
Used with permission under the Open Government Licence v3.0 (http://www.
nationalarchives.gov.uk/doc/open-government-licence/version/3/)

17.4  Unemployment
Housing was not the only battleground. On the broader front, neoliberal ortho-
doxy became increasingly influential (see Chapter 9). Unemployment became
acceptable as a deliberate tool of the market economy, breaking from the post-
war consensus that it was ‘a scourge’ and should be minimized through govern-
ment intervention. As unemployment rose to 3 million across the UK in the
 Unemployment 241

1990s, it became clear that there would be no intervention to soften the impact
of this on people’s lives: ‘rising unemployment and the recession have been the
price that we have had to pay to get inflation down. That price is well worth pay-
ing’ (Norman Lamont, Chancellor of the Exchequer (1991).
The ‘acceptable price’ that was, apparently, ‘well worth paying’ was the dam-
aging health and social effects of unemployment on individuals, their families,
and communities—well documented by research (Fryer 1995; Platt 1984,
1986). The thinking behind the government’s education and economic policies
was exemplified by the Chancellor of the Exchequer, Nigel Lawson, in a speech
to the IMF in Washington in 1984 when he warned Britain’s workforce that
many of the jobs of the future would not be ‘high-tech’ or even ‘low-tech’, but
‘no-tech’. The move towards a low-wage, no-wage economy had begun—with
deliberate policies to ensure that profits would rise faster than wages.
The last coalition and current Tory governments’ welfare cuts and ‘austerity’
programme is targeted at the poor, those who experience disabilities, and all
their families, in preference to reducing the income/wealth of the richest
groups. In England, people in poverty (21% of the population) have borne 39%
of all cuts, disabled people (8% of the population) 29%, and people with the se-
verest disabilities (2% of the whole population) 15% (Duffy 2013).
Work ‘capability assessments’, carried out on those on incapacity benefit by
the multinational private corporation Atos on behalf of the Department for
Work and Pensions, have been subject to allegations of harm and distress. Criti-
cism has come from leading clergy, disability organizations, and claimants. Mi-
chael Meacher, Labour MP, opening a debate in the House of Commons asked
how the insensitive rigour with which 1.6 million claimants on incapacity bene-
fit were being assessed by Atos could be justified when ‘it has led, according to
the Government’s own figures, to 1,300 persons dying after being put into the
work-related activity group, 2,200 people dying before their assessment is com-
plete, and 7,100 people dying after being put into the support group?’
(Meacher 2013).
Drawing from international and historical data, Stuckler and Basu (2013)
conclude that the decisions governments make during financial crises have a
critical impact on the poor when policy can become a matter of life and death.
Examining case studies from the 1930s Depression in the USA, to Russia and
Indonesia in the 1990s, to present-day Greece, Britain, Spain, and the USA, they
show how different policies produce vastly different consequences for the popu-
lation. For example, during the Great Depression in the 1930s, deaths actually
plummeted in the USA due to interventions like the New Deal. In recent times,
Iceland’s decision not to cripple their welfare state by bailing out private banks,
but instead to put money into their social health care systems and increase social
242 Socio-structural violence against the poor

welfare payments to its poorest citizens, has resulted in a healthy economy and
healthy citizens. There has been no rise in suicides or depressive disorders, and
today it is ranked as one of the happiest countries in the world. In contrast, the
UK government’s programme is (literally) having deadly side effects, with
Stuckler citing the UK as ‘one of the clearest expressions of how austerity kills’
(Henley 2013).
The authors comment that it was not only the dire impacts of the policies they
found troubling, but also the heartlessness of the policymakers who have so
vigorously endorsed them. They state that the impact of this financial crisis goes
far beyond people losing their homes and jobs; rather it is a full-scale assault on
people’s health. Worsening health is not an inevitable consequence of economic
recessions, it is a political choice.
These are examples of socioeconomic policies being pursued in the full
knowledge that harm will result. Some authors have described this as a new
form of ‘barbarism’—a belief in the superiority of some people and a willing-
ness to use cruel and vicious behaviours towards those who are considered in-
ferior or undeserving (McCormack 2012; Thomas 2011).

17.5  Shifting values and the common determination

of meaning
The less visible aspect of socio-structural violence is the corrosive influence
which begins to shape and influence public support or acceptance of such pol-
icies and practices through misinformation and manipulation of the facts and
through media, language, and images.
In the 1980s the term ‘inequalities in health’ was replaced in official contexts
with the less emotive ‘variations in health’ (see Chapter 1). These shifts in lan-
guage set the direction for research, for funding, and more importantly for pub-
lic discourse. Inherent in the word ‘inequalities’ is the sense of injustice, which
guides policy and research in directions to remedy this, in contrast to the idea
of variations—‘normal’ individual differences—for which government has no
responsibility (see Whitehead and Dahlgren 2007).
It is the introduction of this language into societal contexts, interwoven with
mechanisms of power, which creates such a powerful and invidious force. ‘Cul-
tural hegemony’ is a term that describes the way in which powerful groups ma-
nipulate the beliefs, perceptions, and values in a society so that their ideological
stance becomes imposed and accepted as natural and inevitable. The UK trajec-
tory since 1979 has been to wage war on the welfare state and the NHS through
enforced privatization and the imposition of a business model. As citizens or
patients, we were re-cast as consumers who should exercise our ‘freedom’ by
 Stigmatization 243

having more say in our public services and more ‘choice’ in this marketplace. It
did not take long to taste the bitter pill of competitive relationships, the impos-
sibility of providing choices within constrained budgets, or, most crucially, to
realize that market values rely on inequalities, the antithesis of what public ser-
vices are about (Jones 2002). The outcome is the deliberate destruction of our
common bonds and a deadening effect on democracy.

17.6.  Stigmatization
This form of cultural violence can be seen to move and harden public opinion
against the welfare state by devaluing, stigmatizing, and blaming particular
groups (see also Chapter 16). It ‘preaches, teaches, admonishes, eggs on and
dulls us into seeing repression as normal and natural—or not seeing it at all’
(Galtung 1990).
Cathy: ‘The singer Frankie Vaughan and the media circus that followed him made my
community in Easterhouse famous for its gang warfare in the 1960s. But there has
never been any public recognition of the very deep political and spiritual violence that
is constantly being inflicted on the hearts, minds and spirits of the unemployed, the
poor and the most vulnerable people in our society.’

The emphasis on individual responsibility as a causal explanation for health in-

equalities moved to a different level in the UK when the financial crisis ex-
ploded in 2008. The drone attacks of the welfare ‘reforms’ and the ‘austerity’ cuts
have not only been directed towards the most vulnerable groups in society (see
Chapter 12), but have also been accompanied by a propaganda war that demon-
izes them. The manipulation and selective use of data has distorted public per-
ceptions so successfully that the average public perception is that 27% of the
welfare budget is claimed fraudulently. The reality, according to YouGov survey,
is 0.7% (TUC/YouGov 2013). Vulnerable groups of people have been re-cast as
‘scroungers’ who constitute a drain on the country’s resources.
The rhetoric of ‘hard-working families’ (who are implicitly contrasted with
welfare-state ‘scroungers’), which began under Blair’s and Brown’s premier-
ships, is now deployed endlessly by government to separate those who are per-
ceived to be ‘deserving’ of respect and support and those who are not. Speaking
on welfare reform at the Centre for Social Justice, Ian Duncan Smith yet again
refers to the ‘twilight world’ of Britain’s ‘ghettoised’ welfare recipients ‘where
people are languishing on welfare’ with no incentive to aspire to a better life
(Duncan Smith 2014).
The way in which areas of council housing or social housing have become
stigmatized as urban hellholes where the ‘problem’ categories of society
collect—­‘benefits streets’—shows how stigma has become activated for political
244 Socio-structural violence against the poor

purposes (Slater 2013). These examples offer a window into the psychological
and cultural mind-set that creates categories of people who are seen as less valu-
able than others, as less human than others; as ‘disposable human waste’ (Bau-
man 2004; Tyler 2013): ‘A social, economic, psychological and propaganda war;
a war fought with briefcases instead of guns against our own fellow citizens to
try and safely dispose of all the people in our world who have become “surplus
to market requirements”’ (McCormack 1993). This metaphorical description is
now becoming a horrific reality. A recent survey found that 38% of waste com-
panies had discovered homeless people in bins in the past 12 months as home-
lessness reached an all-time high (CIWM/StreetLink/Biffa 2014).
According to the Health and Safety Executive, people sleeping in bins are at
risk of getting caught in the bin mechanism, being smothered by the bin con-
tents, or being unable to escape before the bin is tipped into a waste collection
vehicle. They state that there have been a number of occasions in recent years
where a dead body has been discovered only after unloading at the waste depot.
Subsequent investigations revealed that in some of these cases the person con-
cerned was alive prior to being emptied into the waste truck (HSE 2010).

17.7  Shifting practices

Lastly, we want to draw attention to the subtlety of this dominant neoliberal
hegemony—­often invisible, spreading through the everyday, normal function-
ing and practices of institutions and professionals (see Chapters 8 and 9). The
alliances and organizations that have traditionally formed a safety net and a voice
for those who experience the excesses of the system also become deployed and
enmeshed in the web of pressure, policies, and practices. Campaigners and com-
munity activists see, and live with, the consequences of the propaganda aimed at
the working-class communities portrayed by politicians and the media as ‘lazy
scroungers’ who want to live in a ‘dependency culture’ (see also Tyler 2013):
Cathy: ‘Communities became plagued with professional researchers, social workers,
poverty management workers, child support workers, advocacy workers, CBT [cogni-
tive behavioural therapy] specialists, Council-employed policymakers, programme
makers, and health promotion workers all swarming in from their leafy suburbs to treat
the symptoms of poverty and health inequalities. Once their dire warnings about the
dangers of smoking and lack of exercise had been delivered, they then left in their cars,
back to their ‘comfort zones’, further polluting us with their toxic car exhaust fumes. It
became evident to the activist that our society was addicted to treating the symptoms
of everything and tackling the cause of nothing. If there was a “dependency culture” it
was the army of professionals who were employed to treat the symptoms.’

During the 1990s, the unemployed, poor, and oppressed were being pushed
further and further to the edge of society. People in living in social housing
 The new morality 245

schemes began to realize that what they were being subjected to was social and
economic apartheid. Opportunities for them to share their personal testimonies
of the experience of living in poverty were provided by many of the charitable
organizations that claimed to represent and advocate for them. However, rather
than empowering people by analysing and focusing on the stigmatization and
the political propaganda, people were more often displayed as ‘passive objects’
or victims. This activity has itself become a multi-million pound ‘poverty in-
dustry’ (Young 2007). Repeated exposure to distressing stories without any crit-
ical analysis of the causes can begin to normalize inequality and de-sensitize
people to the reality.
Jane: ‘Attending a Church-led initiative in Westminster, to enable “the poor” through-
out the UK to talk to a parliamentary committee, our group, Communities Against
Poverty, from Scotland attended the pre-meeting to discuss what we were going to
bring up. After a lunch of very thin soup, people broke into groups. On seeing “re-­
distribution” as our topic, the organizer swept across and made it very clear that this
was not a topic to be discussed with politicians—we were here to talk about “poverty”.’

The alternative to being patronized is, in most cases, not to be visible at all. In
2007 a conference initiated by the Catholic Archbishop, a fellow of the Royal
Society of Edinburgh, entitled ‘Transcending poverties—will the poor always
be with us?’ involved 16 distinguished speakers from academia, civic life, and
the churches. The cost of attending was (as conferences focusing on inequalities
and poverty so often are) out of the reach for anyone on benefits. Alf Young of
the Glasgow Herald wrote:
[T]o be brutally honest, six hours of learned discourse and debate produced very
little fresh prescriptions for how to bring that resilient system of apartheid to an
end. Around the victims of social and economic apartheid . . . a poverty industry
has grown up that not only claims to represent their interest but also profits from
that same advocacy. . . . It provides lots of well-meaning people with warm homes,
cars in the drive, plasma TVs, meals out and two or three foreign holidays a year—
the material aspirations that are now the norm for British citizens on average and
above-average incomes . . . it was striking that the dispossessed, the real victims of
social and economic apartheid, were nowhere to be seen’.
Reproduced from A. Young, A paucity of ideas for how to tackle poverty,
The Herald, Feb 23rd 2007 © 2007 Herald & Times Group

17.8  The new morality

The stigmatization of those on benefits, the misrepresentation of the causes of
the financial crisis, the policies, and the practices operate to allow punitive
sanctions and threats, such as taking disabled people off benefits, or forcing
people into a cycle of low pay and unemployment, to become ‘the norm’. In
246 Socio-structural violence against the poor

2014, when 27 Anglican Bishops and other church leaders criticized his welfare
reforms, David Cameron unravelled four centuries of progressive social welfare
development by drawing from the Elizabethan Poor Laws and their imposed
moral order on those who were to receive welfare support—a view which dis-
tinguished between the ‘worthy’ and unworthy or ‘feckless’ poor.
In his rebuttal of the concerns of the clergy (Cameron 2014), he insisted that
the reforms were at the heart of his social and moral mission in politics—that
it was ‘wrong’ to reward those who can work but do not. His statement com-
pletely ignores the fact that half of those on benefits are the working poor, who
have to claim benefits because their employers do not provide a living wage.
Shildrick’s research on Teeside (2010) showed no evidence that those who can
work did not, or indeed that work is a route out of poverty. Many people were
trapped in a low-pay, no-pay cycle moving in and out of casual, badly paid
jobs, utterly at the mercy of today’s economic and welfare policies and power-
less to change their situation (see Chapter 12). Her research also captured the
fear of stigmatization that people now express when they are forced to claim
benefits.
Cameron’s ‘moral mission’ is a perfect illustration of the way in which a new
‘morality’ is being forged, one that allows violence to be perpetrated on vulner-
able people.

17.9  The role of research and dissemination

What does this mean for those researching health inequalities? Challenging the
dominant discourse is difficult (see Chapter 8). Community activists and local
campaigners spend years working to draw attention to the effects and causes of
inequalities in health and build a body of knowledge and expertise drawn from
their lived reality. This needs to be aligned with research within academia.
Jane: ‘The woman and health group in Pilton made a presentation “Home Sweet Home”
to show the effects damp housing was having on their own health and their children’s
health—the difficulty of getting their children immunised because they always had
colds, their own stress, and the cost of replacing mouldy furniture and clothes. We tried
to persuade the local GPs to monitor the extent of dampness amongst patients who
reported respiratory problems, but they rejected this idea as being “too political”. We
only managed to turn these private troubles into public issues when we developed a
working relationship with the Research Unit for Health and Behavioural Change
(RUHBC) at Edinburgh University and the senior researcher, Dr Sonja Hunt, arranged
for a presentation to be made in the University.’

Significantly, around the same time, mothers in Easterhouse had also created a
sophisticated exhibition board, ‘Housing Makes you Sick’, and together these
initiatives triggered one of the biggest health and housing surveys ever carried
 PRIVATE TROUBLES INTO PUBLIC ISSUES 247

out in Britain into dampness, fuel poverty, and the associated health problems
which at that time affected an estimated 10 million families in Britain.
The first study was completed in 1987, the second in 1989, taking in five hous-
ing estates (two in Edinburgh, two in Glasgow, and one in London) (Martin
et al 1987, 1989). This research established that those residents living in homes
with mould reported the most ill-health symptoms, even when adjusting for
other variables such as smoking and low incomes. It has been cited as grounds
for action, setting tolerable standards, compensation, statutory repair, rehous-
ing tenants, and suing local authorities. This justified the long-held view of ten-
ants in Easthall and Pilton that there was something wrong with the houses if
residents could not boil a kettle or hang up washing.
While the researchers struggled to get their findings published in the British
Medical Journal, tenant representatives struggled to get a press conference held
in the House of Commons to bring these findings to a ‘nationwide’ audience,
which they achieved. As a result, not only did their joint research receive ‘na-
tionwide’ media coverage, but also the focus of a BBC2 documentary ‘Your
Health is Your Wealth’. Apart from creating a ‘precedent’ that no landlord could
ever again deny the link between damp housing and health, another result was
that our findings were debated at the ‘Scottish Grand Committee’ in the House
of Commons (HMSO 1989). This inspired the ‘Scottish House Condition Sur-
vey’, which through time has resulted in the right of people buying homes to
request an energy audit (McCormack 2009).

17.10  Transforming private troubles into public issues

One of the effects of stigmatizing and blaming vulnerable and low-income
groups, as we have already indicated, is that without a local group for support,
people begin to absorb and internalize the dominant message promulgated by
politicians and the media. Research which gives ‘voice’ to those experiencing
the harsh realities of austerity policies which exacerbate inequality can expose
those myths which inform the practices and policies inherent in socio-­structural
violence (see Chapter 6), for example Shildrick (2010) and Lambie-Munford
et al (2014) on the use of food banks.
Framing research questions which build on the experience of communities,
rather than those devised from the comfort zone of a university desk, can en-
sure that problems are interrogated more thoroughly and solutions better
targeted.
The Easthall Residents’ Association (ERA) worked with a range of different
agencies and researchers in order to find a solution to the issue of damp housing,
which was not only affecting tenants’ health and well-being, but also reducing
248 Socio-structural violence against the poor

their income, impoverishing their diet, and wasting energy. They invited in the
Technical Services Agency (TSA), whose independent research showed that it
would cost two-thirds of people’s benefits to maintain a healthy heat level in the
home. The TSA estimated that, because of the poor insulation of the houses,
people were wasting £10 million a year heating the skies above Easterhouse. The
ERA not only took part in the housing and health study already mentioned, but
also worked with architects, energy conservationists, public health practition-
ers, microbiologists, and tenants’ groups across Glasgow to initiate a £1.3 mil-
lion passive solar-energy demonstration project.
Cathy: ‘The ERA in Glasgow had observed that older people seemed to die like flies in
the winter from heart attacks and cold-related illnesses and they were confident that it
was the inside of the houses, not outside conditions, that were to blame. During their
own research, the ERA found an article by a public health doctor, Dr Evan Lloyd, who
had been researching the role of environmental cold stress in ischaemic heart disease
(IHD). The tenants were convinced that, as well as being subjected to extreme tempera-
ture changes outside, moving from the one warm room in a house to go into a cold one,
to make a cup of tea, etc. meant being doubly exposed to this stress. Bedrooms were
sometimes colder than outside.’

Making links with Lloyd led to an influential report which concluded that im-
proving the thermal quality of housing to eliminate damp and mould and prod-
uce a comfortable temperature throughout the house has a major impact on the
health of residents. It also referred to the financial benefits for the residents and,
indirectly, for the NHS (Lloyd et al 2008).

17.11  Pressure on researchers

The researchers who worked on the issue of damp housing in the 1980s came
under a lot of pressure. Questions were raised about their contracts, requests
were made to see papers in advance of public seminars, and subtle pressure was
exerted by the Chief Scientist’s Office (then part of the government’s Scottish
Office). Attempts by the authors to get the research published by the British
Medical Journal were met with an initial rejection before a successful appeal
(Martin 1989). Lloyd’s research was also challenged, as was his decision to in-
clude three of the local residents who aided him in his research as co-authors.
Working with those who experience inequalities, researching causal explan-
ations or directly interrogating the impact and experience of inequality is not
for the fainthearted or those who fear career reprisal (see Chapter 20 for a per-
sonal account of such difficulties by Pickett and Wilkinson).
However, the positive and important outcome is that it can provide evidence
for communities to utilize in their fight for social justice, turn ‘private troubles
into public issues’, expose myths that can influence public opinion, and help to
 MOVING BEYOND THE ACADEMIC REALM 249

challenge stigmatization. Therefore, there are good reasons for researchers to

work with communities, despite all the difficulties (see Chapter 6).
Researchers require a keen understanding and awareness of the political con-
text they are working in. Policymaking needs evidence, but evidence alone can-
not replace political decision-making. Tackling inequalities in health will not
be improved by more research alone; it will always depend on the political and
philosophical standpoint of those in power and the strength of civic society to
fight for justice. Disseminating research beyond academia is crucial in terms of
its impact and relevance to the serious challenges facing us in the current polit-
ical and ideological climate.

17.12  Conclusion: Moving health inequalities debates

beyond the academic realm to reclaim our humanity
Inequalities research cannot remain within universities or in papers in aca-
demic journals if authors hope to have any significant impact on politics and
policy. Integrity, objectivity, and rigour need not be compromised in forming
alliances with those whose lives are blighted by the current orthodoxy. The
plight of poor people is becoming more and more desperate as a result of the
socio-structural violence being waged against them. Choices and focus, collab-
orations and dissemination, all matter. In these times of class war, it is import-
ant to know which side you are on.
The violence that has been waged against the poor has created huge inequal-
ities that have broken our common bonds as a society. The biggest challenge
facing both rich and poor is how to begin reclaiming our humanity. Perhaps
this is where the real research into ‘inequalities in health’ needs to begin.

References
Agius, M. (2011) How the Big Bang created new life in the Square Mile, by Alistair Os-
borne, Daily Telegraph, 26 October 2011.
Bauman, Z. (2004) Wasted Lives. Modernity and Its Outcasts. Cambridge: Polity Press.
Cameron, D. (2014) Why the Archbishop is wrong about welfare, Daily Telegraph, 18 Feb-
ruary 2014, http://www.telegraph.co.uk/news/politics/david-cameron/10646421/David-
Cameron-Why-the-Archbishop-of-Westminster-is-wrong-about-welfare.html.
CIWM, Street Link and Biffa (2014) Research into the issues, risks and prevention of
­people sleeping in waste containers. Northampton: Chartered Institution of Waste Man-
agement; London: StreetLink; and Edinburgh: Biffa. Available from http://www.biffa.
co.uk/assets/files/Accreditations/Streetlink_CIWM_Biffa%20Research%20Report%
20Final_Feb14.pdf. See also article by Patrick Butler in The Guardian, 10 February 2014.
Duffy, S. (2013) A Fair Society? Sheffield: The Centre for Welfare Reform. Available from
http://www.centreforwelfarereform.org/library/by-date/a-fair-society1.html.
250 Socio-structural violence against the poor

Duncan Smith, I. (2014) Speech on welfare reform, delivered at Centre for Social Justice on
23 January 2014. Transcript of speech accessed 16 June 2015 from The Spectator online at
http://blogs.spectator.co.uk/coffeehouse/2014/01/iain-duncan-smiths-speech-on-welfare-
reform-full-text/.
Fryer, D. (1995) Benefit agency? Labour market disadvantage, deprivation and mental
health. The C. S. Myers lecture, The Psychologist, 8(6): 265–272.
Fryer, D., and McCormack, C. (2012) The war without bullets: Socio-structural violence
from a critical standpoint. Global Journal of Community Psychology Practice, 3(1): 87–92.
Galtung, J. (1990) Cultural violence. Journal of Peace Research, 27(3): 291–305.
Henley, J. (2013). ‘Recessions can hurt, but austerity kills.’ The Guardian, 15 May 2013.
HSE (2010) People in Commercial Waste Containers. London: Health and Safety Executive.
Accessed from http://www.hseni.gov.uk/waste25.pdf.
HMSO (1989) House of Commons Official Report. Scottish Grand Committee, 29
June 1989.
Jones, J. (1999) Private Troubles and Public Issues—A Community Development Approach
to Health. Scotland: Community Learning.
Jones, J., and Jones, L. (2002) Research and citizen participation. Journal of Community
Work and Development, 1(3): 49–66.
Lambie-Mumford, H., Crossley, D., Jensen, E., Verbeke, M., and Dowler, E. (2014)
Household Food Security in the UK: A Review of Food Aid. London: Food Ethics
­Council; and Coventry: University of Warwick. Available from https://www.gov.uk/
government/publications/food-aid-research-report.
Lloyd, E. L., McCormack, C., McKeever, M., and Syme, M. (2008) The effect of improving
the quality of cold housing on blood pressure and general health: A research note.
­Journal of Epidemiology and Community Health, 62(9): 793–797.
Martin, C. J. (1989) Researching the obvious and influencing the influentials. Local Govern-
ment Policy Making, 16(3): 47–51.
Martin, C. J., Platt, S. D., and Hunt, S. M. (1987) Housing conditions and ill-health. British
Medical Journal, 294(6580): 1125–1127.
Martin, C. J., Platt, S. D., Hunt, S. M., and Lewis, C. (1989) Damp housing, mould growth
and symptomatic health state. British Medical Journal, 298(1989): 1673–1678.
McCormack, C. (1993) From the Fourth World to the Third World. Community Develop-
ment Journal, 28(3): 207–209.
McCormack, C. (1999) War without bullets, an article written in 1999 for SEAD, Scottish
Education and Action magazine, http://www.sead.org.uk/about/30-years-of-action/
cathy-mccormack.
McCormack, C. (2009) The Wee Yellow Butterfly. Edinburgh: Argyll Publishing.
McCormack, C. (2012) The price of economic barbarism: An uncomfortable truth. Report
by Commissioner on the Church of Scotland Special Commission on the Purposes of
Economic Activity. Edinburgh: Church of Scotland. Available from: http://www.
churchofscotland.org.uk/__data/assets/pdf_file/0003/10884/The_price_of_economic_
barbarism_an_uncomfortable_truth.pdf.
Meacher, M. (2013) MP speech in House of Commons debate on ATOS Work Capability
Assessments, 17 January 2013, http://www.michaelmeacher.info/weblog/2013/01/my-
speech-on-atos-work-capability-assessments/.
 MOVING BEYOND THE ACADEMIC REALM 251

Platt, S. D. (1984) Unemployment and Suicidal Behavior. Social Science and Medicine, 19(2):
93–115.
Platt, S. D. (1986) Parasuicide and unemployment. British Journal of Psychiatry, 149(4):
401–405.
Shildrick, T. (2010) The Low-pay, No-pay Cycle: Understanding Recurrent Poverty Findings.
London: Joseph Rowntree Foundation.
Slater, T. (2013) Review of Imogen Tyler’s Revolting Subjects: Social Abjection and Resist-
ance in Neoliberal Britain. Antipode Foundation. Available from https://radicalantipode.
files.wordpress.com/2013/09/book-review_slater-on-tyler.pdf.
Stuckler, D., and Basu, S. (2013) The Body Economic: Austerity Kills. New York: Basic
Books.
Thomas, K. (2011) Human Life Matters: The Ecology of Sustainable Human Living vs the
Rule of the Barbarians. Charlston: CreateSpace Independent Publishing Platform.
TUC (2013) Support for benefit cuts dependent on ignorance, TUC-commissioned poll
finds. London: Trades Union Congress. Available from http://www.tuc.org.uk/social-
issues/child-poverty/welfare-and-benefits/tax-credits/support-benefit-cuts-dependent.
Tyler, I. (2013) Revolting Subjects; Social Abjection and Resistance in Neo-liberal Britain.
London: Zed Books.
Whitehead, M., and Dahlgren, G. (2007) Concepts and Principles for Tackling Social
­Inequalities in Health: Levelling Up, Part 1. Copenhagen: WHO Regional Office for
Europe.
Young, A. (2007) A paucity of ideas for how to tackle poverty, article in The Glasgow
­Herald, 23 February 2007.
 Chapter 18

For the good of the cause:

Generating evidence to inform
social policies that reduce
health inequalities
Ben Barr, Clare Bambra, and Katherine E. Smith

18.1  Introduction: Using evidence to tackle health

inequalities
As already outlined (in Chapter 1), health inequalities are defined as avoidable,
unjust, and systematic differences in health between groups with different levels
of underlying social advantage or disadvantage (Whitehead 1992). In a growing
number of countries, reducing inequalities in health has become a specific policy
objective (Mackenbach 2011). Most of these countries have also made commit-
ments to ensuring policy responses to health inequalities are ‘evidence-based’
(Smith 2013). Yet, the evidence base regarding how, specifically, to achieve reduc-
tions in health inequalities remains limited (Petticrew 2007) and most countries
have made little progress in reducing health inequalities (Mackenbach 2011).
It is widely agreed that social policies working at the population, rather than in-
dividual, level have the greatest potential to reduce health inequalities by address-
ing the social conditions and economic and political systems that contribute to
and sustain them (Acheson et al 1998). However, these types of ‘upstream’ policies
present the greatest challenges for researchers trying to evaluate health and other
impacts. This results in the ‘inverse evidence law’, whereby the availability of evi-
dence tends to vary inversely with the potential impact of the intervention (Nut-
beam 2004). This chapter outlines some key issues involved in evaluating the
impact of population-based social policies on health inequalities and considers
some of the ways in which researchers are working to address these difficulties.

18.2  Beyond ‘hierarchies of evidence’

Health researchers often refer to a ‘hierarchy of evidence’, whereby different
study designs are ranked according to their perceived strength in establishing
 Experimentation and realism 253

cause and effect. Traditional ‘hierarchies of evidence’ typically position system-

atic reviews of randomized controlled trials (RCTs) at the top, followed by RCTs
and other experimental methods that can provide evidence about whether a
particular intervention works (SIGN 2008). However, as RCTs of complex so-
cial policies are often difficult to undertake (as we discuss further later in the
chapter), it is likely that they will continue to make up a small part of the evi-
dence that informs effective action on health inequalities. Most social policies
that have the potential to influence health inequalities are implemented without
prior evaluation and are often not amenable to randomization anyway. To rap-
idly develop the evidence base, researchers need to evaluate the impact of policy
alternatives as they happen (‘natural experiments’), whether these are estab-
lished welfare and economic policies or reforms to health, social, and educa-
tional systems. For similar reasons, it has been argued that systematic reviews
and syntheses of available evidence relating to complex interventions may need
to broaden the kinds of evidence they incorporate (Petticrew 2007).
However, broadening research methods to include ‘natural experiments’ and
other innovative approaches raises questions about the nature of causality and
the validity of research methods in health inequalities research. In this chapter,
we briefly discuss experimental and realist perspectives on causality in the
evaluation of social policy. We then explore the limitations of RCTs in generat-
ing evidence to influence policy, and approaches for evaluating natural policy
experiments that reflect these different perspectives on causality. The chapter
then moves on to discuss approaches to systematically reviewing and synthesiz-
ing evidence for public health policy audiences.

18.3  Experimentation and realism in evaluating

the causal impact of social policies
Policymakers often stress that they are particularly interested in knowledge that
will help them make predictions about the probable impact of decisions (e.g. to
invest in intervention X or Y, or legislate for policy A or B) (Petticrew 2004). The
usefulness of evidence from a policymaker’s perspective depends in part on how
much it contributes to this aim. Knowledge about cause and effect is essential for
predicting the consequences of policy decisions and interventions. Investigating
causal relationships is therefore an important component of research that is in-
tended to influence policy. Such research involves two main challenges: (i) ascer-
taining causal relationships within a specific context (often called internal
validity); and (ii) generalizing from that context to a future situation of relevance
to policymakers (external validity). The latter is important because, where pol-
icymakers are using evidence regarding the impacts of policies/interventions, it
254 For the good of the cause

is always being applied in a different context from that in which it was generated.
Even if the research is based on the same population in the same place, it will
inevitably have been conducted at a different point in time from its application.
Both of these challenges are particularly problematic for evaluating complex
social policies. These are policies that work at the population, rather than the
individual, level and comprise multiple interrelated components embedded
within social contexts. How these components interact with each other and the
wider context, to result in particular outcomes, will depend on the meanings
people ascribe to situations and how they react to them. This presents problems
both for determining the causal relationships between components of a policy
and for defining how the components themselves are conceptualized.
Empirical science going back to the eighteenth-century philosopher David
Hume has conceptualized ‘cause’ and ‘effect’ as discrete measurable events, such
as ‘taking a treatment’ and ‘becoming disease free’ in medicine. Causal relation-
ships in this tradition are assessed by investigating the association between
these ‘events’ under specific experimental or quasi-experimental circumstances
(Shadish et al 2001). The definition of cause and effect in this experimental ap-
proach is based on the counterfactual model. An effect is defined as the diffe-
rence between what did happen and what would have happened to those same
people at that same time if the cause were not present (Shadish et  al 2001).
Clearly it is not possible to observe the counterfactual, so the ‘central task of
cause probing research is to create reasonable approximations for this physic-
ally impossible counterfactual’ (Shadish et al 2001, p. 5.) It is this approach to
causality that underpins the experimental method in health sciences.
An influential criticism of this ‘sequentialist’ model of causation derives from
critical realism (Sayer 1999). This alternative ‘realist’ conception of causality
posits that to infer that X causes Y, it is necessary to understand the causal
mechanism that connects X and Y and the contextual factors on which that
connection relies (Pawson et al 2005). With respect to social policy, this realist
approach recognizes that the mechanisms at work depend on the communica-
tive interactions between social actors, their shared meanings and interpret-
ation of situations. These will not be observable in any empirical sense and can
only be investigated through interpretative approaches such as ethnographic
study or other qualitative methods.
These two conceptions of causality are not mutually exclusive. Scientists
working in the experimental paradigm have often also highlighted a concern
with ‘mechanisms’. As Shadish et al (2001, p. 9) recognize, whilst ‘the strength
in experimentation is in describing the consequences of deliberately varying a
treatment, . . . experiments do less well at clarifying the mechanisms through
which, and the conditions under which that causal relationships holds’. The
 Natural experiments 255

pioneering epidemiologist Bradford Hill (1965) developed nine criteria that

could provide a guide to assessing whether associations in observational re-
search are likely to be causal (Bradford-Hill 1965). An important one of these
criteria is to determine a plausible mechanism that may explain observed
associations.
The problem for research from an experimental tradition has been how to
investigate mechanisms, particularly when these are social in nature. The in-
sights from critical realism indicate that it is essential to use interpretative
methods to fully understand the causal mechanisms that are an intrinsic part of
social policy. For example, in-depth case studies including interviews and
documentary analysis were used to evaluate the impact of Health Action Zones
(HAZ), multi-agency partnerships developed to address health inequalities in
England. This showed how the existence of HAZs in a particular area contrib-
uted to the development of planning systems that delivered improved services
for disadvantaged groups (Benzeval 2003).
Realist approaches also recognize that, when investigating the effect of ‘a
policy’ on specific ‘outcomes’, neither the policy itself nor the outcomes tend
to be characterized as discrete, measurable events. The way the policy, out-
comes, and any mediating concepts are defined (whether these are decisions,
rules, institutions, economic activities, or diseases) will always be abstrac-
tions and, as such, dependent on the researcher’s perspective. This will influ-
ence the research findings. As Sayer (1999, p. 19) writes, ‘much rests on the
nature of our ­abstractions—that is our conceptions of a particular one-sided
component of a concrete object, if they divide that which is in practice indi-
visible, or if they conflate what are different and separable components, then
problems are likely to result’.
This realist critique has given rise to a number of theory-based methods of
policy evaluation and evidence synthesis (Pawson et al 2005; Popay et al 2005).
The key aspects of these approaches include an exploration of the concepts,
components, and outcomes of the policy, how they causally relate to each other,
and the use of diverse research methods to develop a theoretical map with em-
pirical findings. These approaches have been used in the evaluation of a number
of policies relevant to health inequalities, including housing policy (Dunn et al
2013), health care reform (Best 2012), and criminal justice policy (Tilley 2004).

18.4  Natural experiments

Many new complex social policies that are likely to have an impact on health
inequalities are introduced without any evaluation of this impact. This is partly
because such policies may be primarily concerned with the social determinants
256 For the good of the cause

of health (e.g. education, employment, housing, etc.) rather than explicitly aim-
ing to improve health. For example (and as argued in Chapter 12), austerity
measures may well have an impact on health inequalities, but have been imple-
mented for economic/political reasons without evaluation and without consid-
eration of the health impacts. As pointed out by Petticrew (2007, p. 411), ‘[t]he
public are frequently “enrolled” in real-life policy “experiments” without giving
their explicit consent, or indeed without any real prospect of anyone learning
anything substantial about the effects of those interventions’.
There are relatively few RCTs of complex social policies and fewer still that
assess differential effects of these policies by socioeconomic groups (Petticrew
2007), although the number is increasing (Thomson et al 2001, 2013).
There are a number of reasons for this lack of RCTs. First, there are practical
reasons: complex social policies may be universally applied across a country or
jurisdiction, limiting opportunities for a control group; the political process of
identifying intervention areas may prevent opportunities for randomization;
and RCTs may be seen as too expensive. Second: in some cases RCTs are not the
most appropriate research method; effects of the policy may be so dispersed
they cannot be restricted to specific intervention units (individuals or clusters);
the timeframe within which effects occur may be too long and diffuse to be ad-
equately captured in an RCT; and it may not be possible or desirable to stand-
ardize interventions in different settings (Hawe 2004). Third, complex social
policies are often determined by politics, ideologies, and principles and are not
so much discrete interventions as policy packages (e.g. welfare reform in chap-
ter 12 or disability discrimination legislation). Fourth, there may be good eth-
ical reasons for not undertaking an RCT. If, for example, there is strong,
empirically informed theoretical evidence (or evidence from observational
studies) which indicates that the impact of an intervention is positive, and does
not cause harm, then it may not be considered ethical to provide the interven-
tion for some people and not others.
These objections do not of course preclude the use of RCTs for evaluating
complex social policies. Oakley (1998) points out that there has been a long his-
tory in the use of RCTs for complex social policies, starting with the income
maintenance experiments in the USA (Oakley 1998). However, it is becoming
increasingly clear that there are limitations, to the extent that evidence from
RCTs can inform action on health inequalities.
Given these limitations, researchers are turning to the investigation of ‘nat-
ural experiments’ to address the gaps in the evidence base (Petticrew et al 2005).
The term ‘natural experiment’ is used to refer to policies that are not under the
control of researchers, but where variation in the population’s exposure to these
policies makes them amenable to research that evaluates their impact (Craig
 Natural experiments 257

et al 2010). Various methods have been developed, particularly in economics,

to estimate the impact of these ‘natural experiments’. These methods generally
apply the conception of causality derived from experimental sciences in non-
experimental situations.
The methods used depend on how exposure to the policy varies across a
population and over time, and the data that are available. There are three com-
mon scenarios. First, there is variation in policy exposure between groups and
over time, for example when a policy is introduced within one area (e.g. state,
province, pilot sites) and information on outcomes is available over time in this
area and comparison areas that have not been exposed to the policy. An ex-
ample of this is the evaluation of the New Deal for communities, a regeneration
initiative in the UK (Stafford et al 2008). This used longitudinal survey data to
compare outcomes in intervention areas with comparison areas (selected from
neighbourhoods in the same local authority with similar deprivation levels but
where the New Deal had not been introduced). Compared to these control
areas, the intervention was not associated with any improvement in outcomes
(Stafford et al 2008).
In the second scenario, only cross-sectional information is available on dif-
ferences in exposure to the policy and outcomes in areas with and without the
intervention. This approach was used in the study by Belsky et al (2006) assess-
ing the initial impact of Sure Start, an early years intervention in the UK. They
used a cross-sectional survey to compare family functioning, parenting, and
child-health indicators in programme areas with those areas waiting to become
programme areas. The intervention was associated with some positive benefits,
but these were mainly amongst relatively less socially deprived children (Belsky
et al 2006).
In the third scenario, information on exposure to a policy and outcomes is
available over time for the same population, before and after the policy is imple-
mented, and there is no unexposed comparison group. So analysis investigates
the change in outcomes experienced by the population exposed. This is referred
to as an ‘interrupted times series design’ (Shadish et  al 2001). For example,
Herttua and colleagues (2009) investigated the effect of a sudden reduction in
the price of alcohol in Finland following deregulation of import quotas within
the European Union. By comparing population data before and after deregula-
tion, they showed that this led to a substantial and rapid increase in alcohol-
related mortality in the Finnish population.
A key problem with these studies is that the groups exposed to a policy may
not be wholly comparable with those not exposed (Petticrew et al 2005). This
means that observed differences in outcomes may be due to underlying differ-
ences between the study groups (i.e. confounding factors) rather than being
258 For the good of the cause

caused by the policy itself, thus reducing the study’s ‘internal validity’ (i.e. the
confidence that the policy caused the observed outcomes). Various analytical
techniques can be used to try to reduce this source of study error. At the sim-
plest level, standard regression techniques are used to adjust for known differ-
ences between the comparison groups, or ‘fixed’ effects can be included to
control for unknown differences between individuals or groups (see Rabe-
Hesketh and Skrondal 2008 for a more detailed explanation).
Other, more complex statistical methods such as propensity score matching,
regression discontinuity, and instrumental variable designs can be used to de-
rive comparable groups from those exposed and unexposed to a policy. In pro-
pensity score matching, exposed and unexposed individuals or groups are
matched on a set of baseline characteristics (e.g. Melhuish et al 2008). Regres-
sion discontinuity designs are used to compare how outcomes vary between
groups just above or just below the threshold for exposure to a policy. For ex-
ample, an early years intervention in the USA, Head Start, was implemented in
communities whose average income placed them below a specific poverty rate.
One study used a regression discontinuity design to compare outcomes in areas
just above and just below this poverty threshold, and found that the introduc-
tion of Head Start was associated with a large drop in child mortality rates (Lud-
wig and Miller 2007). Instrumental variable techniques involve identifying a
variable which has a close relationship with exposure to the policy of interest,
but in itself has no relationship with the outcome except through its effect on
policy exposure. A number of studies have used the fact that in many countries,
due to quirks in educational administration systems, a child’s month of birth
can affect the length of time they stay in education (e.g. Angrist and Krueger
1990; Braakmann 2011). In these studies, ‘month of birth’ is an instrumental
variable for exposure to education. Braakmann (2011), for example, uses this
approach in a study that suggests there were no noticeable health benefits asso-
ciated with attaining some qualifications before leaving school compared to at-
taining no qualifications. For a further explanation of these techniques, see
Shadish et al (2001) or Angrist and Pischke (2009).
One of the benefits of ‘natural experiments’ is that they can offer greater ‘ex-
ternal validity’ than RCTs: in other words, results from these studies can more
readily be applied to other similar communities or contexts (Petticrew et  al
2005). This is because they are often based on whole populations rather than
selected samples, and they investigate the impact of policies as implemented in
‘real life’ rather than under experimental circumstances. Whilst the analytical
techniques described here improve the internal validity of natural experiments,
it is important to recognize that they generally reduce external validity (Angrist
and Fernandez-Val 2010). For example, Ludwig and Miller’s (2007) study of
 Natural experiments 259

Head Start only estimates the impact of the intervention for those areas that are
close to the poverty threshold used to allocate the intervention (i.e. those areas
just above or just below this poverty line). This impact may not be generalizable
to areas with very high poverty rates.
Given the problems presented by natural experiments in terms of both in-
ternal and external validity, public health researchers are increasingly recogniz-
ing the need for more nuanced methods that incorporate insights from
theory-based approaches to evaluation and reflect a realist conception of caus-
ality. A key component of these approaches involves setting out the underlying
theory of policy implementation. Logic models are often used to graphically
outline hypothesized causal mechanisms linking components of the policy, the
wider determinants of health, and health outcomes. Various research methods
can then be used to investigate these mechanisms. An example of this approach
is the evaluation of the policy in Scotland banning smoking in public places. A
‘logic model’ was developed to indicate how short-, intermediate-, and long-
term concepts and outcomes causally relate to each other. A number of quanti-
tative and qualitative studies were then conducted to investigate each of the
pathways to impact within this model (Haw et al 2006).
A number of international comparative studies have used a similar theory-
based approach to categorize countries according to the logic of their policy
models and then investigate the association between these typologies and
health outcomes. For example, a study by Lundberg et al (2008) characterizes
countries based on whether their family support policy system is primarily fo-
cused on supporting dual earner or more traditional households with one male
earner (Lundberg et al 2008). They found that an increase in the generosity of
family benefits in countries with the dual-earner model was associated with a
decline in infant mortality, but in countries with other models it was not (Lun-
dberg et al 2008).
The validity of these evaluations of complex social policies can be enhanced
via an iterative process of matching patterns in the data with a developing the-
oretical model of how a policy works. Shadish et al (2001) refer to this process
as ‘coherent pattern matching’, and indicate that it can increase validity by redu-
cing the plausibility of alternative explanations: ‘The more complex the pattern
that can be successfully predicted the less likely it is that alternative explan-
ations could generate the same pattern so the more likely it is that the treatment
has had a real effect’ (Shadish et al 2001, p. 105).
There is substantial potential for these methods to be applied more exten-
sively to investigate the impact of complex social policies on health inequalities,
particularly at a time when many governments are implementing untested pol-
icies as part of their austerity programmes. Although there have been calls for
260 For the good of the cause

gaps in the evidence base to be filled by investigating natural experiments, there

are still relatively few such studies within health inequalities research (Petticrew
et al 2005).

18.5  Systematic reviews and the accumulation

of evidence
In light of the difficulties associated with evaluating the impacts of complex so-
cial policies, results from single studies can be misleading. Systematic reviews
of evidence are increasingly promoted by public health researchers as more re-
liable tools for amassing evidence for policy audiences (e.g. Lavis 2009). Sys-
tematic review methods are an established method of locating, appraising, and
synthesizing empirical evidence to answer a given question. Well-conducted
systematic reviews showing a consistent effect over diverse populations can
help overcome the lack of external validity often found in individual RCTs, but
they can also exacerbate biases where the sample populations of primary stud-
ies are systematically unrepresentative (Shadish et al 2001).
The WHO CSDH recommended systematic reviews as a source of evidence
for action on health inequalities (Tugwell et al 2010). However, to date, very few
systematic reviews address health inequalities (Bambra et al 2009). There are a
number of barriers to the use of systematic reviews to assess the impact of com-
plex social policies on health inequalities. First, traditional systematic review
methods have tended to focus on synthesizing evidence from RCTs and do not
lend themselves to the synthesis of results from studies using the diverse meth-
ods outlined here. Second, there are limited tools available for the assessment of
the validity of non-experimental evaluation studies (Barr et al 2010).
There have also been criticisms that by looking at average effects across mul-
tiple studies, systematic reviews may provide only limited insight into what
works in what context, or what aspects of a policy enhance effectiveness, par-
ticularly where a policy or intervention does not lend itself to standardization
(Pawson et al 2004; Shadish et al 2001). The challenges to assessing causality
in quasi-experimental evaluations can be exacerbated when combining re-
sults from multiple studies (Pawson et al 2005). To address some of these chal-
lenges, ‘theory-based’ approaches to evidence synthesis have been developed
along similar lines to those found in evaluation research. Guidance on realist
(Pawson et al 2005) and narrative (Popay et al 2005) approaches to systematic
reviews outlines a series of steps that use the underlying theory of a policy as
the framework for synthesizing evidence. Importantly, these approaches in-
volve synthesizing empirical and interpretative evidence from multiple
sources to assess the causal mechanisms of a policy’s impact. This approach
 EXPANDING OUR METHODOLOGICAL TOOLBOX 261

has been recommended when synthesizing evidence for action on health in-
equalities (Tugwell et al 2010).

18.6  Conclusion: The need to expand our

methodological toolbox
In most countries, health inequalities have not reduced—even in England,
where policies were explicitly designed to reduce them (Mackenbach 2011).
The lack of progress may partly be because there has been insufficient evidence
to indicate how complex social policies can be developed to address the funda-
mental causes of health inequalities, the social and economic conditions in
which people live. In this chapter we have argued that RCTs will be of limited
use to policymakers aiming to address these social determinants of health in-
equalities. Growing efforts to assess the impact of ‘natural experiments’ on
health inequalities, and to synthesize diverse kinds of evidence, seem a more
promising route to addressing the many gaps in the current evidence base.
Methods originally developed in economics for evaluating the effect of policies
implemented in non-experimental circumstances may also provide valuable
tools for health inequalities research. Insights from theory-based approaches to
evaluation can enhance the internal and external validity of these methods.
This requires going beyond the dominant paradigm of causality found in the
medical and economic sciences and recognizing that the interpretative investi-
gation of social processes provides robust causal evidence. The synthesis of
econometric and qualitative methods, within a realist framework, has great po-
tential for generating evidence to determine what works, for whom, and in what
circumstances for reducing health inequalities. The hope is that these ap-
proaches will help future policymakers identify more promising policies, and
have greater confidence in the existing evidence.

References
Acheson, D., Barker, D., Chambers, J., Graham, H., Marmot, M., and Whitehead, M.
(1998) Independent Inquiry into Inequalities in Health. London: The Stationery Office.
Angrist, J., and Fernandez-Val, I. (2010) Extrapolating: External validity and over-­
identification in the LATE Framework. National Bureau of Economic Research.
Angrist, J., and Krueger, A. (1990) Does compulsory school attendance affect schooling
and earnings? NBER Working Paper 3572. National Bureau of Economic Research.
Angrist D., and Pischke, J. (2009) Mostly Harmless Econometrics: An Empiricist’s Compan-
ion. Princeton: Princeton University Press.
Bambra, C., Gibson, M. A., Sowden, A., Wright, K., Whitehead, M., and Petticrew, M.
(2009) Tackling the wider social determinants of health and health inequalities: Evidence
from systematic reviews. Journal of Epidemiology and Community Health, 64: 284–291.
262 For the good of the cause

Barr, B., Clayton, S., Whitehead, M., Thielen, K., Burström, K., Nylén, L., and Dahl, E.
(2010) To what extent have relaxed eligibility requirements and increased generosity of
disability benefits acted as disincentives for employment? A systematic review of evi-
dence from countries with well-developed welfare systems. Journal of Epidemiology and
Community Health, 64(12): 1106–1114.
Belsky, J., Melhuish, E., Barnes, J., Leyland, A., Romaniuk, H., and the National Evalua-
tion of Sure Start Research Team. (2006) Effects of Sure Start local programmes on chil-
dren and families: Early findings from a quasi-experimental, cross-sectional study. British
Medical Journal, 332(7556): 1476–1470.
Benzeval, M. (2003) The Final Report of the Tackling Inequalities in Health Module: The
National Evaluation of Health Action Zones. London: Queen Mary and Westfield
College.
Best, A. (2012) Large-system transformation in health care: A realist review. The Milbank
Quarterly, 90(3): 421–456.
Braakmann, N. (2011) The causal relationship between education, health and health-­
related behaviour: Evidence from a natural experiment in England. Journal of Health
Economics, 30(4): 753–763.
Bradford-Hill, A. (1965) The environment and diseases: Association or causation? Proceed-
ings of the Royal Society of Medicine, 58: 295–300.
Craig, P., Cooper, C., Gunnell, D., Haw, S., Lawson, K., Macintyre, S., Ogilvie, D.,
Petticrew, M., Reeves, B., Sutton, M., and Thompson, S. (2010) Using Natural Experi-
ments to Evaluate Population Health Interventions. London: MRC.
Dunn, J., Meulen, E., O’Campo, P., and Muntaner, C. (2013) Improving health equity
through theory-informed evaluations: A look at Housing First strategies, cross-sectoral
health programs, and prostitution policy. Evaluation and Program Planning, 36(1):
184–190.
Haw, S., Gruer, A., Amos, A., Currie, C., Fischbacher, C., Fong, G., Hastings, G., Malam,
S., Pell, J. Scott, C., and Semple, S. (2006) Legislation on smoking in enclosed public
places in Scotland: How will we evaluate the impact? Journal of Public Health, 28(1):
24–30.
Hawe, P. (2004) Complex interventions: How ‘out of control’ can a randomised controlled
trial be? British Medical Journal, 328(7455): 1561–1563.
Herttua, K., Makela, P., and Martikainen, P. (2009) An evaluation of the impact of a large
reduction in alcohol prices on alcohol-related and all-cause mortality: Time series ana-
lysis of a population-based natural experiment. International Journal of Epidemiology,
40(2): 441–454.
Lavis, J. (2009) How can we support the use of systematic reviews in policymaking? PLoS
Medicine, 6(11): e1000141.
Ludwig, J., and Miller, D. (2007) Does Head Start improve children’s life chances?
­Evidence from a regression discontinuity design. The Quarterly Journal of Economics,
122(1): 159–208.
Lundberg, O., Yngwe, M., Stjärne, M., Elstad, J., Ferrarini, T., Kangas, O., Norström, T.,
Palme, J., and Fritzell, J. (2008) The role of welfare state principles and generosity in so-
cial policy programmes for public health: An international comparative study. The Lan-
cet, 372(9650): 1633–1640.
 EXPANDING OUR METHODOLOGICAL TOOLBOX 263

Mackenbach, J. (2011) Can we reduce health inequalities? An analysis of the English strat-
egy (1997–2010). Journal of Epidemiology and Community Health.
Melhuish, E., Belsky, J., Leyland, A., and Barnes, J. (2008) Effects of fully established Sure
Start local programmes on 3-year-old children and their families living in England:
A quasi-experimental observational study. The Lancet, 372(9650): 1641–1647.
Nutbeam, D. (2004) Getting evidence into policy and practice to address health inequal-
ities. Health Promotion International, 19(2): 137–140.
Oakley, A. (1998) Experimentation and social interventions: A forgotten but important
­history. British Medical Journal, 317(7167): 1239–1242.
Pawson, R., Greenhalgh, T., Harvey, G., and Walshe, K. (2004) Realist Synthesis: An
Introduction. ESRC Research Methods Programme. Manchester: University of
Manchester.
Pawson, R., Greenhalgh, T., Harvey, G., and Walshe, K. (2005) Realist review—a new
method of systematic review designed for complex policy interventions. Journal of
Health Services Research and Policy, 10(Suppl. 1): 21–34.
Petticrew, M. (2004) Evidence for public health policy on inequalities I: The reality accord-
ing to policymakers. Journal of Epidemiology and Community Health, 58: 811–816.
Petticrew, M. (2007) ‘More research needed’: Plugging gaps in the evidence base on health
inequalities. The European Journal of Public Health, 17(5): 411–413.
Petticrew, M., Cummins, S., Ferrell, C., Findlay, A., Higgins, C., Hoy, C., Kearns, A., and
Sparks, L. (2005) Natural experiments: An underused tool for public health? Public
Health, 119: 751–757.
Popay, J., Roberts, H., Sowden, A., and Petticrew, M. (2005) Guidance on the Conduct
of Narrative Synthesis in Systematic Reviews: Version 2. Lancaster: Lancaster
University.
Rabe-Hesketh, S., and Skrondal, A. (2008) Multilevel and Longitudinal Modeling Using
Stata (2nd edn). Texas: Stata Press.
Sayer, A. (1999) Realism and Social Science. London: SAGE Publications Ltd.
Scottish Intercollegiate Guidelines Network (SIGN) (2008) SIGN 50: A Guideline Develop-
er’s Handbook. Edinburgh, Scotland: SIGN.
Shadish, R., Cook, T., and Campbell, D. (2001) Experimental and Quasi-Experimental
­Designs for Generalised Causal Inference (2nd revised edn). Boston: Houghton
Mifflin.
Smith, K. (2013) Beyond Evidence-based Policy in Public Health: The Interplay of Ideas.
London: Palgrave Macmillan.
Stafford, M., Nazroo, J., Popay, J., and Whitehead, M. (2008) Tackling inequalities in
health: Evaluating the New Deal for Communities initiative. Journal of Epidemiology and
Community Health, 62(4): 298–304.
Thomson, H., Petticrew, M., and Morrison, D. (2001) Health effects of housing improve-
ment: Systematic review of intervention studies. British Medical Journal, 323(7306):
187–190.
Thomson, H., Thomas, S., Sellstrom, E., and Petticrew, M. (2013) Housing improvements
for health and associated socio-economic outcomes. Cochrane Database of Systematic
Reviews.
264 For the good of the cause

Tilley, N. (2004) Applying theory-driven evaluation to the British Crime Reduction Pro-
gramme: The theories of the programme and of its evaluations. Criminal Justice, 4(3):
255–276.
Tugwell, P., Petticrew, M., Kristjansson, E., Welch, V., Ueffing, E., Waters, E., B
­ onnefoy, J.,
Morgan, A., Doohan, E., and Kelly, M. (2010) Assessing equity in systematic reviews:
­Realising the recommendations of the Commission on Social Determinants of Health.
British Medical Journal, 341(sep13 1): c4739–c4739.
Whitehead, M. (1992) The concepts and principles of equity and health. International Jour-
nal of Health Services, 22(3): 429–445.
 Chapter 19

Influencing policy
with research—public health
advocacy and health inequalities
Katherine E. Smith, Ellen Stewart,
Peter Donnelly, and Ben McKendrick

19.1  Introduction: Conceptualizing the role of research

(and researchers) in policymaking
There is widespread support within public health for the idea that policies
ought to be informed by research (Macintyre 2011), especially in the UK,
where (as Chapter 1 describes) there has been a strong emphasis on using evi-
dence in policy from 1997 onwards (Smith 2013). Yet, analyses of public
health policies tend to conclude that they are not evidence-based (e.g. Ka-
tikireddi et al 2011; Macintyre et al 2001; Smith 2007). This apparent disjunc-
ture has fuelled a multitude of studies of, and advice on, the use of public
health research in decision-making (particularly national-level policy). Many
such contributions appear to implicitly conceive of the policymaking process
as a series of stages—see Figure 19.1—and often focus solely on examining the
use of evidence in just one of the particular ‘stage’s. The aim of these studies
tends to be identifying factors that might increase the influence of evidence at
one or more of the policymaking stages.
This focus appears to have been the starting point for much of the research
that has been undertaken on public health knowledge translation and research
impact. As Figure 19.2 depicts, this research tends to rely on a relatively techno-
cratic, instrumental way of thinking about the use of research in policy, a con-
ceptualization which has strong links to the notion of ‘evidence-based medicine’
(see Pawson 2006). From this perspective, ‘politics’ is often framed as a barrier
to achieving rational decisions: ‘the four-hundred pound brute’ that quashes
the ‘six-stone weakling’ that is evidence, in Pawson’s (2006, p. viii) terms. This
way of thinking about the policymaking process, and the potential role of evi-
dence within it, points to the need for researchers to do more to ensure that the
266 Influencing policy with research

Problem
Definition

Policy Agenda
Evaluation Setting

Implement- Policy
ation Development

Fig. 19.1 A simple model of the ‘policy cycle’.

Reproduced from Albert Soer, Policy 2.0: Can we move beyond the classic policy cycle? June 28,
2013 http://europeandcis.undp.org/blog/2013/06/28/policy-2–0-can-we-move-beyond-the-
classic-policy-cycle/.

outputs they produce are timely, accessible, and well communicated (see, for
example, Contandriopoulos et al 2010; Innvær et al 2002; Mitton et al 2007).
Yet, as the former UK policy advisor Geoff Mulgan argues, in democratically
elected countries, ‘the people, and the politicians who represent them, have
every right to ignore evidence’ (Mulgan 2005, p. 224). Indeed, scholars working

Rational, linear Empirically

theories of policy informed
change theories of policy
change

Evidence-based
medicine Traditional, Political science / Values &
policy studies beliefs
public health
perspective on perspective on
Evidence- policymaking policymaking
Public and
based policy media debate

‘Hierarchies of Lobbying / advocacy

evidence’ by particular
interests

Fig. 19.2 Contrasting perspectives on policymaking—public health ‘versus’ political

science.
 CONCEPTUALIZING THE ROLE OF RESEARCH IN POLICY 267

within political science and policy studies tend to take a very different approach
to thinking about policymaking. Here, the starting question often appears to be:
what role do ideas, interests, and/or institutions play in the policymaking pro-
cess (see also Chapters 9 and 13 of this book)? In other words, policymaking is
perceived in far more normative, interest-orientated terms. Hence, whilst re-
search may play a role in informing the ideological/political positions and pref-
erences being advocated by various actors, evidence is certainly not expected to
provide the basis for policy decisions. From this perspective, evidence is posi-
tioned as one factor amongst many that may be influential when employed by
policy actors to further their political, personal, and/or institutional interests/
preferences.
Whilst public health researchers with a policy interest have tended to focus on
analysing and evaluating the policies that are pursued by governments, political
science and policy studies also draw attention to the prior question of why some
areas and issues are deemed worthy of policy attention whilst others are not.
Shiffman and Smith (2007—see Table 19.1) provide a helpful bridge between
these two perspectives by drawing on popular theories about policymaking
(from political science) to help explain public health policy prioritization.
Building on the possibility offered by such a bridge, this chapter seeks to
move beyond the dichotomy depicted in Figure 19.2 to consider what health
inequalities researchers might do to improve the influence (rather than simply

Table 19.1  Determinants of public health policy prioritization

Description Factor
Actor power Strength of individuals and Policy community cohesion
organizations
Leadership
Guiding institutions
Civil society mobilization
Ideas How the issue is understood Internal frame
and portrayed
External frame
Political context Environments in which actors Policy windows
operate
Global governance structure
Issue characteristics Features of the problem Credible indicators
Severity
Effective interventions
Reprinted from The Lancet, 370 (9595), Jeremy Shiffman and Stephanie Smith, Generation of political
priority for global health initiatives: a framework and case study of maternal mortality, pp. 1370–9,
­Copyright (2007), with permission from Elsevier.
268 Influencing policy with research

increase the flow into) of health inequalities research in policy. Taking a holistic
approach to thinking about the potential role of evidence in policy debates, the
chapter considers the various ways in which researchers and the outputs they
produce can (and do) interact with decision-making debates and processes in
what is (inevitably) a political system.

19.2  What do we already know about the relationship

between health inequalities research and policy?
As several chapters in this book make clear, there is a lot of support amongst
researchers and policymakers in the UK for the idea that policies are needed to
reduce health inequalities and that these policies should be based on, or at least
informed by, available research evidence (see, for example, Chapters 1, 2, 7, and
18). Yet, it also seems clear, from both the personal reflections of senior high-
profile researchers provided in this book (see Chapters 2 and 20), and previous
studies of the relationship between health inequalities research and policy (Pet-
ticrew et al 2004; Smith 2013; Whitehead et al 2004), that researchers feel they
have struggled to influence policy, and that policymakers feel the available evi-
dence has not met their requirements (see also Chapter 6). These studies pro-
vide some insights into why researchers and policymakers feel this is the case
(see Box 19.1) and how actors in both communities think the situation might be
improved (Box 19.2).
As Box 19.1 illustrates, explanations for the difficulties that have been en-
countered in using health inequalities research to inform UK policy responses
can be divided into two broad categories: those which focus on the limitations
of the available research; and those which emphasize the democratic, political
aspects of policymaking. These two categories map onto the different ways of
thinking about policymaking that are depicted in Figure 19.2. Reflecting this,
suggestions as to how the relationship between health inequalities research and
policy might be improved can also be categorized as those that focus on evi-
dence and its communication and those that favour a more political, strategic
approach (see Box 19.2).
The recommendations for improving the impact of health inequalities
research on policy listed under headings ‘1’ and ‘2’ in Box  19.2 are largely
uncontroversial, although questions should perhaps be asked about why
policymakers still appear to be vocalizing concerns about the available evidence
in 2012 (Smith 2013) that were raised almost ten years earlier (Petticrew
et al 2004; Whitehead et al 2004). The suggestions that take a more strategic,
­advocacy-orientated approach to thinking about research impact (see ‘3’ in
Box 19.2), however, raise rather more challenges. As Chapters 6 and 20 both
 WHAT DO WE ALREADY KNOW? 269

Box 19.1  Why has the impact of health inequalities

research on UK policy been so limited?

1. Evidence-based explanations
◆ Too much of the available evidence concerning health inequalities is con-
cerned with behaviours and clinical factors rather than broader social
determinants of health (Petticrew et al 2004; Smith 2013).
◆ Research tends to be explanatory rather than evaluative (Petticrew et al
2004; Smith 2013).
◆ Evidence often has weak account of ‘causal pathways’ connecting pol-
icies/interventions to outcomes (Petticrew et al 2004; Smith 2013).
◆ There is a lack of evidence taking economic factors (e.g. costs of problems
and/or potential solutions and cost-effectiveness) into account (Pet-
ticrew et al 2004; Smith 2013).
◆ There is a lack of policy-focused/solution-orientated research (Petticrew
et al 2004; Smith 2013).
◆ Not enough evaluative research provides information on distributional
outcomes (Petticrew et al 2004).

2. Political, democratic explanations

◆ The political will be necessary to implement the kinds of ‘upstream’ pol-
icies that the available evidence suggests is required has been lacking
(Smith 2013).
◆ Policymakers do not believe they have a sufficient public mandate to im-
plement policies reflecting the available research evidence (Smith 2013).
◆ Other policy issues eclipse health inequalities as a policy priority
(Smith 2013).
◆ The institutional location of responsibility for health inequalities with
departments of health has limited the scope for policy responses to health
inequalities that relate to other policy areas (Smith 2013).
◆ Those seeking to reduce health inequalities tend to be ‘out-lobbied’ by
other interests, including alcohol, food, and beverage companies
(Smith 2013).
270 Influencing policy with research

Box 19.2  How might we improve the impact of health

inequalities research on UK policy?

1. Improve the evidence base (Petticrew et al 2004; Smith

2013; Whitehead et al 2004)
◆ Undertake more evaluation-focused research that considers distribu-
tional impacts.
◆ Make more of the opportunities provided by ‘natural experiments’.
◆ Ensure research evidence has a clear account of ‘causal pathways’ con-
necting policies/interventions to outcomes.
◆ Develop and employ evidence around the costs of policies/interventions
and inaction, including via scenario modelling.
◆ Provide more information on the ‘costs and distributional effects of
interventions’.

2. Improve communication and understanding between

researchers and policymakers (Petticrew et al 2004;
Smith 2013; Whitehead et al 2004)
◆ Ensure research messages are clear, accessible and well communicated.
◆ Ensure research is ‘timely’ and ‘relevant’ to ongoing policy debates.
◆ Do more to acknowledge the contrasting research needs at local and na-
tional levels.
◆ Researchers should undertake more work to better understand the pol-
icy process.
◆ Researchers and policymakers should consider working more collabora-
tively and/or undertaking secondments.
◆ Do more to develop clear policy messages based on existing research
evidence.

3. Engage in strategic, advocacy-orientated work

(Smith 2013)
◆ Develop clear and persuasive policy objectives/scenarios.
◆ Be strategic and opportunist in promoting these policy objectives/scenarios.
◆ Work with a wide variety of policy actors, including third-sector
organizations.
 What is public health ‘advocacy’? 271

Box 19.2  How might we improve the impact of health inequalities research on
UK policy? (continued)
◆ Monitor and highlight actors and policies negatively impacting on health
inequalities.
◆ Do more to listen to and engage with the public, including via research
and media.

make clear, whilst many of the actors working to reduce health inequalities rec-
ognize the need for more ‘advocacy’ around this issue (e.g. Mackenbach 2011),
there is a great deal of debate about whether this is something researchers ought
to be proactively engaging with. The following sections reflect on why this is by
considering what exactly ‘advocacy’ involves.

19.3  What is public health ‘advocacy’?

Most of the literature on public health advocacy is, as one of its most enthusias-
tic promoters notes (Chapman 2007), lacking in empirical research. This may
explain the paucity of clear definitions of the term and the variations between
the definitions that do exist. The WHO defines health advocacy as ‘a combin-
ation of individual and social actions designed to gain political commitment,
policy support, social acceptance and systems support for a particular health
goal or programme’ (WHO Europe 2006, p. 21). In itself, this does not appear
to be particularly controversial. Indeed, of the various definitions of public
health advocacy that exist, most overlap with other concepts, many of which
appear more acceptable within public health, such as ‘knowledge brokerage’,
‘knowledge dissemination’, ‘knowledge exchange’, and ‘social marketing’ (see
Table 19.2).
An article by Carlisle (2000) argues that there are two distinct ways of defining
‘public health advocacy’. The first involves strategically ‘selling’ public health ob-
jectives to a range of non-academic audiences. From this perspective, health in-
equalities researchers need to work to place and maintain public health issues on
public and political agendas (and strategically exploit opportunities to do so),
discredit opponents of public health objectives, and work to frame evidence in
persuasive ways (e.g. Chapman 2007). Carlisle (2000) terms this way of thinking
about advocacy as ‘representational’. The second type is what Carlisle (2000)
terms ‘facilitational’ advocacy. This way of thinking about ‘advocacy’ is more akin
to Burawoy’s (2005) notion of ‘public sociology’, in which researchers engage in
dialogue with members of the public (particularly those whose voices are other-
wise often ignored), work collaboratively with organizations representing public
272 Influencing policy with research

Table 19.2  Varying definitions of public health advocacy

Definition Definitions of ‘advocacy’ from Similar to . . .

emphasis available health literature
Using evidence ‘Health advocates utilize available Knowledge brokerage
to achieve evidence and knowledge about an issue (Lomas 2007) and research
influence to push for improved public health over impact (RCUK undated)
the long-term’ (Asbridge 2004, p. 16)
Working to [Public policy advocacy is] ‘the attempt Lobbying
influence policy to influence what will, or will not be, a (Contandriopoulos 2011),
on behalf of matter of public policy, the content of community activism/
specific goals, policies as they are made, and the way education (see Chapter 17),
communities, in which they are implemented, once and some qualitative
or interests agreed to by the government’ research (see Chapter 16)
(Carr-Gregg 1993, p. 35S).

Advocacy in health involves helping

people to ‘provide a voice or voices for
themselves, and perhaps a wider group
of consumers, in public debate and to
influence decision making . . . ’ (Bastian
1998, p. 11)
Working with ‘Public health advocacy, particularly Public relations (Pieczka
the media to through media advocacy, is the strategic 2002) and a pathway to
disseminate key use of news media to advance a public research impact (ESRC
messages policy initiative, often in the face of such 2014)
opposition’ (Chapman 2004, p. 361)
Achieving ‘Public health advocacy is advocacy that Social marketing (Morris
changes to the is intended to reduce death or disability and Clarkson 2009) and
benefit of in groups of people (overall or from a public health generally
public health specific cause) and that is not confined (Hunter et al 2010)
to clinical settings’ (Christoffel 2000,
pp. 722–723)
Working with ‘[C]ollaborative efforts, including Knowledge exchange and
others/ building relationships with policy makers guidance on achieving
developing and the media and developing coalitions, research impact (e.g. ESRC
coalitions are often a strong catalyst for effective 2014; RCUK undated)
advocacy’ (Goodhart 2002, p. 342)

and local community interests, and generally try ‘to make visible the invisi­ble’
(Burawoy 2005, p. 264). From this perspective, advocacy is less about dissemi-
nating and promoting ‘expert’ knowledge and more about supporting
community-­led action (e.g. Altman et al 1994). For health inequalities research-
ers this way of thinking about advocacy would entail a shift in the focus of
knowledge-­translation efforts to something more people-centred (as, indeed,
some of the contributors to this book are calling for—see Chapters 6, 16, and 17).
 What is public health ‘advocacy’? 273

Overall, ‘public health advocacy’ clearly involves something more than the
widely accepted model of researchers working with senior civil servants to try
to develop evidence-informed policy responses to public health problems, but
precisely what kinds of activities are involved varies with different definitions
of the term. With a view to providing some rather clearer ‘lessons’ for health
inequalities researchers, Box 19.3 therefore provides some reflections from a
seasoned public health advocate (McKendrick) on the factors that contributed
to the success of advocacy efforts around tobacco control in Scotland, many of
which map onto the factors outlined in Table 19.1. These efforts helped to se-
cure: legislation making public places in Scotland smoke-free; bans on to-
bacco displays at the point of sale; bans on cigarette vending machines; Scottish

Box 19.3  What factors facilitated effective advocacy

for tobacco control policies in Scotland?
◆ The formation of a single, formal coalition, the Scottish Coalition on To-
bacco (SCOT), involving health charities, patients’ organizations and
medical organizations, as well as organizations that would not necessar-
ily be expected to have an interest in tobacco control, such as children’s
charities and environmental health organizations (adding weight to
arguments);
◆ Agreed terms of reference for this group from the outset;
◆ Identification of a lead organization (in this case, ASH Scotland) which
played a secretariat role and facilitated and guided SCOT’s direction;
◆ Identification of clear areas of consensus around deliverable policy solu-
tions on which member organizations agreed (whilst accepting that
member organizations would have different views on some issues);
◆ Regular deployment of these messages by SCOT members in their day-
to-day engagement with politicians (e.g. at cross-party meetings and at
party political conferences);
◆ Commitment to sharing information, strategies, and tactics in pursuit of
agreed wider goals;
◆ Identification and use of ‘policy windows’;
◆ Close joint working with civil servants, ministers, and parliamentarians,
which helped build trust and longer-term relationships (e.g. coalition
partners were ultimately invited to join the Scottish Ministerial Working
Group on Tobacco Control).
274 Influencing policy with research

Government support for the introduction of standardized tobacco packaging;

and a proposed Members Bill on Smoking in cars where children are present.

19.4  Can tobacco control advocacy successes offer

lessons for efforts to reduce health inequalities?
Taking tobacco control as one successful example of public health advocacy,
Table  19.3 highlights differences in the approach taken to influencing policy
compared to health inequalities. The differences between these two public health
concerns (some of which are evident in Table 19.3) inevitably limit the possibil-
ity that those seeking to reduce health inequalities might adapt precisely the
strategies and tactics that have been successfully employed in tobacco control.
Nonetheless, tobacco control successes do appear to offer some potential les-
sons for those seeking to reduce health inequalities. In addition to the import-
ance of developing a well-organized coalition with diverse members (which is
discussed in more detail in Section 5), these include: agreeing terms of refer-
ence and areas of consensus amongst coalition members at an early stage; con-
structing and promoting clear, deliverable policy solutions (preferably which fit
the ethos of existing policy objectives); and developing and maintaining close
relationships with politicians and civil servants.

Table 19.3  Factors contributing to the success of advocacy in tobacco control versus

the difficulties facing advocacy efforts to reduce health inequalities

Factors contributing to successful Related factors contributing to the difficulties

advocacy efforts in tobacco control
Exposure of tobacco industry strategies
and tactics to influence research and
policy have served as a catalyst for
public health advocacy.
Researchers have helped develop clear,
research-informed policy proposals for
addressing tobacco-related health
problems.
Many of the policy proposals being
advanced by tobacco control
researchers have (over time) come to
be viewed as publicly and political
acceptable.
Large health charities and organizations
representing health professionals have
prioritized tobacco control.
in developing similarly successful advocacy
efforts to reduce health inequalities
No clear opponent to serve as a catalyst for
advocacy group formation.
Researchers often appear reluctant/unable to
develop clear policy proposals for reducing
health inequalities.
There are currently few, if any, publicly or
politically acceptable alternatives to the market-
driven economic system that many researchers
believe underpins health inequalities.
No large charities or organizations representing
health professionals appear to be prioritizing
health inequalities.
 WHO IS RESPONSIBLE FOR ADVOCACY? 275

19.5  Who is responsible for advocacy to reduce health

inequalities?
In all the varying definitions of public health advocacy, it seems clear that, to be
effective, broad coalitions of actors from multiple professions and sectors need
to be involved. Yet, for health inequalities, it is not necessarily clear who ought
to be involved. This partly reflects the fact that, with a few notable exceptions
(e.g. Qureshi 2013), very little attention has been paid to examining who is try-
ing to influence the policies that impact on health inequalities (e.g. parliamen-
tarians, lobbying and campaign organizations, business interests, etc.—see
Chapter 13). However, it also, in sharp contrast to tobacco control, reflects the
lack of any clear advocacy coalition to reduce health inequalities in the UK (see
Table 19.3). Indeed, Smith (2013) notes that almost none of her 141 interview-
ees (researchers, civil servants, politicians, and policy advisors) were able to
identify any advocacy organizations that they perceived to be actively working
to address (let alone prioritize) health inequalities. As one politician inter-
viewed in her study reflected, ‘there’s no big lobby for tackling inequality’ (Smith
2013, p. 123).
With no clear enemy and no clear ‘vision’ of an alternative policy scenario, it
is perhaps unsurprising that the anti-inequalities lobby are fragmented and dis-
jointed. Nonetheless, there is a range of organizations and individuals beyond
academia and central government who have at least some interest in health in-
equalities. These include:
◆ local organizations, activists, and/or practitioners working in communities
that are particularly affected by health inequalities;
◆ commercial interests (e.g. pharmaceutical companies, such as Pfizer, which,
for example, co-sponsored a round-table discussion on reducing health in-
equalities with The New Statesman in November 2005);
◆ journalists with an interest in public health and/or social inequalities;
◆ knowledge-brokerage organizations with a public health/inequalities focus
(e.g. the UCL Institute for Health Equity, led by Michael Marmot, FUSE – the
Centre for Translational Research in Public Health – in the North-East of Eng-
land, and The Equality Trust, which is discussed in more detail Chapter 20);
◆ NGOs representing communities affected by health inequalities or health-
related issues for which inequalities are known to exist;
◆ organizations representing health professionals (e.g. the British Medical As-
sociation, the Faculty of Public Health, and the Royal Colleges); and
◆ researchers working beyond academia (e.g. in think tanks, the NHS, the
civil service, and the wider public sector).
276 Influencing policy with research

The lack of clear coalitions around health inequalities across these different pro-
fessional communities is probably at least partly because of the various interests
within and across each of these communities. For example, whilst some tobacco
control NGOs work to highlight the close links between health inequalities and
smoking, they tend to do so in ways which promote the idea that tobacco con-
trol interventions could be used to achieve reductions in health inequalities
(e.g. Crosier, on behalf of ASH 2005), rather than promoting the idea that re-
ductions in ‘upstream’ inequalities are necessary to substantially reduce
smoking­-related inequalities. Indeed, very few of the organizations/individuals
listed here are primarily concerned with reducing health inequalities via the
kinds of long-term, upstream mechanisms that most researchers appear to sup-
port (Smith and Kandlik Eltanani 2014). In this context, building a functioning,
research-informed advocacy-coalition is extremely difficult.
So where does this leave health inequalities researchers committed to achieving
policy or societal changes that will reduce health inequalities? Simply continuing
to try to promote research evidence to senior civil servants and ministers in the
hope they will feel able to act on this to a greater extent at some point in the future
does not seem sensible given the evident failure of this approach in achieving the
kinds of changes many health inequalities researchers in the UK had hoped for
(see Chapters 1, 2, 6, 8, 16, and 17). Improvements in the kind of information that
researchers provide policymakers with may help somewhat (see Chapters 6 and
18). However, given the innately political nature of policymaking in democracies
(see Figure 19.2), the need for advocacy to achieve the necessary public and pol-
itical support for evidence-informed policy responses to health inequalities
seems hard to deny (Mackenbach 2011; Sabatier and Jenkins-Smith 1993; Smith
2013). Yet, as Chapters 6 and 20 make clear, there are numerous difficulties facing
researchers who decide to engage in more advocacy-orientated work.

19.6  Health inequalities researchers as advocates

These difficulties appear to stem not from an aversion to any of the specific ac-
tivities that this kind of work might involve, but rather from a concern that en-
gaging in advocacy can lead to the partial (or biased) use of research; a concern
which is heightened by ‘the reductionist epistemology that underscores most
public health enterprise’ (Chapman 2007 p. 29). The lack of research into public
health advocacy means it is difficult to empirically assess the extent to which
this concern is justified, so the following sections simply employ the available
literature to (in 19.6.1) highlight some of the perceived risks of researchers en-
gaging in public health advocacy and (in 19.6.2) consider potential means of
managing these risks.
 Health inequalities researchers as advocates 277

19.6.1  The risks of engaging in public health advocacy

The available literature points to at least five risks facing researchers who engage
in public health advocacy. First, like all outward-facing, non-traditional aca-
demic activities, advocacy can be extremely time-consuming (see Chapter 20;
and Hicks et al 2012). Where academic rewards still revolve around more trad-
itional kinds of academic work, this may impact on an individual’s career
(Smith 2013) or their ability to achieve a healthy work–life balance (see Chap-
ter  20). Second, viable advocacy campaigns often focus on ‘winnable issues’.
From a research perspective, this may mean putting more research effort into
issues which appear ‘feasible’ or already on the policy agenda, and less on those
that seem too challenging for the current policy context (e.g. Behague and
Storeng 2008). From the perspective of health inequalities, it is easy to see how
this way of thinking could reinforce a research and policy focus on downstream,
behavioural interventions (see Chapter 8) and not the kind of ‘upstream’, larger-
scale policy changes researchers in the UK tend to support (Smith and Kandlik
Eltanani 2014). Third, once a researcher has spent time developing and express-
ing a clear policy position, it may be difficult to consider (or acknowledge)
other points of view, even as the research evidence evolves (Cruz and Walt
2012). Likewise, it has been suggested that advocates ‘tend to cite only the data
supporting their position, while ignoring or actively disparaging contradictory
evidence’ (Carr-Gregg 1993, p. 36S). It is perhaps for this reason, above others,
that academics who adopt public media profiles risk criticism from academic
colleagues (Smith 2013). As academics’ credibility within policy circles is often
closely linked to their perceived academic credibility (Rychetnik and Wise
2004; Smith 2013), this third risk can lead to a fourth, which is that, through the
very act of trying to influence policy, academics become perceived as somehow
less credible (Smith 2013). This, in turn, may limit their ability to influence
policy and public debates. Finally, adopting a clear policy position on a research
issue can implicitly or explicitly suggest that the available research is sufficient.
This may require a researcher to downplay the uncertainty in their findings and
may limit researchers’ ability to make a case for the need for further research on
a particular issue (Rychetnik and Wise 2004).
In addition to the risks facing researchers themselves, there are also risks to
the causes for which researchers might be advocating. First, as Rychetnik and
Wise (2004) point out, researchers may not have the right skill-sets for
­advocacy-orientated work and, where they do not, their efforts may be damag-
ing rather than helpful. Second, attracting public attention to research findings
might not always be the most effective way to influence policymakers (Rock et al
2011; Veerman et al 2006). Rock and colleagues (2011), for example, explain
278 Influencing policy with research

how a media campaign concerning food instability amongst poorer Canadian

families resulted in an unexpectedly negative public response. This kind of situ-
ation may mean policymakers feel constrained (rather than enabled) to take
research-informed action. Third, as noted earlier, the process of advocacy is
likely to require researchers to adopt and promote a clear set of policy proposals.
Trying to decide what these should be may reveal (or deepen) divisions across
the various actors with an interest in the issue (Behague and Storeng 2008; Cruz
and Walt 2012). Fourth and finally, if researchers lose, or damage, their own
credibility by engaging in advocacy work, then any campaigns associated with
those researchers may also be damaged (Veerman et al 2006).

19.6.2  Managing the risks involved in advocacy

Overall, there is little doubt that there are risks entailed in public health re-
searchers becoming involved in advocacy, but it also seems feasible that some of
these potential risks are manageable. For example, researchers could ensure that
there is a strong empirical basis for any advocacy work they engage with. Alter-
natively, undertaking further research may be positioned as a necessary first step
in a longer-term advocacy process. Second, it may be less risky for researchers
who have already developed a strong academic career (e.g. in senior, permanent
posts), with high levels of academic credibility, to engage in advocacy than it is
for earlier career researchers. Third, researchers can ensure that they are not
‘lone voices’ by working to build coalitions with other researchers and actors
from other sectors who share a (research-informed) belief in a particular public
health objective/goal. Finally, health inequalities researchers could support calls
for more advocacy-focused training within public health (e.g. Chapman 2007).

19.7  Conclusion: The specific challenges of working

to improve the influence of health inequalities research
After reflecting on some of the difficulties that have been encountered in efforts
to develop effective, evidence-informed policy responses to health inequalities
in the UK, this chapter considered the idea that advocacy may be needed to
achieve the necessary public and political support to implement the kinds of
policy responses that many health inequalities researchers support. However, as
the chapter went on to note, whilst there may be opportunities to learn from
relatively more successful examples of public health advocacy, such as tobacco
control (see Chapman 2007), it also seems likely that the complex, fractured,
and often deeply political nature of health inequalities debates entail specific
challenges. For one thing, there is a noticeable lack of major third-sector organ-
izations prioritizing reductions in health inequalities compared to the plethora
 WORKING TO IMPROVE THE INFLUENCE OF RESEARCH 279

of such organizations that have promoted, or are promoting, tobacco control

(Smith 2013). Yet, whilst this may make it more difficult for health inequalities
researchers to engage in advocacy, it also serves to underline the need for them
to do so. For, if researchers do not, who will?

References
Altman, D. G., Balcazar, F. E., Fawcett, S. B., Seekins, T., and Young, J. Q. (1994) Public
Health Advocacy: Creating Community Change to Improve Health. Palo Alto, CA:
­Stanford University Press.
Asbridge, M. (2004) Public place restrictions on smoking in Canada: Assessing the role of
the state, media, science and public health advocacy. Social Science and Medicine, 58(1):
13–24.
Bastian, H. (1998) Speaking up for ourselves: The evolution of consumer advocacy in health
care. International Journal of Technology Assessment in Health Care, 14(1): 3–23.
Behague, D. P., and Storeng, K. T. (2008) Collapsing the vertical–horizontal divide: An
ethnographic study of evidence-based policymaking in maternal health. American
­Journal of Public Health, 98(4): 644–649. doi: 10.2105/AJPH.2007.123117.
Burawoy, M. (2005) 2004 American Sociological Association presidential address: For pub-
lic sociology. British Journal of Sociology, 56(2): 259–294.
Carlisle, S. (2000) Health promotion, advocacy and health inequalities: A conceptual
framework. Health Promotion International, 15(4): 369–376.
Carr-Gregg, M. (1993) Interaction of public policy advocacy and research in the passage of
New Zealand’s Smoke-free Environments Act 1990. Addiction, 88(Suppl.1): 35s–41s.
Chapman, S. (2004) Advocacy for public health: A primer. Journal of Epidemiology and
Community Health, 58(5): 361–365.
Chapman, S. (2007) Public Health Advocacy and Tobacco Control—Making Smoking
­History. Oxford: Blackwell.
Christoffel, K. K. (2000) Public health advocacy: Process and product. American Journal of
Public Health, 90(5): 722–726.
Contandriopoulos, D. (2011) On the nature and strategies of organized interests in health
care policy making. Administration and Society, 43(1): 45–65.
Contandriopoulos, D., Lemire, M., Denis, J.-L., and Tremblay, É. (2010) Knowledge
­exchange processes in organizations and policy arenas: A narrative systematic review of
the literature. Milbank Quarterly, 88(4): 444–483.
Crosier, A. (on behalf of ASH (Action on Smoking and Health) (2005) Smoking and Health
Inequalities. London: ASH.
Cruz, V. O., and Walt, G. (2012) Brokering the boundary between science and advocacy:
The case of intermittent preventive treatment among infants. Health Policy and Planning.
doi: 10.1093/heapol/czs101.
ESRC (Economic and Social Research Council) (2014) What is research impact? Available
from http://www.esrc.ac.uk/funding-and-guidance/impact-toolkit/what-how-and-why/
what-is-research-impact.aspx.
Goodhart, F. W. (2002) Teaching advocacy to public health students: The New Jersey expe-
rience. Health Promotion Practice, 3(3): 341–346.
280 Influencing policy with research

Hicks, S., Duran, B., Wallerstein, N., Avila, M., Belone, L., Luccro, J., Magarati, M.,
Mainer, E., Martin, D., Muhammad, M., Oetzel, J., Pearson, C., Sahota, P., Simonds,
V., Sussman, A., Tafoya, G., Hat, E.W. (2012) Evaluating community-based participa-
tory research to improve community-partnered science and community health. Progress
in Community Health Partnerships: Research, Education, and Action, 6(3): 289–299.
Hunter, D. J., Marks, L., and Smith, K. E. (2010) The Public Health System in England.
­Bristol: Policy Press.
Innvær, S., Vist, G., Trommald, M., and Oxman, A. (2002) Health policy-makers’ percep-
tions of their use of evidence: A systematic review. Journal of Health Services Research
and Policy, 7(4): 239–244.
Katikireddi, S. V., Higgins, M., Bond, L., Bonell, C., and Macintyre, S. (2011) How evi-
dence based is English public health policy? British Medical Journal, 343(d7310): d7310.
Lomas, J. (2007) The in-between world of knowledge brokering. British Medical Journal,
334(7585): 129–132.
Macintyre, S., Chalmers, I., Horton, R. and Smith, R. (2001) Using evidence to inform
health policy: case study. BMJ 322(7280): 222–5.
Macintyre, S. (2011) Good intentions and received wisdom are not good enough: The need
for controlled trials in public health. Journal of Epidemiology and Community Health,
65(7): 564–567.
Mackenbach, J. P. (2011) Can we reduce health inequalities? An analysis of the English
strategy (1997–2010). Journal of Epidemiology and Community Health, 5(7): 568–575.
Mitton, C., Adair, C. E., McKenzie, E., Patten, S. B., and Waye Perry, B. (2007) Knowledge
transfer and exchange: Review and synthesis of the literature. Milbank Quarterly, 85(4):
729–768.
Morris, Z. S., and Clarkson, P. J. (2009) Does social marketing provide a framework for
changing healthcare practice? Health Policy, 91(2): 135–141.
Mulgan, G. (2005) Government, knowledge and the business of policy making: The poten-
tial and limits of evidence-based policy. Evidence and Policy, 1(2): 215–226.
Pawson, R. (2006) Evidence-based Policy: A Realist Perspective. London: SAGE
Publications.
Petticrew, M., Whitehead, M., Macintyre, S. J., Graham, H., and Egan, M. (2004) Evidence
for public health policy on inequalities: 1: The reality according to policymakers. Journal
of Epidemiology and Community Health, 58(10): 811–816.
Pieczka, M. (2002) Public relations expertise deconstructed. Media, Culture and Society,
24(3): 301–323.
Qureshi, K. (2013) It’s not just pills and potions? Depoliticising health inequalities policy in
England. Anthropology and Medicine, 20(1): 1–12.
RCUK (Research Councils UK) (undated) Mission Statement of Expectation on Economic
and Societal Impact. RCUK: http://www.rcuk.ac.uk/RCUK-prod/assets/documents/
innovation/missionsei.pdf.
Rock, M. J., McIntyre, L., Persaud, S. A., and Thomas, K. L. (2011) A media advocacy
intervention linking health disparities and food insecurity. Health Education Research,
26(6): 948–960. doi: http://dx.doi.org/10.1093/her/cyr043.
Rychetnik, L., and Wise, M. (2004) Advocating evidence-based health promotion: Reflec-
tions and a way forward. Health Promotion International, 19(2): 247–257.
 WORKING TO IMPROVE THE INFLUENCE OF RESEARCH 281

Sabatier, P. A., and Jenkins-Smith, H. C. (eds) (1993) Policy Learning and Change: An
­Advocacy Coalition Approach. Boulder, CO: Westview Press.
Shiffman, J., and Smith, S. (2007) Generation of political priority for global health initia-
tives: A framework and case study of maternal mortality. The Lancet, 370: 1370–1379.
Smith, K. E. (2007) Health inequalities in Scotland and England: The contrasting journeys
of ideas from research into policy. Social Science and Medicine, 64(7): 1438–1449.
Smith, K. E. (2013) Beyond Evidence-based Policy in Public Health: The Interplay of Ideas.
Basingstoke: Palgrave Macmillan.
Smith, K. E., and Kandlik Eltanani, M. (2014) What kinds of policies to reduce health in-
equalities in the UK do researchers support? Journal of Public Health. Online first. doi:
10.1093/pubmed/fdu057.
Soer, A. (2013) Policy 2.0: Can we move beyond the classic policy cycle? UNDP ‘Voices
from Eurasia’ blog, 28 June 2013, http://europeandcis.undp.org/blog/2013/06/28/
policy-2–0-can-we-move-beyond-the-classic-policy-cycle/.
Veerman, J., Bekker, M., and Mackenbach, J. (2006) Health impact assessment and advo-
cacy: A challenging combination. Sozial- und Präventivmedizin SPM, 51(3): 151–152.
doi: 10.1007/s00038–006–0034-z.
Whitehead, M., Petticrew, M., Graham, H., Macintyre, S., Bambra, C., and Egan, M.
(2004) Evidence for public health policy on inequalities 2: Assembling the evidence
­jigsaw. Journal of Epidemiology and Community Health, 58(10): 817–821.
WHO Europe (2006) Gaining health: The European strategy for the prevention and control
of noncommunicable diseases. Copenhagen: World Health Organization, http://www.
euro.who.int/__data/assets/pdf_file/0008/76526/E89306.pdf.
 Chapter 20

The Spirit Level: A case study

of the public dissemination
of health inequalities research
Kate Pickett and Richard Wilkinson

20.1  Introduction: Deciding to do it

We should perhaps start by explaining how we came to write The Spirit Level
(Wilkinson and Pickett 2010), and why we decided that it was a good idea to try
to write a ‘popular book’ about the health and social effects of greater income
inequality. We were, after all, relatively successful academic researchers: we had
secured grant funding, published widely on the social determinants of health
and health inequalities (Richard had written many successful academic books),
spoke regularly at conferences, and were teaching and training students—so
why decide to write something so different from our usual peer-reviewed pa-
pers in academic journals?
Perhaps the primary driver was our day-to-day frustration with the public
discourse on the causes of health and social problems. Every day, we woke up to
Radio 4’s Today programme, continued to check in with radio and television
news programmes throughout the day, and ploughed through the newspaper.
And almost every day, we felt incredible frustration with the level of debate, and
content, of items concerning population health, violence, social dysfunction,
etc. If a problem like teenage births was being discussed, various ‘talking heads’
would be brought in to comment, and there was no mention of the role of in-
equality. One of us was even told, by a Member of the Scottish Parliament, that
discussion of inequality was forbidden in New Labour. Nobody was talking
about an issue which our own research, and that of many others, revealed to be
a major problem. Richard was keen to make a last effort, before retirement, to
get political attention for the impact of inequality.
Why did nobody know about the empirical evidence that was steadily accu-
mulating on the impact of inequality? Because nobody, apart from academics,
reads research papers. And not many researchers read most academic papers.
 Deciding the format 283

We once thought about writing a rebuttal of a research paper that we thought

had misrepresented the independent effects of absolute and relative income on
health, but when we checked a citation index, we found it had only been refer-
enced four times . . . Why spend time critiquing an analysis that clearly nobody
had read in the first place?
We had come to feel that we were sitting on a large and robust body of evi-
dence that deserved to be more widely known, and we decided to try to get that
research out there.
For Richard in particular, who was coming up to retirement and had a long
career behind him that had involved many intense academic debates on the
psychosocial versus material determinants of health, and the role of income
inequality, it seemed like a good idea to try to do something that would pull
together an evolving and broad interpretation of the evidence and have a
political impact. At this stage, we thought of a very short book, almost a
pamphlet.

20.2  Deciding the format

The first choice we made after deciding to go ahead was to seek a commercial,
rather than an academic publisher. We studied lists of the annual bestsellers
in non-fiction, ignoring the cookbooks and celebrity biographers, looking for
the publishers of serious works of non-fiction. Penguin was a clear winner.
However, their guidance for authors was clear; like many commercial pub-
lishers, they do not consider unsolicited manuscripts, and we did not have an
agent. Luckily, we knew others who had published with Penguin and were
given an editor’s name by a colleague. We wrote to him directly, and that was
how we were lucky enough to fall into the editorial arms of one of Penguin’s
most experienced editors, who was to prove immensely helpful throughout,
with advice, rigorous editing, and support for our project. Although we did
not know it at the time, our editor is known for supporting the publication of
serious history, politics, science, and other academic disciplines. When it
came to publication date, Penguin was also able to provide influential mar-
keting and public relations that made a significant contribution to the book’s
success.
We also made a careful study of books that had managed to communicate
serious social science to lay audiences. Two were particularly influential: Rich-
ard Layard’s Happiness (Layard 2005) (also published by Penguin), and Robert
Putnam’s Bowling Alone (Putnam 2000). From Happiness we saw, in particular,
how useful cartoons, quotes, and stories could be. From Bowling Alone we
learned how to simplify our graphs and then simplify them again.
284 THE SPIRIT LEVEL CASE STUDY

We deliberately eliminated such things as correlation coefficients, p-values,

equations of any kinds, and the use of any technical language to describe our
methods. That was to get us into trouble in some quarters later on—we were
accused by a member of Radical Statistics of ‘dumbing down’. But of course our
book was not aimed at statisticians; they are not a very large segment of the
population and, if they wanted the coefficients and the p-values, they could read
our peer-reviewed papers, or look them up on the linked website we provided.
As we wrote, we strove for clear and simple language, but this is easier said
than done for academic researchers. We each worked on initial drafts of half of
the chapters, then we swapped, commented, swapped again and revised,
swapped, and commented again. We also had two rounds of our editor’s com-
ments on the whole manuscript and then the comments of a professional proof-
reader, so each chapter went through at least six drafts and the clarity improved
with each revision. It is not always easy writing in partnership, since one tends
to get attached to particular phrases or stories and it is sometimes hard to take
yet another round of feedback, but we do feel the book was improved by the
process.

20.3  The Equality Trust

Whilst we were writing The Spirit Level and between handing in our manuscript
and actual publication, we were also working to set up The Equality Trust
(http://www.equalitytrust.org.uk). Richard had been approached by Bill Kerry,1
who asked if anybody was campaigning on inequality. There were plenty of
charities and activist groups aimed at combating poverty, but none which cam-
paigned specifically on the gap between rich and poor.
We established The Equality Trust as a not-for-profit company (it is now a
charity), set up an advisory group of people who we thought could help us get
the Trust off the ground, and were lucky enough to get help from the start from
the Joseph Rowntree Charitable Trust (JRCT), who supported us working
with the Sheila McKechnie Foundation to develop a vision and strategy. The
Equality Trust aims to make the evidence more accessible and better known,
and to campaign to reduce income inequality in order to improve the quality of
life in the UK. In 2008 we were awarded core funding by JRCT, and we were able
to commission a website from e-campaigning experts and employ our first
member of staff. The Equality Trust’s launch coincided with publication of The
Spirit Level in March 2009. Five years on, the Trust is still funded in part by
JRCT, has incorporated the One Society project supported by the Network for
Social Change, and now has six staff. We now serve on a Board of seven people,
which oversees and guides the work of the Trust.
 Unexpected success 285

The Equality Trust now has 23 UK local groups and 28 international groups,
including eight in the USA, as well as more than 8,000 followers on Twitter and
more than 7,000 on Facebook. The Trust and One Society have produced di-
gests and updates of new research that are widely cited in the media, and ori-
ginal reports on subjects such as pay distribution within FTSE companies and a
half-term report on the Coalition government. Additional funding has ranged
from a grant from the Amiel and Milburn Trust to employ a research fellow,
resulting in a published review of time-series studies of inequality and crime, to
a grant from Arts Council England to create a photography exhibition inspired
by research on inequality, to a grant from the ESRC Follow-on Fund to create
educational materials for young adults. We have also benefited from donations
of money, time, experience, and skills from many people, including a film
maker, Babycakes Romero, who made a number of short films for us, one of
which has been watched almost 50,000 times (http://babycakesromero.com/
films/the-spirt-level/).
In the lead up to the 2010 General Election, One Society commissioned the
think-tank Demos to produce three pamphlets to present the case that a
more equal society is both advantageous and plausible, with each pamphlet
tailoring its argument to a different one of the three largest UK political par-
ties. The Equality Trust asked parliamentary candidates to sign an Equality
Pledge, which described The Spirit Level research, and to ‘actively support the
case for policies designed to narrow the gap between rich and poor’—it was
signed by 75 MPs who entered the new parliament, including 11 Conserva-
tives, 18 Liberal Democrats (including 2 cabinet ministers), 1 Green, and 45
Labour MPs.
Local Equality Trust groups are active in local campaigning, using the re-
search base as evidence. For example, the London branch, My Fair London,
developed a pledge for candidates in the London Mayoral election and Equality
Bristol produced an ‘Equality Declaration’ for local election candidates to sign.
The Newport group successfully campaigned for the setting-up of a local Fair-
ness Commission.
Establishing The Equality Trust created a platform for disseminating research
on inequality more widely, through different media and to different audiences.

20.4  Unexpected success

In March 2009 The Spirit Level was published, to almost immediate critical and
popular acclaim. We were bowled over by its reception and, to mix metaphors,
have been swept up by that success to an extent that dealing with requests and
questions remains almost a full-time job for both of us, even after six years. It
286 THE SPIRIT LEVEL CASE STUDY

is, of course, tempting to try to take some credit for this, and certainly we think
that some of the choices we made, such as publisher, format, and style, helped.
But they probably only helped a bit. There are lots of well-written, serious books
out there, backed by major publishers, so the answer lies elsewhere—we think
there are probably three major factors underpinning the book’s unexpected
success.
First, sadly, was the Global Financial Crisis. Suddenly, business (economics
and politics) as usual was thrown into disarray. People were looking for alterna-
tive perspectives on what the economy should look like, what it was for, and
whether or not capitalism, in particular its neoliberal form, and continuous
economic growth were sensible systems for ensuring human well-being and
quality of life. Over time, economists and others have started to focus on the
role of inequality in precipitating the financial crash, the demand for credit,
high welfare bills, and what Will Hutton calls ‘our fragile banking system and its
still feral proclivities’ (Hutton 2014). Inequality, through its negative impact on
family life, education, and social mobility, has led to a tragic waste of human
capital, productivity, and innovation. In this context, our research and analysis
was welcomed in a way that would not have been possible a couple of years
before.
Second, we found that our empirical approach and presentation of ‘evidence’
resonated with the vast majority of people, who had long-felt intuitions about
inequality and unfairness. This was an issue they felt in their bones, had experi-
enced personally, and could relate to. We were giving them something for their
heads which connected with what they felt in their hearts. Our experience at
talk after talk, to widely varied audiences, was looking out at a sea of slightly
nodding heads and murmurs of agreement. People were thirsty for the story we
were telling.
Third, we had some really lucky breaks. Before publication, both the Fabian
Society and The Guardian newspaper had invited us to give seminars to their
staff. Not only did The Guardian publish a very supportive, long review of the
book, they also produced a two-page spread of graphics and facts, and pub-
lished a long interview with us, all of which helped to get the book off to a good
start. And there is no doubt that journalists and graphic designers can do a lot
to tell a story that is beyond the capacity of most academics. Look, for instance,
at the following three graphs. The first, Figure  20.1, is typical of a graph we
might produce linking our Index of Health and Social Problems to income in-
equality for publication in a peer-reviewed scientific journal; next comes Fig-
ure 20.2, the kind of graph we included in our book, followed by The Guardian’s
representation (Figure 20.3).
 Unexpected success 287

2
Index of health and social problems, SD units
1
0
–1

3 4 5 6 7 8 9
Income inequality, 20:20 ratio
Fig. 20.1 The relationship between an Index of Health and Social Problems and income
inequality—for publication in a peer-reviewed scientific journal, including confidence
bands and a z-score y-axis.

Worse USA
Index of health and social problems

Portugal

UK

Greece
Ireland New Zealand

Austria France Australia

Denmark Germany Canada Italy
Spain
Belgium Switzerland
Finland
Norway Netherlands
Sweden

Japan

Better
Low High
Income Inequality
Fig. 20.2 The relationship between an Index of Health and Social Problems and
­income inequality—as published in The Spirit Level, labelling countries and with sim-
ple axis labels.
 288
Combined social problem score US

More problems

THE SPIRIT LEVEL CASE STUDY

Odd couples
Japan and Sweden are chalk and cheese
societies. Sweden has a big welfare state
and a progressive stance on women’s rights, Portugal
whereas in Japan the government is a small
spender by international standards and
traditional gender divides remain important.
But in both countries incomes are unusually
evenly spread, and the chart reveals that both UK
suffer from fewer social problems than other
industrial societies.

Greece
Ireland New Zealand
France
Austria Australia
Canada
Germany Italy
Denmark

Belgium
Spain Odd couples
Finland Switzerland Spain and Portugal are Mediterranean neigh-
Netherlands bours with many cultural connections and
Norway close parallels in their recent history - both
democratised in the 1970s after the fall of
authoritarian regimes. One difference is that
Fewer problems

Sweden Spain is the more ethnically diverse, and

diversity is sometimes said to strain social
solidarity. But Spain is mid-table in the
inequality league while Portuguese is near the
top. And the chart shows that the Portuguese
Japan side of the Iberian peninsula has many more
social problems.
More equal More unequal

Fig. 20.3 The relationship between an Index of Health and Social Problems and income inequality.
Reproduced with permission from ‘Inequality: mother of all evils?’, The Guardian, 13 March 2009, Copyright © Guardian News & Media Ltd 2009.
 Commitment to dissemination 289

20.5  Commitment to dissemination

In the immediate period after publication, we were invited to participate in
some radio, television, and print media, and invitations to speak about the book
began to pour in. They still do. Initially, we had thought that it was worth re-
sponding to everything we were asked to do—because it could not last for long,
and also because you cannot write a book about inequality and then decide that
some audiences are not important enough to talk to, or not big enough to mat-
ter. And so we embarked on a series of speaking engagements (more than 700
to date), talking to audiences as different as national, foreign, and international
government ministries and agencies, the UK Cabinet Office, health authorities,
political party conferences, universities, trade unions, faith groups, NGOs,
think tanks, and charities. We have spoken everywhere, from old people’s
homes and small groups in draughty church halls to the Palais des Nations at
the UN in Geneva and the US Congress.
And as Penguin began to negotiate foreign editions of our book (we are now
up to 24), we have increasingly travelled abroad. We have presented our work
on all continents except Antarctica, and still the invitations keep coming.
As well as talking, we have been continuously invited to write more. We have
written for newspapers and magazines, and websites, and reports for think
tanks and others; at least 50 such pieces, which help to bring the research to
people who tend not to read books. Even more effective in reaching large num-
bers are radio, TV, and online appearances. Richard’s TED talk, for example, has
received almost 2.2 million views so far.
And how has this helped? Have we managed to achieve anything beyond sell-
ing a few more books?
In the run-up to the 2010 UK General Election, we were consulted by the
Liberal Democrat’s Policy Consultation on Inequality and the Green Party’s
strategy group, each of which was developing manifesto commitments to
greater equality and fairness. In his Hugo Young lecture, prior to the election,
David Cameron said that our research had ‘shown that among the richest coun-
tries, it’s the more unequal ones that do worse according to almost every quality
of life indicator’ (Cameron 2009). Then-Labour leader Ed Miliband wrote
about the importance of academic research for changing politics in The New
Statesman, saying, ‘The Spirit Level . . . is a book in the best of that tradition’
(Miliband 2010). Following the election, BBC 4 journalist Mukul Devichand
said, ‘Both Prime Minister David Cameron and Labour leader Ed Miliband ap-
pear to be disciples of The Spirit Level’ (Devichand 2010).
There is growing international recognition of The Spirit Level research; head
of the International Monetary Fund, Christine Lagarde, has said, ‘Now all of us
290 THE SPIRIT LEVEL CASE STUDY

have a better understanding that a more equal distribution of income allows for
more economic stability, more sustained economic growth, and healthier soci-
eties with stronger bonds of cohesion and trust’ (Lagarde 2013). United Nations
Secretary General Ban Ki-Moon stated, ‘Social and economic inequalities can
tear the social fabric, undermine social cohesion and prevent nations from
thriving. Inequality can breed crime, disease and environmental degradation
and hamper economic growth’ (Moon 2013). Nobel Prize winning economist
Paul Krugman wrote, ‘Wilkinson-type views about the corrosive effects of in-
equality are going seriously mainstream’ (Krugman 2012).
Still, there are words and then there are actions. We know that our work has
been cited in legislative assemblies, including both Houses of Parliament in
England, the Scottish Parliament, the Welsh Assembly, and the New Zealand,
Australian, and Canadian parliaments. The UK Equality Act, which received
Royal Assent in 2010, included a duty that local and national public bodies
must ‘have regard to the desirability of reducing socio-economic inequalities’ in
their decision-making. The Spirit Level was cited in the Lords debate introdu-
cing the bill and by the Labour Government’s Equalities Office in support of the
socioeconomic duty. We can also trace citations of the book through numerous
policy documents and reports. But what about real change on the ground?
In terms of UK policy impacts, The Spirit Level has perhaps been most influ-
ential in the establishment and outcomes of local Fairness Commissions. A use-
ful review of these has been published by the Beatrice Webb Memorial Trust
(http://www.webbmemorialtrust.org.uk/uncategorized/civil-­s ociety-and-
poverty/). Since 2010, at least 12 Local Authorities (Birmingham, Blackpool,
Islington, Leicester, Liverpool, Newcastle, Newport, Portsmouth, Sheffield,
Southampton, Tower Hamlets, York) have established ‘Fairness Commissions’
to investigate and implement ways of reducing inequality in their areas, such as
recommending and campaigning for the payment of a Living Wage. Richard
was a Commissioner for Islington and has spoken to all the commissions, both
of us were Commissioners for York, and Kate was a Commissioner for the na-
tional, independent Living Wage Commission, which published its final report
in June 2014, recommending a strategy to lift a million more UK workers
up to the Living Wage (http://livingwagecommission.org.uk/living-­­wage-
commission-reveals-blueprint-for-lifting-1 m-out-of-low-pay/).

20.6  Not all fun and games

There are risks inherent in trying to disseminate quite complex research and
ideas very broadly. Some of the decisions we made, notably the presentation of
a set of very simple analyses for a consistent group of countries, left us open to
 Not all fun and games 291

accusations of over-simplification, and indeed to attempts to refute or overturn

the picture the book paints. With hindsight, we should have been much more
explicit about the weight of the evidence and the vast numbers of other studies.
However, we do not regret the choice to present things simply—that was essen-
tial in order to communicate what we had to say to the readers we wanted to
reach.
Research on the impact of inequality has always been controversial because
the political and policy implications of accepting the links between inequality,
poor health, and other social problems are seen as so problematic. It is generally
acceptable, across the political spectrum, to show that poverty alleviation would
be a good thing, but as soon as one starts to suggest that the rich having too
much is as great a problem as the poor having too little, then powerful interests
and ideologies are provoked.
We knew there would be critics of our work, particularly from the political
right, but we were perhaps unprepared for their nature, and especially for the per-
sonal nature that some criticisms have involved. It is perhaps an indicator of suc-
cess that we did provoke such responses, and certainly journalist friends on the
political left view this as the ultimate accolade—you have obviously had an im-
pact if your enemies are out to get you. But the personal effect can be bruising.
In 2010 two published responses to our work made it essential for us to engage
with critics: The Spirit Level Delusion (Snowdon 2010) by Christopher Snowdon,
a freelance author and fellow of the right-wing free market UK-based Institute
for Economic Affairs and the US-based Cato Institute, who had previously con-
centrated on opposing state tobacco- and alcohol-control policies; and ex-­
academic sociologist Peter Saunders, now an independent researcher, who
claims that his focus is ‘exploring practical solutions to pressing social problems
that do not entail more government spending, or more control of our lives by the
state’. Through the right-wing think tank Policy Exchange, he published a
pamphlet criticizing our book titled ‘Beware False Prophets’ (Saunders 2010).
It is not very nice to be called either delusional or a false prophet (although we
are aware we have been called worse on social media, including by a student at
Kate’s university with serious Twitter incontinence), but these two publications
needed an intellectual, as well as an emotional, response. In late 2010 a new
paperback edition of The Spirit Level was published, with a new chapter re-
sponding to the claims made by these critics and other points people had raised,
as well as describing new research published since we had submitted our manu-
script in 2008. We also took part in a public debate with critics at the Royal So-
ciety for Arts in London, published responses on The Equality Trust website,
and were delighted by an independent and thorough debunking of the Saun-
ders tract by Hugh Noble in Radical Statistics (Noble 2011).
292 THE SPIRIT LEVEL CASE STUDY

Some good things came out of this painful situation, although the personal
toll, for Kate in particular, was heavy. Our scoping of new literature and further
analyses led to new insights, which are informing the book we are currently
writing, and an increased faith in the robust picture provided by the data.

20.7  Just what is a ‘public intellectual’?

One consequence of writing our book has been the extent to which we have
been called upon and encouraged to adopt the role of ‘public intellectuals’. This
is a strange role, which the Oxford English Dictionary describes as ‘an intellec-
tual who expresses views (especially on popular topics) intended to be access-
ible to a general audience’.
As social epidemiologists we had seen our role as describing how a social fac-
tor, income inequality, was related to, and determined, a range of health and
social problems, and to think about whether or not, and how, this might be a
causal relationship. We did not expect, and neither do we have the expertise, to
prescribe political or policy solutions, although we can certainly suggest alter-
native approaches. Nevertheless, we are often approached by the media, polit-
ical and policy organizations, and others to speak and write about a range of
topics such as gender equality, human rights, poverty, sustainability, and con-
sumerism. We have more expertise on some of these issues than others, and as
our research on inequality continues, we are making connections to many of
these issues, but on others we simply have an opinion. We are learning to think
about the boundaries between expertise and opinion, and the balance between
our rights to express our opinion and the responsibility of being grounded in
our science. We tend to refuse invitations to write and speak on topics where we
have no expertise and try to focus now on putting over a vision of what greater
equality would mean to people and planet.
Our research, and our writing, is interdisciplinary and broad, and the dem-
onstrated effects of inequality are also widening, so for now we think we are
probably getting the balance more or less right, but it is something we discuss
and worry about.

20.8  Moving from research to advocacy

and campaigning
We have made a clear and deliberate move from working purely as researchers
to also becoming campaigners and advocates of social change. This is a slightly
different ‘problem’ than the potential pitfalls of a role as a ‘public intellectual’. At
what point, if ever, should researchers adopt a campaigning and advocacy role?
Is it not our job to be as objective as possible, to distance ourselves from the
 MOVING FROM RESEARCH TO ADVOCACY & CAMPAIGNING 293

political and policy implications of our research, and leave advocacy and cam-
paigning to others? This is certainly how some scientists and social scientists
view their role, influenced by ideologies and theories underpinning scientific
discovery and knowledge.
Luckily, Richard had the good fortune, when he was a student at the LSE, to
attend the lectures of Karl Popper. Popper taught that it is not the sources of
theories which have to be objective, but rather the methods of testing them. We
can be, and all are, influenced by our politics and ideology when choosing dis-
ciplines, preferring theoretical approaches, or developing hypotheses—that is
fine, as long as we test them rigorously.
And for epidemiologists, and others who work in an observational rather
than an experimental framework, there is reassurance in the words of
Thomas Kuhn:

No theory ever solves all the puzzles with which it is confronted at a given time; nor
are the solutions already achieved often perfect. On the contrary, it is just the in-
completeness and imperfection of the existing data-theory fit that, at any given
time, define many of the puzzles that characterize normal science.
Reproduced from T.S. Kuhn, The structure of scientific revolutions,
2nd Edition © 2007, The University of Chicago Press

There are other compelling reasons for us, as social epidemiologists, to move
towards campaigning and advocacy. The UK has a long, proud tradition of re-
search, and major reports, on the social determinants of health and health in-
equalities (as discussed in Chapters 1 and 2), and a now long-ish (although less
proud) tradition of government policy attempting to address health inequal-
ities (as discussed in Chapter 1). Yet life-expectancy gaps between the richest
and poorest areas of large UK cities are typically around ten years. Social epi-
demiology as an academic discipline and public health as a profession have not
been effective in addressing either the social determinants of health or health
inequalities over many decades of trying.
Some of that is a result of our scientific caution—we understand that the pic-
ture is complex, we know that no single policy or solution will fix everything,
we know that theories can be overturned, that observational data is rarely, if
ever, definitive—and so we hold back from advocating for radical social change,
even when we believe, on the best evidence, that it would be the best solution.
And some of this is a result of our caution as real people; it does not always
feel safe outside of the ivory tower, it is not always a happy place to be. When we
are debating subtle points of statistical models, or potential confounding fac-
tors, or bias in our samples, with other researchers who have read the same
things that we have, life is not as challenging as it is if we come out of that safe
294 THE SPIRIT LEVEL CASE STUDY

place and make ourselves vulnerable to the comments, criticisms, and some-
times hatred of people who do not want to grapple with the complexities or
understand the nuances, but who are quite simply opposed to everything
we say.
I suppose we have felt it imperative to try to help break the impasse between
the research evidence and the lack of effective action, but it is not a comfortable
decision to make and it will get no less uncomfortable unless more of us take
similar actions and look for different ways out of the impasse, supporting each
other as we do so. Some of our most difficult times in the past five years have
been when we felt that our own academic community was less supportive than
it could have been, and less positive about maximizing any chance we have of
bringing about the social change we all believe is needed. It is important to re-
member that unless we can get our research into the public domain, we are
simply ineffective.
Ted Schrecker recently wrote that if we adopt ‘what has been called a tobacco
industry standard of proof with respect to social determinants of health . . . the
evidence may never be strong enough’ (Schrecker 2013). Our choice has been
to pull together empirical work into a plausible and coherent causal narrative
and then, believing it to be an important issue of social justice and human
rights, to go out and campaign as hard as we can. Others will make different
choices, but as an academic community it would be nice if we could more often
put aside minor academic debates, controversies, and differences and work for
what we feel to be right.

20.9  Moving on
It has to be said that a major drawback of focusing on disseminating research is
how it gets in the way of doing new work. In the six years since publishing our
book, we have made slower progress with more traditional academic work
than previously. We are writing a new book and struggling to find the time for
concentrated periods of writing and to have anything like the work–life bal-
ance so necessary for health and well-being. We work in the evenings, we work
at weekends, we work on holidays, but there is never enough time. Richard, in
retirement, is busier than he has ever been. Kate is lucky enough to have been
working with a wonderful group of research fellows and students over this
time, many of whom are helping to push the research agenda along in import-
ant ways, but full-time academic positions impose many other duties and re-
sponsibilities as well.
And of course, many new opportunities have arisen. Perhaps most important
is the work we are doing with an international group of collaborators, the Alliance
 Moving on 295

for Sustainability and Prosperity (ASAP, http://www.asap4all.org) to ensure that

inequality is a central issue for the post-2015 development agenda and in the new
Sustainable Development Goals.
The links between income inequality and environmental issues grow increas-
ingly clear. Moving towards sustainability and optimizing well-being both in-
volve changing our social and economic systems. We cannot develop sustainable
economies and ways of life on the basis of huge international inequalities, un-
bridled consumerism, international conflict, and with our economic life dom-
inated by powerful corporations which avoid democratic accountability (see
Chapter 13). These are big and complex issues, but connect local and national
agendas to address health inequalities to international issues of development.
As always, the big issues are the hard ones, but we generally remain optimistic
and feel that even small efforts can have unexpected pay-offs.
In many ways, the best part of our Spirit Level experiences has been our part-
nership, the ways in which collaboration leads to new insights, new analyses,
and new opportunities, and the solidarity and support that comes from work-
ing on a common cause. The academic life is too often more about competition
than cooperation, but when we work together, we can achieve so much more.

Note
1 Prior to the launch of The Equality Trust, Bill worked as a Company Secretary across the
private, charitable, and social enterprise sectors, a role he now performs for the Trust as
well. He also looks after the Trust’s network of supporters and autonomous local groups.

References
Cameron, D. (2009) Hugo Young Lecture, 10 November.
Devichand, M. (2010) The Spirit Level: Britain’s new theory of everything? BBC News Radio
4, 12 October.
Hutton, W. (2014) We are scared to face the real issue—it’s all about inequality. Observer,
19 January.
Krugman, P. (2012) The economics of marginalization and hopelessness. New York Times.
Lagarde, C. (2013) Speech at World Economic Forum, Davos, 23 January.
Layard, R. (2005) Happiness: Lessons from a New Science. London: Allen Lane.
Miliband, E. (2010) What this country needs is Labour with a new vision. New Statesman,
26 August.
Moon, B.-K. (2013) Remarks at informal General Assembly Thematic Debate on Inequality
[Online], http://www.un.org/apps/news/infocus/sgspeeches/statments_full.asp?statID=
1918#.UfDb943EPO4: United Nations (accessed 25 July 2013).
Noble, H. (2011) Comments on The Spirit Level controversy. Radical Statistics, 104: 49–60.
Putnam, R. D. (2000) Bowling Alone: The Collapse and Revival of American Community.
New York: Simon and Schuster.
296 THE SPIRIT LEVEL CASE STUDY

Saunders, P. (2010) Beware False Prophets: Equality, the Good Society and The Spirit Level.
London: Policy Exchange.
Schrecker, T. (2013) Can health equity survive epidemiology? Standards of proof and social
determinants of health. Preventive Medicine, 57 (6): 741–744.
Snowdon, C. (2010) The Spirit Level Delusion: Fact-checking the Left’s New Theory of Every-
thing. Ripon: Little Dice.
Wilkinson, R. G., and Pickett, K. (2010) The Spirit Level: Why Equality is Better for Every-
one. London: Penguin.
 Chapter 21

Conclusion—where next
for advocates, researchers,
and policymakers trying
to tackle health inequalities?
Katherine E. Smith, Sarah Hill,
and Clare Bambra

21.1  The challenge of reducing health inequalities

Reducing health inequalities is no easy task. Despite the mass of research that
has been undertaken and the multiple policy interventions that have been tried
in the UK and other countries (see Chapters 1–4), health inequalities persist
and have even widened in many contexts. Reflecting on the various perspec-
tives provided in this book, Box 21.1 highlights what appear to be the major
challenges for understanding and tackling health inequalities. The wide-­
ranging nature of these challenges underlines the futility of seeking a ‘magic
bullet’ to ‘fix’ health inequalities. Nonetheless, the various contributions to this
book also point to the potential for health inequalities researchers and others to
do more in addressing health inequalities, though realization of this potential
may require a departure from the familiarity of traditional approaches.
In this concluding chapter we develop some ideas for strengthening health
inequalities research, reflecting on contributions and insights offered by the
contributors in this book. As academics, we are particularly focused on the po-
tential for researchers to help reduce health inequalities, but we also recognize
that research is only one part of this effort. We have therefore set out some sug-
gestions for how individuals working in a range of other professional settings
might also contribute to tackling health inequalities.

21.2  Using historical and international research

to understand the impact of ‘policy packages’
As Chapters 1–5 make clear, the UK has played a leading role in developing
our understanding of health inequalities. There are limits to the lessons that it
298 WHERE NEXT?

Box 21.1  Seven key challenges for better

understanding and reducing health inequalities
1. Generating and maintaining concern for health inequalities: Al-
though health inequalities have officially been on the UK policy agenda
since 1997, policy interest in the issue has fluctuated over time (see
Chapters 1 and 2). In many other contexts, health inequalities have re-
ceived low priority as a policy issue (Chapters 4 and 5). Substantial ef-
forts are needed to attract and maintain concern for health inequalities
so these remain a central issue in countries’ policy agendas.
2. Challenging dominant neoliberal paradigms: A recurrent theme
throughout this book is the extent to which health inequalities reflect
broader social inequalities, which are created and maintained by un-
equal power relations (Chapters 6–9, 13, and 15–17). Addressing health
inequalities therefore requires researchers, policymakers, and practi-
tioners to move beyond a focus on individual choice to consider the
structural drivers of inequalities. This has particular implications for re-
search methods and health policy (see point 5), but also requires us to
challenge dominant ideologies that privilege individual and market ‘lib-
erty’ at the expense of social equity and broader freedoms.
3. Developing clearer policy responses and resisting ‘lifestyle drift’:
There is a need for those concerned with health inequalities to more
clearly articulate the kinds of policy responses required to promote
health equity. This is made more difficult by a lack of consensus among
researchers, policymakers, and advocates over the implications of exist-
ing evidence (Chapter  6). Nevertheless, several authors in this book
highlight the need to resist ‘lifestyle drift’ in health policy, arguing for a
more explicit focus on reducing inequalities in income, wealth, and
power (Chapters 3, 8, 15, and 16).
4. Strengthening available evidence: A number of contributors highlight
challenges and opportunities for generating the kinds of evidence
needed to support development of effective policy responses to health
inequalities. A key challenge is the ‘inverse evidence law’ (Chapter 18),
meaning it is much easier for traditional forms of research to generate
evidence on individual (‘downstream’) interventions compared with so-
cial (‘upstream’) policies. For this reason, health inequalities research
often mirrors the ‘lifestyle drift’ evident in policy (Chapters 6, 8, 15, and
16). There is a need for innovative approaches to generate the kinds of
 USING HISTORICAL AND INTERNATIONAL RESEARCH 299

Box 21.1  Seven key challenges for better understanding and reducing health
inequalities (continued)

evidence that can inform and support ‘upstream’ policy responses to

health inequalities.
5. Methodological development: In order to generate the kinds of evi-
dence needed to address health inequalities, researchers need to move
beyond traditional approaches and employ a broader and more so-
phisticated range of research tools. Health inequalities research has
much to gain from broader disciplinary perspectives including geog-
raphy, sociology, and political analysis (Chapters 9 and 13–16), and
from the application of social theories that help draw attention to the
politics of health inequalities (Chapters 16 and 17). ‘Natural experi-
ments’ and econometric and qualitative methods offer important
methodological tools for future health inequalities research (Chap-
ters 6, 16, and 18).
6. Understanding and engaging in policy development: Alongside the
need for innovative approaches to generating evidence, there is a sense
across this book that those concerned with health inequalities need to
develop a more sophisticated understanding of how policy develops and
is informed by research, advocacy, and public opinion (Chapter 19). Just
as economic recessions, ‘austerity’ policies (Chapter 12), and ongoing
policy reforms (Chapters 10 and 11) make it more difficult to achieve
reductions in health inequalities, so at other times policy ‘windows’ may
facilitate change (Chapter  2)—particularly with support from third-
sector and campaigning organizations and strategic engagement with
the media (Chapters 6 and 19).
7. Moving beyond ‘knowledge translation’: Overall, this book chal-
lenges the assumption that the use of evidence in decision-making is a
neutral, technical matter and instead presents health inequalities re-
search and policy as inherently political and value-oriented. This belies
the traditional separation of science and advocacy, and challenges those
who study health inequalities to also consider what such inequalities
mean for our communities, our society, and ourselves. Such consider-
ation may lead us to take a more active role in tackling inequalities—
whether through challenging dominant political and policy paradigms
(Chapters 9, 13, 15, and 17) or stepping outside the academic world to
share our understanding and ideas with the wider public (Chapters 19
and 20).
300 WHERE NEXT?

is possible to garner from one context, however, particularly when efforts to

reduce health inequalities here have not been successful. As Chapters 5, 6, 7,
and 14 suggest, the value of UK-based evidence could be substantially en-
hanced via its integration with more international and historical research on
health inequalities. By expanding the range of empirical data we consider
through engagement with international and/or historical research findings,
we are likely to gain a better understanding of the causes of health inequalities,
including how different ‘policy packages’ influence health inequalities in dif-
ferent contexts.

21.3  Broadening our focus and alliances

Second, as Chapters 8, 14, 15, and 16 imply, in order to challenge the perva-
sive problem of ‘lifestyle drift’ we may need to develop new discursive frames
for studying and thinking about health inequalities. New frames could help
reorient research and policy away from a focus on health behaviours and to-
wards the contexts in which the upstream determinants of health inequal-
ities are shaped over time. Several contributors note the tendency for health
inequalities research (and policy) to focus on the mechanisms by which so-
cial inequalities are translated into health inequalities, rather than address-
ing the underlying causes of the social gradient. In order to ‘paddle upstream’
(as Douglas puts it in Chapter 8), we may need to broaden our focus from
‘health inequalities’ to ‘social inequalities’ (see Chapter 20). Such a refram-
ing can be somewhat uncomfortable for those of us from a health back-
ground, but it may also offer potential allies in other fields, including other
academic disciplines and broader movements such as social justice and
human rights.

21.4  Emerging research topics for health inequalities

Third, the contributions to this book highlight a range of important areas in
which health inequalities remain under-studied. These include: (i) moving be-
yond a focus on social class to consider how multiple axes of social position
interact (Chapter 7); (ii) better understanding how powerful ideologies (Chap-
ters 9 and 17) and actors (Chapters 13 and 19) influence policy; (iii) studying
how contemporary policy changes are impacting on health inequalities (Chap-
ters 10, 11, 12, and 15); (iv) working to better understand how the geographical
and historical contexts in which we live and work shape patterns of health in-
equalities over time (Chapter 14); and (v) doing much more to examine health
inequalities in other settings, perhaps particularly low- and middle-­income
contexts (Chapter 5).
 Developing an advocacy-coalition 301

21.5  Expanding our methodological toolbox

Fourth, there is a need for health inequalities research to move beyond trad-
itional methodologies to employ a broader range of research tools. Chap-
ters 14–18 suggest how traditional public health methods, such as epidemiology,
can be enhanced and supplemented by other disciplinary perspectives, particu-
larly those with strong theoretical underpinnings (including sociology, political
analysis, and other social sciences). Other disciplines also offer potentially valu-
able research tools, with ‘natural experiments’ and econometric analyses pro-
viding important opportunities to evaluate the impacts of upstream policy
changes on health inequalities, while qualitative methods can enhance our
understanding of both the drivers and impacts of health inequalities. Indeed,
the ‘health inequalities evidence industry’ (Chapter 18) would benefit from tak-
ing a plurality of approaches as a way of strengthening our engagement with
policymakers and the public (Chapters 19 and 20).

21.6  Working with the communities most affected

by health inequalities
Fifth, as Chapters 6, 16, and 17 suggest, health inequalities researchers should
do more to work with the communities most affected by health inequalities and
take more seriously the everyday knowledge and experiences evident within
these communities. However, in undertaking such work it is essential to ensure
that this research itself is not stigmatizing and that the difficulties experienced
by such communities are adequately linked by researchers to relevant macro-
level policies (see Chapters 9, 15, and 17) and potential solutions. If this does
not happen, such research risks locating problems within particular communi-
ties and/or providing demoralizing (and potentially stigmatizing) accounts of
life in particular places.

21.7  Developing an advocacy-coalition to reduce

health inequalities
Sixth, in order to maintain (or increase) the policy profile of health inequalities,
researchers need to do more than simply generate evidence. There are many
ways in which researchers can raise the profile of their work and the issues they
seek to address, particularly by engaging with key actors and institutions work-
ing to influence policy—including politicians, advocacy organizations (in the
third sector and beyond), and mass and social media. Whilst it may not be pos-
sible to develop broad coalitions around health inequalities generally (see
Chapters  19 and 20 on the difficulties facing those who engage in advocacy
302 WHERE NEXT?

work), it may still be possible to develop coalitions around specific, empirically

informed policy proposals.
In order for such coalitions to emerge, actors working in other settings need
to be aware of and concerned about health inequalities. Currently, such actors
are more likely to be dealing with the consequence of health inequalities in spe-
cific areas (this tends to form the focus of most large campaigning organiza-
tions representing health professionals, chronic diseases, or specific health
risks). In order to create the potential for broad-based coalitions, researchers
(and others) concerned with health inequalities need to explore how their con-
cerns might coincide with those of third-sector and other professional cam-
paigning organizations. As discussed earlier, a broader framing of ‘social
inequalities’ may help facilitate such coalitions, creating opportunities for those
in different areas to work together in calling for greater public and policy atten-
tion to the underlying drivers of health inequalities.

21.8  Potential contributions to reducing health

inequalities in policy and practice
The aforementioned reflections are primarily focused on ways in which re-
searchers might strengthen the available evidence on health inequalities,
and ensure this evidence feeds into public debate and policy development.
Recognizing that research is only one part of the effort to reduce health in-
equalities, we also offer some suggestions for how those working in policy
and practice might contribute to this agenda. This is by no means a compre-
hensive or perfect list; rather, it is intended as a starting point for further
discussion.
i) A recurrent theme in this book is the tendency towards ‘lifestyle drift’ in
policy and practice. Whilst addressing individual behaviours is a relevant
part of health promotion, it can, in isolation, detract attention from the
broader drivers of such behaviours and further stigmatize those who are
already disadvantaged. Both policymakers and practitioners can be alert to
this risk and can draw attention to the situations in which they encounter
lifestyle drift in action (see Chapter 8).
ii) Another recurrent theme is the need for ‘better evidence on what works’ in
reducing health inequalities. Natural experiments offer the best opportun-
ities for evaluating the impact of upstream policy intervention. Those
working in policy can help strengthen the available evidence base by mak-
ing researchers aware of opportunities for studying the impacts of forth-
coming policy changes on health inequalities—even where they are not in
a position to fund or even officially support such research.
 PREPARING FOR FUTURE ‘POLICY WINDOWS’ 303

iii) In some instances, there is adequate evidence to guide policy ­decisions—

but (for a variety of reasons) policymakers may pursue interventions that
are not supported by this evidence. Those working in policy and practice
can challenge policy decisions which appear to run counter to available
research evidence (e.g. decisions to shift the locus of responsibility for tack-
ling health inequalities on to local policy groups with limited power). Even
where there is little will to reverse such decisions, bringing attention to
them will help highlight the ways in which pursuit of other policy goals
may come at the expense of widening health inequalities.
iv) As noted already, in order to generate meaningful evidence and give a voice
to those most affected by health inequalities, researchers need to engage
with relevant communities and learn about their experience and know-
ledge. Those involved in health practice and advocacy can be instrumental
in helping forge such links. They also have an important role to play in
bringing together those from academic and other sectors to develop more
joined-up, evidence-informed proposals for responding to health
inequalities.

21.9  Conclusion: Preparing for future ‘policy windows’

to reduce health inequalities
In conclusion, the task of reducing health inequalities is a challenging one, and
no country has fully succeeded in developing an effective policy package to
‘close the gap’ between those at either end of the social gradient. Whilst this
book describes a range of challenges facing researchers, policymakers, and
practitioners concerned with health inequalities, it also sets out a number of
opportunities and priorities for taking forward this agenda. Key among these is
the need to continue developing our understanding of the causes and remedies
of health inequality, even when this does not feature on the public policy
agenda, in media discussion, or in research funding objectives. One of the most
important lessons of the UK and Nordic experiences is that health equity is a
long-term project. Whilst we cannot necessarily create the conditions neces-
sary for a broad-based political commitment to addressing health inequalities,
we can ensure we are ready to make the best possible use of the next ‘policy
window’—whenever that may arise.
 Index

A class  95, 101, 102, 103, 104, 105

access to health care  71–2, 153 conceptual and methodological
accountability  76, 147–8 implications 102–4
Acheson, Sir Donald  25, 26, 28 ethnicity 96–8
Acheson Report  85 gender 98–9
legacy  25–7, 52, 54 intersectionality 99–100
of Black Report  28 smoking 100–1
Norwegian context  34 socioeconomic position  95, 96, 97, 98, 99,
policy  13–14, 15, 28–9 100–1, 103
Addressing Inequalities in Health (Canada)  54
advocacy 265–81 B
Canada 58 Ban Ki-Moon  290
coalition 301–2 Berlin, Isaiah  222
community engagement by researchers  303 Better Care Fund  148
England’s changing public health Bevan, Aneurin  151, 157
system 144 Beveridge, William  126
future of health inequalities research  89, 90, Bill and Melinda Gates Foundation  78
91, 92 birth cohort studies  29
health inequalities researchers  276–8 Black, Sir Douglas  28
impact of health inequalities research, Black Report  7–9
improving the  89, 90 causes of health inequalities  109, 115
lessons from tobacco control  274 cultural–behavioural perspective  9, 24
LMICs  76, 78 legacy  24–5, 28, 51
public health  92, 265–81 materialist perspective  9
responsibility for  275–6 Norwegian context  34
The Spirit Level (Wilkinson and policy  13, 14, 15
Pickett) 292–4 recommendations rejected by
aid  73, 74, 78 government  115, 239
alcohol Blair, Tony  128, 243
Finland 257 Bloomberg, Mayor Michael  183
industrial epidemics  177, 178, 179–80, Blunkett, David  91
181–2, 183, 184–5 Brazil 78
UK mortality trends  7 BRICS countries  72
Alliance for Sustainability and Prosperity British Medical Association  275
(ASAP) 294–5 Brotherston, Sir John  23–4
Alma Ata Declaration  69 Brown, Gordon  26, 243
area deprivation  153, 169, 171, 179, 233 Burns, Sir Harry  209
causes of health inequalities  112, 114 Bush, George H. W.  169
England’s changing public health
system 145
equigenic environments  200–1 C
psychological fundamentalism  212–13 Cameron, David  246, 289
stigma 87–8 Canada
UK trends in health inequalities  7, 8 advocacy 278
Argentina 127 axes of health inequalities  96
assets-based approaches  209–10 ethnicity 5
Association of Directors of Public Health  147 health disparities term  1
austerity  167, 169–71, 241, 242, 259 indigenous peoples  100, 231–2
Australia  5, 96, 97, 100, 101 legacy of Canadian health inequalities
axes of health inequalities  95–108 research 55–9
306 Index

Canada (continued) community engagement by researchers  301, 303

legacy of UK health inequalities research in complexity thinking  196
Canada  50, 60 Conflict of Interest Coalition  184
Canadian policy  53–5 Conservative governments
conceptual contributions  51–2 1970–74: 127
intersectorality 67–8 1979–97
overview of health inequalities  50 Black Report  24, 115
Senate 55 neoliberalism  124–5, 126
smoking behaviour  100 NHS spending  157
socioeconomic position  99 policy agenda  13
capabilities approach  210 socio-structural violence against the
causal impact of social policies, evaluating poor  239, 241
the 253–5 2015–:  58, 241
causes of health inequalities  109–23 control, theory of transformative action  231–2
defining the problem  114–18 critical social transitions  12
downstream 110–11 cultural–behavioural perspective  9
everyday life  222–37
framing health inequalities  112
fundamental 109–10
D
Denmark
implications for research and practice 
economic downturns  168
118–21
industrial epidemics  183, 185
mitigate, prevent, and undo  118
policy, compared with Norwegian
traditional public health approach  109
context  38, 39, 40, 45
upstream 112–14
Department for Transport (UK)  26
Center for Alcohol Policies  182
Department of Health (DoH, England)  25, 26,
Chadwick, Edwin  2
141, 144, 147
Chicago School of Economics  126, 127
deprivation  70, 113, 120, 131, 200, 210, 257
Chief Health Officer of Canada  54
biological effects  24
childcare 34
financial 27
child mortality rates, USA  258
health  4, 15
child poverty  13
impact 229
Chile  75, 127
material  207, 213
China 73
measures of inequality  119
class see social class
multiple 195
Clinton, Bill  128
non-material dimensions  210
Coalition government (2010–15, UK)
socioeconomic  201, 213
England’s changing public health
see also area deprivation
system  141, 142
development assistance  73, 74, 78
health system reforms  155–7
diet  177, 178, 179, 180, 181–2, 183, 184–5
industrial epidemics  182
Directors of Public Health, England  142–3
policy agenda  58
disability 102
socio-structural violence against the
Disraeli, Benjamin  125
poor 241
Doll, Richard  115
Commission on the Social Determinants of
Douglas, Roger  130
Health (CSDH)
drug-related mortality  7
accountability 76
Duncan Smith, Iain  243
causes of health inequalities  109–10
evidence, nature of  70
Framework Convention on Tobacco E
Control 186 ecological public health (EPH)  195, 196–7,
LMICs  72, 74, 76, 77, 78 200, 202, 203
Marmot, Sir Michael  69, 72 economic downturns  164–76
measurement of health inequalities  74 and health inequalities  167–71
Norwegian context  37 and population health  164–7
psychological fundamentalism  208 socio-structural violence against the
research on health inequalities  2 poor  241–2, 243
systematic reviews  260 education
World Conference (Brazil, 2011)  74 access to  9, 126
 Index 307

administration systems  258 causes of health inequalities  223, 233–4

alcohol industry  181 England’s changing public health
attainment  3, 111, 168, 206 system  138, 140
axes of health inequalities  95, 98, 101 experimentation and realism in evaluating
control over  231 social policies  253–5
data 199 future research  89, 92
Denmark 38 hierarchies of evidence  252–3
effects of income inequality  29 impact of health inequalities research on
full-time 27 policy and practice, improving the  89
improvements 148 legacy of UK health inequalities
LMICs  71, 75, 76, 77 research  70–1, 85
local authorities  145 measures of health inequalities  119
Norway  33, 34, 35, 37, 41, 43, 44, 45 methodological toolbox  261
parental roles  230 natural experiments  255–60
policy  241, 253, 256 nature of  70–1
quality 119 policymaking  13, 14, 15
young adults  285 psychological fundamentalism  208–9
employment research methodologies  301
Norway 34 strengthening  298–9, 302
socio-structural violence against the poor  246 systematic reviews  133, 224, 227, 253, 260–1
workfare  213–15, 217
England
economic downturns  166, 168
F
facilitational advocacy  271
equity implications of health system
Faculty of Public Health  141, 275
change  151, 152, 155–6, 157, 160
Finland  39–40, 45, 166, 168, 257
evidence for policymaking  261
food banks  171
Health Action Zones (HAZs)  255
food industry  177, 178, 179, 180, 181–2, 183,
industrial epidemics  179
184–5
life expectancy  169
Framework Convention on Tobacco Control
mortality trends  7
(FCTC)  178, 182–3, 184, 186
policy compared with Norwegian
France 165
context  38, 39, 40, 45
Friedman, Milton  126
privatization of everyday life  233
fundamental causes theory of health
Programme for Action  111, 117
inequalities 110
public health system, changes in the  138–50
future of health inequalities research  81–94,
social class differences in mortality  22
297–303
socio-structural violence against the
impact of research, improving the  88–90
poor  241, 246, 247
UK research legacy  83–5
Sure Start  14
understanding of ‘health inequalities’
trends in health inequalities  7, 8
concept 81–3
environmental justice perspective  194–5
epidemiology  2–3, 70
Equality Act (UK, 2010)  117, 290 G
equality legislation  117 gender 4–5
Equality Trust  29, 275, 284–5 axes of health inequalities  96, 98–9, 104
equigenic environments  195, 199–202, 203 economic downturns  168
Equinet Africa  76 indicators of social position  102
Equity Gauge  76 smoking behaviour  101
ethics and morality see also men; women
poverty 245–6 Geographical Information Systems (GIS)  198–9
psychological fundamentalism  208, 216 geography 192–205
randomized controlled trials  256 comparative perspective  165, 166, 167–8,
Ethiopia 75 169–70
ethnicity 5–6 ecological public health  196–7
ethnographic research  87, 91 importance of geographic thinking  192–5
evidence 252–64 life course  197–9
advocacy  265–8, 269, 270, 273, 276, 277 limitations in approach to health
Canadian research contributions  58 inequalities 4
308 Index

geography (continued) hypothesis 10

resilience and equigenic environments  measures 119
199–202 neoliberalism  130, 131, 132, 133, 134,
scale 4 135
global financial crisis  165, 167, 171, 286 Norway  34, 43
Global Fund to Fight AIDS TB and Malaria redistribution policies  119
(GFATM)  73, 78 The Spirit Level (Wilkinson and
globalization 127 Pickett) 282–95
Gorbachev, Mikhail  131 UK  13, 15, 170
Great Recession  165, 167, 171, 286 upstream changes, need for  13
Greece  166, 167 India 73
‘greedy bastards hypothesis’  88 indigenous peoples
axes of health inequalities  96, 97
control, collective  231–2
H LMICs 71
Hayek, Friedrich  126 New Zealand  130
health and safety legislation  26 smoking behaviour  100
Health and Social Care Act (UK, 2012)  138, individual issue, health as an  114
140, 156 Indonesia 167
Health and Well-being Boards (HWBs, industrial epidemics  177–91
England)  142, 143–4, 146, 147–8 inequality/inequalities
health care  151–63 axes of  94–108
access to  9, 26, 59, 111 intersectionality 95–108
Alma Ata Declaration  69 smoking behaviour  43–5, 100–1, 103–4,
Canada 54 115, 177–86, 195, 259, 273–4
control 231 inequality paradox  197
delivery 116 infant mortality  26, 168, 169
England’s changing system  138–63 institutional racism  98
equity in the healthcare system  39, 41–2, institutional responsibilities  116
151–63 instrumental variables  258
Iceland 241 insurance  153–4, 155, 159–60
migration 195 intersectionality  6, 95–108
neoliberalism  126, 129 axes of health inequalities  95–6
New Zealand  170 conceptual and methodological
Programme for Action 117 implications 102–4
reform 255 ethnic inequalities  96–8
targeted 114 gender inequalities  98–9
USA  59, 169 legacy of UK health inequalities research  53,
Health Council of Canada  54, 55 67–8, 76
Health for All Movement  69 smoking 100–1
Health Impact Assessment (HIA)  120–1 social position  95
Health in All Policies  39, 140 inverse care law  152
health inequalities impact assessment inverse evidence law  252, 298
(HIAA) 111
Healthy, Productive Canada: A Determinants of
Health Approach 55 J
Heath, Edward  127 Japan 167–8
hierarchies of evidence  252–3 Joint Strategic Needs Assessments
homelessness 244 (JSNAs) 146–7
housing  240, 246–8 Joseph Rowntree Foundation  26, 284
human rights  300
K
I Kenya 75
Iceland  167, 241–2 Keynes, John Maynard  126
impact of health inequalities research on policy Keynesian welfare state (KWS)  125–6, 127,
and practice, improving the  88–90 130
income distribution  10 knowledge translation  299
income inequalities  115 Krugman, Paul  290
equigenic environments  202 Kuhn, Thomas  293
 Index 309

L M
Labour governments Malaysia 167
1974–79: 28 marketing 179–80
1997–2010:  28, 60 marketization 156
Acheson Report  25–7 market liberalism  125, 126, 134
Canadian research contributions  56 Marmot, Sir Michael  15, 29
equity in health care  153 Commission on the Social Determinants of
funding to address health inequalities  142 Health  69, 72
interest in health inequalities  85 social gradient  38
policy agenda  13–15 UCL Institute for Health Equity  275
rationing by waiting  161n5 Whitehall Study  72
Labour Party (Norway)  33, 36 Marmot Review
Labour Party (UK)  126, 158, 282 Coalition government’s support  142
Lagarde, Christine  289–90 England’s changing public health
Lawson, Nigel  241 system 145
Layard, Richard, Happiness 283 fundamental causes of health
legacy of UK health inequalities research  22–32 inequalities 110
Acheson Report  25–7 legacy of Acheson Report  27
Black Report  23–5 Norwegian context  33, 34
future directions for health inequalities policy 15
work 30 materialist perspective  9–10, 210
lessons for the future  83–5 maternal mortality  99
LMICs’ perspective  69–80 Médecins Sans Frontières (MSF)  73
Marmot Review  27 media 112
North American perspective  50–68 men
policy implications  27–9 economic downturns  168
research challenges  29–30 life expectancy  35, 193
social class health differences  22–3 research on health inequalities  5
liberalism(s)  124–7, 134 social class differences in mortality  22
life course perspective  11–12 see also gender
England’s changing public health mental health problems during economic
system  145, 146 downturns  165, 166, 167
geographical health inequalities  195, 197–9, Mexico 183
203 migration 195
legacy of UK health inequalities research  29, Miliband, Ed  289
52 Millennium Development Goals (MDGs) 
UK policy  15 70–1, 75
life expectancy minimum wage  14, 30
causes of health inequalities  113 Ministry of Health, Denmark  38
economic downturns  169, 170 Monitor 156
England  145, 169 morality see ethics and morality
neoliberalism  130, 131 Morris, J. N.  30
Norway 35 mortality rates
lifestyle drift  111, 112, 186, 196, 298, 300, 302 economic downturns  166, 169–70
living wage  290 infant  26, 168, 169
Local Government Association  147 maternal 99
logic models  259 neoliberalism  130, 132
low- and middle-income countries (LMICs) Norway  44, 45
addressing health inequalities  71–7 UK  6–7, 22–3, 27, 211
emerging research topics  300 USA 258
health care, emphasis on  152
health inequities term  1 N
legacy of UK health inequalities National Institute for Health and Care
research 69–80 Excellence (NICE)  143
addressing health inequities  71–7 National Institute for Health Research
evidence, nature of  70–1 (NIHR) 147
preventing a revolution?  77–8 national minimum wage  14, 30
social determinants of health  69 natural experiments  15, 253, 255–60, 261, 299,
non-communicable diseases  177 302
310 Index
neighbourhoods perspective  194
neoliberalism 124–37
actually existing neoliberalism(s)  127–30
causes of health inequalities  222, 228
challenge to public health  134–5
challenging 298
health inequalities  124, 130–2, 170
inequality and pathways  133–4
liberalism(s) 124–7
political economy perspective  11
psychological fundamentalism  217
socio-structural violence against the
poor  239, 240, 244
trends in health inequalities  7
New Deal
UK 257
USA 241
New Democratic Party (NDP), Canada  60
New Zealand
axes of health inequalities  96
economic downturns  169–70
ethnicity  5, 97, 104
geographical health inequalities  195
neoliberalism  7, 130
smoking behaviour  100–1
Noble, Hugh  291
non-communicable diseases (NCDs)  177–91
LMICs  72, 73, 77
Nordic welfare state ‘paradox’  34, 42–4, 45
Northern Ireland  141, 155, 166
Norway 33–49
economic downturns  168
Nordic ‘paradox’  42–4
strategies to reduce health inequalities  34–7
appraisal 40–2
comparative perspective  37–40
O equity implications of health system
obesity  144, 177, 183, 184
occupation 27–8
data 2
psychosocial perspective  10
trends in health inequalities  7, 8
One Society project  284–5
P impact of health inequalities research
People’s Health Movement  76
Pfizer 275
Pickett, Kate
Equality Trust  29, 275, 284–5
The Spirit Level see Spirit Level, The
Pinochet, General Augusto  127
policy
advocacy 265–81
health inequalities researchers  276–8
lessons from tobacco control  274
responsibility for  275–6
agendas 298
causes of health inequalities  109–13, 118–21,
223–4, 230–4cycle 265, 266
development, understanding and engaging
in 299
economic downturns  167, 168, 170, 171
England’s changing public health
system  139, 141–2, 147, 148
evidence in policy  70, 252–64
future of health inequalities research 
91–2
geographical health inequalities  196, 199,
201, 202
intersectionality 103
legacy of UK health inequalities research  52,
53, 54–5
LMICs  71, 72–4, 75
non-communicable diseases  178, 181–6
Norway 34–7
appraisal 40–2
comparative perspective  37–40
packages 297–300
potential contributions to  302–3
psychological fundamentalism  207, 215
public health versus political science
perspective  265, 266
socio-structural violence against the
poor  238–9, 241–2, 244, 245, 246, 247,
249
The Spirit Level (Wilkinson and
Pickett)  285, 290, 291, 292, 293
UK  1, 13–15, 27–9, 69, 77, 87, 91–2, 110–11,
297, 298
Acheson Report  13–14, 15, 25, 28–9
advocacy  265, 268–71, 275, 276, 277
austerity  167, 170, 171, 247
Black Report  13, 14, 15, 24
causes of inequality  120–1
change  151–2, 153, 155, 157, 160
evaluation 119
geographical inequalities in health  196,
201
Health Improvement Groups  113
Health Inequalities Action
Framework 118
 
88–90, 92
income redistribution  119
intersectionality  101, 103
legacy 50–68
lessons 83–5
lifestyle drift  112
Marmot Review  15, 27
neoliberal  7, 124–5, 128, 129, 135, 232
New Deal  257
Programme for Action  111, 117
psychological fundamentalism  207

socio-structural violence against the
poor  238–9, 241–2, 244, 245, 246,
247, 249
The Spirit Level (Wilkinson and
Pickett)  285, 289, 290, 291, 293
workfare 215
windows  28, 303
political economy perspective  11, 56, 58, 128,
168
Popper, Karl  293
Population Health Policy: International
Perspectives 55
positive affect  207, 214–15, 216
positive psychology  209, 214, 216
poverty
absolute and relative poverty  73, 133
causes of health inequalities  112, 114
children 13
legacy of UK health inequalities research  52
LMICs 73
neoliberalism  129, 130, 131, 133
Norway 34
policy, UK  15
psychological fundamentalism  210, 211–13,
216–17
socio-structural violence against the
poor 238–51
housing 240
humanity, reclamation of  249
new morality  245–6
private troubles transformed into public
issues 247–8
research and dissemination, role of  Putnam, Robert, Bowling Alone 283
246–7
researchers, pressure on  248–9
shifting practices  244–5
shifting values and the common
determination of meaning  242–3
stigmatization 243–4
unemployment 240–2
power
industrial epidemics  182, 186
intersectionality 104–5
neoliberalism  134, 135
of positive affect  207
privatization  156, 233
progressive taxation  34, 155
propensity score matching  258
psychological fundamentalism  206–21
absence of debate  207
assets-based approaches  209–10
evidence base  208–9
materialist analysis, limitations of  210
positive affect, increasing  216
public health and the Glasgow pSoBid
study 211–13
rise of  206–7
strengths-based discourse  207
Index 311
workfare 213–15
psychosocial perspective  10–11
public health
advocacy  92, 265–81
health inequalities researchers  276–8
lessons from tobacco control  274
responsibility for  275–6
causes of health inequalities  112, 116, 121
ecological  195, 196–7, 200, 202, 203
evidence, nature of  70
Finland 39
industrial epidemics  178, 182, 183, 184, 185,
186
innovation, cumulative  27
minimum wage  30
natural experiments  259
neoliberalism 134–5
Norway  36–7 political nature 116
psychological fundamentalism  211–13, 216,
217
systematic reviews  133, 224, 227, 253,
260–1
traditional approach  109
Public Health Act (Norway, 2012)  42
Public Health Agency of Canada  54
Public Health England (PHE)  144–5
public health system, UK  141–2
England’s changing system  138–50
assessment 147–8
challenges and opportunities  145–7
public intellectuals  291
public policy see policy
Q
qualitative research on health
inequalities  224–30, 233, 234
R
race  5–6, 96, 97
racism 98
randomized controlled trials (RCTs)  253, 256,
258, 260, 261
rationing by waiting  158, 159
Reagan, Ronald  127, 130, 169
recessions see economic downturns; Great
Recession
Red/Green Government (Norway)  33, 40–1,
45
regression discontinuity  258
Relative Index of Inequality  7
representational advocacy  271
research agendas see future of health
inequalities research
resilience  195, 199–202, 210, 212, 216
road traffic accidents  166–7
Robert Wood Johnson Foundation  59–60
312 Index

Royal Society for the Prevention of commercial sector  179

Accidents 26 evidence  70, 261
Royal Society of Public Health  141, 147 LMICs  74–5, 76–7, 78
Russia 131 neoliberalism 130
Nordic welfare state ‘paradox’  42
S Norway  34, 36–7, 43
scale, geographical  4 psychological fundamentalism  208, 213
Scotland Rio declaration  33, 76
advocacy for tobacco control  273 UK 151
assets-based approaches  209–10 England’s changing public health
causes of health inequalities  112–14, 118 system  139, 140, 142, 143
economic downturn  165 leadership 69 (see also Commission on the
Equally Well  111, 113, 116 Social Determinants of Health)
geographical health inequalities  198–9 research legacy 52–3
Glasgow pSoBid study  211–13 research tradition  293
health system reforms  155, 156 social exclusion  52
industrial epidemics  179, 180 social gradient  4, 300
mortality trends  7 causes of health inequalities  109–10, 112,
psychological fundamentalism  209–10, 114, 119, 120, 121
211–13 cultural–behavioural perspective  9
public health system  141 Denmark  38, 39, 40
smoking 259 England  38, 40, 145, 146
social identity  229 equity implications of UK health system
socio-structural violence against the change 151–2
poor  240, 245, 247 Finland  39, 40
trends in health inequalities  7, 8 Norway  40, 41, 42, 43, 44
Scottish Coalition on Tobacco (SCOT)  273 qualitative research  227
sex  98, 99 smoking behaviour  100–1
sexual orientation  96, 102 Sweden  38–9, 40
Slope Index of Inequality  7 social identity  228–30
smoking social justice  77, 78, 146, 222, 231, 300
advocacy for tobacco control  273–4 neoliberalism  126, 129
Doll, Richard  115 psychological fundamentalism  216, 217
geographical health inequalities  195 UK  146, 151
industrial epidemics  177, 178, 179, 180, 181, social liberalism  125, 134
182–3, 184, 185, 186 social policy see policy
intersectionality  100–1, 103–4 social position
natural experiments  259 axes of  95, 96–8, 104
Norway  43–4, 45 cultural–behavioural perspective  9
Snow, John  109, 115, 116 equity in the health care system  154
Snowdon, Christopher  291 ethnicity 98
social class gender 99
Black Report  7–9, 24 indicators of social position  102
causes of health inequalities  224 industrial epidemics  177, 179
cultural–behavioural perspective  9 intersectionality  95, 102–3
data 2 neoliberalism 133–4
identity 229–30 smoking behaviour  100–1, 104
importance for health inequalities  104 socioeconomic position  3–4, 9, 95, 98, 99,
indicators of social position  102 100–1, 103, 133–4, 154, 177, 179
UK  3–4, 22–3 socio-structural violence against the poor see
Acheson Report  25, 27 under poverty
Black Report  7–9, 24 solidarity 232–3
health inequalities research  95–6 South Africa  75, 76, 78
mortality  22–3, 27 Soviet Union  131
trends in health inequalities  7 Spain  165, 166, 167
social determinants of health spatial inequalities in health  7
axes of health inequalities  96 Spirit Level, The (Wilkinson and Pickett)  282–96
Canada  52, 55–6, 58 advocacy 292–4

dissemination, commitment to  289–90
Equality Trust  284–5
format 283–4
public intellectuals  292
risks 290–2
success 285–8
stigma
benefits claimants  170
causes of health inequalities  112, 114
community engagement by researchers  equality legislation  117
301
psychological fundamentalism  211, 217
research 87–8
social identity  229
socio-structural violence against the
poor  243–4, 245, 246, 247, 249
structural (political economy) perspective  11,
56, 58
suicide rates  7, 165, 166, 167
Sure Start  14, 26, 27, 257
Sustainable Development Goals  295
Sweden
economic downturns  165, 166, 168
policy compared with Norwegian
context  38–9, 40, 45
systematic reviews  253, 260–1
T legacy of health inequalities research
taxation  13, 14, 26, 41, 169–70, 194, 239
progressive  34, 151, 155, 157
regressive 169
saturated fat  183, 185
Thailand  167, 182
Thatcher, Margaret  124–5, 126, 127, 130, 170,
239
tobacco see smoking
Townsend, Peter  28
transformative action, theory of  230–3
trends in UK health inequalities  6–7, 8
U tradition 293
UCL Institute for Health Equity  275
UK Public Health Register  141
unemployment
economic downturns  164–5, 166
morbidity and mortality associated with  165
neoliberalism  128, 129, 130
Norway 34
psychological fundamentalism  208
socio-structural violence against the
poor 240–2
United Kingdom
advocacy  265, 268–71, 275–6, 277
aid to India  73
axes of health inequalities  95–6
causes of health inequalities  110–11, 112,
115
Index 313
contrasting perspectives on ‘health
inequalities’ concept  82
devolution  14, 15, 56, 141, 160, 161
economic downturns  167
austerity  169, 170–1
Great Recession  167
socio-structural violence against the
poor  242, 243
unemployment 165
equity implications of health system
change 151–63
context of reforms  155–7
NHS’s financial context  157–60
ethnicity and race  95, 96, 97, 98, 101
experiences of health inequalities  1–21
conceptualization, measurement, and
monitoring 2–6
empirically informed theories  7–13
policy responses  13–15
trends  6–7, 8
failure to substantially reduce health
inequalities, explanations for  83–5
geographical health inequalities  192, 193,
195, 199
Gini-coefficient 46
‘greedy bastards hypothesis’  88
industrial epidemics  181, 182, 184
 
297–300
liberalism 125–6
neoliberalism  7, 124–5, 127, 128, 129, 130,
132
New Deal  257
overview of health inequalities  50
policy interest in health inequalities  298
public health system  141–2
research legacy see legacy of UK health
inequalities research
smoking behaviour  100, 101
social determinants of health, research
socio-structural violence against the
poor 239–48
The Spirit Level (Wilkinson and
Pickett)  289, 290
Sure Start  14, 26, 27, 257
see also England; Northern Ireland;
Scotland; Wales
United Nations  73, 183, 185, 239
United States of America
axes of health inequalities  96
Buffalo Creek disaster  232
economic downturns  165, 166, 167, 169,
241
ethnicity and race  5, 97, 98, 104
Exceptionalism  59, 60
Head Start  258, 259
314 Index

United States of America (continued) socio-structural violence against the

health care, emphasis on  152 poor 243
health disparities term  1 workfare 213–15
indigenous peoples  100 UK 56
industrial epidemics  179, 181, 183, 185 Keynesian  125–6, 127, 130
legacy of UK health inequalities research  50, liberalism 125
59–60 neoliberalism  124, 125
liberalism 125 Whitehall Study  10, 72
neoliberalism  7, 127, 128, 129, 130, 132 whole-of-government approach see
overview of health inequalities  50 intersectionality
smoking behaviour  100, 101 Wilkinson, Richard vi–x
Universal Declaration of Human Rights  Equality Trust  29, 275, 284–5
239 The Spirit Level see Spirit Level, The
Upstream 58 Unhealthy Societies 50
upstream factors  3, 37, 45, 70, 86, 112–14, women
118–21, 252, 298–302 economic downturns  168
advocacy  269, 276, 277 indicators of social position  102
axes of health inequalities and industrial epidemics  179–80
intersectionality  95, 103 intersectionality  101, 102
changes, need for  12–13 life expectancy, Norway  35
industrial epidemics  178, 181, 185–6 research on health inequalities  5
LMICs  70, 72, 73, 74, 77, 78 smoking behaviour, Norway  44
Uruguay 127 see also gender
workfare  213–15, 217
V World Health Assembly  74, 184
Venezuela 75 World Health Organization (WHO)
violence, UK trends  7 constitution 69
development assistance  73
Framework Convention on Tobacco
W Control  178, 182–3, 184, 186
waiting times in UK health system  157, 158,
Global Strategy on Diet, Physical Activity and
159, 160
Health 183
Wales
Global Strategy to Reduce Harmful Use of
Aberfan disaster  232
Alcohol 183
health system reforms  155
Health 2020:  217n2
policy 141
health advocacy defined  271
public health system  141
health inequities term  1
social cohesion  227–8
industrial epidemics  184, 185, 186
trends in health inequalities  7, 8
Tobacco Free Initiative  184
‘We are the  99%’ movement 76, 77
see also Commission on the Social
welfare states
Determinants of Health
economic downturns  168, 169–71
World Trade Organization (WTO)  182
Iceland 241–2
neoliberalism  124, 125, 135
Norway  33–4, 36, 37, 43 Z
policy agenda  58 Zambia 72