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Health Inequalities
Health Inequalities
Critical perspectives
Edited by
Katherine E. Smith
Sarah Hill
and
Clare Bambra
1
1
Great Clarendon Street, Oxford, OX2 6DP,
United Kingdom
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Foreword
Debbie Abrahams MP
Chair of the Parliamentary Labour Party Health
Committee
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
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
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
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Acknowledgements
Index 305
List of Acronyms
Assis sur son derrière, Kazan, après avoir jeté son cri lointain, se
mit à renifler dans l’air la liberté qui maintenant était la sienne.
Autour de lui s’évanouissaient, avec l’aurore, les abîmes de nuit de
la forêt.
Depuis le jour où tout là-bas, sur les bords du Mackenzie [7] , il
avait été, par des marchands qui trafiquaient dans ces parages,
acheté aux Indiens et, pour la première fois, attelé aux harnais d’un
traîneau, il avait souvent, en un désir ardent, songé à cette liberté
vers laquelle le repoussait le sang de loup qui était en lui. Jamais il
n’avait complètement osé. Maintenant que c’était fait, il en était tout
désorienté.
[7] Le fleuve Mackenzie prend sa source dans les
Montagnes Rocheuses, traverse le Canada vers l’ouest
et va se jeter dans la Mer Glaciale du Nord, après avoir
côtoyé les Grands Lacs de l’Ours et de l’Esclave.