The pernicious problem of widening health inequalities

The Black Report, published in 1980, was the catalyst for a change in our collective consciousness: it marks a moment in time where our acknowledgement of social inequalities in health, and the policy focus on reducing health inequalities, really took shape.  The question is, how far how have we come?

I recently had the pleasure of attending the Behaviour and Health Research Unit Annual lecture, given this year by Professor Johan Mackenbach.  This blog is inspired by some of the key points from Professor Mackenbach’s lecture (or my interpretation of them!)

What have we learnt? 

  1.  The great paradox of public health: despite increasing prosperity and more equal income distribution, social inequalities in health persist – and relative inequalities appear to be widening.
  2. One size does not fit all: The causes of social inequalities in health are multifactorial, and vary by regional context across Europe.  Locally tailored policy solutions are necessary.  For example: for women in Spain the social patterning of obesity is an important contributor to social inequalities in mortality, where as smoking is not.  For men in England, the pattern is reversed: social patterning in smoking behaviour is an important cause of social inequalities in mortality: but obesity has a limited role as a determinant of health inequalities for this group.
  3. The presence of a strong welfare state is not associated with greater success in reducing health inequalities: in fact, evidence suggests the reverse.

This latter point is perhaps an important lesson to us all.  Overall, it seems that countries with a strong welfare state and who invest in a national policy strategy to reduce health inequalities, are no more effective than those countries who do nothing (or little) to reduce social inequalities in health.  Why is this?

Professor Mackenbach ended his lecture with some astute observations about why we in England are continuing to see widening social inequalities in health.  Two in particular struck a chord with me:

  1. Differences in access to material and non-material resources are not eliminated by the welfare state
  2. The welfare state is not effective against the determinants of disease that are linked to consumption behaviour (e.g., obesity)

The big picture here seems to show (a) that a strong welfare state is not a successful strategy for reducing health inequalities; (b) our policy approach to reducing health inequalities in England so far has been largely ineffectual.

Is it time for some fresh thinking?


Interested in learning more?
1. Behaviour and Health Research Unit (bringing research and policy together to promote sustained behavioural change at a population level)
2. Mackenbach, J.P. The persistence of health inequalities in modern welfare states: The explanation of a paradoxSoc Sci Med 2012;75:761-769.
3. UCL Institute of Health equity & Fair Society Healthy Lives (the Marmot Review)


Finally, I’d like to acknowledge Professor Mackenbach’s lecture as a key source for material in this blog, and thank him for an inspirational and informative evening.   All errors of interpretation are my own, of course.

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