Introduction
Understanding what is meant by health inequalities is the first step in addressing the issue. Two central and separate UK health inquiries; one from Acheson and the other from the black report, helped to develop extensive debate regarding health inequalities. Subsequently, they triggered the need for policy and action in addressing the issue.
Different conceptual models have been used to explain and demonstrate how various factors influence individual and community health. Some of these factors such as age and sex are beyond d human intervention.
On the other hand, there are other wider factors which affect an individual’s health, and which can be controlled. There are various numerous debates related to the causes of these inequalities as well as on the most plausible action that should be taken to address these inequalities.
Health equity, also known as healthcare inequality or healthcare disparities refers to the differences that prevail with regard to the quality of health and related activities transversely different populations. The concept of health inequalities was not been a priority for the UK government in the 1980s and early 1990s.
In the 21st century, evidence for escalated inequalities in the social pattern of health is beyond reasonable doubt and there is vast literature to support this. More than 800 empirical and conceptual papers have dedicated their time and effort to this topic since the late 1990s.
The area of research in health inequalities has been greatly politicized, right from the ideological context through explanatory frameworks to the various discourses that propose remedies to the problem. Reducing inequalities in health has become an integral part in as far as the UK Government policy is concerned.
The key debates related to inequalities and health in the UK, are on the causes on these inequalities and how they can be resolved.
Public health in Britain today is more or less of a paradox where despite the fact that Britain now experiences greater health than it has ever experienced in history, health inequalities had remained to be stubbornly ubiquitous. Several authors have come forth to present the setbacks of health inequalities in the United Kingdom.
This paper aims at identifying and critically reviewing what different authors have got say about this issue in their different works. It has analyzed different conceptual and policy debates which are paramount in as far as inequalities in health are concerned. It has pointed out the respective material and psychosocial influences on health inequalities.
The paper is quizzical on the direction ought to be taken by public health professionals in influencing policies, as well as their implementation in relation to health inequalities. This is of concern in a world where much emphasis is on wealth creation as opposed to addressing poverty.
Discussion
The years 1980-2005 were a period marked by huge growth in international research and vast literature aimed at demonstrating the inequalities in health, and the governance of poverty as a potential cause of these inequalities. Davey Smith and colleagues at the University of Bristol have made great contributions to this concept by generating evidence to support it.
Davey Smith, et al (1999) responded to Acheson’s report (1998) on health inequalities evident in the UK. The Acheson’s report shows the existence of health disparities and their correlation with social class. The findings showed a general decline in mortality between 1970 and 1990, but that of the upper social classes was characterized by a more rapid decline.
Acheson mentions 39 policies that are applicable in ameliorating health inequalities in various sectors of the economy that range from taxation to agriculture. This report had a great influence on “Out Healthier Nation: A Contract for Health”, the 1998 government green paper and the 1999 “Saving Lives: Our Healthier Nation”, white paper.
Davey Smith, et al not only reviewed Acheson’s data indicating the escalation in health inequalities but also argued that the solution to this escalation could be easily solved.
He states, “Any child can tell you how this can be achieved: the poor have too little money so the solution to ending their poverty is to give them more money. Poverty reduction therefore can be really attained by throwing money at the problem”, (Davey Smith, et al., 1999, 378).
Labonte, 1999 has also placed an argument based on Acheson’s report. Labonte says that there is need to go beyond just analyzing health inequalities to grappling with policy options. Labonte notes that Acheson’s and related reports did not bring about change, instead they became legitimizing tools for those who were committed to change.
They are basically ideological tools which are more essential than evidence base in creation and development of policies. However, Acheson did not provide a basis for continued debate on inequalities within the government.
Acheson has been criticized by Labonte as not relating economic practices with social inequalities as he has done with social aspects and health inequalities. Acheson also failed to probe into the existence of poverty hence has left some crucial components related to health and inequalities unturned.
O’Keefe (2000) has argued out the causes of health inequalities based on globalization, which is considered to have an increasing influence on social policy in all countries.
She explains that decisions related to health inequalities are made by “undemocratic trans-national regulatory organizations that include the World Trade Organization”.
O’Keefe suggests that deliberative democracy placed at the heart of such trans-national bodies could be an ideal solution for the health inequalities experienced in the different countries. However, this was dependant on the world-wide strength to question the unjust social structures that operate on a global level.
In her work, Stewart-Brown 2000 probes into the causes of social inequality. Stewart-Brown is puzzled by the impression derived from this question. It has become more or less like a taboo in literature. Stewart-Brown has used a contrary analytical approach different from that of Davey Smith, et al., and Labonte as discussed earlier on. She has borrowed from conflict management and psychotherapeutic theory.
She implies that the problem of social inequalities in health can be resolved by a development in the direction of emotional literacy involving all income groups and especially those with most wealth by so doing (Stewart-Brown, 2000).
Davey Smith, et al., (2000) have demonstrated that ethnic differences in health status in their review on the UK epidemiological evidence on ethnic health inequalities. Various types of explanations have been explored in this review that entail migration, culture, artefact, behaviour, biology, socioeconomic factors and racism.
They conclude by suggesting that influences falling under the different explanations would largely contribute to the production of ethnic differentials in health. However, production of more sensitive socioeconomic indicators is required if clarity and definitiveness is to be achieved.
Bolam, et al., (2003) have focused on an important and current issue of debate on inequalities in health based on the contribution of psychological factors while looking at structural, material and economic factors related to health.
Bolam and others have advanced this debate by coming up with a more complex and entirely socialized theory that examines the key component in psychological explanations known as the “the sense of control over health”. In their article, Bolam and others explore these determinants by analysing interviews where 30 lower socioeconomic status participants engaged in the interviews.
The participants were obtained from two qualitative studies on health inequalities. The major findings were bent on the correlation of two contrasting factors on control over health, that is, “fatalism and positive thought”.
The debate on material and psychosocial explanations for health inequalities has imperative policy implications and especially macro-economic policy and appropriate interventions with regard to health services. There is one important health service intervention in the UK aimed at reducing health inequalities, and this is the nation-wide programme on smoking cessation.
Woods et al (2003) have noted the implementation of this programme during early implementing health action zones. Woods and others are not at all enthusiastic about this programme because it is only a rhetoric act by the government but, despite this, smoking cessation has been categorically and centrally steered.
They argue that despite the fact that smoking cessation may lead to an overall population-level minimization in smoking, it have the potential of causing a wider gap than the current one in as far as health inequality is concerned.
A similar theoretical debate by Muntaner, et al., (2000) in their thought provoking article have brought focus on the worth of the concept of ‘social capital’ with regard to comprehending and identifying an appropriate action on health inequalities. Muntaner and others have challenged the theoretical value as well as the evidence base that shows social capital to be a determinant of health inequalities.
They show the use of social capital as an alternative to party politics and economic redistribution within the state and it is because of this that they are sceptical about its practical benefit in addressing health inequalities.
Morrow (2000) explores the accounts of young people with regard to the community and neighbourhood while using the concept of social capital, and the effect on health inequalities. In his work, it is evident that Morrow realises the limitations of the social capital concept but Morrow has argued out that it is valuable in helping the young people explicitly understand their social environment.
Ostry, et al., (2000) studied the “relationship between unemployment, technological change and psychological work conditions in restructured work places in British Columbian sawmills”. In this study there was a downsizing of the employees where reduction took place in terms of number and job title.
It was evident that psychosocial conditions of work were ameliorated after the downsizing but, only few workers experienced these better work conditions. Even though this was the case there was a need for future improvements based on the lessons learnt.
To start with, a population based approach is very important while assessing the implication of downsizing because a long-term follow-up of the downsized workers is important. Secondly, there is great need to pay attention to the long-term implications associated with employment and their effects on health with regard to the downsized workers and especially those who are less than 35 years.
Also, the downsizing resulted in escalated levels of control, which was more steepened across the different job categories in 1997 as compared with 1965. This was considered to have health implications and mainly so for the unskilled workers where downsizing had taken place. Lastly, the method used for assessing the working conditions needed improvement. Self-reports ought to be used in such future studies.
Methodological challenges are evident in relation to evaluating the policy interventions aimed at reducing health inequalities. Evans Shito and Keskimaki (2000) have placed great attention on the description of the long term Finnish policy goal addressing health inequalities. They have outlined the barriers to successful policy programmes with regard to addressing these inequalities.
In a similar light of debate, Evans and Killoran (2000) have made a report on “realistic evaluation”. In this report they have realistically evaluated five UK projects put in place so as to test the effect of five partnership models in addressing health inequalities.
They identify six key themes, which are “shared strategic vision, leadership and management; relations and local ownership; accountability; organizational readiness and responsiveness to a changing environment”.
The need to understand how the mechanisms used in the project were executed in the light of local and national policy change has been greatly emphasized. Lessons for programmes on health improvement in the UK, primary care groups and health action zones have been identified.
Asthana and Halliday (2006) have argued about health inequalities with regard to how they should be objectively tackled in the UK. This is in accordance with the prevailing scepticisms on the best approach to take while translating broad policy recommendations into practical actions. The value of local level initiatives has remained to be a great concern due to its implicit nature.
In this book, key targets for intervention have been identified via a comprehensive exploration of the directive and procedures that lead to health inequalities across populations. The authors have examined both national policy content and local practice in determining what is applicable in addressing health inequalities, why and how it works.
This book is authoritative but, very much accessible in providing a detailed account of “theory, policy and practice” hence, creating a good debate ground for what works and what does not work in as far as addressing health inequalities in the UK is concerned.
An article by Buch, 2010 on “Health Inequalities in the UK-Our most Pressing Problem” has presented a debate that was held by the British Medical Association on health inequalities. The debate was centred on the most pressing problem at hand: why there was such a great gap between the different sections of the British population in relation to health and what the most ideal solution to the problem was.
Evidence by Professor Marmot showed that there was a seven year gap with regard to life expectancy. There was also a 19 year gap with regard to healthy life expectancy between the lowest and the highest socioeconomic groups. Ameliorating health inequalities via trying to equalize the socioeconomic status of each and every person would be faced by major challenges. Health agenda was considered to rhyme the environmental agenda where walking, moderate consumption of meat and cycling were encouraged (Buch, 2010).
The question therefore was on how health inequalities could be effectively addressed. Lack of commitment and will are some of the suggested reasons for the persistent escalating health inequalities. There is weighted evidence that the gap related to health inequalities can be filled through policies already developed.
However, the politicians are still struggling with the direction in which they would take in implementing the changes. The government continuously comes up with various ideologies on how to address the health inequalities. Unfortunately, they never get to seriously work on them as they are always debating on how these inequalities could be addressed without doing anything.
“The Impact of Inequality: How to make Sick Societies Healthier” by Wilkinson (2005) is a continuation of his book, “Unhealthy Societies: The Afflictions of Inequality”. The current book reviews the present status of knowledge and offers an explanation as to what causes the health inequalities as well as providing potential solutions to the problem.
This book consists of highly assembled and valuable evidence with an articulate and convincing argument suitable for use by epidemiologists, policy makers, social scientists, public health officials and students.
It is Wilkinson’s ideologies that provoke thought like when he wonders of the difference in government’s response to health inequalities if income gradient in relation to health were to be different. An illustration of this is what the response would be if the higher income groups were the ones experiencing worst health.
Wilkinson has written the book from a particular point of view, that which focuses on social justice and reform. He does not criticize capitalism as per se and does not posit extreme ideologies. Wilkinson’s view of social progress is very much in existence in the contemporary UK society, where market is part and parcel of the existing societal structure.
According to Wilkinson, inequalities in health can be reduced, better stress management mechanism developed to reduce social stress and the quality of social relations made to be better. All these efforts would play a very vital role in improving the health and well-being across populations in the society.
His conclusion is on an optimistic stand-point as he acknowledges the health inequalities across populations but then again, he says that change is very much possible and that the health inequalities can be reduced.
The universe is still in the process of expansion in as far as moral democratic values are concerned, this coupled with growing sensitivity to the suffering of others, Wilkinson points out that a decrease in inequality and improvement of well-being across the social classes was very imperative in strengthening political goals.
Carlisle (2001) has presented the debates related to inequalities and health based on three different explanatory discourses as presented by Macintyre (1997). The first, hereditarianism explanations, on class variations in relation to disease have been presented based on the argument that people’s social position is dependent on natural capacity that is biologically determined.
Based on this perception, variations in health are considered to be inevitable and nothing much can be done about them. Behavioural explanations have been used to justify the high mortality rate amongst labouring classes and ill health of the economically poor sections of the population as a subsequent result of working-class maternal ignorance alongside living conditions that are not up to standard.
In this case, education would have been a preferable measure in improving health. The environmental aspect attributed causes of inequalities in health considered to widespread poverty and material components of urban industrial life. Based on the latter, social reforms were considered to be of great value in addressing the environmental aspect in as far as health and inequalities were concerned.
Popay, et al., (1998) in their review of modern research, have presented a debate based on two main constructions that continue to govern research pertaining to health inequalities. The first construction is individual behaviours and lifestyle while the second one is social inequalities and injustice.
There are some elements of continuity with regard to historical environmental explanations on poverty and deprivation, and behavioural/ hereditarianism explanations on lifestyle and culture the causes of health inequalities.
Nonetheless, differences exist in relation to social values and political ideology in the different explanatory discourses and all are directed at identification of appropriate and applicable policies.
Carlisle concludes by suggesting that lack of clarity revolving around competing explanations fosters political skilful moves at the policy level where the UK government seeks leadership in grappling with the issue, while delegating responsibility to community members and individual figures.
Carlisle presents an overview of three but highly contested explanations that are linked to inequalities in health in the contemporary world. These are poverty/deprivation, psychological stress and individual deficit. The deprivation facet is a strong evidence for the inequalities but it is not complete.
Various critics focus on the barrier of the gradient since health inequalities are not only found within the poorer segments of the society but are a sequel of social class gradients (Marmot et al., 1991). Material differences therefore are not adequate in explaining this. The psychosocial stress model was developed to fill in the gaps from the poverty model.
It views the problem as a generative mechanism for inequalities in health based on the relationship between the individual person and social structure. The individual deficit model has similarly acknowledged social inequality but does not focus much on restructuring the society as compared with addressing the problem and at individual level, examining their culture as well.
Heller, et al., (2002) has argued out the widening and large gap in mortality rate between those at the extreme ends of social distribution despite the amelioration in overall mortality rate. It is this gap between the extremes that has been indicated to be the relative mortality variation between those who experience greatest and least deprivation.
Heller and others have shown that the changes in social distribution that transverse the population has been a major contributor to the reduced mortality rate. Heller and others have argued out that based on their findings, there is no widening gap in overall health inequality when redistribution within the social classes is factored in.
According to the review of both Mackenbach and Kunst (1997) on the different methods of overall health inequality assessment in any population, none of them can be pointed out to be the very best.
Heller and others have used a method that does not directly address the issue despite the fact that it is flexible to changes in social class distribution and allows description of mortality within social classes. Unfortunately, Heller and others have used a method that presumes that every member within a certain social class has the same predisposing risk of mortality.
In addition, when one moves from one social class to another, he or she adopts that mortality profile of that new social class. This is not usually the case and especially in the short-term. The method used to sasses the degree of health inequality in relation to the widening gap of mortality between the extremes of social distribution may be inaccurate as the change may be partly attributed to artefact of health selection.
Conclusion
Inequality is a term that has been used in relation to the distribution of health or ill-health across populations. This ideology or concept is not just an expression of existing differences in relation to race, sex, age and species which exist.
It is neither a mere expression of the natural physiological constitution or procedures involved that have been socially and economically developed. The vast literature and attention on “health inequalities” show that this issue is very much complex. This literature has demonstrated that recognizable and discernable factors related to health inequalities are not easy to isolate from one other as they are very much entangled with one another.
The differences that prevail between people are considered to be eternal and not capable of being modified. The society is made up of various institutions. These institutions can influence health inequalities indirectly and subtly, or directly and evidently.
Some individuals think that this concept of health inequalities is associated with moral reinforcement while others consider it to be non-existent or not yielding into any consequences. The latter consider health inequalities to be inevitable and are as a result of man’s desire to build society. They consider the scope for change to be limited and of miniscule importance.
The concept of social class has been evident in the various literatures. Populations are not alike in terms of literacy, wealth, income and housing. The population is thus divided into strata and societies differ based on these strata. However, it is difficult to identify the borders between the different the different strata but, this does not mean that the strata are less real.
On the contrary, the social strata are sections of the population that share the same types of resources and have similar lifestyles. Controversy continues to prevail with regard to the origin and importance of social class in as far as health inequalities and change are concerned.
Despite the fact that some literatures show that there no significant correlation between health inequalities and poverty/deprivation, one cannot ignore the need to improve the health of those with the highest degree of deprivation. The approach to addressing health inequalities in the UK should be comprehensive in that it focuses on various possible causes of these inequalities.
This will aid in developing the comprehensive approach required to address these causes. Therefore, there is need to include determination of relevant polices that should be put to work so as to improve the overall socioeconomic status of the population.
A reduction in mortality rate between the extremes in social distribution is the not the only way through which health inequalities can be addressed. Rather it is one facet of social inequality on health inequalities. Irrespective of the rhetorical commitment in addressing issues related to health inequalities, it is a great issue that continues to persist in the UK society.
References
Acheson, D. 1998. Independent Inquiry into Inequalities in Health. BMJ, 317, (7173) 1659.
Asthana, S., & Halliday, J. 2006. What Works in Tackling Health Inequalities? Pathways, Policies and Practice through the Life course (Studies in Poverty, Inequality & Social Exclusion). Policy Press.
Bolam, B., Hodgetts, D., Chamberlain, K., Murphy, S., & Gleeson, K. 2003. ‘Just do it’: An analysis of accounts of control over health amongst lower socioeconomic status groups. Critical Public Health, 13, pp. 15–32.
Buch, R. 2010. Health Inequalities in the UK-our most pressing problem. Web.
Carlisle, S. 2001. Inequalities in health: contested explanations, shifting discourses and ambiguous policies. Critical Public Health, 11, pp. 267–281.
Davey Smith, G., Chaturvedi, N., Harding, S., Nazroo, J., & Williams, R. 2000. Ethnic inequalities in health: a review of UK epidemiological literature. Critical Public Health, 10, pp. 375–408.
Davey Smith, G., Dorling, D., Gordon, D., & Shaw, M. 1999. The widening health gap: What are the solutions? Critical Public Health, 9, pp. 151–170.
Evans, D., & Killoran, A. 2000. Tackling health inequalities through partnership working: Learning from a realistic evaluation. Critical Public Health, 10, pp. 125–140.
Evans Shito, M., & Keskimaki, I. 2000. Does a policy matter? Assessing the Finnish health policy in relation to its equity goals. Critical Public Health, 10, pp. 273– 286.
Heller, R. F., McElduff, P., & Edwards, R. 2002. Impact of upward social mobility on population mortality: analysis with routine data. BMJ, 325, pp. 134-136.
Labonte, R. 1999. Some comments on the Acheson Report. Critical Public Health, 9, pp. 171–174.
Macintyre, S. 1997. The Black Report and beyond: what are the issues? Social Science & Medicine, 44 (6), pp. 723–745.
Mackenbach J. P., & Kunst, A. E. 1997. Measuring the magnitude of socioeconomic inequalities in health: an overview of available measures illustrated with two examples from Europe. Soc Sci Med, 44, 75771.
Marmot, M. G., Davey Smith, G., Stansfled, S., Patel, C., North, F., Head, J., White, I., Brunner, E., & Feeney, A. 1991. Health inequalities among British civil servants: the Whitehall II study. Lancet, 337, pp. 1387–1393.
Morrow, V. 2000. ‘Dirty looks’ and ‘trampy places’ in young people’s accounts of community and neighbourhood: Implications for health inequalities. Critical Public Health, 10, pp. 141–152.
Muntaner, C., Lynch, J., & Davey Smith, G. 2000. Social capital and the third way in public health. Critical Public Health, 10, pp. 107–124.
O’Keefe, E. 2000. Equity, democracy and globalization. Critical Public Health, 10, pp. 167–178.
Ostry, A., Marion, S., Green, L., Demers, P., Teshke, K., Hershler, R., et al., 2000. The relationship between unemployment, technological change and psychosocial work conditions in British Columbia sawmills. Critical Public Health, 10, pp. 179–192.
Popay, J., Williams, G., Thomas, C., & Gatrell, T. 1998. Theorising inequalities in health: the place of lay knowledge. Sociology of Health and Illness, 20 (5), pp. 619–644.
Stewart-Brown, S. 2000. What causes social inequalities: Why is this question taboo? Critical Public Health, 10, pp. 233–242.
Townsend, P. 1998. Inequalities in Health: The Need to Construct More Comprehensive Health Policies, HEA Occasional Paper, 11 March (London, HEA).
Wilkinson, R. G. 2005. The Impact of Inequality: How to make Sick Societies Healthier. New York: The New Press.
Woods, S., Lake, J., & Springett, J. (2003). Tackling health inequalities and the HAZ smoking cessation programme: The perfect match? Critical Public Health, 13, pp. 61–76.