Elsevier

Public Health

Volume 129, Issue 7, July 2015, Pages 849-853
Public Health

Governance for Health Special Issue Paper
Health inequalities – why so little progress?

https://doi.org/10.1016/j.puhe.2015.03.026Get rights and content

Abstract

Studies of the health of the population of Scotland over many years have provided new insights to the basis of inequalities in life expectancy across the Scottish population. Conventional descriptions of health inequalities as being due predominantly to smoking, obesity and alcohol do not fully account for the situation in Scotland. The deeper insights obtained from comprehensive analysis have prompted new approaches to narrowing the gap. Opportunities for well-being are created within the complex system of a well functioning society and novel methods are required if the outcomes of such a complex system are to improve.

Introduction

In many countries, there is a marked and growing gap in life expectancy between the poorest and most affluent members of society.1 Differences in risk of premature death associated with wealth have been known about for many years. One of the first statistically important studies of wealth and mortality is to be found in the city records of Glasgow for 1861. John Strang, the City Chamberlain, an officer of the city who was responsible for collecting taxes, calculated the ratio of domestic servants to total population in each electoral district of the city as a proxy for economic status. He showed that in the most affluent area, where there was one domestic servant for every 2.8 residents, infant mortality was 17.8 deaths/1000 live births in the first year of life. However, in the poorest district, with one servant for every 67.8 residents, 260 of every 1000 babies born alive died in their first year of life.

Many studies since then have confirmed a striking relationship between poverty, poor health and premature mortality. In the UK, the Report on Inequalities produced by Sir Douglas Black2 showed that, in the 1970s, unskilled workers were 2.5 times more likely to die before the age of 65 years than professional classes. More recently, figures based on mortality data from 2010 to 2012 show that male life expectancy at birth in the city of Glasgow is 72 years,3 15 years lower than in the most affluent areas of England. This gap is also seen within the localities of west central Scotland. Glasgow Centre for Population Health4 reports a 15 year gap in male life expectancy at birth across neighbourhoods in the Greater Glasgow area and an equivalent 11 year gap in female life expectancy in the period 2008–12.4

Initially, attempts to explain these differences focused on a behavioural model.5 The commonly held view, perhaps encouraged by a UK Government report of 19766 was that individuals were responsible for their own health, implying that those with poorer health at the lower end of the social scale were more likely to indulge in unhealthy behaviours and less likely to access health care. Inequalities were seen as the consequence of choices made by the poor and the remedy was to provide them with better information to make it clear that they were making the wrong choices.

Those who recognized the poor as victims of circumstance questioned this approach. Attempts to explain inequalities as being due to decisions made by individuals have, rightly, been dismissed as ‘victim blaming.’ In 1980, The Black Report suggested the idea that the material circumstances in which poor people lived were the principal cause of inequality.2 Poverty exposes people to health hazards, the report argued, because it made them more likely to live in poorly built houses which were cold and damp and often in areas affected by air pollution. While there is some evidence to support this argument in part, it is clear that it fails to explain much of the inequality in health and it does little to explain many of the other inequalities encountered in poor areas. Yes, unhealthy habits were commoner in deprived areas and these areas may have poorer environments which might contribute to inequality in health status but, as Sir Michael Marmot has often stated ‘We need to look behind the obvious explanations. We need to understand ‘the causes of the causes’ if we are to improve the situation’.7

Section snippets

Inequality in Scotland – an alternative analysis

For many years, the explanation for the gap in mortality in Scotland, as in other countries, was assumed to be due largely to health related behaviours. The affluent were more likely to eat well, take exercise, be non-smokers and drink alcohol more sensibly than the poor. There remains, in Scotland, as in other societies, a clear association between higher levels of healthy behaviour and relative affluence. However, association tells us little about causation. In the last few decades,

Inequality is widest in younger people

An important study was that carried out by Leyland and colleagues.8 They examined in detail the underlying pattern of inequality across the life span of the Scottish population. Many studies simply look at overall life expectancy without giving enough consideration to the underlying patterns of death. Their work showed that the widening gap in life expectancy in Scotland is partly due to the fact that ischaemic heart disease mortality has fallen faster in wealthier areas than amongst the poor

Social turbulence in the latter decades of the 20th century

The widest inequalities in life expectancy in Scotland are to be found in the cities of Glasgow and Dundee. In the 1970s, both these cites experienced major loss of employment in traditional industries.9 In Glasgow, jobs in shipbuilding and heavy engineering were lost as competition from Far Eastern countries became more intense. At the same time, the production of jute based products which, at its height, had provided employment in 130 mills in Dundee declined precipitously.

The loss of

Salutogenesis rather than pathogenesis

Clues as to the drivers of inequality and possible remedies are to be found in the idea of salutogenesis. This is a term introduced by the American sociologist, Aaron Antonovsky who developed an approach to health promotion that focused on those factors that support human health and well-being, rather than on factors that cause disease. More specifically, the ‘salutogenic model’ is concerned with the relationship between health, stress, and coping. The medical, or pathogenic paradigm, on the

The biology of social chaos

The evidence linking adverse and chaotic social circumstances to elevated stress levels is extensive and compelling. A clear relationship between adversity and stress exists across all ages. Children living with depressed parents show elevations in cortisol levels from an early age. Hertzman and Boyce13 have reviewed such observations and concluded that adverse experiences in early life become ‘embedded’ in ways that affect health across the life course.

The physical consequences of these

The cycle of alienation

Children who experience adversity are more likely to have mental health problems in early life, are less likely to succeed at school and are more likely to be unemployed on leaving.17 While poverty is often seen as a cause of adversity in early life, it is also likely to be a consequence of failed childhood. An intergenerational cycle of alienation from mainstream society is perpetuated as young people who have not experienced a nurturing childhood become, in their turn, dysfunctional parents.

Breaking the cycle

The statement that ‘insanity is continuing to do what you've always done and expecting different results’ is often attributed to Einstein. Our analysis of the drivers of inequality in Scotland convinced us that the complexity of the problem could not be overcome through conventional policy approaches. Such approaches usually involve convening a group of experts who will meet regularly over several months. The end product of such a process is normally a policy recommendation to a minister based

Ethical approval

None sought.

Funding

None declared.

Competing interests

None declared.

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