While it can be politically expedient for governments to engage with health inequalities, in a neoliberal world they struggle to realistically propose actions which will substantially reduce them – such as tackling power inequalities, patriarchy-sustaining institutions or class inequality. A dominant ‘policy paradigm’ prioritising economic growth restricts even their ability to imagine alternative, equitable scenarios. In this context, politicians, policy makers and some researchers have devised a parallel fantasy world in which proximal, downstream and easily tackled exposures are put forward as viable solutions to the causes of health inequalities (and sometimes even positioned as the causes). The consequence of this is a widespread public sector culture in which well-meaning policy-makers, practitioners, researchers and the public collude in sustaining a ‘cargo cult’ around the ‘worship’ of health behaviourism.
It’s now widely accepted that health inequalities – unfair, unjust differences in health determinants and outcomes within and between populations – have serious immediate and long-term negative impacts on individuals and societies. As a result, many governments have at least a rhetorical commitment to reducing the causes of health inequalities. It is rare for national inequality reduction strategies to include any analysis of the causal pathways that result in health inequalities and rarer still for them to suggest interventions that seek to tackle the fundamental causes of health inequalities. Instead, most policy approaches (even the few that acknowledge material and structural causes) put forward lists of ‘downstream’ (proximal) health determinants, such as smoking, unhealthy dietary choices, poor housing conditions, or failure to use contraception, whose social patterning – ie, greater prevalence among working class people – is itself presumed to represent the cause of the relevant inequality.
There are however persuasive reasons to believe that health inequalities will only be reduced as a result of deeper analysis and more fundamental policy change. Health inequalities are increasingly viewed as an outcome of material, social and cultural inequalities across societies, which are in turn the product of inequalities in power, income, wealth, knowledge, social status and social connections. Viewed from this perspective, sustained long-term reductions in health inequalities are dependent on strategies that engage effectively with these fundamental causes.
The long-term persistence of health inequalities provides additional justification for reviewing the action required to achieve health equity. Differences in health and survival between more and less advantaged groups have persisted across centuries. Only the immediate causes of those inequalities have changed: premature death among disadvantaged groups is now primarily the result of long-term conditions like cancers and cardiovascular diseases rather than infectious diseases, as was formerly the case. What remains unchanged is that it’s still the more disadvantaged folk who die prematurely.
Despite this, even policies designed to improve the health of disadvantaged people have little or no impact on long-term health inequalities. One obvious explanation for this is that politicians are attracted by policy options which focus on accessible ‘targets’ and which can be implemented in the short timeframe prior to the next election. It’s far easier to focus on exhorting downstream ‘lifestyle changes’ such as encouraging people to smoke less, eat more healthily, drink less alcohol and exercise more, than it is to legislate for ‘midstream’ policies like standardised (plain) packaging of cigarettes, restrictions on the content or marketing of unhealthy food and alcohol products, or the provision of more cycle lanes – let alone engaging with power inequalities or the other upstream causes listed above. Furthermore, in a capitalist society, where liberal macroeconomic policy prioritises economic growth (at a national level) and profit-maximisation (at a corporate level), there is an inbuilt incentive to ‘blame the victim’ rather than to tackle problems caused by economic policies or corporate actions.
The example of the UK
In the UK, as in other countries with a history of welfare state development, the public sector occupies an important role in the determination of the causes of health inequalities. This is reinforced by a centralised style of government which allows little local flexibility on the part of public authorities in the way they allocate the social determinants of health – such as access to social housing, education, state benefits, or health / public health services and policies. Devolution strategies currently under way in England will not substantially change this, because their main focus is on devolving responsibilities rather than the power to generate resources.
As a result, local public services such as the National Health Service (NHS) and local government – and so-called voluntary ‘third sector’ services which have also become providers of health and social care, as governments ‘roll back the welfare state’ – have increasingly ‘sung to the government’s tune’ in their engagement with the causes of health inequalities
In the UK, this is especially the case in the period since 1997, as the Thatcher Conservative government (1979-90) refused to engage in any way with health inequalities and its successor, the Major Conservative government (1990-97) acknowledged only ‘variations’ – and even here, its strategic focus was explicitly restricted to Whitehall and NHS policy.
The Blair Labour government came to power in 1997 after 18 years in which Labour had, in opposition, frequently and consistently emphasised the importance of addressing health inequalities. Indeed, Labour’s – and England’s – first Minister for Public Health, Tessa Jowell, travelled the country in the summer of 1997 telling public health audiences that they ‘should feel free once again to use the word inequalities’ – something they had effectively been prevented from doing during 18 years of Conservative government, as a result of the centrally dominated public sector culture.
But while the NHS public health services and local authorities now had ‘a new song to sing’ regarding health inequalities, it was very clearly a two-part harmony. Following the publication by the Labour government of the Health Inequalities Decennial Supplement (1997) and the Acheson Inquiry report (1998), both of which were wide-ranging and relatively radical in their review of health inequalities trends and research, a series of government pronouncements and strategies emerged over the next decade which, while impressive in their rhetoric around ‘wider determinants of health’ were in reality largely focused on individualistic interventions such as behaviour modification programmes. Local public health and health promotion practitioners had very little encouragement or flexibility to address ‘upstream’ issues.
In addition, from 2010, a further dimension was provided by the Labour government’s equalities legislation which prohibited discrimination on the grounds of age, disability, gender reassignment, marriage and civil partnership, race, religion or belief, sex, and sexual orientation in the provision of public and private services and of employment. These welcome civil rights policies were accompanied by a new range of equalities staff, tools and training programmes, which occasionally duplicated and frequently caused confusion with existing inequalities tools and methods, especially when equalities staff moved beyond civil rights to engage with outcome inequalities – typically at an individual rather than population level.
What existed, then, during the period of Labour government (1997-2010) and has continued since, under the Conservative – Liberal Democrat Coalition (2010-15) and the current Conservative (2015 onward) government, was a government-driven NHS, local authority and third sector ‘fantasy paradigm’ which positions health inequalities as ‘fixable’ via interventions and policies to address lifestyle differences between population subgroups – in particular, between social classes. This is despite the fact that – as a recent synthesis of systematic review evidence demonstrates – these kinds of interventions tend to exacerbate, rather than reduce health inequalities. .
This fantasy paradigm is promoted and reproduced by a large body of well intentioned and often idealistic state / third sector employees, who have developed diverse plans and projects and who spend public and other funds on primarily downstream, chiefly outcome-focused activities, in the name of reducing health inequalities – inequalities that are largely unaffected by these methods.
An equally large body of quantitative knowledge in the form of indicators, targets, monitoring tools and other performance measures has been developed to assess this programme of activity. The frequent demonstrations of failure are typically explained with reference to the ‘challenging and persistent nature’ of health inequalities. Especially notable are the former Coalition and current Conservative governments’ continuing rhetorical attachment to the reduction of health inequalities despite these same governments’ systematic dismantling of the public sector which often provided the only external support for people experiencing poverty, disadvantage and inequality.
Towards an end to fantasy
At the time of writing, there are few if any signs of an end to politicians’ infatuation with their health inequalities fantasy paradigm in the UK or elsewhere (a parallel ‘health disparities’ fantasy paradigm exists in many other high income countries, notably the US). We are four austerity-driven years from an unpredictable UK general election and can only hope that raising awareness of these issues will stir a little truth into the toxic cocktail that passes for government.
I gratefully acknowledge the constructive comments of Dr Katherine Smith on an earlier draft. An extended version of this discussion can be seen in: Scott-Samuel A, Smith KE. Fantasy paradigms of health inequalities: Utopian thinking? Social Theory & Health 2015; 13, 418-436. doi:10.1057/sth.2015.12
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