John Ashton

We would all prefer to live in a society where there are not extremes where there is social justice, but even in egalitarian societies there are complications.

When the Black Report was published I was working at the London School of Hygiene. One of the problems with the report was that the recommendations were not prioritised, making it easy for the Conservative government to denounce it.

We need to think about how to make progress. The UN report published yesterday (8th September, 2005) stated that the inequalities in the US are on par with a third world society.

Are policies made since 1997 making an impact? There has been progress and several initiatives such as the Sure Start work. This was modelled on the Head Start programme in the US, which 30 or 40 years later has demonstrated beneficial effects.

Impulses for Public Health reform have not, historically, come from altruistic desire to improve health for health’s sake – but from other reasons such as nationalistic and militaristic reasons. In 1848, throughout Europe there was a fear of insurrection which led to liberal reform in a number of countries. Lessons from the Boer War, when more than a third of working class recruits to the army were found to be unfit for military service led to measures which in due course paved the way for the welfare state. There was fear and the need for a decent army. In 1906, free school meals and milk and the school health service were introduced. The Beveridge report arose from anger over what had happened during the previous twenty years combined with the radicalisation of Second World War conscripts who had been educated during their training. Inter-generational solidarity was generated with previous generations investing for us – can we claim the same solidarity today with either those remaining from that generation or with those generations still to come?

It was Tawney who reflected on the deterioration of socialist parties when they come to power and it will be for historians to evaluate the legacy of the post 1997 Labour administration. I found it ironic that in the 1981 Labour Party Conference, when I moved the health resolution that it was considered old-fashioned to refer to the five giants that underpinned the Beveridge Report – Want, Ignorance, Squalor, Idleness and Disease. There has been a profound shift from universal policies to targeted ones over the past 30 years. This contrasts with the Public Health framework which considers whole populations; and populations at risk; and further sub-populations who are in trouble as a three-tracked approach for health protection and improvement. For example, teenage pregnancy work has to start with a population approach looking at sexual health, relationships and sex before moving onto more targeted work for those at risk or those unwantonly pregnant or suffering from sexually acquired infections. If we are serious about tackling health inequalities, there needs to be a similar three track approach to all government policies which affect health.

A serious question to ask is whether our obsession with mortality statistics suggests that we are continuing to tackle yesterday’s problems whilst life expectancy is an important measure of equality one of the biggest challenges to social justice in the foreseeable future will be the huge differences in quality of life between different geographic areas and social groups particularly in later life.

We need to think in a more rounded way about health inequalities. The issues to be considered include control over the very many different types of resources, such as the environment and social networks which impact on health, not just disposable income. This understanding needs to be translated into policy. Our opportunities lie with: tackling perinatal health; childhood deaths and ill-health especially from accidents and external causes; adult violence and alcohol use; the health of the 50+ population; old age and pensions.

The Northwest has a large population and the largest concentration of health inequalities in the country. If we cannot meet our targets by 2010, then England cannot arithmetically meet its targets. We are drawn into thrall about risk factors, but what about risk conditions which occur in the various settings of everyday life – the home, the school, the workplace, the natural and built environment? Parental behaviour relating to accidents may not be the key approach to tackling health inequalities. Where is the universal adoption of home zones for residential areas? There are wide differences between social classes 1 to 5 in terms of young boys being killed in accidents. Frequently these depend on the provision of adequate supervision and safe recreation in the areas where people live and the times such as evenings, weekends and the school holidays when youngsters are especially at risk. A narrow medical focus on health doesn’t help us improve this situation.

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