Round table discussion. Health inequalities and the health of the poor.

Abstract

I have been asked to consider Davidson Gwatkin's article in the light of the Report of the United Kingdom's recent Independent inquiry into inequalities in health which I chaired (1). While it is clearly inappropriate to generalize from the experience of one country in terms of particular policies, the weight of scientific evidence suggests, as indeed does Davidson Gwatkin's article, that a socioeconomic explanation of health inequalities is likely to be relevant for all countries rich and poor throughout the world. The socioeconomic model traces the roots of ill-health far beyond health services to such determinants as income, education and employment as well as to the material environment and lifestyle. This has the practical implication that the necessary policy developments to reduce health inequalities will extend far beyond the remit of departments of health, some of them relating to the government as a whole while others will fall within the terms of reference of a range of other government departments. As has been the experience elsewhere, the Inquiry found that although health in England (as judged by reductions in mortality rates) had over the past 50 years on average improved greatly, in recent decades inequalities in health had either remained static or widened. These inequalities can be identified at all stages of the life course from pregnancy to old age. The Report selected the following three of its 37 recommendations as crucial. * All policies likely to have an influence on health should be evaluated in terms of their impact on health inequalities. * A high priority should be given to the health of families with children. * Further steps should be taken to reduce income inequalities and improve the living standards of poor households. While the reasoning which supports the second and third of these priorities is self-evident, the first, which recommends an important development in health impact assessment, needs further explanation. Experience shows that a well-intended policy which improves average health in a population may have no effect on inequalities. Indeed it often widens them by having a greater impact on the better-off. This has happened in some initiatives concerned with immunization and cervical screening, as well as in some campaigns to discourage smoking or promote breastfeeding. These examples highlight the need for health policies to focus extra attention on the health of the less well-off. This could be done both by policies directed specifically at the less well-off, and by an approach which would require inequalities to be considered wherever universal services are provided (such as publicly funded education or health care) and where other policies are likely to have an impact on health. The Report identified a wide range of areas for future policy development relevant to the reduction of health inequalities judged on the scale of their potential impact and the weight of the evidence. These policy areas include poverty; tax and benefits; education; employment; housing and environment; mobility; transport and air pollution; and nutrition. …