Education And Debate

All together now: why social deprivation matters to everyone

BMJ 1996; 312 doi: (Published 20 April 1996) Cite this as: BMJ 1996;312:1026
  1. Graham C M Watt, professor of general practicea
  1. a University of Glasgow, Woodside Health Centre, Glasgow G20 7LR
  • Accepted 3 April 1996

Inequalities in health in the United Kingdom are widening as a result of economic policy. By focusing on specific diseases, health policy fails to address why less prosperous groups die earlier from most major categories of death. By concentrating on actions which can be taken by individuals and local communities health policy ignores actions which require the support and involvement of society as a whole. Clinicians see the consequences of health and economic policy in their everyday practice and could contribute more effectively to public debate. There is a crying need to improve public and professional understanding of the links between health, education, and economic policy and the consequences for everyone of the increasing social and economic exclusion of a substantial proportion of the population.

“Alcoholics, drug addicts, rioters, vandals and criminals, the obese, the handicapped, the mentally ill, the poor, the homeless, the unemployed and the hungry, whether close at hand or in the Third World—all these are seen as problem groups, different and separate from the rest of their society,” wrote the late Geoffrey Rose.1 Writing on the epidemiology and prevention of health and social problems, Rose likened these problems to the tips of icebergs, commenting that the visible tip could be neither understood nor properly controlled if it were seen as the whole problem.

The visible tip of the iceberg, or prevalence, is a function of its total mass, which is determined by the population average. Rose argued that a population strategy to sink the iceberg rather than to attack its tip is necessary whenever risk is widely diffused throughout a population.2

We are familiar and comfortable with this argument in relation to variables such as blood pressure,3 cholesterol,4 and alcohol.5 Less familiar is the iceberg effect which determines the higher prevalence …

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