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From across the Atlantic in America please permit me to share with
the British my distinctly positive reaction evoked by Independent Inquiry
into Inequalities in Health(1), the Sir Donald Acheson Report invited by
the Labour Government to identify priority areas for the development of
policies to reduce inequalities in health in England.
The central findings of a large body of research initiated nearly 25
years ago by social and health scientists in England, and joined in the
last 15 years by research in Canada and in the United States are: 1)
population health (disease prevalence and mortality rates) varies widely
within a nation, and among nations; 2) within a population (city, state or
nation) variations in health are not distributed randomly, but rather are
systematically and consistently related to social class as identified by
differences in income, education, and job classification. Progressively
higher levels of income, education and job are associated with
progressively better levels of health; 3) the health/social gradient is
not due simply to differences between the poor and the rich, but the
gradient is continuous throughout the spectrum from lower classes, through
middle classes, to the upper classes; 4) in comparing the average health
status among nations (OECD member nations) of several nations, the rank
order of life expectancy for example is in reverse order to the degree of
incline of the hierarchical social class structure, e.g., the steeper the
gradient of income inequality across the population the shorter is the
nation's average life expectancy. The middle classes in the U.S. and
Britain are not nearly as healthy as the same classes in Sweden when
assessed by life expectancy or prevalence rates of most chronic diseases;
5) although income or job class are commonly used as identifiers of social
class the root causal connection to the gradient in health might be more
complex, textured, and deeply embedded in societal structures than the
more easily measured income or job class. Research seems promising in
this regard on social capital, social cohesion, labor market features,
population connectedness to (or alienation from) the institutions,
organizations and policies that provide structure for living within the
social order.
The societal structures referred to in point 5 above include laws,
regulations, social norms and expectations, work, wages, systems of access
to food, clothing, shelter, medical care, learning, transport,
communication, physical and economic security, fair treatment, respect for
self and others, and so forth. Provision of needs is often mediated
through institutions such as governments, schools, religious
organizations, businesses, non-profit associations and the like. The
purposes of these institutions are uniformly benevolent, but with passage
of time and failure to revise, update or eliminate, these institutions'
functions can evolve into forces that create distortions of social
purposes and population disharmony. Although these distortions can appear
benign, they also can do violence to the social order, and thus to
health.
Given a more comprehensive view of societal ecology, it is doubtful
that public policies to reduce inequalities in income by redistribution
alone will accomplish a socially significant improvement in population
health and a reduction in health disparities. Rather, a more pervasive
social restructuring will be required. The objective will have to be to
reduce the sharp grating edges of steep gradients in material things like
income, housing, and transport but also to reduce the harsh unfairness of
inequalities in privilege, opportunity, influence, access, security and
social respect. A broad approach to moderate the steep hierarchical
structure will be required to improve the average British (and American)
population health and to reduce health inequalities. The Independent
Inquiry takes that approach in its recommendations on income, education,
employment, housing, physical environment, transportation, agriculture,
nutrition, families, youth, elders, ethnically diverse populations and
medical care. On reducing crime, for example, the Inquiry gives priority
to pre-school education, the welfare needs of youth, landscape and
architecture design, reduction of income inequality and poverty, and
restoring social cohesion. It states "The most effective approaches to
crime prevention are likely to be those which are integrated with wider
social and economic policies. . ." The Inquiry's comprehensive approach
is one reason I am enthusiastic about the Report, and why I disagree with
the criticisms of the Report by Davey-Smith and colleagues.2
Social restructuring, or even modest socio-structural revision, to
improve population health will require substantial political activity.
But political productivity is the end-game in most social transformations.
Prior to political action a broad public understanding needs to be
acquired of the root causes of substandard and unequally distributed
health. Once that understanding has been assimilated an evident desire at
a high enough priority must develop among a sufficient proportion of the
population to create an authorizing environment or momentum for action.
When sufficient momentum has developed, the political process will be
authorized to pursue policies to address the problem. The Independent
Inquiry's Report, written simply but comprehensively, and broadly
distributed has the potential for building public understanding. Another
reason I disagree with the Davey-Smith commentary is its emphasis on
politics.
The Independent Inquiry Report is a major accomplishment that
possibly might be a beacon guide for many nations, not only Britain, to
achieve improved population health. In America I am grateful for the
Report's leadership.
Alvin R. Tarlov, M.D.
Executive Director, The Health Institute
at New England Medical Center
Chairman, Working Group on Mind, Brain, Behavior:Society and Health
Harvard University
Professor of Health Promotion
Harvard School of Public Health
Professor of Medicine
Tufts University School of Medicine
1 Report of the Independent Inquiry into Inequalities in Health.
London: Stationery Office, 1998.
2 Davey-Smith G, Morris JN, Shaw M. The Independent Inquiry Into
Inequalities in Health. BMJ 1998; 317:1465-6, (28 November).
Response to George D. Smith
January 29, 1999
To the Editor, British Medical Journal
From across the Atlantic in America please permit me to share with
the British my distinctly positive reaction evoked by Independent Inquiry
into Inequalities in Health(1), the Sir Donald Acheson Report invited by
the Labour Government to identify priority areas for the development of
policies to reduce inequalities in health in England.
The central findings of a large body of research initiated nearly 25
years ago by social and health scientists in England, and joined in the
last 15 years by research in Canada and in the United States are: 1)
population health (disease prevalence and mortality rates) varies widely
within a nation, and among nations; 2) within a population (city, state or
nation) variations in health are not distributed randomly, but rather are
systematically and consistently related to social class as identified by
differences in income, education, and job classification. Progressively
higher levels of income, education and job are associated with
progressively better levels of health; 3) the health/social gradient is
not due simply to differences between the poor and the rich, but the
gradient is continuous throughout the spectrum from lower classes, through
middle classes, to the upper classes; 4) in comparing the average health
status among nations (OECD member nations) of several nations, the rank
order of life expectancy for example is in reverse order to the degree of
incline of the hierarchical social class structure, e.g., the steeper the
gradient of income inequality across the population the shorter is the
nation's average life expectancy. The middle classes in the U.S. and
Britain are not nearly as healthy as the same classes in Sweden when
assessed by life expectancy or prevalence rates of most chronic diseases;
5) although income or job class are commonly used as identifiers of social
class the root causal connection to the gradient in health might be more
complex, textured, and deeply embedded in societal structures than the
more easily measured income or job class. Research seems promising in
this regard on social capital, social cohesion, labor market features,
population connectedness to (or alienation from) the institutions,
organizations and policies that provide structure for living within the
social order.
The societal structures referred to in point 5 above include laws,
regulations, social norms and expectations, work, wages, systems of access
to food, clothing, shelter, medical care, learning, transport,
communication, physical and economic security, fair treatment, respect for
self and others, and so forth. Provision of needs is often mediated
through institutions such as governments, schools, religious
organizations, businesses, non-profit associations and the like. The
purposes of these institutions are uniformly benevolent, but with passage
of time and failure to revise, update or eliminate, these institutions'
functions can evolve into forces that create distortions of social
purposes and population disharmony. Although these distortions can appear
benign, they also can do violence to the social order, and thus to
health.
Given a more comprehensive view of societal ecology, it is doubtful
that public policies to reduce inequalities in income by redistribution
alone will accomplish a socially significant improvement in population
health and a reduction in health disparities. Rather, a more pervasive
social restructuring will be required. The objective will have to be to
reduce the sharp grating edges of steep gradients in material things like
income, housing, and transport but also to reduce the harsh unfairness of
inequalities in privilege, opportunity, influence, access, security and
social respect. A broad approach to moderate the steep hierarchical
structure will be required to improve the average British (and American)
population health and to reduce health inequalities. The Independent
Inquiry takes that approach in its recommendations on income, education,
employment, housing, physical environment, transportation, agriculture,
nutrition, families, youth, elders, ethnically diverse populations and
medical care. On reducing crime, for example, the Inquiry gives priority
to pre-school education, the welfare needs of youth, landscape and
architecture design, reduction of income inequality and poverty, and
restoring social cohesion. It states "The most effective approaches to
crime prevention are likely to be those which are integrated with wider
social and economic policies. . ." The Inquiry's comprehensive approach
is one reason I am enthusiastic about the Report, and why I disagree with
the criticisms of the Report by Davey-Smith and colleagues.2
Social restructuring, or even modest socio-structural revision, to
improve population health will require substantial political activity.
But political productivity is the end-game in most social transformations.
Prior to political action a broad public understanding needs to be
acquired of the root causes of substandard and unequally distributed
health. Once that understanding has been assimilated an evident desire at
a high enough priority must develop among a sufficient proportion of the
population to create an authorizing environment or momentum for action.
When sufficient momentum has developed, the political process will be
authorized to pursue policies to address the problem. The Independent
Inquiry's Report, written simply but comprehensively, and broadly
distributed has the potential for building public understanding. Another
reason I disagree with the Davey-Smith commentary is its emphasis on
politics.
The Independent Inquiry Report is a major accomplishment that
possibly might be a beacon guide for many nations, not only Britain, to
achieve improved population health. In America I am grateful for the
Report's leadership.
Alvin R. Tarlov, M.D.
Executive Director, The Health Institute
at New England Medical Center
Chairman, Working Group on Mind, Brain, Behavior:Society and Health
Harvard University
Professor of Health Promotion
Harvard School of Public Health
Professor of Medicine
Tufts University School of Medicine
1 Report of the Independent Inquiry into Inequalities in Health.
London: Stationery Office, 1998.
2 Davey-Smith G, Morris JN, Shaw M. The Independent Inquiry Into
Inequalities in Health. BMJ 1998; 317:1465-6, (28 November).
Competing interests: No competing interests