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Is inequality bad for the national health?
Is
inequality bad for the national health?
report", much information has been inequalities in health based on socioeconomic position (occupational class, wealth, income, education). But research into health inequalities has unexpectedly undermined its own social and political agenda. Here, I argue that the policy consequences of inequality are almost the opposite of those usually Since the "Black gathered about
advocated.
Deprivation model of sickness This model implicit in work on health inequalities assumes that deprivation is an absolute state which causes sickness and early death through cold, dampness, filth, malnutrition and starvation, overcrowding, and endemic infectious diseases.2 Thus redistribution of wealth and income would abolish poverty and improve the health of the community.1 The idea that such redistribution is the single most effective strategy for improving public health has reached the status of orthodoxy in some medical and sociological circles. Proponents argue that egalitarian political policy flows directly from, and is justified by, the findings of medical research. Equality is good for the national health. The deprivation model assumes that at high levels of income and wealth, health benefits plateau. Further increments of income produce diminishing returns of health gain until no significant benefit is seen. In crude terms, if resources are redistributed from the rich to the poor, then the poor will gain health but the rich will not lose health, because they are some distance along the plateau. Implicit in this model is health as the natural state, a "right" of every citizen, and any deviation as an infringement of that right. Prosperity is natural, but poverty is caused by human agency: man is born well, but is everywhere made sick. Deprivation is thus a negative model-negative health is caused by negative social conditions.
Health
inequalities reconsidered
Research into health
inequalities has moved the debate to a new agenda, and inadvertently undermined the deprivation model. Davey Smith and co-workers have established that the relation between health and socioeconomic position is positive and progressive-whether health is measured by mortality or by morbidity, and whether socioeconomic position is defined in terms of occupation, income, education, or any other relevant measure. The findings suggest that health inequalities are universal, finely stratified, and extend from top to bottom of the socioeconomic scale.3-8 All societies, rich and poor have demonstrated significant inequalities in health. 3,4,9 Inequality is not, therefore, caused by deprivation or poverty in an absolute sense,
Department of Epidemiology and Public Health, University of Newcastle upon Tyne, NE2 4HH (Bruce G Charlton MD)
rather inequality is a consequence of the distribution of social advantages. So health inequality is not necessarily an index of poverty or injustice; it is found even in the wealthiest and most egalitarian societies. Refinement of the instruments for classsifying socioeconomic position has increased the degree of inequality. Precise measures of income and/or socioeconomic position (such as employment grade in the Whitehall studies,5,7 or the combined factors of the Townsend index,8,10 or measures of educational attainment in North American studies3,11-14) are able to demonstrate greater degrees of inequality than crude measures such as occupational class. The more precise the measure the more inequality may be detected. Furthermore, health stratification extends from the bottom to the very top. Inequality is not only seen between the extremes of socioeconomic position but also persists among the wealthiest, the most educated, and the highest occupational classes. 3,-5,6There does not appear to be a limit where the benefits of increased income, or extra
education,
or
higher status occupation are
seen to
plateau.
The relation between socioeconomic position and health is incremental. This absence of diminishing returns explains the data on widening inequalities in health. The increase in life expectancy over the twentieth century has been greater in the upper social classes than in the lower; 1,3,4,5 nevertheless the improvement has been shared across the range of socioeconomic groups. It is not so much that poverty is bad for your health as that wealth is good for your health; and the more wealth the better. The most plausible explanation of these findings has been offered by Davey Smith and colleagues. factors are markers Socioeconomic representing differences in life trajectory between social classes.5,6.16 On average, a person at a higher income or with a higher level of occupational status will have enjoyed multiple long-term
advantages in, for instance, intrauterine environment, hygiene, safety at home and at work, housing, nutrition, education, and lifestyle, compared with those at a lower point on the social scale. It is this cumulative life trajectory that is suggested as the explanatory variable for health outcome.
Salutogenic model of health I propose
of health as the best of socioeconomic differentialsY-19 explanation Salutogenesis is the process of health creation: as opposed to pathogenesis which is the process of disease causation. Rather than regarding pathological breakdown as an unusual situation, salutogenesis regards health as the abnormal state. Life is maintained in the face of endemic environmental hostility to the organism. Health-far from being a natural state or universal right-is an achievement, a privilege, and a consequence of good luck. a
salutogenic model
221
People who are fortunate enough to enjoy the advantages typical of a high socioeconomic position are, on average, able than those below them to build up resiliances and resistances that make a longer lifespan more probable. In this sense they are able to accumulate more positive health. Instead of sickness being caused by deprivation, salutogenesis sees health as caused by socioeconomic advantage. Man is conceived and develops in a vulnerable state; good health is made possible by social arrangements. Positive health is thus the achievement of a positive environment. The consequences for policy are profound. If health is salutogenic and made possible by advantage, then redistribution of resources is not an attractive option for improving the health of the nation, because redistribution works by removing advantage. If the relation between socioeconomic position and health is progressive and positive, redistribution would not necessarily result in a net gain of health for the population, but might only transfer health from the rich to the poor. There would be health ’losers as well as gainers. Such redistribution may or may not be desirable, but is not self-evidently the best option. Egalitarian policies do not so much create health, as move it around. more
happiness. However, redistribution of income and other resources has little to offer in improving the national health: it is merely robbing Peter to pay Paul. This paper was stimulated by the speakers and other participants at the Northern Epidemiology Group conference in Newcastle upon Tyne on July 9,1993. Special thanks to Dr George Davey Smith, Dr Martin White and Dr Gillian Rye.
References 1 2 3
4
5
6 7
8
Health
Inequality and policy
Inequalities in health are less a sign of deliberate failure to address deprivation than an unintended consequence of success in expanding advantage. Instead of redistributing a fixed quantity of health, policy might aim to create more health, by reducing the proportion of the population at lower socioeconomic positions and increasing the proportion at higher socioeconomic positions. This would continue the prevailing social trend, and presumably also the health trend of increasing average life expectancy. There would be a net gain in health and nobody need lose; although the lower social classes may not gain so much as the higher. This kind of health strategy would enable the many to gain the advantages at present enjoyed by the few, rather than levelling the few down to the disadvantage of the of research
The
that
implications high waged, highly educated, highly skilled, economically expanding, and predominantly middle-class society is good for the national health-despite its accidental promotion of inequality. Whether such a society is desirable from other points of view (harmony, justice, humanity, creativity, and ecology) makes another, broader, and political debate. We
222
10
11
12
13
14
15
many.
may, after
9
all, wish
to
are
a
sacrifice health in order
to
promote
16
17
Townsend P, Davidson N, Whitehead M. The Black report and the health divide. Harmondsworth: Penguin, 1982, M’Gonigle GCM, Kirby J. Poverty and public health. London: Victor Gollancz, 1936. Feinstein JS. The relationship between socioeconomic status and health: a review of the literature. Milbank Q 1993; 71: 279-322. Davey Smith G, Bartlet M, Blane D. The Black report on socioeconomic inequalities in health 10 years on. BMJ 1990; 301: 373-76. Davey Smith G, Shipley MJ, Rose G. Magnitude and causes of socioeconomic differentials in mortality: further evidence from the Whitehall study. J Epidemiol Public Health 1990; 44: 265-70. Davey Smith G, Eggar M. Socioeconomic differences in mortality in Britain and the United States. Am J Public Health 1992; 82: 1079-81. Marmot MG, Davey Smith G, Stansfield S, et al. Health inequalities among British civil servants: the Whitehall II study. Lancet 1991; 337: 1387-93. Eames M, Ben-Shlomo Y, Marmot MG. Social deprivation and premature mortality: regional comparison across England. BMJ 1993; 307: 1097-102. Davey Smith G, Carroll D, Rankin S, Rowan D. Socioeconomic differentials in mortality: evidence from Glasgow Graveyards. BMJ 1992; 305: 1554-57. Townsend P, Phillimore P, Beattie A. Inequalities in health in the Northern Region. University of Bristol & Northern Regional Health Authority, 1986. Guralink JM, Land KC, Blazer D, Fillenbaum GG, Branch LG. Educational status and active life expectancy among older blacks and whites. N Engl J Med 1993; 329: 110-16. Keil JE, Sutherland SE, Knapp RG, Lackland DT, Gazes PC, Tyroler HA. Mortality rates and risk factors for coronary disease in black as compared with white men and women. N Engl J Med 1993; 329: 73-78. Pappas G, Queen S, Hadden W, Fisher G. The increasing disparity in mortality between socioeconomic groups in the United States, 1960 and 1986. N Eng J Med 1993; 329: 103-09. Adler NE, Boyce WT, Chesney MA, Folkman S, Syme SL. Socioeconomic inequalities in health: no easy solution. JAMA 1993; 269: 3140-45. Le Fanu J. A phantom carnage. Social Affairs Unit: London, 1993. Blane D, Davey Smith G, Bartley M. Social selection: what does it contribute to social class differences in health? Social Health Illness
1993; 15: 1-15. Antonovsky A. Health
stress
and
coping. San Fransisco: Jossey Bass,
1985. 18 19
Kelly MP, Charlton BG. A scientific basis for health promotion: time for a new philosophy? Br J Gen Pract 1992; 42: 223-24. Kelly MP, Davies JK, Charlton BG. Healthy cities: a modern problem or a post-modern solution? In: Davies JK, Kelly MP, eds. Healthy cities: research and practice. Routledge: London 1993.
inequality bad for the national health?
report", much information has been inequalities in health based on socioeconomic position (occupational class, wealth, income, education). But research into health inequalities has unexpectedly undermined its own social and political agenda. Here, I argue that the policy consequences of inequality are almost the opposite of those usually Since the "Black gathered about
advocated.
Deprivation model of sickness This model implicit in work on health inequalities assumes that deprivation is an absolute state which causes sickness and early death through cold, dampness, filth, malnutrition and starvation, overcrowding, and endemic infectious diseases.2 Thus redistribution of wealth and income would abolish poverty and improve the health of the community.1 The idea that such redistribution is the single most effective strategy for improving public health has reached the status of orthodoxy in some medical and sociological circles. Proponents argue that egalitarian political policy flows directly from, and is justified by, the findings of medical research. Equality is good for the national health. The deprivation model assumes that at high levels of income and wealth, health benefits plateau. Further increments of income produce diminishing returns of health gain until no significant benefit is seen. In crude terms, if resources are redistributed from the rich to the poor, then the poor will gain health but the rich will not lose health, because they are some distance along the plateau. Implicit in this model is health as the natural state, a "right" of every citizen, and any deviation as an infringement of that right. Prosperity is natural, but poverty is caused by human agency: man is born well, but is everywhere made sick. Deprivation is thus a negative model-negative health is caused by negative social conditions.
Health
inequalities reconsidered
Research into health
inequalities has moved the debate to a new agenda, and inadvertently undermined the deprivation model. Davey Smith and co-workers have established that the relation between health and socioeconomic position is positive and progressive-whether health is measured by mortality or by morbidity, and whether socioeconomic position is defined in terms of occupation, income, education, or any other relevant measure. The findings suggest that health inequalities are universal, finely stratified, and extend from top to bottom of the socioeconomic scale.3-8 All societies, rich and poor have demonstrated significant inequalities in health. 3,4,9 Inequality is not, therefore, caused by deprivation or poverty in an absolute sense,
Department of Epidemiology and Public Health, University of Newcastle upon Tyne, NE2 4HH (Bruce G Charlton MD)
rather inequality is a consequence of the distribution of social advantages. So health inequality is not necessarily an index of poverty or injustice; it is found even in the wealthiest and most egalitarian societies. Refinement of the instruments for classsifying socioeconomic position has increased the degree of inequality. Precise measures of income and/or socioeconomic position (such as employment grade in the Whitehall studies,5,7 or the combined factors of the Townsend index,8,10 or measures of educational attainment in North American studies3,11-14) are able to demonstrate greater degrees of inequality than crude measures such as occupational class. The more precise the measure the more inequality may be detected. Furthermore, health stratification extends from the bottom to the very top. Inequality is not only seen between the extremes of socioeconomic position but also persists among the wealthiest, the most educated, and the highest occupational classes. 3,-5,6There does not appear to be a limit where the benefits of increased income, or extra
education,
or
higher status occupation are
seen to
plateau.
The relation between socioeconomic position and health is incremental. This absence of diminishing returns explains the data on widening inequalities in health. The increase in life expectancy over the twentieth century has been greater in the upper social classes than in the lower; 1,3,4,5 nevertheless the improvement has been shared across the range of socioeconomic groups. It is not so much that poverty is bad for your health as that wealth is good for your health; and the more wealth the better. The most plausible explanation of these findings has been offered by Davey Smith and colleagues. factors are markers Socioeconomic representing differences in life trajectory between social classes.5,6.16 On average, a person at a higher income or with a higher level of occupational status will have enjoyed multiple long-term
advantages in, for instance, intrauterine environment, hygiene, safety at home and at work, housing, nutrition, education, and lifestyle, compared with those at a lower point on the social scale. It is this cumulative life trajectory that is suggested as the explanatory variable for health outcome.
Salutogenic model of health I propose
of health as the best of socioeconomic differentialsY-19 explanation Salutogenesis is the process of health creation: as opposed to pathogenesis which is the process of disease causation. Rather than regarding pathological breakdown as an unusual situation, salutogenesis regards health as the abnormal state. Life is maintained in the face of endemic environmental hostility to the organism. Health-far from being a natural state or universal right-is an achievement, a privilege, and a consequence of good luck. a
salutogenic model
221
People who are fortunate enough to enjoy the advantages typical of a high socioeconomic position are, on average, able than those below them to build up resiliances and resistances that make a longer lifespan more probable. In this sense they are able to accumulate more positive health. Instead of sickness being caused by deprivation, salutogenesis sees health as caused by socioeconomic advantage. Man is conceived and develops in a vulnerable state; good health is made possible by social arrangements. Positive health is thus the achievement of a positive environment. The consequences for policy are profound. If health is salutogenic and made possible by advantage, then redistribution of resources is not an attractive option for improving the health of the nation, because redistribution works by removing advantage. If the relation between socioeconomic position and health is progressive and positive, redistribution would not necessarily result in a net gain of health for the population, but might only transfer health from the rich to the poor. There would be health ’losers as well as gainers. Such redistribution may or may not be desirable, but is not self-evidently the best option. Egalitarian policies do not so much create health, as move it around. more
happiness. However, redistribution of income and other resources has little to offer in improving the national health: it is merely robbing Peter to pay Paul. This paper was stimulated by the speakers and other participants at the Northern Epidemiology Group conference in Newcastle upon Tyne on July 9,1993. Special thanks to Dr George Davey Smith, Dr Martin White and Dr Gillian Rye.
References 1 2 3
4
5
6 7
8
Health
Inequality and policy
Inequalities in health are less a sign of deliberate failure to address deprivation than an unintended consequence of success in expanding advantage. Instead of redistributing a fixed quantity of health, policy might aim to create more health, by reducing the proportion of the population at lower socioeconomic positions and increasing the proportion at higher socioeconomic positions. This would continue the prevailing social trend, and presumably also the health trend of increasing average life expectancy. There would be a net gain in health and nobody need lose; although the lower social classes may not gain so much as the higher. This kind of health strategy would enable the many to gain the advantages at present enjoyed by the few, rather than levelling the few down to the disadvantage of the of research
The
that
implications high waged, highly educated, highly skilled, economically expanding, and predominantly middle-class society is good for the national health-despite its accidental promotion of inequality. Whether such a society is desirable from other points of view (harmony, justice, humanity, creativity, and ecology) makes another, broader, and political debate. We
222
10
11
12
13
14
15
many.
may, after
9
all, wish
to
are
a
sacrifice health in order
to
promote
16
17
Townsend P, Davidson N, Whitehead M. The Black report and the health divide. Harmondsworth: Penguin, 1982, M’Gonigle GCM, Kirby J. Poverty and public health. London: Victor Gollancz, 1936. Feinstein JS. The relationship between socioeconomic status and health: a review of the literature. Milbank Q 1993; 71: 279-322. Davey Smith G, Bartlet M, Blane D. The Black report on socioeconomic inequalities in health 10 years on. BMJ 1990; 301: 373-76. Davey Smith G, Shipley MJ, Rose G. Magnitude and causes of socioeconomic differentials in mortality: further evidence from the Whitehall study. J Epidemiol Public Health 1990; 44: 265-70. Davey Smith G, Eggar M. Socioeconomic differences in mortality in Britain and the United States. Am J Public Health 1992; 82: 1079-81. Marmot MG, Davey Smith G, Stansfield S, et al. Health inequalities among British civil servants: the Whitehall II study. Lancet 1991; 337: 1387-93. Eames M, Ben-Shlomo Y, Marmot MG. Social deprivation and premature mortality: regional comparison across England. BMJ 1993; 307: 1097-102. Davey Smith G, Carroll D, Rankin S, Rowan D. Socioeconomic differentials in mortality: evidence from Glasgow Graveyards. BMJ 1992; 305: 1554-57. Townsend P, Phillimore P, Beattie A. Inequalities in health in the Northern Region. University of Bristol & Northern Regional Health Authority, 1986. Guralink JM, Land KC, Blazer D, Fillenbaum GG, Branch LG. Educational status and active life expectancy among older blacks and whites. N Engl J Med 1993; 329: 110-16. Keil JE, Sutherland SE, Knapp RG, Lackland DT, Gazes PC, Tyroler HA. Mortality rates and risk factors for coronary disease in black as compared with white men and women. N Engl J Med 1993; 329: 73-78. Pappas G, Queen S, Hadden W, Fisher G. The increasing disparity in mortality between socioeconomic groups in the United States, 1960 and 1986. N Eng J Med 1993; 329: 103-09. Adler NE, Boyce WT, Chesney MA, Folkman S, Syme SL. Socioeconomic inequalities in health: no easy solution. JAMA 1993; 269: 3140-45. Le Fanu J. A phantom carnage. Social Affairs Unit: London, 1993. Blane D, Davey Smith G, Bartley M. Social selection: what does it contribute to social class differences in health? Social Health Illness
1993; 15: 1-15. Antonovsky A. Health
stress
and
coping. San Fransisco: Jossey Bass,
1985. 18 19
Kelly MP, Charlton BG. A scientific basis for health promotion: time for a new philosophy? Br J Gen Pract 1992; 42: 223-24. Kelly MP, Davies JK, Charlton BG. Healthy cities: a modern problem or a post-modern solution? In: Davies JK, Kelly MP, eds. Healthy cities: research and practice. Routledge: London 1993.