- Email: [email protected]
Swimming upstream? Taking action on the social determinants of health inequalities
Social Science & Medicine 71 (2010) 1234e1236
Contents lists available at ScienceDirect
Social Science & Medicine journal homepage: www.elsevier.com/locate/socscimed
Swimming upstream? Taking action on the social determinants of health inequalities Margaret Whitehead a, *, Jennie Popay b a b
University of Liverpool, Liverpool, United Kingdom Lancaster University, Lancaster, United Kingdom
a r t i c l e i n f o Article history: Available online 6 August 2010 Keywords: Health inequalities Fair Society, Healthy Lives (The Marmot Review) Social determinants Global strategy
Common ground Both the Global Commission on Social Determinants of Health (CSDH, 2008) and the subsequent Fair Society, Healthy Lives (The Marmot Review) for England (Marmot, 2010) have much in common (in addition to having Michael Marmot as chair). They both turn up the heat by making much stronger statements based on evidence emphasising that: The reduction of health inequalities is a matter of fairness and social justice; They result from social inequalities in society ultimately caused by “bad politics” and inequalities in power; To reduce health inequalities therefore requires action on inequalities in wider social determinants operating outside the health system; There is a need to tackle ill-health across the whole social gradient in health, not solely concentrate on closing the gap between the most disadvantaged and others, to make an impact on the magnitude of the observed health inequalities. These conclusions, and the policy priorities that flow from them, are elegantly summarised on page one of the global Commission report in one of the strongest statements to be seen in a WHO document:
* Corresponding author. E-mail address: [email protected] (M. Whitehead). 0277-9536/$ e see front matter Ó 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.socscimed.2010.07.004
[Health inequalities are] “caused by the unequal distribution of power, income, goods and services, globally and nationally, the consequent unfairness in the immediate, visible circumstances of people’s lives e their access to health care, schools, and education, their conditions of work and leisure, their homes, communities, towns, or cities e and their chances of leading a flourishing life..poor and unequal living conditions are the consequence of poor social policies and programmes, unfair social arrangements and bad politics.” (CSDH, 2008, p. 1). Both reports have mobilised much needed attention to the issue. The global report flagged up the neglect of health inequalities in low and middle income countries. It received a wealth of coverage in 2008 (with the notable exception of the US (Muntaner, Sridharan, Slar, & Benach, 2009). It stimulated several countryspecific reviews in addition to the English Review, which itself received wide publicity in February 2010. At the latter’s launch, the WHO announced a new Europe-wide review of health inequality policy to begin in March 2010 for completion by the end of 2011. Divided by economic crisis The context into which the reports were published was, however, very different, with one published before and the other after the onset of the global economic crisis. The Marmot Review for England recognised that some would argue that their recommendations were unaffordable in this adverse economic climate. It countered by pointing out the costs of doing nothing. In human terms, these include between 1.3 and 1.5 million extra years of life and a further 2.8 million years free of limiting illness or disability in England that would be lost by inaction. In economic terms, the
M. Whitehead, J. Popay / Social Science & Medicine 71 (2010) 1234e1236
Review estimated that inequality in illness accounts for productivity losses of £31e33 billion per year, with lost tax and higher welfare payments adding a further £20e32 billion per year to the bill, together with £5.5 billion per year of health care costs (Frontier Economics, 2010; Marmot, 2010). Drawing on these analyses, the Review powerfully concludes that “we say that it is inaction that cannot be afforded, for the human and economic costs are too high” (Marmot, 2010, p. 35). Swimming against countervailing forces The global Commission’s report has drawn some criticism, as the Marmot review for England will inevitably do in time. The main criticisms focus on what is missing, rather than what the report contains. Some commentators suggest that it is too cautious when it comes to criticising the role of big business and existing power bases, and lacks the historical perspective that would allow policy learning (Birn, 2009; Escudero, 2009; Muntaner et al., 2009; Navarro, 2009). Whilst it is clearly important that we recognise the limitations of these reports, at least some omissions are likely to be the result of a pragmatic weighing up by the authors of how to maximise the impact without completely alienating the policymakers they sought to influence. Indeed, it could be argued that the global Commission’s report has gone much further than any WHO publication in highlighting the structural determinants of health inequalities. However, as Vicente Navarro, highlights, without political action on forces that are widening inequalities the impact of future health equity efforts will be seriously muted: “the report’s phrase “social inequalities kill” has enraged conservative and liberal forces..And yet, this is where the report falls short. It is not inequalities that kill, but those who benefit from the inequalities that kill. The Commission’s studious avoidance of the category of power .and how power is produced and reproduced in political institutions is the greatest weakness of the report..[which] speaks of policies without touching on politics...It does emphasise, in generic terms, the need to redistribute resources, but it is silent on the topic of whose resources, and how and through what instruments” (Navarro, 2009, p. 15). Extending Navarro’s critique, both reports are light on how to put their recommendations into practice in all but the most general of terms. This is understandable in the global Commission’s report, as there could be no single blueprint for all countries and it would not be feasible to give individual country guidance. But whilst the Marmot Review for England does have a chapter on “Making it happen” tailored to the specific country context, this concentrates largely on action at the local level and on better systems for monitoring progress, leaving responsibilities at the national level to vague sentiments about leadership and co-ordination (Hunter, Popay, Tannahill, & Whitehead, 2010; Popay, Whitehead, & Hunter, 2010). Discussion of how to tackle the countervailing forces driving inequalities is missing completely. Challenges in implementing national strategies What and how to implement strategies to tackle the social determinants of health and health inequalities in individual countries are major questions. The experiences of England and Norway over recent years are instructive in this respect. England: one big natural policy experiment England represents perhaps the longest ‘natural policy experiment’ in attempts to implement a purpose-made action plan on health inequalities. Since 1997 it has had the same government,
1235
publically committed to reducing social inequalities in health (Acheson et al., 1998), backed up by a programme for action (DH, 2003), with dedicated resources and driven by national inequalities targets and a strict system of monitoring (DH, 2005, 2008a). Indeed, it was the Secretary of State’s recognition of the limited progress that had been made towards meeting the health inequalities targets (DH, 2008b) that triggered the setting up of Marmot Review for England in 2008. It is also important to recognise that alongside this Department of Health driven strategy, and intended to be complementary, there have been wider policy programmes to reduce child poverty, unemployment and area deprivation, and to tackle inequalities in educational attainment and as a result of ethnic background (Hills, Sefton, & Stewart, 2009). Community engagement and democratic renewal has also been seen to be key to success across all policy areas. Initially at least these policies had an impact although more slowly than policy makers had hoped. One particularly important outcome has been a reduction in child poverty, albeit falling short of the national target. But this and other improvements in living conditions have slowed in recent years and critically the large income inequality growth between the late 1970s and early 1990s has not been reversed (Hills et al., 2010). So what are the lessons from the English experiment? First, it focuses primarily on the gap between the most disadvantaged groups and the rest of the population rather than the gradient across society. As the Marmot Review has pointed out, “focusing solely on the most disadvantaged will not reduce health inequalities sufficiently” (Marmot, 2010:15). Second, there has been too great an emphasis on individual lifestyle factors and a neglect of the conditions that structure and constrain individual ‘choices’. Third, programmes in all areas have typically been wound down before they had chance to demonstrate an impact. For example, whilst evidence from Sure Start Local Programmes was positive they have been replaced by larger Children Centres. These meet the needs of larger populations and arguably provide a more secure future, but potentially key elements of the original programmes have been diluted. Particularly important here is the damage done to relationships between public sector organisations and the communities they serve as shorter-ism has undermined effective community engagement and empowerment (Popay et al., 2007). Fourth and perhaps most crucially, countervailing forces have been operating in the UK at the same time as these positive initiatives, working against any advances. These have included the operation of the global economic system that has perpetuated the widening of social and economic inequalities; the erosion of universalism in social welfare systems; the fragmentation and privatisation of health services; and regional and global labour market policies that have led to the growth in insecure and precarious employment (Povall, Whitehead, Gosling, & Barr, 2008). Norway: the first social gradient approach? Norway has come late to the health inequalities policy arena, publishing its first national strategy in 2007 (Norwegian Ministry, 2007). Perhaps because of this lateness, it has had the opportunity to learn from the experiences and pitfalls of other countries. It is certainly one of the few national strategies, possibly the only one, that has explicitly taken a whole social gradient approach. The strategy therefore combines universal policies and programmes encompassing the whole of the population with selective measures to help the most disadvantaged. It covers upstream social reform, mid-stream risk reduction and downstream effect reduction, each with universal and selective measures. Early on, the national politicians agreed to the comprehensiveness of the strategy which
1236
M. Whitehead, J. Popay / Social Science & Medicine 71 (2010) 1234e1236
crucially included income redistribution (Poulsson Torgersen in Poval et al., 2008). It could be argued that Norway is in one of the most favourable positions from which to launch an attack on inequalities. Most other countries are in less favourable situations. Even so, as the English experience shows, implementing such a comprehensive strategy will not be easy. As it gets underway, progress in Norway is being followed closely, not least from outside the country, to learn from what is bound to be a very challenging exercise in swimming upstream.
Conclusion The report of the WHO Commission and the Marmot Review of England’s Health Inequalities strategy are groundbreaking. They have helped to propel the need to tackle the social determinants of health inequalities up the political agenda world-wide. We recognise that there are important implementation issues locally (Hunter et al., 2010; Popay et al., 2010; Whitehead, Doran, Exworthy, Richards, & Matheson, 2009). In view of the major omission from both reports flagged up here, however, we see an urgent task for concerted scientific and public scrutiny at the macro-policy level, both national and transnational. This involves analysing existing policies for their positive and negative impacts on the life chances of different groups in the population. In terms of negative impacts, there is a need for political leaders to acknowledge what and who is generating and making inequalities worse. This means acknowledging that some individuals and groups benefit from perpetuating inequalities and that their actions need to be carefully scrutinised. In some European WHO publications, it has been possible to approach this issue, for instance in terms of analysing “healthy and unhealthy economic growth strategies” (Dahlgren & Whitehead, 2007; Povall et al., 2008). But more public support is needed for this type of analysis. Equally, we need to expand the evidence base on the health impact of universal health and welfare systems. These, by their very nature, are complex and not amenable to experimental design, yet have the potential for huge population health impact. Both the Global Commission report and the English review also pointed to the crucial role for greater citizen participation in policy and science in the pursuit of greater health equity. This requires revitalised ways of evaluating policies with potential to address the social determinants of health inequalities that allow for the joint creation of citizen and scientific expertise. This would produce not just a more inclusive and democratic form of science, but a more reliable, valid, effective and context rich science better able to inform policy and social action (Forrester, Potts, & Rosen, 2002).
References Acheson, D., Barker, D., Chamber, J., Graham, H., Marmot, M., & Whitehead, M. (1998). Report of the independent inquiry into inequalities in health (the Acheson Report). London: The Stationery Office. Birn, A.-E. (2009). Making it politic(al); Closing the gap in a generation: health equity though action on the social determinants of health. Social Medicine, 4(3), 166e182. CSDH. (2008). Commission on social determinants of health final report: Closing the gap in a generation: Health equity through action on the social determinants of health. Geneva: World Health Organization. Dahlgren, G., & Whitehead, M. (2007). European strategies for tackling social inequities in health: Levelling up part 2. In Studies on social and economic determinants of population health No. 3. Copenhagen: World Health Organization Regional Office for Europe. DH. (2003). Tackling health inequalities: A programme for action. London: DH. DH. (2005). Tackling health inequalities: Status report on the programme for action. London: DH. DH. (2008a). Tackling health inequalities: 2007 Status report on the programme for action. London: DH. DH. (2008b). Health inequalities: Progress and next steps. In Review for the Secretary of State for health. London: DH. Escudero, J. C. (2009). What is said, what is silenced, what is obscured: the report of the commission on social determinants of health. Social Medicine, 4(3), 183e185. Forrester, J., Potts, L., & Rosen, P. (2002). Creating science’s new social contract. Conference paper at European Association for the Study of Science and Technology, University of York, UK. Frontier, Economics. (2010). Estimating the costs of health inequalities. A report prepared for the Marmot Review. http://www.marmotreview.org/Englishreview-of-hi/economic-costs.aspx. Accessed 26.07.2010. Hills, J., Brewer, M., Jenkins, S., Lister, R., Lupton, R., Machin, S., et al. (2010). An anatomy of economic inequality in the UK. Report of the National Equality Panel. London: Government Equalities Office. Hills, J., Sefton, T., & Stewart, K. (Eds.). (2009). Towards a more equal society? Poverty, inequality and policy since 1997. Bristol: Policy Press. Hunter, D. J., Popay, J., Tannahill, C., & Whitehead, M. (2010). Getting to grips with health inequalities at last? British Medical Journal, 340, c684. Marmot, M. (2010). Fair society, healthy lives. In The Marmot review: Strategic review of health inequalities in England post-2010. London: The Marmot Review. www. ucl.ac.uk/marmotreview. Muntaner, C., Sridharan, S., Slar, O., & Benach, J. (2009). Against unjust global distribution of power and money: the report of the WHO commission on the social determinants of health: global inequality and the future of public health policy. Journal of Public Health Policy, 30(2), 163e175. Navarro, V. (2009). What we mean by social determinants of health. Global Health Promotion, 16(1), 5e16. Norwegian Ministry of Health and Care Services. (2007). National strategy to reduce social inequalities in health. Report No. 20 (2006-2007) to the Storting (Translation from the Norwegian). Oslo, Norway: Norwegian Ministry of Health and Care Services. Available online at. http://www.regjeringen.no/pages/1975150/ PDFS/STM200620070020000EN_PDFS.pdf. Popay, J., Attree, P., Hornby, D., Milton, B., Whitehead, M., French, B., et al. (2007). Community engagement to address the wider social determinants of health: A review of evidence on impact, experience & process. London: National Institute for Health & Clinical Excellence. Available from. http://www.nice.org.uk/ guidance/index.jsp?action¼folder&o¼34709. Popay, J., Whitehead, M., & Hunter, D. (2010). Injustice is killing people on a large scale e but what is to be done about it? Journal of Public Health, 32, 148e149. Povall, S., Whitehead, M., Gosling, R., & Barr, B. (2008). Focusing the equity lens: Arguments and actions on health inequalities. Liverpool: WHO Collaborating Centre for Policy Research on Social Determinants of Health. Whitehead, M., Doran, T., Exworthy, M., Richards, S., & Matheson, D. (2009). Delivery systems and mechanisms for reducing inequalities in both social determinants and health outcomes. Task Group 7 Final Report to the Marmot Review. http://www. marmotreview.org/English-review-of-hi/supporting-evidence.aspx
Contents lists available at ScienceDirect
Social Science & Medicine journal homepage: www.elsevier.com/locate/socscimed
Swimming upstream? Taking action on the social determinants of health inequalities Margaret Whitehead a, *, Jennie Popay b a b
University of Liverpool, Liverpool, United Kingdom Lancaster University, Lancaster, United Kingdom
a r t i c l e i n f o Article history: Available online 6 August 2010 Keywords: Health inequalities Fair Society, Healthy Lives (The Marmot Review) Social determinants Global strategy
Common ground Both the Global Commission on Social Determinants of Health (CSDH, 2008) and the subsequent Fair Society, Healthy Lives (The Marmot Review) for England (Marmot, 2010) have much in common (in addition to having Michael Marmot as chair). They both turn up the heat by making much stronger statements based on evidence emphasising that: The reduction of health inequalities is a matter of fairness and social justice; They result from social inequalities in society ultimately caused by “bad politics” and inequalities in power; To reduce health inequalities therefore requires action on inequalities in wider social determinants operating outside the health system; There is a need to tackle ill-health across the whole social gradient in health, not solely concentrate on closing the gap between the most disadvantaged and others, to make an impact on the magnitude of the observed health inequalities. These conclusions, and the policy priorities that flow from them, are elegantly summarised on page one of the global Commission report in one of the strongest statements to be seen in a WHO document:
* Corresponding author. E-mail address: [email protected] (M. Whitehead). 0277-9536/$ e see front matter Ó 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.socscimed.2010.07.004
[Health inequalities are] “caused by the unequal distribution of power, income, goods and services, globally and nationally, the consequent unfairness in the immediate, visible circumstances of people’s lives e their access to health care, schools, and education, their conditions of work and leisure, their homes, communities, towns, or cities e and their chances of leading a flourishing life..poor and unequal living conditions are the consequence of poor social policies and programmes, unfair social arrangements and bad politics.” (CSDH, 2008, p. 1). Both reports have mobilised much needed attention to the issue. The global report flagged up the neglect of health inequalities in low and middle income countries. It received a wealth of coverage in 2008 (with the notable exception of the US (Muntaner, Sridharan, Slar, & Benach, 2009). It stimulated several countryspecific reviews in addition to the English Review, which itself received wide publicity in February 2010. At the latter’s launch, the WHO announced a new Europe-wide review of health inequality policy to begin in March 2010 for completion by the end of 2011. Divided by economic crisis The context into which the reports were published was, however, very different, with one published before and the other after the onset of the global economic crisis. The Marmot Review for England recognised that some would argue that their recommendations were unaffordable in this adverse economic climate. It countered by pointing out the costs of doing nothing. In human terms, these include between 1.3 and 1.5 million extra years of life and a further 2.8 million years free of limiting illness or disability in England that would be lost by inaction. In economic terms, the
M. Whitehead, J. Popay / Social Science & Medicine 71 (2010) 1234e1236
Review estimated that inequality in illness accounts for productivity losses of £31e33 billion per year, with lost tax and higher welfare payments adding a further £20e32 billion per year to the bill, together with £5.5 billion per year of health care costs (Frontier Economics, 2010; Marmot, 2010). Drawing on these analyses, the Review powerfully concludes that “we say that it is inaction that cannot be afforded, for the human and economic costs are too high” (Marmot, 2010, p. 35). Swimming against countervailing forces The global Commission’s report has drawn some criticism, as the Marmot review for England will inevitably do in time. The main criticisms focus on what is missing, rather than what the report contains. Some commentators suggest that it is too cautious when it comes to criticising the role of big business and existing power bases, and lacks the historical perspective that would allow policy learning (Birn, 2009; Escudero, 2009; Muntaner et al., 2009; Navarro, 2009). Whilst it is clearly important that we recognise the limitations of these reports, at least some omissions are likely to be the result of a pragmatic weighing up by the authors of how to maximise the impact without completely alienating the policymakers they sought to influence. Indeed, it could be argued that the global Commission’s report has gone much further than any WHO publication in highlighting the structural determinants of health inequalities. However, as Vicente Navarro, highlights, without political action on forces that are widening inequalities the impact of future health equity efforts will be seriously muted: “the report’s phrase “social inequalities kill” has enraged conservative and liberal forces..And yet, this is where the report falls short. It is not inequalities that kill, but those who benefit from the inequalities that kill. The Commission’s studious avoidance of the category of power .and how power is produced and reproduced in political institutions is the greatest weakness of the report..[which] speaks of policies without touching on politics...It does emphasise, in generic terms, the need to redistribute resources, but it is silent on the topic of whose resources, and how and through what instruments” (Navarro, 2009, p. 15). Extending Navarro’s critique, both reports are light on how to put their recommendations into practice in all but the most general of terms. This is understandable in the global Commission’s report, as there could be no single blueprint for all countries and it would not be feasible to give individual country guidance. But whilst the Marmot Review for England does have a chapter on “Making it happen” tailored to the specific country context, this concentrates largely on action at the local level and on better systems for monitoring progress, leaving responsibilities at the national level to vague sentiments about leadership and co-ordination (Hunter, Popay, Tannahill, & Whitehead, 2010; Popay, Whitehead, & Hunter, 2010). Discussion of how to tackle the countervailing forces driving inequalities is missing completely. Challenges in implementing national strategies What and how to implement strategies to tackle the social determinants of health and health inequalities in individual countries are major questions. The experiences of England and Norway over recent years are instructive in this respect. England: one big natural policy experiment England represents perhaps the longest ‘natural policy experiment’ in attempts to implement a purpose-made action plan on health inequalities. Since 1997 it has had the same government,
1235
publically committed to reducing social inequalities in health (Acheson et al., 1998), backed up by a programme for action (DH, 2003), with dedicated resources and driven by national inequalities targets and a strict system of monitoring (DH, 2005, 2008a). Indeed, it was the Secretary of State’s recognition of the limited progress that had been made towards meeting the health inequalities targets (DH, 2008b) that triggered the setting up of Marmot Review for England in 2008. It is also important to recognise that alongside this Department of Health driven strategy, and intended to be complementary, there have been wider policy programmes to reduce child poverty, unemployment and area deprivation, and to tackle inequalities in educational attainment and as a result of ethnic background (Hills, Sefton, & Stewart, 2009). Community engagement and democratic renewal has also been seen to be key to success across all policy areas. Initially at least these policies had an impact although more slowly than policy makers had hoped. One particularly important outcome has been a reduction in child poverty, albeit falling short of the national target. But this and other improvements in living conditions have slowed in recent years and critically the large income inequality growth between the late 1970s and early 1990s has not been reversed (Hills et al., 2010). So what are the lessons from the English experiment? First, it focuses primarily on the gap between the most disadvantaged groups and the rest of the population rather than the gradient across society. As the Marmot Review has pointed out, “focusing solely on the most disadvantaged will not reduce health inequalities sufficiently” (Marmot, 2010:15). Second, there has been too great an emphasis on individual lifestyle factors and a neglect of the conditions that structure and constrain individual ‘choices’. Third, programmes in all areas have typically been wound down before they had chance to demonstrate an impact. For example, whilst evidence from Sure Start Local Programmes was positive they have been replaced by larger Children Centres. These meet the needs of larger populations and arguably provide a more secure future, but potentially key elements of the original programmes have been diluted. Particularly important here is the damage done to relationships between public sector organisations and the communities they serve as shorter-ism has undermined effective community engagement and empowerment (Popay et al., 2007). Fourth and perhaps most crucially, countervailing forces have been operating in the UK at the same time as these positive initiatives, working against any advances. These have included the operation of the global economic system that has perpetuated the widening of social and economic inequalities; the erosion of universalism in social welfare systems; the fragmentation and privatisation of health services; and regional and global labour market policies that have led to the growth in insecure and precarious employment (Povall, Whitehead, Gosling, & Barr, 2008). Norway: the first social gradient approach? Norway has come late to the health inequalities policy arena, publishing its first national strategy in 2007 (Norwegian Ministry, 2007). Perhaps because of this lateness, it has had the opportunity to learn from the experiences and pitfalls of other countries. It is certainly one of the few national strategies, possibly the only one, that has explicitly taken a whole social gradient approach. The strategy therefore combines universal policies and programmes encompassing the whole of the population with selective measures to help the most disadvantaged. It covers upstream social reform, mid-stream risk reduction and downstream effect reduction, each with universal and selective measures. Early on, the national politicians agreed to the comprehensiveness of the strategy which
1236
M. Whitehead, J. Popay / Social Science & Medicine 71 (2010) 1234e1236
crucially included income redistribution (Poulsson Torgersen in Poval et al., 2008). It could be argued that Norway is in one of the most favourable positions from which to launch an attack on inequalities. Most other countries are in less favourable situations. Even so, as the English experience shows, implementing such a comprehensive strategy will not be easy. As it gets underway, progress in Norway is being followed closely, not least from outside the country, to learn from what is bound to be a very challenging exercise in swimming upstream.
Conclusion The report of the WHO Commission and the Marmot Review of England’s Health Inequalities strategy are groundbreaking. They have helped to propel the need to tackle the social determinants of health inequalities up the political agenda world-wide. We recognise that there are important implementation issues locally (Hunter et al., 2010; Popay et al., 2010; Whitehead, Doran, Exworthy, Richards, & Matheson, 2009). In view of the major omission from both reports flagged up here, however, we see an urgent task for concerted scientific and public scrutiny at the macro-policy level, both national and transnational. This involves analysing existing policies for their positive and negative impacts on the life chances of different groups in the population. In terms of negative impacts, there is a need for political leaders to acknowledge what and who is generating and making inequalities worse. This means acknowledging that some individuals and groups benefit from perpetuating inequalities and that their actions need to be carefully scrutinised. In some European WHO publications, it has been possible to approach this issue, for instance in terms of analysing “healthy and unhealthy economic growth strategies” (Dahlgren & Whitehead, 2007; Povall et al., 2008). But more public support is needed for this type of analysis. Equally, we need to expand the evidence base on the health impact of universal health and welfare systems. These, by their very nature, are complex and not amenable to experimental design, yet have the potential for huge population health impact. Both the Global Commission report and the English review also pointed to the crucial role for greater citizen participation in policy and science in the pursuit of greater health equity. This requires revitalised ways of evaluating policies with potential to address the social determinants of health inequalities that allow for the joint creation of citizen and scientific expertise. This would produce not just a more inclusive and democratic form of science, but a more reliable, valid, effective and context rich science better able to inform policy and social action (Forrester, Potts, & Rosen, 2002).
References Acheson, D., Barker, D., Chamber, J., Graham, H., Marmot, M., & Whitehead, M. (1998). Report of the independent inquiry into inequalities in health (the Acheson Report). London: The Stationery Office. Birn, A.-E. (2009). Making it politic(al); Closing the gap in a generation: health equity though action on the social determinants of health. Social Medicine, 4(3), 166e182. CSDH. (2008). Commission on social determinants of health final report: Closing the gap in a generation: Health equity through action on the social determinants of health. Geneva: World Health Organization. Dahlgren, G., & Whitehead, M. (2007). European strategies for tackling social inequities in health: Levelling up part 2. In Studies on social and economic determinants of population health No. 3. Copenhagen: World Health Organization Regional Office for Europe. DH. (2003). Tackling health inequalities: A programme for action. London: DH. DH. (2005). Tackling health inequalities: Status report on the programme for action. London: DH. DH. (2008a). Tackling health inequalities: 2007 Status report on the programme for action. London: DH. DH. (2008b). Health inequalities: Progress and next steps. In Review for the Secretary of State for health. London: DH. Escudero, J. C. (2009). What is said, what is silenced, what is obscured: the report of the commission on social determinants of health. Social Medicine, 4(3), 183e185. Forrester, J., Potts, L., & Rosen, P. (2002). Creating science’s new social contract. Conference paper at European Association for the Study of Science and Technology, University of York, UK. Frontier, Economics. (2010). Estimating the costs of health inequalities. A report prepared for the Marmot Review. http://www.marmotreview.org/Englishreview-of-hi/economic-costs.aspx. Accessed 26.07.2010. Hills, J., Brewer, M., Jenkins, S., Lister, R., Lupton, R., Machin, S., et al. (2010). An anatomy of economic inequality in the UK. Report of the National Equality Panel. London: Government Equalities Office. Hills, J., Sefton, T., & Stewart, K. (Eds.). (2009). Towards a more equal society? Poverty, inequality and policy since 1997. Bristol: Policy Press. Hunter, D. J., Popay, J., Tannahill, C., & Whitehead, M. (2010). Getting to grips with health inequalities at last? British Medical Journal, 340, c684. Marmot, M. (2010). Fair society, healthy lives. In The Marmot review: Strategic review of health inequalities in England post-2010. London: The Marmot Review. www. ucl.ac.uk/marmotreview. Muntaner, C., Sridharan, S., Slar, O., & Benach, J. (2009). Against unjust global distribution of power and money: the report of the WHO commission on the social determinants of health: global inequality and the future of public health policy. Journal of Public Health Policy, 30(2), 163e175. Navarro, V. (2009). What we mean by social determinants of health. Global Health Promotion, 16(1), 5e16. Norwegian Ministry of Health and Care Services. (2007). National strategy to reduce social inequalities in health. Report No. 20 (2006-2007) to the Storting (Translation from the Norwegian). Oslo, Norway: Norwegian Ministry of Health and Care Services. Available online at. http://www.regjeringen.no/pages/1975150/ PDFS/STM200620070020000EN_PDFS.pdf. Popay, J., Attree, P., Hornby, D., Milton, B., Whitehead, M., French, B., et al. (2007). Community engagement to address the wider social determinants of health: A review of evidence on impact, experience & process. London: National Institute for Health & Clinical Excellence. Available from. http://www.nice.org.uk/ guidance/index.jsp?action¼folder&o¼34709. Popay, J., Whitehead, M., & Hunter, D. (2010). Injustice is killing people on a large scale e but what is to be done about it? Journal of Public Health, 32, 148e149. Povall, S., Whitehead, M., Gosling, R., & Barr, B. (2008). Focusing the equity lens: Arguments and actions on health inequalities. Liverpool: WHO Collaborating Centre for Policy Research on Social Determinants of Health. Whitehead, M., Doran, T., Exworthy, M., Richards, S., & Matheson, D. (2009). Delivery systems and mechanisms for reducing inequalities in both social determinants and health outcomes. Task Group 7 Final Report to the Marmot Review. http://www. marmotreview.org/English-review-of-hi/supporting-evidence.aspx