International Journal of Epidemiology 2003;32:472-473
Book Review
Interpreting and addressing inequalities in health:
from Black to Acheson to Blair to ...?
Professor Robert Evans. London: Office of Health Economics, May 2002, pp. 92,
ISBN:
1-899040-32-3.
Michael Fitzpatrick
When I was a left-wing medical student in the 1970s, Thomas McKeown
's thesis
that increasing life expectancy over the
previous century owed more to improved social conditions than to medical
intervention was a key theme in the radical critique of the contemporary medical
profession. The social class gradient in mortality and other health indicators,
exposed by Richard Wilkinson, Peter Townsend, and others, was another issue
eagerly taken up by radical students. At a time when the medical profession was
inclined towards a conservative approach, both in terms of biomedical theory and
practice, and in its wider political outlook, these subversive views were
generally ignored or marginalized.
How times change! Now that I have become a middle-aged general practitioner
(GP), from every side I hear echoes of the radical themes of my youth. McKeown
would surely turn in his grave to discover that he is now quoted by every
anti-immunization zealot and his critical insights used to justify reactionary
prejudices. The rhetoric of health inequalities is now mobilized to justify a
wide range of government social policies, from Sure Start to initiatives against
teenage pregnancy. In his lecture to the Faculty of Public Health last November,
Health Secretary Alan Milburn declared his intention to tackle inequalities in
access to health services, invoking the 'inverse care law' formulated by the
communist GP Julian Tudor Hart some 30 years earlier. Controversies around
health inequalities are now a prominent feature of the general medical press as
well as of specialist epidemiological journals.
In his (expanded and updated) June 2000 lecture to the Office of Health
Economics, the Canadian economist and health policy advisor Robert Evans traces
the evolution of the debate about health inequalities. Professor Evans provides
a useful survey of attempts to discover the mediating links between social
hierarchies and health outcomes?and of the problems of formulating policies to
reduce inequalities. Yet he neglects the key contextual factor: the
transformation in the salience of class in Society over the past two decades.
Between 1848 and 1989 class was the critical cleavage of capitalist society. For
upholders of the established order, the
working class was the major threat to stability and prosperity: hence it was an
object of fear and hatred, and of increasingly sophisticated study and
statistical analysis. For opponents of the capitalist system, the working class
was the most powerful countervailing social force; for many, it was the agency
that offered the promise of social transformation. The tension between Capital
and labour, usually contained through a complex system of social institutions
and practices, occasionally erupting in industrial and political conflict,
provided the organizing principle of social and political life. In the Cold War
era, it also structured international relations and the polarization between
West and East.
Mrs Thatcher's censure of the Black Report in 1980 confirmed her recognition
that any exposure of the socially oppressive character of capitalist society had
an inherently subversive character. After the defeat of the miners and the trade
union movement in the mid-1980s and the collapse of the Soviet Union and the
Eastern Bloc in 1989?1990, the British government could begin to take a more
relaxed approach to matters of class, and even of its health consequences. Yet,
when launching the Health of the Nation policy in 1992, Conservative ministers
still could not utter the word 'inequalities', preferring the anodyne
'variations'.
The collapse of socialism as an alternative to capitalism at home and abroad
meant that class conflict no longer took a political form (the subsequent
transformation of the Labour Party and the collapse of the Conservative Party
were consequences of this). Class could now safely become the object of academic
study and even medical intervention. However, it was not until the advent of New
Labour in 1997 that health inequalities became a prominent feature of government
policy. Though some radicals celebrated the fact that the government seemed to
be taking up a cause that had been pursued by left wing academics and activists
in the long years in opposition, the old rhetoric concealed the substance of the
new policy. It was striking that Tony Blair's enthusiasm for tackling
inequalities in the sphere of health followed his insistence that New Labour
abandon its historic constitutional commitment to equality (Clause IV) and any
suggestion of a redistributionist tax and benefit policy. As Evans notes, this
was the dog that failed to bark in response to Donald Acheson's independent
inquiry into inequalities in 1998. This failure was all the more conspicuous
given that disparities of income had increased substantially through the 1980s
and 1990s.
Evans appraises the New Labour approach to health inequalities as 'rhetorically
powerful, but politically very cautious'. Not only has Blair ducked income
redistribution, he has also ignored Acheson's recommendations in relation to
transport and has even stalled on his proposals on water fluoridation. But there
are sins of commission as well as of omission. Whilst the menace of the working
class may have receded, it has been replaced by a perception of a more diffuse
threat arising from trends towards social disintegration. The government's focus
on issues such as crime and drugs, anti-social behaviour, teenage pregnancy, and
child poverty reflects its preoccupation with problems that appear to be the
consequence of the breakdown of the family and of traditional communities. Under
the banner of tackling health inequalities, the government is promoting a range
of initiatives?such as Sure Start, neighbourhood renewal, and remedial education
programmes?that have an intrusive and authoritarian character.
If hearing the old radical rhetoric now makes me queasy, the policies it seeks
to legitimize are likely to make life worse -and less healthy -for those on the
receiving end.
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