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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.

Interpreting and addressing inequalities in health: from Black to Acheson to Blair to …?Professor... 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. © International Epidemiological Association 2003 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png International Journal of Epidemiology Oxford University Press

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.

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Publisher
Oxford University Press
Copyright
© International Epidemiological Association 2003
ISSN
0300-5771
eISSN
1464-3685
DOI
10.1093/ije/dyg095
Publisher site
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Abstract

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. © International Epidemiological Association 2003

Journal

International Journal of Epidemiology – Oxford University Press

Published: Jun 1, 2003

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