A broader picture

Chapter 5 (‘A broader picture’) first discusses why not only health inequalities, but also social inequality is so persistent. After reviewing sociological theories from both the ‘functionalist’ and ‘conflict’ traditions, it chooses a middle road which acknowledges the ineradicable nature of social inequality. It then describes recent trends in welfare state reform, and identifies several areas, such as pensions and active labour market policies, where more attention to health inequalities is required. It also evaluates the common intuition that health inequalities are ‘unjust’, by applying five theories of justice (‘equality of welfare’, ‘capabilities approach’, ‘luck egalitarianism’, ‘justice as fairness’, and ‘equality of opportunity’). It concludes that, although health inequalities are not simply a form of social injustice, there are several compelling reasons to reduce health inequalities, including avoiding accumulation of disadvantage, solidarity with the less well-off, and reducing costs to society.

Introduction

Chapter 1 (‘Introduction’) provides a short history of the discovery and rediscovery of health inequalities, as well as a short history and typology of the welfare state, and lays out the paradox that this book tries to explain: the persistence of health inequalities in even the most universal and generous European welfare states. It argues that micro-level studies alone cannot resolve this paradox, and that macro-level studies are needed to identify the determinants of health inequalities as seen at the population level. This will also make it easier to put health inequalities into a broader perspective, for example, that of social inequality per se. This chapter ends with an extensive preview of the main conclusions of the book.

Policy implications

Chapter 6 (‘Policy implications’) describes how several European countries have tried to reduce health inequalities. Even the well-resourced English strategy (1997–2010) has not reduced health inequalities at the population level, due to a combination of lack of evidence-based interventions and lack of scale of the efforts. Quantitative analyses of actually observed trends in European countries and of the potential impact of equalizing the distribution of risk factors show that reducing relative inequalities in health is almost impossible when overall health improves. It is therefore advisable to aim for reducing absolute inequalities in health, and to avoid overly ambitious quantitative targets. The book ends with a number of partly personal reflections on the sobering conclusions of 30 years of research, but also highlights some new inspirations for continued efforts to reduce health inequalities.

Patterns of health inequalities

Chapter 2 (‘Patterns of health inequalities’) sets the scene for the rest of the book, by explaining the measurement of health inequalities and by providing a profusely illustrated overview of inequalities in morbidity and mortality by education and occupational class in 30 European countries. It shows that health inequalities are a generalized phenomenon affecting young and old, men and women, and all aspects of health, but with important differences by age, gender, and type of health problem. It shows that health inequalities are present in all European countries, but with striking variations between countries, suggesting that there is great scope for reducing health inequalities. It also shows that although health inequalities are persistent, they are also highly dynamic, with relative inequalities often increasing and absolute inequalities sometimes declining over time. This chapter includes a comparison with other high-income countries (United States, Canada, Australia, New Zealand, Japan, and South Korea).

Patterns of health inequalities explained

Chapter 4 (‘Patterns of health inequalities explained’) is based on in-depth studies of the macro-level determinants of health inequalities, especially conducted for this book. It shows that the persistence of health inequalities is partly due to broader changes in society, such as educational expansion, increasing rates of intergenerational mobility, and more intermarriage of highly educated people. Another factor is that health improvements have been faster in higher than in lower socioeconomic groups, also because higher socioeconomic groups have benefited more from rising prosperity and rising health care expenditure, and have suffered less negative health impacts from rising income inequality and the transition towards liberal democracy in Central and Eastern Europe. Finally, it demonstrates the importance of the continued social patterning of health determinants, particularly poverty and smoking. It ends with a summary of how differences in the magnitude of health inequalities between European regions (North, South, East) should be understood.

Explanatory perspectives

Chapter 3 (‘Explanatory perspectives’) provides a digest of the vast amounts of explanatory research on health inequalities that has been conducted over the past three decades. It introduces recent methodological advances, such as the counterfactual approach to causality, quasi-experimental study designs, and mediation analysis. It reviews the scientific evidence that education, occupational class and income have a causal effect on health. It introduces life-course models, summarizes current understanding of the role of six groups of contributing factors (genetics, childhood environment, material living conditions, social and psychological factors, health-related behaviours, and health care), and describes the biological mechanisms of ‘embodiment’ of social inequality. It also discusses the merits of nine overarching theories of health inequalities: ‘social selection’, ‘diffusion of innovations’, ‘cultural capital’, ‘inverse equity’, ‘inverse care law’, ‘neo-materialism’, ‘psychosocial environment’, ‘fundamental causes’ and ‘political economy of health’.