Studying Health Inequalities

An Applied Approach

Wistow, Jonathan, Jonathan Wistow

• Publisher: Policy Press
• Year: 2015
• Print ISBN: 9781447305286
• eBook ISBN: 9781447313687
• Edition: 1
• Topic: Medicine
• Subtopic: Health Care Delivery

New public health governance arrangements under the coalition government have wide reaching implications for the delivery of health inequality interventions.

Through the framework of understanding health inequalities as a 'wicked problem' the book develops an applied approach to researching, understanding and addressing these by drawing on complexity theory. Case studies illuminate the text, illustrating and discussing the issues in real life terms and enabling public health, health promotion and health policy students at postgraduate level to fully understand and address the complexities of health inequalities.

The book is a valuable resource on current UK public health practice for academics, researchers and public health practitioners.

Part One

Context and theory: developing an applied approach to studying health inequalities

TWO

Health inequalities, wicked problems and complexity

Introduction

We have already noted that the term ‘health inequalities’ is used to describe systematic differences in health status between, and within, different socioeconomic groups. We’ve also recognised that the social (including economic) determinants of health are broad and complex. Before considering the development of policy responses in England in relation to health inequalities, it will be useful to understand better the concepts of health and inequality. This analysis forms part of the context for understanding the nature of policy options and outcomes. To do so, as noted in the previous chapter, we need to consider the notions of complexity and wicked problems more fully. Together, these concepts provide fundamental underpinnings of the perspective adopted in this book to help understand the nature of health, health inequalities and possible strategies for addressing them. Consequently, this chapter provides our approach to framing and making sense of health inequalities.

What is health?

‘The whole point of this country is if you want to eat garbage, balloon up to 600lbs, and die of a heart attack at 43, you can. You are free to do so. To me that is beautiful.’ (Ron Swanson,³ Parks and Recreation, NBC [National Broadcasting Company])

Ron Swanson has a point. In terms of our lifestyles and health-related behaviours we have wide areas of discretion. Like him, we also recognise that these freedoms do not necessarily lead to good health outcomes for us as individuals or (as he fails to add) for society and the state more widely. Moreover, the extent and exercise of such discretionary health-related behaviours are neither unbounded nor random. So-called free choice is a chimera.⁴ Both it and our linked behaviours are socially and economically structured by many influences in our different environments. We have noted in the previous chapter that the social gradient is a key determinant of health inequalities and their associated outcomes. We can begin to deepen our understanding of the relationship between social inequality and health status as we explore more closely what we mean by health.

The constitution of the World Health Organization (WHO) defines health as ‘a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity’ (WHO, 1948). For Illich (1976: 7), on the other hand, ‘health’ is an everyday word used ‘to designate the intensity with which individuals cope with their internal states and environmental conditions’. He also argues that the health of populations depends on the way in which political actions create the environment and circumstances that favour self-reliance, dignity and autonomy for all. Taylor and Marandi (2008) state that ‘social determinants – social, economic, political, cultural, and environmental factors – heavily influence people’s demand for, access to, and use of health services’. In other words, social determinants cut across why and how people become ill, and how – and whether – they are treated by health and health-related professionals. What all these viewpoints have in common is a fundamental understanding of health as being socially structured and not merely to be equated with the absence of remediable disease or the treatment of ill health. In short, we can expect to find social as well as medical models of causation and intervention in the broad field of health. The topic of disability provides a very clear example of differences in conceptions of health.

Models of health

In 1983 Mike Oliver conceptualised models of disability through a binary distinction between individual and social models of disability. For Oliver, the individual model is underpinned by what he calls the ‘personal tragedy’ theory of disability which, in turn, is underpinned by the medical model of health. From this perspective, the condition of the ‘disabled’, their ‘limitations’ and ‘problems’ are the consequence of an individual characteristic:

I locate the medicalisation of disability within the individual model and as I have argued that this model is inappropriate, so, it logically follows, is the medicalisation process … disability is a social state and not a medical condition. Hence medical intervention in, and more importantly, control over disability is inappropriate. Doctors are trained to diagnose, treat and cure illnesses, not to alleviate social conditions or circumstances. (Oliver, 1990: 3)

The social model of disability does not deny the ‘problem’ of disability but locates it squarely within society. It is not individual limitations which are the cause of the problem but society’s failure to provide appropriate services and adequately ensure that the needs of disabled people are fully taken into account in its social organisation. This is a powerful argument, which has great resonance for how we choose to view health more generally and inequalities in health in particular. How far do we understand inequalities in health outcomes as a problem of the individuals experiencing them or as a product of, and problem for, society? We are explicitly formulating our concern in these terms to avoid polarising the medical and social models of health too sharply. Rather, we wish to explore the case for rebalancing the medical and social models. It is a distinction, therefore, that provides a framework within which both to identify and to consider the balance between different approaches for improving health and reducing health inequalities. We use it in the remainder of this section as we turn to the role of two key strategies frequently advocated for improving the health of individuals and populations: health promotion and health services delivery.

The role of health promotion

If we adopt an understanding of health as being socially determined, the role of health promotion cannot be restricted to the modification of individual behaviours. If, at the same time, we also recognise that the social determinants of health lie largely outside the role and influence of health services, it follows that health promotion is necessarily conceptually complex and organisationally complicated (Baum, 2007). Warr et al reflect this understanding in arguing that ‘health promotion is the process of enabling people to increase control over, and to improve, their health. It moves beyond a focus on individual behaviour towards a wide range of social and environmental interventions’ (2013: 95). In their study of health promotion in Australia, the same authors suggest that the field is characterised by two categories of activity: ‘procedural’ and ‘cooperative’. The former is a specialised set of activities and technical knowledge focused on the dissemination of health information, while the latter comprises a broader-based approach focused on socioeconomic and health equality and delivered through processes of community engagement and participation as well as professional service delivery systems. As a result, they suggest, health promotion workers in community-based contexts must move between two radically different ways of working (the cooperative and procedural) so as to navigate the frequently conflicting demands of community, service and professional expectations (Warr et al, 2013: 106). Indeed, they suggest there may even be a direct conflict between the growing professionalisation of health promotion and its delivery on the one hand, and its ability to stimulate collective community action approaches to address socioeconomic disadvantage on the other (Warr et al, 2013: 107). Whatever the case, it is clear that a service model based on providing information to individuals so that they are better equipped to maintain and improve their own health calls on different skills and understandings from one which seeks to address the social determinants of health through collective social action. Both approaches may have important roles to play but, if we accept our earlier point that health-promoting choices and behaviours are socially structured, the provision of information alone is unlikely to overcome the influence of social determinants and may even reinforce their impact.

Impact of social determinants

The impact of social determinants is not absent from the related field of the early detection and treatment of disease (which is more closely related to the individual/medical model of health). Social determinants affect not only the distribution of disease but also the distribution of and access to services intended to be part of the National Health Service (NHS)’s supposedly universal offer of care and treatment. As Dorling (2013a: 11) demonstrates, high levels of economic inequality may push medical practitioners away from those most in need. By this he means that medical doctors prefer to live and work in the areas of higher socioeconomic status in which better health outcomes are concentrated. In more equitable countries, doctors tend not to avoid serving areas with greater health needs because the differences are less pronounced (Dorling, 2013a). Evidence for the existence of an ‘inverse care law’ (Tudor Hart, 1971), according to which services are distributed inversely to population health needs,⁵ has been repeatedly demonstrated in the UK: people living in areas where need is relatively low have better access to the most specialised and skilled medical services (Shaw and Dorling, 2004). By contrast, the same authors derived data from the 2001 census, which apparently demonstrates that informal care (provided by the families and friends of those in need and at limited extra cost to the state save the benefits and allowances paid to some carers) is provided in almost direct and exact proportion to need. This conclusion led Shaw and Dorling (2004) to postulate the operation of a ‘positive care law’ in relation to informal care, where the cheapest (for the state) and least skilled form of care is positively related to need. We also need to recognise that informal care may also be what people need and families want to see supplied as part of an agreed mix of formal and informal services. For example, Wistow et al (2015) found that during emergencies older people tend to turn to informal networks of care in the first instance, and out of preference, rather than more formal networks.

Whether we take a narrower (individual/medical) or broader (social) view of health, there are clear disadvantages in terms of health outcomes for those occupying lower socioeconomic positions. At the same time, Kelly points out that:

a fully-rounded approach to public health requires both the individual and social levels of explanation … to capture the significant interactions between the individual and social level phenomena. These interactions are important because they not only articulate the causal pathways to the individual disease outcomes, but they demonstrate the various linkages between different phenomena. (2010: 271)

An understanding of these linkages is fundamental to the design of appropriate interventions. In this respect, Taylor and Marandi argue that ‘[health inequity] is not inevitable. Health care systems and services can promote health equity if they are designed to maximise the “fit” between patients’ needs and providers’ supply’ (2008: 266). Nevertheless, Graham and Kelly (2004) identify that policies aimed at tackling the determinants of health do not automatically tackle the determinants of health inequalities. Instead, we need to focus on the unequal distribution of health determinants. In summary, therefore, policy and practice need to recognise that, as Glasby notes, ‘people do not start equal and so treating everyone in the same way can perpetuate or exacerbate existing inequalities’ (2012: 119). These inequalities are the focus of the next section.

Inequality

Having explored some of the different ways of viewing health, it is also necessary to unpack the notion of inequality further. Inequality is frequently used as a term to describe differences in income between different parts of the population (Cribb et al, 2013). The way we view or interpret different degrees of income inequality tends to be associated with different political and ideological positions. Byrne (2005) identifies three such positions: possessive individualist; liberal ‘collectivist’; and Marxist, each of which we briefly consider below. Possessive individuals⁶ (originating from Locke’s ideas around individual emancipation) view the market as the epitome of rationality, in which citizenship is constructed around individual (as opposed to collective) rights. According to this view, inequality is a natural function of individuals’ merits and contributions to society. Liberal collectivists cover a broad church, with the common goal of regulating capitalism in order to ameliorate the excesses of inequality. For traditional Conservatives, the management of capitalism is necessary for maintaining stability in an inherently unstable system. Keynesians, for example, believe in a capitalist system but with progressive taxation to limit economic inequalities. In this view, overall inequality is necessary because the growth of the economy makes us all wealthier. Marxists and socialists regard inequality as essentially exploitative; they want to minimise economic inequality and distribute resources based on individual needs through a project of collective transformation. These different ideological positions have significant implications for the nature of the macroeconomic environments, social structures, local systems and individual lifestyles that will be possible or predominant at any point in time. In England, for example, all of these attributes have been affected in recent years by what is generally accepted to have been a significant shift from socialist collectivism to classic liberalism, explicitly endorsed by almost all political elites in the name of a perceived necessity for a more flexible labour market in a competitive globalised world (Byrne, 2005).

How we view inequality also depends to a large extent on how we view equality. Westergaard and Resler (1975: 281) note that ‘equality’ is associated with different meanings in America and Europe. In the US the notion of ‘equality of opportunity’ has been the dominant position, in which each individual will find their own level in the hierarchy of inequality, according to their ability and motivation, and regardless of parentage and the circumstances of early life. The authors point out that there is no challenge to the existence of a socioeconomic hierarchy in itself. The European conception of equality, however, includes just such a challenge in its advocacy of ‘equality of condition’ and the eradication of significant divisions of power, wealth and security. In reality, Westergaard and Resler (1975) contend, the notion of equality of condition was not generally transferred to policy when social democrats were in office but provided an important buffer to prevent the total encapsulation of labour policies under capitalism.

Inequality and liberal capitalism

Over the past 30–40 years the UK has been a particularly enthusiastic advocate of a free-market form of liberal capitalism. Indeed, Hutton (2003) points out that Blair and Brown were no less enthusiastic about US economic dynamism than Thatcher, and that as result Britain defined itself in Europe as the English-speaking Anglo-Saxon model – a stock market-based capitalism, complete with a minimal welfare system⁷ and flexible labour markets. Consequently, the dominant view of inequality has shifted to one of possessive individualists and the view of equality is more closely associated with equality of opportunity. This raises important questions about equity and fairness and whether equality of opportunity can be achieved from an unequal playing field. Key concepts such as social mobility (see Blanden et al, 2005; Goldthorpe and Jackson, 2007), social capital (see Putman, 1995; Ferragina, 2010) and accumulated capital (see Bourdieu, 1986), in particular, draw attention to the significance of social determinants such as social class, family background, ethnicity and geography for environmental inequalities that shape life courses in such a competitive society as that favoured by possessive individualists. This is beyond the strict scope of this book but is highly relevant to our concern with ineq...

Table of contents

• Cover Page
• Title Page
• Copyright Page
• Table of Contents
• List of figures and tables
• About the authors
• Preface
• One Introduction
• Part One: Context and theory: developing an applied approach to studying health inequalities
• Part Two: Health inequalities in England
• Notes
• References
• Appendix A
• Appendix B
• Appendix C