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As shown in Chapter 4, substantial evidence from dozens of countries has linked social inequalities with health. Consistently, these studies show that people of lower socio-economic status (SES) have more illness and lower longevity than those in higher socio-economic groups. There is a gradient such that those one step down the ladder are unhealthier than those above. This persistent gradient is often referred to as a ‘health gradient’. When mortality is the measure, a more apposite term would be ‘mortality’ or ‘death gradient’. ‘Death gradients’ have been observed in all human societies in both rich/developed countries and poor/developing countries (Marks, 2004). Such gradients are normally continuous throughout the range of economic variation. If the gradient were stepped or flat at one end of the range and steep at the other, it could be inferred that the causative mechanism(s) had a threshold value before any of the ‘ill-effects’ could appear. However, there is no evidence of such thresholds; the gradient is a continuous one.

One of the earliest reports on the health gradient was by the French physician Louis-René Villermé (1782–1863) who, in the 1820s, examined the health of residents in different neighbourhoods of Paris. From a careful review of the data, Villermé concluded that there was a relationship between the wealth of the neighbourhood and the health of its residents. Those living in the poorer neighbourhoods had a higher death rate, and military conscripts from those neighbourhoods were smaller and had more illnesses and disabilities (Krieger and Davey Smith, 2004). Shortly afterwards, Friedrich Engels published his classic work on The Condition of the Working Class in England in 1844 (Engels, 1845/1958). This book provided a detailed description of the appalling conditions and the limited health care of working-class residents of Manchester.

When Engels compared death rates within the city he found that they were much higher in the poorer districts. Further, he realized the importance of early development and noted: ‘common observation shows how the sufferings of childhood are indelibly stamped on the adults’ (1845/1958: 115). Although these early researchers realized the importance of the impact of adverse social conditions, interest in the social aspects of health was marginalized with the rise of germ theory and the growth of Social Darwinism and eugenics (e.g. Krieger and Davey-Smith, 2004). The former theory focused on controlling specific pathogens rather than social reform, whereas the second argued that innate inferiority, not social injustice, was the cause of ill health (see also Chapter 3). However, the growth of social movements in the 1960s rekindled interest in social justice.

The foundation of the National Health Service (NHS) in the UK in 1947 was an attempt to remove inequalities that existed in health care provision. Health services were provided for all – free at the point of delivery. Titmuss (1968: 196) observed, after 15 years’ experience of the NHS, that the higher income groups:

know how to make better use of the service; they tend to receive more specialist attention; occupy more of the beds in better equipped and staffed hospitals; receive more elective surgery, have better maternal care, and are more likely to get psychiatric help and psychotherapy than low-income groups – particularly the unskilled.

These continued disparities led Tudor Hart (1971) to describe the ‘inverse care law’: the availability of good medical care tends to vary inversely with the need for the population served.

In 1977 the UK government established a working group to further investigate social inequalities in health. The subsequent Black Report (Townsend and Davidson, 1982), named after Sir Douglas Black, the working group’s chair, summarized the evidence on the relationship between occupation and health. It showed that those classified as unskilled manual workers (Social class V) consistently had poorer health status compared with those classified as professionals (Social class I). Further, the report graphically portrayed an inverse relationship between mortality and occupational rank for both sexes and at all ages. A class ‘gradient’ was also observed for most causes of death, particularly respiratory, infective and parasitic diseases. Inequalities in terms of utilization of health care, especially among preventive services, were also apparent.

In a follow-up study, similar trends persisted in the 1980s as social inequalities in health continued to widen (Townsend et al., 1992). As discussed in Chapter 4, the Whitehall studies provided supporting evidence on the relationship between SES and health. As Marmot and Allen (2014: S517) explained:

To reduce health inequalities requires action to reduce socioeconomic and other inequalities. There are other factors that influence health, but these are outweighed by the overwhelming impact of social and economic factors—the material, social, political, and cultural conditions that shape our lives and our behaviours […] In fact, so close is the link between social conditions and health, that the magnitude of health inequalities is an indicator of the impact of social and economic inequalities on people’s lives. Health then becomes an important further cause for concern about the rapid increase in inequalities of wealth and income in our societies. Increasingly, we are using the language of health inequity to describe those health inequalities that, though avoidable, are not avoided and hence are unfair.

Tackling health inequalities is not just about combatting the growing social inequalities, but also about understanding and addressing the material, behavioural and psychosocial pathways by which these inequalities impact health.

In understanding and dealing with health inequalities, it is important to recognize all determinants of health – from micro to macro levels – and to consider how many of these are within the control of individuals in society. The idea of capabilities is related to the actual freedom and rights enjoyed by people (Sen, 1999). In this respect, freedom does not only entail one’s freedom to choose; rather, it also involves freedom from the barriers that restrain people from reaching their fullest human potential. Only when individuals have the ‘capability’ to exert control over the factors that influence their health can they truly exercise their ‘right to health’. The vast levels of social inequalities pose serious questions regarding the capacity of individuals to exercise their human rights. The emergence of new centres of power extends the issue to the international scale where the capacity of nation states to protect and promote their citizens’ right to health is also being threatened.

The Acheson Report (1998) outlined recommendations to address health and social inequalities in the UK. In 2008, the WHO Global Commission on the Social Determinants of Health published a report to address health equity by taking action regarding the social determinants of health. In the same year, the Scottish government (2008) published the Equally Well report, which provided substantial evidence on the relationship between health and socio-economic deprivation in Scotland. The UK government commissioned Sir Michael Marmot to review current trends and to propose the most effective evidence-based strategies to reduce health inequalities in England. In 2010, Marmot’s report entitled Fair Society, Healthy Lives recognized the reduction of health inequalities as a matter of fairness and social justice (Marmot, 2013). The report underlined that solely focusing action on the most disadvantaged would be inadequate. Fair distribution of health, well-being and sustainability are more important measures of success than economic growth. As expressed in the final report of the Commission on Social Determinants of Health, inequities in power, money and resources were to blame for many of the inequities in health within and between countries. In order to address inequities in health effectively, cross-government commitment to action is needed across all of the social determinants of health (for more details see http://www.instituteofhealthequity.org and https://www.podsocs.com/podcast/health-inequalities).