Inequalities: The public health puzzle

Bettina Döbereiner reports on theories, policy strategies and current projects aired in the Berlin conference Reducing Health Inequalities. What do we really know about successful strategies?

In almost all industrialised countries the general health status – for example, as indicated by infant mortality, prevalence of disease, subjective health and life expectancy – has improved during the last four decades. However, at the same time there is a proven, close correlation between good and poor health and high and low socio-economic status. For 20 years these inequalities in health in and among countries have been recognised and analysed, and in some global regions they have been addressed. Nevertheless, they remain a largely unsolved puzzle. The difference in life expectancy among the 27 member states of the European Union, and within these states, is larger today than 20 years ago.

For most European welfare states these inequalities contradict their aim to protect civil and human rights and offer equal opportunities for all. The conference Reducing Health Inequalities: What do we really know about successful strategies? addressed this phenomenon. For two days in May, in Berlin, close to 240 international guests heard presentations made by 22 speakers who analysed these health inequalities, discussed recent research, outlined innovative policy strategies and showed current projects. Held at IGES, a private R&D institute for health and healthcare, the conference was co-funded by the Federal Centre for Health Education of Germany (BzgA) and initiated and organised by Hertie School of Governance, a school for public policy based in Berlin, and the School of Public Health in Bielefeld.

Theory debate: Comparability of health inequalities

The conference focused on Europe and, to some extent, the USA. The theoretical framework was provided by the concept of the so-called ‘three worlds of welfare capitalism’, a term introduced in the early 1990s by Danish sociologist and political scientist Gøsta Esping-Anderen. It was the first and still is the most widely used approach to distinguish between traditions and types of public policy. Based on historical analyses, Esping-Andersen defines three ideal types of welfare states - liberal, conservative and social democratic, which are mainly characterised by their different way of organising social welfare. The social-democratic system is shaped by an extended de-commodification, i.e. an almost independent social security system granted by the state. The conservative welfare state relies on work-based insurance contributions, thus welfare benefits are closely linked to status. Liberal welfare states, such as Great Britain, emphasise market-based mechanisms to support the needy. In the social sciences, this welfare typology framework is being used to analyse cross-national differences in population health. Esping-Anderson’s original concept has been modified and expanded, but remains the foundation.

Almost all studies concluded that population health is enhanced by the relatively generous and universal welfare provided by the social democratic Scandinavian countries. However, despite their comparatively strong performance in terms of overall health, the social-democratic welfare states tend to show more pronounced inequalities in health than conservative countries, such as Germany, which seem to have the least health inequalities. At the conference, these unexpected research results were widely discussed.

Clare Bambra of Durham University called it a ‘public health puzzle’, which should be solved soon. She proposed further research on the interaction of macro-level welfare state characteristics and health inequalities within and between countries. Espen Dahl, Professor at Oslo University College, sees no evidence of a link between types of welfare states and health inequality and concludes that the welfare state typology does not particularly help to explain comparative data on health inequalities. Therefore, he suggested refining the typology. Klaus Hurrelmann, Professor at the Hertie School of Governance and main initiator of the conference, demanded a broader perspective on the phenomena of inequalities and thus suggested future research should apply a wider European concept of social policy, which includes not only healthcare but labour policy, social security, social housing, criminal justice, education policy, unemployment insurance. Overall, the speakers concluded that there is still no framework that allows identification of the factors that cause inequalities in health in a country and comparison of these factors across countries.

The life-course theory

Laura Kestilä, from Finland, described the life-course approach, which suggests that long-term exposure to physical risks, or adverse social and economic circumstances in childhood, or concurrent adverse circumstances due to unfavourable living conditions in earlier life, may lead to poor health, detrimental health behaviour, disease and even premature death. She also presented the results of her recent study Childhood social circumstances as predictors of health and health behaviour - independent and mediated effects and concludes that childhood circumstances affect health and health behaviour of young Finnish adults. The study results indicate that the impact of childhood on early adult health varies according to the measure of health: childhood conditions are strongly associated with poor self-rated health and psychological distress, whereas somatic diseases and disorders typical of young adults show no, or only weak, associations with these factors. Kestilä assumes that childhood circumstances predict health-damaging behaviours. These indicators of health behaviour (smoking, heavy alcohol use and obesity) are shaped throughout the life-course. This corroborates the assumption that health differences related to education also develop throughout the life-course.

Change instead of scientific analyses

The title of Martin McKee’s lecture was chosen as the title of the entire conference. Professor of European Public Health at the London School of Hygiene and Tropical Medicine, co-director of the European Centre on Health of Societies in Transition and Research Director of the European Observatory on Health Systems and Policies, McKee started out with a famous quote by Karl Marx ‘The philosophers have only interpreted the world, the point is to change it’ – a fitting motto for his presentation. In his opinion public health researchers have been remarkably good at measuring and understanding inequalities in health. However, they have been less successful in discovering what to do about them. All know what should be done; there is no need for more research.

McKee considers the debate about the different types of welfare states and their comparability an academic amusement. For him, the causes of health inequalities are as clear as they are diverse. People, according to McKee, differentiated in many ways and these differences are mainly responsible for the very different causes for inequalities in health. His advice sounds provocative in its simplicity: give very poor people money, food, clean water, shelter, protection from violence, satisfying and rewarding jobs, build them safe environments, stop other people from killing them and make them vote.

To underline the importance of this framework, McKee quoted a study that indicates crime reduction can promote health. Swedes aged 35-64 years, living in violent neighbourhoods, had higher incidence of coronary heart disease after adjusting for other factors. In addition, work contributes to health. In all countries studied so far, people in employment are in better health than those who are not, even when the unemployed receive 100% salary replacement. McKee proposed to identify the disadvantaged groups, find out how they are disadvantaged, look at how this impacts on health, and identify possible points of intervention. He is convinced that the main problem is the lack of political will and, foremost, the lack of will to offer money for measures to reduce health inequalities.

In the final discussion he was adamant that neither the German chancellor Angela Merkel, nor the British Prime Minister, are interested in reducing health inequalities for humanitarian or ethical reasons. Consequently, the argument that health equality will increase overall economic productivity is a more promising strategy. McKee’s critics were reluctant to ‘sell’ their point rather than to convince with moral and ethical arguments. Moreover, there were doubts that politicians will indeed buy the economic argument. McKee, who said that his many conversations with politicians had led him to his conviction and disabused him of any ideals, pointed out that politicians have memories like goldfish, i.e. only thirty seconds. He also underlined the fact that in Europe, national health ministries are in general not stepping-stones for political careers, that there are many changes in staff and that, in many countries, ministries are bound by weak coalition partners with little influence.

Part 2: Inequalitites: The public health puzzle
Will be published in the Thursday issue of EH@MEDICA2009


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