A Conversation with Richard Wilkinson about the Origin of the Black Report
by VIRGINIA BERRIDGE
During the course of the witness seminar on the Black Report there was a discussion of how the Department of Health’s working-group on health inequalities first came to be set up. Sir Douglas Black mentioned the role of Professor Brian Abel-Smith of the London School of Economics, who was health adviser to the Labour government, and his connections with the Child Poverty Action Group.
Subsequently a conversation I had with Richard Wilkinson during a meeting on health inequalities at the Institute of Advanced Study in Berlin in May 2001 threw light on the origins of the committee – and also on the influence exerted by the media on policy-making. This note reproduces the substance of the discussion and its elaboration afterwards.
Richard Wilkinson, while a student on the M.Sc. in community medicine at Nottingham University, spent a year on a research project examining the widening social class differences in death rates. The gap between upper and lower social classes appeared to be two or three times as large in the 1970s as it had been during the 1930s. It had widened slightly during the 1930s and 1940s and dramatically during the 1950s, despite the introduction of the National Health Service.
Originally trained as an economic historian, Wilkinson confined his search for explanations of these class differences to social and economic indicators related to class. He looked at 20 possible influences, including housing, education and jobs, comparing these with death rates from 20 different diseases in the London and county boroughs. He then went on to look at the relationship between death rates and different items of personal consumption and expenditure in the regions. The statistical results confirmed the findings of other studies – that factors such as housing conditions and occupational mortality made little difference to overall death rates. They also confirmed the strong association between income and death rates. This association seemed to be due to the close statistical relationship between diet and death rates. He drew attention to the almost uniformly worse diets of poor people; the only thing less good about the diet of the rich was the little bit of extra fat it contained. But heart disease was more common among the poor despite the differences in fat consumption.
Wilkinson entered his dissertation for an essay competition run by the food company Van den Bergh. Although it came second (the first prize went to Gill Gordon’s essay on baby milk), the media picked up the story. ‘It was in all the newspapers, on News at Ten on ITV … and, via a press agency, into lots of local papers.’
On 16 December 1976, a two-page article by Wilkinson appeared in New Society entitled ‘Dear David Ennals‘. It started: As Labour Secretary of State for Social Services you have the misfortune to be confronted by the largest social class differences in death rates since accurate figures were first collected.’ It set out the substance of the research and issued a political challenge: ‘Of course you will want not only to halt this trend, but also to reverse it.’ It ended by asking Ennals ‘to set up an urgent inquiry to look into these issues and recommend action’.
The article had an impact – but not until the following spring did Wilkinson realise this. Ennals read it and his private secretary, Margaret Moodie, wrote on 16 March 1977 specifically replying to Wilkinson’s New Society piece. The department had been carefully going through Wilkinson’ s work and were already doing various things about the issues. She wrote: ‘I am afraid that the Secretary of State is not persuaded of the need for the urgent inquiry for which you ask.’ Wilkinson wrote back and arranged, at her suggestion, to see someone in the Public and Environmental Health Division of the Department of Health. Two weeks later, on 29 March 1977, Margaret Moodie wrote again, sending a copy of the speech Ennals had delivered to the Socialist Medical Association on 27 March, in which he announced the setting up of the Black Inquiry. In that speech, Ennals drew attention to the fact that class differences in health had widened despite the achievements of the Welfare State, and said:
The first step towards remedial action is to put together what is already known about the problem. A good deal of information has been gathered for different purposes in this and other countries. But it needs to be assembled and analysed to bring out as clearly as possible what the cause and effect relationships might be, what the implications for policy are and what other research we need. I have already set this in motion. My Chief Scientist has appointed three scientific advisors with a particular interest in the matter to commission a comprehensive survey as quickly as possible.
Wilkinson commented: ‘It is clear that the decision to set up an inquiry was made after some shilly-shallying very soon after Margaret Moodie wrote to me on 16 March saying Ennals was not persuaded of the need for an inquiry.’
On 1 April a letter from the department followed, telling him that Sir Douglas Black’s ‘new group’ would be holding its first meeting on 7 April.