Inequalities In Health: Social Determinants Of Ill-Health

Margaret Whitehead contribution to Health, Wealth and Poverty conference 1992. , Margaret Whitehead is an independent health policy analyst and author of The Health Divide. A new edition of ‘The Health Divide” (1) has just been published to review the hundreds of new studies on this issue which have accumulated since the first edition in 1988.

These new studies provide ample evidence that social inequalities in health still exist in Britain as well as in many other countries. I have been looking at the countries in the European Region of the World Health Organisation in particular. The evidence can be summed up in one sentence in the words of Louise Gunning-Schepers:

“The mounting scientific evidence …all points to a better health status for those who earn more, know more, or have morepower” (2).

This brings out the point that different countries use different social classifications to measure social position – income, education, occupation and so on – but a consistent pattern emerges whichever classification is used, showing better health for the more advantaged in society.

New Evidence

In Britain, this shows up, for example, in the latest available figures on infant mortality by social class. These 1990 figures show a gradient in death rates in babies -moving down the social scale, the death rates increase so that there is approximately a two-fold difference in rates between social class I and V (3). The same pattern can be seen in the death rates of children aged 1-15, and at various stages of the life-cycle, up to and including old age.

But mortality is only one measure of health: there are many other dimensions to the concept of health and evidence is extending rapidly in these areas. Rather a neat illustration of this point comes from Canada, where differences between income groups have been studied. Comparing the life expectancy at birth of the richest 20% of the population with that of the poorest 20%, there is a gap of over six years between the richest and the poorest men, and a gap of nearly 3 years between the richest and poorest women. However, if the number of years spent without disability is calculated (disability-free life expectancy), then there is a difference of over 14 years between the richest and poorest men, and over 7 years between the richest and poorest women (4). In effect, such findings indicate that wealthier people not only live longer but also spend a significantly smaller proportion of their life disabled. It is important to consider quality of life as well as quantity.

In Britain, differences in morbidity between socio-economic groups can be seen for a range of physical conditions, using, for example, standardised longstanding illness ratios as in the 1988/89 General Household Survey data for respiratory disease, circulatory and musculoskeletal conditions (5).

A consistent pattern can also be seen for aspects of social and mental health. For example, in Mildred Blaxter’s work on the Health and Lifestyle Survey, levels of “psycho-social malaise” were studied (6). This is an index of symptoms including sleep disturbances, depression, feelings of strain, etc. There is a social gradient using this index, with the percentage reporting high levels of psycho-social malaise increasing steadily from social class I plus II to IV plus V in each of the three age groups shown – 18-39, 40-59 and age 60+. This study also illustrates the differences between men and women for this dimension of health. In each social class, a greater proportion of women reported high levels of psycho-social malaise than their male counterparts. Higher levels of ill-health can be seen for women using a range of morbidity measures, whereas the reverse is found using mortality measures, when men generally have higher death rates than women. However, gender differences in health are far more complex when the social and economic circumstances in which men and women live are taken in to consideration ‘.

The evidence discussed so far helps to fill in some of the gaps in knowledge evident when the Black Report was published. In 1980, the Black Report had to rely heavily on evidence concerned with mortality, based on men rather than women, with the under 65s, and with measures of social position using occupation. Since then new studies have extended and strengthened the conclusions on inequalities by developing new social classifications – particularly useful for looking at inequalities between women and of people over retirement age – and by devising new measures of health beyond death rates.

There are also important health differentials between groups of different ethnic origin. In 1990, infant mortality analysed by mother’s country of birth showed that the mortality of babies with mothers born in the UK was approximately 7.5 deaths/1,000 live births, but for babies with mothers born in Pakistan the rate was nearly double that – 14 deaths/ 1,000 live births. Mortality was also raised for babies with mothers born in the Caribbean, while the rates for babies with mothers born in India and Bangladesh were lower than for their UK counterparts (3). This contrasts with the picture of infant mortality in the mid-1970s, when babies with mothers born in India and Bangladesh also had excess mortality over those with UK-born mothers, but there has been a great improvement since then for these groups. In adults, there are raised death rates for some ethnic groups, for example, higher than average rates of coronary heart disease for people of Asian origin.

Central and Eastern Europe

Only in the last two to three years has evidence become available on inequalities in health in some of the central and eastern European countries, following the general opening up of information in the region ‘, (7). Looking at inequalities between countries, an East-West health divide has opened up, with life expectancy at birth approximately six years greater in the west than in central and eastern countries and with a two to three fold difference in infant mortality rates, also favouring the west (8).

This gap in health between east and west is a fairly recent phenomenon, developing in the 1960s and ’70s. In the immediate post-war period various health indicators, like life expectancy at age 45, were similar in eastern and western countries. In fact, life expectancy was slightly better in some eastern countries than in the UK at that time. However, during the 1960s and 1970s, life expectancy continued to improve in the west, while halting or even deteriorating in central and eastern Europe.

A similar trend could be seen for inequalities in health within countries, though the evidence relies on rather crude date. In Hungary, for example, wide differentials in health between different occupational groups could be seen before the war. These differentials narrowed after the war up until 1960, but by the late 1960s the gap had widened again and persisted into the 1980s.

This type of evidence focuses attention starkly on the question of what has been happening in these countries over the past 30 years to bring about these changes. The trends illustrate the interplay of various determinants of ill-health. For example:

  • Rapid industrialisation leading to widespread pollution and dangerous working conditions.
  • Economic crisis leading to falling living standards.
  • Growing social stress and deterioration of living conditions.
  • Inadequate access to essential health care.
  • Food supply problems leading to inadequate nutrition.
  • Increases in behavioural risk factors, such as alcohol abuse.

To a great extent, all these determinants of ill-health are inter-related. The rise in alcohol abuse, for example, can be seen as one way that people might cope with economic and social crises. Inadequate nutrition is a reflection not only of personal choice but also of whether there is food in the shops and whether people have money to buy it.

From the evidence available, it seems that not all sections of society in central and eastern European countries were affected equally by the rise in these determinants of ill-health. Those who were already disadvantaged were hardest hit by falling living standards and the deterioration in living and working conditions.

Uneven Distribution of Determinants

Because the socio-economic changes have been so dramatic in central and eastern European countries, they show very clearly the determinants of ill-health in operation. But the determinants can be considered in Britain and western Europe in general in the same way, that is, in three main categories:

  • Health hazards in the physical and socio-economic environment.
  • Inadequate access to health care.
  • Behavioural risk factors and barriers to changing personal lifestyle.

If we look at the distribution of these determinants across the population in Britain and western countries, it can be seen that the distribution is uneven, with a heavier burden falling on more socially disadvantaged groups. So, for example, looking at working conditions, the lower the occupational class the more likely are people to suffer physical strain, high noise levels, shiftwork and unsocial hours, polluted breathing air and other indicators of harmful conditions. A similar pattern can be seen for housing conditions, social support networks and so on. With health care, Julian Tudor Hart has even coined a phrase for the phenomenon – the Inverse Care Law – to describe the common finding that medical care is least available where it is most needed (9). He was referring to the geographical distribution of health care, which is often found to be more concentrated in prosperous areas compared with deprived areas with the highest levels of ill-health. However, the Law also operates (to varying degrees in different countries), in terms of quality and acceptability of care.

Again, if the distribution of behavioural risk factors is considered, there is an increasing prevalence of these risk factors with decreasing socio-economic group for smoking, poor diet and lack of exercise in leisure time. It should also be noted that disadvantaged groups face greater barriers to choosing a healthier personal lifestyle because of lack of income, time or opportunity’,(1), (6).

To sum up, one important point to come out of a consideration of the uneven distribution of determinants of ill-health is that people have unequal chances of achieving and maintaining good health. Some groups have the cards heavily stacked against them – they are struggling against much greater odds to achieve their full health potential. A basic unfairness comes out of this evidence because some of these distributions are a) potentially avoidable, and b) unacceptable, especially when they can be see to be caused by factors outside individual control. These fall into the category of “inequities in health”, the converse of what a recent World Health Organisation paper defines as equity in health:

“Equity in health implies that ideally everyone should have a fair opportunity to attain their full health potential and, more pragmatically, that no one should be disadvantaged from achieving this potential, if it can be avoided” (10). It is obvious from the evidence in this country and across Europe, that there are large sections of the population who are disadvantaged from achieving anywhere near their full health potential.

What Can Be Done?

Such evidence immediately raises the question of what can be done about this problem. There are two general points to be made before Richard Wilkinson goes on to look at one specific policy area in greater detail.

Firstly, the determinants of health contributing to the health divide operate at different policy levels. It should be possible to inject a consideration for the uneven distribution of the determinants into every level of policy-making. Whether people in this conference are working to promote healthier personal lifestyles, to provide health or social services, to improve housing or working environments, or to influence structural factors, they could take into account in their work:

  • the uneven distribution of health and disease
  • the uneven distribution of health hazards in the physical and social environment
  • the uneven distribution and quality of health care
  • the uneven distribution of behavioural risk factors and uneven opportunity to adopt a healthier personal lifestyle.

All too often at the moment, blanket policies are pursued which ignore these factors completely and proceed as if everyone was equal in these respects.

Secondly, policies to tackle the problem can have three quite distinct aims or goals”:

  1. A direct attack on the determinants of the health divide (for example, tackling unemployment through the creation of jobs and training).
  2. Indirect attack by ameliorating/minimising the damage to health caused by the determinants (for example, setting up support services for unemployed people to help prevent a deterioration in mental health caused by the experience of unemployment).
  3. Matching services to increased need (for example, accepting that areas of high unemployment are likely to have poorer health profiles and providing additional levels of services to meet that greater need).

The rest of this pamphlet is devoted to discussion of structural policy, mainly at the national level, but it should be remembered that all three aims are valuable and can make a contribution to tackling the problem. Indeed, everyone has a responsibility to take action to promote greater equality in health at whatever level of policy they are working.


1 Whitehead, M. ‘The Health Divide” in Townsend, P., Whitehead, M., and Davidson, N. “Inequalities in Health: New Edition”, London, Penguin, 1992.

2 Gunning-Schepers, L. “A policy response to socioeconomic differentials in health”. Paper presented to EC workshop on “Socioeconomic factors in health and health care”, Lisbon, 23-25 May, 1991.

3 OPCS “Mortality statistics: perinatal and infant mortality: social and biological factors, 1990”, London, HMSO, 1992.

4 Robine, J.M. and Ritchie, K. “Healthy life expectancy: evaluation of a global indicator of change in population health”, British Medical Journal, 1992, 302, 457-60.

5 OPCS “General Household Survey for 1989”, No. 20, London HMSO, 1991.

6 Blaxter, M. “Health and Lifestyles”, London, Tavistock/Routledge, 1990.

7 Wnuk-Lipinski, E. and Illsley, R. (eds) “Social equity in health in non-market economies”, Social Science and Medicine, 1990, 31, 833-889.

8 World Health Organisation “Health for All Statistical Database”, September 1991 edition, Copenhagen, WHO Regional Office for Europe.

9 Hart J.T. “The Inverse Care Law”, Lancet, 1971, i, 405-12.

10 Whitehead, M. ‘The concepts and principles of equity in health”, Copenhagen, World Health Organisation, 1990.

11 Dahlgren, G. and Whitehead, M. “Policies and strategies to promote equity and health”, Copenhagen, World Health Organisation, 1992.