Black Report Introduction: Inequalities and Health

1. In its published reports the Department of Health has frequently expressed concern with Britain’s failure to match the improvement in health observed in some other countries and has acknowledged the relationship of this to persistent internal inequalities of health (for example, Prevention and Health Everybody’s Business, 1976 especially Chapters 1 and 4). In a speech on 27 March 1977 the then Secretary of State for Social Services stated:

“….. The crude differences in mortality rates between the various social classes are worrying. To take the extreme example, in 1971 the death rate for adult men in social class V (unskilled workers) was nearly twice that of adult men in social class I (professional workers) even when account has been taken of the different age structure of the 2 classes. When you look at death rates for specific diseases the gap is even wider. For examples for tuberculosis the death rate in social class V is 10 times that for social class I; for bronchitis it was 5 times as high and for lung cancer and stomach cancer 3 times as high. Social class differences in mortality begin at birth. In 1971 neo-natal death rates – deaths within the first month of life – were twice as high for the children of fathers in social class V as they were in social class I. Death rates for the post-neo-natal period – from one month up to one year – were nearly 5 times higher in social class V than in social class I … The first step towards remedial action is to put together what is already known about the problem … it is a major challenge for the next 10 or more years to try to narrow the gap in health standards between different social classes.”

2. In his Galton lecture in 1975, Sir John Brotherston had voiced the concern felt by many of those working in the health services (Brotherston 1976):

“For the most part the evidence suggests that the gaps remain as wide apart as a generation ago and in some instances the gaps may be widening.”

This was a source of perplexity and disappointment to those who “believe in the NHS as a means of bringing improved health and more equal opportunities for health within our communities”.

3. In April 1977 at the then Secretary of State’s request the Department’s Chief Scientist appointed a Working Group with the following broad objectives:

i. To assemble available information about the differences in health status among the social classes and about factors which might contribute to these, including relevant data from other industrial countries;

ii. To analyse this material in order to identify possible causal relationships, to examine the hypotheses that have been formulated and the testing of them, and to assess the implications for policy; and

iii. to suggest what further research should be initiated.

4. The membership of the Working Group was:

Sir Douglas Black (Chairman) – Chief Scientist at the DHSS (to April 1978) and President of the Royal College of Physicians;

Professor J N Morris Professor of Community Health in the University of London at the London School of Hygiene and Tropical Medicine;

Dr Cyril Smith – Secretary of the Social Science Research Council;

Professor Peter Townsend – Professor of Sociology at the University of Essex.

Dr Stuart Blume was Scientific Secretary to the Group, and the Administrative Secretary was Mr A J Forsdick. Dr Nicky Hart was seconded by the University of Essex to act as Research Fellow to the Group. Sir Douglas Black and Dr Cyril Smith wish respectively to emphasize that the views expressed in the Report are not necessarily those of the Royal College of Physicians or of the Social Science Research Council.

5. The Working Group has sought to assemble the national and international evidence and to draw some of the implications for policy within the health services and outside them. The problem of inequalities in health, it believes, lies at the heart of the problem of better integrating British society. The latest evidence shows a markedly higher proportion of the poorer than the richer socio-economic groups among both males and females reporting chronic ill-health (General Household Survey for 1977, pp-90 and 94). The poorer health experience of the lower occupational groups applies at all stages of life. If the mortality rates of class I (professional workers and members of their families) had applied to classes IV and V (partly skilled and unskilled manual workers and members of their families) during 1970-72 (the dates of the latest review of mortality experience) 74,000 lives of people aged under 75 would not have been lost. This estimate includes nearly 10,000 children, and 32,000 men aged 15-64 (Appendix 4).

6. The following Report falls broadly into 3 parts. The first 5 chapters consider the problems of defining and measuring inequalities of health, and look in turn at the social structure of health, trends in inequalities of health, problems of utilisation of health services, and the international evidence. There follows a review of approaches to the explanation of social inequalities of health. Chapter 7 reviews the implications for future research and information. The recommendations for policy are developed in 2 chapters: Chapter 8 dealing with health and associated services, and Chapter 9 with some other key aspects of social policy.

7. In developing recommendations for the health services the Working Group benefitted from visits paid to 2 areas with the highest mortality in England and Wales. We wish to express our gratitude for information and the facilities furnished for study in the Area Health Authorities of the City and East London (which includes Tower Hamlets), and Gateshead. We would also wish to express our thanks to staff of the DHSS, and of the OPCS in particular, for providing information.

8. Achieving a high standard of health among all its people represents one of the highest of society’s aspirations. Present social inequalities in health in a country with substantial resources like Britain are unacceptable, and deserve so to be declared by every section of public opinion. Socially and educationally we must encourage a broader understanding of the meaning of health and of the means of its achievement. This will include improvement in incomes as well as better housing and environmental and working conditions. Health services represent only a part, though a significant Part, of the task. Echoing the 19th century pioneers of social medicine Henry Sigerist in his book Civilisation and Disease pointed out the need in highly industrialised countries for a balance between social and economic policies, and health service policies, in achieving high health standards’.

“Poverty remains the chief cause of disease, and it is a factor which is beyond the immediate control of medicine.”

But he pointed out the simultaneous importance of making medical services more effective and added, “Medical science is wasted unless it can be applied without reservations We need a system of health services that reaches everybody, healthy and sick, rich and poor, and there is no reason why we should not be able to establish such a system” (Sigerist, 1943, pp 239-40). That aim also lay behind the discussions during the Second World War of the reorganisation of health services and became the central motivation in the establishment of the National Health Service. More than 30 years later it is necessary to evaluate progress towards that aim and understand why the obstacles to achieving it still persist. This report is intended to make some contribution to such an understanding. We have no doubt that greater equality of health must remain one of our foremost national objectives and that in the last 2 decades of the twentieth century a new attack upon the forces of inequality has regrettably become necessary and now needs to be concerted.



[The Socialist Health Association (SHA) regularly posts articles on its independent blog about the social determinants of health. Except where explicitly stated, these articles should not be taken as official statements of policy on such matters. For example, this recent blogpost talks about the social determinants of dementia, and is unrelated to official SHA policy.]