Black, Thatcher and Blair – reflections on health inequalities and hypocrisy

Alex Scott-Samuel (Joint Chair, Politics of Health Group)

‘Inequality is not inevitable!’ was my concluding assertion in a 1986 Lancet review of action around health inequalities since the Black report. I wasn’t just hoping to raise the spirits of chronic sufferers from hegemonic Thatcherism: I was actually referring to an Israeli study demonstrating associations between the egalitarian social organisation of kibbutzim and reduced gender differences in members’ life expectancy.

At that time, such optimism might have seemed justified: despite Thatcher’s continuing inhuman excesses, Labour-led local authorities were busy producing ‘local Black reports’ and the recently-released World Health Organisation European Health for All strategy was explicitly prioritising equity and the social determinants of health. And the Labour Party was getting the message: shadow health secretary Michael Meacher had set up a series of advisory groups, whose progressive proposals led to commitments in Labour’s 1987 Health for All Charter to eliminating the sources of health inequalities through healthy public policies.

Seven years earlier I had been one of the enthusiasts who, having waited four months for health secretary Patrick Jenkin to finally release the Black report over the August Bank Holiday, had sent my cheque to the DHSS Policy and Planning Unit and obtained one of the 260 typescripts which represented the initial publication run. The Guardian reported at the time that ‘some of its authors are very unhappy about its treatment at the hands of the department. They feel that they have to try to find some other way of making it available – if a publisher can be interested. Whether the DHSS would agree is not clear’. Inspired by this, I took the law into my own hands and reproduced pages 355-369 – the summary and recommendations – together with Patrick Jenkin’s dismissive introduction, in the Autumn edition of the journal Radical Community Medicine.

Aside from the government and government-controlled institutions like the National Health Service (NHS), there was widespread enthusiasm in the health community for the analysis of the Black report and for its reformist and redistributive prescriptions. The publication in 1987 of Margaret Whitehead’s successor report The Health Divide added to the momentum. And after the fall of Margaret Thatcher, the acknowledgement of health inequalities by the Major government – albeit in the restricted form of NHS responses to health ‘variations’ – drip-fed the health community’s optimism.

In the first two years of New Labour government, this optimism was further encouraged. The Our Healthier Nation Green Paper recognised a socio-environmental model of health, and emphatic rhetorical commitments to tackling health inequalities appeared to be reflected in a range of multisectoral policy developments. But by the turn of the century Labour’s embarrassingly evident deference to the market increasingly contradicted the rhetoric on challenging inequality. Traditional Labour commitments to the public nature of the public sector were replaced by enforced use of private finance and insistence on widespread contracting out to private sector services. Even the NHS succumbed as Blair and his like-minded health secretaries Milburn and Reid went far beyond Thatcher in handing out public money to private sector health care providers from a wide range of countries. Sickeningly, this NHS privatisation was badged as ‘promoting equity’ through the ’empowerment’ created by offering patients a choice of treatment locations. Blair even imported an academic inequalities expert into 10 Downing Street as his health policy adviser.

Perhaps the clearest indication of the emptiness of New Labour’s continuing rhetoric on health inequalities is the absence of any suggestion that these inequalities are decreasing. If this is ever to happen, we will require action that addresses the ‘upstream’ root causes of health inequality rather than the downstream diseases (and their proximal determinants) which merely represent its current face. 100 years ago we had the same health inequalities between rich and poor – though their face then was that of infectious diseases and their immediate precursors.

Eliminating health inequalities requires us to voyage upstream from diseases and their immediate context, to deal with their real causes – the gendered, power-driven economic and social inequalities which are an intrinsic feature of the neoliberal ideology with which we are indoctrinated. I cannot do better than to end with the words of John Hewetson, anarchist GP and author of the original Black report – Ill-health, Poverty and the State – which he wrote while in prison as a conscientious objector during World War 2 and which was published by Freedom Press after his release in 1946. ‘The achievement of full health demands a radical change in our economic system. It requires nothing short of the abolition of poverty, the placing of production on a basis of needs…Full health is a mirage until profit economy is swept away. But it will be easily realised when the means of life are freely available to all.’

Politics of Health Group