HEALTH ECONOMICS

Health Econ. 9: 569–570 (2000)

HEALTH INEQUALITIES

HEALTH INEQUALITIES: BRINGING THEHIDDEN ASSUMPTIONS INTO THE OPEN

RUDOLF KLEIN*King’s Fund, London, UK

Imagine that Ministers, under pressure to dosomething about health inequalities, are given achoice between two policy options. Option A is toset a target for a reduction in global health in-equality, as measured by the ratio of standardizedmortality ratios (SMRs) between social classes 1and 2 and social classes 4 and 5, or one of theother similar indicators used in the Acheson report[1] and much of the literature. Option B is to settargets for improvements in the health of specificgroups of the population at risk for specific condi-tions. Clearly, they should choose option B. Thereasons why this should be so will become clear asI unwrap some of the highly questionable assump-tions that shape much of the inequalities debate.

The first assumption is that identifying differ-ences in health status between social classes isanalytically useful and helpful as a guide to policymaking. It is neither. As Illsley [2] has argued,social class is a rubber tin-opener—particularlywhen used to identify trends over time. Not onlyhas the proportion of the population in differentsocial classes changed over time: social classes 1and 2 have expanded while social classes 4 and 5have shrunk. But, so, too, have the methods usedto allocate people to them: successive adaptationsof the system of classification means, in the wordsof an Economic and Social Research Council(ESRC) review [3], that we are using ‘a constantlychanging measuring rod’. Most important of all,perhaps, social class based on occupational statusis a hold-all concept: an attempt to capture avariety of dimensions—patterns of expenditureand consumption, social relations, educationetc.—in one single category. It therefore tends to

blur rather than to reveal the role of any of thesefactors in influencing health status.

The second assumption is that demonstratingdifferences in health status between any socialgroups (whether categorized by social class or not)automatically sets up a presumption that this callsfor public intervention, as distinct from being apiece of useful diagnostic information. Inequalityis used as a synonym for inequity. But this, surely,is over-simple. If differences in health status arethe result of individuals making autonomouschoices—for example, by smoking or refusing totake exercise—then it is difficult to argue that thiscan be described as inequitable [4]. To the extentthat society has to pick up the costs of suchchoices, there may still be a case for trying tochange the behaviour of those individuals, but itcannot be argued on equity grounds.

To make this point is, however, to open up astill more complex question, all the more impor-tant given that the burden of ill-health and prema-ture mortality has shifted from the diseases ofpoverty to those related to individual behaviour[2]. How socially determined is individual be-haviour? Here the dominant structural theories,which inform the Acheson report and much else,tend to slide imperceptibly into a form of deter-minism which appears to leave little scope forwhat used to be known as free will and is nowfashionably known as ‘agency’ [5]. The assump-tion is that a particular set of constraints—whether it is low income, poor social support orlack of employment—dictate patterns of be-haviour. They certainly influence, but do theydictate?

* Correspondence to: King’s Fund, 11–13 Cavendish Square, London, W1M 0AN, UK.

Copyright © 2000 John Wiley & Sons, Ltd.

R. KLEIN570

Consider the case of smoking. Over the pastfew decades, rates of smoking, as is well known,have been falling faster in social classes 1 and 2than in social classes 4 and 5 (which, in itself,would lead one to expect differences in mortalityand morbidity between them to be maintained ifnot to increase). But a majority of social classes 4and 5 do not smoke. This leads to two conclu-sions. The first is to reiterate that social class is apoor analytical tool, because it is too broad andheterogeneous, The second is to suggest that so-cial scientists and epidemiologists should paymore attention to variations within groups in or-der to identify why members, apparently exposedto the same constraints and pressures, behave indifferent ways.

The third assumption is that reducing inequali-ties in health—because they are inequitable andbecause they are evidence of people being denieda basic good that is essential for making the mostof their capacities—should have priority overother goals of policy. Implicitly, the assumption isthat minimizing inequality trumps maximizinghealth. That the two goals of policy may conflictis clear [6,7]. Again, the case of smoking illus-trates the point. Given that anti-smoking cam-paigns appear to affect the behaviour of socialclasses 1 and 2 more than that of social classes 4and 5, one way of reducing the differences be-tween them would be to abandon the attempt.Inequalities would probably diminish; so, too,would the rate of improvements in the popula-tion’s health. If, irrespective of social position orincome, everyone’s life expectancy fell to 70 years,this would be a triumph for equality. It wouldalso, however, be a social disaster. Given limitedresources—and given, also, that it may be moreexpensive to buy an extra life year for someone atthe bottom of the social scale than for someone atthe top—policy makers have to choose betweenthe two competing goals.

The last assumption that needs to be unravelledis that inequalities in health set up some specialclaims on society: a point related to, but notidentical with, the assumption (see above) thatdifferences have prescriptive force as well as diag-nostic utility. In effect, health inequalities are

often used as a kind of battering ram for widersocial reforms or, indeed, as an argument forchanging the very nature of society. In its extremeform, the structuralist–determinist view leads tothe conclusion that it is the very nature of capital-ist society—with its distribution of income andorganization of work—which must be changed ifhealth inequalities are to be eliminated. Given thestarting premise, this is certainly a logical view—though the evidence on which it is based is farfrom conclusive. It is also a mischievous view inso far as the quest for utopia may distract us fromuseful, incremental micro-interventions. Most ofthe changes sought by the inequality lobby (forsuch it is) are desirable in themselves. Eliminatingpoverty, strengthening the education system andimproving the environment in which people liveare all desirable aims in a civilized society. Theyshould be advocated and pursued in their ownright, irrespective of their impact on health—letalone inequalities in health. For, just maybe,health is like happiness: the by-product of pursu-ing other ends.

REFERENCES

1. Acheson D (chairman). Independent Inquiry into In-equalities in Health: Report. The Stationery Office:London, 1999.

2. Illsley D, Baker D. Inequalities in health: adaptingthe theory to fit the facts. Bath Social Policy PaperNo. 26. Centre for the Analysis of Social Policy,University of Bath: Bath, 1997.

3. Rose D. ESRC Re6iew of OPCS Social Classifica-tions. Office of Population Censuses and Surveys:London, 1995.

4. Le Grand J. Equity and Choice. HarperCollins: Lon-don, 1991.

5. Deacon A, Mann K. Agency, modernity and socialpolicy. J Soc Policy 1999; 28: 413–435.

6. Klein R. Acceptable inequalities. In Acceptable In-equalities? IEA Health Unit Paper No. 3, Green D(ed.). Institute of Economic Affairs Health Unit:London, 1988.

7. Culyer AJ. Inequality in health services is in general,desirable. In Acceptable Inequalities? IEA HealthUnit Paper No. 3, Green D (ed.). Institute of Eco-nomic Affairs Health Unit: London, 1988.

Copyright © 2000 John Wiley & Sons, Ltd. Health Econ. 9: 569–570 (2000)