Who owns health inequalities?

Author(s)/Editor(s): Nathanson CA
Publisher/Organizer: The Lancet
Publication date: Volume 375, Issue 9711, 23 January 2010
Language: English


"Health inequalities are old news—very old news. John Graunt's analysis of the English Bills of Mortality, statistically documenting the fact of inequality in death, was published in the mid-17th century. Beginning early in the 19th century, death rates by occupation compiled by the Registrar General's Office in London left no doubt that those in the bottom ranks died at substantially higher rates than those at the top. At much the same time, French scholars concluded that the condition most closely associated with an early death was poverty, basing their findings on a series of remarkable studies published in the first public health journal, Annales d'hygiène publique.

The facts of inequality in disease and death were well known before the beginning of the 20th century. Their perennial rediscovery in the years since has little to do with lack of knowledge and much to do with heated (and value-laden) disagreement among scholars, bureaucrats, and politicians about why inequalities exist, what should be done about them, and who should do it.”

“Are health “inequalities” a problem of the poor (and thus soluble by changing poor people's circumstances or behaviour) or are they an effect of rigid patterns of social stratification (requiring that resources be redistributed)? Are they “voluntary”—the result of bad choices (“booze and fags”)—or “involuntary”—the consequence of oppressive social structures? Should inequalities be framed as “disparities”—mere differences that may or may not be the result of human action—or as unacceptable “inequities”?

And finally, who “owns” health inequalities? Are they—as in the 19th century—a public health problem or are they a medical care problem? Are they a private problem or a public problem? These are not logical or empirical questions. They are political questions. How they are answered will depend on the policy preferences of those in power, or who aspire to power. I illustrate these points with the examples of the UK and the USA, countries at the extremes of public policy in this domain.”