THE PERSISTENCE OF HEALTH INEQUALITIES IN MODERN WELFARE STATES

The explanation of a paradox

Prof. Dr Johan P. Mackenbach

Department of Public Health

Erasmus MC, University Medical Center Rotterdam

P.O. Box 2040

3000 CA Rotterdam

Netherlands

E j.mackenbach@erasmusmc.nl

T +31107038460

5743 words in main text

Acknowledgement: The author would like to thank Dr Mauricio Avendano, Dr Terje Eikemo

and Dr Frank van Lenthe for their comments on a previous version of this paper. The valuable

comments of the anonymous reviewers have also helped to further improve this paper and

clarify its reasoning.

This paper has been published as: Mackenbach JP. The persistence of health inequalities in

modern welfare states: The explanation of a paradox. Social Science and Medicine

2012;75:761-769.

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ABSTRACT

The persistence of socioeconomic inequalities in health, even in the highly developed

‘welfare states’ of Western Europe, is one of the great disappointments of public health.

Health inequalities have not only persisted while welfare states were being built up, but on

some measures have even widened, and are not smaller in European countries with more

generous welfare arrangements. This paper attempts to identify potential explanations of

this paradox, by reviewing nine modern ‘theories’ of the explanation of health inequalities.

The theories reviewed are: mathematical artifact, fundamental causes, life course

perspective, social selection, personal characteristics, neo-materialism, psychosocial factors,

diffusion of innovations, and cultural capital.

Based on these theories it is hypothesized that three circumstances may help to

explain the persistence of health inequalities despite attenuation of inequalities in material

conditions by the welfare state: (1) inequalities in access to material and immaterial

resources have not been eliminated by the welfare state, and are still substantial; (2) due to

greater intergenerational mobility, the composition of lower socioeconomic groups has

become more homogeneous with regard to personal characteristics associated with ill-

health; and (3) due to a change in epidemiological regime, in which consumption behavior

became the most important determinant of ill-health, the marginal benefits of the

immaterial resources to which a higher social position gives access have increased.

Further research is necessary to test these hypotheses. If they are correct, the

persistence of health inequalities in modern European welfare states can partly be seen as a

failure of these welfare states to implement more radical redistribution measures, and partly

as a form of ‘bad luck’ related to concurrent developments which have changed the

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composition of socioeconomic groups and made health inequalities more sensitive to

immaterial factors. It is argued that normative evaluations of health inequalities should take

these explanations into account, and that a direct attack on the personal, psychosocial and

cultural determinants of health inequalities may be necessary to achieve a substantial

reduction of health inequalities.

Key contributions to knowledge

1. The persistence of health inequalities in modern welfare states is difficult to explain.

2. We hypothesize that it is partly due to persisting inequalities in access to material and

immaterial resources.

3. We hypothesize that it is partly due to greater intergenerational social mobility and

stronger selection.

4. We hypothesize that it is partly due to consumption behavior becoming the most

important determinant of ill-health.

5. Tackling the personal, psychosocial and cultural determinants of health inequalities may

be needed to reduce health inequalities in modern welfare states.

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INTRODUCTION

The persistence of socioeconomic inequalities in health is one of the great disappointments

of public health. All countries, including those ranking high on indices of economic prosperity

and human development, have systematic inequalities in mortality and morbidity between

citizens with a higher and a lower socioeconomic position, as indicated by education,

occupation, income or wealth. These health inequalities are often substantial, and usually

amount to between 5 and 10 years difference in average life expectancy at birth, and

between 10 and 20 years difference in disability-free life expectancy (Commission on Social

Determinants of Health 2008, Mackenbach et al., 2008, Sihvonen et al., 1998).

This also applies to the highly developed ‘welfare states’ of Western Europe. All

Western European countries have created extensive arrangements aiming to reduce

socioeconomic inequality and its various consequences. With notable variations all these

‘welfare regimes’ include measures to redistribute income (e.g. by progressive taxation and

social security) and a range of collectively financed provisions (e.g. public housing, education,

health care, access to culture and leisure facilities) (Esping-Andersen, 1990, Ferrara, 1996).

There is good evidence that welfare policies have contributed to a reduction of

inequalities in income, housing quality, health care access and other social and economic

outcomes (Esping-Andersen, 1990, Kautto et al., 2001), but they have apparently been

insufficient to eliminate health inequalities. Long-term time-series of health inequalities

spanning the whole of the 20th century are rare, but English data suggest that while

inequalities in mortality have narrowed until 1950 they have since then substantially

widened (figure 1) (Pamuk, 1985, Wilkinson, 1989). If we take 1920-1980 to be the period in

which European welfare states (including the British welfare state) were being built up, any

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narrowing effect on inequalities in mortality must have occurred in its early stages. The

widening of mortality inequalities has continued into the 21st century, not only in Britain (Fair

Society, Healthy Lives 2010) but also in other countries with available data. During the last

three or four decades, a widening of inequalities in mortality, on a relative and sometimes

also on an absolute scale, has been reported for many Western European countries

(Mackenbach et al., 2003, Strand et al.,2010, Fawcett et al., 2005, Valkonen et al., 2000). This

widening started well before the welfare reforms (with cutbacks in provisions and

entitlements) of the 1990s (Wilkinson, 1989, Strand et al., 2010, Fawcett et al., 2005,

Valkonen et al., 2000).

This paradoxical situation is made even more puzzling by the lack of association

between the extent or intensity of welfare policies in a country on the one hand, and the

magnitude of its health inequalities on the other hand. Comparative studies have found that

socioeconomic inequalities in mortality and morbidity are not smaller in countries with

relatively universal and generous welfare policies (e.g. the Nordic countries) than they are in

other countries (e.g. the United Kingdom with its more liberal welfare regime, or Southern

European countries with their more family-based welfare arrangements). This was first

observed for the 1980s (Mackenbach et al., 1997) and then confirmed for the 1990s

(Mackenbach et al., 2008) and 2000s (Eikemo et al., 2008a, Eikemo et al., 2008b), and applies

both to relative and absolute measures of health inequalities. Recent reviews have

concluded that the association between welfare regimes and health inequalities is

inconsistent (Beckfield & Krieger, 2009, Muntaner et al., 2011).

Table 1 illustrates this for absolute inequalities in mortality in a sample of Western

European countries. Within Western Europe, both relative and absolute inequalities in total

mortality tend to be smallest in the South, e.g. in the regions of Turin and Madrid. This is

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primarily due to small inequalities in mortality from cardiovascular disease (among men and

women) and cancer (among women) (Mackenbach et al., 2008). In the North of Europe,

Sweden tends to have relatively small inequalities in mortality, but Norway’s inequalities in

mortality are considerably larger than those seen in the South or in England/Wales, partly

because of large inequalities in smoking-related causes of death (Mackenbach et al., 2008,

van der Heyden et al., 2009).

In this paper I will explore the explanation of this paradox. What explains the

persistence and even widening of socioeconomic inequalities in health in the highly

developed welfare states of Western Europe, and the lack of association between

generousness of welfare policies and the magnitude of health inequalities? Although this

question has been discussed before (Dahl et al., 2006, Eikemo & Huijts, 2009, Hurrelmann et

al., 2011, Bambra 2011), clear hypotheses have not emerged. I will review current scientific

theories on health inequalities, and evaluate what elements they could contribute to an

explanation of the paradox. My approach resembles that in Bambra (2011), but while the

latter study’s main conclusion is that “[existing] theories provide little insight into the issue”

and that this “public health puzzle highlights the limitations of existing theories”, I will argue

that some of these theories do suggest plausible hypotheses on the explanation of the

paradox. I will also review a wider range of potentially relevant theories. The conclusions of

the analysis will then be used to discuss some policy implications, starting with the question

what these explanations would imply for the normative evaluation of health inequalities in

modern welfare states. The main purpose of this paper is to generate hypotheses, and to

provide a starting point for further scientific discussion.

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CURRENT THEORIES AND HOW THEY MAY HELP TO EXPLAIN THE PARADOX

The three components of social stratification

Socioeconomic inequalities in health ultimately derive from social inequality, and an analysis

of why health inequalities persist therefore should be based on an understanding of social

stratification. According to general sociological theory, systems of social stratification are

made up of three components, each of which can vary between societies and over time: (1)

mobility mechanisms that “sort” individuals into social strata, (2) allocation rules that

distribute resources to social strata, and (3) social processes that render some resources

more valuable than others (Grusky, 2010).

This distinction in three components can also be used to identify the general

mechanisms underlying health inequalities. The magnitude of health inequalities in a society

will then be a function of: (1) social mobility, and the resulting differences between social

strata in personal characteristics of their individual members, (2) resource distribution, and

the resulting differences between social strata in access to material and immaterial

resources, and (3) resource benefits, i.e. the value of the resources for the avoidance of

health problems which are prevalent in that society. Variations over time or between

countries in any of these factors may give rise to variations in the magnitude of health

inequalities.

Over the last two decades, the persistence and widening of health inequalities in

Western Europe, despite advances in material well-being and welfare policies, has given rise

to a rich body of empirically grounded literature. Box 1 gives an overview of nine ‘theories’ of

the explanation of health inequalities which are potentially relevant for the explanation of

the paradox. Not all of these ‘theories’ may fully deserve this label – the notion of

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‘mathematical artifact’ is a rather narrow account only, and the ‘life course perspective’

could perhaps better be labeled a broad conceptual scheme – but for convenience we will

consistently use the term ‘theory’ to refer to each of them. None of these theories was

developed to explain the paradox that is central to this analysis, but I will assess them for

their usefulness in explaining the paradox, by deriving hypotheses that are compatible with

the observations of persisting and even widening health inequalities, also in highly

developed welfare states. Please note that I do not intend to provide a general assessment of

the validity of these theories. None of these theories is mutually exclusive, and they may

therefore operate simultaneously and reinforce each other. With the exception of three very

general theories (‘mathematical artifact’, ‘fundamental causes’, and ‘life course perspective’)

each relates to one of the three components of health stratification mentioned above.

It is important to note that, in order for a theory to contribute to the explanation of

the paradox, the strength of the proposed mechanism or pathway must have become larger

over time, and/or be larger in countries with more extensive welfare arrangements. As

modern European welfare states have to some extent been successful in reducing

inequalities in access to material resources, one or more of the other components must have

counteracted that beneficial effect.

Three general theories

The theory of ‘mathematical artifact’ suggests that increasing relative inequalities in health

outcomes are inevitable when the overall level of the outcome falls (Scanlan, 2001, Scanlan,

2006, Vagerö & Erikson, 1997). In intuitive terms, the idea is that when the background risk

of mortality or morbidity is lower (as it tends to be in more recent time-periods, and in more

advanced welfare states), it is ‘easier’ for determinants to produce a high relative risk (even

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though the absolute risk difference declines). There is indeed an association between the

average frequency of health problems in a population and the level of the relative risk for

socioeconomic status: relative risks for mortality and morbidity tend to be higher when

average mortality and morbidity are lower (Eikemo et al., 2009). However, it has been shown

that larger inequalities are not a mathematical necessity when over-all health improves

(Houweling et al., 2007), and an association between average frequency and relative risk

does not prove causality. Furthermore, absolute inequalities in mortality have also increased

in several countries (Mackenbach et al., 2003, Strand et al., 2010, Valkonen et al., 2000), and

their pattern of between-country variation is largely similar to that of relative inequalities in

mortality (Mackenbach et al., 2008), so that it is difficult to see how this theory could explain

the paradox.

The theory of ‘fundamental causes’ stipulates that it is the social forces underlying

social stratification which ultimately cause health inequalities, and not exposure to the

proximal risk factors which are usually studied by social epidemiologists (like smoking,

psychosocial stress, working conditions, …). According to this theory, the persistence of

health inequalities in different time-periods and different national conditions is due to the

fact that a person’s socioeconomic status provides him or her with “flexible resources”. These

include “knowledge, money, power, prestige, and beneficial social connections” which can be

used “to avoid disease risks or to minimize the consequences of disease once it occurs”

regardless of the prevailing circumstances. The association between socioeconomic status

and health “is reproduced over time via the replacement of intervening mechanisms”, and as

opportunities for avoiding disease continue to expand so will health inequalities continue to

exist (Link & Phelan, 1995, Phelan et al., 2010, Phelan et al., 2004). This theory is an elegant

reformulation of the problem, and the paradox may actually be seen as an example of the

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workings of this theory. But it does not provide a specific explanation of the paradox. What

are the new “intervening mechanisms” which replace the mechanisms eliminated or

attenuated by the welfare state? Or are health inequalities perhaps “reproduced” in highly

developed welfare states because people with higher socioeconomic status make better use

of these welfare resources? We thus need other theories to provide more specific

explanations.

The ‘life course perspective’ is another useful and increasingly popular approach to

the explanation of health inequalities, and is based on the observation that health at adult

ages is partly determined by experiences in early life, both biological and social. ‘Biological

programming’ of the fetus has been hypothesized to increase vulnerability to chronic

diseases like diabetes and cardiovascular disease (Barker et al., 1989), and unfavorable social

and health conditions in childhood may be the starting-points of pathways leading into both

health and social disadvantage in adulthood (Wadsworth, 1997). Some of these processes

have been shown to extend over several generations (Modin & Fritzell, 2009). While this may

explain a long delay between exposure to modern welfare arrangements and a reduction of

health inequalities among adults, it does not explain the fact that even among generations

who were born during the welfare state there is no association between welfare policies and

the magnitude of health inequalities (Bambra et al., 2010). Furthermore, long delays are not

inevitable as both mortality and morbidity often respond quickly and dramatically to

changing social conditions (Vaupel et al., 2003). In any case, as with ‘fundamental causes’

more specific explanations will be needed.

Two theories focusing on social mobility and the composition of social strata

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The theory of ‘social selection’ suggests that health inequalities result from health-related

selection during social mobility. Health problems may lead to downward social mobility

(thereby creating ‘direct health selection’) (Inequalities in Health, 1982), and upward

mobility is more likely for those with personal characteristics conducive to good health

(thereby creating ‘indirect health selection’) (West, 1991). Direct health selection is

equivalent with reverse causality (health problems leading to low socioeconomic status,

instead of vice versa), while indirect health selection can also be thought of as confounding

(by third factors which influence both health and socioeconomic status). This theory would

help to explain the paradox if social mobility has increased over time, or if social mobility has

become more selective with regard to health-relevant characteristics, particularly in

countries with generous welfare arrangements.

Intergenerational social mobility has increased slowly but systematically in all high

income countries since the Second World War, both with regard to educational achievement

and occupational class (Heath, 1981, Ganzeboom, 2007, Ganzeboom et al., 1989, Breen,

2004, Raad voor Maatschappelijke Ontwikkeling, 2011). International-comparative studies

have not found consistent differences between countries in rates of intergenerational social

mobility, but countries with well-developed welfare policies such as the Nordic countries

usually also have egalitarian education policies and substantial social mobility (Erikson &

Goldthorpe, 1992). As a result, the scope for both ‘direct’ and ‘indirect health selection’ is

likely to have become larger over time and to be larger in more advanced welfare states.

While mobility reduces the degree of intergenerational transmission of social

(dis)advantage in a society, and therefore may ‘dilute’ the health effects of social

stratification, it also increases opportunities for selection into higher social positions on the

basis of personal characteristics, such as cognitive ability and personality profiles. To a

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certain degree modern societies have become ‘meritocracies’, in which educational and

occupational achievement are no longer dependent on family background but on personal

talent and effort (Arrow, 2000). To the extent that these personal characteristics are

important for health, e.g. because they determine health-related behaviour, inequalities in

health could have increased as a result.

A number of studies has shown that cognitive ability and the Big Five personality

traits statistically explain part of the gap in health between socioeconomic groups (Batty et

al., 2006, Hart et al., 2004, Judge et al., 1999, Nabi et al., 2008). Socioeconomic inequalities

in these personal characteristics may partly arise from differences in early environment,

because the comparatively harsh living conditions of families of low socioeconomic status

increase family stress and hamper family investments in children, which could harm their

personality and cognitive ability (Mackenbach, 2010), partly from selection during social

mobility. While inequalities in early environment are likely to have become smaller over time,

and to be smaller in countries with more extensive welfare arrangements, opportunities for

social selection on the basis of these personal characteristics may well have become larger as

noted above.

Two theories focusing on the distribution of specific resources

The ‘neo-materialist theory’ emphasizes the fact that despite increases in average prosperity

and some redistribution inequalities in access to material resources are still universal, and

still generate health inequalities (Lynch et al., 2000, Davey Smith et al., 1994). There is indeed

no doubt that inequalities in material advantage are still substantial everywhere, even in

countries with relatively small income inequalities (Luxembourg Income Study, 2011). The

welfare state, and its redistribution of lifetime welfare through taxation, cash transfers and

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non-cash benefits, does attenuate material inequalities, but what remains is still substantial

(Ter Rele, 2007). Over the past decades, even ‘diseases of affluence’ have become associated

with material disadvantage, because the latter partly determines health-related behaviours,

such as leisure-time physical exercise, diet etc. (Van Oort et al., 2005).

However, while this theory may provide a plausible explanation for the persistence of

health inequalities, it is unlikely to explain their widening. Over the 20 th century income

inequality has declined in Western European countries, partly as a result of welfare policies,

and the same applies to wealth inequalities (Nolan & Lenski, 2004). It is only since the 1980s

or 1990s that income and wealth inequalities have tended to rise again, partly as a result of

welfare reform, partly as a result of other influences (changes in household composition,

globalization, …) (OECD, 2008). Inequalities in mortality started to rise well before that

(Pamuk, 1985, Strand et al., 2010, Valkonen et al., 2000). Also, within Western Europe there

is no clear association between the magnitude of income inequalities and the magnitude of

socioeconomic inequalities in morbidity or mortality (Mackenbach et al., 1997).

Similarly, the ‘psychosocial theory’, which emphasizes the role of psychosocial stress,

lack of social support, and sense of control (Marmot, 2004, Wilkinson, 2005), cannot

plausibly explain the widening of health inequalities, although the unequal distribution of

these psychosocial factors may contribute to their persistence. Despite the welfare state,

considerable differences in power and prestige have continued to exist. People with a higher

level of education and income have a much stronger sense of control over their own lives,

and this is linked to healthier behaviour, and lower rates of morbidity and mortality (Bosma

et al., 1999). The perception of material inequality, and in particular of one’s own ‘relative

deprivation’, may have a direct effect on a person’s health via psychosocial stress

mechanisms (Wilkinson & Pickett, 2009). The welfare state may have blurred some of the

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inequalities in psychosocial stress, but the middle classes have also benefited from the

welfare state, for example because it has reduced the psychosocial stress of job insecurity

even among the employed (Sjoberg, 2010).

However, in order to explain the widening of health inequalities one would have to

assume that inequalities in exposure to psychosocial risk factors have increased over time,

and this is unlikely, if only because material hardship in lower socioeconomic groups must

have been a powerful source of psychosocial stress in the past. It has sometimes been

argued that advanced welfare states may raise unrealistic expectations of a better life among

people with a lower socioeconomic position, and therefore induce higher levels of frustration

and stress (Dahl et al., 2006, Wilkinson & Pickett, 2009), but this is largely speculative.

Two theories focusing on the value of resources for health gain

Studies of the ‘diffusion of innovations’ have observed that people with a higher

socioeconomic position often tend to be early adopters of new behaviors, only later to be

followed by those with a lower social position (Rogers, 1962). This theory provides a

plausible explanation for a (temporary) widening of health inequalities when major

improvements in population health occur that are mediated by behavior change. Many

Western European countries, particularly those in the North and West, have entered a new

phase of the epidemiological transition, in which the ‘diseases of affluence’ (cardiovascular

disease, some cancers, injuries, …) which dominated the third stage are rapidly being pushed

back (Omran, 1971, Olshansky & Ault, 1986). This is partly the result of health care

interventions, partly the result of behavior change, such as quitting smoking and adopting a

more healthy diet (Goldman & Cook, 1984, Capewell et al., 1999). As predicted by this

theory, these behavior changes tend to follow a trajectory through populations in which

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those with a higher social position adopt the new behavior first (Lopez et al., 1994, Sobal &

stunkard, 1989). As a result, this dynamic phase is characterized by large and widening

inequalities in health behaviors, which in their turn lead to large and widening inequalities in

mortality (Cavelaars et al., 2000, Roskam et al., 2010). Within Western Europe, countries in

the South happen to be in a later stage of this transition, with inequalities in health

behaviors only recently arising and inequalities in ‘diseases of affluence’ still being small

(Mackenbach et al., 2008, van der Heyden et al., 2009, Avendaño et al., 2006).

The ‘inverse equity’ hypothesis, which postulates that “new interventions will initially

reach those of higher socioeconomic status and only later affect the poor [….] which results

in an early increase in inequity ratios” (Victora et al., 2000) is based on a similar line of

reasoning, but focuses on the emergence of inequalities in the use of preventive or curative

health care during periods of rapid health improvement. These inequalities may be due to

differences in both access and uptake, and may explain part of the socioeconomic

inequalities in mortality from conditions which have become amenable to medical

intervention in Western Europe (Stirbu et al., 2010).

It is as if, during the most dynamic phases of health improvement, the marginal

benefits of a higher social position for health temporarily become larger. Economic resources

may play a role: in the early stages of their implementation new interventions are often

expensive, and being rich may temporarily become very important for preserving health. But

in the case of behavior change cultural resources may also play a role. The theory of ‘cultural

capital’ explains inequalities in consumption behaviour from differences in attitude,

knowledge and competency between socioeconomic groups which are transmitted across

generations. These differences partly arise from the need for ‘social distinction’: people in

higher socioeconomic groups behave differently to show off their social position, but doing

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this successfully requires a lot of ‘cultural capital’ (Bourdieu, 1984). It is unlikely that, during

the last decades, inequalities in ‘cultural capital’ have increased, but the need for ‘social

distinction’ on the basis of health-related behaviour may have increased due to the decline in

opportunities to distinguish oneself by outward signs of material prosperity. More

importantly, the relevance of cultural capital for health is likely to have increased with the

rise and subsequent decline of the consumption-related diseases which happen to be

prevalent in highly developed welfare states (Abel, 2008).

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DISCUSSION

Synthesis

Only some of the reviewed theories can provide a plausible and specific explanation for the

persistence and even widening of health inequalities in the advanced welfare states of

Western Europe. The ‘mathematical artifact’, ‘fundamental causes’ and ‘life course’ theories

reframe the problem in different (and potentially useful) terms but do not provide a specific

explanation for the paradox. ‘Neo-materialist’ and ‘psychosocial’ theories help to understand

why health inequalities persist, i.e. because inequalities in access to material and immaterial

resources persist. If modern welfare states would have abolished the economic and social

structures which produce unequal lives, health inequalities would probably have largely

disappeared. But these theories do not explain their widening, or the fact that health

inequalities do not tend to be smaller in countries with more generous welfare policies.

The other four theories hold more promise, and can be used to derive two general

hypotheses on the explanation of the paradox. The first hypothesis is that the lower social

strata have become more exclusively composed of individuals with personal characteristics

which increase the risks of ill-health. This is the result of decades of upward

intergenerational social mobility, which may have increased opportunities for social selection

and may have made the lower social groups more homogeneous with regard to personal

characteristics like low cognitive ability and less favorable personality profiles. The increase

of intergenerational social mobility is primarily due to changes in the economy which have

led to an expansion of higher education, but to the extent that welfare policies have

contributed to making the education system more merit-based, they may paradoxically have

contributed to a widening of health inequalities.

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 The second hypothesis is that advanced welfare states happen to be further in their

epidemiological development, and have now reached the fourth stage of the epidemiological

transition in which health improvement depends to a large extent on behavior change. This

may have increased the importance of immaterial factors like cultural capital (and personal

characteristics like cognitive ability) for health – factors which may be as strongly (cultural

capital) or even more strongly (personal characteristics) socially differentiated than they

were before, because they have largely been left untouched by the welfare state. To the

extent that welfare policies have contributed to making an ‘affluent lifestyle’ widely

affordable, they may again paradoxically have contributed to a widening of health

inequalities.

That inequalities in access to material and immaterial resources have not been

eliminated could be seen as a partial failure of the welfare state: had more radical

redistribution measures been taken, then social inequalities might have been reduced more

effectively, and health inequalities might have declined as well. The welfare state, however,

has never had such revolutionary goals. On the contrary, its rise reflected a compromise

between the interests of employers and employees, between the laboring and the middle

classes, and between the political ideologies representing these interests (Hicks 1999). It

therefore should not come as a surprise that its redistributive effects were modest.

It is also not surprising that the welfare state did not have effective solutions for

widening inequalities in ‘diseases of affluence’. The welfare state’s ‘bad luck’ was that, while

it had been invented to remediate poverty and its consequences, it was soon overtaken by

the rise and subsequent fall of ‘diseases of affluence’, against the social patterning of which

the old arsenal was largely ineffective. One poignant illustration is tobacco control: countries

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which have made stronger tobacco control efforts tend to have larger socioeconomic

inequalities in smoking (Schaap et al., 2008).

As explained in the introduction, the approach followed in this paper was similar to

that in Bambra (2011). The latter paper reviewed six theories: ‘artifact’, ‘health selection’,

‘cultural-behavioural’, ‘materialist’, ‘psychosocial’, ‘life course’. Although they were

sometimes conceptualized differently, these theories roughly correspond with what I have

labeled ‘mathematical artifact’, ‘social selection’, ‘diffusion of innovations’, ‘neo-material

factors’, ‘psychosocial pathways’ and ‘life course’. Bambra did see some value in the ‘cultural-

behavioural’ approach for explaining the ‘puzzle’ or ‘paradox’, but her over-all conclusion was

that these theories “provide little insight”, mainly because most of them “to a greater or

lesser extent expect health inequalities to be smaller in the Scandinavian countries”. The

analysis reported here reviewed three additional theories (‘fundamental causes’, ‘personal

characteristics’, ‘cultural capital’), and comes to rather different conclusions. It articulates

two hypotheses based on, respectively, a combination of the ‘social selection’ and ‘personal

characteristics’ theories, and a combination of the ‘cultural capital’ and ‘diffusion of

innovations’ theories. It also emphasizes the importance of the ‘neo-materialist’ and

‘psychosocial’ theories for understanding why health inequalities persist (because the

welfare state has far from eliminated inequalities in access to material and immaterial

resources).

Limitations

As stated in the introduction, this analysis had a hypothesis-generating character, and does

not pretend to provide final answers. Its limitations include the theoretical nature of the

analysis: although most of the nine ‘theories’ have substantial empirical support, empirical

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analyses that try to explain the persistence and widening of health inequalities in advanced

welfare states from these theories are almost non-existent. I suggest that further research on

the paradoxical relationship between welfare policies and health inequalities should focus on

the specific hypotheses that can be derived from these theories. This will require

considerable efforts in data mining and/or data collection, because internationally and/or

historically comparable data on the composition of social strata or on the social distribution

of immaterial resources are difficult to find. The hypothesis on the changing composition of

social strata can be empirically tested by comparing socioeconomic inequalities in e.g.

personality profiles and cognitive abilities between different birth cohorts. The hypothesis on

the rising importance of immaterial resources can be empirically tested by comparing the

contribution of socioeconomic inequalities in indicators of cultural capital to the explanation

of inequalities in health behavior and health outcomes.

It is likely that further research would also benefit from unpacking welfare regimes

into specific components: some Nordic welfare policies may reduce inequalities in health,

while others are neutral or may even exacerbate them. The same applies to measures of

socioeconomic status. This analysis was limited in the sense that I have used a global concept

of socioeconomic status, ignoring the fact that education, occupational class, income, … have

partly different associations with mortality and morbidity. The various mechanisms which

were reviewed may also have different relevance for each of these indicators of

socioeconomic position: for example, selection effects (reverse causality) are likely to be

more important for income than for education. Further research will benefit from a higher

degree of specificity with regard to the social determinants as well.

Policy implications

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Can health inequalities as they are currently found in Western Europe still be regarded as

‘unfair’, and do widening health inequalities imply that they are becoming more unfair?

These are questions that immediately arise when one considers the hypotheses suggested

above. Contrary to what social epidemiologists usually assume (Commission on Social

Determinants of Health, 2008), that health inequalities are ‘unfair’ is not obvious. Health

inequalities are certainly ‘tragic’ – it is sad that people who have less of everything also tend

to live shorter lives and spend more years in ill-health, and it is disappointing that after all

that has been done to reduce social inequalities and their consequences, health inequalities

have not been eliminated. But because health is not a ‘good’ that lends itself for

redistribution, the unfairness of health inequalities does not automatically follow from their

existence, however tragic this may be. Normative evaluations need to focus on how health

inequalities arise: it is the processes by which, or the circumstances from which they arise

that should be evaluated for their distributive fairness (Whitehead, 1991, Daniels et al., 1999,

Deaton, 2011). The analysis presented in this paper of how health inequalities arise therefore

also raises potentially important normative questions.

If the hypotheses presented in this paper are correct, then current health inequalities

arise from partly different mechanisms as compared to those observed before the rise of the

modern European welfare state, some 50 years ago (with variations between countries).

Nowadays, health inequalities arise in a society with considerable social mobility, and

whether one stays poor when one is born poor may have become partly dependent on

personal characteristics like cognitive ability and personality factors. Some of the involuntary

causes of health inequalities have been taken away by extensive welfare arrangements, and

although patterns of oppression and exploitation can still be distinguished these have to

some extent been softened by democratization and equal rights movements. Health

21
inequalities between social strata partly arise from differences in consumption behaviour,

which may partly be determined by cultural factors and personal characteristics, and not only

by material disadvantage. Health inequalities have recently widened, not necessarily because

of widening inequalities in access to material or even immaterial resources, but possibly also

because of changes in the composition of social strata and because the marginal benefits of a

higher social position are larger in times of rapid epidemiological change.

Even those (like the present author) who believe that current inequalities in income,

status and power are too large to be justified by whatever differences there are between

individuals in merit or effort, and must therefore partly result from subtle and less subtle

forms of exploitation, and who believe that social inequalities in consumption behaviour do

not result from the exercise of free choice but from differences in material and immaterial

living conditions, may ask themselves whether if the hypotheses presented here are correct,

current health inequalities are perhaps less unfair than those observed 50 years ago – even

though they are larger. Can health inequalities that result from differences in composition of

social strata be considered unfair, even if they are a by-product of social policies promoting

equal educational opportunities? Can health inequalities that result from to differences in

immaterial resources (such as cultural capital), which do not directly result from forms of

oppression or exploitation, and which do not easily lend themselves for redistribution

between social strata, be considered unfair? Can health inequalities that are a temporary

side-effect of over-all progress, from which everyone in the end will probably benefit, be

considered unfair?

But even if current health inequalities would not unambiguously and completely be

considered unfair, they are still likely to be seen as partly unfair, and unfairness is not the

only legitimate reason for reducing them. One may also find them tragic, and want to reduce

22
them because they reinforce social inequalities by depleting the smaller resources of people

in lower socioeconomic groups, and by preventing them to reinforce their social position.

Other reasons include the huge population health losses due to health inequalities, and the

economic costs of health inequalities (e.g. through lost labour productivity and costs of

health care and social security) (Mackenbach et al., 2011).

It is no wonder, therefore, that there have been many pleas for reducing or even

eliminating health inequalities, and that several European countries have developed and

sometimes implemented national programs to tackle health inequalities (Mackenbach et al.,

2003, Independent Inquiry into Inequalities in Health, 1998, Mackenbach & Stronks, 2002,

The 2005 Public Health Policy Report, 2005, National strategy to reduce social inequalities in

health, 2007, National Action Plan to Reduce Health Inequalities 2008-2011). These attempts

have so far, however, been insufficiently effective. The most powerful attempt at tackling

health inequalities so far, the English strategy of successive Labour governments in the

period 1997-2010, has produced a few positive intermediate results but has failed to reduce

health inequalities. This was due to a lack of policies of proven effectiveness and a lack of

political determination to pursue sufficiently radical solutions (Mackenbach, 2010,

Mackenbach, 2011).

If the hypotheses presented in this paper are correct, neither of these two

circumstances is surprising. According to these hypotheses, modern European welfare states

have been ineffective against health inequalities, partly because of a failure to implement

more radical redistribution measures, partly because of concurrent developments which

have changed the composition of socioeconomic groups and made health inequalities more

sensitive to immaterial factors. In that case, a substantial reduction of health inequalities can

only be achieved with more radical redistribution measures, and/or a direct attack on the

23
personal, psychosocial and cultural determinants of health inequalities. As long as there is

insufficient political support for the first, and as long as the second is unfeasible because of a

lack of effective interventions, those who want to reduce health inequalities will have to be

satisfied with small steps forward.

24
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31
Figure 1. Mortality by occupational class among men in England and Wales, ca. 1920 – ca.
1980.
Source: modified data from Pamuk 1985

32
Table 1. Excess deaths among the lowest educated, by cause of death, 1990s (Slope Index
of Inequality, expressed as age-adjusted deaths per 100,000 person-years).

Men All Cancer Cardio- Injury Alcohol- Smoking-

causes vascular related related
disease causes causes

Sweden 625 90 309 52 50 71

Norway 980 169 434 70 62 166

England/W 862 225 401 19 28 241

France 1044 333 232 109 196 204

Italy 639 232 140 23 63 177

(Turin)

Spain 530 181 38 26 75 170

(Madrid)

Women All causes Cancer Cardio- Injury Alcohol- Smoking-

vascular related related
disease causes causes

Sweden 381 73 172 8 15 39

Norway 518 103 239 5 16 79

England/W 462 111 236 1 7 103

France 375 50 130 36 30 17

Italy (Turin) 197 15 94 -3 8 -4

Spain 51 -76 56 7 3 -24

(Madrid)

Source: Mackenbach et al. 2008

33
Box 1. Theories which may help to explain the persistence of health inequalities in high-
income countries with extensive welfare arrangements

Focus of theory Main Short description Evaluation

proponents
Mathematical Scanlan [a] Increasing relative inequalities Relative inequalities in
artifact Vagero [b] in health outcomes are mortality tend to be higher
inevitable when the overall when over-all mortality is
level of the outcome falls, and lower, but this is not a
persistence of health mathematical necessity.
inequalities is an artifact of the Paradox also applies to
focus on relative inequalities in absolute inequalities in
negative outcomes. mortality.
Fundamental Link [c] Socioeconomic position Reformulates the problem
causes Phelan [d] involves access to resources without identifying the specific
which can be used to avoid pathways linking
disease risks or to minimize the socioeconomic position and
consequences of disease once health. However, refocusing
it occurs, regardless of what the attention on fundamental
current profile of diseases and aspects of social stratification is
known risks happens to be useful.
Life course Wadsworth [e] Health at adult ages is partly May explain why health
perspective Bambra [f] determined by exposure to inequalities at adult ages
biological and social factors at respond with long delays only
the start of life, and the roots of to more equal living conditions.
health inequalities may However, there is no evidence
therefore lie in inequalities that health inequalities are
experienced in the womb and smaller in generations exposed
during childhood and to more extensive welfare
adolescence arrangements .
Social selection Black Report In modern societies, people are Evidence for ‘direct’ health
[g] socially mobile, and are sorted selection mainly limited to
West [h] into social classes on the basis income-health relationship.
of health (‘direct health ‘Indirect’ health selection
selection’) or health difficult to measure, but may
determinants (‘indirect health explain paradox if it has
selection’) increased over time or is
associated with welfare
policies.
Personal Batty [i] In modern societies, Empirical support is growing.
characteristics Mackenbach socioeconomic position is May provide pathway for ‘social
[j] strongly associated with selection’ theory, and may
personality, cognitive ability explain paradox if relative
and other personal importance of ‘personal
characteristics which affect characteristics’ for health has
health. increased over time.
‘Neo-material’ Lynch [k] Inequalities in material Persistence of inequalities in
factors Davey Smith resources, both at the material resources is well
[l] individual and community level, documented, and availability of
are still universal, and lead to material resources still affects
accumulation over the life- health, but cannot explain

34
 course of exposures and trends over time or
experiences which affect health geographical patterns within
Western Europe.
Psychosocial Marmot [m] Socioeconomic position is still Persistence of inequalities in
pathways Wilkinson [n] strongly associated with exposure to psychosocial stress
psychosocial stress, e.g. is well documented, and
through variations in exposure psychosocial stress does affect
to demand-control imbalance health, but cannot explain
or through relative deprivation. trends over time or
geographical patterns within
Western Europe.
Diffusion of Rogers [o] Increasing inequalities in health Supported by a lot of evidence,
innovations Victora [p] outcomes result from a faster but theory does not identify
rate of improvement in higher the specific pathways linking
socioeconomic groups, which is socioeconomic position and
due to earlier adoption of new adoption of new behaviors or
behaviors and earlier uptake of uptake of new interventions.
new interventions.
Cultural capital Bourdieu [q] In modern societies, Empirical support is limited,
Abel [r] socioeconomic position is still but may provide specific
strongly associated with pathway for ‘diffusion of
cultural factors such as innovations’ theory. May
normative beliefs and explain paradox if relative
knowledge on health risks, importance of ‘cultural capital’
which strongly affect health for health has increased over
because the latter is largely time.
determined by lifestyle.

a. Scanlan JP. Race and mortality. Society 2001; 37(2):29-35.

b. Vagerö D, Erikson R. Socioeconomic inequalities in morbidity and mortality in Western Europe [letter]. Lancet
1997; 349:516.
c. Link BG, Phelan JC. Social conditions as fundamental causes of disease. J Health Soc Behav 1995;extra issue:80-
94.
d. Phelan JC, Link BG, Tehranifar P. Social conditions as fundamental causes of health inequalities: theory,
evidence, and policy implications. J Health Soc Behav 2010;51:S28-S40.
e. Wadsworth MEJ. Health inequalities in the lifecourse perspective. Soc Sci Med 1997;44:859-869.
f. Bambra C, Netuveli G, Eikemo TA. Welfare state regime life courses : the development of Western European
welfare state regimes and age-related patterns of educational inequalities in self-reported health. Int J Health Serv
2010;40:399-420.
g. Black Report
h. West P. Rethinking the selection explanation for health inequalities. Soc Sci Med 1991;32:373-384.
i. Batty GD, Der G, Macintyre S, Deary IJ. Does IQ explain socioeconomic inequalities in health? Evidence from a
population based cohort study in the west of Scotland. BMJ 2006;332:580-4.
j. Mackenbach JP. New trends in health inequalities research: now it’s personal. Lancet; 376(9744): 854-855.
k. Lynch JW, Davey Smith G, Kaplan GA, House JS. Income inequality and mortality: importance to health of
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