If education and income are primary determinants of health, then social policies to improve both should improve health. This is reflected in Great Britain’s 1998 Acheson report, an authoritative government-commissioned report that linked health disparities and social class. It noted that death rates had fallen between 1970 and 1990, but at a much steeper rate for higher social classes, creating a larger disparity between the haves and have-nots. The report recommended 39 policy steps in areas such as taxes, education, employment, housing, nutrition and agriculture to improve the health of lower-income citizens, although the entire population could benefit. The goal was to attack the social inequalities that reliably produce health inequalities.
The problem is that funding for social policies is much less stable than for medical care. Programs that address the needs of those who some believe are not deserving struggle to maintain support. Government is more likely to assist those who are considered not at fault for their vulnerability, such as children, the disabled and the elderly. Unwed mothers, substance abusers and ex-convicts attract far fewer sympathizers.
Social programs that boost education, food security, employment and neighborhood stability can be considered investment in disease prevention. However, government is far more inclined to intervene with expensive health-care services when medical conditions present themselves.
University of Oxford researchers analyzed the health effects of deep social-welfare budget cuts in Europe. They looked at funding for programs that support families and children, help the unemployed find jobs and assist the disabled, from 1980 to 2005.
The analysis showed a strong association between social spending and risk of death, especially from heart attacks and binge drinking. They found that when social-welfare spending was high, mortality rates fell. When spending fell, death rates rose substantially. They found no such effect from cuts in spending for the military or prisons.
Low SES is associated with poorer health behaviors. It accounts for higher rates of smoking, binge drinking, obesity and, ultimately, death. Many argue that risky behavior is only an indirect cause of poor health and is itself a consequence of low income and education and powerlessness. However, a 1998 study examined the degree to which four risk factors – cigarette smoking, alcohol consumption, inactivity and being overweight – contributed to the death rate at various income levels. Researchers found that poor health behavior explained only a small portion of the higher death rate for those with low SES. They concluded the death-rate disparity would persist even if the disadvantaged improved their health behavior to the level of those with more education and income. In other words, there was a wide array of factors involved beyond health behavior.
Many assume prompt, affordable health care improves the health of the socially disadvantaged. This medicalization of social reform encourages the view that health disparities can be solved by improving health-care access, use and quality. The result is that health-care access is overvalued and overemphasized, perhaps because medical interventions are easier to provide than fundamental social and economic reforms.
Canadian researchers wanted to find out whether lack of access to health care explained poor health for those with low SES. They tracked about 15,000 patients in the nation’s universal health-care system for more than 10 years. They found that low-income Canadians used the health-care system more. The increased use had little impact on their poorer health outcomes, especially the death rate. Likewise, SES health disparities actually widened after Great Britain established the National Health Service, its publicly funded universal health-care system.
Although medical innovations are intended to improve population health, they actually worsen health disparities. The rich and well-educated have the resources to use them more readily and reap the benefits more swiftly. On the other hand, cost-effective public-health measures aimed at broad populations have the ability to decrease health disparities. Examples include water fluoridation, fortified food and environmental efforts against toxic substances.