In keeping with earlier reports, the Marmot review of the English health inequalities strategy argues that social injustice is killing people on a large scale: up to 2.6 million extra years of life could be gained across all social groups if health inequalities were significantly reduced.1 Despite the considerable effort and resources that have gone into research and action over recent decades, the health gradient has remained largely unchanged and in some instances has worsened.2 Tellingly, inequalities in income, wealth and life chances have also widened.3 It is therefore imperative that public health redoubles its efforts to reduce health inequalities. But if these are to be more effective in future we need a more sophisticated understanding of the barriers to progress as well as a renewed commitment to addressing them.
The need for radical changes in local systems, including new forms of adaptive leadership and looser partnership structures that allow for flexible solutions tailored to local contexts, is part of the solution.4 But other equally intransigent barriers must be dismantled.5 Prominent amongst these is ‘lifestyle drift’—the tendency for policy to start off recognizing the need for action on upstream social determinants of health inequalities only to drift downstream to focus largely on individual lifestyle factors. Coupled with this is a move away from action to address the social gradient towards activities targeted at the most disadvantaged. For example, the House of Commons Health Committee's report on health inequalities6 concluded that the causes were complex encompassing lifestyle factors and ‘wider determinants such as poverty, housing and education’. But this analysis was not reflected in their proposed actions. The most strongly expressed and ‘urgent’ recommendation—immediate legislation introducing a statutory traffic light labelling system for foods—may be important, but lack of information on food labels is not a major cause of inequalities in health.
Inadequate community empowerment is also slowing down progress on health inequalities. Empowerment can have positive health and social outcomes for individuals and communities but done badly it can do harm.7 Much current policy and practice assumes that the main barrier to effective empowerment is the lack of skills and competencies at the community level but research suggests that barriers arising from professional and organizational culture and practice are more important. These include negative stereotypes of communities, inappropriate timing and style of meetings, failure to accommodate cultural diversity, accessibility issues, inadequate resources and misuse of professional power to control agendas. Short-termism in central government also impacts negatively on empowerment processes and outcomes. Consequently, individuals and communities become increasingly unwilling to engage in decision-making, thereby undermining democratic accountability.
Finally, with lifestyles in the ascendancy, action to address the upstream determinants of inequalities in health is at best neglected, at worse undermined. Public policy in general and welfare systems in particular mimic markets in the search for economic efficiency and higher productivity. As welfare services are redesigned to support flexible labour markets, public health appears to embrace the ‘worklessness’ agenda and neglect the possible negative impacts of poor working conditions on health inequalities. Social life and relationships—the ethics of care—are secondary, and must adapt, to the work ethic and economic growth. The personalization agenda, which aims to meet individuals' unique needs, is effectively a consumerist agenda that risks undermining collective approaches to meeting need. Area-based regeneration subordinates social development to the primary goal of economic growth (e.g. housing market renewal). In contrast, evidence suggests that a welfare system aiming to support and promote social justice and hence reduce health inequalities would need to establish clear limits to the operation of markets not be subservient to them. It would consist of high quality, publicly funded, universally accessible services that promote social cohesion and the values that sustain social co-operation.
Public health must resist lifestyle drift, silo-based working and the drive in policy and delivery for ‘quick fixes’ and low-lying fruit. But the wider changes needed to reduce health inequalities will not happen without ‘popular’ pressure for greater social justice. The public health community played a pivotal role in developing the social movement for legislation to ban smoking in public places—it could have an equally significant role in a social movement for health equity. Working for more genuine and sustainable community empowerment, particularly amongst those social groups with least power over decisions that affect their lives, will contribute to this. But the public health community should also give higher priority to their professional duty to comment publicly on the health consequences of social injustice—a duty highlighted by Bevan in the 1940s. Now is the time for the profession to play a more prominent role in fostering public debate about redistribution and the kind of society people want to be part of. Without a concerted effort along these lines the transformation needed to significantly reduce health inequalities will not happen.