Health Inequalities: The evidence and the options
Diana Smith investigates how serious inequalities in health are in Europe and what can be done to reduce them.
As Europe opens up to the East, Western Europeans are becoming increasingly aware that people living in the less wealthy countries of central and eastern Europe have poorer health and shorter life expectancy that those in western Europe. Male life expectancy in the Russian Federation is 62.7 years compared with 73.7 years in Germany.
What is less well known is that poverty and disadvantage in western European countries are taking an increasingly serious toll on the health of disadvantaged groups. For example, in the UK, recent figures from the Office for National Statistics bulletin show that females born in wealthy London health authorities would be expected to live to 82.4 years compared with a life expectancy of 76.5 years for women born in the greater Glasgow (Scotland) region.(1)
“Health gap” widens
Even more shocking were the findings of a report in 2000 entitled “Independent inquiry into inequalities in health”. It found that although health in England (as judged by reductions in mortality rates) had greatly improved on average over the past 50 years, in recent decades inequalities in health had either remained static or widened.(2)
National reports highlighting how inequality and disadvantage damages health have been published by other Member States including Sweden, Holland, Norway and Spain. Most European countries have identified links between inequality and health. Quoting a European study, INSERM (Institut national de la santé et de la recherche médicale) says that mortality in France among blue-collar workers aged 45-59 years is 71% higher than among their white-collar peers.(3)
A report to be published soon by the European Forum for Child Welfare says 30% of children are living in poverty in certain EU Member States, and approaching 15% of children in several countries in live households where poverty is so harsh that it threatens their health and growth.(4)Rates are even higher in Eastern Europe. Unicef says that one in three children in Albania, Uzbekistan and Tajikistan is malnourished.(5)
Vicious life-cyle of poverty
Working directly on the issue of tackling inequalities in health, the Flemish Institute for Health Promotion (VIG)(6)sees inequality and poor health as a vicious cycle from birth to death. Infants born into disadvantaged families tend to have a lower birth weight, which is explained by harmful influences during pregnancy such as poor diet, tobacco and alcohol consumption. Growing up these children from poorer homes are more likely to incur accidents. They are less likely to attend university where only one student in four in Belgium smokes compared with one in three among people with lower educational backgrounds.
When working life begins, underprivileged people often face job insecurity or hard, high risk and monotonous tasks with little financial or personal gratification. The resulting chronic stress adversely affects their health. Repeatedly disappointed professional and private expectations not only cause long-term disease, but can also push people towards substance abuse.
Consequently, the socially disadvantaged tend to be more frequently subjected to fatal illnesses, including cancer, strokes and heart f ailure. Their chance of surviving such illnesses tends to be lower than those of middle-class individuals.
Governments often see making access to health care more equitable as the key to reducing health inequalities. While there is no doubt that publicly-funded health and education services are very important to maintaining good national health, even more significant results are likely to be produced by a reduction in economic and social inequities.
Redistribution of income
Research published in 2000 indicates that even a minor shift in wealth could prevent 10,000 premature deaths in the UK each year.(7)It shows that returning inequalities in income and wealth to their 1983 levels through redistribution would prevent about 7,500 annual deaths among the under 65s while achieving “full” employment (where no one was receiving long-term unemployment benefit) would prevent about 2,500 premature deaths a year. EPHA member, the UK Public Health Association, responded to the publication of the report by calling on the British government to introduce a redistributive tax policy.
Sadly trends in redistribution of income in Europe are moving in the opposite direction. Relative poverty continues to rise with incomes of top executives rising sharply. A report from Eurostat, the EC statistical office, shows that the poorest 20% of the EU population now receive only 8% of total income while the richest 20% pocket almost 40%, or five times more. But the gap varies considerably and is narrowest in Finland and Denmark and widest in Portugal.(8)
Social transfers (such as rent rebates and child allowances, and other than pensions) make a difference. A Eurostat report published in September 1999 shows that these transfers are already responsible for reducing the EU poverty rate by one-third – and that countries that are most successful at reducing inequality and poverty are those that spend the largest amounts on social transfer payments.(9)
Reform of the Common Agricultural Policy
Diet plays an extremely important role in health yet many Europeans do not have the opportunity to eat well. The World Health Organization says that the lack of a safe healthy diet (called “food inequity”) may be responsible for over 1 million deaths yearly (14% of all deaths) in its European Region.(10)EPHA believes that the CAP should be reformed so that safe, healthy food as a human right is the objective as emphasised in WHO’s policy framework Health21. An EPHA statement on CAP, produced in collaboration with over 50 other NGOs, proposes that the EU “should increase financial support to healthy consumption and production, including an increased availability of fruits and vegetables. This must be accompanied by health promotion efforts to raise awareness of the risks associated with an unhealthy diet.”
Reducing homelessness and making improvements in housing
Changes in housing policies would also save lives. The homeless risk freezing as they sleep on the streets of European cities while poor old people die in their own homes because they cannot afford adequate heating. One housing initiative might involve renovating accommodation to reduce heating costs. A new study by researchers at the London School of Hygiene and Tropical Medicine shows that the lives of several hundred people in the UK each year could probably be saved by improvements in the insulation and heating of their homes.(11)
Supporting health promotion activities
Health promotion is defined as “the process of enabling people to exert control over the determinants of health and thereby improve their health.”(12)Traditional approaches to health promotion, such as providing heal th information, fail to make a major impact on reducing health inequalities. This is because providing health information tends to benefit the wealthy more than the poor(13). It is also because health messages about exercise, for example, will not be effective if parks and sports grounds are not accessible and if bicycle lanes do not exist.
Thus a wider vision of how to use health promotion to reduce health inequalities in Europe has been developed with the help of the European Commission (see page 5). Measures proposed include developing national health inequality targets, working at the local level, reducing barriers in access to health services, and integrating health determinants into other policy areas. All of these are vital and the emphasis given to working with other policy areas is particularly important.
To reduce the unnecessary ill-health and shortened life span of disadvantaged people in Europe, key policy areas must be addressed. Working alone, the health sector can do little to reduce inequalities in illness, injury and life expectancy. Working with fiscal, education, agriculture and housing leaders, a great deal could – and should – be done to ensure that everyone benefits from the aspirations of the “European social model”.
- 1. Life expectancy rates show health inequalities, BMJ 2001; 323:471 (1 September).
- 2. Donald Acheson, Chairman of the Inquiry, quoted in Bulletin of the World Health Organization, 2000, 78 (1), p. 75.
- 3. Social inequalities in health, a publication coordinated by INSERM and published by La Découverte, 448 pp
- 4. To be published soon, www.efcw.org
- 5. A decade of transition, www.unicef-icdc.org/publications/
- 6. This section is developed from an article by Catherine Ancion, Vlaams Instituut Voor Gezondheidspromotie (VIG), Belgium, and from material from John Middleton, Sandwell Health Authority, UK.
- 7. “Wealth distribution will save lives”, Health Matters, Issue 42, p.2
- 8. Focus on European Lifestyles, Eurostat,http://europa.eu.int/comm/eurostat
- 9. Social benefits and their redistributive effect, Eurostat,http://europa.eu.int/comm/eurostat, and Targeted Socio-Economic Research Programme using results of 1994 European Community Household Panel survey by Eurostat.
- 10. Available under Campaigns on EPHA website, www.epha.org
- 11. Excess winter deaths linked to temperatures in cold homes, BMJ 2001;323:1207 (24 November)
- 12. Ottawa Charter for Health Promotion, 1986.
- 13. Inequalities in health, Bulletin of the World Health Organization, January 2000. Website: www.who.int
Diana Smithis the Editor of the European Public Health Alliance’s bi-monthly publication “UPDATE”. This article was published in Issue No.60 (January/February 2002) of the European Public Health UPDATE.
<em>European Public Health Alliance(EPHA) represents over 80 NGOs working in support of health in Europe. It aims to promote and protect the health interests of all people living in Europe and to strengthen the dialogue between the EU institutions, citizens and NGOs.