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Chapter 4 (‘Patterns of health inequalities explained’) is based on in-depth studies of the macro-level determinants of health inequalities, especially conducted for this book. It shows that the persistence of health inequalities is partly due to broader changes in society, such as educational expansion, increasing rates of intergenerational mobility, and more intermarriage of highly educated people. Another factor is that health improvements have been faster in higher than in lower socioeconomic groups, also because higher socioeconomic groups have benefited more from rising prosperity and rising health care expenditure, and have suffered less negative health impacts from rising income inequality and the transition towards liberal democracy in Central and Eastern Europe. Finally, it demonstrates the importance of the continued social patterning of health determinants, particularly poverty and smoking. It ends with a summary of how differences in the magnitude of health inequalities between European regions (North, South, East) should be understood.

This chapter shows how the population-wide effect of proximate psychosocial factors on public health can be truly enormous. It argues that the social shocks associated with the transition to capitalism in the 1990s in Eastern Europe are responsible for a massive increase in cardiovascular disease among working-age men. Population health statistics suggest that during the first four years of the transition period, there were dramatic increases in mortality among males and females of working age.

Twelve new countries joined the European Union in 2004 or 2007. Ten of them were former communist countries while the other two were Malta and Cyprus. Negotiations have also been launched with other countries including Turkey and later Croatia and Serbia. With the exception of Malta, Cyprus and Turkey all those countries shared a common past being part of the communist block for decades. As such, they operate very similar health systems oriented toward extensive hospital development, polyclinics and traditional state based systems of health protection covering hygiene and sanitation control. Changing political and societal conditions naturally lead to changes in health systems. Health protection became more influenced by modern public health ideas of disease prevention and health promotion. The search for new ways of working provided a reason for interest in health impact assessment (HIA).