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The most important ethical implication of the diffusion of the health agenda is the growth in salience of health inequalities. Taking a broad social perspective on health opens up the consideration of patterns of determinants and patterns of health experiences. This chapter addresses the following issues: (i) What they might entail in practice, in other words: ‘What would a more equal health polity have to aim at?’ and (ii) How far should health or public policy be led by a concern with equity where this comes into conflict with other relevant values? The first part of the chapter sets out the rationale for thinking that health inequalities are ethically important. The chapter later places more emphasis on the problems of interpreting the implications of this ethical significance.

During the last two decades, socio-economic inequalities in health have increasingly been recognized as an important public health issue throughout Western Europe. A search for evidence-based strategies to reduce these inequalities has begun. This chapter reviews recent European experiences in this area. It begins with a brief overview of the size and pattern of socio-economic inequalities in health in western Europe. It then reviews national policy developments, including various innovative approaches and comprehensive blueprints for tackling health inequalities that have been proposed. Finally, it discusses the types of evidence needed to underpin policies to tackle socio-economic inequalities in health. These requirements are illustrated with an analysis of some of the new findings on explanation of health inequalities as reported in this volume.

This chapter begins by re-evaluating the reasons one might have to expect that some welfare states regimes, and especially the Nordic ones, can be expected to influence inequalities in population health. It then examines whether the expected effects of welfare state regimes are observed in recent research on inequalities in health. It reviews the empirical evidence brought forward by recent comparative studies, paying special attention to comparative studies on health inequalities that include both Nordic countries and countries with different welfare state regimes. Available evidence shows that health inequalities are not consistently, significantly, and systematically smaller in the social democratic countries than in countries belonging to the other welfare regimes, i.e., the conservative and the liberal. However, for inequalities in mortality, except for Finland, the other Scandinavian countries do perform rather well, in relative terms (Denmark and Norway) or in absolute terms (Norway and Sweden).

When interpreting legislation, courts are often presented with opportunities to address health-care inequalities. This chapter describes four instances showing the judiciary's reluctance to confront health-care inequalities. It argues that despite precedent for judicial intervention to change social policy in public education, welfare rights, and judicial takeovers of certain institutions, there has been considerable judicial reluctance to do so in health care. The courts have systematically chosen markets over equity. Medicare/Medicaid, the Emergency Medical Treatment and Active Labor Act of 1986 (EMTALA), the Hill-Burton Act, and the Employee Retirement Income Security Act (ERISA) are examples that several trends advocates should consider in devising strategies for reducing health-care inequalities.

The introductory chapter provides an overview of different ways of defining, conceptualizing, and measuring health inequalities. This includes outlining common axes of inequality, including social class and socioeconomic status, geographical area, ethnicity, and gender. The chapter briefly explores the UK’s history as a leader in health inequalities research before going on to review trends in health inequalities patterns in the UK over the past four decades. Next, the chapter provides a succinct overview of key empirically informed theories which aim to explain health inequalities, including cultural–behavioural, materialist, psychosocial, and political economy (structural) accounts. In each case, the chapter briefly explains the rationale and evidence underlying such accounts before considering key criticisms. Finally, the chapter provides a brief account of the UK’s policy responses to health inequalities, considering potential explanations for why these policy efforts appear to have had limited success in reducing health inequalities and examining the extent to which post-1997 interventions have reflected the available evidence.

This chapter discusses two topics related to health inequalities: the measurement of health inequality and social inequalities as determinants of health status. It suggests an alternative framework for studying health inequality, wherein ‘health inequality’ refers to the variation in health status across individuals in a population. This is a use distinct from the concept of health inequalities used in studies of health differences between social groups. The use of ‘health inequality’ to refer to a composite measure of individual-level variation is consistent with other disciplines studying inequality across individuals.

This introductory chapter shows how work and worklessness are not the discrete activities of individuals but essential parts of the way in which the totality of society is organized politically, socially, and economically. Work based hierarchies are reflected to greater or lesser extents in wider societal hierarchies, and socio-economic class is determined largely by occupation and work-related income. Work and worklessness and their relationships with health and health inequalities therefore exist within the broader political and economic structures of society. The chapter is divided into three main sections. The first examines the key concepts of work and worklessness, focusing on their relationship with the state in advanced market democracies. The second section provides an overview of the social determinants of health and health inequalities. The final part of the chapter reflects on matters of structure and agency in explaining the relationship between work, worklessness, and health.

This chapter reflects on the insights UK research and policy experiences have offered those working to address health inequalities in Canada and the USA. Written by leading Canadian experts on the social determinants of health, it argues that the UK has provided researchers and policymakers with numerous insights into how to conceptualize, research, and act to reduce health inequalities, whilst also summarizing some of the key contributions that Canadian and American researchers have made to health inequalities debates. The authors argue that, whilst policy developments in the USA have been extremely limited when it comes to health inequalities, there are reasons to be more optimistic about the possibilities for addressing health inequalities and the social determinants of health in Canada.

Drawing on personal experiences of working to reduce health inequalities in policy and practice, this chapter reflects on the ongoing failure to effectively reduce health inequalities in the UK. It points out that, whilst social inequality is now accepted as a key determinant underpinning health inequalities, it tends not to be viewed in the same way as other health determinants have been in public health. Hence, rather than asking how to reduce exposure to the inequalities in income, wealth, power, and status that lead to poorer health, we often accept social inequality as a given and ask instead how we can direct health services and health promotion interventions to the groups of people who are most disadvantaged. The chapter considers some reasons for this, including the emphasis that tends to be placed on ‘health’ in framing health inequalities, and discusses potential consequences for research and actions to reduce health inequalities.

This chapter argues that inequalities in health and health care by racial and ethnic group are abundant but their underlying cause, and the contribution of racism, is a complex and much debated matter. The major cause of inequalities in health, and even more of inequalities in access to health care, is inequality in wealth. Topics discussed include the genesis of inequalities in health status; forces underpinning ethnicity and race, and their relation to those generating inequalities in health; measuring ethnic inequalities in health; and the dimension of, and trends in, inequalities by ethnicity and race.

This chapter reviews the current state of affairs on this intersection between the older health inequalities tradition and the evolving health impact assessment (HIA) field. It then summarizes the available evidence on health inequalities. It outlines the next possible approaches for assessing the impact of policies on health inequalities, and a few HIA examples are discussed in which health inequalities have been explicitly considered. Finally, a research agenda is laid out to develop the tools that will in the future help us to assess reliably and validly the impact of policies on health inequalities.

This chapter begins by looking at three concepts which underpin research and policy to promote people's health: inequalities, equity, and risk. It then discusses how childhood conditions influence adult health, pointing to the importance of a set of interconnected pathways that operate from before birth and across the life course. It presents a framework which captures these processes. This framework is applied to UK policies in order to illustrate how it can inform policy review and development.

This chapter examines the research on health inequalities in Great Britain. It explains that the Black Report had a limited impact on policy making during the 1980s and much of the 1990s but it stimulated extensive research into health inequalities by social scientists and, increasingly, epidemiologists. Some research presented different explanatory frameworks for the persistence of variations in health while others highlighted the relationship between health risk factors and socioeconomic position at an individual level. However, research on the role of socio-structural factors in health has not advanced greatly.

This introductory chapter has two main goals. First, it identifies and reflects on some of the main issues addressed in the book, and explores their interconnections. It then looks at some important questions that are not directly addressed by the book. It discusses the relationship between ethics, policy, and science, and how far these impact the way inequalities are understood and acted upon.

This chapter examines health inequality — its definition, measurement and theory — and then examines the role of welfare states in determining overall population health outcomes. The main studies in the comparative epidemiological literature on European health inequalities are then summarised, with a focus on the relative performance of the Nordic welfare states. The effects on health inequalities of changes to the Nordic welfare state are also examined. The chapter then uses the theories of health inequalities to examine why it is that the highly decommodifying Nordic welfare states do not have the smallest health inequalities in Europe. It concludes by reflecting on how any further changes to the Nordic welfare model may impact on health inequalities in the future.