Review

Taking the long view

Reducing Inequalities in Health: a European perspective
Johan Mackenbach and Martijntje Bakker
Routledge 2002. £18.99

How ironic that the UK which, through Edwin Chadwick, ‘discovered’ health inequalities, and through the Black report began the movement to tackle them, has one of the worst inequalities records in the developed world.

In Europe, only Turkey has wider income inequality. With state education so evidently failing in the UK, the prospects for progress seem bleak. Surprisingly, the government’s approach to the problem is considered to be at the highest level on Margaret Whitehead’s action spectrum, namely that of ‘comprehensive coordinated policy’, one stage ahead even of the Swedes. Is this spin masking a lack of real action?

There is a substantial literature describing and analysing inequalities but remarkably little on the evaluation of remedial interventions. One reason for this is methodological – randomised controlled trials are not possible in this area. It was an appreciation of this problem which, in part, led to the establishment of the European Network on Interventions and Policies to Reduce Socio-economic Inequalities – sponsor of this book – to develop suitable new methodologies.

So what do we know works to combat inequalities? Providing employment and adequate income support are evidently crucial. Reducing unfavourable physical and psychosocial working conditions is important, although achieving the latter is difficult. Tackling smoking in lower socio-economic groups is key. In the field of nutrition both selective policies such as food co-operatives and universal ones such as cutting the fat and salt content of cheap and fast foods have a place.

Targeted vaccination and screening programmes, and early educational interventions, can contribute to reducing childhood health inequalities. And making healthcare more accessible through home visits and specially provided clinics is also important. Also important is cross-cutting policy development within central government, linked to effective partnership working between local government and other key agencies at community level. But above all it is education, education and education.

Interestingly, the authors propose a kind of Cochrane Collaboration for inequality interventions and policies, to further the international study of inequalities. This would undoubtedly be useful but for me the book’s message is that we must pursue the holy grail of cross-party consensus on the main strands of policy, as in the Netherlands and Sweden. This would mean a long-term strategy could be put in place that would not be subject to the cyclical volte-face of party politics.