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  • 1974
  • First public statement by a national government (Canada) proposing that the major determinants of health outcomes lay outside of the health care system and were social rather than medical
  • Later adopted by the World Health Organisation
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  • 1978 and 1991
  • Longitudinal study of civil servants of differing ranks in the UK
  • Found lowest ranks had death rates 3x higher than those of top rank
  • Links between low occupational status and many illnesses such as depression, some cancers, heart disease and so on
  • Such links could not be attributed to lifestyle choices
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  • 1980
  • Sir Douglas Black appointed by Labour government in late 70s to review the evidence of inequalities in health
  • Found large differentials in morbidity and mortality that favoured the rich and that not enough was being done about these
  • Initially buried by Conservative government but gained attention when reprinted by Penguin two years later
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  • 1999
  • The Conservatives had promised to review the evidence of health inequalities after being attacked by Labour for inaction over the Black Report
  • In 1997, under Blair, Sir Donald Acheson was appointed to lead the investigation
  • Showed social class mortality gap was “even wider than previously thought” and “emphasised the centrality of the issue of health inequalities” to public policy
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  • 2000
  • Sir Michael Marmot, who had led the Whitehall studies, was commissioned by the Labour government to review the latest research into health inequalities
  • Most comprehensive to date, clearly linking health and social divisions
  • Found that people living in the poorest neighbourhoods in England will die on average 7 years earlier than those in the richest neighbourhoods
  • Also found those living in the poorest areas suffer with life limiting disabilities and illnesses much longer than those in rich neighbourhoods- an average difference of 17 years
  • Even excluding the richest and poorest 5% the gap in life expectancy was still 6 years and diability free life expectancy 13 years
  • Concluded that these inequalities were worsening as the gap between rich and poor widened
  • Also showed steep social gradient in respiratory illness, cancer deaths and mental health problems
  • Averages misleading: In Britain's poorest areas the situation is even more extreme
  • 28 year life expectancy gap in Glasgow area-with male life expectancy in some wards a mere 53.9yrs
  • Putting such inequalities right mean a redistribution of power and wealth
  • Clear economic rationale as well as social and political- it is costly to treat large numbers for illnesses that can be prevented etc
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Health inequalities not a product of:

  • Genetics – although genes do play a role, mix too great to account for population level trends
  • Access to healthcare – most people in UK have access to adequate medical services
  • Lifestyle (smoking, drinking, diet and exercise) – again plays a part, but a smoker from a higher socio-economic position can outlive a non-smoker in a lower one, just as some of the heaviest drinkers in society (professional women 25-34) suffer less from alcohol-related illness than moderate drinkers in lower social classes. Harm, like health, unequally distributed
  •  Happiness/psycho-social wellbeing – again important, but a symptom not a cause


  • Health outcomes have their basis in socio-economic relationships
  • Changing these mean changing those relationship
  • For Marmot, “health inequalities ... are unfair. Putting them right is a matter of social justice”
  • That means addressing “inequities in power, money and resources"

“The economic prosperity, as well as the health and wellbeing of today’s children depends on us having the courage and imagination to rise to the challenge to do things differently, to put sustainability and wellbeing alongside economic growth and bring about a more equal and fair society.”

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