Injustice is killing people on a large scale--but what is to be done about it?

Abstract

In keeping with earlier reports, the Marmot review of the English health inequalities strategy argues that social injustice is killing people on a large scale: up to 2.6 million extra years of life could be gained across all social groups if health inequalities were significantly reduced.1 Despite the considerable effort and resources that have gone into research and action over recent decades, the health gradient has remained largely unchanged and in some instances has worsened.2 Tellingly, inequalities in income, wealth and life chances have also widened.3 It is therefore imperative that public health redoubles its efforts to reduce health inequalities. But if these are to be more effective in future we need a more sophisticated understanding of the barriers to progress as well as a renewed commitment to addressing them. The need for radical changes in local systems, including new forms of adaptive leadership and looser partnership structures that allow for flexible solutions tailored to local contexts, is part of the solution.4 But other equally intransigent barriers must be dismantled.5 Prominent amongst these is ‘lifestyle drift’—the tendency for policy to start off recognizing the need for action on upstream social determinants of health inequalities only to drift downstream to focus largely on individual lifestyle factors. Coupled with this is a move away from action to address the social gradient towards activities targeted at the most disadvantaged. For example, the House of Commons Health Committee's report on health inequalities6 concluded that the causes were complex encompassing lifestyle factors and ‘wider determinants such as poverty, housing and education’. But this analysis was not reflected in their proposed actions. The most strongly expressed and ‘urgent’ recommendation—immediate legislation introducing a statutory traffic light labelling system for foods—may be important, but lack of information on food labels is not a major cause of inequalities in health.

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