Introduction to the Third Edition

The study of health inequality is often traced back to around fifty years ago. Many of those who studied health inequality in the 1970s and '80s saw it as a chance to improve our understanding of disease and our ability to prevent ill-health in the whole population regardless of social background. Social differences in premature mortality from almost all causes were so large, it seemed that, if we could understand the ways in which socioeconomic adversity 'gets under the skin' to produce disease, this might lead to major improvements in population health and ways of making medical care more effective. What is the point, we asked, of treating someone's bronchitis in hospital and then sending them back to a damp, cold house to become ill again?

The existence of health inequalities was seen as proof that diseases were indeed preventable by changes to the environment. Although the British National Health Service had offered medical care free at the point of use to all citizens since 1947, by the 1970s it was clear that this provision was not reducing the level of health inequalities in the UK; in fact, they increased (see Chapter 2). This made it all the more important to regard prevention as being better than cure. After all, even free operations are not a pleasant experience; most people would prefer not to become ill in the first place. But more surprising was that health inequalities continued to increase even after forty years of a welfare state that, in theory, prevented the worst extremes of poverty, and had actually succeeded in reducing income inequality.

The 1980 Black Report, published by the UK Department of Health and Social Security, was the first attempt of its kind anywhere in the world to drill down into the statistics and identify what it was about social class (the measure of social inequality used in British official statistics, further discussed in Chapter 1) that produced these large differences in risk. The Black Report put forward four possible models of explanation: selection, artefact, material, and behavioural-cultural. In the early 2000s, the artefact explanation (which suggests that there is no causal link between class status and health outcomes, but that they are just coincidental measurements) had been completely discredited and the selection explanation (which makes health the key causal factor, suggesting that social class is the result of a process of 'selection' based on health) was little considered outside economics. Accordingly, the first edition of this book concentrated on the material and behavioural-cultural models and tried to assess how well each of them fitted the existing evidence. It also described and assessed three additional factors that had been increasingly investigated in research between 1980 and 2000: psychosocial stress at work, social isolation and life-course effects. This third edition has the exciting task of showing the ways in which the focus on the individual is receding from health inequality research, to be replaced by a much more sophisticated understanding of the ways in which the environment - material, economic, commercial and political - is implicated in health inequality (Bambra et al., 2019).

Between 1997 and 2001, when the ideas behind the first edition of this book were being gestated and written down, the UK had a 'New Labour' (moderate social democratic) government that was in many ways determined to reduce health inequality, and was prepared to do so by addressing at least some of the social and economic factors (the so-called 'upstream factors') believed to be involved, such as the absence of a minimum wage, low pensions, widespread educational failure and child poverty (Douglas, 2016). The successor to the Black Report, the Acheson Report (1998), set out a large number of rather precise recommendations, and a government plan published in 2002 described the ways in which many of these would be met (Department of Health, 2002). As pointed out by Mackenbach (2010a), the British programme was 'by far the best resourced of all the Western European strategies to reduce health inequalities which started during the decade'. It should have been a golden age during which the research paid off in terms of real world reductions in health disparities between social groups, and overall improvements in population health.

So it was surprising and dismaying to see the verdict on the years of policy initiatives that followed the Acheson Report. According to most commentators, they did not succeed in reducing health inequality in the UK (Department of Health, 2009; Mackenbach, 2010b; Law et al., 2012). But this is not a universal opinion. Official statistics on health inequality gradually abandoned measuring social inequality in terms of social class and adopted 'area deprivation' as the most commonly used measure (Case and Kraftman, 2022). From this perspective, there did seem to be the beginning of some improvement in health inequalities between richer and poorer geographical areas between 1999 and 2010, only for these to widen again after 2010 (Robinson et al., 2019; Vodden et al., 2023). This observation points to one of the new features of the data we now have for several nations: it covers a period of great change in policy, a period of government austerity, and of course a worldwide pandemic.

One major problem for those of us who are attached to testing ideas with data is that the availability of data that can be used to evaluate the success or failure of new policies has changed. When we decided it was time for a third edition of Health Inequality, we could soon see that the problems besetting the second edition had become even more acute. The evaluations of the strategy for reducing health inequality from 2002 had only required a comparison of mortality by geographical areas, not by social class, as had been done every ten years since 1921 in England and Wales, for example (see Chapter 2). Social class gaps were only assessed in infant mortality. It appears that the degree of class inequality in infant mortality did begin to fall quite a lot (Bambra, 2012). But that is not the same as being able to extend the seventy-year-old analysis of social class differences in the premature death of adults that gave rise to the whole issue of health inequality in the first place. There are many problems with the use of area measures, although, as we will see, it also has some advantages. It has long been known that not all poor people live in deprived areas. One study has reported that fewer than half of those who were either unemployed or receiving welfare benefits in Scotland, for example, were living in the most deprived 20 per cent of areas (McCartney et al., 2023).

Moreover, if research is to inform policy, we need to unravel the potential pathways that link factors such as exposure to hazards, housing, health care, labor markets - and many other socially structured facets - to health. Deprivation indices, which are usually composite measures at an area-level including factors like occupation, education, material assets, income, crime, etc., may obfuscate these underlying mechanisms of relevance. These issues will be developed in Chapter 1.

In this edition, the major reorientation of our explanatory efforts is to place the processes (pathways) within the context of the political and commercial determinants of health. In 2005, Bambra and her colleagues had criticized the ways in which health has been 'depoliticized', adding that this has not happened 'by chance: both the masking of the political nature of health, and the forms of the social structures and processes that create, maintain and undermine health, are determined by the individuals and groups that wield the greatest political power' (Bambra et al., 2005, p. 192). The growing body of research in global health was giving rise to a different perspective on health inequality within nations, focused on the power of big corporations both to persuade us to consume unhealthy products and to motivate governments not to control unhealthy consumption (Schram and Goldman, 2020; Lacy-Nichols et al., 2023; Lancet, 2023). Earlier research focused on the activities of large companies that produce and promote tobacco goods and highly processed foods (Kickbusch et al., 2016; Marteau et al., 2019). This work has now developed even further into an appreciation of how these companies actually formulate government policies (Buse et al., 2017; McKee and Stuckler, 2018), and even the research that is supposed to inform policymaking. McKee and Krentel write of 'the use of false experts who seek to lend credibility to the corporation's arguments, and "moving the goalposts", where corporations dismiss evidence presented in response to a specific claim by continually demanding some other, often unfulfillable, piece of evidence' (2022, p. 91-2).

A sobering conclusion from some of these new studies has been that the researcher herself needs to be very aware of the power of corporations to influence the content of science itself. For example, as van Schalkwyk and colleagues point out: 'There is ample evidence on the ways in which industries conduct research - for example by conducting large numbers of studies in secrecy until the desired results are obtained, and then commissioning independent researchers to conduct the study that will produce those results' (2022, p. 97). In 20014, when the second edition of this book was being written, such claims would have seemed far-fetched. But since then, the...