Margaret Whitehead – a legend in health inequalities
I had the honor of hearing Margaret Whitehead, professor of public health in Liverpool, speaking at a confernce in Belfast on 2 October. Whitehead is synonymous with strategies to reduce health inequalities and improve the health of the poorest. She wrote the follow up to the seminal Black Report in England which was the first official government report in the developed world to document the extent of health inequalities that existed between rich and poor. This work also made clear the social gradient that exists in health, ie the more income you earn and the higher you are up the social scale, the better your health. Whitehead’s book ‘The Health Divide’ which also included the Black Report was a classic Penguin best seller and sold well over 100,000 copies – a very unusual achievement in public health literature. Here are some of the interesting points she made in Belfast and some quick thoughts of mine on strategies (or lack of them) to reduce health inequalities in Ireland, North and South. Currently Margaret Whitehead is one of the leaders of the World Health Organisation’s work on the social determinants of health. This work looks at the evidence in the developed world on the extent of health inequalities and most importantly what can be done about it.
Speaking in Belfast lsat week Whitehead used the definition of health inequalities cited in the above mentioned WHO work – “the unequal distribution of power, income, goods and services, globally and nationally”. These health inequalities are the consequence of poor social policies, unfair social arrangements, and bad politics.
What is so important about this definition is that it means if there are better social policies, fairer social arrangements and better policies, we can reduce and even eliminate health inequalities in health.
Whitehead gave a range of examples on how improving the conditions of daily life can tackle health inequalities. Examples given were national policy efforts which make work more secure (which greatly enhances mental health), tackling child poverty and having generous family policies, universal public services which all impact most on the health of the poorest. Countries like the United States of America, England and Ireland have been very weak in these areas, where as countries such as Sweden, Norway and Spain have been much more effective in reducing health inequalities.
Whitehead was emphatic that national policies matter, especially tax and welfare policies and education. She gave the example of the the former Soviet Union coutnries who experienced the most dramtic drop in life expectancy after the fall of the Soviet block, and that it was low educated men who epxerienced the msot severe drop in life epxectancy.
Whitehead also made the case for using natural experiment such as the Ireland of island where we have two governments with different policies, which provides fertile ground for analyses. She also made the case for looking at the impact of policies on the most vulnerable, to always consider who benefits and pays for such policies. In England in the 19980s and 1990s, when Thatcher and right wing economic policies reigned supreme, average incomes rose by 40∞, but if one looks at the detail of these figures, it shows that the income of the richest ten per cent of the population increased by 65% while the income of the bottom ten per cent decreased by five per cent. This demonstrates the impact that tax and welfare policies can and do have on the health and wealth of the poorest. Examination of policies post 2000 in England show a better redistributive effect but no where near sufficient to address inequalities casued by 18 years of Conservative party policies.
The day I heard WHitehead speak I did my radio slot on this. I also looked briefly at Ireland North and South and track records on reducing health inequalities. In short my synopsis on these are:
Northern Ireland has a really high quality health strategy called Investing for HEalth. THis is currently being reviewed but it provides an excellent blueprint on how inequalities can be addressed. It puts health and public health and reducing health inequalities at the core of all policy development. IT provides a statutory duty of well being on all service providers. It has put significant energy and resources in to setting up and evaluating local Investing for HEalth partnerships. The new Public Health Agency set up in APril of this year is driving the process. The only down side to the Northern Policy is Northern politics which still does not have control over macro economic polices and is limited in its ability to influence redistributive tax and welfare policies. But definitely Northern Ireland is worth watching in terms of its policies to reduce health inequalities.
And in Ireland, we are not even on the map. Our health strategy, albeit redundant is a sickness service strategy not a public health strategy. There is a total absence of leadership on public health issues, we do not have a public health policy not a minister who is interested in public health let alone health inequalities.
One more thought: Margaret Whitehead referred to ‘lifestyle drift’. By this she meant that when people talk about addressing health inequalities, very quickly they drift into talking about and focussing on lifestyle factors such as smoking, drinking and obesity. The speaker from the Dept of Health in the SOuth did just that at the conference, while he spoke broadly favourably about reducing health inequalities the minute he had to talk about about it was back to the traditional lifestyle issues…