BMJ  2007;334 (3 March), doi:10.1136/bmj.39140.571759.43

Editor's Choice

Editor's choice

Our unequal society

Back in the 1980s, when Margaret Thatcher was confidently asserting that there was no such thing as society, researchers ploughing the unfashionable furrow of health inequalities must have despaired of ever being heard. Things have moved on since then, though not perhaps as far as we might have hoped. There is now good evidence, some of it published in the BMJ (1999;319:953) that the healthiest and happiest societies are those with the most equal distribution of income. And compared even with a decade ago, when wider issues such as poverty and housing were excluded from discussion (BMJ 1995;311:1177), governments have become braver about embracing these social issues when talking about health. The 2004 Wanless report showed that the British government is taking seriously the need to take action to reduce health inequalities.

But the reality lags far behind. In 2005 George Davey-Smith and colleagues looked at health inequalities in the UK (BMJ 2005;330:1016, doi: 10.1136/bmj.330.7498.1016) They concluded that, despite government promises of action, inequalities in life expectancy have continued to widen, alongside widening inequalities in income and wealth. Last month's Unicef report has put unwelcome flesh on the bones of this evidence, ranking Britain bottom among the 21 most developed nations in terms of the wellbeing of our children, while countries with more equal wealth distribution, most notably the Netherlands, can celebrate happy healthy children who are not living in a climate of fear. As with health care, the individualistic, market forces and US model—that potent mix of individualism, market forces, and illiberal social policies—does not look like the one that countries should follow. Instead the evidence points towards the benefits of liberal policies on drugs and sex, and comprehensive social welfare.

Doctors deal every day with the fallout of our unequal society and may feel, with good reason, that they lack the tools to make a difference. "We doctors are hiding," says Des Spence, "in a dugout in the comfort zone of scientific medicine, so often of questionable benefit, so that we have lost sight of the wider problems in society. Perhaps it is time to look over the edge and see the devastation that childhood is becoming" (doi: 10.1136/bmj.39139.462361.59)

The science may be comforting but it can also be powerful. As Hilary Thompson writes (doi: 10.1136/bmj.39133.558380.BE), the Wanless report highlighted the almost complete lack of evidence for interventions to reduce health inequalities. A study in this week's BMJ addresses that lack. Philippa Howden-Chapman and colleagues have pulled off an impressive feat with their randomised trial of improved insulation in low income housing in New Zealand, finding that it improved self reported and objective measures of health (doi: 10.1136/bmj.39070.573032.80). Before this trial, the debate was stuck on whether low household income rather than substandard housing was the main problem underlying health inequalities. As the authors of this study conclude, it is easier to upgrade low income housing than to redistribute income.

Reducing inequity is a global responsibility. One of the four cornerstones of WHO's health for all policy is ensuring equity in health. The BMJ and other journals are focusing on poverty and health later this year (http://www.bmj.com/channels/research.dtl#call) and this year's Global Forum for Health Research in China has taken health inequity as its theme. Good research can change the way people think.

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