The ten steps for acting on health inequalities

1. Introduction

There are ten steps, which if taken by academics, policy makers and politicians, would help them to understand better, and in turn act on reducing health inequalities. These ten steps move the discussion about health inequalities beyond both the conventional accounts of lifestyle risk factors and the wider determinants of health.

Health inequalities are the avoidable differences in health and disease between groups of people based on a social characteristic. Acting on health inequalities is an urgent priority because in the UK health inequalities are widening [1]. As a consequence, people belonging to some communities die younger than others in different communities and places. This includes members of some ethnic minorities, those living with a disability, and people that are relatively poor and disadvantaged. Permitting inequalities to widen in a rich country such as the UK, is morally wrong and is also harmful to long-term prosperity. The ten steps described should be front and centre in the thinking and policy development for all political parties in the UK, as they gear-up for the forthcoming general election.

1.1. Step one: Take a syndemic approach

Health inequalities must be approached syndemically [2]. The syndemic approach is based on understanding the dynamic set of interdependent interactions between disease, behaviour, biology, and social conditions [3]. It involves not focussing on proximal risk behaviours, separate physical and mental health conditions, and distinct aetiological pathways. It involves not defaulting to explanations which cite the wider determinants of health, without explaining how such wider determinants work causally [4].

Syndemic means that social and economic circumstances are not mere background or context, nor distant wider determinants of health. Syndemic means that social and economic circumstances are intrinsic to the ways that patterns of morbidity develop and progress. Syndemic involves at least a three-way interaction between two diseases or disease processes, and the social conditions in which people live and work (as depicted in Fig. 1). The diseases may originate in infection or another aetiological precursor. But these interacting disease processes also interact directly with social conditions. Adverse social conditions interact synergistically and simultaneously with the health condition and/or risk behaviour to influence biological pathways. There are mechanistic causal linkages between the biological and the social, and the social and the biological [5]. The social is not a set of background risk factors, nor are behaviours – like eating, drinking, and smoking - just risk factors. Their link to human biology is directly causal.

Fig. 1.

The syndemic model of health. Adapted from Singer et al. [6].

Population health can only be improved in places and communities where health is on average poor, through the actions which may follow from syndemic understanding. The patterning of population level health inequalities, and the morbidity and mortality of individual people, do not have single causes or risk factors. It is also important to remember that health inequalities do not simply affect the poorest or the most disadvantaged people. Inequalities in health stretch across the whole spectrum of society in a health gradient. Action on health inequalities needs to address the entire gradient, and in ways reflecting the needs of different social groups [7,8].

The patterning at the population level is the consequence of multifactorial sets of syndemic interactions, which are simultaneously biological, social, material and psychological. They also involve interactions between the different axes of social differentiation in the population – class, ethnicity, gender, age, disability, sexual orientation, geography, education, and income. The syndemic approach involves taking account of the multiple interactions [9]. It is also important to frame the thinking in such a way that politics, the economy, labour markets, working conditions, all play a role in these syndemic interactions [10]. Syndemic thinking then leads to the next steps.

1.2. Step 2: Thinking beyond multimorbidity

It is commonly observed that as people age, it is not unusual for them to have several medical problems – often referred to as multimorbidity. Frequently the default position is to think of each of the conditions as separate disease entities and for separate treatments to be applied to each condition.

A syndemic approach does not focus on the idea of multimorbidity as a collection of discrete illnesses with discrete causes. Rather, a syndemic approach involves understanding the totality of the interactions between the biological, social, and physical phenomena that result in morbidity by affecting multiple biological pathways in the human body all at once [11]. The potential for treating all the phenomena as intrinsically linked, having simultaneous effects on all elements in the complex systems of the human body and the social world, must be realised.

The idea of complex systems has been widely discussed, but the conceptual and empirical linkages of elements in the system are seldom analysed in a way that illustrates how systems actually work [12]. Systems and systems thinking are more often than not, convenient rhetorical devices, rather than helpful pathways to solutions. In contrast, a syndemic framework is useful in understanding, and then seeing beyond not only multimorbidity but also the causal mechanisms in the wider systems themselves.

1.3. Step 3: Going beyond association to cause

There is an enormous amount of evidence showing the associations between social and economic circumstances and rates of disease. Demonstrating an association or correlation, however, is not the same thing as demonstrating cause [13]. In some cases, mechanistic causal pathways between social and economic circumstances and disease, are well-documented. For example, the well-established lines of research in epigenetics showing the consequences of in utero exposures to the foetus, as a result of noxious insults to the mother, on the subsequent adult health of the foetus [14]. In other lines of research, studies of the metabolome inform us about the interactions between the human genome and the social world [15] Research, examining the experience of stress or of stressors variously defined, via pathways from social disadvantage producing an inflammatory response in the human body, are also well known [16]. These types of investigation suggest there are strong mechanistic and interactive links between social and biological phenomena. However, these causal links have only been elucidated for some associations. More specifically, the precise connection between the social world external to the human body and the biological processes internal to the body that unfold, are very little described scientifically. This is a major gap in the evidence, and the Research Councils and NIHR should be encouraging and funding research to fill the gaps.

The established and evidence-based causal pathways should be drawn into future studies of health inequalities much more explicitly than has conventionally been the case. This is important because fuller understandings of causal pathways can enable more effective health inequality interventions to be developed and evaluated. It can also provide policy makers and the general public with robust explanations of how inequalities in health occur. Such causal explanations may be necessary to establish and maintain the societal and political support needed for implementing policies that reduce such inequalities [13].

1.4. Step 4: Going beyond cause to action

A large amount of public health research is about identifying risk factors for human disease. However, knowing the risk factors or the precise aetiology, even within a syndemic frame of reference, is not sufficient to do effective prevention [17]. Effective prevention requires evidence which is not only about causes, but also about how to do interventions in an effective way. To know that exposure to cigarette smoke causes disease, does not tell you how-to help people to stop smoking, nor how to control the tobacco industry. We need to know more about “How to”., especially at local level. This will require working with local political organisations, emphasising the fundamental importance of intersectoral working, and seriously and meaningfully engaging with vested interests and other stakeholders.

There is plenty of evidence, though it is not completely comprehensive, about what works and what is cost effective, and about which interventions improve, and which make worse, health inequalities [18]. But how to do these things locally, and in, and especially with, the communities where the consequence of inequity are felt most keenly, is at best haphazard and at worst non-existent. That requires different evidence derived from research about doing prevention. Building the evidence base on “How to“ is an urgent priority.

The public health community must answer the question of “How to do it!”, at local level, in conjunction with local people and local service providers. The assets of localities must be harnessed with the resources of all the services which serve the local communities. This will involve understanding syndemic interactions from the point of view and the experience of the people living in those communities.

There is relatively little of this “How to” in the public health evidence base, because studies and evaluations that attempt to answer this question generally do not rank highly in the traditional hierarchy of evidence. Their small scale and limited resources, small samples, limited follow-up, and no control group, count against them. They may also rely heavily on qualitative research methods. And each intervention may be unique after being adapted to its local context and community. How may we improve this state of affairs?

The academic community needs to think differently about the learning that can be gained from studies such as these. Without using the resource which is to be found in such evaluations, policy will not be made, or it will be made anyway in the absence of evidence. Generating meaningful inferences from this type of evidence requires adopting a flexible and nuanced approach [19]. It may also require using a range of different research paradigms. Continuous intelligence and data gathering is basic to efforts to understand what is going on, along with continual evaluation. And these activities need to focus on the local as much as on the national level. At local level they need to be available and accessible to local communities and the various public health actors.

1.5. Step 5: Really work at local level

The ideas, energy and focus for local improvement has to come from within communities. Communities have much of the “How to” knowledge, and will share it if they are asked. For many years the idea of asset-based approaches has been talked about, and the idea behind this is undoubtedly compelling [20]. But getting it right with communities has often proved to be much more difficult. Heavy-handed local authorities, ministerial dictat as well as centralised control in Westminster and Edinburgh, have frequently undermined these locally based activities. At its most basic, communities and community members know a lot about themselves and their lives. In other words, they have what is sometimes called lived experience. But harnessing this for the communities’ own benefit has proved to be elusive. At the heart of an assets-based approach is giving people control over their own lives. We need to tap into the life worlds of the people we want to help, if we are going to help. If we start from the premise that we already know what the problem is, our efforts will likely fall on barren ground [21]. In turn this requires resources and training. There is on the whole, little shortage of good will in this regard, but getting in and with communities is not easy. It needs dedicated time and space.

The aim should be to work at the locality level where the granularity of social differences plays out and where community assets may be harnessed. Despite much supportive rhetoric, that is not the way the systems currently function. It's not so much taking a bottom-up approach, as the well-worn cliché has it, as starting at the bottom. Finding out what is happening on the ground, and generating solutions which are both evidence-based and workable at that level.

Community led organisations will play a critical role here. However, it is vitally important not to impose burdens on people to do extra things as volunteers, without providing additional resources or support. A task which an employee in the service of local or national government, or the NHS, would do as a paid job, can't be sloughed off to community members. Instead, employees can support volunteers to be more effective at helping their community by assisting with bureaucratic and funding type problems. Due to the considerable time and the emotional resource that has to be invested by volunteers, failure to take this approach will likely result in burn-out and exhaustion, followed by withdrawal from volunteering.

1.6. Step 6: Taking the life course seriously

It is not sustainable to leave the preventive effort till people are in middle age. The chronic mental and physical health problems associated with non-communicable diseases tend to manifest in mid-life. But their origins are much earlier in the life course. There is a great deal of evidence about the consistent exposures to social and environmental conditions across the life course [22]. These exposures set-in motion, and interact with health behaviours and biological pathways that last throughout life [23]. The preventive actions must apply, in other words, across the entire life course, but with a particular focus on early years, in order to alleviate the worse consequences of noxious stressors and exposures. This is not of course to argue that therefore no one would ever get sick, but it is to argue that a good deal of what the health and social care services have to deal with, is preventable or could be delayed.

1.7. Step 7: Harness the behavioural evidence and evidence of cost effectiveness

All and any intervention undertaken in the name of health improvement or protection must be based on evidence. There is a significant evidence armoury about health-related behaviour change, which is frequently by-passed in policy, but should be central in any interventions in which behaviour change is part of the mix. Behaviour change is never a panacea. The most effective population interventions have involved multilevel, multifaceted activities including policy, taxation, education, financial incentives, and sometimes legal sanction. Behaviour change is nevertheless one important component. It is therefore important to get it right. In other words, to use the best available evidence, and not to rely on non-evidence-based approaches [24]. In this regard there are several important conceptual models which may be pressed into service, most notably the COM-B Model and associated behaviour change wheel [25]. Although well-known in academic circles, the failure by policy makers to fully use them in favour of that which seems like common sense, needs to be fixed. The problem with common sense is that it tends to focus on individuals and this in turn leads to victim blaming [24]. This is neither helpful, nor fair, and it is why syndemic thinking is so important.

In the UK, NICE have developed the methods and have a history of assessing public health interventions, and producing public health guidelines and recommendations about cost-effective interventions which address health inequalities [26]. Spurred on by the Covid pandemic, NICE have recently renewed their efforts to highlight how their guidelines can support reducing health inequalities. This programme should be taken further and be the basis for the forward programme of health improvement. As the Brown-Blair Ministries were drawing to a close, one idea which was gaining currency in the then Department of Health, was to put NICE public health recommendations on a par with its recommendations about new drugs i.e., to make them mandatory for health jurisdictions to implement. With the arrival of the Coalition Government this idea was quickly dropped. However, it is an idea that could, and should be revisited.

1.8. Step 8: A new dialogue

We need to facilitate the development of a new dialogue about health and illness and especially in relation to the ideologies that often cloud the issue. Down the centuries politicians have been intrinsic to public health improvement. Some have also been responsible for preventing health improvement and making population health worse. Public health is always political because one person's or group's benefit is another's disbenefit. Too often we portray public health policies as ‘win-win’. For example, if we focus our efforts at improving the health of people with the worst health, such as the most disadvantaged or of ethnic minorities, then those efforts are not spent improving the health of those that are less disadvantaged or who are not ethnic minorities. Taking this approach is in part equitable and can be morally justified, but it is not efficient. Some groups would gain nothing, even though in relative terms on the health gradient, their overall pattern of health is not good. Generally, the most efficient way to increase the health of the population overall is to focus on improving the health of the whole health gradient. But this may not be equitable - not everyone benefits to the same degree. Acknowledging that there is a trade-off between equity and efficiency is key to having an honest dialogue with the general public and policy makers.

The benefit - disbenefit argument also applies to profit-making companies. If we restrict sales of tobacco, or sugary drinks, or alcohol, we restrict the operation of the market and in turn the profits of organisations making and marketing such products. Population health would improve and the public purse will likely save money, but there is nevertheless a cost to some, which needs acknowledged.

More generally, public health measures are frequently seen by some as restrictions on the individual freedoms of people to live their lives in ways of their own choosing – the accusation is that public health measures are the Nanny State writ large. However, when considering the advertising budgets and lobbying techniques of alcohol, betting, sugary drinks and fast-food companies, and the influence these have on individuals being able to live their lives in ways of their own choosing, it seems fair to ask who the Nanny really is [27].

The fact is that the conflict between individual freedoms and societal benefit is always the background political reality of public health and health improvement. The differences between these viewpoints will not be solved by ever more shrill accusations of bad faith on both sides. Instead, an acknowledgement of the knotty nature of the problem has to be the starting point for a mature dialogue.

1.9. Step 9: Think health and prosperity

So we need a mature dialogue in which first, the underlying benefit – disbenefit argument is acknowledged, and second, in which health improvement and economic prosperity are not cast as irreconcilable opposites. Historically, the evidence demonstrates that there is a two-way relationship between health and economic prosperity. Where we have had periods in English society where living standards were protected and improved, populations prospered and the overall health of the population also improved [28]. Where the social and economic conditions of the majority declined, so too did the overall health of the population.

Health contributes to economic growth by increasing the size of the workforce, and increasing the effectiveness of the workforce to make goods and services (its productivity). In the UK, the number of people who are economically inactive because of long-term sickness has risen from 2 million at the start of 2019 to 2.5 million at the start of 2023 [29]. This trend pre-dated COVID19 but was exacerbated by it. To reverse it, and return to a state where health contributes to a prosperous society, will require concerted efforts to improve population health and reduce inequalities. But of course, it has to be prosperity underpinned by economically sustainable and climate friendly productivity. This might mean that profits are not as great as an unregulated market might permit, but there will still be profits. One idea which ought to be considered, and would help the dialogue enormously, is the establishment of an independent apolitical committee to oversee, public health policies. This could be rather like the Bank of England's committee which considers interest rates.

1.10. Step 10: Holding the responsible to account

We must stop deliberately pursuing policies which damage people's health. We already seek to hold accountable those industries, organisations and specific companies whose activities pollute the atmosphere, or create noxious and health damaging products [30] Likewise, we must hold policy makers accountable for policies which are health damaging, for example by reducing life expectancy or widening inequalities. It is important, looking to the future, to hold governments accountable for deliberately, or inadvertently, damaging the health of the population, or for assuming that the negative health consequences of political decisions are simply unfortunate collateral damage for policies that are otherwise beneficial to some (but not all) sectors of society.

This may sound far-fetched, but we are already seeing examples of this with regards to environmental policies. The 2008 Climate Change Act committed the UK government by law to reducing green gas emission to net zero by 2050. The Act also established the independent Climate Change Committee (CCC) to measure progress against net zero and make evidence-based policy recommendations. One CCC transport recommendation, put into legislation by the Welsh government, was to reduce car-mileage per person. This has caused new Welsh roads projects to be shelved after an expert panel assessed them to not be compatible with the statutory car-mileage reduction targets https://www.gov.wales/future-road-investment-wales The Institute for Public Policy Research have advocated for a similar Health and Prosperity Act that could establish a 30 year ‘mission’ to improve health. Based on the CCC, a Health and Prosperity Committee could provide independent advice, monitor progress, and help hold future governments to account.

2. And finally

It is vital first, to ameliorate poor social and material conditions in such a way, that life as it is lived, is comfortable, where home environments are warm, safe, and under the control of the people living in those home environments. Second, it is important that there is enough money available for families to eat, and in ways that satisfy their hunger, as well as providing the basic needs of human nutrition. Third, providing support for maternal and child health is paramount. Fourth, managing alcohol consumption so it may be a pleasure and an opportunity for safe socialising, not a means of retreat from the harsh realities of life, is an important priority. Fifth, it is absolutely necessary to close down the opportunities for criminal elements to prey upon and exploit vulnerable and disadvantaged people. Sixth, the local physical environment needs to be protected so that streets, gardens and parks are well-maintained and not littered with debris.

These are not novel suggestions, but getting them to happen, knowing “How to” bring about these things, remains a large gap in the understanding of what to do, and is not what happens in many communities across the UK. In order for a population to enjoy good health, in short, we need a better world. But we cannot create a better world by wishing it, by ideological dictat, by legislation or even by well-intentioned beneficence. Pragmatically, what can be achieved is to do things that we know will reduce heath inequalities and avoid doing things which we know will cause harm and widen inequalities. To do that, we need to think differently - syndemically - about the problem and to provide solutions that avoid the mistakes that have been made so often in the past.

Author contributions

MK developed the original idea for the article, and wrote the initial draft. AC contributed to the critical appraisal of the argument, and the drafting of the manuscript. Both authors have approved the submitted version.

Declaration of competing interest

The authors have no conflicting interests to declare.