Inequalities in health

Editor—In their editorial Davey Smith et al welcome the report of the independent inquiry into inequalities in health but criticise it for not sufficiently tackling the underlying causes of health inequalities, which they see as following from inequalities in wealth, material resources, and especially income.¹ As partial evidence they refer to the simultaneous increase in income inequalities and social inequalities in mortality in Britain over the past 20 years.

The role of income inequality as the fundamental cause of health inequality may not be as evident as these authors claim. A recent comparative study in the European Union on social inequalities in health among men indicate that the association between income inequality and inequalities in health is weak. For example, in four Scandinavian countries—Finland, Sweden, Norway, and Denmark—social inequalities in morbidity and mortality are roughly comparable to or larger than those in Britain, yet income inequality is much smaller.² Furthermore, in these countries changes in income inequalities were not closely associated with changes in social class differences in mortality. Finland and Denmark have experienced increasing inequalities in mortality since the 1970s.³ Both countries, however, had relatively constant income inequalities until at least the early 1990s.⁴

In Sweden social inequalities in mortality have increased rapidly since the late 1960s, the increase being especially rapid in the 1970s. In the 1970s and 1980s similar increases were also observed in Norway.³ In both countries, however, income inequalities started to increase slowly only after the mid-1980s,⁴ well after the period of most rapid increase in social inequalities in mortality.

These results—together with the well established observation that social inequalities in mortality can also be observed between the social categories at the top of the social hierarchy—cast doubt on the hypothesis that increasing income inequality and poverty are the main underlying cause of social inequalities in mortality. Although policies to reduce income inequalities can be applauded in many countries as a means of increasing social justice and equality, the experience of the Scandinavian countries indicates that such policies are unlikely to be efficient in eradicating inequalities in mortality.