ROTTERDAM—People who are lower on the socioeconomic ladder (indicated by their level of education, occupation, or income) have shorter and less healthy lives, on average, than those on higher rungs. Indeed, life expectancy at birth often varies by 5-10 years, depending on social and economic well-being, with poorer people spending 10-20 more years of life suffering from illness or disability than their wealthier counterparts.
In the 19th century, this situation would not have been surprising, given low average income, widespread poverty, and lack of social security. But such data are commonly reported for high-income countries today, including those ranking high on indices of economic prosperity and human development—even Western Europe’s highly developed welfare states.
Since the end of World War II, Western European countries have tried to reduce socioeconomic inequality, or offset its consequences, through progressive taxation, social security programs, and a wide range of collectively financed provisions, such as public housing, education, health care, and cultural and leisure facilities. But, while these policies have reduced inequalities in some social and economic outcomes, including income, housing quality, and health-care access, they have been insufficient to eliminate health inequalities.
Long-term time-series data indicate that the socioeconomic mortality gap narrowed before the 1950s, but has grown substantially since then. More puzzling is the fact that more generous welfare policies do not translate into smaller health disparities. Even the Nordic countries—world leaders when it comes to creating universal and well-designed welfare policies that cover citizens from cradle to grave—face significant health disparities, despite their relatively low income inequality.
To be sure, modern welfare states have far from abolished social inequality, with disparities in access to material and human resources continuing to generate highly unequal lives among their citizens. But the welfare state’s aim has never been radical redistribution of wealth. Rather, welfare policies are intended to create a compromise between the interests of employees and employers, laborers and the middle classes. As a result, their redistributive effects are modest.
So, while a partial failure of the welfare state may help to explain the persistence of health inequalities, one must look elsewhere to understand—and reverse—their rise. Two possible explanations have emerged from the rapidly growing scientific literature on the subject: selective upward social mobility and delayed diffusion of behavioral change. In reality, both factors are at work.
During the 20th century, social mobility increased slowly but steadily in all high-income countries, with educational achievement and occupational status depending less on family background and more on cognitive ability and other personal characteristics. As a result, the lower socioeconomic groups have not only shrunk in size, but have probably also become more homogeneous in terms of personal characteristics that increase the risk of health problems.
Moreover, people with a higher socioeconomic position tend to adopt new behaviors first, and to abandon more readily behaviors that are found to damage health, such as smoking and high-fat diets. Given this, new behavioral recommendations by health authorities tend to exacerbate health inequalities, at least temporarily.
Significant disparities in smoking, physical exercise, diet, and alcohol consumption afflict many of Western Europe’s welfare states. The welfare system, which was created to combat poverty, has been less effective against “diseases of affluence” like heart disease and lung cancer.
All of this highlights the need for creative solutions to disparities that unnecessarily and unfairly blight the lives of those who have the least, generate massive health-care costs, and pose a barrier to increased labor-force participation (impeding efforts in some countries to raise the retirement age).
In the last few decades, social policy in most Western European countries has moved away from redistribution. This is a mistake, given that the consequences of this shift—rising income inequality, weaker social safety nets, and reduced health-care access—will aggravate health inequalities in the long run.
In fact, more, better-targeted redistributive policies, which account for the effects of selective upward social mobility and different rates of diffusion of behavioral change, are crucial to improving health outcomes in lower socioeconomic groups.
Income support should be complemented by preventive health programs, while health literacy programs could help to diminish the link between low cognitive ability and bad health.
Equal access to health care is not enough. Reducing inequalities in health outcomes requires more intensive health care for patients in lower socioeconomic brackets, tailored to their specific needs and challenges. For example, revenues from tobacco taxation, which disproportionately affects lower-income groups, should be used to fund cessation-support programs that target disadvantaged smokers.
Significant and persistent health inequality indicates that, by raising the health levels of those with lower incomes or less education, massive strides could be made in improving populations’ overall health. This may require reshaping the welfare system to some extent, but the payoff would be well worth the effort.
Johan P. Mackenbach is professor of public health and chair of the Department of Public Health at Erasmus MC, University Medical Center Rotterdam and a member of the Royal Netherlands Academy of Arts and Sciences.