Improving population health means more than reducing inequality

Reflecting increasing individualism as well as materialism, other studies have found that extrinsic goals (money, image, fame) have become more important since the 1960s among American high school and college students, and intrinsic goals (self-acceptance, affiliation, community) less important; concern for others, civic orientation and environmental action have declined. Such trends have obvious implications for the quality of social relations, and so health and wellbeing. Other US studies have taken adverse trends in young people's psychological health back as early as the 1930s, so spanning a sustained period of declining inequality.

In arguing for a new narrative of declining health and wellbeing among young people in developed countries, I have suggested that the central dimension of the changed trajectory in their health over recent decades is a shift in relative importance from structural determinants to cultural; from socio-economic deprivation to psychosocial deprivation. The costs include a loss of social integration, intrinsic worth, moral clarity and existential confidence. One result is that mental health problems have become more significant, accounting for by far the biggest share of the burden of disease in at least some Western countries. Most mental illness begins in childhood, adolescence and early adulthood and affects people in the most productive years of life, increasing the personal, social and economic costs. In contrast, the burden of chronic physical diseases such as cancer, stroke and heart disease falls predominantly on the elderly.

One reason that research into health inequalities, both within and between countries, has attracted so much attention and support is that it resonates with a progressive ideology, which emphasises social justice and equity, at a time when neoliberalism or market fundamentalism has become more powerful, and inequality is rising in many countries.

This appeal is understandable: the research fits within the current political paradigm, with its contest between the progressive left and the conservative right. Inequality is also relatively easily addressed through changes in public policy in areas such as taxation, housing, education and health. On the other hand, recognising the complex dynamics of social influences on health suggests far deeper, systemic changes in society are required.

In raising my doubts about the role of inequality in health with epidemiological colleagues, one cautioned against a 'narcissism of small differences' (where differences are exaggerated to enhance or distinguish one's own position). The key is to bring together people who want to move society forward rather than emphasising differences, even when these are not that small, he said.

However, science must strive to rise above ideology, and this is especially important in politically laden issues like inequality. Furthermore, there are costs in overstating the importance of inequality (as distinct from poverty and disadvantage) to health. First, given the legitimate doubts and uncertainties about the research, it risks weakening the arguments for equality. More importantly, in the wider context of humanity's problematic future, the case for fundamental change becomes much stronger when we look, not just at inequality, but at all the structural and cultural foundations of modern life, and the multiplicity of their interactions.

Reducing inequality may well be a good thing for many reasons, including improving health, but it will not solve the persistent and sometimes worsening problems of population health and wellbeing.