The health inequalities turn as a dangerous frame shift

Journal of Public Health | Vol. 39, No. 4, pp. 653–660 | doi:10.1093/pubmed/fdw140 | Advance Access Publication January 9, 2017
Reframing inequality? The health inequalities turn
as a dangerous frame shift
Julia Lynch
Department of Political Science, University of Pennsylvania, Philadelphia, PA 19104, USA
Address correspondence to Julia Lynch, E-mail: [email protected]
ABSTRACT
Background Politicians in many countries have embraced the notion that health inequalities derive from socioeconomic inequalities, but
European governments have for the most part failed to enact policies that would reduce underlying social inequalities.
Methods Data are drawn from 84 in-depth interviews with policy-makers in four European countries between 2012 and 2015, qualitative
content analysis of recent health inequalities policy documents, and secondary literature on the barriers to implementing evidence-based health
inequalities policies.
Results Institutional and political barriers are important barriers to effective policy. Both policy-making institutions and the ideas and practices
associated with neoliberalism reinforce medical-individualist models of health, strengthen actors with material interests opposed to policies that
would increase equity, and undermine policy action to tackle the fundamental causes of social (including health) inequalities.
Conclusions Medicalizing inequality is more appealing to most politicians than tackling income and wage inequality head-on, but it results in framing
the problem of social inequality in a way that makes it technically quite difficult to solve. Policy-makers should consider adopting more traditional
programs of taxation, redistribution and labor market regulation in order to reduce both health inequalities and the underlying social inequalities.
Keywords health policy, health inequalities, medicalization, social determinants
Introduction
Growing recognition of socioeconomic inequalities in health in
the rich western democracies presents politicians with an apparent opportunity: by embracing health inequalities as a political
problem, they can proclaim their attachment to the issue of
equity while at the same time avoiding direct discussion of
contentious issues like redistribution of income and wealth.
Framing the problem of social inequality in health terms
may be safer for politicians than speaking directly about inequalities in the fundamental causes of health;1 but, I argue, it
reshapes the policy-making environment surrounding social
inequality in ways that make it more difficult to reduce both
social inequality and health inequalities. Political and institutional
factors associated with shifting from a social inequality to a
health inequality frame pose substantial barriers to reducing
inequality, bringing into play institutions that act to reinforce
medical, behavioral and neoliberal policy approaches.
To show how reframing social inequality in health terms
may make it harder to reduce both forms of inequality, I draw
on a variety of sources and methods. These include 84 in-depth
interviews with health policy experts and policy-makers in
England, Finland, France, Belgium and at the WHO Regional
Office for Europe; qualitative content analysis of recent government reports and plans and process-tracing reviews of the
secondary literature on policy responses to health inequalities
in (see Table 1 for details).
The health inequality problem frame
and its policy outputs
Epidemiologists and policy actors have long been aware of the
link between social inequality and health inequalities.2–4 In the
modern era, the 1980 Black Report in the UK5 set in motion
a process of linking health and social inequality in political discourse (see Table 2)—most visibly in the 1997 national election campaign in Britain, in which the Labour party
Julia Lynch, Associate Professor of Political Science
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successfully used the issue of health inequalities to ‘kick the
Tories’ (UK4), highlighting the failure of the incumbent
Conservative government’s health and economic policies.
Scholars and international organizations have helped to
define the policy problem of health inequalities in a way that is
closely linked to social inequality more broadly. The dominant
definition of health inequalities, articulated by Whitehead6 and
echoed in the final report of the WHO Commission on the
Social Determinants of Health (CSDH),7 invokes social
inequality as the driver of health inequalities and recommends
redistributive policies to combat these inequalities. Key policy
statements such as the CSDH report and the Lancet-University
of Oslo Commission report8 say little about ‘whose resources,
and how and through what instruments’ ought to be redistributed.9–12 But despite this lack of a roadmap for producing a
more equal distribution of the upstream social determinants of
health, the health inequalities problem frame has disseminated
throughout Europe via scholarly networks like the Eurothine
Table 1 Sources and methods
Context Number of interviews conducted Dates
(a) Interviews
Belgium 24 May–June 2013
Finland 13 March 2015
France 41 June 2011, July 2013 and June 2014
United Kingdom 6 July–October 2014
European Union 2 May 2013 and July 2014
WHO Regional Office for Europe 3 March 2015
Topics covered in interviews: history of political and policy attention to health inequalities; political context of policy-making on health inequalities;
inventory of health policy apparatus and outputs; major schools of thought and network analysis of scholarly research community working on health
inequalities; relationship between scholarly and policy communities working on health inequalities.
Context Date Title
(b) Recent policy documents consulted
Belgium 2010 Les inégalités sociales de santé en Belgique [Social inequalities in health in Belgium]
2007 Recommandations politiques—inégalités en santé [Political recommendations: health inequalities]
Denmark 2013 Ulighed i sundhed [Inequality in health]
2011 Inequality in health: causes and interventions
Finland 2008 National action plan to reduce health inequalities 2008–2011
France 2011 Les inégalités sociales de santé: déterminants sociaux et modèles d’action [Social inequalities in health: social determinants and
models for action]
2009 Les inégalités sociales de santé: sortir de la fatalité [Social inequalities in health: escape from fatalism]
Norway 2007 National strategy to reduce social inequalities in health
2005 The challenge of the gradient
United
Kingdom
2010 Healthy lives, healthy people
2010 Fair society, healthy lives: the Marmot review
2009 Tackling health inequalities: 10 years on
2008 Health inequalities: progress and next steps
Sweden 2010 Public health of the future–Everyone’s responsibility. A summary of the Swedish public health policy report 2010
2005 Folkhälsopolitisk rapport 2005 [Public health policy report 2005]
European
Union
2011 European Parliament resolution of 8 March 2011 on reducing health inequalities in the EU
2009 Commission communication Solidarity in health: reducing health inequalities in the EU
WHO 2013 Health 2020: a European policy framework and strategy for the 21st century
2013 Review of social determinants and the health divide in the WHO European Region: final report
Documents coded for: causal theories of health inequalities (biomedical, behavioral, downstream social determinants, upstream social determinants,
fundamental causation), with special attention to causal force attributed to income/earnings inequality versus poverty/low income; attribution of treatment
responsibility (individuals, communities, society, market actors, local government, national government); proposed concrete actions to reduce income/
earnings inequality; use of diagrams, models and concepts derived from WHO materials; references to other major government or scholarly reports.
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collaboration and through key policy statements of the World
Health Organization’s Regional Office for Europe13–15 and the
European Union.16–19
With the social determinants of health (SDOH) problem
framing as a backdrop, some political actors in Europe have
followed the example set by the Labour party in 1997 and
embraced health inequalities as a political issue. Between
May 2012 and March 2015, I conducted interviews with 84
policy experts and policy-makers that touched on motivations for politicizing the issue of health inequalities in their
country. Interviews with English policy actors confirmed
that the health inequalities problem frame, with its focus on
the social determinants of health, allowed center-left policymakers to reintroduce the possibility of redistributive social
policy when the neoliberal consensus of the 1980s and
1990s made consideration of such policies fraught.
Other interviewees, notably in France and Finland,
explained that the health inequalities issue was politically
useful because it resonated with a longstanding political
emphasis on social equality in their countries without directly referencing income inequality or redistribution.
Raising the issue of health inequalities was also viewed by
French, Finnish and Belgian interviewees as lending legitimacy to policy-makers’ attempts to reform other aspects
of the health system (e.g. limiting expenditures, controlling
providers or insurers, reducing geographical variation in
health services consumption or supply). (Other cited rationales for adopting health inequalities as a political issue
that were mentioned by multiple respondents were because
the issue was ’in vogue’ or being promoted by actors at
the EU level or within the WHO; because the issue of
health inequalities was electorally popular; because it
Table 2 Political motivations for and difficulties with health inequalities as a political strategy
Interview codea Year of
interview
Quotation
UK4 2014 ‘The way we kicked the Tories was to say that they were literally killing people. Labour absolutely loved the
early health inequalities [research] because it said you are child killers, your trickle-down isn’t working’.
UK3 2014 ‘The Labour government didn’t want to explicitly address income inequality. They would never have
framed what they were doing in terms of reducing the gap between the rich and the poor. That would be
political suicide.’
UK5 2014 ‘[Labour] are keen to talk about health inequalities providing they don’t have to talk about income and
wealth inequalities. … They are terrified of being labeled as a tax-raising party.’
FI12 2015 ‘The issue of equality is such an important value in Nordic public debate, and for the right it’s easier to
emphasize their pro-equality position by talking about health inequalities, because it doesn’t concern
distributing income, which is a more difficult for them.’
FI5 2015 ‘Health is such an easy issue for politics because everyone agrees, and it can be used by all political parties.
But when you come to the determinants of health, then the controversies and differences of interest come
out immediately. … [I]f you understand that this may require redistribution of resources, then we are in a
hot political area. And this link remains somehow untouched if possible because it is too difficult.’
FR10 2011 ‘Talking about SES health inequalities is still kind of taboo because there is such a restricted range of
options for reducing SES inequalities in health unless you’re going to address the underlying social
disparities. And the French don’t even like to talk about inequalities (fair or not) in earnings. They are still
sitting on a social volcano when it comes to talking about class inequalities in France.’
FR34 2014 ‘The social inequalities in health framing is window dressing. The global context is a strong contraction of the
budget, including within health insurance. This is not a politically popular agenda! The politicians needed to
affirm that they have some big plan for reforming health without spending any money. The social
inequalities in health framing allows them to show political will without actually spending any money.’
BE16 2013 ‘To be honest, I wasn’t aware that [health inequalities] would be so difficult [politically] – much harder than
poverty. Even most right wing parties in Belgium are in favor of programs to combat poverty. These don’t
involve questioning the system. But health inequalities are much more dangerous because they involve
questioning the system, for example income inequalities.’
a
Interviews were conducted in English and French. Quotations were drawn from verbatim notes and cross-checked against audio recordings of the interviews. Interviewees have been anonymized in accordance with IRB regulations regarding the protection of human subjects. The prefix of the interview
reflects the national context about which the interviewee was questioned: BE, Belgium; FI, Finland; FR, France; UK, United Kingdom.
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seemed a topic capable of generating political consensus
across levels of government, regions, parties or within
center-left parties.)
Since politicians adopt health inequalities as a political
problem for different reasons, and with varying degrees
of commitment, many aspects of the policy response to
health inequalities naturally also differ across countries.20–
24 Nevertheless, the health inequality issue ‘package’ by
now comes with a standard set of widely publicized policy
recommendations from the WHO: coordinated, multisectoral action, led by national governments, that reaches
beyond the health sector to reduce or eliminate the inequalities in the upstream social determinants of health. It is
therefore surprising that policy in countries where health
inequality is on the political agenda is not more consistent
with this problem frame.
Even when key national policy documents regarding
health inequalities pay lip service to the social determinants
of health, government policies to reduce health inequalities
often rely on medicalized understandings of primary care
and prevention25–27 and health promotion policies enacted
with an eye to reducing health inequalities tend to target
individuals and their behaviors rather than the structures
within which these behaviors take place.28 Furthermore, systematic efforts to reduce inequalities in the ‘fundamental
causes’
1 of health have been vanishingly rare. Actions against
poverty and marginalization have played a role in health
inequalities plans from England to France to Finland, but to
date only Norway among the European countries has a
national health inequalities reduction program that highlights
reducing income inequality as a means to reduce health
inequalities.29,30
Increasing political attention to health inequalities has not
been accompanied by substantial reductions in health
inequalities.15,31,32 If measured against the increase in underlying social inequality, some health inequalities reduction
plans may be counted as successes merely because they have
prevented health inequalities from growing. Nevertheless, it
seems noteworthy that political attention to health inequalities has not produced policies that are consonant with the
dominant paradigm that shapes thinking about health
inequalities in European countries. To the extent that the
recommended policy strategy of acting on the fundamental
causes, upstream social determinants, or causes of the causes
would in fact reduce health inequalities, explaining why these
policies have not become more common after the ‘health
inequalities turn’ can help us understand why political attention to health inequalities may undermine attempts to reduce
inequality.
Why the health inequalities frame makes
it harder to reduce health inequalities
Public health scholars have advanced a number of explanations
for the failure of government policy meaningfully to reduce
health inequalities. Many analysts cite a lack of data about health
inequalities or a lack of evidence about what works as a major
obstacle to creating policies that are adapted to reducing health
inequalities.33 Some skepticism still exists concerning the central
causal claim of the dominant health inequalities problem frame
that socioeconomic inequality is the primary cause of health
inequalities.34–36 Nevertheless, the epidemiological literature is
replete with macro-level evidence that would support the
CSDHs recommendation to focus on the ‘causes of the causes’
of health.7,37–43 If policy responses do not correspond to the
health inequality frame’s hypothesized causal processes, it is
likely due less to a lack of evidence than to a lack of evidencebased policy-making.28,44,45 Why has policy-making not followed the standard health inequalities prescription?
One reason may be that reframing social inequality as a
problem of health medicalizes the problem of inequality, making it seem less amenable to systemic or structural solutions.
As several scholars have noted, a belief in individualism links
neoliberalism and the medical model of health, and makes the
two meta-frames especially compatible.9,28,46 This resonance
may allow neoliberal ideas to influence policy styles, particularly in institutional settings like health ministries that are
dominated by actors who have a medicalized understanding
of health, or among public health professionals whose training
and outlook is primarily biomedical rather than social.47 The
medicalization of health inequalities policy can also occur as a
result of more subtle forms of institutional filtering.45,48 Even
when actors understand the social determinants paradigm and
are committed to reducing health inequalities, the power of
medical actors in the health field, the disease- and issue-based
‘silos’ between and within departments, and historical decisions to prioritize certain health problems may explain why
some ideas within the dominant health inequalities frame are
translated more or less intact into policy, while others—like
the need to act on the upstream determinants of health—are
transformed or ignored.45
Beyond medicalization, framing the issue of social inequality as a problem of health inequalities may make the problem
seem more difficult to solve. One reason is that health
inequalities are the result of multiple, interacting and distal
causes. The standard policy remedy, multisectoral policymaking, is in fact extremely difficult, requiring clarity about
goals; capacities for joint action; relationships on which to
base cooperative action; well-conceived policies that can be
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implemented and evaluated; clear roles and responsibilities;
and plans to monitor and sustain outcomes.49 Barriers to
cross-sectoral action include coordination problems, issues of
sustainability, political power-plays and the need to negotiate
the roles and resources of (public) health versus medical
actors and health versus other sectors.50,51 Interviewees
reported that officials in non-health policy sectors could be
resistant to the very language of ‘Health in All Policies,’
which suggested an imperialism of the health sector (FI5,
FI6, BE8, EU1, WHO1 and WHO2). Indeed, in the arena
of health inequalities policy, cross-sectoral policy-making can
work, but often it does not.52
The difficulty of cross-sectoral policy action is only one
result of framing the issue of social inequality in terms that
foreground complex causation. Many analysts of health
inequalities policy-making understand health inequalities as a
‘wicked problem’.
33,49,53–56 Such problems involve disputes
over the definition of the public good and have no definitive
solutions; evidence about how to solve the problem is often
missing or uncertain; and there are numerous possible intervention points, the consequences of which are hard to foresee. Together, these characteristics create problems that are
surrounded by uncertainty, and likely to seem insoluble using
policy approaches within the current repertoire of policymakers.
The health inequalities problem frame spotlights many of
these troubling characteristics. The social determinants causal
interpretation and the cross-sectoral treatment recommendation highlight the complexity of causation and the multiple
systems that must be recruited into the solution. A focus on
inequalities operating over the life-course implies that outcomes of interventions are bound to be distal. Furthermore,
the moral evaluation inherent to the health inequalities problem frame—exonerating individuals and blaming market
inequalities and government policies for health inequalities—
brings into focus how value-laden are both the definition of
and the solutions to the problem of health inequalities. By
highlighting the ‘wickedness’ of inequality, the health inequalities policy framing renders the problem of social inequality
impossible to solve.
If health inequalities are wickedly complex, with a relatively weak evidence base to attest to the effectiveness of
specific interventions, it should not be surprising that even
governments that are committed to reducing health inequalities might find it difficult to enact these policies. Of course
the wider political environment can also influence decisions
about the policies that ought to be enacted in order to
address the problem of health inequalities. In democratic
settings, we might expect demand for policies, in the form
of public beliefs, to play a role. Baum and Fisher28 argue
that the behavior-based policy frame that is the main alternative to the SDOH model is resilient partly because public
beliefs support it. But while some researchers have found
that members of the public are not prone to think about
health inequalities or generally understand disease as an outcome of lifestyle or healthcare factors,28,57,58 other studies
find greater public understanding of the link between social
deprivation and ill health.59–63 Further, framing the issue of
health inequalities in terms of social-structural factors or
fairness, rather than individual responsibility, can prompt the
public to support policies aimed at reducing health inequalities.64–66 Public opinion is probably not a decisive obstacle
to enacting policies that would reduce health inequalities,
then. However, other aspects of the political environment
may well be.
One important component of the wider political environment is the dominant neoliberal economic policy paradigm,
which much research has shown erects obstacles to reducing
health inequalities.67–71 Many of the policy professionals I
interviewed described neoliberal practices and policies that
reinforce health inequalities and prevent effective government actions to redress them. Key examples of such practices included campaign contributions and direct lobbying
pressure on policy-makers for open markets from purveyors
of health-harming products and trade agreements that
enforced privatization of health services.
Constraints on macroeconomic policy deriving from
domestic and international financial markets or international
financial institutions could also contribute to reticence about
implementing bold redistributive policies designed to reduce
inequalities in the upstream determinants of health. In all but
the most extreme cases of financial bailouts, however, the
motive force here lies in ideas and anticipated reactions, rather
than in direct conditionality. Given the status of neoliberalism
as an epistemically privileged master-narrative,72 it is plausible
that neoliberal ideas might have their own motive force.
However, as Berman points out, to understand how neoliberal
(or other) ideas come to influence policy, we need to see ‘how
ideas become embedded in particular groups, organizations, or
structures, thereby outlasting the initial conditions shaping their
emergence.’
73 It is clear that the main articulators of the health
inequalities problem frame, epidemiologists and public health
professionals are simply not as well-integrated into policymaking in most countries as are medical actors, central banks
or lobbyists for multinational corporations; and policy-making
structures tend to be organized around an ecology dominated
by medical, rather than the social determinants of health. Both
of these conditions make it more likely that policies will match
the dominant neoliberal meta-frame rather than the social
determinants health inequalities frame.74
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Conclusion
Health inequalities may be a politically appealing problem
frame, making palatable certain proposals to reduce inequality
that would be politically infeasible if posed baldly as redistribution. But health inequality is also a complicated, perhaps even
‘wicked,’ problem, and reframing social inequality as a problem
of health inequality introduces a great deal of complexity. It
implies a need for difficult coordination across policy sectors,
and makes the problem at hand seem unamenable to policy
intervention, all of which makes it more difficult to combat
the power of neoliberal ideas and actors already present within
the policy-making arena. The health inequalities problem
frame contributes to medicalizing policy-making around the
issue of social inequality, recruiting into the inequality policy
space actors whose worldviews, expertize and institutional
power bases may clash with or overwhelm those of other policy actors whose top priority is social equality more broadly.
All these institutional and political obstacles help to explain
why, even when policy-makers adopt and promote the problem of health inequalities in part in order to address the underlying inequalities, this problem frame can fail to produce a
policy response that would redress either health inequalities or
the fundamental causes of these inequalities.
Where does this leave political actors who might have
hoped to use the health inequalities frame strategically, as a
way to reintroduce redistributive policy after three decades
of neoliberal hegemony? Policy-makers interested in reducing either social inequalities or health inequalities would do
well to eschew the health inequalities problem frame and
instead adopt a more ‘traditional’ plan for reducing social
inequality consisting of taxation, redistribution and labor
market regulation. These policies may seem too politically
risky to consider, and near impossible to enact in a neoliberal era; but they have the benefit of being relatively
straightforward to imagine and to implement by a single
ministry.
The movement for social equity faces a difficult task of
political navigation. On one side lurks the shoal of Scylla, a
health inequality frame that is politically attractive but makes
policy-making technically difficult. On the other swirls
Charybdis, redistributive social policies that threaten to
drown supporters of equity in the ire of powerful market
actors. Scylla, I would contend, is ultimately the more dangerous of the two obstacles. Getting around Charybdis safely
will require political ingenuity and favorable winds; but the
passage is ultimately made easier by the presence of policy
tools like taxation and labor market regulation that are relatively straightforward and within the range of technical feasibility for economic policy-makers.
Supplementary data
Supplementary data are available at the Journal of Public
Health online.
Acknowledgements
For helping me think through the ideas behind this paper,
I thank Isabel Perera, Mark Blyth, Kate McNamara, Jason
Beckfield, Abigail Saguy, Ted Schrecker and Katherine
Smith. Seminar participants at the University of Michigan
School of Public Health, Princeton’s EU Studies program,
the Philadelphia Europeanist Workshop, the LSE Comparative
Politics Workshop and BIARI Madrid provided additional valuable feedback.
Funding
Financial support for research on this project was provided
by a New Directions fellowship from the Andrew W. Mellon
Foundation and by the University of Pennsylvania.
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