Round table: Re-thinking health inequalities
Authors:   Organised by: Erasmus MC, Rotterdam Chair persons: Johannes Siegrist - Germany
Published: November 2019

Abstract

Health inequalities - systematically higher rates of morbidity and mortality among people with a lower socioeconomic position - have been on the public health agenda for decades now. However, despite massive research efforts (and somewhat less massive policy efforts) health inequalities have not narrowed - on the contrary, relative inequalities have widened considerably. It is therefore time for a re-think: after decades of research we need to step back and ask ourselves: what went wrong?
Johan Mackenbach argues, in a book published by Oxford University Press (2019), that the main problem is that public health researchers and policy-makers have misunderstood the nature of health inequalities. They have too often ignored insights from other disciplines, such as economics (which has a stricter attitude to issues of causality) and sociology (which has a subtler understanding the nature of social inequality). They have also failed to integrate contradictory research findings into mainstream thinking.
This workshop will focus on three such contradictions, and will discuss whether it is possible to re-think health inequalities in a way that will allow more effective policy approaches. (1) It has been surprisingly difficult to find convincing scientific evidence for a causal effect of socioeconomic disadvantage on health. Should public health reconsider its idea that health inequalities are caused by social inequalities, and widen their scope to give more room to social selection, genetic factors and other non-causal pathways in their analysis?
(2) There is not a single country in Europe where over the past decades health inequalities, as measured on a relative scale, have narrowed. This is due to the fact that all groups have improved their health, but higher socioeconomic groups have improved more. This is even true in the only European country (i.e., England) in which the government has pursued a large-scale policy program to reduce health inequalities. Should public health accept that reducing relative inequalities in health is impossible, and focus on reducing absolute health inequalities instead?
(3) The Nordic countries, which have been more successful than other European countries in reducing inequalities in material living conditions, do not have smaller health inequalities. It is as if inequalities in other factors, such as psychosocial and behavioural factors, in these countries have filled the gap left by reduced inequalities in material living conditions. Should public health reconsider its idea that material living conditions are the foundation for health, and re-focus on psychological, cultural and other less tangible factors instead?
In this round table Johan Mackenbach will present and illustrate these contradictions and propose his answers to these contentious issues. Then, the four panelists will present their view-points, followed by a general discussion between panelists and the audience.

Key messages
After four decades of research into health inequalities, it is necessary to step back and ask ourselves why it has so far been impossible to reduce health inequalities. More effective policies to tackle health inequalities will only be possible when public health has come to grips with contradictory research findings.
Johan Mackenbach
Contact: j.mackenbach@erasmusmc.nl
Johannes Siegrist
Contact: johannes.siegrist@med.uni-duesseldorf.de
Alastair Leyland
Contact: Alastair.Leyland@glasgow.ac.uk
Olle Lundberg
Contact: olle.lundberg@su.se
Ramune Kalediene
Contact: ramune.kalediene@lsmuni.lt