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At the heart of public health in contemporary Britain is a paradox. Britain is now collectively healthier than it has ever been in its history. Life expectancy improves and some of the great killer diseases are in retreat as the benefits of both a preventive approach to public health and advances in treatment bear fruit. Yet at the same time, the problem of health inequalities remains stubbornly ubiquitous. While the health of the population as a whole may be improving, the health of the least and less well off either improves more slowly than the rest of the population or in some cases gets worse in absolute terms. This is a challenge to policy makers and practitioners. It suggests that while some of our policy and interventions undoubtedly work they also manifestly fail some sections of the population. To sharpen the tools for policy making in this arena, this paper reviews some of the important conceptual problems associated with discussions of health inequalities.
The Health Development Agency (HDA) has the task of developing the evidence base in public health to inform policy and practice to reduce inequalities. Since 2000 the HDA has been reviewing the evidence on health inequalities and on the effectiveness of interventions. Reviews have been undertaken of the evidence dealing with the prevention of low birth weight, social support in pregnancy, the prevention of drug misuse, sexually transmitted infections and HIV, the promotion of physical activity, accidental injury prevention, the management of obesity and overweight, the prevention of alcohol misuse and smoking, the promotion of breastfeeding, and the prevention of teenage pregnancy. The full results of these reviews are at: www.hda.nhs.uk/evidence.
The HDA reviews found that dimensions of social position and social difference such as ethnicity, gender, disability, place, age and geography, while never explicitly denied as important, are under- developed empirically and theoretically. The question of social position, in other words, requires much more prominence in research and in policy making than it has hitherto received. In addition, the conceptual distinction between the determinants of health and the determinants of inequalities in health is frequently obscured, and therefore has little purchase on the policy making process.