Social Science & Medicine 74 (2012) 639642

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Social Science & Medicine

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Introduction

Health, wealth and ways of life: What can we learn from the Swedish, US and UK experience? Overview

This collection of commentaries starts with contributions by authors writing on how we might expect population health to be affected by the current economic recession. George Kaplan (University of Michigan, USA), offers a conceptual model of the various ways that health might be impacted by economic recession and discusses some examples of studies in the US, Sweden and the UK which illustrate the likely processes involved (Kaplan, 2012). He calls for more research on the long term effects of economic shocks over the lifecourse and the role of social policies in mitigating these effects. Marc Suhrcke (University of East Anglia, UK) and David Stuckler (University of Cambridge, UK) then summarise results of research examining the links between economic recession and health at the individual and the population level (Suhrcke & Stuckler, 2012). Their results demonstrate the typically deleterious effects of recession on less advantaged groups, who are more likely to become unemployed and may be most affected by restraints on welfare programmes. However, for other groups there may be short term benets to health, perhaps through moderation of unhealthy or risky lifestyles during periods of austerity. Their paper underlines the need in wealthy countries such as the USA, UK, and Sweden, to take measures to protect the health of those most at risk of unhealthy outcomes. Bo Burstrm (Karolinska Institutet, Sweden) makes a critical assessment of the evidence concerning health inequalities in Sweden and the ways these have been impacted by an economic recession experienced in the 1990s (Burstrm, 2012). He argues that, in terms of population health, the Swedish population weathered the initial phases of this recession quite successfully with little growth in health inequality and continued average improvement in health of the national population. However, over the longer term, given protracted impacts of recession on the labour market, certain social groups, including lone mothers, can be seen to have suffered relative disadvantages both in socio-economic position and in health outcomes. This experience suggests that even in a country with a relatively generous welfare state, the long term reverberations of economic recession on health can lead to growing inequalities. These three authors, writing from various national perspectives, therefore underline the complex and uneven impact of recession on health of different populations. Understanding this complexity, they argue, will be crucial for effective policy making. Health inequality and the ways that this will be impacted by recession is a challenge in all three countries. A series of commentaries are then presented which examine health inequality and its determinants in further depth. All of them underline the importance of maintaining a focus on measures
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to address the wider determinants of health, as well as on delivery of curative medicine. Lisa Berkman (Harvard University, USA) argues that in the USA, improvement in population health is lagging behind other wealthy countries (Berkman, 2012). She examines how demographic trends and labour market factors are putting particular pressure on women because the growing demands placed on them in terms of caring roles for children and older people are incompatible with the inexible demands of organization of work and conditions in the workplace. She argues that these trends are crucial for the health and wellbeing of Americans. Mel Bartley (University College London, UK), presents evidence from the UK that summarises results from a historical study of changes in inequalities in mortality from the early to the later periods of the 20th Century (Bartley, 2012). Her insights complement other commentaries in this group, suggesting that we can understand issues of health inequality in the present better by considering what we can learn from the past. Her analysis underlines that growth in average national wealth over the 20th century was accompanied by increasing social class disparities with the least advantaged socio-economic groups becoming progressively more disadvantaged. This applies to diverse causes of death, suggesting a rather general growth in the signicance of inequality of wealth for risk of death. This commentary refers to current debates about social determinants and capabilities important for population health to argue that reductions in average wealth during a period of economic recession, such as we are experiencing now in countries like the UK, may be less important for health inequality than collective measures to ensure a more even distribution of wealth and the means to a long and healthy life. Margareta Kristenson (Linkping University, Sweden) also discusses socioeconomic health inequalities associated with the wider determinants of health (Kristenson, 2012). She points to evidence that, although average health in Sweden is better than in poorer, neighbouring countries such as Lithuania, nevertheless, inequalities of health between socio-economic groups are evident in Sweden. She emphasises the psychosocial determinants of health differences. Her analysis also stresses the importance of reorienting medical services to develop their role in health promotion and illness prevention, as well as treatment, and the need to foster better coordination between medical services and other partners at the community level. Furthermore, she underlines the potential for medical institutions to set an example as healthy workplaces for their staff. In her piece, Paula Braveman (University of California, San Francisco, USA) highlights international differences in discourses about health inequalities (Braveman, 2012). Public

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Introduction / Social Science & Medicine 74 (2012) 639642

debate and academic research in the US has tended to focus on disparities by race, not by social class, as is the case in Europe. Her analysis of recent U.S. data shows that, across multiple indicators and life stages, disparities in health by socio-economic group are large and pervasive, and persist after controlling for racial differences. Nevertheless, inequalities in both health and wealth between U.S. racial groups are large and persistent, and diverse experiences rooted in racial discrimination are likely to be important explanatory factors. This commentary describes the patterning of socio-economic and racial inequalities in health in the US. It argues that these patterns are evidence for the role of social advantage and disadvantage in shaping health, and that they underscore the importance of actions beyond medical care to address the wider determinants of health and health inequalities by race and class. Consistent in these four commentaries is an insistence on prioritizing the health of the most disadvantaged groups in all three of the countries concerned, particularly during periods of economic recession. These arguments are extended through the next group of commentaries which explore measures that may make a difference to health and health inequalities. Sven Bremberg (Swedish National Institute of Public Health and Department of Public Health, Karolinska Institute) argues that the relatively good level of health enjoyed by the Swedish population, both in terms of good average health and low levels of health inequality, may be due particularly to the long term public investment in a high level of education and literacy in the population as a whole (Bremberg, 2012). Education, more than medical care or welfare state benets, may be a crucial ingredient in Swedens success in terms of population health. Neil Halfon (University of California, Los Angeles, USA) argues on the basis of US experience for greater investment in physical and mental health and development in childhood, when the foundations of health throughout the lifecourse are laid down (Halfon, 2012). He argues that there are economic as well as public health and welfare arguments supporting this approach. He also argues for a multi-sectoral approach supported by accessible sources of information on public health. Other measures may include reforming the nance and management of health systems. Gail Wilensky (at Project HOPE, and formerly Administrator for Health Care Financing Administration in the US government and WHO Commission on the Social Determinants of Health) presents a health economists view (Wilensky, 2012), based on her experience inside the policy making process that has driven recent moves to reform the US health care system, and leading up to legislative changes through the The Patient Protection and Affordable Care Act, 2010. Important elements of the legislation included extension of health insurance cover to include a signicant number of people in low income groups. Wilensky also discusses how far reforms are leading to changes in information to guide policy and service delivery and to incentives at the institutional level to encourage more cost effective health care provision. These changes, that have fascinated observers around the world, seem critical to achieving better health for all in the US. Achieving change in a period of global and national scal stress is especially challenging. Success may depend on careful piloting of innovations and making contingencies for unanticipated outcomes emerging from these changes to a complex system. It is interesting to compare Wilenskys account of the situation in the USA with the view from Sweden, discussed by Johan Calltorp (The Nordic School of Public Health, Gothenburg and The Jnkping Academy of Health Improvement, Jnkping, Sweden) (Calltorp, 2012). He describes the political processes that have enabled Swedish society to maintain a prudently managed health service over time. The need to address new challenges associated with an ageing population and a complex burden of chronic diseases requires

Swedish policy makers and funding agencies to focus more on new ways to organize and manage services, as well as on clinical developments in hospital and community care. Strategies have included an expansion of the role of the private sector and adaptation for application in Sweden of health service management principles and methods from other countries. Viewed together, Wilenskys (2012) and Calltorps (2012) accounts suggest a gradual erosion of the national differences in welfare ideologies and practices and they raise interesting questions about the possibility of a more uniform, globalised structure for health systems in the future, informed by an enhanced evidence base to guide health service policy and delivery. The set of commentaries concludes with further calls to expand the horizons of health policy and revise conventional ways of thinking that separate health, wellbeing and sustainability of our economic systems. Andy Haines (London School of Hygiene and Tropical Medicine, UK) moves the debate beyond the socioeconomic determinants of health and discusses the links between policy for greater environmental sustainability and public health objectives (Haines, 2012). Given the potential health benets of policies for more sustainable socio-economic systems, and the socially unequal risks of unsustainable growth, health equality impact assessment of these policies is a priority. Martin McKee (London School of Hygiene and Tropical Medicine, UK), Sanjay Basu (University of California, San Francisco, USA) and David Stuckler (University of Cambridge, UK) argue that there are economic as well as social benets associated with having a healthy population (McKee, Basu, & Stuckler, 2012). The discussion criticises the failure of governments for their lack of intervention to curb the behaviour of nancial institutions that led to the 2008 nancial crisis. On the basis of previous experience of major nancial crises, the authors comment on possible implications for health of the present nancial situation affecting countries like the US and the UK and argue that investment in health care and other measures to protect health and reduce health inequalities is as important as ever. In their account, health is emphasised as a vital national resource, essential to our economic success, as well as being of fundamental importance in other ways. The arguments they present suggest that economic development that supports and sustains population health should be one of the most essential goals for society in all of the countries considered here. Many of the themes raised here are of special interest to readers of this journal, who may also be interested in further publications in Social Science & Medicine on related topics. For example, we note here a selection of papers which focus on the links between economic recession and health in various countries, showing how these relationships vary internationally, and which illustrate the range of health conditions that may be considered as potentially inuenced by conditions in an economic downturn (Chang et al, 2009; Arkes, 2009; Borowy, 2011; Brenner, 1987; Chen, Yip, Lee, Fan, & Fu, 2010; Davies, Jones, & Nuez, 2009; Edwards, 2008; Fritzell, Ringbck Weitoft, Fritzell, & Burstrm, 2007; Gonzalez & Quast, 2010; Keskimki, 2003; Neumayer, 2004; Roelfs, Shor, Davidson, & Schwartz, 2011; Sargent-Cox, Butterworth, & Anstey, 2011). Other papers in Social Science & Medicine have also analysed health variation using varying approaches to examine the lifecourse perspectives that are emphasised in this collection of commentaries (see for example: Burstrm et al., 2010; Curtis, Southall, Congdon, & Dodgeon, 2004; Graham, 2002; Hallerd & Gustafsson, 2011; Hallqvist, Lynch, Bartley, Lang, & Blane, 2004; Lemelin et al., 2009; Van den Berg, Doblhammer, & Christensen, 2009; Van den Berg, Lindeboom, & Lopez, 2009; Whitehead, Burstrm, & Diderichsen, 2000). Debates over the signicance of socio-economic position, race, and education as factors in health inequality in US, UK and Nordic settings, considered in these

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commentaries, are also discussed by many authors in this journal. Recent examples, which especially focus on the countries of interest in this collection of commentaries, include: Huijts, Eikemo, and Skalick (2010), McDonough, Worts, and Sacker (2010), Scribner, Theall, Simonsen, Mason, and Yu (2009), Szanton, Thorpe, and Whiteld (2010), Whitehead and Popay (2010). Several commentaries in this collection have drawn attention to issues of management and reform of health systems in times of nancial austerity, and further examples of these debates can be found in papers by: Asthana (2011), Fredriksson and Winblad (2008), Light (2011), Marmor and Oberlander (2011), Radnor, Holweg, and Waring (2012), Viladrich (in press), Waring and Bishop (2010). Furthermore, the discussion in some of these commentaries on sustainability, environmental justice and health and the relationships between economic growth and health and wellbeing is also reected in Social Science & Medicine publications including: Briggs, Abellan, and Fecht (2008), Carlisle, Henderson, and Hanlon (2009), Labonte and Schrecker (2004), Pearce, Richardson, Mitchell, and Shortt (2011), Powell-Jackson, Basu, Balabanova, McKee, and Stuckler (2011), Schrecker, Chapman, Labont, and De Vogli (2010), Steinbach, Green, Datta, and Edwards (2011). All of this literature underlines the importance, for the debates invoked in these commentaries, of the multidisciplinary perspectives represented in this journal. The commentaries show that it is more important than ever, in a period of global economic recession, to use the kinds of knowledge published in Social Science & Medicine to argue the case that governments should continue to prioritise action on health inequalities, and the social processes which are important for health. Acknowledgements We would like to thank the following colleagues for providing editorial assistance in the production of this collection of commentaries: Nicola Bramtt, Durham University; Amy Graber, UCLA Center for Healthier Children, Families & Communities; Colleen Barclay, Family and Community Medicine Center, University of California, San Francisco; Dr Ryan Mowat, Managing Editor, Social Science & Medicine. Also thanks to Professor Ellen Annandale, Editor-in-Chief of Social Science & Medicine for her valuable advice.

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Sarah Curtis* Professor of Health and Risk, Durham University, UK Giovanni S. Leonardi President of the Epidemiology & Public Health Section, Royal Society of Medicine, UK Head of Epidemiology Department, Health Protection Agency Centre for Radiation, Chemical and Environmental Hazards, UK London School of Hygiene and Tropical Medicine, UK E-mail address: giovanni.leonardi@hpa.org.uk * Corresponding author. Tel.: 44 (0)2078825400. E-mail addresses: s.e.curtis@durham.ac.uk, ssm.editor@durham.ac.uk Available online 24 December 2011