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Social Science & Medicine 74 (2012) 639–642
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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 UKexperience? Overview
This collection of commentaries starts with contributions byauthors writing on how we might expect population health to beaffected by the current economic recession. George Kaplan (Univer-sity of Michigan, USA), offers a conceptual model of the variousways that health might be impacted by economic recession anddiscusses some examples of studies in the US, Sweden and theUK which illustrate the likely processes involved (Kaplan, 2012).He calls for more research on the long term effects of economicshocks over the lifecourse and the role of social policies in miti-gating these effects. Marc Suhrcke (University of East Anglia, UK)and David Stuckler (University of Cambridge, UK) then summariseresults of research examining the links between economic reces-sion and health at the individual and the population level(Suhrcke & Stuckler, 2012). Their results demonstrate the typicallydeleterious effects of recession on less advantaged groups, who aremore likely to become unemployed and may be most affected byrestraints onwelfare programmes. However, for other groups theremay be short term benefits to health, perhaps through moderationof unhealthy or risky lifestyles during periods of austerity. Theirpaper underlines the need in wealthy countries such as the USA,UK, and Sweden, to take measures to protect the health of thosemost at risk of unhealthy outcomes. Bo Burström (Karolinska Insti-tutet, Sweden) makes a critical assessment of the evidence con-cerning health inequalities in Sweden and the ways these havebeen impacted by an economic recession experienced in the1990s (Burström, 2012). He argues that, in terms of populationhealth, the Swedish population weathered the initial phases ofthis recession quite successfully with little growth in healthinequality and continued average improvement in health of thenational population. However, over the longer term, given pro-tracted impacts of recession on the labour market, certain socialgroups, including lone mothers, can be seen to have suffered rela-tive disadvantages both in socio-economic position and in healthoutcomes. This experience suggests that even in a country witha relatively generous welfare state, the long term reverberationsof 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 recessionon health of different populations. Understanding this complexity,they argue, will be crucial for effective policy making. Healthinequality and the ways that this will be impacted by recession isa challenge in all three countries.
A series of commentaries are then presented which examinehealth inequality and its determinants in further depth. All ofthem underline the importance of maintaining a focus onmeasures
0277-9536/$ – see front matter � 2011 Elsevier Ltd. All rights reserved.doi:10.1016/j.socscimed.2011.12.004
to address the wider determinants of health, as well as on deliveryof curative medicine. Lisa Berkman (Harvard University, USA)argues that in the USA, improvement in population health islagging behind other wealthy countries (Berkman, 2012). Sheexamines how demographic trends and labour market factors areputting particular pressure on women because the growingdemands placed on them in terms of caring roles for children andolder people are incompatible with the inflexible demands of orga-nization of work and conditions in the workplace. She argues thatthese trends are crucial for the health and wellbeing of Americans.Mel Bartley (University College London, UK), presents evidencefrom the UK that summarises results from a historical study ofchanges in inequalities in mortality from the early to the laterperiods of the 20th Century (Bartley, 2012). Her insights comple-ment other commentaries in this group, suggesting that we canunderstand issues of health inequality in the present better byconsidering what we can learn from the past. Her analysis under-lines that growth in average national wealth over the 20th centurywas accompanied by increasing social class disparities with theleast advantaged socio-economic groups becoming progressivelymore disadvantaged. This applies to diverse causes of death, sug-gesting a rather general growth in the significance of inequalityof wealth for risk of death. This commentary refers to currentdebates about social determinants and capabilities important forpopulation health to argue that reductions in average wealthduring a period of economic recession, such as we are experiencingnow in countries like the UK, may be less important for healthinequality than collective measures to ensure a more even distribu-tion of wealth and the means to a long and healthy life. MargaretaKristenson (Linköping University, Sweden) also discusses socio-economic health inequalities associated with the ‘wider determi-nants’ of health (Kristenson, 2012). She points to evidence that,although average health in Sweden is better than in poorer, neigh-bouring countries such as Lithuania, nevertheless, inequalities ofhealth between socio-economic groups are evident in Sweden.She emphasises the psychosocial determinants of health differ-ences. Her analysis also stresses the importance of reorientingmedical services to develop their role in health promotion andillness prevention, as well as treatment, and the need to fosterbetter coordination between medical services and other partnersat the community level. Furthermore, she underlines the potentialfor medical institutions to set an example as healthy workplaces fortheir staff. In her piece, Paula Braveman (University of California,San Francisco, USA) highlights international differences indiscourses about health inequalities (Braveman, 2012). Public
Introduction / Social Science & Medicine 74 (2012) 639–642640
debate and academic research in the US has tended to focus ondisparities by race, not by social class, as is the case in Europe.Her analysis of recent U.S. data shows that, across multiple indica-tors and life stages, disparities in health by socio-economic groupare large and pervasive, and persist after controlling for racialdifferences. Nevertheless, inequalities in both health and wealthbetween U.S. racial groups are large and persistent, and diverseexperiences rooted in racial discrimination are likely to be impor-tant explanatory factors. This commentary describes the patterningof socio-economic and racial inequalities in health in the US. Itargues that these patterns are evidence for the role of social advan-tage and disadvantage in shaping health, and that they underscorethe importance of actions beyondmedical care to address thewiderdeterminants of health and health inequalities by race and class.Consistent in these four commentaries is an insistence on priori-tizing the health of the most disadvantaged groups in all three ofthe countries concerned, particularly during periods of economicrecession.
Theseargumentsareextendedthroughthenextgroupofcommen-taries which explore measures that may make a difference to healthand health inequalities. Sven Bremberg (Swedish National InstituteofPublicHealthandDepartmentof PublicHealth,Karolinska Institute)argues that the relatively good level of health enjoyed by the Swedishpopulation, both in terms of good average health and low levels ofhealth inequality, may be due particularly to the long term publicinvestment in a high level of education and literacy in the populationas a whole (Bremberg, 2012). Education, more than medical care orwelfare state benefits,may be a crucial ingredient in Sweden’s successin terms of population health. Neil Halfon (University of California, LosAngeles, USA) argues on the basis of US experience for greater invest-ment in physical and mental health and development in childhood,when the foundations of health throughout the lifecourse are laiddown (Halfon, 2012). He argues that there are economic as well aspublic health and welfare arguments supporting this approach. Healsoargues foramulti-sectoral approachsupportedbyaccessible sour-ces of information on public health.
Other measures may include reforming the finance andmanagement of health systems. Gail Wilensky (at Project HOPE,and formerly Administrator for Health Care Financing Administra-tion in the US government and WHO Commission on the SocialDeterminants of Health) presents a health economist’s view(Wilensky, 2012), based on her experience ‘inside’ the policymaking process that has driven recent moves to reform the UShealth care system, and leading up to legislative changes throughthe The Patient Protection and Affordable Care Act, 2010. Importantelements of the legislation included extension of health insurancecover to include a significant number of people in low incomegroups. Wilensky also discusses how far reforms are leading tochanges in information to guide policy and service delivery andto incentives at the institutional level to encouragemore cost effec-tive health care provision. These changes, that have fascinatedobservers around theworld, seem critical to achieving better healthfor all in the US. Achieving change in a period of global and nationalfiscal stress is especially challenging. Success may depend on care-ful piloting of innovations and making contingencies for unantici-pated outcomes emerging from these changes to a complexsystem. It is interesting to compare Wilensky’s account of the situ-ation in the USA with the view from Sweden, discussed by JohanCalltorp (The Nordic School of Public Health, Gothenburg and TheJönköping Academy of Health Improvement, Jönköping, Sweden)(Calltorp, 2012). He describes the political processes that haveenabled Swedish society to maintain a prudently managed healthservice over time.
The need to address new challenges associated with an ageingpopulation and a complex burden of chronic diseases requires
Swedish policy makers and funding agencies to focus more onnew ways to organize and manage services, as well as on clinicaldevelopments in hospital and community care. Strategies haveincluded an expansion of the role of the private sector and adapta-tion for application in Sweden of health service management prin-ciples and methods from other countries. Viewed together,Wilensky’s (2012) and Calltorp’s (2012) accounts suggest a gradualerosion of the national differences in welfare ideologies and prac-tices and they raise interesting questions about the possibility ofa more uniform, ‘globalised’ structure for health systems in thefuture, informed by an enhanced evidence base to guide healthservice policy and delivery.
The set of commentaries concludes with further calls to expandthe horizons of health policy and revise conventional ways ofthinking that separate health, wellbeing and sustainability of oureconomic systems. Andy Haines (London School of Hygiene andTropical Medicine, UK) moves the debate beyond the socio-economic determinants of health and discusses the links betweenpolicy for greater environmental sustainability and public healthobjectives (Haines, 2012). Given the potential health benefits ofpolicies for more sustainable socio-economic systems, and thesocially unequal risks of unsustainable growth, health equalityimpact assessment of these policies is a priority.
MartinMcKee (London School of Hygiene and TropicalMedicine,UK), Sanjay Basu (University of California, San Francisco, USA) andDavid Stuckler (University of Cambridge, UK) argue that there areeconomic as well as social benefits associated with having a healthypopulation (McKee, Basu, & Stuckler, 2012). The discussion criticisesthe failure of governments for their lack of intervention to curb thebehaviour of financial institutions that led to the 2008 financialcrisis. On the basis of previous experience of major financial crises,the authors comment on possible implications for health of thepresent financial situation affecting countries like the US and theUK and argue that investment in health care and other measuresto protect health and reduce health inequalities is as important asever. In their account, health is emphasised as a vital nationalresource, essential to our economic success, as well as being offundamental importance in other ways. The arguments theypresent suggest that economic development that supports andsustains population health should be one of themost essential goalsfor society in all of the countries considered here.
Many of the themes raised here are of special interest to readersof this journal, whomay also be interested in further publications inSocial Science & Medicine on related topics. For example, we notehere a selection of papers which focus on the links betweeneconomic recession and health in various countries, showing howthese relationships vary internationally, and which illustrate therange of health conditions that may be considered as potentiallyinfluenced by conditions in an economic downturn (Chang et al,2009; Arkes, 2009; Borowy, 2011; Brenner, 1987; Chen, Yip, Lee,Fan, & Fu, 2010; Davies, Jones, & Nuñez, 2009; Edwards, 2008;Fritzell, Ringbäck Weitoft, Fritzell, & Burström, 2007; Gonzalez &Quast, 2010; Keskimäki, 2003; Neumayer, 2004; Roelfs, Shor,Davidson, & Schwartz, 2011; Sargent-Cox, Butterworth, & Anstey,2011). Other papers in Social Science & Medicine have also analysedhealth variation using varying approaches to examine the ‘life-course’ perspectives that are emphasised in this collection ofcommentaries (see for example: Burström et al., 2010; Curtis,Southall, Congdon, & Dodgeon, 2004; Graham, 2002; Halleröd &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,Burström, & Diderichsen, 2000). Debates over the significance ofsocio-economic position, race, and education as factors in healthinequality in US, UK and Nordic settings, considered in these
Introduction / Social Science & Medicine 74 (2012) 639–642 641
commentaries, are also discussed by many authors in this journal.Recent examples, which especially focus on the countries of interestin this collection of commentaries, include: Huijts, Eikemo, andSkalická (2010), McDonough, Worts, and Sacker (2010), Scribner,Theall, Simonsen, Mason, and Yu (2009), Szanton, Thorpe, andWhitfield (2010), Whitehead and Popay (2010). Several commen-taries in this collection have drawn attention to issues of manage-ment and reform of health systems in times of financialausterity, and further examples of these debates can be found inpapers by: Asthana (2011), Fredriksson and Winblad (2008), Light(2011), Marmor and Oberlander (2011), Radnor, Holweg, andWaring (2012), Viladrich (in press), Waring and Bishop (2010).Furthermore, the discussion in some of these commentaries onsustainability, environmental justice and health and the relation-ships between economic growth and health and wellbeing is alsoreflected 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, Labonté, and DeVogli (2010), Steinbach, Green, Datta, and Edwards (2011).
All of this literature underlines the importance, for the debatesinvoked in these commentaries, of the multidisciplinary perspec-tives represented in this journal. The commentaries show that itis more important than ever, in a period of global economic reces-sion, to use the kinds of knowledge published in Social Science &Medicine to argue the case that governments should continue toprioritise action on health inequalities, and the social processeswhich are important for health.
Acknowledgements
We would like to thank the following colleagues for providingeditorial assistance in the production of this collection of commen-taries: Nicola Bramfitt, Durham University; Amy Graber, UCLACenter for Healthier Children, Families & Communities; ColleenBarclay, Family and Community Medicine Center, University of Cal-ifornia, San Francisco; Dr Ryan Mowat, Managing Editor, SocialScience & 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. LeonardiPresident of the Epidemiology & Public Health Section,
Royal Society of Medicine, UK
Head of Epidemiology Department, Health Protection AgencyCentre for Radiation, Chemical and Environmental Hazards, UK
London School of Hygiene and Tropical Medicine, UKE-mail address: [email protected]
* Corresponding author. Tel.: þ44 (0)2078825400.E-mail addresses: [email protected],
Available online 24 December 2011
