Social Class and Health Inequalities: Sociology Revision

The Marmot Review (2010) applied WHO commission findings to England, producing six key recommendations: giving every child the best start in life, education and lifelong learning, employment and working conditions, minimum income for healthy life, healthy communities, and social determinants approach to lifestyle. A 10-year follow-up showed limited progress. Regional commissions were established for Europe and the Americas (PACO), adapting the WHO framework to address structural drivers including political, social, cultural, economic structures, natural environment, climate change, history, colonialism, and structural racism.

The Marmot Review (Fair Society, Healthy Lives) established six core domains for addressing health inequalities: giving every child the best start, education and lifelong learning, employment and working conditions, ensuring everyone has enough money to live, creating healthy places to live and work, and adopting a social determinants approach to prevention. Two additional domains were later added: tackling discrimination and pursuing environmental sustainability. The review emphasized that health is a reflection of how society meets people's needs, and that improving health requires addressing the root causes of inequality rather than just treating illness.

The study of health inequalities in the UK has evolved significantly since the 1980s. The Black Report (1980s) was the first major examination but was suppressed by the Conservative government, shifting discourse to neutral terms. The Acheson Report (1998) followed as a Blair government inquiry. The Wanless Report (2004) took a broad view of population health. The Stern Review (2006) examined climate change health implications. The Marmot Report (2010) established 'fair society and healthy lives' principles. These reports progressively informed public health policies across government departments. Health inequalities refer to differences in health status or distribution of health determinants between different population groups, while health equity means the absence of avoidable or remediable differences. Regional disparities exist, with northern England having significantly lower healthy life expectancy than southern England, with some areas having nearly 20-year gaps in healthy life expectancy compared to more affluent regions.

The UK pioneered comprehensive health inequalities policy in Europe, with the Black Report (1980) documenting persistent inequalities despite free healthcare. Labour commissioned the Acheson Review (1998) and Marmot Review, yet the National Audit Office found inequalities unchanged by 2010. Policy activities spanned individual behavior change, community funding (healthy living zones), healthcare system interventions, and work/living conditions. However, outer layers addressing socio-economic and cultural conditions received minimal attention. A significant conceptual shift occurred from upstream approaches (tackling socio-economic determinants) to downstream approaches (individual lifestyle behaviors). This reframed health inequalities as gaps from poor behaviors rather than structural issues. Evidence-based policy faces challenges: pioneers cannot expect strong existing evidence and must implement innovative approaches. The Marmot Review provides aspirational goals but lacks specific policy actions.

Students should evaluate whether major health inequality reports like the Black Report and Acheson Report led to meaningful change. This involves researching what recommendations were made, whether they were implemented, and what impact they had on reducing health disparities. Assessing the success or failure of such reports provides practical context for understanding how research influences policy.

Social health inequalities can be measured across multiple axes: territory/geography, social class (occupation and education), gender, ethnicity, migration status, employment conditions, age, sexual orientation, discrimination, and functional diversity. These axes rarely operate in isolation but interact through intersectionality—the cumulative and synergistic effect of multiple social identity factors. This approach recognizes that people rarely experience only one form of social positioning, and health outcomes reflect the compounded effects of intersecting social factors.

Health disparities persist across demographic categories even when controlling for socioeconomic status. Racial minorities experience worse health outcomes due to chronic stress from discrimination and systemic racism, combined with disproportionate exposure to environmental hazards. Gender creates distinct patterns: while women live longer, they receive inferior healthcare treatment and are often dismissed by providers; conversely, men suffer from toxic masculinity that discourages healthcare-seeking behavior and promotes risky lifestyles. These intersections reveal how multiple forms of social stratification compound to produce differential health experiences.

Gender does not operate in isolation but intersects with other social categories including social class, ethnicity, and age. A poor indigenous woman faces greater disadvantages than a wealthy university-educated woman. The most disadvantaged position is being a poor indigenous woman, as she faces compounded disadvantages from multiple intersecting social categories. Health disparities vary significantly based on these intersections, demonstrating that gender must be analyzed in conjunction with other social determinants to understand health outcomes.

Intersectionality is a relatable issue in DEI work, as many initiatives focus on single identity groups without addressing how multiple identities compound challenges. Research from seven major U.S. cities (2019-2020) found 38% of transgender women tested positive for HIV, with 44% in the low-income spectrum, 39% experiencing homelessness, and 40% facing severe food insecurity. These disparities are linked to lower likelihood of receiving HIV prevention and healthcare services. Women who contract HIV often receive it from men who did not disclose their status, creating unique challenges for disclosure, grief management, and family care responsibilities.

Dark-skinned Black women face exclusion from femininity due to racism and colorism stemming from colonization and Eurocentric beauty standards. In Toni Morrison's The Bluest Eye, Pecola Breedlove (dark-skinned, impoverished) faces bullying and abuse, while biracial Maureen Peal (light-skinned, wealthy) receives new clothes and becomes the prettier, more feminine character. White women have historically used oppression of women of color to elevate themselves—owning slaves made white women better marriage prospects. This intersectional analysis reveals how race and class compound to determine who is permitted to be seen as feminine.

This research examines how welfare state interventions influence health and health inequalities across 30+ countries using the 2011 ISSP data, finding that while overall welfare state size shows no significant association with health outcomes, public health spending exhibits a non-linear relationship where lower levels of public health spending correlate with larger gender health gaps, suggesting targeted health interventions may be more effective than general welfare state generosity in reducing health inequalities.

Governments can successfully reduce health inequalities through comprehensive policy interventions that address multiple social determinants simultaneously, including welfare state expansion, improved healthcare access, reduced income inequality, and political inclusion; however, these gains are often temporary and require sustained political commitment to maintain, as demonstrated by four case studies from the USA (Great Society), Brazil, Germany, and England spanning fifty years.

The research identifies policy interventions as potential moderators of wealth-health inequalities. The most significant narrowing of the wealth-health gap occurred around 1945, coinciding with the introduction of the National Health Service and the welfare state in Britain. This suggests that large-scale social interventions can temporarily mitigate fundamental causes of health inequalities by providing universal access to healthcare and social services. However, the persistence of wealth effects indicates these interventions do not completely eliminate underlying socioeconomic determinants. The findings support the view that health inequalities are not deterministic but can be altered through deliberate policy changes that address the broader social factors shaping health outcomes.

National policies significantly influence health inequalities. Under the Labour government (1997-2010), England reduced the life expectancy gap between the poorest 20% of local authorities and everyone else. After the Conservative-led coalition government took office, this gap began increasing again. This correlation suggests that national strategies to reduce health inequalities work effectively, while abandoning such strategies leads to worsening inequalities. The halt in life expectancy gains in 2011 and subsequent slowdown across Europe during the austerity period demonstrates that economic policies directly impact population health outcomes.

Specific policy interventions can effectively reduce health inequalities even within varying welfare system contexts. Research has shown that regions implementing comprehensive health promotion interventions—including both general screening offers and personalized follow-up (such as letters and telephone calls)—achieved better outcomes in reducing inequalities. These interventions work not only independently but also interact with the structure of the welfare system to produce improved health equity.