THE DETERMINANTS OF

THE HEALTH OF THE PEOPLE

Dr Stephen Monaghan

1
THE DETERMINATION OF HEALTH
As a first step towards improving health and reducing health inequalities, it is natural
to ask what factors lead to our current pattern of ill health and health inequality.

Usually in this context, the medical concept of causation comes to mind as the
required element. However, for these purposes the medical notion of a necessary and
sufficient cause is too narrow, implying a direct “follow-on” relationship and
originating from the doctrine of specific aetiology whereby each disease has a single
cause.

This is commonly the position for infectious diseases, which are actually defined and
classified according to their causative agent. But for the majority of health conditions,
it has become clear that at best a complex web of causation involving many
interacting factors is involved, and it is even debatable how useful the narrow concept
of direct causation is over and above the concept of the wider determining factors.

Furthermore, in the circumstances of chronic disease and ill-health, “causative” and

determining factors cannot logically be limited to biological, chemical and physical
agents as various psychological and socio-economic factors are just as strongly
related to these health states.

Why we are seeking to understand what influences health? Presumably, this is in

order to suggest interventions that could be applied to improve human health. Even in
the rare instances, such as infectious diseases, where we can describe a single
causative factor, this in itself may not be enough to suggest a useful intervention.

Rather, in order to effect a useful intervention, we may need to understand what

influences the exposure of susceptible humans to this agent, which may be a “vehicle
of transmission” - for example drinking water contaminated with sewage, or else
some situational factor such as poverty or homelessness.

Similarly, in the more common situation of chronic multi-factorial disease, we need to

look much further than physical, chemical, biological or psychosocial agents to what
influences exposure and / or susceptibility if we are to understand what leads to these
conditions. Frequently we can usefully do this even where we do not know the
identity of the agent(s) or even whether an environmental agent is involved at all.

Broadly, there are two approaches to gaining this knowledge, basic laboratory science
and human population research (epidemiology). Epidemiology is the study of the
distribution and the determinants (of the distribution) of health related states in human
populations. It is this epidemiological information on the determinants of health and
disease in that population that we mainly require for public health policy.

WHAT DETERMINES HEALTH STATUS?

Blum (1974, 1981) has usefully grouped the determinants of health within a model
which comprises the four fields of Environment, Lifestyle, Heredity (Genetics), and
Health Care Services. Lalonde used a similar classification, the Health Field Concept
(Laframboise 1973) in his famous public health strategy (Canadian Government
1974).

2
Building upon Blum’s framework, Evans and Stoddart (1990 and 1994) developed a
detailed model (below) suggesting interactive pathways in the production of health.

3
Considering the determinants of health in turn, within the original categories of
Environment, Lifestyle, Heredity (Genetics), and Health Care Services as suggested
by Blum (1974, 1981).

THE ENVIRONMENT

The environment can usefully be sub-divided into the pre-natal environment - before
birth, within the womb; and the post-natal environment to which we are exposed
following birth during childhood and adult life.

THE PRE-NATAL ENVIRONMENT

A growing body of evidence supports recognition of the central importance of the pre-
natal environment within the womb as a central determinant of subsequent adult
health and mortality (Barker and Robinson 1992) and of health inequalities (Barker
and Osmond 1987a, Osmond 1987, Barker et al 1989a, Barker et al 1989c, Osmond et
al 1990).

Adverse maternal factors compromise the intrauterine environment; maternal illness,

smoking or high blood pressure result in low birthweight babies, whereas
uncontrolled maternal gestational diabetes results in overweight babies.

There is also a huge literature on the sensitivity of the foetus to intrauterine

environmental agents. These range from ionising radiation to maternal medication and
nutrition (eg a diet lacking in folic acid), resulting most graphically in congenital
malformations while also having other less obvious implications for lifetime health.

The adult mortality rate from stroke and ischaemic heart disease appears to be
powerfully determined by adverse maternal factors acting before and during
pregnancy. The same factors cause neonatal mortality, and in a given geographical
area, the adult mortality rate from stroke and ischaemic heart disease is closely
correlated with the neonatal mortality rate which applied some sixty years earlier
(Barker and Osmond 1986 and 1987b) (Barker, et al 1989a and 1989c). These
intrauterine factors may be linked with stroke and ischaemic heart disease though the
mediator of high blood pressure (Barker et al 1990b and 1992) (Law et al 1992) or
maternal anaemia or iron deficiency (Godfrey et al 1991). Impaired intrauterine
growth is also strongly predictive of non-insulin dependent diabetes in late adulthood
(Hales et al 1991) and impaired glucose tolerance in early adulthood (Robinson et al
1992).

THE POST-NATAL ENVIRONMENT

Research evidence has shown beyond reasonable doubt that the dramatic
improvements in the health experienced by all societies as they develop can be
attributed less to improvements in medicine and surgery and more to improvements in
wider environmental conditions (McKeown 1979). These include access to sufficient
nutritious food, the provision of pure drinking water and separate disposal of
sewerage, improvements in working conditions and in housing, and a voluntary
reduction in birth rate. The environment can be usefully sub-categorised into the

4
physical, chemical and biological environment and the social, psychological and
economic environment.

The social, psychological and economic environment

Social inequalities in population health have in the past been principally

environmentally determined, with the most important component probably being the
socio-economic environment (McKeown 1979). Evidence suggests that the socio-
economic environment remains the primary determinant of current social inequalities
in health status seen between populations and between areas (Townsend et al 1992,
Whitehead 1995, Davey-Smith et al 1997).

Social factors powerfully determine health and ill-health, and this is clearly
exemplified by the very strong association between health and socio-economic status
as measured according to the Registrar General’s Social Class Classification. Within
this schema individuals are allocated to social classes depending on occupation with
high prestige professionals (doctors and lawyers) placed in social class I, managers
and other professionals (teacher and nurses) in social class II, skilled non-manual and
skilled manual workers in social class III, semi-skilled manual in social class IV and
unskilled manual in social class V.

In the UK there is a 5 year difference in life expectancy between males in social class
I and in social classes IV and V. The corresponding figure for females is 3 years
(Davey-Smith et al 1997, Hattersley 1997). Both of these differentials are wider than
they were 15 years ago (Harding et al 1997) with the gap for young males opening
most markedly (Drever and Bunting 1997). Long standing limiting illness is 40
percent more common in social class V than social class I in the UK, while no such
differential exists in acute sickness (Bunting 1997).

Socio-economic status throughout adulthood is the more important socio-economic

indicator over a life time for differentiating groups with differing risks of mortality
from cancer and non-cardiovascular non-cancer causes, whereas socio-economic
status in childhood is particularly important in determining lifetime risk of death from
cardiovascular disease (Davey-Smith 1997) which like most other diseases is much
more common in poorer socio-economic groups (Morrison et al 1997).

Infant mortality in the UK is 70 percent higher in social class V than in social class I
(Botting 1997), and again this is a differential that has widened in the last decade and
a half. Children in the manual social classes are more likely to suffer from chronic
sickness and tooth decay than those in non-manual classes (Botting and Bunting
1997).

A real association or an artefact?

Clearly the socio-economic environment is strongly associated with health. However,

the next consideration is whether this association is real or whether it is due to some
artefact or bias or confounding factor. The evidence suggests that these associations
are unlikely to be explained by artefact or by the social drift hypothesis (whereby
health determines social class) or by genetics determining both health and social class
(Marmot et al 1995). Historically, neither social class nor health status have been

5
primarily genetically determined. Similarly, health status has not been the main
determinant of social class, though it does have some effect (Fox and Benzeval 1995).

Given that artefact is not the explanation, and that the association is therefore real, it
is natural to enquire into the possible mechanisms linking the socio-economic
environment and health, and also into the particular aspects of the socio-economic
environment which are responsible for determining health. These issues are now
considered in turn, beginning with a discussion of the possible mediating pathways
between the socio-economic environment and health, before moving on to a
discussion of the important (general and later specific) socio-economic environmental
factors which determine health.

Mediators between the socio-economic environment and health

The main mediators acting between the socio-economic environment and ill health are
likely to be psychosocial stress (Patrick et al 1995) and other psychological states
including self-esteem, identity, and personality, which also influence personal and
social expectations. Some of the translation from socio-economic environment to
biological health state probably occurs through endocrine hormone release and other
biological signals (Tarlov 1996). The psyche (the mind) and the soma (the body) are
likely to be much more closely linked than the philosopher Descartes implied when he
separated them within his model of “Cartesian Dualism”, a conceptual separation
which unhelpfully persists to this day.

The socio-economic environment in turn considerably determines the level of

exposure to physical environmental hazards - wealthier people have more choices,
being able to buy their way out of unhealthy environments, and also appears to
produce the lifestyles and behaviour that lead on to ill-health, probably as a result of
stress and peer pressure (Brenner 1995, Davey-Smith et al 1997).

General socio-economic environmental determinANTS

The general factors within the socio-economic environment which act to determine
health status can be summarised by the “3 Rs” of “relational position” (social
integration and cohesion), “resource position” (wealth, poverty and deprivation), and
“relative position” (social stratification, inclusion and exclusion) (Miller 1995). These
will be taken in turn:

Relational Position (Social Integration and Cohesion)

The relational position of a society or group refers to how closely individuals relate to
each other. Research dating back as far as the great 19th century French sociologist
Emile Durkheim (1897) has suggested that the closeness of a society in terms of a
sense of belonging (anomie as opposed to atomie) and community is a strong
determinant of mental health particularly of suicide. Similarly, more recent work
shows clear links between social networks, confiding relationships and depression
(Brown 1978). Community cohesion, including family structures, is also related to
physical health indices (Patrick et al 1995).

6
Resource Position (Wealth, poverty, and deprivation)

Wealth, income, poverty and deprivation are strongly related to social class and a very
close correlation between the pattern of deprivation and the pattern of ill-health and
disease is evident.

The level of material well being experienced by an individual is largely determined by

their social class, which is therefore also a key indicator of poverty and deprivation;
and almost every health state and every disease is strongly social class related, being
more common among poorer people (Hart, N 1997).The health differentials seen by
social class probably result partly from absolute resource poverty but also from the
social barriers created by relative lack of resources.

Relative Position (relative poverty and social exclusion)

There is considerable evidence suggesting that once one gets above a basic third
world developmental level, then it is relative rather than absolute deprivation and
poverty which is the more important determinant of health. Countries with lower
levels of inequality in wealth (relative poverty) have lower levels of health inequality
(Wilkinson 1996, 1997, Marmot et al 1995).

If relative poverty is more important than absolute poverty (at least in a country with a
welfare state) this may suggest that health disadvantage may be more a result of
psychological mediators (Brunner 1997) related to relative social position than to
differential exposure to hazardous material physical agents.

Absolute poverty can be prevented by benefits, and some argue that absolute poverty
barely exists in the UK, at least in the way that it did 50 years ago. However, benefits
may also create dependence resulting from a poverty trap caused by the perverse
incentives built into the benefit system.

Relative deprivation can be tackled by social engineering to flatten out differentials

through re-distributive policies (which are far more politically controversial) or
alternatively if the mediators are psychosocial then perhaps the effects of relative
deprivation can be ameliorated through psychosocial support mechanisms or policies
to reduce psychosocial stress (Wilkinson 1997a).

Specific socio-economic environmental determinaNTS

Unemployment, economic inactivity and economic dependency

Unemployment is a key determinant of health (Brenner 1995) with a close correlation,

even after correction for social class, with various measures of health status including
premature mortality, suggesting that it is an independent determinant of health
(Bethune 1997). This relationship is not explained by pre-existing ill health leading to
unemployment. Unemployment and economic inactivity also appear to have an effect
on self-esteem and mental health, over and above the health effects of unemployment
mediated through poverty.

7
Employment and the Occupational Environment

On the whole, employment is healthier than unemployment. However, there is a long

legacy of occupationally caused ill health in post-(heavy)industrial parts of the UK in
particular. Although much of the hazardous heavy industry has now disappeared,
while that which remains is probably more closely regulated than previously in health
and safety terms, nevertheless most exposure to health damaging agents probably still
occurs in the occupational setting. Psychosocial stress in the workplace (Everson et al
1997), particularly that related to low autonomy at work, and “high effort - low
reward” work has been implicated as an occupational determinant of ill health, with
those of lower employment status within organisations being most disadvantaged
(Marmot and Feeney 1996, Marmot et al 1997, Bosma et al 1997, Johnson and Hall
1995).

Education

After age, the largest determinant of differential health status is probably social class.
However, social class and education are strongly correlated in both directions in a
virtuous cyclical relationship (Blane et al 1996). The absence of wealth and education
acts in a vicious cycle potentially spiralling towards a socially excluded position
associated with ill health (Wadsworth 1996).

The main determinant of adult social class is the social class into which one was born.
However, general education appears to offer the greatest potential for social class
mobility and is probably the key intervention available to prevent poverty, deprivation
or exclusion and thereby to reduce health inequalities and to promote public health
(Wadsworth 1996, Blane et al 1996).

Maternal education level is a particularly strong predictor of various parenting skills

and behaviours beneficial to foetal and infant health including duration of breast
feeding (Wadsworth 1996).

Economic Growth and Recession

There is a relationship between economic growth and health (Brenner 1995).

Population health status decreases in recessions mediated through social mechanisms
such as poverty, unemployment and loss of social position (Brenner 1995).

Culture and Social Norms

Cultural factors and social and group norms (peer pressure) are powerful health
determinants (Patrick et al 1995) through their effect on behaviour. Social norms
condition (normative) behaviour patterns that are socially acceptable but not
necessarily healthy. Traversing social norms can also lead to felt stigma or enacted
stigma (labelling) resulting in secondary deviant health related behaviour.

Lifestyle (which is covered separately later) represents a predictable combination of

several specific behaviours, ranging across different aspects of life experience.
Lifestyle is a strong determinant of health, and obviously is partially subject to “free
will”. However, research suggests that lifestyle is actually largely determined by these
social processes involving culture and social norms (Patrick et al 1995).

8
Crime and Violence

If the social environment becomes unsafe this can influence the mental health status
of an individual. A safe environment free of crime (or fear of crime) is an important
factor and contributes significantly to individuals’ sense of well being (Patrick et al
1995). Violent crime directed at the person is of particular importance as a health
determinant. However, crime against property is also relevant. The challenge is not
just to be “tough on crime” for health as well as other reasons, but also to be “tough
on the causes of crime”, which are largely the same socio-economic factors which
determine health.

The physical, chemical and biological environment

Physical, chemical and biological environmental influences are highly important

determinants of health (Last 1998). Exposure to hazards in these environmental
categories is strongly correlated with social class and determined by socio-economic
status, acting largely through occupation and precise geographical area of residence.

Shelter and housing (and the domestic environment)

After food and water, shelter from the extremes of the natural environment is
probably the other important physical environmental pre-requisite for health.
Homelessness, which has been seen with increasing frequency in recent years, is
therefore a fundamental threat to health. Alongside the availability of shelter, the
quality of housing has also been a crucial factor related to health. The links between
housing conditions and health have long been recognised. Generally, those living in
good housing are in better physical and mental health than those who are not.

These links were most prominent in Victorian Britain, which established the
connection between overcrowded and insanitary housing, high death rates and high
rates of disease. The link was probably mainly between overcrowding and poor
ventilation and respiratory infections such as TB. Massive slum clearance and
significant investment in private sector and social housing improved these conditions
but often broke up community psychosocial support. Even though the condition of
housing has now improved, it is still likely that many of the inequalities in health
which we see in today’s adults and elderly are related to the poor housing conditions
they experienced many years ago when they were children (Barker and Osmond
1987a). Poor adult respiratory health status and adult death from chronic obstructive
airways disease are both determined by childhood respiratory infection, which is
partly related to overcrowded living conditions (Barker et al 1991).

The indoor environment is believed to influence allergic respiratory disorders, some

of which may be related to dampness, central heating and wall to wall carpeting (Best
1995). These environmental conditions have particular impact on children (Barker
and Osmond 1987a). Fuel poverty is also an issue that is under increasing
examination and especially its impact on the poorest and oldest in whom it causes
hypothermia.

9
Pollution of the general environment

Pollution, whether generalised, as in air quality in urban areas, or localised, as in

incidents such as oil spills, is often believed, and may sometimes be proved, to be the
cause of ill health and may therefore account for health inequalities. A lot is known
about the health damaging effects of exposure to high doses of myriad different
chemicals in the occupational setting. Much less is known about low dose exposure in
the general community (Last 1998). However, a large evidence base now exists on the
health effects of urban pollution principally emanating from motor vehicle emissions.
These are principally the provocation of asthma attacks in the susceptible (Last 1998).

Water and sanitation

Historically, following the industrial revolution, domestic water polluted with sewage
was probably the greatest single threat to health. The efficient separation of drinking
water from effluent achieved by the sewer system in cities was probably the greatest
achievement of the public health movement. The maintenance of this system remains
crucial today, and drinking water providers have to consider new microbiological
threats such as Cryptosporidium which are particularly difficult to deal with. The
main chemical hazard in drinking water is lead from piping which can cause lead
poisoning and mental retardation. Fluoride in drinking water at appropriate naturally
occurring (or artificially created) levels substantially reduces the incidence of dental
decay across all classes and age groups. This benefit is not enjoyed in large parts of
the UK.

Food and agriculture

Availability of sufficient quantities of safe nutritious food is a fundamental

determinant of health and its lack is a form of absolute deprivation.

LIFESTYLE

Another important factor which influences health is the lifestyle of each individual;
whether a person chooses to smoke, exercise frequently, or limit intake of fatty foods.

At first sight lifestyle may be thought to be a matter of free choice. However,

evidence suggests that in addition to being influenced by educational level and
personal skills, it is also strongly determined by wider factors related to local and
personal situation. These include peer pressure, social norms, socio-economic factors
(including poverty and deprivation) social class, and also by product marketing and
advertising and local availability (Abel-Smith 1994).

DIET AND NUTRITION

A healthy or unhealthy diet, is a key determinant of health (Last 1998).

Evidence suggests that poor nutrition in early childhood related to family poverty
some sixty to seventy years ago increased subsequent susceptibility to death from
ischaemic heart disease and stroke in adulthood (Barker and Osmond 1986, Barker
and Osmond 1987a, Barker et al 1989b, Barker et al 1990a). Several of these papers

10
suggest hypertension as the mediator within this relationship, though evidence also
implicates high serum cholesterol concentration again resulting from poor nutrition in
childhood earlier this century (Fall et al 1992).

In more modern times, deficient maternal and early childhood diets may be less
common. However, the important recent discoveries of the nutritional value of
maternal folic acid for the prevention of neural tube defects and of breast feeding for
the promotion of general health and the prevention of disease makes it clear that this
issue remains relevant. Furthermore breast feeding has actually been declining,
particularly in poorer groups (James et al 1997). Diet in adulthood may be less
important in explaining inequalities in health than diet in childhood (Cade et al 1988),
though there is also a wealth of evidence of a relationship.

Green vegetables, salads and fruit provide antioxidant vitamins and fibre and are
thought to be protective against bowel diseases and cancers in general (James et al
1997). Current health promotion campaigns advise five helpings of fruit or vegetables
daily. Diets high in saturated fatty acid cause heart disease and strokes and high salt
intake causes high blood pressure and heart disease and strokes (James et al 1997).
Similarly, it is well known that foods high in refined sugar cause obesity and dental
caries.

For each component of a healthy diet a consistent picture relating poor diet, poverty
and low social class is seen throughout the UK (James 1997).

SUBSTANCE MISUSE

The misuse of nicotine, alcohol and drugs has major implications for health.

SMOKING

Smoking increases the risk of having a small baby, and of suffering heart disease,
lung cancer, bronchitis and emphysema, limb amputation and various other problems,
A major concern is the continued high number of teenage girls who smoke.

ALCOHOL

In excess, alcohol causes cirrhosis of the liver and high blood pressure in addition to
social problems. In moderation, alcohol is probably beneficial to health.

EXERCISE AND OBESITY

Both exercise and obesity are strong risk factors for coronary heart disease, which is
the biggest killer in the UK.

OVERWEIGHT / OBESITY

Obesity increases risk of heart disease and stroke, among other problems. The UK has
some of the worst rates of obesity in the world – and rising.

11
EXERCISE
Regular strenuous exercise has a protective effect for heart disease and stroke, builds
bone mass, improves posture and helps control body weight.

HEREDITY (GENETICS) AND OTHER INTRINSIC FACTORS

These factors include genetic endowment (including sex) and biological age. The
genetic constitution of individuals and populations is the key intrinsic determinant of
health. All human diseases have a genetic component, including those due to
infectious diseases or toxic agents, where the host response, in terms of the extent and
severity of the effect, is at least in part a function of genetic susceptibility. Some
diseases, which are due to single gene or chromosomal deficits, appear to be
completely genetically determined.

Genetics is also potentially the most powerful arena for medical intervention to
improve the health of individuals and could therefore also be a key focus for public
policy in facilitating the treatment of those who could benefit. Thus far, medical
intervention cannot change the genetic constitution of individuals to improve their
health, but the power of the genetic revolution is to enable greater understanding of
the interaction between genetic and environmental factors. This will allow
conventional public health interventions to be focused on genetically susceptible sub-
populations, and health promotional messages to be targeted at individuals at specific
risk of disease.

Genetic testing and screening for diseases can at this stage only identify those at
greater or lesser risk, with little prospect for direct curative intervention. Nevertheless,
in some cases useful medical or personal action can be taken to reduce that risk, while
in others the information may lead to benefit for other family members. The extent to
which such knowledge may give rise to unnecessary anxiety is unclear but the whole
question of genetic testing and screening raises significant ethical questions.

In the area of pre-conceptual counselling and foetal screening, recourse is available to

more definitive intervention, though in the latter case, this means termination of
pregnancy, a course of action few find easy. Furthermore, again there are ethical
questions about falsely alarming those who are not affected.

In summary, at the moment there is only limited scope for clinical or public health
intervention, but a number of policy issues can reasonably be set out at this time. This
provides a window of opportunity to debate the ethical and financial implications of
genetic science, yet however these resolve, there can be little doubt that the greater
understanding of disease mechanisms brought about by the genetic revolution will
have significant benefits for the public health (see also Zimmern and Cook 2000).

HEALTH CARE SERVICES

A person’s health can also be influenced by access to good quality (effective) services
(Bunker et al 1995). However, contrary to popular opinion, the evidence from

12
historical studies (McKeown 1979), between countries comparisons (Cochrane 1978),
and other studies (Marmot et al 1995) suggests that this influence of medical and
health care upon the health of the population has been and remains smaller than each
of the three other fields of environment, lifestyle and genetics. It follows therefore
that inequalities in access to effective medical and health care services are not likely
to be the main explanation for inequalities in health status.

It should be noted that these conclusions are based largely on mortality based
evidence and it is possible that health care may well play a larger part in improving
quality of life rather than increasing length of life.

Nevertheless, the evidence which does exist is sufficiently convincing to be able to

conclude that prevention through social and environmental policy and public health
action is more effective than medical and healthcare services, in achieving population
health gain (Hobbs and Jamrozik1997). This has been the position across the sweep of
history though the contribution of clinical medicine has been increasing in the late
twentieth century. Nonetheless, in simple terms, and perhaps unsurprisingly, it
appears that it is easier to prevent health from being forfeited in the first place than it
is to restore health after it has been lost.

Within the domain of clinical medical and health care services, it is preventive
medicine in the form of immunisation and preventive maternal and child health, rather
than “curative” services that have historically been of greatest value in advancing
population health and also in reducing health inequalities (Bunker et al 1995, Hobbs
and Jamrozik 1997). Large though this contribution has been, it should not distract
from the fact that overall, prevention has most effectively and efficiently been
achieved by social and environmental policy than by public health or preventive
medical services.

Therapeutic medicine has benefited the health of the population most through the
antibiotic treatment of sexually transmitted diseases and of some other infectious
diseases, particularly Tuberculosis (Hobbs and Jamrozik 1997). However, in the latter
case, the role of improving social and environmental conditions (including provision
of clean water and better housing leading to reduction in overcrowding) and better
nutrition was much more important in the decline of this disease than the advent of
effective treatment.

There have been some notable medical successes in the treatment of cancer in
younger patients particularly in the case of childhood leukaemia, and of testicular
cancer in young men, both of which are now almost invariably curable, however the
population health impact of successful treatment of these rare diseases is small.

Outside medical drug therapy, orthopaedic and accident surgeons have a claim to be
among the doctors achieving greatest population health gain particularly as a result of
treating fractures due to trauma in younger patients (Hobbs and Jamrozik 1997).
Ophthalmic surgeons can rival these claims as a result of the great benefits to be
derived from cataract surgery (Hobbs and Jamrozik 1997).

In recent times there have been considerable advances through medical innovation
and it is often assumed that this must therefore translate into a greater benefit to the
health of the population. It is reasonable to assume that there has been benefit at the

13
population as well as the individual level. However, there is little convincing evidence
to suggest that the the relative contribution made by medical and health care to the
health of the population has increased markedly compared to wider social,
environmental and public health policy and action.

Following the success of the latter interventions in combating infectious diseases, the
current picture of population ill-health is different from that in the past, comprising
largely chronic degenerative diseases in older people. These patients are in health
terms on a downward trajectory and their diseases being degenerative in nature, are
more refractory to medical intervention. Hence there is also a law of diminishing
returns, whereby progressively larger increments of expenditure on medical care for
these groups achieves progressively smaller incremental health improvement. Health
maintenance may be a more realistic goal than health improvement for these groups.

Ironically therefore, just as medicine appears to have become more potent, the
prevalent degenerative health conditions make it more difficult for it to demonstrate
unequivocably that it is making a larger contribution to the health of the population.
These degenerative diseases are usually amenable more to delay than prevention, and
to quality of life improvement rather than cure. Because medical treatment benefits
might therefore be more evident in quality of life improvement rather than mortality
rates or longevity, they may also be more difficult to demonstrate unequivocably.

CONCLUSION

Although absence of evidence of benefit is not synonymous with failure, rational

public policy should as far as possible be made according to the evidence which does
exist. This favours social, environmental and public health policy over clinical
medicine and healthcare.

14
 REFERENCES

Abel-Smith B. 1994. An introduction to health policy, planning and financing.

Longman.

Barker DJP, Osmond C. 1986. Infant mortality, childhood nutrition, and ischaemic
heart disease in England and Wales. Lancet 1986; I: 1077-81.

Barker DJP, Osmond C. 1987a. Inequalities in health in Britain: specific explanations

in three Lancashire towns. BMJ 1987; 294: 719-52.

Barker DJP, Osmond C. 1987b. Death rates from stroke in England and Wales
predicted from past maternal mortality. BMJ 1987; 295: 83-6.

Barker DJP, Osmond C, Law CM. 1989a. The intrauterine and early postnatal origins
of cardiovascular disease and chronic bronchitis. J. Epidemiol Community Health
1989; 43: 237-10.

Barker DJP, Winter PD, Osmond C, Margetts B, Simmonds SJ. 1989b. Weight in
infancy and death from ischaemic heart disease. Lancet 1989; ii: 577-80.

Barker DJP, Osmond C, Golding J, Kult D, Wadsworth MEJ. 1989c. Growth in utero,
blood pressure in childhood and adult life, and mortality from cardiovascular disease.
BMJ. 1989; 298: 564-7.

Barker DJP, Osmond C, Golding J. 1990a. Height and mortality in the counties of
England and Wales. Ann Hum Biol 1990;17:1-6.

Barker DJP, Bull AR, Osmond C, Simmonds SJ. 1990b. Fetal and placental size and
risk of hypertension in adult life. BMJ 1990; 301: 259-62.

Barker DJP, Godfrey KM, Fall C, Osmond C, Winter PD, Shaheen SO. 1991.
Relation of birth weight and childhood respiratory infection to adult lung function and
death from chronic obstructive airways disease. BMJ 1991; 303: 671-5.

Barker DJP, Robinson RJ. 1992. Fetal and infant origins of adult disease. BMJ
Publishing Group. London.

Barker DJP, Godfrey KM, Osmond C, Bull A. 1992. The relation of fetal length,
ponderal index and head circumference to blood pressure and the risk of hypertension
in adult life. Peadiatr Perinat Epidemiol 1992; 6: 35-44.

Benzeval M, Judge K, Whitehead M. 1995. The role of the NHS. In: Benzeval M,
Judge K, Whitehead [Link] inequalities in health – an agenda for action. Kings
Fund. London.

Best R. 1995. The housing dimension. In: Benzeval M, Judge K, Whitehead M.

Tackling inequalities in health – an agenda for action. Kings Fund. London.

15
Bethune A 1997. Unemployment and mortality. In: Drever F, Whitehead M. Health
inequalities. Office for National Statistics. London.

Blane D, White I, Morris J (1996). Education, social circumstances and mortality. In:
Blane D, Brunner E, Wilkinson R. Health and Social Organisation - Towards a health
policy for the 21st century. Routledge. London.

Blum H. 1974, 1981. Planning for health. Human Sciences Press, New York (1st and
2nd edition).

Bosma H, Marmot M, Hemingway H, Nicholson A, Brunner E, Stansfield S. Low job

control and risk of coronary heart disease in Whitehall II (prospective cohort) study.
BMJ. 1997; 314: 558-65.

Botting B. 1997. Mortality in childhood. In: Drever F, Whitehead M. Health

inequalities. Office for National Statistics. London.

Botting B, and Bunting J. 1997. Children’s health and lifestyle – a review. In: Drever
F, Whitehead M. Health inequalities. Office for National Statistics. London.

Brenner MH. 1995. Political economy and health. In: Amick BC, Levine S, Tarlov
AR, Walsh DC. Society and health. Oxford University Press. Oxford.

Brown G, and Harris T. 1978. Social origins of depression: a study of psychiatric

disorders in women. Tavistock. London.

Brunner E. 1997. Stress and the biology of inequality. BMJ 1997; 314: 1472-6.

Bunker JP, Frazier HS, Mosteller F. 1995. The role of medical care in determining
health: creating an inventory of benefits. In: Amick BC, Levine S, Tarlov AR, Walsh
DC. Society and health. Oxford University Press. Oxford.

Bunting J. 1997. Morbidity and health related behaviours of adult – a review. In:
Drever F, Whitehead M. Health inequalities. Office for National Statistics. London.

Cade JE, Barker DJP, Margetts BM, Morris JA. 1988. Diet and inequalities in health
in three English towns. BMJ. 1988; 296:1359-62.

Canadian Government. 1974. A new perspective on the health of Canadians. (Lalonde

Report). Department of Health and Social Welfare. Ottawa

Cochrane A L, St Ledger AS, Moore F. 1978. Health Service “input” and mortality
“output” in developed countries. J Epidemiol Community Health 32: 200-205.

Davey-Smith G, Hart C, Blane D, Gillis C, Hawthorne V. 1997. Lifetime socio-

economic position and mortality: prospective observational study. BMJ 1997; 314:
547-52.

Drever F, and Bunting J. 1997. Patterns and trends in male mortality. In: Drever F,
Whitehead M. Health inequalities. Office for National Statistics. London.

16
Durkheim, E. 1897. Suicide. (Translated by Spalding JA and Simpson G and reprinted
in 1951). New York: Free Press.

Evans RG, Stoddart GL. (1990). Producing health, consuming healthcare. Soc Sci
Med. 31: 1347-1363.

Evans, RG , Stoddart GL. (1994). Producing health, consuming healthcare. In Evans,

RG, Barer ML , Marmor TR. Why are some people healthy and others not? The
determinants of health of populations. Walter de Gruyter. Berlin.

Everson SA, Lynch JW, Chesney MA, Kaplan GA, Goldberg DE, Shade SB, Cohen
RD, Salonen R, Salonen JT. Interaction of workplace demands and cardiovascular
reactivity in progression of carotid atherosclerosis: population based study. BMJ
1997; 314: 553-8.

Fall CHD, Barker DJP, Osmond Q Winter PD, Clark PMS, Hales CN. 1992. Relation
of infant feeding to adult scrum cholesterol concentration and death from ischaemic
heart disease. BMJ 1992; 304: 801-5.

Forman D. (1998). Helicobacter infection and cancer. In: Farthing MJG, Patchett SE
(1998). Helicobacter infection. British Medical Bulletin. Vol 54. No1.

Fox J, and Benzeval M. (1995) Perspectives on social variations in health. In:

Benzeval, M. Judge, K. Whitehead, M. Tackling inequalities in health: an agenda for
action. Kings Fund. London.

Godfrey KM, Redman CWG, Barker DJP, Osmond C. 1991. The effect of maternal
anaemia and iron deficiency on the ratio of fetal weight to placental weight. Br J
Obstet Gynaecol 199l; 98: 886-91.

Hales CN, Barker DJP, Clark PMS, Cox LJ Fall C, Osmond C, Winter PD. 1991.
Fetal and infant growth and impaired glucose tolerance at age 64. BMJ. 1991;
303:1019-22.

Harding S, Bethune A, Maxwell R, Brown J. Mortality trends using the

Longitudinal Study. 1997. In: Drever F, Whitehead M. Health inequalities. Office for
National Statistics. London.

Hart JT. 1971. The inverse care law. Lancet, I, 405-12.

Hart N. 1997. The social and economic environment and human health. In Detels, R,
et al: The Oxford textbook of public health (3rd ed). Oxford University Press. Oxford.

Hattersley L. 1997. Expectation of life by social class. In: Drever F, Whitehead M.

Health inequalities. Office for National Statistics. London.

Hobbs M, Jamrozik K. 1997. Medical care and public health. In: Detels, R, et al: The
Oxford textbook of public health (3rd Ed). Oxford University Press. Oxford.

17
James WPT, Nelson M, Ralph A, Leather S. 1997. The contribution of nutrition to
inequalities in health. BMJ 1997; 314:1545-9.

Johnson JV, Hall EM. 1995. Class, work, and health. In: Amick BC, Levine S, Tarlov
AR, Walsh DC. Society and health. Oxford University Press. Oxford.

Laframboise HL. 1973. Health policy: breaking the problem down into manageable
segments. Canadian Medical Association Journal; 108: 388-393.

Last J. 1998. Public health and human ecology (2nd ed). Appleton Lange.

Law CM, Barker DJP, Bull AR, Osmond C. 1991. Maternal and fetal influences on
blood pressure. Arch Dis Child 1991; 66: 1291-5.

Marmot M, Bobak M, Davy-Smith G. 1995. Explanations for social inequalities in

health . In: Amick BC, Levine S, Tarlov AR, Walsh DC. Society and health. Oxford
University Press. Oxford.

Marmot M, Bosma H, Hemingway H, Brunner E, Stansfield S. 1997. Contribution of

job control and other risk factors to social variations in coronary heart disease
incidence. Lancet 1997; 350: 235-39.

Marmot M, Feeney A. 1996. Work and health - implications for individuals and
society. In: Blane D, Brunner E, Wilkinson R. Health and social organisation -
towards a health policy for the 21st Century. Routledge. London.

McKeown T. 1979. The role of medicine. Oxford: Basil Blackwell.

Miller, SM. 1995. Thinking strategically about society and health. In: Amick BC,
Levine S, Tarlov AR, Walsh DC. Society and health. Oxford University Press.
Oxford.

Morrison C, Woodward M, Leslie W, Tunstall-Pedoe H. 1997. Effect of socio-

economic group on incidence of, management of, and survival after myocardial
infarction and coronary death: analysis of community coronary event register. BMJ
1997; 314: 541-6.

Osmond C, Barker DJP, Slattery JM. 1990. Risk of death from cardiovascular disease
and chronic bronchitis determined by place of birth in England and Wales. J
Epidemiol. Community Health 1990; 44: 139-41.

Osmond C. 1987. Time trends in infant mortality, ischaemic heart disease and stroke
in England and Wales. Southampton: Medical Research Council Environmental
Epidemiology Unit, 1987: 28-34. (Scientific report no 8.)

Patrick DL, Wickizer TM. 1995. Community and health. In: In: Amick BC, Levine S,
Tarlov AR, Walsh DC. Society and health. Oxford University Press. Oxford.

18
Robinson S, Walton RJ, Clark PM, Barker DJP, Hales CN, Osmond C. 1992. The
relation of fetal growth to plasma glucose in young men. Diabetologia 1992; vol 35:
444-6.

Tarlov AR. 1996. Social determinants of health. The sociobiological translation. In:
Blane D, Brunner E, Wilkinson R. Health and social organisation - towards a health
policy for the 21st century. Routledge. London.

Townsend P, Whitehead M, Davidson N (eds). 1992. Inequalities in health: The Black

Report and the health divide. Penguin Books.

Wadsworth M. 1996. Family and education as determinants of health. In: Blane D,

Brunner E, Wilkinson R. Health and social organisation - towards a health policy for
the 21st century. Routledge. London.

Whitehead M. 1995. Tackling inequalities: a review of policy initiatives. In:

Benzeval, M. Judge, K. Whitehead, M. Tackling inequalities in health: an agenda for
action. Kings Fund. London.

Wilkinson R. 1996. Unhealthy societies. Routledge London

Wilkinson R. 1997. Health Inequalities: relative or absolute material standards? BMJ:

314: 591-5.

Zimmern R, Cook C. 2000. Genetics and health. Policy issues for genetic science and
their implications for health and health services. The Nuffield Trust. London.

19