People who are lower on the socioeconomic ladder (indicated by their level of education, occupation or income) have shorter and less healthy lives, on average, than those on higher rungs. Indeed, life expectancy at birth often varies by five to 10 years, depending on social and economic well-being, with poorer people spending 10 to 20 more years of life suffering from illness or disability than their wealthier counterparts.
In the nineteenth century, this situation would not have been surprising, given low average income, widespread poverty and lack of social security. However, such data are commonly reported for high-income countries today, including those ranking high on indices of economic prosperity and human development — even Western Europe’s highly developed welfare states.
Since the end of World War II, Western European countries have tried to reduce socioeconomic inequality, or offset its consequences, through progressive taxation, social security programs and a wide range of collectively financed provisions, such as public housing, education, healthcare and cultural and leisure facilities. However, while these policies have reduced inequalities in some social and economic outcomes, including income, housing quality and healthcare access, they have been insufficient to eliminate health inequalities.
Long-term time-series data indicate that the socioeconomic mortality gap narrowed before the 1950s, but has grown substantially since then. More puzzling is the fact that more generous welfare policies do not translate into smaller health disparities. Even the Nordic countries — world leaders when it comes to creating universal and well-designed welfare policies that cover citizens from cradle to grave — face significant health disparities, despite their relatively low income inequality.
To be sure, modern welfare states have far from abolished social inequality, with disparities in access to material and human resources continuing to generate highly unequal lives among their citizens. However, the welfare state’s aim has never been radical redistribution of wealth. Rather, welfare policies are intended to create a compromise between the interests of employees and employers, laborers and the middle classes. As a result, their redistributive effects are modest.
So, while a partial failure of the welfare state may help to explain the persistence of health inequalities, one must look elsewhere to understand — and reverse — their rise. Two possible explanations have emerged from the rapidly growing scientific literature on the subject: selective upward social mobility and delayed diffusion of behavioral change. In reality, both factors are at work.
During the twentieth century, social mobility increased slowly but steadily in all high-income countries, with educational achievement and occupational status depending less on family background and more on cognitive ability and other personal characteristics.
As a result, the lower socioeconomic groups have not only shrunk in size, but have probably also become more homogeneous in terms of personal characteristics that increase the risk of health problems.
Moreover, people with a higher socioeconomic position tend to adopt new behaviors first, and more readily to abandon behaviors that are found to damage health, such as smoking and high-fat diets. Given this, new behavioral recommendations by health authorities tend to exacerbate health inequalities, at least temporarily.