Physical health is a site of social inequality. Unequal social relations create unequal chances of staying alive, unequal possibilities of health across lifetimes and inequalities in the experience of ill health. Profound, unjust suffering results. Social work in its own right can contribute to changing this situation: to creating greater equality in physical health. Yet this dimension to practice has barely gained recognition within social work, despite its crucial importance for people’s well-being. In this article we examine the devastating impact of social inequalities on physical health, how social work generally – not simply in health care settings – may tackle this, and how such practice can be developed. We focus specifically on health inequalities as a key issue for social work, for three fundamental reasons:

• The unjust, unnecessary suffering resulting from socially-constructed inequalities in physical health should be a cause of concern to social workers.

• Social work is implicated in processes which produce and maintain such inequalities.

• Social work can make its contribution to a more equal experience of physical health. We now introduce each of these main themes in turn.

SOCIAL WORK: COMPOUNDING HEALTH INEQUALITIES

Inequality in physical health requires attention from social workers because of the gravity of the damage it inflicts on people’s welfare and because of its socially constructed nature. It also demands attention because social work is itself implicated in the processes which produce and maintain such inequalities. We analyse this tendency in detail in Articles 3 to 6. Here we indicate the extent to which it is institutionalised in practice.

A neglected issue at the heart of practice

Professional social work has shown a lack of awareness of the issue of inequalities in physical health despite the significance of this issue in the lives of the vast majority of its own service users, in whose experience the unequal social conditions which have such threatening and damaging effects on health are almost universal. Although there is relatively little systematic analysis of contact with social workers by social status (partly because most service users exemplify those groups not well recognised in statistics based on the employment of the male head of the household: Graham 1995) there is evidence of extensive poverty and deprivation. For example, studies in Strathclyde in the 1980s found that around 80 per cent of all service users were living on social security benefits and most on means-tested benefits (Becker 1997). Most children enter the care system from a family living in poverty (Bebbington and Miles 1989), while families with disabled children are disproportionately likely not to have the material resources to be able to sustain a healthy standard of living (Joseph Rowntree Findings 1998a).

Moreover, the few studies which analyse the health of service users show that the majority are either currently living with illness or caring for someone in poor health, often jeopardising their own health in the process. Corney’s (1985) analysis of referrals to a generic intake team found that less than 10 per cent were free from physical symptoms, while almost two-thirds described themselves as suffering from a profound health problem. Redmond et al. (1996) investigated untreated health problems in seventy-seven older people receiving home care. Sixty-eight were assessed as likely to benefit from further intervention. In total 192 referrals were made. Studies of the outcome of caring for someone with a long-term illness in the absence of adequate material and personal support consistently demonstrate adverse consequences for carers’ health (Anderson and Bury 1988; Spackman 1991).

A problematic record

Although the negative association between social inequalities and health is manifest in the lives of users of its own services, social work’s record of addressing such situations is problematic. This is epitomised in the following two issues. First, social work has failed to implement measures to combat poverty as a consistent and central feature of practice (Becker 1997; Davis and Wainwright 1996), while too often adopting a pathologising, individualistic approach (Jones 1997). In Clark and Davis’ (1997) survey of social workers’ approaches to poverty, a depressing picture of the absence of even preliminary engagement with this issue was found. Limited awareness of poverty as a social problem and its significance in the daily lives of service users was accompanied by underestimation of levels of debt. Attempts to maximise income were far from routine – not surprising when almost half the employers questioned did not regard addressing relative poverty as an appropriate role for social workers. Second, social work’s record has also proved questionable in ensuring equality in access to, and in the experience of, the community-based domiciliary day-care and residential services which provide much-needed sources of practical, emotional and social support for people living with ill health. To give one example, successive studies have shown differential levels of information about services between minority ethnic groups and the majority population, and amongst minority groups in general. Coupled with institutionalised barriers to access this has resulted in inequalities in the use of mainstream services, not adequately compensated for by a ‘special projects’ approach which has often been dependent on temporary and vulnerable funding arrangements (Butt and Mirza 1996).

A bad situation exacerbated

Moreover, through the role assigned to it by state policies social work has been sucked into exacerbating social inequalities, with adverse consequences for health. As highlighted earlier, through the 1980s and 1990s state policies in Britain intensified social and economic inequalities. This process was also marked by a developing programme designed to individualise, domesticate, privatise and commercialise health and welfare provision, resulting in a worsening experience of ill health for the least powerful members of society. Social workers were drawn into this process of restructuring the state’s role in welfare provision. This led to such trends in local authority social work as: gatekeeping increasingly inadequate financial resources; targeting at the expense of prevention; and a narrowed repertoire of intervention reflecting a more bureaucratised approach (Lymbery 1998; Means and Smith 1998; Parton 1996). Despite identifying social work as necessary to its programme for tackling health inequalities, current welfare policy is characterised by some significant continuities with that of the previous administration. There remains a strong emphasis on individual, family and community responsibility; a focus on containing risk and dangerousness; and an expectation that social workers will act as managers of rationed provision with narrow eligibility criteria. Within this conception social work continues to occupy an ‘essentially contested and ambiguous position … between the respectable and the dangerous classes’ (Parton 1996: 6); a balancing act characterised as protecting the vulnerable, while not undermining the independence of the private citizen in providing for their own and their family’s welfare. This approach is manifest in the government white paper ‘Modernising Social Services’(DoH 1998c) and linked policy documents which emphasise the management and regulation of social care provision rather than a substantial redistribution of material and social resources to underwrite service users’ welfare.

Oppression in bodily form In this article we underline the case that inequalities in health should be a central concern for social work. We give evidence of the extent of this major social problem and the complex ways in which health inequalities are linked with multiple dimensions of social inequality. We argue that oppression is physically embodied in the suffering involved in ill health and premature death. We present evidence of widening inequalities across the UK population and show how these inequalities are woven into the fabric of people’s daily lives as they work to secure and maintain health for themselves and those close to them. We discuss the economic and policy backdrop to this daily labour of lay health work and argue that inequalities in health are not simply the visible outcome of a particular economic system but are part of the process through which the economic and political system is sustained. We focus on policy relating to health care as an example of the wider reconstruction of welfare. This article prepares the ground for a detailed examination across Articles 3 to 7 of the actual and potential role of social work in reducing health inequalities. It is not concerned with inequalities in the experience of illness, which are also the focus of later articles, but primarily with inequalities in ‘health chances’: people’s chances of staying well, getting ill or dying prematurely (Moore and Harrison 1995). The production of health: Social, economic and environmental factors In Britain, the Black Report on Inequalities in Health (Department of Health and Social Security (DHSS) 1980) proved to be a landmark study, demonstrating that the NHS and social services had been ineffective in closing the gap in health between rich and poor (Davey Smith et al. 1990 and 1998a). Since then an extensive body of evidence on the association between social inequalities and inequalities in health has been developed (Whitehead 1987; Davey Smith et al. 1990; Smaje 1995; Watt 1996). In 1998 the government-commissioned review of research, the Acheson Report, concluded: ‘The weight of scientific evidence supports a socio-economic explanation of health inequalities.

This traces the roots of ill health to such determinants as income, education and employment as well as to the material environment and lifestyle’ (Independent Inquiry 1998: xi). The vast majority of the improvement in life expectancy in the UK over the last 200 years has resulted from changes in the material and environmental circumstances in which people live, with public health measures such as clean water, good sanitation, safe food and vaccination also playing a significant role (Gray 1993). Even within relatively prosperous, ‘developed’ economies with apparently comprehensive health care systems supported by ‘scientific’ medicine, health chances are tied to economic, social and environmental factors. These vital resources for human life are unequally distributed, not only in terms of social class but of other dimensions of social difference associated with ‘race’, gender, age, disability and sexual orientation. Patterns of health and illness in a population reflect the multi-layered impact of economic, political and cultural forms and practices. As Graham (1993) exemplifies, the combination of caring responsibilities, inadequate material resources and temporary accommodation constitutes a particularly powerful primary threat to health: ‘I can’t get registered with a doctor. I’ve lived here a year without one, and with a baby. He’s been in hospital twice. He caught a virus from the hotel, which was growing in his bowel. He lost over six pound in a week. Then he had a blocked intestine so he was in hospital for nearly two weeks that time … I feel so old, I mean I don’t class myself as being young. I’m 34. But I don’t know – I feel so old now, so very, very old.’ (Miller 1990, quoted in Graham 1993: 175) The primacy of economic, social and environmental factors is reflected in evidence that treatment-oriented health care has relatively little impact on the health chances of populations.

In 1979 McKeown demonstrated that most of the reduction in morbidity and mortality due to infectious diseases such as TB and measles occurred before, rather than after, the introduction of effective drug treatments. More recent work on this issue has supported his view. As Mackenback et al. (1990) concluded, ‘even among those conditions where the influence of medical care ought to be maximised, a review of studies shows that death rates are still more closely related to social and economic factors than to medical care variables’ (quoted in Wilkinson 1996a: 66). These arguments do not imply that medicine is of no benefit. They reflect a critical approach to equating the health of the population with the state of medical care or with the size or quality of the NHS. They look ‘upstream’ to the causes of inequalities in health, as well as ‘downstream’ to the lived experience of health and illness. As Wilkinson (1996a: 67) argues: The smallness of any influence which medical care may have on population health is not … a reason for thinking it is ineffective. An army medical corps may do invaluable work on battle wounds and yet never be an important determinant of the number of casualties in a battle. In terms of civilian health, the battlefield is the social and economic circumstances in which we live. It is the health consequences of deprivation, discrimination and inequality to which we now turn.