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Part V Summary: What Is to Be Done?

KATHERINE NEWMAN

Kennedy School of Government, Harvard University, 79 John F. Kennedy Street, Cambridge, Massachusetts 02138, USA

There is much left to be done to understand the mechanisms whereby social and eco-nomic inequality “get under the skin.” Yet as the papers in this volume underscore,the existence of a gradient connecting stratification to health outcomes is hardly inquestion any more. Hence, the chapters that follow assume the relationship betweeninequality and health and go on to pose the next question: What should our societydo to counteract these forces? How should government, the private sector, publichealth officials, the nonprofit world, our educational leadership, and social serviceagencies intervene in the transmission that leads from inequality to deleterioushealth outcomes that disadvantage those who lie in the middle and the bottom of thecontinuum?

At least three options are worthy of debate: (1) address inequality “head on,”through the redistribution of wealth, income, education, housing, and exposure toenvironmental hazards; (2) develop ameliorative interventions that leave the basicdistribution of resources untouched, but redress some of the consequences of ine-quality; or (3) leave the status quo undisturbed and accept that inequalities in basicresources will cause the outcomes we see in our society at present.

In practice, as the papers in this section suggest, the United States has invoked allthree of these strategies. As Philip Lee points out, the Social Security Act was a fun-damental intervention that redistributed income in a way that virtually broke the con-nection between old age and poverty, beginning in the 1930s. Unemploymentinsurance, Aid to Families with Dependent Children, and even the introduction of theprogressive income tax system were and remain today redistributive programs that—at least in theory—reduced socioeconomic inequality. More contemporary examplesmight include college scholarship programs or affirmative action, both of which seekto open access to higher education or employment that will, in turn, reduce inequal-ity through redistribution. In theory, absent these interventions, we would see evenstarker degrees of inequality in the United States and attendant increases in morbid-ity and mortality toward the lower end of the class spectrum.

Significant investment in anti-smoking or sex education programs, civic recre-ation programs that encourage exercise, the creation of the Medicare and Medicaidsystem, and public health measures designed to inform the public about health-promoting behaviors are well-known examples of interventions that do nothing to al-ter socioeconomic inequality itself, but may go some distance toward arresting theimpact of stratification on health. The United States has pursued these ameliorativemeasures for decades as a means of opening access to resources that the less fortu-nate might otherwise have to forego entirely.

Finally, there have been many periods in our history when inequality was accept-ed as a natural condition of our economic system, and intervention either resisted ordismantled in an effort to return the social order to a purer version of a laissez-faire

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economy or a privatized social order. Some would argue that just such a set of as-sumptions is making a comeback now. After 60 years of experience with the redis-tributive reforms of the 1930s, the United States has embarked on an experiment inwelfare reform, for example, which effectively ends the federal commitment to thesupport of the indigent poor. The theory behind this reform is that the discipline ofthe market will work more effectively to channel personal behavior toward positiveends. If inequalities persist, on this account, they are the price we pay for living in afree market social system.

Unlike the other parts of this volume, which are based primarily on scientific ev-idence, this section reminds us that the problem of inequality and health is at leastpartly an issue of political will. At various points in our history, public commitmentsto the reduction of inequality, or to blunting its impact, have made meaningful con-tributions to improving the life chances and health profiles of millions of Americans.The results are visible in the form of economic well-being, particularly among theelderly (who have benefited considerably from social policies designed to lift retir-ees out of poverty and to guarantee their access to health care). We have done lessfor the nation’s children, among whom poverty has increased by a considerable mar-gin in the past 20 years. Minority families have also been on the receiving end of sev-eral decades of widening inequality, with black and latino youth particularly hard hitin a changing economy that leaves the less skilled with fewer opportunities for oc-cupational mobility. Middle class families have weathered the storms of downsizing,the increasing pressures on dual-career households to balance the demands of workand family, and the concomitant reduction in leisure time among professionals. Allalong the SES continuum, social pressures are building that may be related in sys-tematic ways to the health outcomes this volume is designed to address.

Alvin Tarlov’s paper examines the conditions under which the political will canbe harnessed toward both redistribution and amelioration and takes as a case study arecent attempt to garner support for both forms of policy intervention in England—the Atcheson Report. Tarlov argues for the importance of a parallel effort in the Unit-ed States in order to redress the fundamental maldistribution of resources that seemsto underlie inequalities in health outcomes.

The section ends with a call for interdisciplinary research that will help to guidethe social policies necessary to come to grips with inequality and health. Appropriatepolicies will have to address not only

patterns

of health inequality, but also the

path-ways

that lead from the distribution of wealth, education, and opportunity to thehealth gradient that is so clear in the data. The National Institutes of Health standready to further this field so that, in the end, national initiatives will be based onsound scientific findings. As Norman Anderson explains in his contribution, the NIHis poised to embark on a number of major initiatives, supported by the federal gov-ernment, whose purpose is to explore systematically the relationship between racial,economic, ethnic, regional, and class-based forms of inequality that appear to havean impact on health outcomes. Anderson argues that the kind of interdisciplinary ap-proach represented in this volume is vital to developing a clear understanding of thecauses, effects, and pathways that we must map in order to ground social, economic,and medical interventions in firm scientific research.

Policy responses to the research represented in this book are still “under construc-tion.” However, the seriousness with which the task is being undertaken is reflected

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clearly in these three papers, which link the scholarship building up in laboratories,national surveys, animal studies, and cross-national comparisons to what may be thehardest question of all: What is to be done?