Our growing inequalities

New government, new words: out with 'variations' and in with inequalities. Out with 'low income' and in with poverty. The new green paper, Our Healthier Nation - the politically modified off-spring of The Health of the Nation - explicitly acknowledges the link between poverty and ill health. It also makes much of the evidence of growing health inequalities between rich and poor, north and south and black and white.

Straight talking about the fact that unskilled men have four-times the death rate from lung cancer as those in professional classes, and that the unskilled now have a life-expectancy which is five years less than professionals is to be welcomed. The green paper also emphasises the complex nature of

the causes of ill health. The interaction of genetic history, education, lifestyle, access to healthcare, environment and other factors is difficult to disentangle. Nevertheless, if just one of the factors in society's direct control had to be picked as the most important underlying determinant of ill health, it would probably be poverty.

If, as recognised by the green paper, in 'nearly all cases the highest incidence of illness is experienced by the worst off social classes', it would seem that significant inroads into the totality and distribution of ill health could be made by tackling poverty. Despite its commitment to the public health view of health and healthcare, the green paper sticks to its predecessor's format of setting targets for death rates from certain causes. A more imaginative approach could have been to supplement illness- based targets with targets based on the causes of illness - in particular poverty.

Government - rather than individuals - has a clear and significant role in redistributing income. For example, as a result of taxation, cash benefits from the welfare system and benefits in kind (the NHS, education etc),in 1995-96 the basic earned income of the bottom 20 per cent of the population was effectively increased from around pounds2,500 to pounds8,300.

For the top 20 per cent, on the other hand, the net effect of taxation and state benefits reduced average income from pounds41,300 to pounds29,200. In effect, the poorest had their incomes increased at the expense of the richest through the actions of government.

The recent trend in income redistribution has not been to the advantage of the poor, however. For example, although real household disposable income per head has risen by nearly 60 per cent overall since 1981, the number of households below average income increased from 59 per cent in 1979 to 63 per cent in 1995; and the proportion of people in households below a quarter of the national average disposable income doubled between the mid-1980s and 1995.

So, what about an explicit Treasury target - to be included in the Our Healthier Nation white paper - to adjust tax rates to increase the incomes of the poorest in the country?

John Appleby is senior lecturer in health economics at the school of health, University of East Anglia.