A blueprint ahead of its time

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The Independent Online
The original Black report was published on August Bank holiday, 1980. It was called Report on Inequalities in Health Related to Social Class. There was no press conference and only a limited number of copies were ever printed. Most people came to know the report through the abridged version by Peter Townsend and Nick Davidson originally published by Pelican and re-printed by Penguin in 1992 under the title Inequalities in Health.

A key recommendation was that children of poor families should be given a better start in life, partly through better antenatal care and improved nutrition in pregnancy. Since the report was published evidence has accumulated that poor nutrition in the womb and in the early months of life can have consequences stretching far into later decades.

The most controversial aspect of the report was its linking of ill-health with deprivation rather than with unhealthy behaviour - principally smoking. Sir Douglas Black, who chaired the working party that produced the report, wrote in The Independent in 1993: "Although we considered the significance of various forms of unhealthy behaviour, including smoking, we took a view that they were not the major determinant of the relationship between deprivation and health. Our view was supported by a study of 17,000 men in various grades in the civil service which showed that most ill health was associated with socio-economic status, as measured by grade, rather than unhealthy behaviour. Among those who had no detectable disease at the beginning of the long-term study, premature death was still more marked among the lower than the higher grades."

Social problems called for social solutions, Sir Douglas said. Although the NHS could help alleviate ill health it could do nothing about its causes. He wrote: "For a radical cure we must recognise that the direct pursuit of wealth by some leads to unacceptable poverty for many. Unless greed is once again tempered by social compassion, embodied in a revitalised welfare state, so culpably diminished in the 1980s, we will continue in the avoidable waste of human life and health."

In 1995, the Kings Fund, the independent health policy think tank, published its own analysis of the health divide entitled Tackling Inequalities in Health with a foreword by Sir Donald Acheson. Sir Donald wrote that during his eight years as the government's chief medical officer, from 1983 to 1991, he had become concerned that although the health of the nation overall was improving inequalities between social groups were increasing. He added: "Today the question is not whether these facts are valid but who cares and what can be done about them."

The report made a series of recommendations including greater investment in public housing (to be financed by the abolition of mortgage tax relief), tax changes to alleviate family poverty, increasing the price of cigarettes, targeting of NHS resources to deprived areas, and improvements in childcare.