Health inequalities : critical

perspectives 1st Edition Bambra

Visit to download the full and correct content document:
https://ebookmass.com/product/health-inequalities-critical-perspectives-1st-edition-ba
mbra/
Health Inequalities
Health Inequalities
Critical perspectives
Edited by

Katherine E. Smith
Sarah Hill
and
Clare Bambra

1
1
Great Clarendon Street, Oxford, OX2 6DP,
United Kingdom
Oxford University Press is a department of the University of Oxford.
It furthers the University’s objective of excellence in research, scholarship,
and education by publishing worldwide. Oxford is a registered trade mark of
Oxford University Press in the UK and in certain other countries
© Oxford University Press 2016
The moral rights of the authors have been asserted
First Edition published in 2016
Impression: 1
All rights reserved. No part of this publication may be reproduced, stored in
a retrieval system, or transmitted, in any form or by any means, without the
prior permission in writing of Oxford University Press, or as expressly permitted
by law, by licence or under terms agreed with the appropriate reprographics
rights organization. Enquiries concerning reproduction outside the scope of the
above should be sent to the Rights Department, Oxford University Press, at the
address above
You must not circulate this work in any other form
and you must impose this same condition on any acquirer
Published in the United States of America by Oxford University Press
198 Madison Avenue, New York, NY 10016, United States of America
British Library Cataloguing in Publication Data
Data available
Library of Congress Control Number: 2015946890
ISBN 978–0–19–870335–8
Printed and bound by
CPI Group (UK) Ltd, Croydon, CR0 4YY
Oxford University Press makes no representation, express or implied, that the
drug dosages in this book are correct. Readers must therefore always check
the product information and clinical procedures with the most up-to-date
published product information and data sheets provided by the manufacturers
and the most recent codes of conduct and safety regulations. The authors and
the publishers do not accept responsibility or legal liability for any errors in the
text or for the misuse or misapplication of material in this work. Except where
otherwise stated, drug dosages and recommendations are for the non-pregnant
adult who is not breast-feeding
Links to third party websites are provided by Oxford in good faith and
for information only. Oxford disclaims any responsibility for the materials
contained in any third party website referenced in this work.
 Foreword
Debbie Abrahams MP
Chair of the Parliamentary Labour Party Health
Committee

As Frank Dobson (Health Secretary, 1997–2000) said in 1998, ‘Inequality in

health is the worst inequality of all. There is no more serious inequality than
knowing that you’ll die sooner because you’re badly off.’ Despite the strong ef-
forts of the 1997–2010 Labour government to reduce health inequalities, they
persist today. For example, a baby girl born in inner-city Manchester in the
North West of England will live 15 years longer in poor health than a baby girl
born in leafy Richmond-upon-Thames in the South East of England. In some
parts of the UK, even travelling just a few miles can lead to radically different
life chances—with life expectancy gaps of over 15 years in towns like Stockton
on Tees, Liverpool or Glasgow. Within this context, this book is vital: first be-
cause it emphasises the persistence, and importance, of health (and wider so-
cial) inequalities in the UK and elsewhere; second because it offers critical
analysis that goes beyond mere description to suggesting the reasons why
health inequalities persist in rich countries and makes suggestions as to what
more policymakers need to do to tackle them; and third because it argues that
health inequalities researchers seeking to influence policy in this area need to
take the political and democratic aspects of policy-making processes more ser-
iously than many perhaps have. As a policymaker myself I particularly welcome
the latter interjection into the health inequalities debate. As such, the collection
offers food for thought for those in the academy, policy, and practice. It will be
bedside reading for myself and others within the Labour Party, as reducing
health inequalities is a vital part of our programme.
 Foreword
Richard Wilkinson
Emeritus Professor of Social Epidemiology

Even without the benefit of hindsight, it was probably naïve to expect a smooth
transition from research on health inequalities to policies which would solve
the problem. Despite lots of good research, health inequalities have—as this
book shows—not diminished. The message is that we all need to be more active
in policy and politics.
An important part of the background to this picture is that the Black Report
on health inequalities, published in 1980—which kicked off modern research
on health inequalities—coincided with the rise to power of neoliberal econom-
ics under Reagan and Thatcher—as discussed by Collins, McCartney, and Gra-
ham in Chapter 9 of this volume. From then until at least the financial collapse
of 2007–8 the political pendulum swung to the right. Top tax rates were re-
duced, trade unions weakened, utilities were privatized, and income differences
widened dramatically. Indeed, almost all the progress towards greater material
equality which took place from the 1930s till the late 1970s has now been
undone.
In such a hostile context, it is perhaps a tribute to the strength of commitment
to social justice in the public health community that at least research on health
inequalities managed to make substantial progress during those decades, as de-
scribed by Bartley and Blane in Chapter 2, and Raphael and Bryant in Chap-
ter 4. Research has played a crucial role in ensuring health inequality has gained
a growing public recognition.
Since the financial crash the political pendulum has, however, started to
swing back in a more progressive direction. The amount of attention the media
gave to inequality rose dramatically after the Occupy movement. More recently,
world leaders, including the US President Barack Obama, Pope Francis, Ban Ki
Moon, the Secretary General of the UN, and Christine Lagarde, the head of the
IMF, have all made very strong statements about the urgent need to reduce in-
come inequality. As Douglas notes in Chapter 8, a renewed focus on social in-
equality provides an opportunity for public health to return to the root causes
of health inequalities—perhaps using the kinds of research strategies outlined
by Barr, Bambra, and Smith in Chapter 18.
 Foreword vii

So far progress in reducing inequality has been more a matter of lip service
than of real change, but there have been a few policy gains. The OECD has
reached agreement with many of the world’s most important tax havens to share
(but not until 2017) information on bank accounts with the tax authorities in
different countries. Until that is done, the rich can so easily hide their money
away from tax authorities that it is hard to make higher top tax rates stick. The
OECD’s action was apparently not prompted simply by a desire for social justice
or even by a concern for the loss of government revenues: it also reflected a de-
sire to cut terrorist funding and prevent money laundering. Although political
commitment to greater equality has—with the exception of some South Ameri-
can countries—been rare since widening income differences swept across so
many developed countries from around 1980 onwards, countries such as Nor-
way and Finland remind us that it can be a central goal of national policy, as
Dahl and van der Wel discuss in Chapter 3.
As well as slowing the rightward swing of the political pendulum, the finan-
cial crash has also had the perverse effect of justifying cuts in government pub-
lic social expenditure, so shoring up a range of conservative policies under the
rubric of reducing the deficit. The impact of austerity on both health and health
inequality is highlighted by Bambra et al in Chapter 12, while the human mis-
ery caused by ‘deficit reduction’ is compellingly described by McCormack and
Jones in Chapter 17, and by Friedli in Chapter 15. But swings in public opinion
tend to be long and slow, and the current more progressive direction of change
is likely to outlive concern for the deficit. The British Social Attitudes Survey
now shows that over 80% of the population think income differences are too
big—even though they underestimate how large they are. As people have grad-
ually become more aware of the scale of tax avoidance, the bonus culture, and
the continuing tendency for top incomes to rise while other incomes are held
down, it is unlikely that political parties of left or right will be allowed to forget
these issues before they have been effectively addressed.
This sustained shift in public awareness means the future context in which
policies affecting inequalities are developed may be quite different from what
we have been used to in the past. This changing context is not simply a matter
of public opinion; there is also an urgent need to move towards more sustain-
able forms of living, reducing our reliance on fossil fuels and our impacts on the
environment. Pearce et al (Chapter 14) advocate an ‘ecological public health’
perspective, reminding us of the links between social justice and environmental
justice. The United Nations and many think tanks, official bodies, and NGOs
have called for a fundamental transformation in the way our societies’ eco-
nomic systems work. Encouragingly, the post 2015 Sustainable Development
Goals include a clear statement of the need to reduce inequalities both within
viii Foreword

and between countries. As Hanefeld reminds us in Chapter 5, the equality

agenda concerns the distribution of resources for health at a global as well as a
national level and, as Hill says in Chapter 7, ethnic, gender, and socioeconomic
status inequalities all contribute to our social and health divides.
In Chapter 13, Collin and Hill explore the role of large corporations impli-
cated in non-communicable diseases, including the tobacco, alcohol, and pro-
cessed food industries. They cite Nick Freudenberg, whose important book,
Lethal but Legal, shows how these major business sectors—along with the phar-
maceutical, gun, and automobile industries—inflict major damage on public
health. Big corporations act as drivers of inequality, reinforcing the uneven dis-
tribution of the social determinants of health and undermining regulatory ef-
forts to limit the harm they do to public health. The insidious nature of their
power is shown in the extent to which they succeed in packing regulatory com-
mittees so they can defend their profits against attempts to tackle the health
problems they have caused. Another example of the encroachment of corporate
interests into public services is provided in Chapter 11, where Hellowell and
Ralston examine the privatization and marketization of the UK National Health
Service.
But it is not just health which is compromised by corporate interests. They are
the source of the most formidable opposition both to a more egalitarian and to
a more sustainable society. By concentrating wealth and power in the hands of
a few, these transnational corporations effectively undermine democratic polit-
ics. Corporations bigger than many national economies are able to run rings
round national governments which compete to attract inward investment by
offering lower corporation tax and other inducements. The massive economic
and political power of the fossil fuel industry has, as Naomi Klien has recently
documented, subverted effective action on climate change. Nor are such devas-
tatingly anti-social policies confined to the fossil fuel sector. Almost all large
corporations have nominal subsidiaries in tax havens to enable them to avoid
tax payments. The Tax Justice Network estimated that tax havens may handle
(on paper) as much as half of all world trade and banking assets as well as a third
of all foreign investment.
Increasingly, politicians find themselves trying to serve two masters: their
electorate at the ballot box on one side, and the interests of multinational cor-
porations wedded to the frequently anti-social pursuit of profit on the other.
Their weak-kneed attempts to straddle these opposed interests have led inexor-
ably to the discrediting and mistrust of politicians in the public eye. In the long
run, a clash between corporate power and the democratic state looks as in-
escapable and as far reaching as the historical clash between church and state.
What is at stake is the future of democracy itself: without a major rebalancing in
 Foreword ix

favour of democratic forces, the power of elected governments will increasingly

be pushed to the margins.
Reducing carbon emissions is widely regarded as an unwelcome belt-­
tightening exercise. It is seen as if it means making do with a bit less of every-
thing while continuing to cope with our lives as they are now. But life in the rich
world is not an efficient system for ensuring human well-being. Redressing the
balance between private corporations and democratic government, moving to-
wards sustainability, making dramatic reductions in health inequalities, or re-
ducing income differences (even to Scandinavian levels), all require very major
change, but they are central to improving the real quality of life for all of us.
Moving towards greater equity and sustainability is not only an opportunity to
end the sense that we are here to serve the economy rather than it serving us,
but it is also an opportunity to start to address the neglected social needs on
which health and well-being depend.
In Chapter 6 of this book, Smith and Garthwaite discuss contrasting views on
how to address health inequalities. Just as we become aware of the environmen-
tal costs of further economic growth, it has also become evident, first, that
growth no longer improves either health, happiness, or well-being in the rich
countries, and, second, that further improvements in the quality of life now de-
pend on improving the social environment rather than on increases in levels of
material consumption. Though we continue to need technical innovation, we
must turn from growth to address the quality of social and community life.
What has to grow is no longer crude measures of production and consumption,
but well-being.
The good news is that the strength of community life, how cohesive a society
is, levels of violence, and how much people feel they can trust others, are all im-
proved by reducing the scale of income differences between rich and poor. Re-
ducing income differences also makes sustainability easier to achieve. To give
just one example: consumerism is one of the main obstacles to sustainability, yet
research shows that it is driven by status competition which is intensified by
greater inequality—so reining in consumerism means reducing inequality. At
the same time, by reducing status competition, greater equality also strengthens
community life and improves well-being.
As explored in Chapters 19–21 of this book, the role of researchers concerned
with health inequalities must extend beyond the generation of evidence to the
stimulation of public debate and advocacy for change. In Chapter 16, Elliot,
Popay, and Williams suggest that it is time to think imaginatively about the kind
of future society we want and to develop a new vision capable of inspiring the
social movement needed to bring it into existence. Although a Foreword is not
the place for a manifesto for a new society, some key ideas are outlined in a
x Foreword

pamphlet (which can be downloaded for free from the Fabian Society website)
called A convenient truth: a society better for us and the planet, by Wilkinson and
Pickett. We think the road to a more equal society lies through the radical ex-
tension of democracy into the economic sphere—not only through legislation
(as in many EU member countries) for employee representation on company
boards, but also via incentives to expand the sector of the economy made up of
employee-owned companies and cooperatives. Economic democracy not only
reduces income differences within companies: it also redistributes capital and
redirects unearned income. Evaluations suggest that it brings reliable improve-
ments in productivity while at the same time enhancing working relationships
and the experience of work. Greater representation and accountability in the
economic sector is also an important step towards dealing with undemocratic
concentrations of power and wealth in large multinational corporations. Demo-
cratic control has been increased at least within the public health system as
Hunter and Marks outline in Chapter 10, but this is a small change in the con-
text of much wider economic threats to social justice.
What we have to look forward to is a future in which community life starts to
recover from the divisive effects of inequality, and outward wealth ceases to be
the overriding measure of personal worth: a society in which our social needs
are more nearly met, in which the manipulative power of multinationals is re-
duced and the experience of work is less dominated by the extrinsic motivations
of wage labour. As the real quality of social life and relationships improves, we
will increasingly prefer to use greater productivity to give us more leisure, more
time for friends, family, and community—rather than to increase consumerism
and status competition as big business would have us do. In reducing inequality,
we can make a happier, more democratic, and more sustainable society.
 Preface

Health inequalities have long been a cause of both concern and controversy in
British society. The need to reduce inequalities in health contributed to the de-
cision to establish the tax-funded, free-at-the-point-of-delivery National
Health Service (NHS) in 1948. Yet, by the 1970s it was becoming increasingly
evident that free access to health care had not been enough to stem the widen-
ing inequalities in health, and in 1977 the then Secretary of State for Health and
Social Services, David Ennals, faced fresh calls to do something about the issue.
Ennals responded by asking the Chief Scientist Sir Douglas Black to appoint a
working group of experts to investigate the matter and make policy recom-
mendations (see Berridge and Blume 2003 for more detail).
In the resulting report, widely referred to as the Black Report (Black et al 1980),
the authors argued that materialist explanations were likely to play the largest
role in explaining health inequalities and, therefore, that policymakers ought to
prioritize the reduction of differences in material and economic circumstances.
Significantly, the associated policy recommendations, which focused on poverty
alleviation and support for families with children, were wholeheartedly rejected
by the newly elected Conservative government that had come to power between
the commissioning and publication of the Report (Black et al 1980).
Indeed, under the Conservative governments in power from 1979 to 1997,
health inequalities were excluded from the official policy agenda (Berridge and
Blume 2003). Even the term ‘health inequalities’ was discarded and health dif-
ferences between social groups were instead referred to using the less emotive
term ‘health variations’ (which implied that health differences could be ‘natural’
and therefore not something for which policymakers were responsible).
Nevertheless, the Black Report had a significant impact on the research com-
munity, and a mass of research on health inequalities was undertaken and pub-
lished during this period (see Acheson 1998; Bartley et al 1998; Macintyre
1997). The report remains a seminal document for our understanding of health
inequalities—not only in the UK, but also internationally, having influenced
thinking around health inequalities in the USA (Lynch and Kaplan 2000), Can-
ada (Humphries and van Doorslaer 2000), New Zealand (Davis 1984), and
Australia (Najman et al 1992).
The Black Report also stimulated local efforts to address health inequalities in
the UK. The city of Liverpool was a good example of this: local policymakers
xii Preface

and practitioners worked to produce one of England’s first regional reports on

public health (Ashton 1984), and also forged international links with other re-
gional public health efforts, such as those being undertaken in North Karelia in
Finland (see Hunter et al 2010). There have been subsequent national govern-
ment commissioned reports into health inequalities in 1998 (Acheson Inquiry)
and 2010 (Marmot Review)—both of which had many similar recommenda-
tions to the Black Report (Bambra et al 2011).
Over the past 40 years the UK has become recognized as a global leader in
health inequalities research and policy, with a prominent international expert
describing government-led policy efforts to reduce health inequalities in Eng-
land as ‘historically and internationally unique’ (Mackenbach 2010). Between
1997 and 2010 the UK Labour government introduced a raft of policies to re-
duce health inequalities (Smith and Hellowell 2012), informed by the wealth of
available research (Bambra et al 2011). Despite this sustained political commit-
ment, by most measures the UK’s health inequalities have continued to widen
(Audit Scotland 2012; Mackenbach 2011; National Audit Office 2010). This
failure, whilst largely attributable to the nature of the policies and interventions
employed (see Chapters 6, 8, 9, 12, 15, and 17), has prompted calls for new ap-
proaches to health inequalities research. There is also an increasing consensus
that public health researchers ought to be more actively involved in ‘public
health advocacy’ (e.g. Bambra et al 2011; Freudenberg 2005; Mackenbach
2011). Yet there is currently no agreement as to what these new research agen-
das should be or what precisely public health egalitarians ought to be advocat-
ing (Horton 2012).
It is against this backdrop that the idea for this book emerged. We wanted to
bring together established and new health inequalities research experts, local
community activists, policymakers, and campaigners, national and local UK
perspectives, and those working on health inequalities beyond the UK, in both
high- and low-income settings. Many of the themes explored in this book
emerged during a cross-sector symposium to explore future directions for
health inequalities research (held in Edinburgh in December 2012). The dis-
cussions at this symposium confirmed our sense that the time was right for a
new edited collection on health inequalities, one which would reflect critically
on research, policy, and practice to date and which would take seriously the
idea that more political activity may be required to achieve greater inroads
into addressing health inequalities. This also comes at a time when academic
researchers are being incentivized to ensure their work has more ‘real world’
impact.
This edited collection draws on research from leading international research-
ers in the field of health inequalities. It is divided into four parts. Part 1 provides­
 Preface xiii

reflections on the UK’s legacy of health inequalities research. C ­ hapter 1 pro-

vides an overview of key concepts to inform the rest of the book. Chapter 2 then
provides a more detailed and personal perspective on the UK’s health inequali-
ties research legacy from the point of view of two of the field’s longest-standing
experts, Mel Bartley and David Blane. In Chapters 3 and 4, Espen Dahl and
Kjetil A. van der Wel, and Dennis Raphael and Toba Bryant, respectively, pro-
vide European and North American perspectives on efforts to develop
­evidence-informed policy approaches to reducing health inequalities, consid-
ering what these experiences suggest about the most fruitful directions for fu-
ture research and policy. Finally, in Chapter 5, Johanna Hanefeld reflects on
international (e.g. World Health Organization) efforts to promote ideas in-
formed by UK health inequalities research to policymakers, practitioners, and
advocates working in low- and middle-income countries (LMICs), highlight-
ing some of the particular difficulties of attempting to reduce health inequalities
in these contexts.
The second part of the book moves on to identify and explore some of the
challenges facing future health inequalities research and policies. This section
starts, in Chapter 6, by drawing on the data from the cross-sector symposium to
comparatively examine what individuals working in different sectors think
about current efforts to research and address health inequalities in the UK, and
where they think health inequalities researchers ought now to be focusing their
efforts. In Chapter 7, Sarah Hill considers how theories of intersectionality may
be useful in moving beyond a conception of health inequalities focused primar-
ily on social class. In Chapter 8, Margaret Douglas, a Public Health Consultant
in NHS Lothian (Scotland), argues that one means of tackling the much-­
discussed ‘lifestyle drift’ in health inequalities research, policy, and practice
may be to move beyond a focus on ‘health’. In Chapter 9, Chik Collins, Gerry
McCartney, and Lisa Garnham examine the political factors implicated in gen-
erating health inequalities, focusing particularly on neoliberalism. In Chap-
ter 10, David J. Hunter and Linda Marks assess different ways of understanding
a ‘public health system’ and the ensuing action (or in-action) to tackle health
inequalities, taking recent changes to the public health system in England as a
case study. In Chapter 11, Mark Hellowell and Maximilian Ralston provide a
detailed examination of contrasting claims about the impact of much debated
English NHS reforms on health inequalities. In Chapter 12, Clare Bambra, Kay-
leigh Garthwaite, Alison Copeland, and Ben Barr examine evidence concern-
ing the actual and potential health impacts of ongoing cuts to welfare provision
in the UK. In Chapter 13, Jeff Collin and Sarah Hill draw on research and policy
concerns with non-communicable diseases to highlight key challenges for pol-
icymakers in engaging with corporations implicated in health inequalities.
xiv Preface

The next four chapters outline some emerging agendas within health inequal-
ities research, many of which aim to address concerns and gaps relating to exist-
ing research. In Chapter 14, Jamie Pearce, Rich Mitchell, and Niamh Shortt
consider the apparent paradox that, whilst area-based interventions have dom-
inated UK policy responses to health inequalities, much of the available research
evidence continues to pay limited attention to the importance of place, context,
and locality for health inequalities. They argue that a more ‘holistic’ interpret-
ation of the environment that recognizes the socio-spatial patterning of a range
of environmental pathogens and salutogens is now needed. In Chapter 15,
Lynne Friedli considers the rise of psychosocial explanations for health inequal-
ities, looking specifically at the growing influence of salutogenesis and
‘­assets-based approaches’ to public health, notably in Scotland. This chapter
considers the social, political, and advocacy implications of ‘assets-based’ ap-
proaches to health inequalities. In Chapter 16, Eva Elliott, Jennie Popay, and
Gareth Williams make the case for a citizen social science that builds knowledge
and understanding about health inequalities, and ideas for policy and social ac-
tion, through ‘narratives of living and being’. In Chapter 17, Jane Jones and
Cathy McCormack reflect on their experiences of working as community activ-
ists trying to change the toxic circumstances in which many people live, drawing
on these understandings to outline what they believe to be the major challenges
currently facing their communities. They go on to consider how researchers
interested in health inequalities might do more to help address these issues.
The third part of the book turns to addressing questions about how best to
ensure health inequalities research is used to support action to tackle health
inequalities. In Chapter 18, Ben Barr, Clare Bambra, and Katherine E. Smith
chart the ascendancy of experimental evaluations of interventions to reduce
health inequalities and systematic reviews of evidence, considering the benefits
and limitations from research and policy perspectives. In Chapter 19, Katherine
E. Smith, Ellen Stewart, Peter Donnelly, and Ben McKendrick reflect on various
efforts to improve the use of health inequalities research in policy and practice,
considering the differences and similarities between ‘knowledge brokerage’, ‘ad-
vocacy’, and ‘lobbying’ in the context of health inequalities. In Chapter 20, Kate
Pickett and Richard Wilkinson, authors of The Spirit Level, one of the most
high-profile books concerning health inequalities to have been published in the
past 20 years (Wilkinson and Pickett 2009), provide some personal reflections
on their experiences of trying to promote health inequalities research to audi-
ences beyond academia. It concludes by suggesting what lessons this case study
might offer other health inequalities researchers.
In the final part of the book, Chapter 21, the editors draw together the ideas
and findings presented in this edited collection, summarizing both the legacy of
 Preface xv

UK health inequalities research to date and critically assessing the various chal-
lenges and emergent research and policy agendas identified by the contributors.
It considers some of the major difficulties facing researchers trying to produce
policy-relevant research and policymakers trying to employ research evidence to
tackle an issue as complex and cross-cutting as health inequalities, outlining what
appear to be the most promising areas for future health inequalities research.

References
Acheson, D. (1998) Independent Inquiry in Health Inequalities: Report. London: The
­Stationery Office.
Ashton, J. (1984) Health in Mersey—A Review: Liverpool. Liverpool: Department of
­Community Health, University Medical School.
Audit Scotland (2012) Health Inequalities in Scotland. Edinburgh: Audit Scotland.
Bambra, C., Smith, K. E., Garthwaite, K., Joyce, K.E. and Hunter, D.J. (2011) A labour of
Sisyphus? Public policy and health inequalities research from the Black and Acheson
­Reports to the Marmot Review. Journal of Epidemiology and Community Health, 65(5):
399–406.
Bartley, M., Blane, D., and Davey Smith, G. (1998) Introduction: Beyond the Black Report.
Sociology of Health and Illness, 20(5): 563–577.
Berridge, V., and Blume, S. (eds) (2003) Poor Health—Social Inequality Before and After
the Black Report. London: Frank Cass.
Black, D., Morris, J. N., Smith, C., Townsend, P. (1980) Inequalities in Health—Report of a
Research Working Group. London: DHSS.
Davis, P. (1984) Health patterns in New Zealand: Class, ethnicity and the impact of eco-
nomic development. Social Science and Medicine, 18(11): 919–925.
Freudenberg, N. (2005) Public health advocacy to change corporate practices: Implications
for health education practice and research. Health Education and Behavior, 32(3): 298–319.
Horton, R. (2012) Offline: Dangerous oligarchies. The Lancet, 379(9827): 1688.
Humphries, K. H., and van Doorslaer, E. (2000) Income-related health inequality in
­Canada. Social Science and Medicine, 50(5): 663–671.
Hunter, D. J., Marks, L., and Smith, K. E. (2010) The Public Health System in England.
­Bristol: Policy Press.
Lynch, J. W., and Kaplan, G. (2000) Socioeconomic position. In L. Berkman and I. Kawachi
(eds), Social Epidemiology. New York: Oxford University Press, pp. 13–35.
Macintyre, S. (1997) The Black Report and beyond: What are the issues? Social Science and
Medicine, 44(6): 723–745.
Mackenbach, J. P. (2010) Has the English strategy to address health inequalities failed?
­Social Science and Medicine, 71(7): 1249–1253.
Mackenbach, J. P. (2011) Can we reduce health inequalities? An analysis of the English
strategy (1997–2010). Journal of Epidemiology and Community Health. 65(7): 568–75.
Marmot, M. (chair) (2010) Strategic Review of Health Inequalities in England post-2010
(2010) Fair Society, Healthy Lives: The Marmot Review. Available at: http://www.
marmotreview.org/AssetLibrary/pdfs/Reports/FairSocietyHealthyLives.pdf accessed
8/7/2015
xvi Preface

Najman, J. M., Bor, W., Morrison, J., Andersen, M., and Williams, G. (1992) Child devel-
opmental delay and socio-economic disadvantage in Australia: A longitudinal study. So-
cial Science and Medicine, 34(8): 829–835.
National Audit Office (2010) Department of Health: Tackling Inequalities in Life Expect-
ancy in Areas with the Worst Health and Deprivation. London: The Stationery Office.
Smith, K. E., and Hellowell, M. (2012) Beyond rhetorical differences: A cohesive account of
post-devolution developments in UK health policy. Social Policy and Administration, 46:
178–198.
Wilkinson, R., and Pickett, K. (2009) The Spirit Level: Why More Equal Societies Almost
­Always Do Better. London: Penguin.
Woolf, S. and Aron, l. (eds.) (2013) US health in International Perspective: Shorter Lives,
Poorer Health (Washington, DC: National Academies Press). Available at: http://
download.nap.edu/cart/download.cgi?&record_id=13497. accessed 8/7/2015
 Acknowledgements

We are grateful to all of the authors who contributed to this book—several of

the individual chapters also have their own acknowledgements. Significant
thanks are also due to Rebecca Hewer, at the University of Edinburgh, for her
help with the final stages of compiling the manuscript. Finally, Kat would like to
thank Nasar Meer for support and feedback on several aspects of the book.
The following grants helped with the production of this book: MRC-ESRC
grant number PTA-037–27–0181, ESRC grant number ES/K001728/1 and a
University of Edinburgh College of Humanities and Social Sciences Challenge
Investment Fund, which was further supported by funding from the Wolfson
Research Institute for Health and Wellbeing, Durham University.
 Contents

List of Acronyms xxvi

List of Contributors xxvii

1 Background and introduction: UK experiences of health

inequalities 1
Katherine E. Smith, Clare Bambra, and Sarah Hill
1.1 Health inequalities in the UK 1
1.2 Debates about how health inequalities are conceptualized,
measured, and monitored 2
1.3 Trends in the UK’s health inequalities over the past
30 years 6
1.4 Empirically informed theories for understanding health
inequalities 7
1.5 UK policy responses to health inequalities 13
1.6 Conclusion 16

2 Reflections on the legacy of British health inequalities

research 22
Mel Bartley and David Blane
2.1 Introduction: Social class health differences in Britain 22
2.2 Before and after the Black Report 23
2.3 Policy implications 27
2.4 Research 29
2.5 Summary and conclusions: Future directions for health
inequalities work 30
3 Nordic health inequalities: Patterns, trends, and policies 33
Espen Dahl and Kjetil A. van der Wel
3.1 Introduction to Nordic health inequalities 33
3.2 The Norwegian background 33
3.3 National strategies to reduce health inequalities 34
3.4 The Norwegian strategy in comparative perspective 37
3.5 An appraisal of the Norwegian strategy: How has the Norwegian
strategy been implemented since its inception in 2007? 40
3.6 The Nordic ‘paradox’ revisited 42
3.7 Summary and conclusion 44
xx Contents

4 Reflections on the UK’s legacy of health inequalities research

and policy from a North American perspective 50
Dennis Raphael and Toba Bryant
4.1 Introduction: Reflecting on UK insights from a North American
perspective 50
4.2 Overview of the UK, Canadian, and American health inequalities
scenes 50
4.3 Conceptual contributions 51
4.4 Research contributions 52
4.5 Public policy contributions 53
4.6 Key policy documents in Canada and UK influences 54
4.7 Canadian contributions of interest to UK researchers 55
4.8 The situation in the USA 59
4.9 Conclusion 60

5 Reflections on the UK legacy of health inequities research,

from the perspective of low- and middle-income countries
(LMICs) 69
Johanna Hanefeld
5.1 UK leadership on the social determinants of health 69
5.2 The nature of evidence on health inequities 70
5.3 Addressing health inequities in LMICs 71
5.4 Challenges to addressing health inequities in LMICs 74
5.5 The legacy of UK health inequities research—preventing a
revolution in LMICs? 77
6 Contrasting views on ways forward for health inequalities
research 81
Katherine E. Smith and Kayleigh Garthwaite
6.1 Introduction: Contrasting perspectives on health inequalities 81
6.2 How do different actors understand ‘health inequalities’? 81
6.3 Reflecting on health inequalities research and policy in the UK
so far: What have we learnt? 83
6.4 Where next for health inequalities research? 85
6.5 What should researchers do to improve the impact of health
inequalities research? 88
6.6 Concluding discussion 91

7 Axes of health inequalities and intersectionality 95

Sarah Hill
7.1 Introduction: Intersecting axes of social position 95
7.2 Axes of health inequality 95
 Contents xxi

7.3 Ethnic inequalities in health 96

7.4 Gender inequalities in health 98
7.5 Intersectionality and health inequalities 99
7.6 Inequalities in smoking—‘contours of disadvantage’ 100
7.7 Intersectionality and health inequalities: Conceptual and
methodological implications 102
7.8 Conclusion 104

8 Beyond ‘health’: Why don’t we tackle the cause of health

inequalities? 109
Margaret Douglas
8.1 A traditional public health approach? 109
8.2 Fundamental causes 109
8.3 Drifting downstream 110
8.4 Framing health inequalities: Confusion and blame 112
8.5 Trying to paddle upstream 112
8.6 Defining the problem 114
8.7 Mitigate, prevent, and undo 118
8.8 Staying upstream—implications for research and practice 118
8.9 Conclusion 121

9 Neoliberalism and health inequalities 124

Chik Collins, Gerry McCartney, and Lisa Garnham
9.1 Introduction: Neoliberalism and health inequalities 124
9.2 Liberalism(s) 124
9.3 Actually existing neoliberalism(s) 127
9.4 Neoliberalism and health inequalities 130
9.5 Debates: The place of inequality and pathways 133
9.6 Conclusion: Neoliberalism and the challenge to public health 134

10 Health inequalities in England’s changing public health system 138

David J. Hunter and Linda Marks
10.1 Introduction: England’s changing public health system 138
10.2 Background and context to England’s changing public health
system 139
10.3 The public health system across the UK 141
10.4 The new public health system in England 142
10.5 Persistent challenges and new opportunities: Improving health
and tackling health inequalities 145
10.6 An interim assessment of the new arrangements: New dawn or
poisoned chalice? 147
10.7 Conclusion: Testing England’s new public health system 148
xxii Contents

11 The equity implications of health system change in the UK 151

Mark Hellowell and Maximilian Ralston
11.1 Introduction: Health care and health inequalities 151
11.2 Equity in the health system: An international perspective 152
11.3 The UK Conservative–Liberal Democratic Coalition government’s
reforms in context 155
11.4 The NHS: A changing financial context 157
11.5 Conclusion: Why health care is a priority for health inequalities
research 160
12 All in it together? Health inequalities, austerity, and the ‘Great
Recession’ 164
Clare Bambra, Kayleigh Garthwaite, Alison Copeland, and Ben Barr
12.1 Introduction: Economic downturns and poor health 164
12.2 Economic downturns and population health 164
12.3 Economic downturns and health inequalities 167
12.4 ‘Austerity’ and health inequalities 169
12.5 Conclusion: A growing health divide? 171

13 Industrial epidemics and inequalities: The commercial sector as a

structural driver of inequalities in non-communicable diseases 177
Jeff Collin and Sarah Hill
13.1 Introduction: Health inequalities and the growing burden of
non-communicable diseases (NCDs) 177
13.2 Industrial epidemics and health inequalities: The commercial sector
as a structural driver of inequalities in NCDs 178
13.3 Towards coherence across NCD policies? 184
13.4 Conclusion: Corporations producing unhealthy commodities as
‘upstream’ drivers of inequalities 185
14 Place, space, and health inequalities 192
Jamie Pearce, Rich Mitchell, and Niamh Shortt
14.1 Introduction: Why is it important to think geographically? 192
14.2 Ecological public health 196
14.3 Life course and place 197
14.4 Resilience, and equigenic environments 199
14.5 Conclusion: The promise of geographical approaches 202

15 The politics of tackling inequalities: The rise of psychological

fundamentalism in public health and welfare reform 206
Lynne Friedli
15.1 Introduction: The rise of psychological explanations
and interventions in public health 206
 Contents xxiii

15.2 Absence of debate 207

15.3 Strengths-based discourse: The power of positive affect 207
15.4 Engaging with the evidence base 208
15.5 Count your assets 209
15.6 Limitations of materialist analysis 210
15.7 Public health and the Glasgow pSoBid study 211
15.8 Workfare 213
15.9 Increasing positive affect 216
15.10 Conclusions 216

16 Knowledge of the everyday: Confronting the causes of health

inequalities 222
Eva Elliott, Jennie Popay, and Gareth Williams
16.1 Introduction: Capitalist ‘wolves’ 222
16.2 Understanding health inequalities through knowledge
in everyday life 223
16.3 Towards a theory of transformative action 230
16.4 Conclusion: The battle between evidence and meaning 233

17 Socio-structural violence against the poor 238

Jane Jones and Cathy McCormack
17.1 Introduction: The view from community activism 238
17.2 Socio-structural violence 239
17.3 Housing 240
17.4 Unemployment 240
17.5 Shifting values and the common determination of meaning 242
17.6 Stigmatization 243
17.7 Shifting practices 244
17.8 The new morality 245
17.9 The role of research and dissemination 246
17.10 Transforming private troubles into public issues 247
17.11 Pressure on researchers 248
17.12 Conclusion: Moving health inequalities debates beyond the
academic realm to reclaim our humanity 249
18 For the good of the cause: Generating evidence to inform social
policies that reduce health inequalities 252
Ben Barr, Clare Bambra, and Katherine E. Smith
18.1 Introduction: Using evidence to tackle health inequalities 252
18.2 Beyond ‘hierarchies of evidence’ 252
18.3 Experimentation and realism in evaluating the causal impact
of social policies 253
xxiv Contents

18.4 Natural experiments 255

18.5 Systematic reviews and the accumulation of evidence 260
18.6 Conclusion: The need to expand our methodological
toolbox 261
19 Influencing policy with research—public health advocacy
and health inequalities 265
Katherine E. Smith, Ellen Stewart, Peter Donnelly, and Ben McKendrick
19.1 Introduction: Conceptualizing the role of research (and researchers)
in policymaking 265
19.2 What do we already know about the relationship between health
inequalities research and policy? 268
19.3 What is public health ‘advocacy’? 271
19.4 Can tobacco control advocacy successes offer lessons for efforts
to reduce health inequalities? 274
19.5 Who is responsible for advocacy to reduce health inequalities? 275
19.6 Health inequalities researchers as advocates 276
19.7 Conclusion: The specific challenges of working to improve the
influence of health inequalities research 278
20 The Spirit Level: A case study of the public dissemination
of health inequalities research 282
Kate Pickett and Richard Wilkinson
20.1 Introduction: Deciding to do it 282
20.2 Deciding the format 283
20.3 The Equality Trust 284
20.4 Unexpected success 285
20.5 Commitment to dissemination 289
20.6 Not all fun and games 290
20.7 Just what is a ‘public intellectual’? 292
20.8 Moving from research to advocacy and campaigning 292
20.9 Moving on 294

21 Conclusion—where next for advocates, researchers, and

policymakers trying to tackle health inequalities? 297
Katherine E. Smith, Sarah Hill, and Clare Bambra
21.1 The challenge of reducing health inequalities 297
21.2 Using historical and international research to understand
the impact of ‘policy packages’ 297
21.3 Broadening our focus and alliances 300
21.4 Emerging research topics for health inequalities 300
21.5 Expanding our methodological toolbox 301
 Contents xxv

21.6 Working with the communities most affected by health

inequalities 301
21.7 Developing an advocacy-coalition to reduce health inequalities 301
21.8 Potential contributions to reducing health inequalities in policy and
practice 302
21.9 Conclusion: Preparing for future ‘policy windows’ to reduce health
inequalities 303

Index 305

 List of Acronyms

ALMP active labour market policies KWS Keynesian Welfare State

ASAP Alliance for Sustainability and LMICs low- and middle-income
Prosperity countries
CPP Community Planning MDGs Millennium Development
Partnership Goals
CSDH Commission on the Social MSF Medecins Sans Frontiers
Determinants of Health NCDs non-communicable diseases
DPH Director of Public Health NDP New Democratic Party
DsPH Directors of Public Health NEF New Economics Foundation
EPH Ecological Public Health NGO non-governmental
ERA Easthall Residents’ Association organization
ESRC Economic and Social Research NHS National Health Service
Council NICE National Institute for Health
FCTC Framework Convention on and Care Excellence
Tobacco Control NIHR National Institute for Health
GCPH Glasgow Centre for Population Research
Health NS-SEC National Statistics Socio-
GDP Gross Domestic Product Economic Classification
GFATM Global Fund to Fight AIDS TB ONS Office for National Statistics
and Malaria ONS-LS Office for National Statistics
GIS Geographical Information Longitudinal Study
Systems PHE Public Health England
HAZ Health Action Zones RCTs randomized controlled trials
HEA Health Education Authority SARS severe acute respiratory
HIA Health Impact Assessment syndrome
HIIA health inequalities impact SOA Single Outcome Agreement
assessment SOC sense of coherence
HR hazard ratio TINA There Is No Alternative
HWBs Health and Well-being Boards TSA Technical Services Agency
IMR infant mortality rates VIA Values in Action
JRCT Joseph Rowntree Charitable WHO World Health Organization
Trust
WTO World Trade Organization
JSNA Joint Strategic Needs
Assessment
 List of Contributors

Clare Bambra PhD is Professor of Public Health Geography and Director of

the Centre for Health and Inequalities Research, Durham University. Her re-
search focuses on the health effects of labour markets, health and welfare sys-
tems, as well as the role of public policies to reduce health inequalities. She
has published extensively in the field of health inequalities, including books
on Work, Worklessness and the Political Economy of Health (Oxford University
Press 2011), How Politics Makes Us Sick (Palgrave 2015) as well as over 100
book chapters and peer-reviewed journal articles. She contributed to the
Marmot Review (2010), the European Commission’s Health Inequalities in
the EU report (2013), the US National Research Council Report on US
Health in International Perspective (2013), as well as the Public Health Eng-
land commissioned report on health equity in the North of England: Due
North (2014).
Ben Barr is Senior Clinical Lecturer in Applied Public Health Research, Uni-
versity of Liverpool. He studied anthropology as an undergraduate at Univer-
sity College London, trained as a nurse, and undertook postgraduate studies
in public health and epidemiology at LSHTM and the University of Liverpool.
After a number of years working on humanitarian and infectious disease con-
trol programmes in post-conflict countries, he returned to work in applied
public health in the UK for the Health Protection Agency and the NHS. He is
passionate about making a difference to the health of the most disadvantaged.
He was awarded an NIHR doctoral fellowship in 2010, investigating the fac-
tors that influence the employment of people with common mental health
problems and how employment support can be improved. This work is part of
a wider international research collaboration on the differential social conse-
quences of chronic illness with the Karolinska Institute in Sweden, the Univer-
sity of Oslo, the University of Copenhagen, and colleagues at OECD and
Statistics Canada.
Mel Bartley is Professor Emerita of University College London and former dir-
ector (2008–12) of ESRC International Centre for Life Course Studies in Soci-
ety and Health. Her background is in philosophy, sociology, and epidemiology,
and she has researched a number of topics including: unemployment and
health; domestic labour and health; scientific research and social policy; health
inequalities; capability and resilience; and life course effects.
xxviii List of Contributors

David Blane is Professorial Research Associate of University College London, Pro-

fessor Emeritus of Imperial College London, and former deputy director (2008–12)
of ESRC International Centre for Life Course Studies in Society and Health. His
background is in medicine, sociology, and public health, and his research interests
include health inequalities, life course research, and social gerontology.
Toba Bryant PhD is Assistant Professor in the Faculty of Health Sciences at
the University of Ontario Institute of Technology. She has written and re-
searched health inequalities, income and housing as social determinants of
women’s health, and public policy. She is author of the sole-author volume In-
troduction to Health Policy, and co-editor of Staying Alive: Critical Perspectives
on Health, Illness and Health Care.
Jeff Collin PhD is Professor of global health policy at the University of Edin-
burgh. A political scientist, his research focuses on globalization, health gov-
ernance, and corporate strategies to influence public policy. He was a
member of the WHO expert group monitoring tobacco industry influence
on policy, and is a member of the tobacco advisory group of Cancer Re-
search UK, a co-investigator in the UK Centre on Tobacco and Alcohol Stud-
ies, and an expert advisor for the Institute of Alcohol Studies. Recent
publications examine WHO’s Framework Convention on Tobacco Control,
conflict of interest in international health philanthropy, policy coherence in
global health, and UK government support for the global expansion of the
alcohol industry.
Alison Copeland PhD is a lecturer in Human Geography specializing in
Quantitative Methods and Geographic Information Systems (GIS). Her re-
search interests focus on health inequalities, specifically exploring access to
health care for less advantaged groups in the population. She has previously
worked as a nurse in the NHS and in Public Health, and for the Learning Dis-
abilities Observatory as part of the North East Public Health Observatory.
Chik Collins is Reader in Applied Social Science at the University of the West
of Scotland (Paisley). He has written extensively on the role of language in so-
cial change, drawing on the theoretical tradition of Cultural Historical Activ-
ity Theory, and on urban policy and community development. His more
recent research, in collaboration with NHS Health Scotland and the Glasgow
Centre for Population Health, has been on the phenomenon of ‘excess mortal-
ity’ in West Central Scotland, and its relationship to ongoing processes of so-
cial, political, and economic change in the region. He has worked extensively
with Oxfam and its community partners in recent years, and is a co-founder of
the University of the West of Scotland–Oxfam Partnership ‘for a more equit-
able and sustainable Scotland’.
 List of Contributors xxix

Espen Dahl is a Professor at Oslo and Akershus University College in Oslo,

Norway. His research interests are health and social inequalities, social and
health policy, and comparative welfare state research.
Peter Donnelly is President/CEO of and leads Public Health Ontario, an
arm’s-length agency of government providing health protection and health
promotion services to a population of over 13 million in the Canadian prov-
ince of Ontario. He moved to Toronto after six years as Professor of Public
Health at the University of St Andrews, Scotland and is a former Deputy Chief
Medical Officer to the Scottish government. He is a current member of the
technical Board of the New York-based Milbank Memorial Fund, a former
President of the UK Association of Directors of Public Health, and a former
Vice President of the U Faculty of Public Health. He has worked extensively
with the WHO on a variety of public health issues.
Margaret Douglas is Deputy Director of Public Health, NHS Lothian, Edin-
burgh. She has been a Consultant in Public Health in NHS Lothian since 2000
and is currently Deputy Director of Public Health. She is the NHS Lothian
lead on Health Improvement and Health Inequalities. Her main areas of inter-
est are the physical and socio-environmental determinants of health, and ways
to influence these through partnership work with local authorities and other
agencies. She has a long-standing interest in Health Impact Assessment and
chairs the Scottish Health and Inequalities Impact Assessment Network.
Eva Elliott is a lecturer at Cardiff University School of Social Sciences. At the
time of writing she was a co-investigator on two major Connected Communi-
ties projects funded by the Arts and Humanities Research Council (AHRC)
with the Economic and Social Research Council (ESRC). Working with com-
munity and civil society organizations, activists, and members of communi-
ties, both of these aim to rethink and redesign the ways in which underserved,
under-resourced, and otherwise marginalized communities can influence pol-
icy and regulatory practices and create new knowledge spaces about the ways
in poor health and well-being are shaped and experienced unequally.
Lynne Friedli is a freelance researcher, with a special interest in the relation-
ship between mental health and social justice. She is author of a report for
WHO Europe on mental health, resilience, and inequality (http://www.euro.
who.int/document/e92227.pdf) and has contributed to the WHO Europe
Strategy on Mental Health. She is also part of the first residency of The Hub at
Wellcome Collection, exploring the dynamics of rest, noise, tumult, activity,
and work in modern life (http://hubbubgroup.org). She is interested in current
debates about the politics of ‘assets-based approaches’ and the psychologizing
of public health, and is currently researching the (mis)use of psychological ap-
proaches in workfare and other employment programmes.
xxx List of Contributors

Lisa Garnham is a Public Health Research Specialist at the Glasgow Centre for
Population Health. Her research interests centre on spatial and social patterns of
health inequalities, including the ways in which they intersect, and the impact of
‘social’ interventions on reducing them. Her PhD at the University of the West of
Scotland explored the ‘Scottish Effect’ in public health, with a focus on the
socio-political processes that could be understood to underpin its emergence.
Her research often makes use of participatory and creative methods, particularly
when she is working with children and young people.
Kayleigh Garthwaite is a Post-Doctoral Research Associate at the Department
of Geography, Durham University. She has a degree in Sociology, an MA in So-
cial Research Methods (Social Policy), and a PhD in Human Geography (2012),
all from Durham University. Her research interests focus on health inequalities,
welfare-to-work policies, and austerity, with a particular interest in spatial dis-
advantage. She is currently working on an ethnography of health inequalities in
contrasting areas of Stockton-on-Tees. She has published in the fields of social
policy, disability studies, sociology, youth studies, and public health, and is co-
author of Poverty and Insecurity: Life in Low-pay, No-pay Britain (Policy Press,
2012), which won the Peter Townsend Memorial Prize in 2013.
Johanna Hanefeld PhD is Senior Lecturer in Health Systems Economics, An-
thropology, Policy and Politics Group, in the Department of Global Health
and Development, London School of Hygiene and Tropical Medicine. She has
previously worked on social determinants of health at the World Health Or-
ganization’s EURO office and for various public health NGO and advocacy or-
ganisations in a variety of low and middle income settings.
Mark Hellowell is a Senior Lecturer at the Global Public Health Unit, University
of Edinburgh. His research programme focuses on the public/private interface in
health care and health systems, with an emphasis on the equity and efficiency
outcomes from different forms of intersectoral engagement. In addition to pub-
lishing in a diverse array of peer-reviewed journals, he has disseminated his re-
search through a variety of media, including BBC radio and television
documentaries, and newspapers including The Guardian and the Financial
Times. He has acted as special adviser to the House of Commons Treasury Select
Committee, and has advised several multilateral development agencies, including
the World Bank, on the operation of the public–private engagement in areas such
as acute health care, care and control of tuberculosis, and family planning.
Sarah Hill is Director of the Global Public Health Unit in the School of
Social and Political Science at the University of Edinburgh. Her research
focuses on health inequalities and the social determinants of health,
 List of Contributors xxxi

tobacco and health, and global health. She is particularly interested in the
structural drivers of health inequalities, including historical and institu-
tional discrimination and the role of commercial actors in non-communi-
cable disease epidemics. She joined the University of Edinburgh in 2009
having previously worked in research, public health, and medicine in New
Zealand, the USA, West Africa, and the UK.
David J. Hunter is Professor of Health Policy and Management at the Centre
for Public Policy and Health (CPPH), School of Medicine, Pharmacy and
Health, Durham University (www.dur.ac.uk/public.health), and Wolfson Fel-
low in the Wolfson Research Institute for Health and Well-being. He is Deputy
Director of Fuse, the Centre for Translational Research in Public Health
(www.fuse.ac.uk). He is a Non-Executive Director for the National Institute
for Health and Care Excellence (NICE), and advises WHO Europe. CPPH is a
WHO Collaborating Centre on Complex Health Systems Research, Knowl-
edge and Action. David has published extensively on health policy; his books
include The Health Debate (2008), The Public Health System in England (2010)
with Linda Marks and Katherine E. Smith, and Partnership Working in Public
Health (2014) with Neil Perkins (all three published by Policy Press, Bristol).
Jane Jones coordinated the Pilton community health project from 1984 to
1994. Together with Cathy McCormack she was a founder member of the
Scottish Popular Education Forum based on the work of Paulo Freire, the Bra-
zilian educationist. Between 1991 and 1999 she was a member of the Editorial
Advisory Board of the Community Development Journal.
At Edinburgh University she developed the access course ‘Health Issues in
the Community’, which placed community health within a social and political
context. She worked for the Poverty Alliance developing the Communities
Against Poverty (CAP) Scottish network and from 2003 to 2006 she was the
Public Participation Officer for the Scottish Parliament. In 2013 she was in-
vited to deliver the Stephen Maxwell Memorial lecture, ‘The War on the Com-
monweal’. She is a member of the Radical Independence Campaign (RIC).
Gerry McCartney has, since 2010, been Head of the Public Health Observa-
tory at NHS Health Scotland. He was previously a general practitioner and a
public health doctor for NHS Greater Glasgow and Clyde. He trained in medi-
cine at Glasgow University (MBChB 2001, MPH 2006) and has an honours
degree in economics and development (University of London 2007). His MD
thesis (University of Glasgow 2010) was on the anticipated host population
impacts of the 2014 Commonwealth Games. His main research interests and
publications focus on the health impacts of socio-economic, political, and en-
vironmental change, with a particular focus on the ‘excess mortality’ in
xxxii List of Contributors

Scotland as compared to other nations. Views expressed in this chapter are not
necessarily shared by NHS Health Scotland.
Cathy McCormack lives in Easterhouse, Glasgow and since 1982 has been
campaigning on poverty, housing, health, and climate change. Her writings
and broadcasts have received international acclaim, and her biography, The
Wee Yellow Butterfly, was published in 2009. She is also a non-academic com-
munity critical psychologist and has worked with Professor David Fryer,
speaking at conferences all over the world to expose the socio-structural vio-
lence being waged at communities both at home and abroad. In 2013 she ad-
dressed the International Community Psychology Conference at Birzeit
University, Palestine.
In 1994 she was engaged by the World Health Organization as a special ad-
visor at their European Health Policy Conference and in 1995 was an official
representative for the Scottish Environmental Forum at the United Nations
Commission on Sustainable Development.
Ben McKendrick is Chief Executive of the Scottish Youth Parliament, hav-
ing previously worked as Communications and External Affairs Directors
for Myeloma UK. He has worked in and around the devolved institutions in
Scotland since 2000. He initially worked as parliamentary assistant at the
newly formed Scottish Parliament and then as a senior researcher for a pol-
itical parliamentary group. After a period working for a public affairs con-
sultancy, he joined British Heart Foundation (BHF) Scotland as their Senior
Policy and Public Affairs Manager. During that period, he was responsible
for BHF’s tobacco control policy and advocacy work in Scotland and Nor-
thern Ireland, and represented the charity on the high-profile campaigns for
smoke-free public places, for a ban on the display of tobacco at the point of
sale and on the sale of tobacco from vending machines, and for standard-
ized tobacco packaging. He was also responsible for BHF’s policy and advo-
cacy work in Scotland, including on health inequalities and obesity.
Linda Marks is Senior Research Fellow at the Centre for Public Policy and
Health, School of Medicine, Pharmacy and Health, Durham University. With
a background in medical sociology, health policy analysis, and the organiza-
tion of primary care, she has acted as special advisor for WHO Europe’s public
health action plan, as a Non-Executive Director for NHS Darlington, and was
formerly a health policy analyst at the King’s Fund. Her current research inter-
ests include governance, priority-setting and health inequalities, and the im-
pact of the 2012 public health reforms in England. She has published widely
on public health policy and practice, including a recent book, Governance,
Commissioning and Public Health.
 List of Contributors xxxiii

Rich Mitchell is Professor of Health and Environment at the Centre for Re-
search on Environment, Society and Health, and head of the Public Health
Group at the Institute of Health and Well-being, University of Glasgow. He is
also a co-director of the Centre for Research on Environment, Society, and
Health (http://cresh.org.uk), an interdisciplinary and inter-institute centre fo-
cused on exploring how physical and social environments can influence popu-
lation health, for better and for worse. He is an epidemiologist and geographer.
Earlier in his career he focused on monitoring and exploring socio-economic
and geographic inequalities in health. Today, his focus is on the potential for
environments, and natural environments in particular, to positively influence
population health and health inequalities.
Jamie Pearce is Professor of Health Geography at the University of Edin-
burgh, where he is head of the Institute of Geography and Lived Environment,
and co-Director of the Centre for Research on Environment Society and
Health (CRESH). He is Editor-in-Chief of the international journal Health
and Place. His research seeks to understand various social, political, and envir-
onmental mechanisms operating on a range of geographical scales that estab-
lish and perpetuate spatial inequalities in health. Working at the intersection
of human geography, public health, and epidemiology, he has particular inter-
ests in health-related behaviours (e.g. smoking, nutrition, physical activity,
and obesity), environmental justice and health (e.g. air pollution and multiple
environmental deprivation), and macro-level health-related processes (e.g. so-
cial and economic inequality).
Kate Pickett is Professor of Epidemiology at the University of York and a co-
founder of The Equality Trust; her research focuses on the social determinants
of health. She was a UK NIHR Career Scientist from 2007 to 2012 and is a Fel-
low of the RSA and of the UK Faculty of Public Health. She is co-author, with
Richard Wilkinson, of the bestselling The Spirit Level, winner of the 2011 Pub-
lication of the Year from the Political Studies Association and translated into
23 languages. She and Richard were awarded a 2013 Silver Rose Award from
Solidar for championing equality.
Jennie Popay is Professor of Sociology and Public Health at Lancaster Univer-
sity in the UK, Deputy Director of the NIHR School for Public Health Re-
search (SPHR), and Director of Engagement for the NIHR Collaboration for
Leadership in Applied Health Research and Care for the NW Coast (NIHR
CLAHRC NWC). She is also co-Director of the Liverpool and Lancaster Col-
laboration for Public Health Research (LiLaC), one of eight academic mem-
bers of the SPHR. She has worked as a teacher, policymaker, and researcher in
academia and in the public and voluntary sectors in the UK, Africa, and New
xxxiv List of Contributors

Zealand. Her research interests include the social determinants of health and
health equity, the evaluation of complex ‘natural’ policy experiments, com-
munity empowerment, and the sociology of knowledge. She has been in-
volved in a wide range of mixed methods studies, but has particular expertise
in qualitative methods. Her current research includes an evaluation of a
large-scale community empowerment initiative in England and leadership of
a programme of work developing and evaluating local authority approaches
to addressing health inequalities. She has recently completed studies of the
impact on health inequalities and their social determinants of the English
New Deal for Communities regeneration programmes and their approaches
to community engagement. She also led a collaboration undertaking an
MRC-funded study focusing on methods to assess the impact of public in-
volvement in research, which resulted in an online resource for researchers
(piiaf.org.uk). She ran the global Social Exclusion Knowledge Network sup-
porting the WHO Commission on the Social Determinants of Health, and
has held public appointments with the Commission on Health Improvement,
the Commission on Patient and Public Involvement in Health, and the Bevan
Commission in Wales, and is presently chair of the English charity The Peo-
ple’s Health Trust.
Maximilian Ralston is a hospital doctor. He graduated from the University of
Edinburgh’s Medical School in 2015, having previously gained a BMedSci with
Honours in International Public Health Policy in 2012. He has a particular in-
terest in health and public policy, especially in the areas of health economics,
health inequities and social justice, and health care quality improvement.
Dennis Raphael PhD is a Professor of Health Policy and Management at
York University in Toronto. He is editor of Social Determinants of Health:
Canadian Perspectives (2008, Canadian Scholars’ Press), co-editor of Staying
Alive: Critical Perspectives on Health, Illness, and Health Care (2008, Cana-
dian Scholars’ Press), and author of Poverty in Canada: Implications for
Health and Quality of Life (2011, Canadian Scholars’ Press) and About Can-
ada: Health and Illness (2010, Fernwood Publishing). He is also co-author of
Social Determinants of Health: The Canadian Facts (2010, Toronto: York
University School of Health Policy and Management), a primer for the Ca-
nadian public that has been downloaded over 250,000 times from http://
thecanadianfacts.org. His latest edited books are Tackling Health Inequali-
ties: Lessons from International Experiences (2012, Canadian Scholars’ Press)
and Immigration and the Modern Welfare State: Public Policy, Immigrant Ex-
periences, and Health Outcomes (in press, Canadian Scholars’ Press).
 List of Contributors xxxv

Niamh Shortt is a Senior Lecturer in Health Geography at the Centre for En-
vironment, Society, and Health (CRESH), School of Geosciences, University
of Edinburgh. Her research considers how the environment shapes our health,
health behaviours, and resulting health inequalities. She focuses on the effect
of place and in particular the idea of the locale in which various aspects of the
social and natural environment converge to influence health outcomes. Based
on the premise that place matters for health, her research explores a wide
range of area effects and considers the implications for health. Her current
work focuses on alcohol and tobacco environments in Scotland.
Katherine E. Smith PhD is a Reader at the Global Public Health Unit in the
School of Social and Political Science at the University of Edinburgh. Her re-
search focuses on analysing policies affecting public health (especially health
inequalities) and better understanding the relationships between public health
research, policy, advocacy, and lobbying. She recently brought some of this
work together in a book entitled Beyond Evidence-based Policy in Public
Health: The Interplay of Ideas, which is part of a new book series, Palgrave
Studies in Science, Knowledge, and Policy that she co-edits with Professor Rich-
ard Freeman. Between January 2011 and December 2012 she held an MRC-
ESRC Post-Doctoral Fellowship, which was followed, in 2013–2015, by an
ESRC Future Research Leaders award (grant number ES/K001728/1). Both
grants helped support the development of this edited book.
Ellen Stewart holds a Chief Scientist Office Postdoctoral Research Fellowship
in the Centre for Population Health Sciences, University of Edinburgh, re-
searching evidence use and public engagement in hospital closure in the Scot-
tish NHS. She has previously worked at the University of St Andrews and LSE.
Her research interests bridge social policy and politics, with a particular focus
on how health systems negotiate the input of new types of knowledge in the
policy process, including demands for public engagement and evidence-based
policy. Her first monograph, Publics and their Health Systems: Participation
and Beyond, will be published by Palgrave Macmillan in 2015.
Kjetil A. van der Wel PhD is Associate Professor in the Faculty of Social Sci-
ences, Oslo and Akershus University College of Applied Sciences. His research
is on social inequalities in health and health-related worklessness, including
the role of social policies and labour market conditions.
Gareth Williams is Professor of Sociology in the School of Social Sciences
and Director of the Cardiff Institute of Society, Health, and Well-being at Car-
diff University. He previously worked at the University of Manchester and the
University of Salford. He is also Editor-in-Chief of the journal Sociology of
xxxvi List of Contributors

Health and Illness and is a Non-Executive Director on the Board of Public

Health Wales.
Richard Wilkinson is Emeritus Professor of Social Epidemiology at the Uni-
versity of Nottingham, Visiting Professor at the University of York, Honorary
Professor at UCL, and a co-founder of The Equality Trust. He has played a
formative role in international research on the social determinants of health
and on the societal effects of income inequality. He studied economic history at
LSE before training in epidemiology. He is co-author, with Kate Pickett, of the
bestselling The Spirit Level, winner of the 2011 Publication of the Year from the
Political Studies Association and translated into 23 languages. He and Kate
were awarded a 2013 Silver Rose Award from Solidar for championing equality.
 Chapter 1

Background and introduction:

UK experiences of health
inequalities
Katherine E. Smith, Clare Bambra,
and Sarah Hill

1.1 Health inequalities in the UK

In this chapter we introduce key debates in health inequalities research regard-
ing: (i) the best means of conceptualizing, measuring, and monitoring health
inequalities; (ii) trends in the UK’s patterns of health inequalities compared to
other high-income countries; (iii) empirically informed theories to explain
health inequalities; and (iv) the UK’s recent policy efforts to reduce health in-
equalities. The term ‘health inequality’ is usually employed to refer to the sys-
tematic differences in health which exist between different population groups
(e.g. different social classes or ethnic groups). In the UK, discussion of health
inequalities usually focuses on the distribution of health by social class and/or
socioeconomic position. Health inequality may be defined in a purely descrip-
tive way. For example, Kawachi and colleagues refer to health inequality as ‘a
term used to designate differences, variations, and disparities in the health
achievements of individuals and groups’ (Kawachi et al 2002, p647). More com-
monly, however (and in this book), the moral and ethical dimensions of the
term are emphasized: inequalities in health are therefore conceptualized as ‘sys-
tematic differences in the health of people occupying unequal positions in soci-
ety’ (Graham 2009, p 3), with an explicit recognition that such differences are
socially produced and therefore avoidable, unfair, and unjust (Whitehead
2007). In other contexts, slightly different terms may be preferred. For example,
in the USA and Canada, ‘health disparities’ are often employed, and inter-
nationally (e.g. at the World Health Organization (WHO)) and in low- and
middle-­income countries, the preferred term tends to be ‘health inequities’ (as
is evident in Chapter 5 of this book).
2 BACKGROUND & INTRODUCTION: UK EXPERIENCES

1.2 Debates about how health inequalities are

conceptualized, measured, and monitored
This section provides a brief summary of the main ways in which health in-
equalities are conceptualized, particularly in terms of the indicators used to
stratify health. It is by no means a comprehensive account but rather considers
the ways in which researchers focusing on the UK have tended to conceptualize
health inequalities over the past 30 years and some of the key challenges to these
approaches (critiques which are developed later in the book).

1.2.1 Health inequalities research: Data and theory

Health inequalities research relies heavily on empirical data to demonstrate and
explore differences in health status (see Chapter 2). The discipline of epidemi-
ology (the study of patterns of health and disease in human populations using
quantitative methods) has played an important role in this work, and continues
to be vital in describing and monitoring health inequalities within and between
populations. Indeed, the WHO Commission on the Social Determinants of
Health (CSDH), targeted at a global audience, included the need to measure,
understand, and monitor health inequalities as one of its three overarching re-
commendations (CSDH 2008).
The UK’s position as a leading centre for health inequalities research owes
much to its historically strong administrative data systems and to some pion-
eering epidemiologists. As early as the 1840s, researchers such as Edwin Chad-
wick used administrative data to demonstrate that those in manual occupations
died an average of seven years earlier than tradesmen and 20 years earlier than
the gentry (Chadwick 1842). The routine collection of data on mortality and
occupation since the mid-nineteenth century has allowed generations of UK
researchers to continue to examine the association between occupational class
and health (Macintyre 1997), while data relating to residential location have
provided health researchers with a proxy for social class in both the UK (Mac-
intyre 1997) and continental Europe (Susser et al 1985).
While epidemiology has much to offer in describing health inequalities, it has
perhaps been less helpful in understanding the causes of these inequalities. This
partly reflects the quantitative nature of its methods (see also Chapter 18), but
also reflects its links with clinical medicine and an associated tendency to focus
on data relating to the behaviours and lifestyle of individuals rather than the
broader structures and circumstances that shape such behaviours (see Chap-
ter 8). Beaglehole and Bonita (2004), for example, criticize what they describe as
epidemiology’s implicit reliance on a theory of biomedical individualism and its
lack of interest in the social drivers of health and disease. They caution against an
 HOW HEALTH INEQUALITIES ARE CONCEPTUALIZED 3

increasing tendency for epidemiologists to take a mechanistic view of health

while neglecting the population perspective, linking this bias with an ideo-
logical emphasis on individual rather than collective responsibility (Beaglehole
and Bonita 2004, p 145).
These tensions are evident in conflicting explanations for observed health
differences. As Section 1.4 outlines, popular, empirically informed explanations
for health inequalities stress the importance of ‘upstream’ factors, such as the
social and economic context in which behavioural decisions and lifestyle ex-
posures take place. In contrast, much epidemiological research focuses on indi-
vidual factors in seeking to explain patterns of disease, thus emphasizing what
are often regarded as poor, uninformed, or irresponsible lifestyle ‘choices’ on
the part of those with worse health status (see Section 1.4, and Chapters 16 and
17). Such explanations often reflect the underlying (usually unstated) assump-
tions of the researchers, or limitations in available data (as this section con-
siders further), and should therefore be treated cautiously.

1.2.2 Social class, socioeconomic position, and health

Social class, and the concept of ‘general standing in the community based on
occupational skill’ (Bartley 2004, p 1), has a long history in the UK. More re-
cently, health inequalities researchers in the UK have moved to a focus on so-
cioeconomic position as the principal marker of social inequality. This shift
reflects both the difficulties involved in measuring ‘social class’ and its less
widespread use in countries outside of Europe (Bartley 2004; Lynch and Kaplan
2000). However, it has also been criticized as a move away from an explicit focus
on the unequal distribution of power within society.
Various indicators of social class and social position exist, most of which
focus on occupational classifications and/or indicators of income, wealth, or
educational attainment (Galobardes et al 2006). The complexity of social class
and social position means that the indicators employed are inevitably imperfect
proxies and, as Grundy and Holt (2001) point out, the choice of indicator(s)
used is not often adequately reflected on, possibly hampering efforts to under-
stand the underlying mechanisms via which social position affects health.
Scambler and Higgs (1999) argue that a further implication of this tendency is
that ‘class’ is often ‘explained away’ by authors focusing on ‘class-constitutive’ or
‘class-associated’ factors (income, occupation, housing status, etc.) rather than
considering class as a ‘phenomenon in its own right’ (in a more sociological
sense). In a review of the ways in which health is stratified in the UK and the
USA, Krieger and colleagues (1997) argue that health inequalities researchers
necessarily have to focus on these kind of class-associated factors since ‘class’ is
not readily measured or quantified. Nevertheless, the authors note that social
4 BACKGROUND & INTRODUCTION: UK EXPERIENCES

class should be regarded as ‘logically and materially prior to’ socioeconomic

position, which can be seen as the ‘expression’ of social class in terms of the dis-
tribution of material and prestige-based resources across society (Krieger et al
1997, p 346).
Despite the difficulties in pinning down precisely what ‘social class’ is, or how
we might measure such an amorphous concept, there is now a clear consensus
that those positioned higher up the ‘class’ gradient in Britain experience better
health and life expectancy than those further down for many health outcomes
(Bartley 2004; Graham 2009; Marmot 2004). This pattern is evident across the
population, so that ‘even comfortably off people somewhere in the middle tend
to have poorer health than those above them’ (Marmot 2006). Consequently, as
Graham and Kelly (2004) argue, it is important to understand health inequal-
ities as a continual social gradient, rather than as ‘health gaps’ which result from
‘health deprivation’ in poorer communities.

1.2.3 Area and health

An alternative means of conceptualizing health inequalities, and one which also
has a long history in Britain (see Chapter 14), is to consider differences in health
indicators between areas. In many instances, indicators of neighbourhood are
used as another imperfect proxy for social position (see Tunstall and Lupton
2003). Whilst the existence of differences in population health between various
areas of the UK is widely acknowledged, there are also important debates about
how these differences are measured. The choice of scale at which geographically
bounded data are drawn from inevitably influences findings; while compari-
sons of large-scale areas may obscure significant variations in health within
those areas, a focus on health patterns within extremely small-scale areas may
fail to capture variation between larger areas (see Wilkinson 2005). Further, as
Chapter 14 explains, geographical approaches to health inequalities have
tended to ignore the historical and social production of places.

1.2.4 Gender and health

A less common strand of health inequalities research involves considering
health differences from a gendered perspective. Intrinsic to this research is a
distinction between sex, which is biologically defined, and gender, which is so-
cially defined (Annandale and Hunt 2000) and has important implications for
the relative position of men and women in any given society (Ostlin et al 2001).
This is not to say that health differences between women and men can be attrib-
uted proportionally to either the biological or the social; rather, the two elements
interact in their impacts on health such that ‘[b]iological differences between
 HOW HEALTH INEQUALITIES ARE CONCEPTUALIZED 5

the sexes may be in part socially determined, while social differences arising
from gender relations may also have a biological element’ (Ostlin et al 2001,
p 176). In other words, the impact of biologically defined differences (such as
reproductive capacity) will differ depending on socially defined norms and
structures, while differences in the socially defined roles and positions of men
and women may relate to biological differences between them.
As well as considering gender differences in health, there has also been re-
search interest in relation to how health is stratified amongst women, particu-
larly as most of the research on health inequalities in Britain in the 1970s and
1980s tended to focus solely on variations in men’s health (with married women,
where they were included, being categorized according to their husband’s class).
From the late 1980s onwards, researchers began doing more to explore whether
the same kinds of health differences were evident amongst women (e.g. Arber
1991; Bartley et al 1992), whilst also comparing health experiences between
men and women. In most countries (including the UK), such research suggests
that women have a longer life expectancy than men (Salomon et al 2013) but
experience higher levels of many chronic health conditions (Borchers and
Gershwin 2012).

1.2.5 Ethnicity, ‘race’, and health

While health inequalities research in the UK has historically focused on the role
of class and social position, researchers in other English-speaking contexts have
placed greater emphasis on ethnic inequalities in health. This is particularly
true of inequalities research in the USA, but is also an important theme in Can-
ada, New Zealand, and Australia—all former British colonies in which racial
ideology has played an important role in the historical process of colonization
and the establishment of contemporary societal norms and institutions (Armit-
age 1995).
In the US literature, the term ‘race’ is often used where UK researchers would
use ‘ethnicity’ (just as ‘disparities’ is often used in place of ‘inequalities’) (Isaac
2013). The prominence of race within the US partly reflects its historic signifi-
cance in the legal, political, and social development of US society, but also its
long-standing use as a key demographic category (Williams 1997). Some health
researchers in the USA have called for a shift away from the use of ‘race’ to ‘eth-
nic group’, but others argue that a continued focus on race is appropriate in
understanding the important role of racism for health (and other) inequalities
(Thomas 2013; Williams 1997). Ethnicity is a form of collective social identity
that typically includes elements of language, culture, shared history, and com-
mon ancestry (Karlsen and Nazroo 2007; Williams 1997). Ethnic identity is so-
cially constructed by both internal and external group membership; it involves
6 BACKGROUND & INTRODUCTION: UK EXPERIENCES

a complex and dynamic negotiation between those included in a particular eth-

nic grouping and the society in which that grouping has social significance. This
identity is not fixed: on a broad level, the boundaries and terminology used to
define ethnicity change with time and place; and on an individual level, the
same person may identify with different ethnic identities in different social con-
texts and at different points in their life course (though official records often
treat ethnicity as a single category—Aspinall and Song 2013).
The study of health inequalities in relation to ethnicity has historically been
something of a speciality interest in British health research, although it is now
becoming increasingly common (e.g. Chandola 2001; Davey Smith et al 2000;
Nazroo 2006). The research that does exist suggests that most minority ethnic
groups in Britain experience poorer health outcomes for many measures than
their ‘white British’ counterparts (Nazroo 2006). This conclusion in itself can
cause tensions; as Chaturvedi (2001) points out, research which emphasizes
high rates of disease in minority ethnic groups can imply that such disease rates
(and therefore the ethnic groups in question) are a problem.

1.2.6 Intersectionality
Although these various axes of inequalities are often studied in isolation, the
reality of people’s lived experiences involves ongoing intersections across all of
these different axes. The concept of ‘intersectionality’ describes the multiple
intersecting aspects of social identity and structure, particularly those associ-
ated with experiences of exclusion or subordination (Walby et al 2012). Origi-
nating in Black feminist critique, intersectionality is increasingly used in other
areas of research to theorize the experience of simultaneously held identities
with relevance for social position (Meer 2014). In relation to health inequalities,
the concept of intersectionality has not yet been widely employed, but, as Chap-
ter 7 explains, it offers a useful framework for understanding the multiple layers
of advantage and disadvantage that have relevance for health and well-being. It
recognizes that a single person has multiple aspects of identity (including social
class, ethnicity, gender, sexual orientation, ability/disability) which have rele-
vance for their relationships with others and with the structures and systems of
power in society—and, therefore, for their health.

1.3 Trends in the UK’s health inequalities over the past

30 years
Mortality rates in the UK, and across western and central Europe, have been
improving for around 150 years (McCartney et al 2011). However, underlying
the overall improvement in mortality rates, some specific causes of mortality
 Empirically informed theories 7

have increased markedly. For example, alcohol-related mortality increased dra-

matically during the late 1980s and early 1990s in the UK, in contrast to the
improving trends in other parts of Europe (Scott-Samuel et al 2014). Increases
were also evident in drug-related mortality, suicide, and violence over the same
period (Mok et al 2012; Shaw et al 2002; WHO 2012).
Within the UK, mortality rates improved much more slowly in northern and
inner-city areas than in the more affluent southern England (Hacking et al
2011), to the extent that in some areas mortality rates actually worsened (Nor-
man et al 2011). Indeed, for young adults in Scotland there has been no im-
provement over the course of the last 30 years (Whyte and Ajetunmobi 2012).
The rise in spatial inequalities in health since the 1980s is also reflected in a
rapid rise in mortality inequalities by occupational social class in England and
Wales and by area deprivation in Scotland (Leyland 2004). Figure 1.1 shows
that the absolute gap in mortality (as measured by the Slope Index of Inequal-
ity1) between the least and most deprived postcode areas in Scotland remained
high but stable between 1981 and 2001; whilst relative inequalities (as measured
by the Relative Index of Inequality2) increased rapidly, leaving Scotland with
the highest inequalities in western and central Europe (Mackenbach et al 2008;
Popham and Boyle 2010). In England and Wales, life expectancy increased for
all social class groups amongst males and females over time, but the increase
was more rapid amongst the highest social classes (I + II) than in the lowest so-
cial classes (IV + V), such that the inequalities increased.
It has been argued that these trends reflect the neoliberal (small state, free-
market orientated—see Chapters 9 and 12) policies that were adopted in the
UK in this era (see Scott-Samuel et al 2014). This is supported by the fact that
other countries which adopted neoliberal policies in this period also saw rises
in health inequalities, such as the USA and New Zealand (Beckfield and Krieger
2009). These rises in health inequalities were not inevitable: from the 1920s to
the 1970s in both the UK and the USA, inequalities in mortality declined
(Krieger et al 2008; Thomas et al 2007).

1.4 Empirically informed theories for understanding

health inequalities
The government-commissioned Black Report of 1980, which reviewed avail-
able evidence regarding health inequalities, provided a landmark analysis of
social class differences in the health of the population in England and Wales
(Black et al 1980). It remains a seminal document in health inequalities re-
search, not only in the UK but also internationally (e.g. Cutler et al 2006; Lynch
and Kaplan 2000). The Report’s authors ultimately rejected explanations reliant
8 BACKGROUND & INTRODUCTION: UK EXPERIENCES

0.8

0.7 Males
Relative Index of Inequality

0.6

0.5 Females
0.4

0.3

0.2 Relative inequalities in mortality by

Carstairs area deprivation
0.1
(Scotland)
0.0
800

700
Males
Slope Index of Inequality

600

500

400

300 Females

200
Absolute inequalities in mortality by
100 Carstairs area deprivation
(Scotland)
0
80 SC I
SC II
78
SC IIINM
Life expectancy at birth

76 SC IIIM
SC IV
74
SC V
(years)

72

70

68

66 Male life expectancy by social class

(England & Wales)
64
86
SC I
Life expectancy at birth (years)

84 SC II
82 SC IIINM
SC IIIM
80
SC IV
78 SC V

76

74 Female life expectancy by social class

(England & Wales)
72
81
79

93

95

07
97

99

01

05

09
77

83

85

87

89

91

03

11
75

19
19

19

19

20
19

19

20

20

20
19

19

19

19

19

20

20
19

19

Year

Fig. 1.1 Trends in health inequalities in England and Wales 1975–2003 (by occupa-
tional social class) and Scotland 1981–2001 (by Carstairs area deprivation).
Source: Data from National Records for Scotland and Office for National Statistics.
Another random document with
no related content on Scribd:
7, but it seems that there were four children in all. Those who write the more
common form of Suarez are more explicit, and deserve at least equal credit with
Gomara.

[68] Velazquez was married not long after his arrival in Cuba to the daughter of
Contador Cuéllar. The bride died within the same week. Herrera, dec. i. lib. ix. cap.
ix. ‘Velazquez fauoreciala por amor de otra su hermana, q̄ tenia ruin fama, y aun
el era demasiado mugeril.’ Gomara, Hist. Mex., 7. Delaporte, Reisen, x. 141-2,
assumes that Cortés won the love of her whom Velazquez wished to possess;
while Gordon, Anc. Mex., ii. 32, supposes that the bride had been the object of
Velazquez’ gallantry; hence the trouble. Folsom, on the other hand, marries one of
the Suarez sisters to Velazquez, and calls him the brother-in-law of Cortés.
Cortés, Despatches, 9, 11-12.

[69] Gomara, Hist. Mex., 7, insists that Velazquez had no motive for anger except
the refusal of Cortés to marry. The meeting of conspirators at his house gave
plausibility to the charges of his enemies. By others it is even stated that at these
meetings Cortés defended the governor against the charges of the conspirators
and overruled their plots. De Rebus Gestis Ferdinandi Cortesii, in Icazbalceta, Col.
Doc., i. 325-6. The preponderance of evidence, however, is against this
supposition.

[70] ‘Estando para se embarcar en una canoa de indios con sus papeles, fué
Diego Velazquez avisado y hízolo prender y quísolo ahorcar.’ Las Casas, Hist.
Ind., iv. 11. He was cast in the fort prison, lest the army should proclaim him
general. ‘Timebat ne si quis,’ etc. De Rebus Gestis Ferdinandi Cortesii, in
Icazbalceta, Col. Doc., i. 325 and 326-7.

[71] In De Rebus Gestis Ferdinandi Cortesii, in Icazbalceta, Col. Doc., i. 326-7, it

is related that Cortés broke the ropes holding him by means of a stick, and filed
the padlock of the chains. Seizing a bludgeon he advanced on the sleeping jailer,
resolved to break his head if he moved. But Cristóbal de Lagos either slept or
pretended not to hear the noise as Cortés seized the sword and shield at his head.
Swinging open a small window, Cortés slid down and hurried to the sanctuary,
giving on the way a word of cheer and advice to the conspirators who were held
within the prison.

[72] ‘Cortés ... tuuo por cierto q̄ lo embiariã a santo Domingo o a España.’
Gomara, Hist. Mex., 7. There would have been no reasons for his fears on this
score, if he possessed papers implicating Velazquez, as Gomara states. Another
version is that the alcaldes imposed a heavy sentence on Cortés, after his
capture, and that Velazquez, on being appealed to by Duero and others, was
noble-minded enough to grant a pardon. He discharged him from his service,
however, and had him placed on board a ship for Española. Torquemada, i. 348.
Herrera says that Catalina lived near the church, and while Cortés was making
love to her an alguacil named Juan Escudero, whom Cortés afterward hanged in
Mexico, came up behind him and pinioned his arms, while the soldiers rushed to
his assistance. Dec. i. lib. ix. cap. ix.; Cortés, Residencia, i. 63, etc. Las Casas,
Hist. Ind., iv. 11; De Rebus Gestis Ferdinandi Cortesii, in Icazbalceta, i. 327-8, give
minutely the mode of capture.

[73] Broke the pump and crawled through, ‘Organum pneumaticum,’ etc. De
Rebus Gestis Ferdinandi Cortesii, in Icazbalceta, Col. Doc., i. 329.

[74] The current of the Macaguanigua River did not allow him to enter it, and
elsewhere the breakers would upset the boat. Stripping himself, he tied to his
head certain documents against Velazquez, held by him as notary of the
ayuntamiento and clerk of the treasurer, and thereupon swam ashore. He entered
his house, consulted with Juan Suarez, and reëntered the temple, armed.
Gomara, Hist. Mex., 7. De Rebus Gestis Ferdinandi Cortesii, in Icazbalceta, vi.
329-30, refers to a friend of Cortés chained in the same ship’s hold, and states
that Cortés rowed ashore. On the way to the house of Suarez he narrowly
escapes a patrol. Having secured arms, he proceeds to cheer his captive
partisans, and then enters the sanctuary. At dawn the captain of the vessel from
which Cortés escaped comes also to the temple, to secure himself against
Velazquez’ wrath, no doubt, but is refused admission into the sacristy by his
fellow-refugee, who suspects the man, and fears that the provisions may not
outlast the siege. In Herrera, dec. i. lib. ix. cap. viii., Cortés drifts about on a log
and is finally cast ashore.

[75] So the story was current at the time, and I doubt not it contains some degree
of truth, notwithstanding Las Casas, Hist. Ind., iv. 11-12, scouts it as a pure
fabrication. He knew both men; Velazquez as a proud chief, exacting the deepest
reverence from those around him, and making them tremble at his frown; while
Cortés was in those days so lowly and humble as to be glad to curry favor with the
meanest servants of the governor. The good bishop is evidently prejudiced. In De
Rebus Gestis Ferdinandi Cortesii, in Icazbalceta, Col. Doc., i. 332-4, the facts are
a little elaborated and contradictory, as usual. Cortés escapes the guard round the
church, and reaches the farm. ‘Halloh, señores!’ he shouts, ‘Cortés is at the door,
and salutes Señor Velazquez, his excellent and gallant captain.’ Velazquez is
astonished, yet pleased, at the arrival of one whom he always had regarded as a
friend and beloved brother. He orders supper and bed to be prepared; but Cortés
insists that none shall approach, or he will lance them. He demands to know what
complaints there are against him. He abhors the suspicion of being a traitor, and
will clear himself. ‘Receive me,’ he concludes, ‘in your favor with the same good
faith that I return to it.’ ‘Now I believe,’ answers Velazquez, ‘that you regard as
highly my name and fame as your own loyalty.’ They shake hands, and Cortés
now enters the house to fully explain the misunderstanding. After supper they
retire to one bed. In the morning the messenger, Diego Orellana, arrives to
announce Cortés’ flight, and finds them lying side by side. Cortés will not proceed
with the expedition just then; but after arranging his affairs he joins, to the delight
of the general, who follows his advice implicitly, as he had done in former
campaigns. After their victorious return Cortés enjoys greater honors than ever.
Peralta, who also gives the story at length, states that Cortés surprised Velazquez
asleep. At the request of the governor he gave himself up to the jailer in order to
be formally released. Nat. Hist., 58-62. Still Peralta is a little confused.

[76] She was received by Cortés in Mexico, after the conquest, with great
distinction; but died in about three months after her arrival.

[77] Las Casas, who, as usual, will have a fling at Cortés, writes: ‘Tuvo Cortés un
hijo ó hija, no sé si en su mujer, y suplicó á Diego Velazquez que tuviese por bien
de se lo sacar de la pila en el baptismo y ser su compadre, lo que Diego
Velazquez aceptó, por honralle.’ Hist. Ind., iv. 13. Among Cortés’ children a natural
daughter by a Cuban Indian is mentioned, Bernal Diaz, Hist. Verdad., 238, but it is
not likely that Cortés would ask the governor to stand godfather to a natural child.
The same writer makes Velazquez the groomsman or sponsor at the marriage.
‘Fue su padrino, quando Cortés se velò con Doña Catalina;’ Id., 13; Vetancvrt,
Teatro Mex., pt. iii. 109. Although compadre is not unfrequently used as a mere
term of friendship, it is not likely to have been applied by a marriage padrino;
hence the title of co-father indicates that it originated at the font.

[78] An office granted only to men of note and to leading conquistadores. Solis,
Hist. Mex., i. 46. It conveyed the title of ‘muy virtuoso señor,’ the governor being
called ‘muy magnífico señor,’ Pacheco and Cárdenas, Col. Doc., xii. 225, and
permitted the holder to walk side by side with the governor. Herrera, dec. ii. lib. iii.
cap. xii. ‘Auia sido dos vezes Alcalde en la Villa de Sãtiago de Boroco, adõde era
vezino: porque en aquestas tierras se tiene por mucha honra.’ Bernal Diaz, Hist.
Verdad., 13. He does not refer to him as alcalde at Santiago de Cuba, where the
fleet is fitting out, as he clearly states. Gomara, Hist. Mex., 4, mentions merely that
he was here before the quarrel with Velazquez. Some writers assume that
Santiago de Cuba is the same as Santiago de Baracoa, but Herrera, loc. cit., and
others, observe the distinction.
 CHAPTER V.
SAILING OF THE EXPEDITION.

1518-1519.

The Quality of Leader Desired—Instructions Issued to Hernan Cortés,

Commander-in-Chief—The Character of Cortés Undergoes a Change—
Cost of the Expedition—By whom Borne—Places Established for
Enlistment—The Banner—Cortés Puts on the Great Man—More of his
Character—The Scene at Santiago Harbor—The Governor’s Jester—
Dark Suspicions of Velazquez—Departure from Santiago—Cortés at
Trinidad—Fresh Recruits—Verdugo Receives Orders to Depose
Cortés—The Fleet Proceeds to San Cristóbal, or The Habana—Review
at Guaguanico—Speech of Cortés—Organization into Companies—
Departure from Cuba.

With relations so lovingly established, and with a personal

knowledge of the military genius of Cortés, and the strength and
versatility of his character, it would seem that here would be the first
instant choice of the governor for the command of the important
expedition now in preparation. But the quality of the man required did
not altogether hinge on merit. As we have seen, Velazquez required
for his purpose an anomalous creation. He must be able but humble;
able to command men, and able likewise to obey his chief; honest to
Velazquez, but false, if necessary, to all the world else. It was not an
Alexander or an Alcibiades that was wanted; not so much a man as
a thing: “Piper, non homo,” as Petronius Arbiter said; pungent as
pepper, and not a human being.
 Be this as it may, the sordid friendship of Láres and Duero
prevailed with the governor, and on the 23d of October, 1518, his
instructions to Hernan Cortés, commander-in-chief of the expedition,
were drawn up before the notary, Alonso de Escalante, in
accordance with the permission granted by the authorities at Santo
Domingo, which limited the enterprise to exploration; the privilege to
colonize depending on royal favor for which Velazquez must sue in
Spain.[79]
One would think that after these twenty-five years of experience
there could be found no ecclesiastic or ruler so childish as to expect
morality or humanity from the wolves of Spain let loose among the
naked and defenceless of America. And yet we find the friars of
Española, in pursuance of the devout and high-minded views
expressed by Velazquez, subscribing to instructions which enjoin
Cortés to observe a conduct befitting a Christian soldier, as if there
were any reasonable hope of his doing so. He must prohibit
blasphemy, licentiousness, and gambling among his men, and on no
account molest the natives, but gently inform them of the glory of
God, and of the Catholic king. Possession must be taken in
Velazquez’ name and the secrets of the country ascertained. Search
must be made for Grijalva and Olid, and for the Christian captives
supposed to be in Yucatan. We might again mark the double-dealing
of the governor, who discharges Grijalva for not having settled
contrary to his instructions, while charging the new commander not
to seize the country, yet expecting him to do so.[80] The instructions
consist of thirty clauses, and the document reflects no credit on the
scrivener.[81]
Man and his character are subject to environment. Neither is
finished until decay has well set in. Long before the receipt of his
commission the adolescent Cortés was a creation of the past; even
the adult Cortés was a different being before and after his
appointment. His action now was the expression of new intuitions.
Always under the influence of turbulent emotions, his ambition had
suddenly become more aggressive. In pure impulses, in refined
feelings, in noble instincts, he was essentially defective. He harbored
no ideal of duty, such as we have seen in the mind of Grijalva. His
code of ethics was neither broad nor catholic. And notwithstanding
his great respect for religion, so great indeed as to excite suspicion
that he cared very little for it; notwithstanding his outward piety, and
his devotion to the church, the lighter immoralities fitted him with an
ease and grace that hampered his movements not in the least. Yet
for all this the alcalde of Santiago suddenly became a great man, not
in name only, but actually; wellnigh revolutionizing the society of
which he himself was the product. To him, and to others, his
commission was a match applied to explosive material, letting loose
the latent force. The leaders of the first gulf-shore expeditions,
Córdoba, Grijalva, and Cortés, present themselves before us in
relatively increasing proportions. Córdoba, the first, was least,
though a most gentlemanly and kind-hearted pirate. Grijalva, though
second to Cortés in talents and fame, was far before him in honesty.
During the preparations which quickly followed the appointment of
Cortés, the inherent qualities of the man developed to a degree
alarming alike to friends and enemies, and astonishing to himself. He
found his nature a strong one, with magnetic attractions, and an
affinity with danger. He found himself possessed of that higher
courage of the mind which begets self-confidence, breeds the hero,
and ends in the achievement of the uttermost. And genius was there;
he began to feel it and to know it: the genius of ambition and
egotism, whose central figure was himself, an all-prevailing
sentiment, before which right, religion, humanity, and even life itself,
must be subservient. His rapidly evolving will was becoming
ponderous, overwhelming. Fame was becoming to him what
ambition was to Columbus; only he possessed his idea instead of
being possessed by it. Sufficiently educated for the purposes of
statecraft, opportunity alone was needed to enable him to turn every
weapon to the furtherance of his own designs. Without attempting to
pry into the occult, he now began to see things with a large and
liberal eye. Life was assuming tremendous realities, which bridled
impulse; yet it was an ordeal he believed he could face. While in
sophistry he found himself equal to Euripides, he began to put on
bombast such as Æschylus could not have scorned, and to display
an energy as sublime as that of Archilochus; yet all this time his
good sense was supplemented by graceful courtesy. All who worship
the bright wit and intellectual versatility that flatter ambition and yield
unscrupulous success may henceforth bow the knee to Hernan
Cortés.
No sooner was his commission sealed than Cortés set himself
about the task of collecting his many requirements. His own few
thousand pesos of ready money were quickly spent; then he
mortgaged his estates, and borrowed to the uttermost from his
friends. Velazquez was free with everything except his substance;
free with his advice and ostentation, free with the ships of others,
and willing to sell to the expedition the products of his farm at
exorbitant prices. Nevertheless the investment to the governor, as
well as to Cortés, was large, the former furnishing some ships of his
own and some money, the whole cost of vessels and outfit being
about twenty thousand ducats.[82]
Establishing places of enlistment throughout the island, Cortés
roused to action his many friends, both in person and by letter. At
principal settlements the expedition was proclaimed about the
streets, in the king’s name, by the beating of drums and the voice of
the crier. One third of the proceeds of the adventure was promised
the soldiers and subalterns, two thirds going to the outfitters.[83] A
banner of black taffeta was embroidered with the royal arms in gold,
and blue and white flames surrounding a red cross, and round the
border it bore the inscription, “Amici sequamur crucem, si nos
habuerimus fidem in hoc signo vincemus.” Friends, let us follow the
cross, and if we have faith under this sign we shall conquer.[84]
Assuming a dress and bearing more fitting a military
commander, Cortés threw open his doors, and by judiciously
combining the frank joviality of a soldier with the liberal hospitality of
a man of wealth, he rapidly drew to his adventure all the available
men of the island. There were not lacking those to sneer at this
assumption of preëminence, which flaunted it so bravely with plume
and medal, with martial music and retinue, saying, here was a lord
without lands.[85] But they little knew the strength and firmness of
him who, having once put on the great man, would lay the livery
down but with his life. This soldierly display, always taking to the
Castilian fancy, could scarcely be called affectation, for the genius
which commands success was present, and the firmness of resolve
was covered with such pleasing affability as to render its presence
scarcely suspected. With his fine soldierly qualities were financial
and executive ability, and fair common sense, a rare combination in
a Spanish cavalier. While loving adventure he did not altogether hate
ideas. His world now spread itself before him, as divided into two
unequal classes, those that use others, and those that are used by
others, and he resolved himself forever into the former category. Like
Diogenes, though enslaved at Crete, Cortés felt that if he could do
one thing better than another it was to command men. Coupled with
this egotism was the sensible intuition that the mastery of others
begins with self-mastery. Indeed his command over himself, as well
as over others, was most remarkable. “By my conscience!” was a
favorite oath, which implies not brutal passion. At times a swelling
vein in the forehead, and another in the throat, indicated rising anger,
manifested also by a peculiarity of throwing off his cloak; but the
voice would remain decorous, and the words seldom passed beyond
a “Mal pese á vos!” May it bear heavily upon you. To the insolent
soldier, whom we shall often find overstepping the bounds of
prudence, he would merely say, “Be silent!” or “Go, in God’s name,
and be more careful if you would escape punishment.” Equally
composed in argument, he wielded his persuasive powers to their
best advantage. Rio de Avenida, the Rushing River, was at one time
a nickname, and later he affected long hair and lawsuits. At the
gaming-table, to which he was greatly addicted, he won or lost with
equal sang-froid, ever ready with a witticism to smooth the varying
course of fortune. Though he did not hesitate as gay Lothario to
invade the family of another, most unreasonably he was very jealous
lest his own family should be invaded. While liberal to friend or
mistress, and ready to sacrifice almost anything to gain an object, he
was not always regarded as over-generous by his men, too many of
whom were of that class, however, that nothing would satisfy.
Although a fair eater, he drank but little, and confined himself to
simple diet. This moderation also extended to dress, which, before
his elevation, was not only neat but tasteful in its rich simplicity,
ornamented with few but choice jewels, and with little diversity. A
love of pomp, however, developed with his rising fortunes, more
particularly in the way of showy residences and a large retinue,
which accorded well with the courtly manners native to the Spaniard
claiming noble blood. Cervantes says that in the army even the
niggardly become prodigal.
Cortés found the way of throwing into his cause not only himself,
but others, in some respects as able as himself. His liberal measures
and enthusiasm became infectious, and brought to enrolment
wealthy volunteers, who furnished not only their own outfit, but
helped to provide others.[86] Within a short time there joined over
three hundred men, among them some high in the service and
confidence of the governor—instance, Francisco de Morla his
chamberlain, Martin Ramos de Láres a Basque, Pedro Escudero,
Juan Ruano, Escobar, and Diego de Ordaz mayordomo of
Velazquez, and instructed by him to watch proceedings and secretly
report.
The harbor of Santiago at this time presented a busy scene.
There were the hurrying to and fro of laborers and recruits, the clang
of carpenters’ hammers upon ships undergoing repairs, the
collecting of goods, and the loading of vessels. Every day the
landing was enlivened by the presence of the governor, often arm-in-
arm with his most dutiful and compliant captain-general, surrounded
by gayly dressed attendants and followed by half the town. On one
of these visits of inspection, while engaged in friendly conversation
respecting the progress of affairs, the Governor’s jester,
Francisquillo, who was present, as usual, performing his antics
before his master, cried out, “Ah, friend Diego!” Then to Cortés, “And
how fares our brave captain, he of Medellin and Estremadura? Be
careful, good master, or we shall soon have to beat the bush for this
same Cortés.” Velazquez laughed heartily, and turning to his
companion exclaimed, “Compadre, do you hear this fool?” “What,
señor?” replied Cortés, pretending preoccupation. “He says you will
run away with our fleet,” replied Velazquez. “Pay no attention to the
knave, your worship; I am very sure these infamous pleasantries
never emanated from his mad brain,” rejoined Cortés, deeply
chagrined. And ere the laugh died away on the lips of the governor
his timid breast was chilled by fearful forebodings. What if it were
true, thought Velazquez, and this fellow, whom I have lifted from his
low estate, should declare for himself on reaching New Spain? Then
he called to mind his late quarrel with Cortés, and the courage,
energy, and determination displayed by the latter throughout. The
governor trembled when he thought of it. About him were enough of
the disappointed only too ready to fan these suspicions into a flame.
[87]

I regret having to spoil a good story; but the truth is, the drama
reported by Bartolomé Las Casas, and reiterated by Herrera and
Prescott, was never performed. It tells how Cortés put to sea,
Prescott asserts the very night after the jester’s warning; and that in
the morning, when the governor, early roused from his bed, rushed
down to the landing with all the town at his heels, Cortés returned
part way in an armed boat and bandied words with him. Beside
being improbable, almost impossible, this version is not sustained by
the best authorities.[88] The fact is, some time elapsed, after the
suspicions of the governor had first been aroused, before the sailing
of the fleet, during which interval Grijalva with his ships returned.
Gomara states that Velazquez sought to break with Cortés and
send only Grijalva’s vessels, with another commander; but to this
Láres and Duero, whose advice was asked by the governor, made
strong objection, saying that Cortés and his friends had spent too
much money now to abandon the enterprise, which was very true;
for like the appetite of Angaston which came with eating, the more
Cortés tasted the sweets of popularity and power, the more stomach
he had for the business. And the more the suspicions of the
governor grew, the greater were the captain-general’s assurances of
devotion, and the firmer became the determination of Cortés and his
followers to prosecute this adventure, in which they had staked their
all.[89]
Warned by Láres and Duero of every plot, Cortés hurried
preparations, sending friends to forage, and shipping stores with the
utmost despatch, meanwhile giving secret orders for all to be ready
to embark at a moment’s notice. Finally, the hour having come, on
the evening of the 17th of November, with a few trusty adherents,
Cortés presented himself before the governor, and politely took his
leave. It fell suddenly on Velazquez, in whose eyes all movements
relating to the expedition had of late become the manœuvres of men
conspired to overreach him. But having neither the excuse nor the
ability to stop the expedition he let the officers depart.
 By playing with the devil one soon learns to play the devil. From
the governor’s house Cortés hastened to the public meat depository,
seized and added to his stores the town’s next week’s supply, and
left the keeper, Fernando Alfonso, a gold chain, all he had remaining
wherewith to make payment.[90] It was a dull, dry, gray November
morning, the 18th, very early, after mass had been said, when the
squadron, consisting of six vessels, sailed out of Santiago harbor
amidst the vivas of the populace and the inward cursings of the
governor.[91] But of little avail was Velazquez’ remorse; for Cortés
carried no Æolian wind-bags to drive him back from his destination.

Despatching one of the vessels to Jamaica[92] for provisions,

Cortés touched at Macaca for further supplies, and thence steered
for Trinidad, where he was received with demonstrations of
enthusiasm by the alcalde mayor, Francisco Verdugo brother-in-law
of Velazquez, and by other hidalgos, who placed their houses at his
disposal. Raising his standard before his quarters, he proclaimed the
expedition and invited volunteers, as he had done at Santiago. Soon
his force was augmented by over one hundred of Grijalva’s men.
Here also joined several captains and hidalgos, afterward famous in
New Spain adventure. There were the five brothers Alvarado, Alonso
de Ávila, Gonzalo Mejía afterward treasurer at Mexico, Cristóbal de
Olid, Alonzo Hernandez Puertocarrero cousin of the count of
Medellin, Gonzalo de Sandoval who became so great a friend of
Cortés, Juan Velazquez de Leon a relative of the governor, and
others.[93] From the plantations of Santi Espíritu and elsewhere
came many. This Cortés beheld with proud satisfaction, and
welcomed these important acquisitions with martial music and peals
of artillery.
In seeking supplies Cortés paid little heed to rights of property,
so long as he obtained what he needed; he was subsequently not a
little proud of his success. “By my faith,” he boasts in Spain in 1542,
“but I did play the corsair genteelly.” Among the arbitrary purchases
was that of a vessel from Jamaica laden with provisions for the
mines, for which the owner might accept promissory notes or
nothing.[94] Another vessel from the same place, on the same
mission, Cortés sent Ordaz to seize and convey to Cape San
Antonio, or perhaps to San Cristóbal where we afterward find him,
there to await the fleet. This captain, it will be remembered, was the
spy of Velazquez, and to him, therefore, rather than to another, was
given this mission, to prevent his watching proceedings at Trinidad.
The commander of the seized vessel was Juan Nuñez Sedeño, who
was induced to join the expedition.[95] Meanwhile in the breast of
Velazquez was stirred afresh the poison of jealousy by an astrologer,
one Juan Millan, employed by the enemies of Cortés to work on the
fears of the governor. The result was the arrival at Trinidad, in hot
haste, of two messengers from the governor, with orders for Verdugo
to detain the fleet, the command of which had been transferred to
Vasco Porcallo. Moreover, all the retainers of Velazquez were called
upon to aid in deposing Cortés. It was no difficult matter, however,
for Cortés to persuade Verdugo of two things: first, that there were
no grounds for Velazquez’ fears, and secondly, if there were, force
would now avail him nothing. So strong was Cortés in his position
that he could easily lay the town in ashes should its authorities
attempt to interfere in his purposes. Taking one of the messengers,
Pedro Lasso, into his service, by the other Cortés wrote Velazquez,
in language most respectful, begging him to believe that he would
always be true to his God, his king, and his dear friend and governor.
In like notes the robin and the screech-owl muffle their voices when
danger is near, so as to conceal the distance, and make themselves
seem far away. Thus passed twelve days, according to Bernal Diaz,
at Trinidad, when one of the vessels was despatched to the north
side of the island for supplies, and the fleet departed for San
Cristóbal, then Habana,[96] while Pedro de Alvarado, with fifty
soldiers and all the horses, proceeded thither overland, adding to
their number at the plantations on the way.
One night during the voyage to San Cristóbal, the flag-ship was
separated from the other vessels and stranded on a reef near Isla de
Pinos. With skill and promptness Cortés transferred the contents in
small boats to the shore, set free the lightened vessel, and,
reloading, joined his captains at San Cristóbal. This accident delayed
him seven days, during which time there was no small stir among his
men at San Cristóbal as to who should command the fleet in case its
captain-general failed to appear. Conspicuous among these
questioners was Ordaz, who claimed precedence as Velazquez’
representative. But the arrival of the commander put an end to the
controversy and spread unbounded joy throughout the armada.
Landing, he accepted the hospitality of Pedro Barba, lieutenant of
Velazquez. Among those who joined him here were Francisco
Montejo, the future conqueror of Yucatan, and Diego de Soto, who in
Mexico became the mayordomo of Cortés. Again the commander rid
himself of Ordaz by sending him with a vessel to the plantations near
Cape San Antonio, there to await the fleet. The artillery was landed
and cleaned; the cross-bows were tested and the firelocks polished.
Cotton armor was secured. More provisions being required,
Quesada, the Episcopal tithe-collector, contributed his stock.
Warranted, as he thought, by his success and prospects, and
well aware of the effect on the Spanish mind of some degree of
ostentation and military display, Cortés put on the paraphernalia of
still greater leadership, and appointed a chamberlain, a chief butler,
and a mayordomo, in the persons of Rodrigo Rangel, Guzman, and
Juan de Cáceres, which pomp he ever after maintained.[97] Gaspar
de Garnica now arrived with letters from Velazquez to Barba, Ordaz,
Leon, and others, ordering and entreating them to stop the fleet,
arrest Cortés, and send him a prisoner to Santiago. It was of no
avail, however. Soldiers, officers, even Barba himself, were
enthusiastic for Cortés, who once more wrote the governor, in terms
as courteous as they were costless, and shortly afterward, on the
10th of February, 1519, the fleet again set sail.[98] Guaguanico, on
the north side of Cape San Antonio, was the place appointed for
muster and apportionment.[99] Meanwhile Pedro Alvarado was sent
forward with sixty soldiers in the San Sebastian to bring Ordaz to the
rendezvous, but driven by a gale beyond his goal and near to
Yucatan, he thought it useless to return, and so proceeded to
Cozumel Island, where he arrived two days before the others. The
expedition consisted of twelve vessels, the flag-ship or capitana of
one hundred tons, three others of from sixty to eighty tons, and the
rest small brigantines and open craft, including a transport
commanded by Ginés Nortes. The soldiers numbered five hundred
and eight, and the sailors one hundred and nine, including officers
and pilots. The priests present were Juan Diaz and Bartolomé de
Olmedo, of the Order of Mercy. Under Juan Benitez and Pedro de
Guzman were thirty-two crossbowmen; thirteen men only carried
firelocks, the rest being armed with swords and spears. The artillery
consisted of ten bronzed guns and four falconets, and was in charge
of Francisco de Orozco, aided by Mesa Usagre, Arbenga, and
others. About two hundred Cuban Indians, together with some native
women and negro slaves, were brought for service, despite the
prohibitory clause in the instructions. Sixteen horses receive the
minute description and glowing encomium of the soldier Diaz, and
play an important part in the coming campaign. The supplies
included some five thousand tocinos, or pieces of salt pork, six
thousand loads of maize and yucca, fowl, vegetables, groceries, and
other provisions. For barter were beads, bells, mirrors, needles,
ribbons, knives, hatchets, cotton goods, and other articles.[100]
The force was divided into eleven companies, each under a
captain having control on sea and land. The names of the captains
were Alonso Hernandez Puertocarrero, Alonso de Ávila, Diego de
Ordaz, Francisco de Montejo, Francisco de Morla, Escobar, Juan de
Escalante, Juan Velazquez de Leon, Cristóbal de Olid, Pedro de
Alvarado, and Cortés, with Anton de Alaminos as chief pilot.[101]
From this list it will be seen that those but lately regarded as of
the Velazquez party received their full share in the command. This
cannot be attributed so much to the captain-general’s sense of
fairness, which forbade him to take advantage of interests voluntarily
intrusted to his care, as to a studied policy whereby he hoped to win
for his purposes certain men of influence, whom it would, for that
matter, have been dangerous to remove.
Before the review, Cortés addressed his soldiers in a speech as
shrewd and stirring as that of Marcius at Corioli. Pointing to the
thousands of unbaptized, he awakened their religious zeal; dwelling
on the grandeur of the undertaking, he stimulated their ambition;
referring to the vast wealth these lands contained, he excited their
cupidity. Greater and richer lands than all the Spanish kingdoms, he
called them, and inhabited by strange races, only awaiting
submission to their invincible arms. Their whole fortune was invested
in the fleet that carried them; but who would regret so trifling an
expenditure when compared with the glorious results to follow? They
were setting out upon a career of conquest in the name of their God,
who had always befriended the Spanish nation; and in the name of
their emperor, for whom they would achieve greater deeds than any
ever performed. Riches lay spread before them; but like good and
brave men they must look with him to the higher and nobler reward
of glory. “Nevertheless,” he archly added, “be true to me, as am I to
you, and ere long I will load you with wealth such as you have never
dreamed of. I will not say it is to be won without hardships; but who
of you are afraid? We are few, but we are brave. Let us therefore on
with the work so well begun, joyously and confidently to the
end!”[102] There is no passion so artful as avarice in hiding itself
under some virtue. Sometimes it is progress, sometimes patriotism,
but its warmest cloak has ever been religion. There is a double profit
to the devotee whose religion gratifies his avarice, and whose
avarice is made a part of his religion.
On the morning of February 18th mass was said, the campaign
standard blessed, and Saint Peter invoked, whereupon the prows
were pointed toward the islands of the west. All the vessels were to
follow the flagship, whose light should be their guide by night; in
case of separation they were to steer for Cape Catoche and thence
proceed to Cozumel.[103]

FOOTNOTES
[79] ‘Fray Luys de Figueroa, fray Alonso de santo Domingo, y fray Bernaldino
Mãçenedo, q̄ eran los gouernadores, dieron la licencia para Fernando Cortés
como capitan y armador cõ Diego Velazquez.’ Gomara, Hist. Mex., 12. The
Fathers no doubt required to know the name of the commander. ‘His litteris
Cortesius confirmatus,’ is the statement in De Rebus Gestis Ferdinandi Cortesii, in
Icazbalceta, Col. Doc., i. 344, in reference to their permit. This authority intimates
that Salcedo, at a later date probably, obtained license from the Fathers for
warfare in Yucatan and for the settlement of the mainland, but this is not confirmed
anywhere. Id., 350.

[80] Evidently Velazquez desired his captains to disobey instructions and colonize.
He could not officially authorize them to do so, not having as yet received
permission from Spain. Neither Velazquez nor Cortés had any intention in this
instance of confining this enterprise to trade, or protecting the natives, or imposing
morality upon the men. It was well understood by all that licentiousness and
plunder were to be the reward for perils to be undergone. ‘Atque etiam quod
Grijalvae prætentâ causa auxilii ferendi quod Alvaradus postulabat, ire licebat,’ is
the pointed observation in De Rebus Gestis Ferdinandi Cortesii, in Icazbalceta,
Col. Doc., i. 343-4. Bernal Diaz, Hist. Verdad., 13, refers to promises of Indian
repartimientos in the new regions as an inducement for volunteers. Cortés’
statement at Vera Cruz, that he had no order to settle, means nothing in view of
the motives then actuating him. Secret agreements between governors and
lieutenants for defrauding the crown and promoting their own aims were only too
common; and this is overlooked by those who trust merely to the instructions for
arguments on this point.

[81] The full text of the instructions is to be found in Pacheco and Cárdenas, Col.
Doc., xii. 225-46; Col. Doc. Inéd., i. 385, 406; Alaman, Disert., i. App. ii. 1-27, with
notes, reproduced in Zamacois, Hist. Méj., ii. 791-815. The Muñoz copy, given in
Prescott’s Mex., iii. 434-9, preserved the original spelling in the preamble, but the
clauses are abbreviated, though Prescott does not appear to be aware of it.

[82] The ownership of the expedition has been a moot question, some authors
regarding it as pertaining chiefly to Velazquez, while others accord it wholly to
Cortés and his friends. According to Gomara, after receiving the vessel brought by
Alvarado, and another provided by Velazquez, Cortés, aided by his friends, bought
two large and two small vessels before leaving Santiago; and at least two more
were bought after this with bills forced upon the owners. The rest of the fleet
appears to have been made up from the transport spoken of and from Grijalva’s
vessels. The latter is to be regarded as Velazquez’ contribution, for in the
testimony before the royal council in Spain, Montejo, the trusted friend of the
commander, declares that on delivering them over to the governor he received the
order to join Cortés, with the vessels, of course. His statements, and those of the
captain Puertocarrero, confirmed by the letter of the ayuntamiento of Villa Rica to
the emperor, agree that, from their own observations and the accounts given by
others, Cortés must have contributed not only seven vessels, but expended over
5000 castellanos on the outfit, beside procuring goods and provisions, while
Velazquez furnished only one third, chiefly in clothes, provisions, wines, and other
effects, which he sold through an agent to the company, the witnesses included, at
exorbitant prices. Montejo had heard that Velazquez contributed three vessels, but
whether these were exclusive of Grijalva’s fleet is not clear. He is also supposed to
have lent Cortés 2000 castellanos, and to have given twelve or thirteen hundred
loads of bread, and 300 tocinos, beside 1800 castellanos in goods, to be sold to
the party at high prices. Every other supply was furnished by Cortés, who
maintained the whole force without touching the ship’s stores, while remaining in
Cuba, no doubt. Col. Doc. Inéd., i. 487-90. Puertocarrero adds that Cortés’
liberality to men in advancing means and outfits was generally admitted. He
himself had received a horse from the commander. He gives a list of the
outrageously high prices charged by Velazquez for his supplies. Id., 491-5.
Another member of the expedition states that Cortés furnished seven vessels, and
Velazquez three, two more belonging to the latter joining the fleet afterward.
Cortés paid for all the outfit. Extract appended to Carta del Ayunt. de V. Cruz, in
Col. Doc. Inéd., i. 419-20: ‘Casi las dos partes ... á su (Cortés) costa, asi en
navios como en bastimentos de mar.’ ‘Todo el concierto de la dicha armada se
hizo á voluntad de dicho Diego Velazquez, aunque ni puso ni gastó él mas de la
tercia parte de ella.... La mayor parte de la dicha tercia parte ... fué emplear sus
dineros en vinos y en ropas y en otras cosas de poco valor para nos lo vender acá
(V. Cruz) en mucha mas cantidad de lo que á él le costó.’ Carta de la Justicia de
Veracruz, 10 de julio, 1519, in Cortés, Cartas, 8; Pacheco and Cárdenas, Col.
Doc., xiv. 37. Claiming to have no ready money of his own, Velazquez took for the
expedition 1000 castellanos from the estate of Narvaez in his charge. Gomara,
Hist. Mex., 12-13. ‘Salió de la Isla de Cuba ... con quince navíos suyos.’ Cortés,
Memorial, 1542, in Cortés, Escritos Sueltos, 310. Peter Martyr assumes that
Cuban colonists furnished the fleet with the governor’s consent, and elected
Cortés commander. Dec. iv. cap. vi. Solis, Hist. Mex., i. 61, considers that
Velazquez held only a minor share in the expedition. Montejo stated in a general
way that he spent all his fortune on joining the expedition. Cent. Am., 1554-55,
127-30, in Squiers MS. In De Rebus Gestis Ferdinandi Cortesii it is asserted that
Cortés expended 6000 pesos of his own, and 6000 ducats borrowed money,
beside what Velazquez lent him; his expenditures being in all 15,000 pesos.
Velazquez gave not one real, but merely sold goods at exorbitant figures, or made
advances at a high interest, even the vessels provided by him being transferred to
the commander under an expensive charter. ‘Sunt pretereà, multi Hispani viri boni
qui et nunc vivunt, et qui cum ea classis de qua agimus, apparabatur, aderant. Hi
in hujus causæ defensione, cujus apud Consilium Regium Indicum Cortesius est
accusatus, testes jurati asserunt Velazquium nihil omnino ex propriâ facultate in
Cortesii classem impendisse.’ This would indicate that Montejo and
Puertocarrero’s testimony was confirmed by many others. The agent, Juan Diaz,
who attended to the sale of the goods and the collection of the advances, fell in
the retreat from Mexico, and his money was lost. Icazbalceta, Col. Doc., i. 345-9.
This testimony by members of the expedition merits the foremost attention in the
question, particularly since the fewer statements on the other side are based
wholly on supposition. It is somewhat qualified, however, by the consideration that
both Montejo and Puertocarrero were stanch friends of Cortés, and that the letter
of the ayuntamiento was prepared in his presence. It must also be borne in mind
that a goodly proportion of the share attributed to him consisted of vessels and
effects obtained upon his credit as captain-general of the fleet, and also in a semi-
piratical manner. The statements in Cortés, Memorial, and in De Rebus Gestis
Ferdinandi Cortesii, indicate, beside, a hardly warranted attempt to regard
Velazquez’ contribution chiefly as a loan to the commander or to the party, his
vessels being spoken of as chartered. Another proportion belonged to wealthy
volunteers. On the whole, however, it may be concluded that Cortés could lay
claim to a larger share in the expedition than Velazquez; but the latter possessed
the title of being not only the discoverer, through his captains, of the regions to be
conquered, but the projector of the expedition. Oviedo, while believing that the
fleet belonged with more right to the governor, feels no pity for the treatment he
received, in view of his own conduct to Diego Colon. Complacently he cites the
proverb: ‘Matarás y matarte han: y matarán quien te matare.’ As you do unto
others, so shall be done unto you. Oviedo asserts that he has seen testimony
showing that Cortés and his men did not sail at their own expense, but from his
own statement it appears that the instructions of Velazquez, wherein he speaks of
the expedition as sent in his name, is the chief feature in this so-called testimony;
i. 538-9. Las Casas naturally sides with Velazquez, and estimates that he
expended over 20,000 castellanos; he had no need for, nor would he have
stooped to a partnership, at least with a man like Cortés. Hist. Ind., iv. 448.
Herrera, dec. ii. lib. iii. cap. xi., copies this, and Torquemada, i. 359, reverses this
figure in favor of Cortés.

[83] Testimonio de Puertocarrero, in Col. Doc. Inéd., i. 491. ‘Mãdo dar pregones, y
tocar sus atambores, y trompetas en nombre de su Magestad, y en su Real
nombre por Diego Velazquez para que qualesquier personas que quisiessen ir en
su compañía à las tierras nuevamente descubiertas â los conquistar y doblar, les
darian sus partes del oro plata, y joyas que se huviesse, y encomiendas de Indios
despues de pacificada.’ Bernal Diaz, Hist. Verdad., 13. Mark here the promise of
encomiendas to the volunteers. The word ‘doblar’ doubtless meant to explore or to
sail round the new islands. Bernal Diaz does not fail to observe that the royal
license had not yet arrived to warrant these proclamations.

[84] See Landa, Rel. de Yuc., 23; Tapia, Rel., in Icazbalceta, Col. Doc., ii. 554;
Fancourt, Hist. Yuc., 27, leaves out the middle sentence; Gomara, Hist. Mex., 15;
Torquemada, i. 364, and others give only the Spanish translation. Prescott says
the flag was of velvet, and attributes the sign to the labarum of Constantine, which,
to say the least, is somewhat far-fetched. Bernal Diaz, Hist. Verdad., 13, places
the motto upon ‘estandartes, y vanderas labradas de oro cõ las armas Reales, y
una Cruz de cada parte, juntamente con las armas de nuestro Rey.’

[85] ‘Se puso vn penacho de plumas con su medalla de oro.’ Bernal Diaz, Hist.
Verdad., 13. ‘Tomo casa. Hizo Mesa. Y començo a yr con armas, y mucha
compañía. De que muchos murmurauan, diziendo que tenia estado sin señorio.’
Gomara, Hist. Mex., 13.

[86] Cortés himself was very liberal in advancing money or necessaries.

Puertocarrero, loc. cit. This cavalier received a horse which Cortés bought at
Trinidad with gold fringes taken from his mantle. Bernal Diaz, Hist. Verdad., 14.
‘Dio a muchos soldados ... dineros con obligaciõ de man comun.’ Gomara, Hist.
Mex., 12.

[87] Las Casas, Hist. Ind., iv. 450-1; Herrera, dec. ii. lib. iii. cap. xi. Bernal Diaz,
Hist. Verdad., 13, relates the incident as having occurred on the way to Sunday
mass. The fool, whom he calls Cervantes, was walking in front of his master and
Cortés, uttering nonsense in prose and rhyme; finally he said in a louder voice, ‘By
my faith, master Diego, a nice captain have you chosen: one who will run away
with the fleet, I warrant, for he has courage and enterprise.’ Duero, who walked