Looking back at The Black Report

The publication of the latest in Michael Marmot's reports on health inequality has aroused the curiosity of people who either don't remember the original Black report on heath inequality published in 1980, or only vaguely remember it.

At the time I was working as a clerical assistant on the British Regional Heart Study (BRHS) (my 1st experience of epidemiology), but also hanging out with various left wing people who were into the politics of health. I had studied for the Bedford College MSc in Medical Sociology between 1971-2 and so had an initiation into the fact that health and life expectancy varied according to social class. It was pretty stunning to think that social inequality could actually influence your chances of a long life. The BRHS also studied some aspects of what would now be called "social determinants of health" although only as a side issue. The main hypothesis of the study was that heart disease had something to do with how hard the water was and the policy implications would be whether measures should be taken to harden water in the areas where water was softest. So social conditions and even behaviours were not the main focus, altough the study did concentrate mainly on health behaviour eventually. But it meant that both friends and colleagues were informed observers of the publication of the Black Report.

The Black Report had been commissioned by a Labour Secretary of State at the Department of Health and Social Security (DHSS) , David Ennals, after he had read an article in New Society by Richard Wilkinson. It happened at the time that the DHSS had become disillusioned with the fact that the Medical Research Council (MRC) spent too much money on obscure diseases and genetics (yes, already) and so removed 30% of the MRC budget to be spent on "cinderella specialties" such as the social factors in health and illness. The rumour was that Sir Douglas Black, a very senior medical figure, had been given the funding for the Black Report to make up for the loss of power of the medical royal colleges over the health budget.

In those days, scientists interestd in health inequality had to contend with 2 major strands of thought whose implications were that it did not exist at all (you might say it was fake news). One of these held that health inequality was a normal part of a kind of Darwinian process of selection: fitter people found themselves in the more advantaged social classes because they were fitter & more intelligent, and it was this fitness that also made them healthier (nowadays we might draw a DAG for this). The 2nd was the "artefact explanation", which held that the appearance of health inequality in the official statistics was due to statistical artefacts which I wont go into unless anyone asks me.

So it was really quite an achievement that the Black Report did result in the widespread acceptance that health inequality was real and had something to do with social conditions (although some health economists continued to argue against this, even to this day). And the explanations that Black et al. accepted were (1) "behavioural cultural", i.e. there was something in the culture of the social groups with worse paid, more arduous jobs that encouraged unhealthy behavour (2) "material" explanations, which focused on the actual biological effects of poverty, poor housing, arduous working conditions and stress.

But I know what many people are interested in is the reception of the Black Report. . It was published soon after the election of a Tory government. Only 260 copies were produced, in a kind of cyclostyled typescript form not even properly printed, released on the Friday before an August Bank Holiday.  It is a huge doorstep of a thing, and those of us who managed to get our hands on a copy still treasure it greatly. There was little fanfare. I don't remember Sir Douglas going on the TV though I hardly watched any in those days. A great account of the emergence of the Black Report can be read in the Introduction to

P Townsend, N Davidson , M Whitehead "Inequalities in Health" (Penguin 1988)

A good summary is:

D Blane "An assessment of the Black Report's 'explanations of health inequality'" Sociology of Health and Illness 1985 7; 3: 423-445.

The subsequent story of the inter relationship between research and policy in this area is documented in :
K Smith "Beyond Evidence Based Policy in Public Health :The Interplay of Ideas" (Palgrave, 2013)

The Black Report itself had a lot more influence on research than on policy. Especailly after it was updated as Margaret Whitehead's "The Health Divide". But unfortunately health inequality then became a kind of bandwagon where anything that seemed to show the importance of health behaviours of or "Selection" got published in high impact journals and other papers showing a bigger influence of material factors, often more methodologically complex due to defensiveness, went unremarked.

Partly as a result of this, all the well meaning hype that followed the Health Divide  and the subsequent Acheson Report just fizzled out into "lifestyle drift", that is, in the end, more preaching to poorer people about their "behaviour".

This was where I started from early this morning, as I noticed (& tweeted) that this time round only a single journalist no one ever heard of had written that the recent plateau in life expectancy (with falls in the poorest women) was due to their fact that they are too fat and in any case live quite long enough. It has become quite unrespectable, both for academics and for informed opinion leaders, to blame health inequality on behaviour. I was impressed by this and thought, well, maybe those of us who have worked on this stuff for the last 40 years didnt totally waste our time.