If I am to start travelling again after a fractured femur, what better place to start than Stockholm, albeit the temperature was -11 C, and I was using a walking stick. The Swedes do things remarkably well. I am always struck at Swedish meetings when the chair gives a gracious introduction and welcome, summarises the state of play of the field, lays out the questions we are to address, and does all this inside his allotted ten minutes. Each of the chairs did this admirably.
Things come together. Denny Vagero took the initiative to approach the Royal Swedish Academy of Science to hold a meeting on Health Inequalities in Modern Welfare States. Meanwhile, a few years ago in Kuala Lumpur, I had given a lecture to the Interacademy Medical Panel – an organisation of national academies of medical science. After my lecture I had a meeting with the executive committee, one of whose members was from Sweden, and he was keen for Sweden to be involved in discussions on social determinants of health. Thus the meeting happened with joint sponsors.
The whole meeting was excellent.
A key question for the meeting was the so-called welfare state paradox. Johann Mackenbach said that Sweden has already implemented perhaps 95% of the CSDH recommendations, why do they still have health inequalities. More, he argues, health inequalities in Nordic countries are not narrower than elsewhere. Hence the paradox. Part of his answer, and that of Pekka Martikainen in Finland, is consumption – social differentials in smoking and alcohol. He says that trends in social inequalities may be explained by consumption, and persistence by material conditions and psychosocial factors. He acknowledges in discussion that smoking and alcohol are proximal causes – we need to look at the circumstances that give rise to them. In our language, that is the causes of the causes.
Espen Dahl, from Norway, takes a different view. He says too much of the analysis relies on mortality. Using self-reported health, he shows interactions across Europe: educational inequalities in health are narrower, the more generous in welfare spending. Similarly, a slide that we have been using, unemployment gradients are smaller with more generous welfare spending. Generous welfare spending reduces the unemployment disadvantage of having illness.
Clare Bambra, from Durham, using a post-Black report framework, explores six possible explanations for persisting health inequalities in Nordic welfare states: artefact, health selection, cultural/behavioural, materialist, psycho-social, and life course. No clear answers, but some of the last three.
For me, a high point came in the session on engaging with the political implications. Anders Jonsson is a member of the Swedish parliament for the Centre party, and chair of parliament’s Committee on Health and Welfare. He began by saying that most reports of international commissions are scarcely read and mostly ignored. Emphatically, this was not the case with Closing the Gap in a Generation, the final report of the CSDH. He said it is much discussed, still, in the Swedish parliament.
Made the trip worthwhile right there. I nearly skipped out without my walking stick. It is particularly encouraging because the Swedish government, nationally, has been reluctant to take up the social determinants issue. Discussion of the CSDH findings by parliamentarians over a four year period is a less tangible benchmark of success than setting up of a national commission but it is encouraging, nevertheless. Though there may have been some reluctance at the national government level, there is clear interest in local government. The Malmo Commission on a socially sustainable Malmo is due to report in March; and Margareta Kristenson, from Linkoping told me that she is to chair a new commission on social determinants of health, cross-party, for the region that includes Linkoping, OsterGotland. Anders Jonsson knew of the interest from local government and was strongly supportive.