RHP&EO is the electronic journal of the International Union for Health Promotion and Education

Social determinants of health: Their relevance in the European context

Martin Bobak, David Blane, Michael Marmot
International Centre for Health and Society,
Department of Epidemiology and Public Health, University College London, London United Kingdom

1. Mortality in Europe: things are getting better but not everywhere

As a whole, mortality in Europe improved since WWII. Between 1970 and 1990, European average life expectancy at birth increased by 2.6 years, from 70.5 to 73.1 years (WHO Regional Office for Europe, 1997). However, the improvement has not been equal across Europe. The steady improvement in western Europe contrasted sharply with the stagnation and decline in the East. Similarly, within western populations, not all groups benefited equally from the progress, and some age groups even recorded increasing death rates. This paper will focus on social factors influencing the mortality of individuals and populations, and on the role of macroeconomic trends.

2. Three types of inequalities

At least three types of health inequalities can be distinguished in today Europe: international inequalities, socioeconomic inequalities within countries, and gender differences in health within countries.

2.1. International differences in mortality (East-West gap)

The recently published Atlas of Mortality in Europe (World Health Organisation, 1997) demonstrates the striking differences in mortality in the European region. In general, the more east we look, the higher mortality rates we see. This gradient is stronger among men, and is apparent for most major causes of death. If European countries are ranked by their mortality rates, a clear division emerges which clearly copies the former political division of Europe (Bobak & Marmot, 1996).

During the 1950s and 1960s, health, as measured by life expectancy, improved throughout much of Europe. This improvement had little respect for political boundaries or ideologies. In the late 1960s and 1970s this began to change. For the most part, life expectancy continued to improve in the countries of western Europe and failed to improve, or even declined, in central and eastern Europe (CEE), including the former Soviet Union (FSU). By 1989, there already was a striking gap in life expectancy between east and west (Bobak & Marmot, 1996). What was notable about this trend was the similarity among CEE, except for Yugoslavia and Albania (Gjonca & Bobak, 1997). After 1989, differences among individual countries in the region became more evident.

The causes of these international differences are complex. Part of it may be related to the fact that different countries are at different stages of the epidemiological transition. However, this is only part of the explanation. Even countries which were at similar stages until the 1950s diverged dramatically. For example, Austria, Czechoslovakia and Hungary, parts of one empire until 1918, had similar mortality rates until the 1950s. Since then, however, life expectancy diverged. Austria has followed the western pattern of continuous improvement, but life expectancy in Czechoslovakia and stagnate or declined (figure 1) (Bobak & Feachem, 1992). Similar trends have been reported for the Baltic states and Finland (Hertzman, 1995), or for Eastern and Western Germany (Chenet et al., 1996).

This pattern is consistent with the conceptual framework developed by John Powles (Powles, 1992). He has argued that there are several paths from high to low mortality (figure 2). According to his model, most western countries followed a "central path" to initially intermediate levels of non-communicable diseases; European Mediterranean countries experienced a fast decline in infectious disease while preserving their low levels of non-communicable disease; and Eastern Europe experienced high levels of non-communicable diseases (Powles, 1992).

The current unfavourable mortality and health status of CEE and FSU indeed resembles an unsuccessful epidemiological transition, at least its fourth stage (the "age of delayed degenerative diseases" (Olshansky & Ault, 1986)). While CEE and FSU reduced successfully mortality from infections, they were very soon caught by an epidemic of non-communicable diseases. However, this cannot be simply considered a natural cause of epidemiological transition. While mortality rates in some parts of the region have traditionally been higher than in the West, this was not a universal phenomenon (see the examples above). The roots to the postwar trends are related to political developments in individual countries. Why the epidemic of non-communicable diseases was controlled so rapidly in the West? Why it was not so in the East? Social and economic conditions seemed to play a major role in the speed how rapidly the society can leave the unfavourable phase of transition.

2.2. Socioeconomic inequalities within populations

There is rich literature on socioeconomic differences in mortality and other health outcomes within western populations; emerging evidence also documents the social gradients in health in central and eastern Europe.

A variety of indicators have been used to classify people according to socio-economic status. In Britain, since the early part of the 20th century occupations have been grouped into social classes. This was seen as a means of inferring social position in a manner that paid regard to culture as well as income (Marmot et al., 1995). Since 1921, the figures have shown persisting inequalities in mortality according to this social class measure. Mortality differentials by socio-economic status have also been observed with other indices: education, housing tenure, car ownership, income, characteristics of areas that relate to material deprivation (Goldblatt 1990; Eames et al 1993; Wilkinson 1992).

There has been considerable interest in comparing the magnitude of inequalities in different countries. This has not proved straightforward in large part because of methodological differences, for example, a comparison of social class differences in mortality between Sweden and England and Wales showed narrower differences in Sweden (Vagero & Lundberg, 1989). A later comparison showed that differences in Sweden were wider than in other European countries (Mackenbach et al., 1997). This occasioned some debate. Apparently, if absolute differences in mortality were compared, rather than relative differences the social gap in Sweden was relatively narrow (Vagero & Ericsson, 1997). A similar point has been made by Wilkinson (1992) examining infant mortality.

There have been fewer data on morbidity but now, a range of studies document clear socio-economic differences in morbidity (North et al., 1993; Marmot et al 1997; Blaxter 1987).

The recent research is remarkably consistent in the finding that socioeconomic inequality in health in CEE are as large as, or larger than, in western countries. Several examples will illustrate this observation. They related to mortality, cardiovascular risk factors, birth weight, and self-rated health.

Kunst has analysed mortality by occupation type (manual vs. non-manual) and by education (upper secondary and higher vs. lower than upper secondary) in Czech Republic, Hungary and Estonia (Kunst, 1997), and compared the results with several western countries. The results show that the relative differences in CEE are larger than in the western Europe.

In our study of cardiovascular diseases risk factors in the Czech Republic, we were able to examine the educational gradient in cardiovascular diseases risk factors, and to compare it with western European results, specifically with Finnish data. The comparisons revealed that the gradients in mean total cholesterol, diastolic blood pressure, body mass index and smoking prevalence in Czech and Finish men and women. For cholesterol, smoking and body mass index (women only) the educational differences were larger in Czechs. When gradients in other risk factors were compared with the British civil servant (Whitehall II), similar findings were observed (Bobak, 1996).

Koupilova et al (1998) socioeconomic difference in birth weight in Czech Republic and Sweden in the period 1989-91 (table  1). Again, social variations were larger in the Czech Republic.

The final example relates to self-rated health. We compared social gradient in eastern European populations showed in figure 3 with those found in national samples of western countries (Kunst, 1997).   With the exception of both Polish samples, the results are broadly similar between CEE and western Europe, suggested a considerable gradient in self-rated health.  It may be interesting that in a preliminary ecological analyses, measures of material inequalities were also related to self-rated health, above individual measure of material deprivation (Bobak et al, unpublished).  

Apart from educational differences, marital status appears an important determinant of health in the former communist populations. Analysing routine mortality data from Hungary and Poland,  Hajdu et al. (1995) and Watson (1995), respectively, observed that unmarried men are at particularly increased risk of death. This was also found in Czech data (Blazek & Dzurova, 1997). Subsequent cohort analysis of the Warsaw MONICA sample not confirmed these observations, but also suggested that unmarried men with low education are the most vulnerable  group (figure 4).  Whether this is due to their material circumstances, as suggested by  Hajdu  et al (1995), or to their social isolation and absence of vital social networks, as speculated by Watson (1995), remains an interesting topic for future research.

 The existence and magnitude of health inequalities in CEE raises an important issue: even decades of focused and often ruthless pursuit of material equality goals did not reduce health inequalities. Possibly, the inequalities along material axis have diminished; but they appeared even stronger along the educational axis. As health inequalities in CEE will be better understood, it is possible that other important dimensions will be identified. For example, ethnic minorities emerge as populations with particularly high mortality (Mann, 1992; Toyoshi, 1997).

2.3. Social inequalities within countries and the east-west differences may be related.

Within all western societies, there are socioeconomic gradients in most diseases. The reasons for these gradients are not clear but similar set of explanations have been suggested as those given above for the east-west gap. We have speculated that the east-west gradient may in fact be analogous to the socioeconomic gradient within western societies (Bobak & Marmot, 1996). Figure 5 provide some support for this hypothesis. The figures are based on the observation that different diseases show different relation to socioeconomic status. For example, breast cancer within western societies is usually more common among women from higher social groups, while lung cancer is more common among lower social groups. The figure 5 shows that for death rates from different causes the east-west ratios and social class gradient within England and Wales are markedly correlated.

2.4. Inequalities are widening.

2.4.1. Western populations

In most western populations, available data suggest that inequalities in health are increasing. This is illustrated, for England and Wales in Figure 6 (taken from Drever & Whitehead, 1996). Social class differences in mortality from ischaemic heart disease were present in data collected from the 1971 census. Over the next two census periods the gradient in mortality became steeper. The figures for mortality from suicide are striking. In 1971 suicide mortality was higher in social class 5 but there was little social gradient among the other social classes. By 1991 this had become a steep inverse social gradient.

2.4.2. Eastern Europe

Inequalities in health increase in the east too. It  has been  documented that  the transition  has had  large impacts on living standards (table 2), and these impacts are likely to be divided unequally in the society. Data from UNICEF and the World Bank suggest that there was a relatively rapid increase in income inequalities since 1989 (World Bank, 1996; United Nations Children's Fund, 1997). These macroeconomic data are supported by a series of micro censes conducted by a Czech team to study the impact of transformation on the society (but not including health). The team found a remarkable divergence in income by educational group  (Machonin & Tucek, 1996), while until the end of  1990s , education was only weakly correlated with income. In this context, it is not surprising that the few available data all suggest a divergence in health status between social groups.

National data from the Czech Republic revealed that the gradient in mortality steeper between 1990-91 and 1995 for marital status, and for education between 1980-81 and 1995 (Blazek & Dzurova, 1997). In the case of mortality,  the widening  of inequalities was related to both improvement in the advantaged groups and worsening in the disadvantaged  groups (table 3).    The dramatic increase in mortality of least educated men (by 77%) is alarming, and may indicate that a relatively large segment of the society is highly vulnerable to the social changes.

This widening of inequalities has been also observed in other countries. Forster (unpublished) examined social differences in mortality between Budapest districts between 1980-83 and 1990-93. He found that the while mortality from most causes declined in the most affluent districts over the last decade, they increased in the most deprived. Consequently, the mortality gap between the most and least affluent areas increased by some 13%.

Recent data from Russia also showed the increase in educational differences in mortality between 1988-89 and 1993-94. Mortality in men with better education increased by 35% but among men with lower education the increase was 57%. Among women, the mortality increases were 8% (better educated) and 30% (less educated) (Shkolnikov, 1997).

Data on trends in outcomes other than mortality are sparse but it seems that the gradient in cardiovascular diseases risk factors and behaviours is also increasing. The Czech MONICA study found that educational gradient in most cardiovascular diseases risk factors increased between 1985 and 1992 (Bobak et al., 1997). In contrast to mortality analyses shown above, however, the widening of inequalities in risk factors was caused mainly by improvement in the higher educational groups, not by worsening in the lower groups; one exception was smoking in women where the increase in inequalities was due to rise in smoking among women with lower education.

An recent analysis of birth weight and infant mortality in the Czech Republic also shows widening of the social differentials (figure 7) but, as with the cardiovascular diseases risk factors in the Czech Republic, it seems to be related more to improvement in the higher social groups than to worsening in the lower groups.

These trends of widening social inequalities in CEE and FSU are worrying and require not only more research but also a policy response.

2.5. Gender differences

In all European countries, life expectancy of women is higher than that of men, in all age groups. It is interesting that this difference is related to the overall life expectancy: the longer the life expectancy, the smaller the sex difference; again, the east-west difference in evident (Figure 8) (Bobak & Marmot, 1996b). In Russia, with the shortest overall life expectancy, life expectancy gap between women and men was unbelievable 13.6 years in 1994, the largest in the world (Heleniak, 1995). The explanation for this phenomenon is not clear but it suggests that women were less affected by whatever were the causes of high mortality in the CEE.

In addition, the rapid changes in the gender gap suggest that only a part of them is genetic; much of them, however, seem to be determined socially. The gender gap in mortality is the more intriguing that most indicators of morbidity are higher in women than in men. This is an important area for future research.

3. The causes of inequalities

3.1. Similar diseases contribute to all types of inequalities

Rare diseases, even if they show large social, gender of east-west gradient, would not contribute to the all cause differences less than common diseases showing less steep gradient. For examples, although diseases such as tuberculosis or even lung cancer show large east-west differences, the main contributors to the gap are cardiovascular and external causes. Calculations by the WHO have shown that of the 6.06 year gap in life expectancy between CEE/FSU and Western Europe in 1992, nearly 3.3 years were due to cardiovascular diseases and 1.4 years to external causes of death (Bobak & Marmot, 1996). The largest part of the gap originated in the age group 35-64 (43%) but almost a quarter (23%) originated in those aged 65 and more. Mortality in infancy, on the other hand, contributed only 15% of the gap. Virtually identical results were obtained when death rates were compared between the former Soviet Union and the United States (Kingkade & Boyle Torrey, 1992), former Eastern and Western Germany (Chenet et al., 1996) or several central European countries (Chenet et al., 1996).

The contribution of individual diseases to socioeconomic inequalities in all cause mortality is similar. In the Whitehall study of British civil servants, there was a social gradient for most of the major causes of death. This was particularly steep for mortality from chronic lung disease and lung cancer, but were also strongly in evidence for mortality from cardiovascular diseases and external causes of death (Marmot et al., 1984; Marmot et al., 1987). As in national statistics the gradient was not seen for colon cancer. The contribution of different causes of death to the gender gap is similar to the above pattern.

3.2. Causes of inequalities in health

Socio-economic differences in health are a manifestation of social and economic determinants of health. The question is how these determinants act to cause ill-health.

The phenomenon we are seeking to explain is not the link between poverty and ill- health but inequality and health. Not why people in poverty have worse health but the social gradient. This has led to two types of discussion.

3.2.1. Absolute poverty/deprivation

First, the gradient can be accounted for by degrees of deprivation. In other words if people at the bottom have worse health because of poor housing, cold, infections, malnutrition, polluted environment, then these same factors could account for the gradient. Either because there are degrees of exposure to such material deprivation or because people are exposed to poverty for varying periods of their lives. The length of exposure may relate to position in the hierarchy.

3.2.2. Relative deprivation

The second type of explanation relates to relative deprivation. What is important here is not the absolute deprivation that causes ill-health, but the concept of unequal distribution of the fruits of society. This is a psycho-social concept. If having a set of clothes reserved for special occasions, a night out once every two weeks, or a hobby or leisure activity are seen as necessary for life, then not having these things is to be in poverty. There is clearly a link between material deprivation and relative poverty. Lack of income leads to an inability to afford the items that are defined as necessary prerequisites.

Psychosocial factors may act in more subtle ways importantly connected to position in the social hierarchy and hence to inequality but less obviously connected to material deprivation. These include features of the environment in which people live and work and consequent effect on psychological processes. There is much speculation about the importance of social capital which embraces the concepts of trust and social participation. There is good evidence for the importance of the related concept of social supports. Social integration and collective social efficacy are perhaps different ways of describing and measuring the same phenomenon.

There is a body of work relating to the importance of control. This may be control in the work place which relates to the organisation of work or personal control and mastery.

A third area which relates to the first two is training in life skills, sometimes described as coping resources. This relates to childhood environments. Children, appropriately stimulated, and encouraged to develop skills of language, mathematics and active problem solving are likely to fare better through the educational system and in subsequent life careers.

Just as these two types of explanation, material and psychosocial, should not be thought of as mutually exclusive, they are not exclusive of other types of explanation. Health behaviours, smoking, patterns of nutrition, alcohol, physical activity, risk taking may be thought of as downstream of these other determinants. Valkonen et al (1991), for example, found large contribution alcohol to socioeconomic inequalities in mortality in Finland. That is one mechanism by which these psychosocial factors may operate to cause ill health is through an effect on these health behaviours. On the other hand, in the Whitehall II study, classical risk factors explained only a smaller part of the social gradient in cardiovascular mortality (Marmot, 1989; Rose & Marmot, 1981). There may in addition be more direct pathways, often thought of as "stress", through which psychosocial factors may influence neuroendocrine and immune pathways to affect disease risk.

Is medical care an important factor mediating social and economic determinants of health? There is evidence from European countries of inequity in access to good quality medical care. This will exacerbate the problem of inequalities in health. Lack of medical care is not however the cause of social inequalities in major causes of death and illness such as accidents and violence, heart disease, chronic lung disease and cancer, and mental illness. One way of thinking about medical care is that it is part of social capital. Access to good quality, humane and cost effective medical care is a necessary feature of a civilised society.

3.3. Causes of inequalities in health: the east-west mortality gap

Both concepts are also relevant for the international inequality in health. The broad determinants of health include health care, life style, behaviours and diet, environmental pollution, socioeconomic environment and psychosocial factors. All of them have contributed to some, although different, extent to mortality pattern and health status in CEE and FSU, and their contribution has been extensively reviewed elsewhere (Bobak & Marmot, 1996a; Bobak & Marmot, 1996b). Briefly, environmental pollution and medical care probably played only a modest role in the mortality trends. Life style, behaviours and diet probably had a more substantial impact, and smoking and alcohol seem to have the largest identifiable impact. For example, Peto at al estimated that about a half of the east-west gap was caused by smoking (Peto et al., 1992); Leon and colleagues believe that much of Russian mortality is due to alcohol (Leon et al., 1997). However, even if these views are correct (and they do seem to be overestimates), the next question is: why people in CEE and FSU have been smoking, drinking and eating unhealthy diet?

It is likely that the social environment existing in CEE and the FSU has a strong influence on psychosocial well-being; this would result in poor life style and diet (Bobak & Marmot, 1996). Psychosocial factors have been shown to have a direct effect on health via neuroendocrine pathways (Steptoe, 1997); part of the poor health in CEE and FSU could be due to this direct effect. Psychosocial factors also influence health behaviours and diet; these may "mediate" the rest of the effect of the political, social and economic environment on health. While not important on the biological level, clarification of the hierarchy of causes is essential in designing and promoting policies to improve the currently unfavourable health status.

4. Macro trends

Europe will face many difficult challenges in the next century. Some of them are legacies of the past, others are related to new developments. This section will address some of them.

It is difficult to generalise about an area ('Europe') which stretches from Azerbaijan to Portugal and from Russia to Italy. What follows is based largely upon British data. Most of the trends which are judged important on the basis of these data probably apply equally to the countries of the western European heartland. The peripheral regions of countries like Italy and Spain, together with the countries of central Europe, are probably less affected as yet by these trends. They are, however, likely to move in a similar direction during the early decades of the twenty-first century, although the trajectory of each will be influenced by its distinctive past. Whether, when and at what speed the remaining countries of 'Europe' will be affected by these changes is uncertain; perhaps, optimistically, by the middle of the next century.

4.1. Socio-demographic changes

The challenges which will face the makers of health policy during the twenty-first century will be influenced by the social determinants of health and the socio-demographic context in which they occur. Almost every location within the socio-demographic structure (women's and men's roles; childhood and adolescence; old age; families and households) is being changed profoundly. Each of these changes may have material and cultural effects which are likely to impact on health and formal and informal health care.

4.1.1. Women's role

Life expectancy is increasing and the birth rate is falling. Consequently the proportion of women's lives which could be devoted to child rearing is decreasing. The life expectancy at birth of British women was 49.0 years in 1901, 73.6 years in 1971 and 78.7 years in 1991(Social Trends 1995). The number of births per 1000 women aged 15-44 years in Britain was 114.9 in 1901, 84.2 in 1971 and 62.0 in 1981 (Social Trends 1983). The total period fertility rate (the mean number of children which would have been born per woman if women experienced the age specific fertility rates of the period in question throughout their childbearing lifespan) was 2.40 in 1971, 1.82 in 1981 and 1.76 in 1993 (Social Trends 1995). Even if cultural norms prescribe that women should devote themselves to child rearing it is no longer possible for this activity to fill more than a small fraction of their lives.

Women's labour force participation rate is increasing. Fifty-two per cent of British women aged 20-59 years were in paid employment in 1971, working either part-time or fulltime (1971 Census). In 1991 the comparable figure was 65 per cent (1991 Census). If the reference age range is widened to include adolescence, 72 per cent of women aged 16-59 years are in paid employment or seeking work; 35 per cent working fulltime, 30 per cent part-time and 7 per cent seeking work (General Household Survey 1993). Employment tends to be part-time when children are dependent.

4.1.2. Men's role

Men's involvement with the world of paid employment is becoming less; a trend which is particularly marked towards the end of the working life. Thirty-one per cent of men aged 65-69 were still in paid employment in 1971, despite being over the statutory retirement age (1971 Census); by 1991 the proportion had more than halved to 13 per cent (1991 Census). An even greater reduction has occurred during the final decade of the normal male working life. Nine per cent of British men aged 55-64 years had left the workforce due to permanent sickness or early retirement in 1971; in 1991 the comparable figure was 32 per cent. The rate of early labour market exit was virtually identical for non-manual and manual male employees (1991 Census 2), although the former were more likely to leave through early retirement (Laslett 1996) and the latter through long term unemployment disguised as permanent sickness (Laczko & Phillipson 1991) .

These changes in the labour force participation rate of both men and women mean that fewer men are in the position of being the family or household's sole bread-winner. In household with dependent children, for example, the man is sole earner in only 25 per cent; both adults are in paid employment in 60 per cent, the woman is sole earner in 5 per cent and neither adult is in paid employment in 10 per cent (General Household Survey 1993).

4.1.3. Childhood and adolescence

The length of adolescence is increasing due to the longer periods of time being spent after the statutory school leaving age in training and further and higher education. Forty per cent of British 18 year olds were in some type of education or training in 1991, as were 20 per cent of 20 year olds (1991 Census, 1). If completion of education and training and entry to the labour market marks the transition from adolescence to adulthood, then this social adulthood is increasingly delayed for many young people.

At the same time biological adulthood, as indicated by puberty and menarche, is occurring at younger ages (Zacharias & Wurtman 1969). Societies which are sufficiently affluent materially to lower the age of biological adulthood would appear to be also sufficiently complex that prolonged education and training, and hence delayed social adulthood, is required. The ages of biological and social adulthood increasingly diverge and financial dependence on parents is prolonged.

4.1.4. Elderly

Those aged over the female statutory retirement age of 60 years and the male statutory retirement age of 65 years comprise some one in five of the British population (Social Trends 1995). As a proportion of the population the rate of increase is highest among the very elderly. Those aged 80 years or more form 5.4 per cent of the female population and 2.4 per cent of the male population, compared with 2.1 and 1.0 per cent twenty years earlier (Social Trends 1983). The very elderly are predominantly female; the combined effect of gender differences in life expectancy and gender differences in age at marriage mean that eight years of widowhood is the statistically normal final phase of a woman's life.

 4.1.5. Family and households

Urban regeneration schemes, migration to find employment and career geographic and social mobility mean that the local extended family (kin nuclear families within close proximity) is being replaced by geographically dispersed nuclear families. Only one-quarter of all households consist of two adults and dependent children and in the majority of these households both adults are in paid employment. Households are polarising into dual-earners ('work rich') and zero-earners ('work poor'). Lone parent households are becoming more prevalent due to higher divorce rates and lower marriage rates; the higher divorce rate combined with subsequent remarriage increases the prevalence of reconstituted families.

4.2. Recent socio-economic changes

4.2.1 Material circumstances, the social wage and community

Material circumstances have improved for most western Europeans since 1970. Real wages have increased, residential crowding has decreased, central heating has become more widespread, diets have become more varied, holidays often in other countries are now normal and the range and ownership of consumer durables has widened steadily (Hutton 1995). The experience of most central and eastern Europeans has been somewhat different. Their material circumstances changed little between 1970 and the late 1980s and have deteriorated since 1990. During this time in all European countries, and especially since the mid-1980s, inequalities in material circumstances have widened (Goodman et al 1997). A proportion of all European populations, ranging from around 10 per cent in western Europe to perhaps 50 per cent in eastern Europe, has experienced a fall in their standard of living.

The social wage of State-provided welfare and services has also changed since 1970. After some growth during the 1970s, attempts have been made to limit expenditure on them and to encourage their private provision through the market (Loney, ed. 1987). This has been accompanied by a lessening of social cohesion. Closure of much heavy industrial plant has dispersed local communities and encouraged geographic mobility in search of employment. Increased participation in higher education and subsequent career demands have also encouraged geographic mobility. At the same time active participation in voluntary organisations has fallen, to be replaced by a privatised way of life and nominal membership of pressure groups.

4.2.2. Labour market, child rearing and migration

The reorganisation of production is producing a compression of the years of working life. The trend towards greater participation in further education, higher education and training is likely to continue and the normal age of labour market entry is more likely to be in the mid-20s than during adolescence. At the other end of working life, paid employment after the statutory retirement age is becoming rare and labour market exit at 55 years, into either permanent sickness or 'Third Age' early retirement, is becoming more common. The growing compression of working life to, say, ages 25 years to 55 years has been accompanied by increased intensity of work, in the form of closer supervision, heavier work loads and longer hours of work, and by increased female labour force participation, so that most women of working age and, in most households, both adults are now in paid employment.

These labour market changes have important implications for child rearing because the period of fertility and child care coincides with both parents' highly pressured commitment to paid employment. This is the context in which fertility rates are falling and, if it were not for the contribution of single mothers, western European populations would not be replacing themselves. Migration from outside Europe and from eastern to western Europe offers a straightforward mechanism for correcting any population deficit.

5. Implications for health and health care

The emerging mixture of material circumstances, social wage and community cohesion will probably differ from that which provided the backdrop to the general improvements in health of the earlier post-war period. The effect on health of this new mixture is difficult to predict, but it will provide a natural experiment of the relative importance of its various components. The following are among the issues which may prove important in both eastern and western Europe, and may underlie convergence, or divergence, of health status across Europe.

Health of elderly. Diseases such as Parkinson's, Alzheimer's and CVA, which primarily afflict the elderly, will form an increasingly large proportion of clinical work.

Women's health The shift in the distribution of demands on women's bodies, from child rearing in early adulthood to paid employment plus domestic labour throughout life, may erode women's life expectancy advantage over men and produce a morbidity profile among women which increasingly resembles that among men.

Health in early adulthood The growing divergence between biological and social adulthood may foster lone motherhood, hazard exposure in the unregulated informal economy and a youth culture which includes psychotropics and risk taking.

Informal health care The majority of care during sickness and disability is provided by informal carers who in the main are family members. The provision of informal care will be rendered problematic by the development of work rich, geographically dispersed nuclear families.

Social inequality in health, both within and between populations, will continue to pose a major challenge to public health in Europe in the next century. New approaches will be requited to contain this challenge. The current debate initiated by the WHO is the necessary first step in this process.

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Table 1

Mean birth weight in the Czech Republic and Sweden and differentials by maternal education and marital status; births registered in 1989-1991 (from Koupilova et al., 1998).

* Adjusted for maternal age and parity, and sex of the child.
All p-values for trends and differences less than 0.001.

Table 2

Changes in social indicators in CEE and FSU between 1989 and 1994, from UNICEF (United Nations Children's Fund, 1995).

Table 3

Difference  in mortality and mortality ratios (RR) by marital status in 1990-91 and 1995, and by education in in 1980-81 and 1995. From  Blazek & Dzurova, 1997.

List of figures

1. Trends in life expectancy in Austria, Czechoslovakia, and Hungary 1950-1995

2. Paths to low mortality (J. Powels model)

3. Self-rated health in selected countries

4. Polish MONICA: social status and mortality

5. Scatter graph comparing cause-specific gradients in mortality: east-west gradient and social gradient in England and Wales

6. SMRs, by social class, males, England and Wales, 1970-72, 1979-80, and 199193, for IHD and suicide.

7. CZ bwt trends by education

8. Gender gap in life expectancy in Europe

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