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Lessons in Political Manoeuvring and How to Avoid Taking Action

The highly anticipated report of the Commission on race and ethnic disparities (CRED) has concluded, to much furore, that modern Britain does not have a problem with structural racism. Indeed if the report is to be believed, Britain is a global exemplar of multi-racial harmony and whilst there are ‘health disparities’ these are not the result of racial discrimination.

In drawing these conclusions the 258 page CRED report contradicts decades of evidence that structural racism is an underlying cause of health inequalities. Scientists, public health professionals, charitiespoliticians have been quick to rebut the report, citing for example, the disproportionately high rates of deaths amongst Black African and Caribbean men from COVID-19, and statistics that show that Black, Black British, Asian and Asian British babies are up to twice as likely to be stillborn as evidence of structural racism. However in the clamorous debate about whether structural racism underpins variations in death and disease the Conservative government has been remarkably quiet. The prime minister issued a short statement thanking the Commissioners, committing in the blandest of terms to building a fairer Britain and to addressing disparities. For all the noise in the media it seems that the government is off the hook: no real action is required.

Here it seems history is repeating itself. There is something about the stage management of the Commission and this report that stirs memories of previous Conservative government responses, to two much older reports on health inequalities, The Black Report (1980) and the Health Divide (1987).

Deja vu: health Inequalities in the 1980s

The report of a research working group on health inequalities (known as the Black Report) was commissioned in 1977 by the then Labour government, in part as a response to a short paper in New Society written by Richard Wilkinson. Wilkinson carefully demonstrated that the gap in death rates between the lowest and the highest social classes in Britain had increased since the 1930s despite 30 years of a ‘free’ national health service. The group’s report was completed and ready for publication in 1980, by which time the Thatcher-led Conservative government had replaced the Labour government which had originally commissioned the report. The Black Report confirmed, unequivocally, that those in lower socio-economic groups died younger and had higher rates of illness than those in higher groups.

The then Secretary of State, Patrick Jenkin was apparently horrified at the Black Report’s recommendations for improved housing, redistributive taxation and benefits, regulation of tobacco products, and improved working conditions, which would cost an ‘unthinkable’ £2bn a year. Jenkin’s advice was “to publish in such a way that it clearly distanced the department and government from the conclusions of the report”.  The report was not published in the usual manner; instead, just 260 photocopies were provided to selected media on a Bank Holiday Monday. Some 40 years later the CRED report was published late on a Wednesday evening ahead of the Easter bank holiday weekend. The Huffington Post has reported that parts of the report were ‘handed only to a select few journalists before its release’ mirroring the release of the Black Report.

History repeated itself again in 1987 when Margaret Whitehead and colleagues attempted to publish their update to the Black Report. Containing a similarly damning analysis of class inequalities in health the official press launch of The Health Divide was cancelled, rescheduled and moved amidst the confusion surrounding the disbanding of the Health Education Council who had commissioned it. Questioned about the apparent political suppression of both reports Sir Douglas Black later said he had been reluctant to believe this had occurred in 1980 but that when this happened a second time to the Health Divide he had begun to suspect ministerial involvement.

The way that all three reports – The Black Report, The Health Divide and now CRED have been stage-managed by politicians has not prevented debate or discussion of the evidence for health inequalities. Far from it. In all three cases, the attempts to downplay these examinations of health inequalities have provoked considerable public and political debate. In all three cases there have been political attempts to dilute the language – note that CRED focuses on ‘disparities’ in much the same way that the Thatcher government referred to ‘health variation’, but the argument that people from lower social classes and ethnic minorities will die younger and suffer worse health is not really disputed. Amidst the noise of the current debate, it is worth listening for the silences, of a Conservative government, who like their predecessors in the 1980s, seem unlikely to take action to stop this preventable death and disease.

The Black Report and the Health Divide were unwelcomed by the government of the day because of what they showed and what they recommended. The CRED report apparently says what the government wanted to hear. But all three reports have been carefully politically managed. In all three cases, the problem of health inequality has been rendered starkly visible, and all but a few agree that the causes are structural, but action remains to be taken.

About the author: Catherine Pope is Professor of Medical Sociology at the Nuffield Department of Primary Care Health a Sciences, University of Oxford. She is on twitter @cj_pope