Explaining health inequalities. Beyond Black and Barker - A discussion of some issues emerging in the decade following the Black report

Why does social class continue to exercise so important an influence on health? We examine the explanatory framework provided by the Black Report on 'Inequalities in Health'. We also examine a new medical theory, praised as representing a paradigmatic shift in medicine, developed by the British epidemiologist David Barker. The answers given by Black and Barker to the above question are related. And both are riddled with problems. The typology of four explanations introduced by Black reveals a number of unspoken sociological assumptions. The typology is sometimes obscuring, sometimes not helpful. The favoured explanation is also ambiguous, particularly since there is no clear idea about how poverty is translated into disease in modern society. Barker's theory that disease results from poverty-driven 'biological programming' in foetus, or in infancy, moves the focus of explanation back to the social conditions that existed when the generations now living were born. The link between childhood conditions and adult health, however, need not be biological in character. We suggest an alternative interpretation based on studying health inequalities across the life cycle and in their historical context. Go-evolution of health and social achievement could provide an explanation beyond those of Black and Barker.