• Inequalities SI

Europe's politicians greeted the new millennium with a sense of optimism. Meeting in Lisbon, in March 2000, the heads of government agreed on a strategy to make the European Union ‘the most competitive and dynamic knowledge-based economy in the world capable of sustainable economic growth with more and better jobs and greater social cohesion’.1 The wording was important. The Lisbon Agenda, as it came to be known, sought to ensure that all of Europe's citizens would benefit from economic growth, thereby avoiding the stark inequalities that accompanied growth in other parts of the world where the benefits were concentrated in the hands of a few.

Almost a decade later, with Europe's economies in the depths of the most severe recession in living memory, the Swedish Prime Minister concluded that ‘Even if progress has been made it must be said that the Lisbon Agenda, with only a year remaining before it is to be evaluated, has been a failure’.2 Europe's leaders now focused their attention on getting out of the financial hole they found themselves in.

Their approach involved carrots and sticks. The carrots came in the form of a European Financial Stability Facility,3 which used the collateral of the European Union, Eurozone countries and the International Monetary Fund to raise money that could bale out those member states facing the greatest crises. The stick was the requirement that member states implement austerity programmes to reduce their deficits. However, these measures can only act as first aid, tiding countries over in the short term. It is also necessary to devise a strategy for the long term, which will place Europe once again on a trajectory of growth. This strategy is ‘Europe 2020’, agreed in March 2010 and designed to achieve ‘smart, sustainable, inclusive growth’ with greater coordination of national and European policy. Success will be measured against five key targets: increased employment; increased investment in research and development; reduced greenhouse gas emissions; more adolescents staying on at school; and fewer Europeans living in poverty. Crucially, although achievement of these targets will, indirectly, have beneficial effects for health, they contain no direct reference to improving the health of Europe's citizens.

This is why the accompanying paper by Mackenbach and colleagues4 is so important. Building on earlier work, initially in low-income countries and subsequently in Europe, that demonstrates the contribution of health to economic growth, they quantify the cost, in both human and economic terms, of the inequalities in health that exist within Europe. At a time when some governments are questioning the affordability of European health systems that are faced with ageing populations, Mackenbach and colleagues show how improving the health of those in the bottom half of the health distribution to that already achieved by the top half would save about 20% of the overall healthcare budget. This is far in excess of anything promised by even the most ambitious programmes of health sector reform. But this is only the beginning, as they also calculate that it would save about 15% of social security benefits while boosting labour productivity to the extent of about 1.4% of gross domestic product (GDP). Thus, even on conventional economic grounds, the case for further action on some of the major determinants of health inequalities, such as tobacco, seems unassailable, a view accepted almost a decade ago by the Treasury in the UK,5 although sadly forgotten by the current government.

This research does, however, raise a wider question. What should the goals of governments be? Economic growth is important but, although it often seems to be forgotten, is only a means to an end. Rather, we must ask what economic growth allows us to do. Although often equated with greater human happiness, a growing body of literature has shown how the two measures have become disconnected. In the USA, for example, where growth in GDP has increased considerably in the past 2 decades, alternative measures of welfare, such as the Genuine Progress Indicator6 that considers the costs of certain components of GDP, such as crime, have plateaued. Worse, economic growth can create casualties, with those adversely affected suffering disability and even premature death. The value of their losses must also be taken into account and, when they are, as Mackenbach and colleagues show, they account for a massive 9.4% of GDP every year.

As Europe's governments put in place measures to reduce their deficits, it is essential that they take account not just of the aggregate consequences for their countries but also their distribution. Economic crises always create winners and losers.7 The challenge is to ensure that the policy responses do not exacerbate the existing inequalities. Otherwise they risk increasing the cost, both human and economic, for society as a whole in the longer term.