The Blackwell Companion to Medical Sociology

Health and Social Stratification 87
ities by social status. A death of class development cannot be found, at least so
far, for morbidity and mortality in advanced societies. Regarding the persistence
of health inequalities they are likely to continue in the foreseeable future. Therefore,
health inequalities need to be given a high priority in the future medical
sociological and epidemiological research as well as political agenda.
Havingemphasized the universal patterningof health inequalities it is equally
important to recognize that there are variations between countries and over
time. Additionally, for example, gender and life course modify health inequalities.
Whether occupational social class differences in health will be transformed
outside the labor market in the future and whether a stricter polarization of
health status will develop between the employed and non-employed as the
Norwegian evidence suggested, remains a hypothesis to be tested in other
countries as well. The universal patterningof health inequalities may have partly
common reasons in hierarchically organized societies. However, to understand
the variation between countries, concrete analyses and country-specific explanatory
factors are needed.
Explanations for health inequalities have included a variety of factors which
should not be taken in an exclusive way, as suggested by Macintyre (1997) in her
distinction between the ``hard'' and ``soft'' versions of explanations. Four particularly
important areas of factors, which all provide partial explanations for
health inequalities and their size, can be identified on the basis of current
evidence. First, livingconditions at work (Lundberg1991) and at home (Bartley
et al. 1992; Arber and Lahelma 1993; Hunt and Annandale 1993) contribute to
health inequalities and their size. Secondly, health behaviors, such as smoking
(Cavelaars et al. 1998d), drinking(MaÈkelaÈ et al. 1997), and diet (Pekkanen et al.
1995; Roos et al. 1998) are all factors which contribute to health inequalities. A
third area includes early influences on health: economic and social conditions in
childhood have a bearingon adult health inequalities (Lundberg1993; Rahkonen
et al. 1997a). Fourthly, selective social mobility (Lundberg1993; Rahkonen
et al. 1997b) and discrimination, for example, at the labor market (Bartley and
Owen 1996; Dahl and Birkelund 1999) also play a role in the production of
health inequalities. In other words, health, directly or indirectly, can influence
people's placinginto different social positions which then contributes to health
inequalities between social status groups.
The patterningof observed health inequalities is usually very clear and the size
of absolute health inequalities often large. For example, life expectancy at age 35
among Finnish men with higher education is close to six years longer than that
for men with basic education only (Martikainen and Valkonen 1995). A large
part of this gap is in principle avoidable. In other words, narrowing the health
gap between social status groups provides a large potential not only for improvingequality
in health, but also producinga substantial improvement in the
overall public health. If health amongthe worst off groups could be improved
closer to the best off groups, this would bring about advantages to the population's
health so large that it is difficult to imagine other equally effective policy
options. At the international level the size of health inequalities shows substantial
variation. This, in turn, suggests that countries with particularly large health