Public Health in Europe

A special feature on Public Health in Europe.

Health is a major political, cultural, and societal issue across Europe. While health and illness have, of course, always been a part of the human experience, the epidemiological transition from infectious, deadly diseases to the increased burden of chronic and mental health problems, has put various pressures and constraints on policy makers. Indeed, across Europe, health represents one of the most expensive domains of social policy, and a core objective of the welfare state. The fiscal pressures driven by changing population health are well known, but cutting back on healthcare has proven challenging given public support for high quality health care.

Consequently, health, illness, and healing lie at the heart of understanding the lives of Europeans in the twenty-first century. More specifically, there are several issues that we view as key concern in the current era, including, but not limited to, health inequalities, health policy, mental health, health professions, use of health services, social provision of health care, and the relationship between the health system and the broader welfare system. Of course, each can be studied individually, but it is particularly important to build bridges across different subfields of health scholarship, for example by examining how variations in health policy impact health inequalities differently.

We also argue for the importance of taking a broader perspective rather than simply focusing on health itself. For example, the provision of health care is without a doubt important, yet health and illness are even more fundamentally shaped by the inequalities and political institutions that we find in society. Policymakers, academics, and the public alike have raised concerns about rising income inequality, and various groups that often have been silenced in society have risen up and demanded citizenship rights that include health as a human right. This dovetails with intellectual currents in social epidemiology and demography that illustrate how everyday social life is the number one driver of population health – far more important in fact than health behavior or genetic predispositions. For example, the fundamental cause theory of health shows us that as long as we will have societal inequalities we will have health inequalities. Yet, the shape and size of those inequalities are, at least in part, determined by the political system of a society, by policy choices and constellations, and by what kind of safety-net there is in place for citizens.

Comparative research on health has a long history in multiple disciplines, and the topics have been multiple. Early on, scholars had an interest in classifying and categorizing health care systems (e.g., Anderson 1972) and much has also been written about the relationship between income inequality and aggregate health across nations (e.g., Wilkinson 1996). While this research provided important insights, few of these have been extended into a cross-national perspective. For example, scholarship on medicalization explained how and why various conditions moved from being a sin, to a crime, to an illness (Conrad and Schneider 1992), yet this work was largely embedded within the U.S. context. Consequently this work focused on the relationship between the market and medicine, as that reflects the history of U.S. medicine. However, as pointed out by Olafsdottir (2011), this relationship has never been limited to the market and medicine in European countries, where the state has always been a key player in providing health care and deciding on medical jurisdiction.

Of course, not all European societies are the same and there are many important differences in how states support health care and welfare more broadly. For instance, consider Esping-Andersen’s (1990) three worlds of welfare capitalism. Here, he divided the world into conservative, liberal, and social democratic welfare states, where one of the key differences is how much states do to intervene on market inequalities. While much has been built upon this work, for example with more fine-grained classifications or additions of new countries, it still represents a key way for comparative researchers to think about similarities and differences. For instance, comparative scholars evaluate regime effects on various outcomes of interest, including health and health inequalities. However, some have argued that this approach ignores variations within regimes (O’Connor, Orloff and Shaver 1999). For example, there are large differences in approaches taken regarding health care in the US and the UK, despite both belonging to the liberal welfare states (Olafsdottir and Beckfield 2011). Still others have relied on an approach that uses specific indicators of policy or country-level characteristics (e.g., Bakhtiari, Olafsdottir and Beckfield 2018; Kikuzawa, Olafsdottir and Pescosolido 2008) in an attempt to better capture specific impacts of certain policies. We welcome those different approaches, as they are able to answer different kinds of questions, and we see this tension as a productive one as the field of cross-national comparison of health, illness and healing develops.

Other complications arise when we consider which outcomes are of interest, how measures can be comparable, and what measures of health, illness, and healing mean in cross-national perspective. Life expectancies and self-assessed health are likely the most used indicators in cross-national health research, but they measure very different things. In some ways, life expectancy is a crude measure, as it is based on counts of deaths, but even small differences in this measure at the aggregate level can indicate profound differences in health and well-being across contexts. Conversely, self-assessed health may go as close to individual evaluations as possible. Such measures ask people how they would evaluate their overall, physical and/or mental health. Of course, people can take various things into account when evaluating their health, including diagnosis of various illnesses, so in the end it is about their own evaluations. While various cultural issues are associated with this measure (Grol-Prokopczyk, Freese and Hauser 2011), it has been shown to be a good measure to use in cross-national work and to be a better predictor of morbidity and mortality than physicians’ diagnoses. While those are only two of the hundreds of possible measures of health, they clearly show that no one measure is the best measure to look at health in a cross-national perspective. Rather, we should draw on the full richness of multiple indicators, theorizing their meaning in comparative perspective, and considering how they might vary across contexts.

Fortunately, increased funding and attention to health has led to larger cross-national research projects and data collections. We want to highlight two here in each category. First, NORFACE funded two health related projects in 2015, that both include researchers with a long involvement in CES. One of them is HEALTHDOX, led by Ellen Immergut, that aims to map out changes in health policy across European nations since 1989 with the goal of linking them to outcomes such as health inequalities and attitudes toward the health care system and the welfare state. The other is HiNews, led by Claire Bambra, where one of the goals is to investigate the Nordic Paradox, the existence of health inequalities in strong welfare states. In the second category of data collection, the International Social Survey Programme (ISSP) introduced a new module on health and health care in 2011, and that module will be repeated in 2021. This survey allows for a cross-national analysis of health outcomes, health inequalities, and health care utilization as well as attitudes toward the health professions and health systems. In many cases, it will be possible to compare public attitudes and behavior over the ten-year period. Another important data collection effort is the 2014 European Social Survey (ESS) module on health inequalities, led by Terje Eikemo. This survey provides detailed data both on health outcomes, as well as individual factors such as lifestyle and social support that shape health and health inequalities.

We are delighted to have edited this section of EuropeNow to highlight health and make a case for why health should become a core interest of CES. We are pleased to present important contributions from leading early- and mid-career scholars working in Europe and the United States. We aim to continue and develop conversations about how and why health reflects the social conditions that are so well conceptualized, theorized, and analyzed by the deeply interdisciplinary CES community.

Sigrún Ólafsdóttir is a Professor and the chair of sociology at the University of Iceland. Her research is at the intersection of medical, political, and cultural sociology. The main areas of research are health inequalities, health services research, health policy, mental health, medicalization, stigma of mental illness, and social inequalities. Most of her research uses a cross-national perspective, as one of her primary goals is to understand how larger societal arrangements impact individual outcomes, attitudes and behavior.

Jason Beckfield is Professor of Sociology at Harvard University. His research investigates the institutional causes and consequences of social inequality. His new books include Political Sociology and the People’s Health (2018, Oxford University Press) and Unequal Europe: Regional Integration and the Rise of European Inequality (2019, Oxford University Press).

Click here to listen to Sigrún Ólafsdóttir and Jason Beckfield’s podcast, “The Nordic Paradox: Health Inequalities in World’s Most Equal Societies.”



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To read an earlier feature on Anxiety Culture click here. To read a roundtable on the Politics of Health Equity in Europe click here.

Anderson, Odin W. 1972. Health Care: Can there by Equity? The United States, Sweden and England. New York: John Wiley and Sons.

Bakhtiari, Elyas, Sigrun Olafsdottir and Jason Beckfield. 2018. “Institutions, Incorporation, and Inequality: The Case of Minority Health Inequalities in Europe.” Journal of Health and Social Behavior 59: 248-267.

Conrad, Peter and Joseph W. Schneider. 1992. Deviance and Medicalization: From Badness to Sickness. Philadelphia: Temple University Press.

Esping-Andersen, Gösta. 1990. The Three Worlds of Welfare Capitalism. Cambridge: Polity Press.

Grol-Prokopczyk, Hanna, Jeremy Freese and Robert M. Hauser. 2011. “Using Anchoring Vignettes to Assess Group Differences in General Self-Rated Health.” Journal of Health and Social Behavior, 52: 246–261

Kikuzawa, Saeko, Sigrun Olafsdottir, and Bernice A. Pescosolido. 2008. “Similar Pressures, Different Context: Public Attitudes to Government Intervention for Health Care in 21 Nations.” Journal of Health and Social Behavior 49:385-99.

O’Connor, Julia S., Ann Shola Orloff, and Sheila Shaver. 1999. States, Markets, Families: Gender,Liberalism and Social Policy in Australia, Canada, Great Britain and the United States. Cambridge: Cambridge University Press.

Olafsdottir, Sigrun. 2011. “Medicalization and Mental Health: The Critique of Medical Expansion, and a Consideration of how National States, Markets, and Citizens Matter.” Pp. 239-60 in The SAGE Handbook of Mental Health and Illness, edited by David Pilgrim, Anne Rogers, and Bernice A. Pescosolido. London, England: Sage Publications.

Olafsdottir, Sigrun and Jason Beckfield. 2011. “Health and the Social Rights of Citizenship: Integrating Welfare State Theory and Medical Sociology.” Pp 101-15 in Handbook of the Sociology of Health, Illness, and Healing: A Blueprint for the 21st Century, edited by Bernice A. Pescosolido, Jack K. Martin, Jane D. McLeod, and Anne Rogers. New York: Springer.

Wilkinson, Richard. 1996. Unhealthy Societies: The Afflictions of Inequality. London: Routledge.

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Published on June 11, 2019.


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