Public Health Policy-Making in the Absence of Evidence: Do No Harm.

Health policy is understood to be more than just health services and medical care today thanks to the new focus on population health and the social determinants of health. In this context inequality is a public health topic and a health policy priority. Inequality has been on the rise in the industrialized countries in the last 3 decades. We summarize what is known about the relationship between inequality and health. We conclude that the association between health and inequality is clear but that the causal linkages are complex. Causality may go in several directions that vary across time and geographical location. In short, the evidence from research does not now and may never yield clear directives for policy makers. In the absence of definitive evidence what are policy makers to do? We contend that they may well choose the wise course of implementing policies to halt the increasing inequality observed in industrialized countries. We argue that they are justified in taking such action because it does no harm. The criteria of ?do no harm? comes from the medical literature and is one that policy makers seldom consider though it has substantial advantages. Inattention to inequality by policy-makers has permitted incremental increases to accumulate over time. Inequality in the USA has risen from .349 in 1969 to .435 in 2001. This is testimony to the fact that the absence of policy is itself a policy. It illustrates Bachrach and Baratz? non-issue or non-decision in policy-making. In short, it is unacceptable to argue that the absence of a definitive, established causal link between inequality and health is justification for continued inattention to this public health problem. [ABSTRACT FROM AUTHOR]