Introduction

The link between poverty and illness has been identified for over 200 years. Daly et al (1998, p 315) conclude, ‘It has long been known that the socioeconomic status (SES) of an individual is a pervasive and persistent correlate of that individual's health … the correlation between SES and health is invariably positive and is often best described as a continuous but nonlinear “gradient”.’ Exposure to toxic living and working environments (Krieger et al, 1997), elevated unrelenting stress found in societies with higher income inequality (Wilkinson, 1997), and underinvestment in human capital (Navarro, 1999; Coburn, 2004) are acknowledged to be evidence-based, fundamental causes of health inequities (Link and Phelan, 1995) as described by the World Health Organization (WHO) in their publication entitled The Social Determinants of Health: The Solid Facts (Wilkinson and Marmot, 2003).

Lynch et al (1997) describe the outcome of these ‘solid facts’: cumulative impact on population health derived from unrelenting immersion in severe economic hardship. They link this cumulative impact over the life course to major deficits in adult physical, cognitive, psychological and social functioning. The connection to elevated levels of morbidity and mortality is equally well-documented (Kaplan et al, 1996; Wilkinson, 1999; Blackwell et al, 2001; Isaacs and Schroeder, 2004). Population health, or its absence, is socially constructed, a historical outcome of the distribution of population wealth. Social work could acknowledge, incorporate and act on the structural sources of harsh, cumulative health impact to advance our advocacy and clinical practices in health.

Acknowledging my standpoint for this discussion, a structural focus, and its link to empowering paradigms for social work practice, has been the purpose of my work for more than 35 years (Rose, 1972; 1990; 1992; 2005; Warren et al, 1974; Rose and Black, 1985).