Introduction
Poverty is rarely about one thing - it is about having no money, no voice, no infrastructure and no opportunities. Voices of the Poor (World Bank 2000).
Poverty and other forms of social disadvantage are multidimensional in their manifestations, multifactoral in their causes, and complex in the pathways through which they operate on health and well-being. However, there is a danger that the high level of interest in the public health community in the statistical relationship between unequal income distribution and health may lead to an oversimplification of both the nature of poverty and the action required to address health inequality. Also, a preoccupation with describing associations and developing models for explaining causal pathways leaves public health workers open to criticism of developing a research industry that has few tangible benefits for those whose health is most vulnerable.
This paper raises issues that need to be considered as complex notions of poverty and social disadvantage are transferred from (often complex) sociological to (often relatively simple) public health frameworks. For instance:
• Are measures of income and income distribution simply proxies for a more complex and systemic web of disadvantage?
• Is poverty better understood as a set of issues affecting an individual, family network or community rather than as a single entity in itself?
• Does the current emphasis on relative poverty blind us to the absolute paucity of resources and life chances experienced by some Australians?
• Is our limited analysis of the dimensions of poverty preventing a more sophisticated approach to solutions?
• And most importantly, if, as some argue, the prime cause of health inequalities in developed countries is the very unequal income distribution, and the remedies for this lie so clearly outside the mandate of the health system, are health workers released from any responsibility to act?
Additionally, we reflect on the limitations of the income inequality argument that are emerging in the literature, and examine the ways in which an analysis that is based on simple, strong statistical associations between income inequality and health may be limiting effective action to reduce health inequalities. It is not our purpose to throw the baby out with the bath water. We do not dispute the observed relationship between income inequality and health but seek to reflect on the limitations of this approach in understanding the origins of health inequality and in taking action to redress these inequalities.