Fantasy paradigms of health inequalities: Utopian thinking?

This article argues that, while it can be politically expedient for governments to engage with health inequalities, they cannot, within the confines of neo-liberalism, realistically propose actions that evidence suggests will effectively reduce them - such as tackling power inequalities, social status and connections or class inequality. Indeed, a dominant 'policy paradigm' prioritising economic growth restricts the ability of policy actors to imagine alternative, more equitable scenarios. In this context, some policy actors and researchers have devised a parallel fantasy world in which proximal, downstream, easily tackled exposures are posited as potential solutions to health inequalities. The consequence of this is a widespread public sector culture in which well-meaning policymakers, practitioners, researchers and members of the public collude in sustaining a 'cargo cult' of health behaviourism. In examining this situation, we draw on accounts and critiques of utopian thinking to help explain: (i) the remarkable persistence of policy proposals to tackle health inequalities via downstream interventions, in spite of the strength of evidence challenging such approaches; and (ii) the limited extent to which more upstream proposals inform policy debates. We argue Ruth Levitas' notion of 'utopia as method' offers an imaginative and potentially useful avenue for future health inequalities research.