Introduction

The publication of the Acheson Report (Acheson, 1998) ended nearly two decades of political denial of health inequalities following the publication of the 1980 Black Report (Townsend et al, 1992). The key policy issue since 1997 has been whether New Labour is making progress in tackling health inequalities, including whether the government's initial commitment to tackling them has strengthened or diminished since Acheson. Since much assessment has sought to provide a bird’s-eye view of the adequacy of macro-level policies, this chapter seeks to provide a complementary ‘worm’s-eye’ view of the actual and potential role of local initiatives, particularly those informed by ‘broad’ community development principles.

The chapter starts by revisiting broad alternative macro-level strategies for tackling health inequalities, suggesting that insufficient attention has been given to the question of how they might intersect with micro-level interventions, which has often been implied rather than explicitly stated. The fundamental point made is that contested macro-level strategies are linked to parallel ‘broader’ and ‘narrower’ community development discourses. The implications of this are followed through in the remainder of the chapter. The danger identified is that New Labour has been pursuing a ‘narrower’ approach to community development that, despite some improvements on such approaches in the past, still tends to repeat the mistakes of the 1960s and ‘70s, when radical critics accused governments of merely seeking to ‘gild the ghetto’ rather than tackling external structural causes (Craig, 1989). After a brief conceptual review of the origins of community development approaches to health, New Labour's ‘turn to the community’ is critically assessed in relation to the possibilities and limitations of Area-based Initiatives (ABIs). This leads into a discussion of questions of evidence related to political and scientific evaluation issues, and the necessarily uncertain impact of localised initiatives on health inequalities. My overall conclusion is that broader community development strategies have an integral part to play in developing a new synthesis between ‘top-down’ structuralist approaches and ‘bottom-up’ participative approaches to tackling health inequalities.

Community development and health inequalities policy discourses

The relationship between community development strategies and health inequalities is complex. Originally community development was conceived narrowly in terms of harnessing local ‘self-help’ to tackle poverty independently of the state. However, critiques of this traditional model advocated connecting it to broader questions of politics, empowerment and social justice, in which health gained greater prominence as a feature of community disadvantage.