The previous chapter examined the role of compositional and contextual factors in health divides. However, by only focusing on these individual characteristics or localised neighbourhood effects, geographical analysis misses the bigger picture, as these compositional and contextual determinants of health are themselves shaped by wider political and economic factors, and therefore the relationship between health and place (and the health divides that exist between places) are politically determined: place matters for health, but politics matters for place. Indeed, as Professor Tom Slater of the University of Edinburgh has argued, we need to think not just about how ‘where you live affects your life chances’, but also how ‘your life chances affect where you live’: ‘if where any given individual lives affects their life chances as deeply as neighbourhood effects proponents believe, it seems crucial to understand why that individual is living there in the first place’.

Ultimately, people live where they can afford to live. Private housing markets produce social sorting, and the emergence of spatial concentrations of poverty and poor neighbourhood infrastructures due to lack of investment. Understanding how place relates to health therefore requires insights from the political economy to think about the more fundamental causes of health divides: the politics of health. This ‘scaling up’ of our understanding of the relationship between health and place is sometimes referred to as the ‘political economy’ or ‘political geography’ explanation. The title of this chapter reflects the primacy of these causes. In 1992, ‘It’s the economy, stupid!’ was used by Bill Clinton in his successful US presidential campaign against George Bush Senior. The comment reflected the recession that the US was experiencing at the time, but it is used here as it also encapsulates what is the most fundamentally important driver of health divides. The political addition reflects the fact that the economy we have is the result of political choices we make – as Clinton was, in fact, suggesting. This chapter examines how politics is the fundamental determinant of health divides, outlining key insights from political economy research, and using them to analyse the case studies of the US health disadvantage, the ‘Scottish health effect’, the North–South health divide in England and local health inequalities.