• No results found

Re-thinking health inequalities is necessary

N/A
N/A
Protected

Academic year: 2021

Share "Re-thinking health inequalities is necessary"

Copied!
1
0
0

Bezig met laden.... (Bekijk nu de volledige tekst)

Hele tekst

(1)

...

European Journal of Public Health, 4

ß The Author(s) 2020. Published by Oxford University Press on behalf of the European Public Health Association.

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http:// creativecommons.org/licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com

...

Re-thinking health inequalities is necessary

These thoughtful comments by Ramune Kalediene, Alastair Leyland, Olle Lundberg and Johannes Siegrist illustrate how necessary a re-think of the conventional wisdom on health inequalities is. Kalediene seems to mostly agree with me, and there is little in the others’ responses to my—somewhat provocative—editorial that suggests that we can do without such a fundamental re-think.

Take Leyland’s statement ‘If it is possible to reduce mortality by x% among an advantaged population then the inability to reduce mortality by at least this amount in a disadvantaged population— despite this being the focus of our greatest efforts—must be seen as a failure’. Has anyone ever seriously considered what it would mean to reduce mortality (or any other adverse health outcome) by at least the same percentage in a disadvantaged population? Everything, from higher rates of comorbidity to less compliance with drug prescriptions, and from higher levels of psychosocial stress to lower health literacy, conspires against such equality of outcomes. ‘Proportionate universalism’, the currently popular idea that we must allocate remedial efforts according to need,1 will certainly not be sufficient. In order to achieve equal percentage declines we would need to allocate far more resources per unit of need to disadvantaged populations, which would require a complete re-think of how we run our health and social systems.2

Or take Siegrist’s emphasis on the ‘[t]oxic [. . .] non-material characteristics of work’, such as ‘low control and autonomy, and [. . .] low reward and recognition’. I completely agree that inequalities in these less tangible factors likely play a role in generating health inequalities, and may have replaced inequalities in injury risks and physical exposures as the main occupational pathways to disparities in ill-health. But although several European countries have tried to design comprehensive policies to tackle health inequalities, I have seen very few attempts to systematically address these ‘new’ inequalities.3This is, of course, unsurprising: we do not yet know how to effectively change these non-material working conditions for the better, and deep in our hearts we know that this would require a radical change to existing work relations, for which probably no European government has ever had a democratic mandate. Here again, I believe that some deeper thinking is necessary to determine what the policy options are.

Finally, I am inclined to read Lundberg’s response as a first and important step towards re-thinking health inequalities. It is undoubtedly true that the failure of counterfactual approaches to produce robust evidence for a causal effect of socioeconomic position on health is partly due to the complexity of the phenomenon-to-be-explained.4 The ‘generative process’ includes bi-directional relationships, reinforcing each other, and is further complicated by the fact that human beings are not only passive recipients, but also act on their circumstances. However, this is exactly what I meant to say: the conventional wisdom is that if we change people’s living circumstances, health will automatically improve and health inequalities will diminish. Quod non. If we really want to tackle health inequalities, we need to do more, and we need to also address the other mechanisms which have too often been ignored.

Conflicts of interest: None declared.

References

1 Marmot MG, Allen J, Goldblatt P, et al. Fair Society, Healthy Lives: Strategic Review of Health Inequalities in England Post-2010. London: The Marmot Review, 2010. 2 Mackenbach JP, Martikainen P, Menvielle G, de Gelder R. The arithmetic of

reducing relative and absolute inequalities in health: a theoretical analysis illustrated with European mortality data. J Epidemiol Community Health 2016;70:730–6. 3 Mackenbach J. Health Inequalities; Persistence and Change in European Welfare

States. Oxford etc.: Oxford University Press, 2019.

4 Mackenbach JP, de Jong JP. Health Inequalities: An Interdisciplinary Exploration of Socioeconomic Position, Health and Causality. Amsterdam: Royal Dutch Academy of Arts and Sciences, 2018.

Johan P. Mackenbach

Department of Public Health, Erasmus MC, Rotterdam, the Netherlands Correspondence: Johan P. Mackenbach, Department of Public Health, Erasmus MC, PO Box 2040, 3000 CA Rotterdam, the Netherlands, Tel: +31107038460, e-mail: j.mackenbach@erasmusmc.nl

doi:10.1093/eurpub/ckaa002

4 European Journal of Public Health

Referenties

GERELATEERDE DOCUMENTEN

2QH RI WKH PDLQ DVSHFWV RI WKH YLVLRQ ,QGXVWU\  LV WKH PDFKLQH WR PDFKLQH FRPPXQLFDWLRQ 00  EDVHG RQ &36 7KH FRQFHSW EHKLQG LV WR HQDEOH

Het doel van het onderzoek van Albrecht en O’Brien (1993) was om via een leestaak te kijken of er verschillen zijn in de verwerking van informatie wanneer twee

In order to determine the effects which the adoption of the notion of the smart city has brought about this research adopted a relational perspective through which we have examined

We also hypothesized that the relation between prenatal family alliance and secure infant –mother and infant–father attachment will be mediated by higher postnatal family alliance

Besides ethnicity, it was observed that lower educational level and higher unemployment rate contributed to higher peri-natal mortality, IMR and mortality in weeks

Recipients that score low on appropriateness and principal support thus would have low levels of affective commitment and high levels on continuance and

According to our life-cycle model, co-payments and bequest saving thus jointly explain why higher SES households perceive a larger welfare gain from differences LTC needs and

certain behaviors and access to valued resources (Anderson, & Brown, 2010), it is hypothesized that the greater the status inequality is, and thus the