Editor's Choice |
Infection, medical care and inequalities
Studies of socioeconomic differentials in health have been a major feature of the International Journal of Epidemiology over the past few years.1–17 One of the striking features of social inequalities is that as diseases increase in importance within populations, the gradients of increasing risk with less favourable social circumstances tend to become more marked.18 While this has been discussed as a theoretical issue, Antunes et al.19 consider a concrete case where it may well come into play: the social patterning of AIDS mortality during an era when effective treatment is introduced. In many situations, the ability of better off people to secure treatment should lead to increased inequalities in AIDS mortality; however, in São Paulo, with widespread, cost-free access to antiretroviral drugs, no such increase was observed. Matthias Egger and colleagues discuss the implications of this important study in depth20 and render redundant part of this editor's choice (now deleted) written in advance of their excellent editorial arriving. A different, but equally important, impression of the importance of the AIDS epidemic is revealed by the moving photoessay by Luc Pauwels.21
Death from AIDS, in the age of highly effective anti-retroviral therapy, is clearly strongly related to access to appropriate medical care. For other conditions, the socio-economic gradient will be dependent on different factors. Khang and Kim22 analyse South Korean data and demonstrate that for all-cause mortality early-life influences may be of particular importance. However, among South Koreans, as among the civil servants in the Whitehall II study, social circumstances in adulthood were also important predictors of mortality risk.23
Infectious disease burdens in populations can be explored through media ranging from photographs and individual stories through global statistics. The latter may appear impersonal, but they can reveal the crucial role of economic factors in determining disease rates. Jacobsen and Koopman24 utilise this approach and demonstrate the key role of human development and economic factors in influencing population levels of hepatitis A infection.
It is clear that the focus of many of the papers in the International Journal of Epidemiology is on how the fruits of economic development—between and within countries—translate into improved health. Thomas McKeown remains the most prominent proponent of the view that economic development and its concomitant influence on improved nutrition was the key to decreasing mortality rates in Britain during the latter part of the 19th and the 20th centuries. We reprint a summary statement of this thesis from 197125 together with a series of commentaries26–29 that highlight the (perhaps inevitable?) limitations of the attractive and simple gloss on demographic history that McKeown provided. As Emily Grundy26 suggests, McKeown may have been misleading on some of the details, but his conclusions as to the key importance of the economic domain may remain valid.
One issue where economic and technological development could influence health is in the increased use of assisted reproductive technologies. Lie et al.30 report results of a meta-analysis suggesting that intracytoplasmic sperm injection may not introduce additional risks for birth defects. However, studying these issues is problematic, and Jurek et al.31 demonstrate how some reassuring conclusions about the potential influence of biases may be over-optimistic. As ever, we see that even rigorous methodologies can lead to different conclusions in the differing bottom-line assessment of the importance of fetal development of later cardiovascular risk reached by Kajantie et al.32 and Owen et al.33.
References
1 Razzell P, Spence C, Vines K. Poverty, birthweight, and infant weight gain in Hertfordshire, 1923–1939. Int J Epidemiol 2004;33:1228–33.
2 Singh-Manoux A, Ferrie JE, Chandola T, Marmot M. Socioeconomic trajectories across the life course and health outcomes in midlife: evidence for the accumulation hypothesis? Int J Epidemiol 2004;33:1072–79.
3 Ellaway A, McKay L, Macintyre S, Kearns A, Hiscock R. Are social comparisons of homes and cars related to psychosocial health? Int J Epidemiol 2004;33:1065–71.
4 Regidor E, Banetas JR, Gutiérrez-Fisac JL, Domínguez V, Rodríguez-Artalejo F. Socioeconomic position in childhood and cardiovascular risk factors in older Spanish people. Int J Epidemiol 2004;33:723–30.
5 Stjärne MK, Ponce de Leon A, Hallqvist J, SHEEP Study Group. Contextual effects of social fragmentation and material deprivation on risk of myocardial infarction—results from the Stockholm Heart Epidemiology Program (SHEEP). Int J Epidemiol 2004;33:732–41.
6 Gnavi R, Petrelli A, Demaria M, Spadea T, Carta Q, Costa G. Mortality and educational level among diabetic and non-diabetic population in the Turin Longitudinal Study: a 9-year follow-up. Int J Epidemiol 2004;33:864–71.
7 Blakely T, Kawachi I, Atkinson J, Fawcett J. Income and mortality: the shape of the association and confounding New Zealand Census-Mortality Study, 1981–1999. Int J Epidemiol 2004;33:874–83.
8 Lindqvist K, Timpka T, Karlsson N. Impact of social standing on injury prevention in a World Health Organization Safe Community—intervention outcome by household employment contract. Int J Epidemiol 2004;33:605–11.
9 Kerr-Pontes LRS, Montenegro ACD, Barreto ML, Werneck GL, Feldmeier H. Inequality and leprosy in Northeast Brazil: an ecological study. Int J Epidemiol 2004;33:262–69.
10 Emberson JR, Whincup PH, Morris RW, Walker M. Social class differences in coronary heart disease in middle-aged British men: implications for prevention. Int J Epidemiol 2004;33:289–96.
11 Khang YH, Lynch JW, Kaplan GA. Health inequalities in Korea: age- and sex-specific educational differences in the 10 leading causes of death. Int J Epidemiol 2004;33:299–308.
12 Wright CM, Parker L. Forty years on: the effect of deprivation on growth in two Newcastle birth cohorts. Int J Epidemiol 2004;33:147–52.
13 Mackenbach JP, Bos V, Andersen O et al. Widening socioeconomic inequalities in mortality in six Western European countries. Int J Epidemiol2003;32:830–37.
14 Shaw M, Tunstall H, Davey Smith G. Seeing social position: visualizing class in life and death. Int J Epidemiol 2003;32:332–35.
15 Bopp M, Minder CE. Mortality by education in German speaking Switzerland, 1990–1997: results from the Swiss National Cohort. Int J Epidemiol 2003;32:346–54.
16 Borrell C, Cortès I, Artazcoz L, Molinero E, Moncada S. Social inequalities in mortality in a retrospective cohort of civil servants in Barcelona. Int J Epidemiol 2003;32:386–89.
17 Mendez MA, Cooper R, Wilks R, Luke A, Forrester T. Income, education, and blood pressure in adults in Jamaica, a middle-income developing country. Int J Epidemiol 2003;32:400–08.
18 Davey Smith G, Gunnell D, Ben-Shlomo Y. Life-course approaches to socio-economic differentials in cause-specific adult mortality. In: Leon D, Walt G. (eds) Poverty, Inequality and Health. Oxford: Oxford University Press, 2000, pp. 88–124.
19 Antunes JLF, Waldman EA, Borrell C. Is it possible to reduce AIDS deaths without reinforcing socioeconomic inequalities in health? Int J Epidemiol 2005;34:585–92.
20 Egger M, Boulle A, Schechter M, Miotti P. Antiretroviral therapy in resource-poor settings: scaling up inequalities? Int J Epidemiol 2005;34:509–12.
21 Pauwels L. Culture, community, and disease control. Int J Epidemiol 2005;34:534–6.
22 Khang Y-H, Kim HR. Explaining socioeconomic inequality in mortality among South Koreans: an examination of multiple pathways in a nationally representative longitudinal study. Int J Epidemiol 2005;34:630–7.
23 Ferrie JE, Martikainen P, Shipley MJ, Marmot MG. Self-reported economic difficulties and coronary events in men: evidence from the Whitehall II study. Int J Epidemiol 2005;34:640–8.
24 Jacobsen KH, Koopman JS. The effects of socioeconomic development on worldwide hepatitis A virus seroprevalence patterns. Int J Epidemiol 2005;34:600–609.
25 McKeown T. Medical issues in historical demography. In: Clarke E (ed) Modern Methods in the History of Medicine. London: Athlone Press, 1971, pp. 57–74. (Reprinted Int J Epidemiol 2005;34:515–20.)
26 Grundy E. Commentary: the McKeown debate: time for burial. Int J Epidemiol 2005;34:529–33.
27 Wilson LG. Commentary: medicine, population, and tuberculosis. Int J Epidemiol 2005;34:521–4.
28 Johansson SR. Commentary: the pitfalls of policy history. Writing the past to change the present. Int J Epidemiol 2005;34:526–9.
29 Condran GA. Commentary: history in the search of policy. Int J Epidemiol 2005;34:525–6.
30 Lie RT, Lyngstadaas A, Ørstavik KH, Bakketeig LS, Jacobsen G, Tanbo T. Birth defects in children conceived by ICSI compared with children conceived by other IVF-methods; a meta-analysis. Int J Epidemiol 2005;34:696–701.
31 Jurek AM, Greenland S, Maldonado G, Church TR. Proper interpretation of non-differential misclassification effects: expectations vs observations. Int J Epidemiol 2005;34:680–7.
32 Kajantie E, Osmond C, Barker DJP, Forsén T, Phillips DIW, Eriksson JG. Size at birth as a predictor of mortality in adulthood: a follow-up of 350 000 person-years. Int J Epidemiol 2005;34:655–63.
33 Owen CG, Whincup PH, Cook DG. Are early life factors responsible for international differences in adult blood pressure? An ecological study. Int J Epidemiol 2005;34:649–54.
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