European Health Inequalities: Socioeconomic or Cultural?

The New England Journal of Medicine article by Mackbach, Stirbu et al, "Socioeconomic Inequalities in Health in 22 European Countries," (N Engl J Med 358:23, June 5, 2008) states, as a summary conclusion, "We observed variation across Europe in the magnitude of inequalities in health associated with socioeconomic status. These inequalities might be reduced by improving educational opportunities, income distribution, health-related behavior or access to health care." (p. 2468). This appears to more of a political statement or agenda than public health policy. It also focuses on issues which are easier to analyze and deal with than the hard one: "culture."

In the editorial section of the same issue of the New England Journal of Medicine, Berkman and Epstein (p. 2509), look at Mackbach's article and note that: (i) the results in the 16 country mortality data show higher death rates for socioeconomically disadvantage people; (ii) the size of the risks varies across countries, and that " . . .the proportion of excess deaths related to diseases that are potentially amenable to medical intervention was strikingly low . . ." for the socioeconomically disadvantaged.

Berkman and Epstein (p. 2510) comment that, " . . . . although national health coverage is important for many reasons, we should not count on it to reduce more than a small part of the socioeconomic, racial and ethnic disparities and improve the health of the population."

A politically sensitive, and potentially more rewarding study, would focus on the health characteristics of identifiable cultures and subcultures. What are the cultural characteristics of socioeconomically disadvantaged persons who place a high value on the practice of a healthy life style (diet, alcohol, tobacco, societal value of females, maternal and child health, health education, physical activity) and how do their cultures vary from others which experience higher member illness and mortality? While it may be relatively comforting to identify socioeconomic disadvantage, and write a check to remedy this issue, without identifying and modifying cultural characteristics, no health benefit will accrue. (Those who have treated alcoholism know that alcoholism has cultural attributes which may help to predict treatment success.) While it may be politically easier and less threatening to talk about matters of economics, those who conduct health research should move to study scientific issues and not be constrained by political considerations.