Politicians, however, find it easy to talk about reducing health 
inequality by the application of healthcare, and to examine inequalities 
in the way in which healthcare is delivered.  Attempts to change 
individual behaviour, such as smoking or drinking, makes them nervous. 
Right wing politicians object to state interference in what they see as 
individual choices on principle.  Left wing politicians are quite 
relaxed about the idea of state intervention, but very worried that such 
intervention will upset their supporters, who typically are pretty 
unhealthy.   I used to make jokes about putting statins in the water 
supply, but I recently heard that suggested seriously, so I think I had 
better stop my jokes.  And action to reduce inequality in the way Alex 
would want is really not on the agenda, even among quite radical 
politicians who would like to see it happen.  They simply do not regard 
it as politically possible.  And the reluctance of people who regard 
inequality as an important objective to talk about mechanisms which 
might reduce inequality does not help.

Martin Rathfelder
Director
Socialist Health Association
22 Blair Road
Manchester
M16 8NS
0870 013 0065
www.sochealth.co.uk

If you do not wish to be on our mailing list please let us know and we will
remove you. 



Starfield, Barbara wrote:
>
> No doubt in my mind that focusing the argument on health is the 
> quickest way to get action.  After all, most people feel that people 
> should not be inherently unequal in health opportunities when they 
> would not agree that people should be equal in income. And lots of 
> health changes can occur quickly---not so for income equalization. It 
> is as Virchow said: Politics is medicine on a grand scale.
>
>  
>
> *From:* The Health Equity Network (HEN) 
> [mailto:[log in to unmask]] *On Behalf Of *Kelleher, 
> Kevin
> *Sent:* Saturday, February 28, 2009 4:01 PM
> *To:* [log in to unmask]
> *Subject:* Re: Tackling health inequalities: the need to refocus upstream
>
>  
>
> I suppose this is a good way to get over the pain of playing badly & 
> losing. We only played badly.
>
> K
>
> K
>
> Dr Kevin Kelleher
> Assistant National Director of Population Health - Health Protection
> Tel: +353 61 483347
> Fax: +353 61464205
> Please note new email address  --------------------------
> Sent from my BlackBerry Wireless Handheld
>
>
> ----- Original Message -----
> From: The Health Equity Network (HEN) 
> <[log in to unmask]>
> To: [log in to unmask] 
> <[log in to unmask]>
> Sent: Sat Feb 28 20:43:48 2009
> Subject: Re: Tackling health inequalities: the need to refocus upstream
>
> ok Alex, fair points. Although I would add two further points. First, 
> we don't really know if altering personal lifestyle behaviours (even 
> if it is a morally appropopriate thing to do) will or will not narrow 
> long term health inequalities. It might (smoking is a big killer after 
> all, and smoking prevalence differences by income are large), but it 
> might not (if, for example, people give up smoking but still die 
> relatively young from a different income-related risk factor). So, we 
> don't know, but I take your point. Second, if one believes that income 
> differentials ought to be narrowed, I've never really understood why 
> one has to appeal to narrowing health inequalities as a justification. 
> First, if we're totally honest, we don't really know that narrowing 
> income inequalities will narrow health inequalities (there are plenty 
> of reasons to believe that health inequalities may actually widen, at 
> least in the short term). And second, narrowing income inequality can 
> quite legitimately be an end goal in and of itself (Rudolf Klein has 
> been making this argument for years). And the third of my two points 
> is that it seems sensible to me to place the strongest emphasis on 
> what is politically and economically possible in any given climate. 
>
> All best,
> Adam
>  
>
> ________________________________
>
> From: The Health Equity Network (HEN) on behalf of alex scott-samuel
> Sent: Sat 2/28/2009 8:22 PM
> To: [log in to unmask]
> Subject: Re: Tackling health inequalities: the need to refocus upstream
>
>
> Actually Adam, I'm saying precisely the opposite of what you're 
> suggesting. I do indeed believe that downstream policies are important 
> in changing personal lifestyle behaviours, including of course 
> smoking. And I believe that smoking prevention and cessation should 
> remain very high on the public health agenda, as they will prolong 
> many lives. But what I am also saying is that this prolongation will 
> not have much, if any impact on the scale of long term health 
> inequalities between social classes.
>
> So as long as we have a government committed to reducing health 
> inequalities, let's make them optimally aware that these inequalities 
> will only be reduced by upstream policies that address the root causes 
> of inequalities. And let's hope that they will get the message and not 
> only continue their important lifestyle programmes, but in addition 
> introduce new inequalities strategies that actually have some impact - 
> ie strategies that address the real causes of health inequalities.
>
> Best wishes, Alex
>
> [log in to unmask] wrote:
>
>         Alex
>         
>         Perhaps you could elaborate a bit? Smoking is a personal 
> lifestyle behaviour for many that could be reduced I guess through 
> upstream policies (raising low incomes, narrowing income inequalities 
> etc.), although there is no clear evidence on this as far as I can see 
> (for instance, raising the income of a smoker may lead them smoking 
> more cigarettes). I'm all for raising low incomes and narrowing wide 
> income inequalities of course, but I don't see why one needs to use 
> claims that this would reduce smoking behaviours (even if it does) as 
> an ex ante justification.
>         
>         I would have thought that downstream policies could 
> potentially be very useful in changing personal lifestyle behaviours 
> (if we feel that it is morally justifiable to alter such behaviours). 
> I say 'potentially' because I guess we don't know. But I don't think 
> they ought to be dismissed before we look at them properly. If smoking 
> can be reduced by downstream policies (which is quite possible), what 
> exactly do you have against them?
>         
>         In 1980 (or so), the Black Report (as you know) advocated an 
> extensive set of downstream policies at a time of a major economic 
> crisis in the UK, and was almost totally ignored by policy makers as a 
> consequence. We are now in a major economic crisis again, are possibly 
> on the brink of a Conservative Government, and you are suggesting that 
> we ought to be focussing on upstream policies as the sole research and 
> policy focus. Maybe you and I are living in parallel universes or 
> something, but this, to me, is not only totally lacking in realism. It 
> is irresponsible.
>         
>         Very best,
>         Adam 
>
> ________________________________
>
>         From: The Health Equity Network (HEN) on behalf of alex 
> scott-samuel
>         Sent: Sat 2/28/2009 7:31 PM
>         To: [log in to unmask]
>         Subject: Tackling health inequalities: the need to refocus 
> upstream
>        
>        
>
>         The first longitudinal study linking smoking status, social 
> class and
>         survival has been published online in the BMJ. The data have, 
> in my
>         view, profound implications for policy makers who claim that 
> long term
>         health inequalities can be reduced by addressing 'downstream' 
> / proximal
>         health determinants and/or disease outcomes. I am circulating 
> details of
>         the
>         article and my BMJ rapid response in the hope of generating 
> debate on
>         this important issue.
>        
>         Gruer L, Hart CL, Gordon DS, Watt GCM. Effect of tobacco 
> smoking on
>         survival of men and women by social position: a 28 year cohort 
> study.
>         BMJ 2009;338:b480
>         doi:10.1136/bmj.b480
>         Available online at: 
> http://www.bmj.com/cgi/content/full/338/feb17_2/b480
>        
>         Scott-Samuel A. What the Renfrew / Paisley data really tell us 
> about
>         tackling health inequalities: the need to refocus upstream.
>         Available online at: 
> http://www.bmj.com/cgi/eletters/338/feb17_2/b480
>        
>         
> ****************************************************************************
>        
>         Dr Alex Scott-Samuel
>         EQUAL (Equity in Health Research and Development Unit)
>         Division of Public Health
>         University of Liverpool
>         Whelan Building
>         Quadrangle
>         Liverpool
>         L69 3GB
>         UK
>        
>         Tel  (+44)151-794-5569
>         Fax  (+44)151-794-5588
>        
>         http://pcwww.liv.ac.uk/~alexss 
> <http://pcwww.liv.ac.uk/%7Ealexss> <http://pcwww.liv.ac.uk/%7Ealexss>
>         e-mail  [log in to unmask]
>         
> ****************************************************************************
>        
>
>
> --
> ****************************************************************************
> Dr Alex Scott-Samuel
> EQUAL (Equity in Health Research and Development Unit)
> Division of Public Health
> University of Liverpool
> Whelan Building
> Quadrangle
> Liverpool
> L69 3GB
> UK
>
> Tel  (+44)151-794-5569
> Fax  (+44)151-794-5588
>
> http://pcwww.liv.ac.uk/~alexss <http://pcwww.liv.ac.uk/%7Ealexss>
> e-mail  [log in to unmask]
> ****************************************************************************
>
> Please access the attached hyperlink for an important electronic 
> communications disclaimer: 
> http://www.lse.ac.uk/collections/secretariat/legal/disclaimer.htm
>
> ========= 
> IMPORTANT 
> ========= 
>  
> Information in this email (including attachments) may be 
> confidential. It is intended for receipt and consideration 
> only by the intended recipient. If you are not the intended 
> recipient, any use, dissemination, disclosure, publication or copying 
> of information contained in this email (including attachments) is 
> strictly prohibited. Opinions expressed in this email may be 
> personal to the author and are not necessarily the opinions of the 
> Health Service Executive. If this email has been received by you in 
> error, please notify the sender and then delete the email from your 
> system.
>
>  
>