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
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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
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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]
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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
e-mail [log in to unmask]
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