Forget Diversity; Pass the Wine and Spaghetti Please

Socioeconomic Inequalities vs. Health in 22 European Countries

An article in the New England Journal of Medicine points out that there are health outcome disparities in European countries too. I thought it would generate a lot of newspaper articles and public discussion but there has been silence as far as I can tell. Inequity in health outcome among groups of various socioeconomic status (as measured by education, occupation, and income) constitutes part of the debate about American health care.

It is unknown to what extent such inequalities are modifiable or exactly how they arise. This does not keep persons with strong political agendas from using these disparities to demand specific changes.

For example this list from the Commonwealth Fund gives a rundown of things that need to be done in order to ameliorate health care disparities in the United States.

  • Effective evaluation of disparities-reduction programs.
  • Minimum standards for culturally and linguistically competent health services.
  • Greater minority representation within the health care workforce.
  • Establishment or enhancement of government offices of minority health.
  • Expanded access to services for all ethnic and racial groups.
  • Involvement of all health system representatives in minority health improvement efforts.

But how much benefit should we expect if we do make these changes? Perhaps it would be appropriate to look at conditions in other parts of the world.

Data on mortality according to education level and occupational class in this study came from census-based mortality studies. Deaths were classified according to cause, including common causes, such as cardiovascular disease and cancer, smoking, alcohol use and causes amenable to medical intervention, such as tuberculosis and hypertension. Data were also obtained from health or multipurpose surveys given to 350,000 persons asking them about their general health. For each country, the association between socioeconomic status and health outcomes was measured with the use of regression-based inequality indexes.

Europe offered an excellent opportunities for this type of research because of the intercountry variety of political, cultural, economic, and epidemiologic histories and because good data on inequalities in health are often available.

In almost all countries, the rates of death and poorer self-assessments of health were substantially higher in groups of lower socioeconomic status, but the magnitude of the inequalities between groups of higher and lower socioeconomic status was much larger in some countries than in others.

Findings of interest included the following:

  1. Inequalities in mortality between socioeconomic groups and genders were small in some Southern European countries and very large in most countries in the Eastern European and Baltic regions.
  2. Though higher education was associated with lower mortality in all countries the ratio differed markedly between countries. In England, Wales, and Sweden lower education was associated with less than twice the mortality rate of the more educated persons. In Eastern Europe there was a four fold increase in mortality among the least educated. In the Basque country of Spain the disparities were less pronounced than anywhere else. Southern Europe seemed to be the healthiest area over all.
  3. Among men and women, smaller inequalities in the rate of death from any cause in the Southern European regions are due mainly to smaller inequalities in the rate of death from cardiovascular disease. For example, among men in the Basque country, where the education-related inequality in the rate of death from any cause is below the European average, decreased death from cardiovascular disease accounts for 45% of this difference. Larger inequalities in the rate of death from cardiovascular disease make an important contribution to larger inequalities in the rate of death from any cause in the eastern and Baltic regions as well; however, important contributions are also made by cancer in the eastern region and injuries in the Baltic region.
  4. I wonder about the effect of the Mediterranean diet on this reduction in cardiovascular mortality in men. The custom of eating a high fiber diet rich in monounsaturated fat and low in saturated fat, washed down with a little wine seems a more pleasant alternative to the Commonwealth Fund plan described above. Smaller scale studies really do show unexplained disparities in the way people are treated according to race and gender. But the reasons for this are not clear( See Below)
  5. Smoking and Drinking in Europe as whole, inequalities in mortality from smoking-related conditions, account for 21% of the inequalities in the rate of death from any cause among men and 6% of those among women. In Europe as a whole, inequalities in alcohol-related mortality account for 11% of inequalities in the rate of death from any cause among men and 6% of those among women.
  6. Deaths from conditions amenable to immediate to medical intervention account for 5% of inequalities in the rate of death from any cause when measured among social groups.

Discussion: The authors state that Smoking, obesity, excessive alcohol consumption, and deficiencies in health care represent only some of the determinants of inequalities in health. Yes, Social inequality is important. Yet within Western Europe, there is little evidence that among-country inequalities in health are related to variations in government support for health care. For example, Italy and Spain have welfare policies that are less generous and less universal than those of Northern Europe but they appear to have substantially smaller inequalities in mortality. Do overriding cultural factors, such as the Mediterranean diet and the reluctance of women to take up smoking outweighing government health care activities? Evidently they do. Cultural factors seem to have prevented differences in access to material wealth and other usual health related resources in these populations from translating into inequalities in lifestyle-related risk factors for mortality.

The study also found no evidence for a leveling of health inequalities among classes in countries in Northern Europe. This was surprising, because these countries have long histories of egalitarian policies, reflected in, among other things, welfare policies. These policies provide a high level of social-security protection to all residents of the country, resulting in smaller income inequalities and lower poverty rates. The studies results suggest that although a reasonable level of social security and public services may be a necessary to prevent inequalities in health, it is not sufficient. Lifestyle-related risk factors have an important role in premature death in high-income countries and also appear to contribute to the persistence of inequalities in mortality in Northern Europe.

New York Times Story June 5,2008

This kind of news report
is typical of media hype but is this where the real problem is?

“Race and place of residence can have a staggering impact on the course and quality of the medical treatment a patient receives, according to new research showing that blacks with diabetes or vascular disease are nearly five times more likely than whites to have a leg amputated and that women in Mississippi are far less likely to have mammograms than those in Maine.

The study, by researchers at Dartmouth, examined Medicare claims for evidence of racial and geographic disparities and found that on a variety of quality indices, blacks typically were less likely to receive recommended care than whites within a given region. But the most striking disparities were found from place to place.

For instance, the widest racial gaps in mammogram rates within a state were in California and Illinois, with a difference of 12 percentage points between the white rate and the black rate. But the country’s lowest rate for blacks — 48 percent in California — was 24 percentage points below the highest rate — 72 percent in Massachusetts. The statistics were for women ages 65 to 69 who received screening in 2004 or 2005.

In all but two states, black diabetics were less likely than whites to receive annual glycolated hemoglobin testing.( a test that monitors long term diabetic control) But blacks in Colorado (66 percent) were far less likely to be screened than those in Massachusetts (88 percent).

The study was commissioned by the nation’s largest health-related philanthropy, the Robert Wood Johnson Foundation, which on Thursday planned to announce a three-year, $300 million initiative intended to narrow health care disparities across lines of race and geography.
Such variations may be partly explained by regional differences in education and poverty levels, but researchers increasingly believe that variations in medical practice and spending also are factors.

“In U.S. health care, it’s not only who you are that matters; it’s also where you live,” wrote the study’s authors, led by Dr. Elliott S. Fisher.”

The fact that there are marked state to state variations seems to argue against racism as the cause of these disparities unless Colorado is more racist than Massachusetts. If the European study sited in the first part of the post holds true in the United States, changes in welfare and medical care should be expected to have only marginal effects on mortality as compared to life style and cultural changes. Perhaps the Johnson Foundation would get more bang for the buck by distributing cases of olive oil and wine to the disadvantaged.

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Do you have a link to the NEJM article?

Full article is free- see

Full article is free- see NEJM link at end of third paragraph

Dave - this is very good

I think you didn't get many comments because it's a lot to swallow. Only today did I get the time to read the primary sources.

You're a doc, right? I'd love to have more medical blogging, especially if it is about public health. I'd just advise you to try to make shorter posts. Otherwise people will just give up before reading them.


I figured anybody who can read an article like this one with sentences like this-"Type-D dualism: interactionist dualism. Consciousness, though non-physical, can have effects on the physical world. 2. Type-E dualism is epiphenomenalism, in which consciousness has no effect on the physical world. 3. Type-F dualism is panprotopsychism, in which the essence of the physical is in fact consciousness, or protoconscious properties." would be able to just breeze though my stuff. But from now on I will try to simplify.