The Lancet   Volume 359, Number 9318     11 May 2002

                      Policy and people

                      Poverty is main predictor of heart disease, says Canadian
report

                      Poverty is a greater predictor of heart disease than risk
factors such as smoking, obesity, stress, or blood
                      cholesterol concentrations, a Canadian sociologist says.

                      In a review of more than 100 studies on the causes of
heart disease, associate professor of health policy,
                      Dennis Raphael (York University, Toronto, Canada),
suggests: "the economic and social conditions under which
                      people live their lives, rather than medical treatments
and lifestyle choices, are the major factors determining
                      whether they develop cardiovascular disease". The report
was published on May 3 by the Centre for Social
                      Justice, a Toronto-based advocacy group.

                      Lifestyle approaches to improvement of cardiovascular
health, such as programmes to curb smoking or
                      obesity, are counterproductive, Raphael said in an
interview. They have the negative effect of pushing issues
                      like income distribution, community services, and public
transportation off the health-policy table. Poor people
                      end up blaming themselves for their heart disease and
"that's harmful because it diverts people from these
                      main contributors to their heart disease, which is
material deprivation, psychosocial stress, and the adoption of
                      unhealthy behaviours (like using drugs) as a result of
that stress".

                      Raphael's report, Social Justice is Good for Our Hearts,
which is yet to be published in a peer-reviewed journal,
                      suggests some 22% of life-years lost before age 75 years
(according to a Statistics Canada extrapolation) are
                      because of income differences. "Were all Canadians' rates
of death from cardiovascular disease equal to those
                      living in the wealthiest quintile of neighbourhoods, there
 would be 6366 fewer deaths each year from
                      cardiovascular disease", says Raphael.

                      The poor are at greater risk of developing heart disease
because of "social exclusion", Raphael argues.
                      "Individuals who suffer from material deprivation have
greater exposures to negative events such as hunger
                      and lack of quality food, poor quality of housing,
inadequate clothing, and poor environmental conditions at
                      home and work. In addition, individuals suffering from
material deprivation also have less exposures to
                      positive resources such as education, books, newspapers,
and other stimulating resources, attendance at
                      cultural events, opportunities for recreation and other
leisure activities", he says.

                      Some of the political remedies Raphael advocates are:
higher welfare and unemployment insurance outlays;
                      improved pay equity; establishment of a national
guaranteed minimum income; stronger antidiscrimination
                      legislation; higher taxes on the wealthy, including an
inheritance tax; a national housing strategy; and
                      creation of national day care and pharmacare programmes.
He also suggests "directing attention to the health
                      needs of immigrants and paying attention to the
unfavourable socioeconomic position of many groups and the
                      particular difficulties many New Canadians face in
accessing health and other care services".

                      Wayne Kondro

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