Dear Mel
I think I agree. My main point was to suggest that we should not dismiss conventional risk factors so easily, based on the idea that they apparently explain very little. They remain important targets for intervention. That doesn't mean we do very well at those interventions or that they are socially progressive but nevertheless, these conventional risk factors matter. Recent papers suggest that as much as 60% of social inequality in health across Europe is due to smoking. Maybe thats too high but dismissing smoking would be a mistake.

Not sure that in 2. below, the gradient would be less steep - absolute levels might be lower at every point on the social scale but not necessarily less steep - may be even steeper if as you say, interventions are less effective among socially disadvantaged groups - which they are. But absolute risk would have declined among the less advantaged. Which do we care more about - relative or absolute gradients? Of course the ideal is to reduce both absolute and relative health inequality - but how?

And you are right, we have a pretty lousy track record at interventions aimed at behaviors and physiological risk factors. But 1. that does not mean we should deny their importance at the population level as significant parts of the causal chains of population levels and inequalities, and 2. levels of these risk factors have nevertheless declined markedly in rich countries in terms of secular trends in the population - what are the social causes of that? While income inequality has risen markedly since the 70s, cholesterol and blood pressure etc have declined?

Regards

John


-----Original Message-----
From: Social Determinants of Health on behalf of Mel Bartley
Sent: Fri 8/4/2006 10:36 AM
To: [log in to unmask]
Subject: [SDOH] risk factors etc
 
Dear colleagues

I am finding this really interesting. See what you think
of my attempts to understand the different points.

If nobody smoked or ate too much any more:
1. There would still be a bit of heart disease in the population but
about 80% less 
2. There would still be a social gradient, but a less steep one
3. So by taking action to wipe out smoking and over-eating
we would have saved a large number of lives, and more lives
among the less privileged social groups.

This may not be correct! But if so, then I think the next
question should be about the most effective ways to
combat smoking and over-consumption of food relative
to exercise. We know from 20-30 years' experience that
health education as currently practised is not too good at
this They may even increase health inequality by being
less effective in less privileged social groups (this was
true in the 1970s but not sure if we can still say this any
more). Maybe the next step would be to understand better
what it is about certain lifestyles that make smoking and
over-consumption less attractive?

Mel Bartley





Mel Bartley
ext 41707
mobile: 07746 823099
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