To the Editor: Mackenbach et al. (June 5 issue)1 present interestingfindings on the magnitude of socioeconomic inequalities in healthin Europe, but they provide potentially misleading messagesto policy leaders. The authors show that inequalities in healthare smaller in Italy and Spain than they are in more egalitariannorthern European countries, and they conclude that there islittle evidence that the magnitude of inequalities in healthis related to political factors. However, their conclusionsare based on data that can hardly be considered to be comparable.Data from cities such as Turin (Italy), Madrid, and Barcelonado not include health variations across regions, which can beparticularly large in countries such as Italy.2 Furthermore,there is substantial heterogeneity across countries (especiallysouthern vs. northern Europe) in terms of the validity and reliabilityof health and socioeconomic data.3 Generalizations on the relationshipbetween egalitarian policies and inequalities in health shouldbe based on comparable evidence and a solid theoretical framework;this can prevent misleading interpretations of the importanceof societal determinants of inequalities in health and can promoteadequate policy responses to reduce them.
Roberto De Vogli, Ph.D., M.P.H. David Gimeno, Ph.D. Mika Kivimaki, Ph.D. University College London London WC1E 6BT, United Kingdom r.devogli{at}ucl.ac.uk
References
Mackenbach JP, Stirbu I, Roskam A-JR, et al. Socioeconomic inequalities in health in 22 European countries. N Engl J Med 2008;358:2468-2481. [Free Full Text]
Fantini MP, Stivanello E, Dallolio L, Loghi M, Savoia E. Persistent geographical disparities in infant mortality rates in Italy (1999-2001): comparison with France, England, Germany, and Portugal. Eur J Public Health 2006;16:429-432. [Free Full Text]
The authors reply: Studies using a variety of data sources,including harmonized surveys,1,2,3 have shown that variationswithin western Europe in the magnitude of socioeconomic inequalitiesin health are mostly uncorrelated with variations in welfarepolicies. Our study shows that inequalities in mortality aresmaller in some Spanish and Italian populations than those inother western European countries. Although we acknowledge thatthe situation in these urban regions may be different from thenational average, national data on Spain and Italy from the1980s also suggest that inequalities in mortality in these twocountries are smaller.4 This is unlikely to be due to the policiesor underlying political choices in these countries. The smallerinequalities in smoking, diet, and other immediate determinantsof inequalities in health in these countries more likely reflecttheir cultural and social histories. Although it is impossiblefor other countries to copy these histories, Spain and Italyprovide important policy lessons on how to reduce inequalitiesin health: tackling immediate determinants of such inequalitiesmay be an effective way to reduce health inequalities in countrieswith a reasonable level of welfare provision.
Since the publication of our article, we have discovered anerror in the mortality data from England, related to an ambiguityin the label of one educational category as used in this dataset. The corrected data are available with a revised versionof our article and the full text of this letter at www.nejm.org.These data show that we underestimated inequalities in mortalityin England and Wales, but none of the conclusions of our articleare substantially affected.
Johan P. Mackenbach, M.D., Ph.D. Irina Stirbu, M.Sc. Anton E. Kunst, Ph.D. Erasmus MC 3000 CA Rotterdam, the Netherlands j.mackenbach{at}erasmusmc.nl
References
Eikemo TA, Huisman M, Bambra C, Kunst AE. Health inequalities according to educational level in different welfare regimes: a comparison of 23 European countries. Sociol Health Illn 2008;30:565-582. [ISI][Medline]
Espelt A, Borrell C, Rodríguez-Sanz M, et al. Inequalities in health by social class dimensions in European countries of different political traditions. Int J Epidemiol 2008 March 13 (Epub ahead of print).
Dahl E, Fritzell J, Lahelma E, Martikainen P, Kunst A, Mackenbach J. Welfare state regimes and health inequalities. In: Siegrist J, Marmot M, eds. Social inequalities in health: new evidence and policy implications. Oxford, England: Oxford University Press, 2006:193-222.
Kunst AE, Groenhof F, Mackenbach JP, Health EW. Occupational class and cause-specific mortality in middle-aged men in 11 European countries: comparison of population-based studies. BMJ 1998;316:1636-1642. [Free Full Text]
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