Correspondence

Correction

Socioeconomic Inequalities in Health in 22 European Countries

N Engl J Med 2008; 359:1290-1291September 18, 2008

Article

To the Editor:

Mackenbach et al. (June 5 issue)1 present interesting findings on the magnitude of socioeconomic inequalities in health in Europe, but they provide potentially misleading messages to policy leaders. The authors show that inequalities in health are smaller in Italy and Spain than they are in more egalitarian northern European countries, and they conclude that there is little evidence that the magnitude of inequalities in health is related to political factors. However, their conclusions are based on data that can hardly be considered to be comparable. Data from cities such as Turin (Italy), Madrid, and Barcelona do not include health variations across regions, which can be particularly large in countries such as Italy.2 Furthermore, there is substantial heterogeneity across countries (especially southern vs. northern Europe) in terms of the validity and reliability of health and socioeconomic data.3 Generalizations on the relationship between egalitarian policies and inequalities in health should be based on comparable evidence and a solid theoretical framework; this can prevent misleading interpretations of the importance of societal determinants of inequalities in health and can promote adequate 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@ucl.ac.uk

3 References

1. 1

   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
   Full Text | Web of Science | Medline

2. 2

   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
   CrossRef | Web of Science | Medline

3. 3

   Gnesotto R, DeVogli R. Health Monitoring Systems in Europe: structures and processes. Activity report: conclusions and recommendations. Venice, Italy: European Commission Health Monitoring Program, 2003. (Accessed September 2, 2008, at http://ec.europa.eu/health/ph_projects/2001/monitoring/fp_monitoring_2001_frep_13_en.pdf.)
   

Author/Editor Response

Studies using a variety of data sources, including harmonized surveys,1-3 have shown that variations within western Europe in the magnitude of socioeconomic inequalities in health are mostly uncorrelated with variations in welfare policies. Our study shows that inequalities in mortality are smaller in some Spanish and Italian populations than those in other western European countries. Although we acknowledge that the situation in these urban regions may be different from the national average, national data on Spain and Italy from the 1980s also suggest that inequalities in mortality in these two countries are smaller.4 This is unlikely to be due to the policies or underlying political choices in these countries. The smaller inequalities in smoking, diet, and other immediate determinants of inequalities in health in these countries more likely reflect their cultural and social histories. Although it is impossible for other countries to copy these histories, Spain and Italy provide important policy lessons on how to reduce inequalities in health: tackling immediate determinants of such inequalities may be an effective way to reduce health inequalities in countries with a reasonable level of welfare provision.

Since the publication of our article, we have discovered an error in the mortality data from England, related to an ambiguity in the label of one educational category as used in this data set. The corrected data are available with a revised version of our article and the full text of this letter at www.nejm.org. These data show that we underestimated inequalities in mortality in England and Wales, but none of the conclusions of our article are 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@erasmusmc.nl

4 References

1. 1

   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
   CrossRef | Web of Science | Medline

2. 2

   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).
   

3. 3

   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.
   

4. 4

   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
   CrossRef | Web of Science | Medline

Citing Articles (2)

Citing Articles

1. 1

   E. Regidor, A. E. Kunst, F. Rodriguez-Artalejo, J. P. Mackenbach. (2011) Small socio-economic differences in mortality in Spanish older people. The European Journal of Public Health
   CrossRef

2. 2

   Cleon Tsimbos. (2010) An assessment of socio-economic inequalities in health among elderly in Greece, Italy and Spain. International Journal of Public Health 55:1, 5-15
   CrossRef