Reducing Health Inequalities Is a Matter of Swimming against the Current

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Reducing health inequalities is very much a matter of “swimming against the current”, says Professor Johan Mackenbach, Chair of the scientific committee of the ALLEA-FEAM report Health Inequalities Research: New Methods, Better Insights? “When societies become more unequal, as they do in many European countries, it is very hard to stop the health consequences of these inequalities from widening”, he explains in this interview with the ALLEA Digital Salon.

As one of the leading experts in public health in Europe, Mackenbach has dedicated a career to understanding the underlying causes of what makes some sicker than others. He has (co-)authored more than 700 papers in international, peer-reviewed scientific journals, as well as a number of books, and is a former editor-in-chief of the European Journal of Public Health. Over the course of his prolific career, he has come to recognise that there are no quick fixes to close the health inequalities gap, but points out that with more advanced research methods now available to understand causal mechanisms, perhaps more effective policy interventions can be developed.

“Only a few countries in Europe have taken serious action to translate scientific insights into policies and interventions to reduce health inequalities.”

Question: In the presentation of the report Health Inequalities Research: New Methods, Better Insights?, you said that health inequalities have no clear tendency to decline, and persist in even the most advanced welfare states.  What are some first steps that we can take to narrow this gap?

Johan Mackenbach: It is indeed disappointing that, despite the growth of scientific knowledge on health inequalities, European countries have not been successful in narrowing the gap in morbidity and mortality between socioeconomically disadvantaged people and their richer or better educated counterparts. This is partly due to lack of effort: unfortunately, only a few countries have taken serious action to translate scientific insights into policies and interventions to reduce health inequalities. However, it is also partly due to the fact that trying to reduce health inequalities is very much a matter of “swimming against the current”: when societies become more unequal, as they do in many European countries, it is very hard to stop the health consequences of these inequalities from widening. While this shows that there is no “quick fix”, a lot can be done to reduce health inequalities. Let me give a few examples: Improve working conditions for people in physically or mentally hazardous jobs. Tackle socio-economic inequalities in smoking by raising the price of cigarettes and by offering free smoking cessation support to disadvantaged smokers. Alleviate poverty, particularly among children. Remove barriers to health care, including primary and preventive health care services, in disadvantaged areas.

“In many European countries, smoking is number 1 among the many factors contributing to health inequalities.”

Q.: The study underlines that there is reasonably strong evidence for a causal effect of the number of years of education on mortality in mid-life. Could you elaborate on why this causal effect happens?

J.M.: This is probably due to a cumulation of various beneficial effects of longer, or more, education. Education in large part determines people’s occupational opportunities, and thereby people’s living conditions throughout life. Education also helps people deal with complex problems, such as coping with financial stress or choosing a balanced diet. In addition to these indirect effects, there is also the more direct effect of education on people’s “health literacy”, which is important for understanding health risks and finding your way in the health system. More highly educated people also tend to marry a highly educated partner, which acts as a flywheel for all these beneficial effects.

“If smoking would not be more prevalent among the low educated than among the high educated, inequalities in life expectancy would be reduced by a quarter to a third.”

Q.: What is it not widely known about the causes of health inequalities that we should make people more aware of?

J.M.: In many European countries, smoking is number 1 among the many factors contributing to health inequalities. If smoking would not be more prevalent among the low educated than among the high educated, inequalities in life expectancy would be reduced by a quarter to a third, particularly in North-western Europe where smoking has become highly concentrated in socioeconomically disadvantaged groups. However, what people need to be made more aware of is not this simple fact, but the brutal reality underlying these numbers. The reality of going to school in a poor neighbourhood, where social norms are often pro-smoking and where the likelihood of starting smoking at a young age and thereby getting addicted to nicotine, is much higher. The reality of living in socioeconomic disadvantage makes smoking cessation as an adult much more difficult. And the brutal reality of a tobacco industry which continues to sell its deadly products to people who already have a lower expectancy and deserve to be better protected. If you do not understand these underlying factors, you could be misled to think that health inequalities are mainly a matter of individual responsibility.

“New methods can take advantage of “natural experiments” in which socioeconomic conditions change as a result of non-health-related changes in legislation.”

Q.: The ALLEA-FEAM report provides a review of a new generation of quantitative methods and assesses their contributions in comparison with “conventional” methods. What are the most important takeaways of this evaluation?

J.M.: These new methods can help us answer a number of unanswered questions on the explanation of health inequalities. Scientists are pretty sure that smoking causes lung cancer and other health problems, but they are less certain about causality in the case of education and income versus health, because conventional research methods are more suitable for investigating the health effects of easily identifiable factors like smoking, than for investigating the health effects of socioeconomic conditions. These new methods can help to fill some of these gaps in knowledge, for example by taking advantage of “natural experiments” in which socioeconomic conditions change as a result of non-health-related changes in legislation. This is nicely illustrated by studies looking at the long-term mortality experience of people going to school before and after a change in legislation, which increased compulsory school leaving age by one year. Those who, in this “natural experiment”, went to school longer, simply because they were born later, turned out to live longer as well.

“While there can be no doubt that people living in poverty on average live shorter lives, and suffer from more illnesses during their lives, it is less clear whether this reflects a causal effect of low income on health, or perhaps has other explanations, such as differences in cognitive ability or personality characteristics.”

Q.: As these new methods are being applied, to what extent are they contradicting or shedding light on previous findings regarding the causes of heath inequalities? Could you give an example?

J.M.: An important “contradictory” finding relates to the health effects of low income. While there can be no doubt that people living in poverty on average live shorter lives, and suffer from more illnesses during their lives, it is less clear whether this reflects a causal effect of low income on health, or perhaps has other explanations, such as differences in cognitive ability or personality characteristics. Ideally, one would like to study this by conducting a true experiment in which people are randomized into groups with a higher and a lower monthly income. However, this is only rarely feasible, and these new methods now help scientists take advantage of “natural experiments” in which people receive a higher or lower income as a result of, e.g., a sudden change in welfare benefits or winning a prize in a lottery. Results from these studies have found some evidence for a causal effect of higher or lower income on children’s health and on mental health in adulthood, but surprisingly little evidence for a causal effect of higher or lower income on physical health in adulthood. Because of its policy relevance, this is clearly an area for further research.

“It is essential to include an inequalities perspective in climate change mitigation and adaptation policies, and to make sure that these policies duly protect those who need it most.”

Q.: In your book A History of Population Health: Rise and Fall of Disease in Europe, you argue that the rise of so many diseases indicates that their ultimate cause is not to be sought within the body, but in the interaction between humans and their environment. What does the increasing degradation of the environment and the worsening climate crisis mean for the emergence of new diseases?

J.M.: I am very concerned about the effect of climate change, biodiversity loss, wide-spread chemical pollution and other environmental changes on human health. New health problems are emerging on the horizon before we have solved the problems of the past, such as the tobacco epidemic or, indeed, health inequalities. Unfortunately, health inequalities are likely to become even wider in the future if we do not take effective countermeasures. Climate change is already affecting the health of people in many low-income countries, and when serious effects of climate change reach high-income countries, they will certainly also affect disadvantaged groups more than the rich and high educated. It is therefore essential to include an inequalities perspective in climate change mitigation and adaptation policies, and to make sure that these policies duly protect those who need it most.

About Johan Mackenbach

Johan Mackenbach is Professor Emeritus of Public Health and former chair of the Department of Public Health at Erasmus MC, University Medical Center Rotterdam, the Netherlands. His research interests are in social epidemiology, medical demography, and health policy. He has (co-)authored more than 700 papers in international, peer-reviewed scientific journals, as well as a number of books, including Health inequalities: persistence and change in European welfare states (Oxford University Press, 2019). He is a former editor-in-chief of the European Journal of Public Health, and has been actively engaged in exchanges between research and policy, among others as a member of the Health Council of the Netherlands and the Council for Public Health and Health Care. He is also a member of the Royal Netherlands Academy of Arts and Sciences and the Academia Europaea.

Final Conference: ‘Health Inequalities: New Methods, Better Insights?’

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Hosted virtually by the Royal Netherlands Academy of Arts and Sciences (KNAW) on 8 December, the conference served as the official presentation of the final report produced within the cross-disciplinary ALLEA-FEAM Health Inequalities project.

 

The ALLEA-FEAM report presented at the conference highlights new analytic methods that can help the scientific community to better understand the causal relationship of certain social determinants, such as education, occupational class, and income level, in generating and reproducing health inequalities in Europe. Examples of such new methods include “counterfactual” approaches to assess the causal effect of socio-economic conditions on health, and “natural experiments” to evaluate the to evaluate the impact of policy interventions on health inequalities.

The conference was chaired by Professor Johannes Siegrist, Medical Faculty of the Heinrich Heine University Düsseldorf and member of the ALLEA-FEAM Scientific Committee on Health Inequalities. Speakers included Professor Johan Mackenbach, Director of the Department of Public Health at the Erasmus University in Rotterdam and Chair of the ALLEA-FEAM Scientific Committee; Professor Sjaak Neefjes, Professor of Chemical Immunology at Leiden University Medical Center and KNAW Board Member; and Professor Ana Diez Roux, Professor of Epidemiology at Drexel University, among other experts.

Professor Annette Grüters-Kieslich delivers the closing remarks on behalf of ALLEA.

The closing remarks were delivered by Professor Emeritus of Pediatrics at Charité and ALLEA Vice Pre-sident, Annette Grüters-Kieslich. Professor Grüters-Kieslich praised the interdisciplinary nature of the study and called for a rethinking of research into health inequalities not only at a national level, but also at a European level, as the mechanisms and consequences of inequalities in health transcend political borders. On the value of the report, Professor Grüters-Kieslich remarked:

I am confident that if stakeholders from research, policy, and the wider society come together, there is a potential to see a timely change for the better. The valuable report certainly delivers the necessary data to facilitate immediate actions.

This conference represents the conclusion of the joint ALLEA-FEAM-KNAW project on the topic of health inequalities. You can watch the full conference below or on the KNAW website.

 

 

Read the ALLEA-FEAM report ‘Health Inequalities Research: New methods, better insights?’: Short version / Full report.

Learn more about the ALLEA-FEAM-KNAW joint project on health inequalities here.

 

New Methods to Study Health Inequalities Require Investments in Data Infrastructures, European Academies Report Says

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A new generation of scientific methods are helping to better understand health inequalities in Europe, but investments in data infrastructures are required to make use of its full potential for informing policymaking, European academies say in a new report.

The COVID-19 pandemic has struck disadvantaged groups in society much more severely than others. As a result, the health gap between socio-economic groups has widened, exacerbating inequalities long known to researchers. A better understanding of these inequalities is therefore more important than ever.

In the Health Inequalities Research: New methods, better insights? report published today, experts from the European Federation of Academies of Sciences and Humanities (ALLEA) and the Federation of European Academies of Medicine (FEAM) evaluate scientific methods to study health inequalities with the aim of helping to narrow the health gap across Europe.

“In many European countries, differences in average life expectancy at birth between people with a lower and a higher level of education, occupation, or income amount to between 5 and more than 10 years, and differences in healthy life expectancy often amount to even more than 15 years”, the document says.

Issues in the field of health inequalities are not new to policymakers and have, over the past four decades, been studied extensively by researchers from various disciplines. However, there is still substantial uncertainty about several important issues, such as the extent to which socioeconomic disadvantage causally affects health, and the effectiveness of interventions to reduce health inequalities.

In the newly published report, experts on the scientific committee, chaired by the Royal Netherlands Academy of Arts and Sciences (KNAW), conclude that a range of new analytic methods are a “valuable addition to health inequalities researchers’ tool-box” and should be used as a complement to conventional research methods to resolve these issues and reduce the uncertainties.

Examples of such new methods include “counterfactual” approaches to assess the causal effect of socio-economic conditions on health, and “natural experiments” to evaluate the effect of interventions on health inequalities.

Research using these new methods can play an important role in informing policies to narrow the health gap but requires investments in data infrastructures which allow these methods to be applied, the experts highlight.

The experts therefore call on the European Commission and on national governments to support research on health inequalities, including research that takes advantage of variation in socioeconomic conditions, health outcomes and policies between European countries.

Final conference “Health inequalities: new methods, better insights?” on 8 December

The debate on health inequalities research methods began in 2018 and had as its starting point a discussion paper prepared by the ALLEA-FEAM interdisciplinary scientific committee. Under the chairmanship of Johan Mackenbach of the KNAW, the experts on the committee developed this work further over the last few years and as a result, produced the report.

The official presentation of the Health Inequalities Research: New methods, better insights? report will take place at a symposium to be held on 8 December 2021, 13:30 – 17:30 CET. The event, hosted by KNAW, will be organised in Amsterdam in a hybrid format.

Under the theme How can new research methods help address COVID-related health inequalities?, researchers and policymakers will discuss how to capitalise on new research methods in the field of health inequalities.

Registration and Conference Programme

Download publication (short version, full report)

Expert Workshop on Causality of Health Inequalities Held Online

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On 2 December, the Scientific Committee of the ALLEA-FEAM-KNAW project on Health Inequalities in Europe welcomed external experts to its second workshop, which was held online. Dedicated to exploring causality of socioeconomic inequalities in health, over 50 participants analysed and debated new approaches to assessing causality in an interdisciplinary dialogue. 

Recent quasi-experimental studies have pointed out that a direct relationship between socioeconomic position and health could not be confirmed, and that factors such as education or income may not always lead to the assumption that there is a causal effect of such factors on health. Meanwhile, novel findings in genetics suggest a stronger role of genetic predisposition in ‘confounding’ as opposed to the causal effect of the indicators such as socioeconomic position and physical and mental wellbeing. This and other related perspectives were introduced and discussed by leading European experts in the field, who were joined by their North American counterparts despite the early hour across the pond.  

Moderated by Axel Börsch-Supan, member of the National Academy of Leopoldina and Johan Mackenbach, Chair of the Scientific Committee of this tripartite project, workshop attendees emphasized the importance of causation both in the scientific as well as policy context. As such, they called for the need to adequately address socioeconomic disadvantages vis-à-vis policymakers in a unified voice from scientists. 

Initially set to take place in March 2020 at the Leopoldina Academy in Berlin, this meeting was shifted to an online format due to the restrictions brought on by the current pandemic. In a next step, the Committee will start preparing the final workshop of this project, which will aim at evaluating current policies and interventions to reduce health inequalities. 

Read more about ALLEA’s Health Inequalities activities

Migrants need better access to healthcare, European Academies say

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EU and national authorities need to act now to support the health of migrants, according to European academy networks ALLEA and FEAM.

In a joint statement published today, European academy networks ALLEA and FEAM call on EU and national authorities to undertake crucial actions to support the health of migrants. This situation has become more critical as the lack of basic services and overcrowded conditions in refugee camps start to sound alarms all over Europe, especially during the coronavirus crisis.

The statement reviewed evidence showing that, in contrast to previous concerns, the transmission of communicable diseases from migrants does not appear to be a substantial problem. However, evidence also shows that migrants and other vulnerable populations are at high risk for several non-communicable and communicable diseases, including COVID-19.

“During this terrible crisis the issue of migrant health has been almost completely forgotten in Europe,” says Professor Luciano Saso, Vice-Rector for European University Networks of Sapienza University of Rome. “Forcibly displaced migrants are still struggling to reach Europe, exposing themselves to COVID-19. The incipient economic crisis threatens to further reduce the resources allocated by the EU to face migrant health issues.”

Academies recommend wider and easier access to healthcare services for forced migrants, and at least basic and emergency healthcare for irregular or undocumented migrants. Early access to healthcare may also lead to cost-savings for host countries.

According to Professor Alfred Spira, a member of the French Academy of Medicine,

“All international and European legal instruments recognise the right of everyone to the enjoyment of the highest attainable standard of physical and mental health, and all EU Member States should act to allow access to these basic human rights for everyone, including migrants and refugees.”

The coronavirus crisis has provided a global opportunity to enhance the integration of migrants while addressing shortages of healthcare workers. The recommendations within this statement, though drafted before the COVID-19 outbreak began, have acquired new relevance as several countries such as Germany, the UK, the US and Australia are incorporating refugees with foreign qualifications to address shortages in their health workforce.

The document concludes that reliable, validated and comparable data across countries and regions is the key element that will inform policies and confront myths around migration and health. Academies offer their support to lead the dialogue and scientific work to guide policies in this complex area.

This statement has been published at a time when developing evidence-based policies is particularly important. These recommendations, if transformed into policy, will enhance the protection of migrant health and of public health overall.

The recommendations from the academies include:

  • More scientifically validated data and frequent updates on migrant health should be produced and reflected in evidenced-based policies.
  • Increased cross-sectorial collaboration is needed to address current challenges in migrant health, also with a view towards tackling shortages of healthcare workers.
  • The health sector should be actively involved in policy discussions and actions on migration.
  • National health systems should allow for personal health information to be easily transportable and accessible while ensuring the protection of personal data.

The statement and the full set of recommendations is available in the publications section.  

This statement came about as the result of a joint ALLEA-FEAM conference on Migration, Health and Medicine held on 22 November 2019 in Brussels. Attended by stakeholders from research, policy and the civil society, this event strove to approach the topic of migrant health from a multidisciplinary, cross-sectoral point of view and in a coordinated fashion transcending national boundaries. This places the Academies of Sciences and Medicine in a critical position as they offer impartial scientific advice to policymakers for taking informed decisions.

Academic community calls for multidisciplinary approach to reduce health inequalities

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Inequalities in health may have different causes, yet the most persistent and man-made are linked to the social factor. Socio-economic position, education or access to healthcare are likely to have considerable impact on our physical and mental wellbeing, as they do on the susceptibility to diseases. So what can societies and especially lawmakers do to reduce the inequalities caused by these factors?

Around 200 researchers, civil society representatives, and members of the public discussed these and further questions at the “Social Inequalities in Health Symposium“. The event was organised by Académie nationale de médecine in partnership with ALLEA and FEAM, the Federation of European Academies of Medecine, and took place on 22 January 2020 in Paris.

‘Sadly, health inequalities in all European countries are increasing even though we know many of the causes. It was stressed at the symposium that with so much evidence at our disposal we need to act decisively and bring stakeholders from research, civil society, policy and the wider society together to develop policies concerning inequalities.‘, says Professor Graham Caie, Vice President of ALLEA, who chaired the session on health systems, education and mental health. ‘Medical, social and educational factors of health inequalities are closely interlineked and require a multidisciplinary approach. Our networks of academies can assist with finding the best experts to investigate this vitally important topic.’

The recent symposium in Paris followed a successful joint conference of ALLEA and FEAM in November 2019 in Brussels. This event looked further into exploring how vulnerable groups such as migrants often find themselves challenged for various reasons, from language barriers to adaptability of healthcare systems in receiving countries.

The following day, invited experts from across Europe and North America attended a workshop focusing on key methodologies of health inequalities research. This meeting emerged from a joint ALLEA-FEAM-KNAW (the Royal Netherlands Academy of Arts and Sciences) project that seeks to synthesise the evidence-base and identify consensus among the various disciplines involved in the subject of health inequalities. A subsequent expert workshop will address causalities and socioeconomic inequalities in health will take place on 18 March in Berlin.

Conference report ‘Migration, Health and Medicine’ released

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The ALLEA-FEAM report of the conference ‘Migration, Health and Medicine’ is now available. The publication summarises the discussions of the event held in Brussels on 22 November 2019. It provides the basis for a scientifically sound analysis on migrant health and, among other topics, addresses the methods and strategies to collect valid and comparable data on this issue.

The conference was organised by ALLEA and the Federation of European Academies of Medicine (FEAM), and hosted by the Royal Academies of Medicine of Belgium (ARMB and KAGB) in collaboration with the French Academy of Medicine (ANM).

Migrant health from a scientific perspective

Migrant health is determined by multiple factors, from socio-economic aspects of health to biological and environmental interactions influencing the health of migrant populations. However, the generalisation of research findings from one community or from one country to the regional or global levels faces considerable hurdles.

From the policy side in Europe, the complexity increases due to the various levels of governance at the EU. Whereas many aspects of migration and health can be dealt with an EU approach, the provision of healthcare services is managed by Member States.

The report seeks to inform policy debates on this pressing issue from a scientific perspective. It also underlines the need for academia, policymakers, civil society and international organisations to join forces to provide scientifically validated data on the health of refugees and migrants across Europe and the world.