Blockchain Papers

Thierry Lang, Monique Kaminski, Annette Leclerc

Seen from France, this report underlines how far we still have to go in our country to reduce social inequalities in health. France is not one of the partner countries of the Commission1 and the conceptions of health determinants which are developed in the report appear far removed from the paradigm which predominates in our country. We can no longer say that France is at the ‘pre-contemplative’ stage:2 data exist, the phenomenon of social inequalities in health is known and well documented for numerous states of health. But these efforts, which issue largely from the world of research, have not resulted in a system of routine statistical surveillance. Furthermore, at this ‘contemplative’ stage, there is no explicit public policy and no objective written down in law. In the law on public health policy of 2004, objective 34 touches on this question, but restricts it to the state of health of the most precarious populations. As stated in the report, reduction of social inequalities in health is above all a political problem, but it is essential to provide evidence. In this respect, the report lends support to those who, in France, think that it is important to continue to increase our knowledge of the subject, but that the most pressing question is how we can move on to the active stage. It is strange to see how our country, always ready to give others lessons on human rights, tolerates a problem as well documented as social inequalities in health. Although the right to optimal health is laid down in a number of texts, this question of social justice and ethics does not mobilize opinion. This is so in France, but also throughout the world. The question thus remains to find out on what basis opinion and the decision makers can be mobilized. Though today it is unfortunately a fragile argument, it seems to us that the ethical imperative put forward in the report must remain central. The fact that the reduction of social inequalities can be a source of economic gain, as shown in a Canadian report,1 is an argument to be developed in order to remove economic objections, but it cannot be the central argument for mobilization. This report may well enjoy less popularity in France than a previous WHO report.3 In its World Health Report 2000, the World Health Organisation had no hesitation in describing the French health system as one of the best in the world. In that report, the conception of health determinants was in line with the prevailing conception in France. The health system was described as being the essential factor of the good health of a country. ‘If Sweden enjoys better health than Uganda—life expectancy is almost exactly twice as long—it is in large part because it spends exactly 35 times as much per capita in its health systems.’3 On the basis of this analysis, since 1945 France has enjoyed a system of social protection which proclaims, among its objectives, the improvement of the population's level of health. Within this system of social protection, the general health insurance system, completed by specific schemes for the poorest among the population, should allow widespread access to health care. The number of French people who have the benefit of insurance against ill health has constantly increased over the years and now almost the entire population is covered. In 2002, according to the Health and Social Protection survey, 91% of residents in France also had complementary coverage.4 At the same time, the mortality statistics remind us that in this country social inequalities in health are particularly marked in comparison with our European neighbours. This apparent paradox calls into question such a conception of health. The 2008 report puts the determinants back into perspective in a most useful way. On a world-wide scale, access to drinking water, to a diet which prevents malnutrition, protection against the vagaries of the climate are the major decisive factors in social inequalities in health. In line with this analysis, the report emphasizes actions which target determinants outside the health system and the need for a coherent policy in order to achieve health equity. A large number of spheres are involved, some of which seem a priori far removed from health: these are not only education, but also access to employment, working conditions, the age of retirement, the housing policy and lastly policies of redistribution, through taxation and direct financial aid. These are all relevant to social inequalities in health in France. The impact of investments concerning children at the very start of life and young people, in particular relating to education and training, is strongly pertinent to social inequalities in health, especially because of the links between education, qualification and health later in life. The role of unemployment and working conditions1 and of housing and transports are emphasized. In agreement with studies which have shown the protective influence of social networks and social support, and the role that a sense of control over one's life can play, citizens are encouraged to participate actively in decisions related to health—and this theme is a far-reaching one. Behaviour change is not mediated only by individual approaches to health education. The prices of food products, the industrial processing of foods, institutional catering, advertising, legislative measures and regulations are all paths to be explored. We must thus be delighted that the report stresses the intersectoral aspect of the fight against social inequalities in health, as this is a key issue. For example, the report points out the contradictions which were observed in certain Northern European countries when the common agricultural policy of the European Union came to thwart the efforts of the health authorities, themselves supported by the government.5 It thus will help to promote an intersectoral approach to health, at a national and at a European level, a choice which involves fundamental policy choices. For example, the increase in precarious employment, obligatorily part-time work, poorly paid jobs and their detrimental effects clearly shows that what is at stake here is the choice between a potential political determination and the predominantly economic (and short term) approach which is that of the liberal ideology. Just as for the issue of climate change, the fight against social inequalities in health is clearly revealed here as a global combat implying a choice of development strategy. Measurement and surveillance are one dimension of the solution. With the partial exception of death certificates and of a longitudinal survey of mortality based on the Permanent Demographic Sample, in France social characteristics are ignored by nearly all routine statistics, whether hospital information systems, health insurance data or registers of specific diseases. The data produced by research studies, generally based on one-off surveys or at best surveys repeated every few years, do not allow us to grasp changes in inequalities over time. The proposals for a minimum statistic system and a system which covers social determinants are important and should be developed in France. The information systems of healthcare institutions, starting with those of hospitals, are silent as to the social situation of those who use them, and this evidently restricts their ability to adapt their services to the needs of these persons. Naturally, the report does not elude the question of healthcare and advocates universal access to quality care. At a time when health expenditure is strictly limited, it is important to examine the question of patients’ share in these expenses and its effects on care consumption and health in the light of health inequalities. The Rand Corporation study,6 carried out in the 1970s in a sample of American families, followed for 3–5 years and randomly assigned to health insurance plans which differed by levels of reimbursement and the share to be paid by the household, is still topical. The conclusions of this randomized study showed that the amount of care consumed decreased markedly as soon as >25% of the cost was borne by the patient. No difference in state of health was observed in the population as a whole. But the impact of the cost to be borne made itself felt as soon as the poor population was concerned. It is interesting to point out that the share borne by the patient in France has been around 25% during the last 20 years, a proportion which has tended to increase. But the tendency in France is to increase the participation of households in health expenses, including (particularly) persons who are in a precarious situation because of their state of health, with in due course an impact on social inequalities in health. The report stresses the need for health systems to be proactive. Taking the need for proactivity into account is particularly pertinent in France, where the system is still widely based on a logic of offer. Issues related to secondary access to care are somewhat briefly dealt with in the report, which is strongly centred on primary access. But to ensure that this first phase is well organized is not sufficient if the system is ineffective in other respects, or if its malfunctions concern mainly the most disadvantaged patients.7 The report suggests that the role of the healthcare system goes beyond the treatment of diseases. Physicians and the other health professionals are leaders of opinion, who influence conceptions and representations of health. Finally, this is where analysis of health determinants is put together and where the directions taken by public health and research are given value. This last remark underlines the importance of giving professionals training on social determinants of health. Their commitment is undoubtedly essential to negotiate the turn towards less biological or medicinal concepts of health. The way in which behaviours are conceptualized in fact determines the way in which they will be taken into account by public health. In agreement with what we have said above, the presentation in the report of the aims of research in public health is particularly pertinent: research on the causes of social inequalities in health, on interventions aiming to reduce them, analysis of public policies and lastly statistical measurement and surveillance. In view of the issues at stake and of the nature of the determinants, research on health should be more interdisciplinary and should integrate social determinants. Redressing the balance towards these objectives should enhance their value, unlike a primarily biological or disease-oriented approach. The complexity of the interventions and so of the methods used to evaluate them justifies not only the interdisciplinary approach, but also a reflection on the notion of proof. Going beyond randomized trials, the question is how to make use of qualitative as well as quantitative data. Evaluation of interventions and strategies to reduce social inequalities in health raises a difficult problem, particularly when these are interventions of a structural type or which aim at long-term modifications. Assessing a research programme carried out in the Netherlands on social inequalities in health, it was found that the interventions subsidized by the programme had been specific, targeted interventions that were easy to evaluate. The projects evaluated were all of this type, to the exclusion of any wide ranging, far-reaching public policy.8 The causes of inequalities are multiple, and several levels of explanation coexist, proximal and fundamental causes. We pay tribute to the very ambitious nature of this report, which runs counter to the policies of international bodies (WTO) and so underlines the most fundamental causes of health inequalities. The main messages of the report are all the more essential as the financial and economic crisis may worsen inequalities by affecting the weakest first. Can health be the theme to mobilize us towards humane objectives, not only economic ones? The report stresses that the sector of health and healthcare professionals, including the minister or ministers responsible, could take position as defenders of wide societal objectives giving health and health equality their rightful place as a marker of progress. This supposes that professionals and politicians become aware of the importance of social determinants of health. This task is a particularly important one in France, and it is without doubt one of our primary challenges.

Neil Pearce

I wanted to like this book, and tried hard, but ultimately failed. I have recently written several papers on inappropriate corporate influences on the funding and conduct of epidemiological research, and have discussed several examples of hazards where the epidemiologic findings were strongly, and unethically, opposed by industry and by academic epidemiologists funded by industry.1–3 This book provides ‘the other side of the coin’ and discusses in depth four examples (environmental causes of breast cancer, electromagnetic fields and cancer, residential radon exposure and lung cancer and passive smoking) where, in the author's opinion, the health risks were low or non-existent, but were hyped by researchers and policy makers thus resulting in unnecessary research, inappropriate funding decisions and unjustified public concern. Such things certainly happen, and we need books like this which attempt to discuss them objectively, and which point out that academic researchers may also be affected by a range of influences including career and funding opportunities, even if they only accept peer-reviewed government funding and do not accept corporate funding. Thus, they may have incentives to overstate the evidence, just as industry and industry-funded epidemiologists may have incentives to negate or understate the evidence of health risks from environmental exposures. The book states its case well, is clearly written and discusses complicated issues in a relatively simple and readable way. It makes the case that ‘each side tends to cite the evidence that supports its point of view in order to influence public policy’ (p. 6) and that ‘the tendency to overstate the evidence, for whatever purpose, actually strengthens the opposing party's hand. It sanctions the partisan use of science that should be rejected, no matter who is engaging in it.’ (p. 7) The book also makes the important points that: (i) we have to some extent reached the limits of ‘risk factor’ epidemiology and have identified the strong risks (e.g. active smoking and lung cancer) and are now trying to assess weak risks (e.g. passive smoking and lung cancer), which are much more difficult to assess and much more prone to be overwhelmed by bias; (ii) for many of these risks (e.g. residential radon exposure and lung cancer) it is not possible to directly estimate the risks from low exposures, and it is necessary to make theoretical assumptions to interpolate from the findings of studies of highly exposed occupational populations (e.g. miners exposed to radon); and (iii) many of these risks are very small and have received perhaps excessive funding and scientific attention in comparison with other public health risks. So far so good. I agree with all of the above statements, and started reading the book in a positive frame of mind, with the expectation that it was an important book that would be an essential antidote to the writings of myself and others who have tended to emphasize the hazards of corporate influences. However, I became more frustrated and less impressed as I worked my way through the book, particularly when coming to discussions of issues that I had been involved in (e.g. electromagnetic fields and cancer). This probably reflects my own influences and prejudices. However, it became increasingly difficult, as I worked my way through the book, to avoid the conclusion that the discussions of these issues were, for want of a better word, ‘biased’, as well as being rather ‘grumpy’ and unpleasant in parts. It seems that no one can get it right. No single study is good enough or big enough, but meta-analyses should be discouraged because they combine studies from different exposure settings and with different methodologies. Researchers are criticized for arguing that ‘one must rely upon the evaluation of the data as a whole using expert judgement and the meta-analyses as a guide’ (p. 101), because this simply reflects their vested interests to continue researching a topic when an individual study is inconclusive. The findings of individual studies are dismissed because they are ‘not statistically significant’, even if they are consistent with previous findings. Significant associations are dismissed because they involved multiple comparisons, even if the specific associations were the a priori reason for the study and had been found previously [e.g. ‘the reported association [of EMFs with childhood] leukaemia was one of a very large number of comparisons made by the researchers and hence could well have arisen by chance’ (p. 100)]. Studies that show interesting dose-response associations verging on statistical significance, such as the National Cancer Institute childhood leukaemia study,4 are not only dismissed, but also researchers are condemned for not accepting the findings as proof of lack of risk (‘it is hard to escape the impression that the reluctance of the NIEHS working group to close the door on the possibility of EMF as a cause of leukaemia had more to do with its members’ stake in this area of research than with scientific rigor’ (p. 101). While every academic researcher who wants to study these issues apparently has a vested interest, even if their university salary is already funded, critics of the research are apparently unbiased, reasonable and objective, even if their criticisms are directly or indirectly funded by industry. Researchers into radon and lung cancer are biased because they do not repeatedly emphasize that tobacco smoking is the major cause of lung cancer, and that most cases of radon-induced lung cancer involve joint effects with smoking (the corollary that some cases of lung cancer in smokers are due to joint effects with radon exposure is never mentioned, nor is it mentioned that the same arguments could be applied to many other important lung carcinogens such as asbestos). The book gives particular emphasis to issues of biological plausibility, even though there are many historical examples of associations that were not biologically plausible when they were first discovered by epidemiologists, and the aetiological mechanisms involved were only subsequently discovered in laboratory-based studies. This is why, for example, all of the 30–40 known occupational causes of cancer (as classified by the International Agency for Research on Cancer) were first discovered in epidemiological studies, not in the laboratory. If it had been plausible that these substances caused cancer, then they would not have been used in the workplace. So epidemiology will always be in front of mechanistic research with regards to discovering new environmental and occupational causes of disease. The book also fails to mention that there are many historical examples of risks (dioxin and cancer is one example) where the evidence was initially weak and inconsistent but has strengthened over time (leading to the classification of dioxin as a carcinogen by the International Agency for Research on Cancer in 1997). So what are we supposed to do about ubiquitous environmental exposures that may carry weak risks, but which may account for a substantial number of cases of disease on a population level? Kabat's solution is nihilistic, namely that we simply should not study such exposures, or at least not attempt to quantify their effects: ‘it is entirely plausible that in some cases exposure to ETS may account for a few cases of lung cancer in nonsmokers, but … it is not possible to quantify the excess risk with any certainty’ (p. 150). The argument is essentially that the risks are too small to quantify accurately, and therefore should not be studied, or at least should not be estimated quantitatively. We are never told how we should decide if a risk is too ‘small’ to be concerned about if we do not first attempt to estimate its magnitude. And how are we supposed to tell the public that the risks are small (and their concerns are unimportant) without attempting to estimate them? And who decides what is a ‘small’ risk? The book finishes, literally on the last page, by advocating a ‘broader/integrative vision of epidemiology—one that can accommodate social, economic, and ecological/environmental realities … as well as rapidly evolving knowledge of the mechanisms of disease at the molecular level’ (p. 186).5–8 Such developments are to be encouraged, but they are intended to be inclusive, not exclusive, and we will have to continue to grapple with problems of studying weak risks from ubiquitous environmental exposures, even if they receive less attention than they have in the past. It is important to consider the influences on such research, including influences on academic researchers with regards to career opportunities and funding, even though these will continue to be relatively minor compared with the massive and pervasive influences of corporate funding of research and of critics of research.1–3 This book could have made a major contribution in this regard, but its lack of balance means that it fails to make such a contribution.

Lewis D. Solomon, Tricia Asaro

While Washington has been unable to lead the way in significant health care reform, the health care system has begun to transform itself in terms of curbing skyrocketing health care costs, dealing with the more than forty million Americans who lack health care coverage, and the problems plaguing the Medicare and Medicaid systems. The search has begun for a health care model that ensures quality care to a wide population in a cost-efficient manner. This article explores how the U.S. Health care system currently functions, examines several innovative models, and suggests ways in which a decentralized, community-based approach to health care reform can address our nation’s health care crisis. Specifically, Part I examines the current system of health care financing. Part II discusses current efforts to provide community based care. Part III offers suggestions for a community-based approach to health care reform, including ways to stimulate provider volunteerism, financing mechanisms, and methods to overcome potential legal barriers to local reform efforts.