Wednesday, November 15, 2006

This was to be a busy week. As soon as I finished teaching on the Tuesday afternoon it was off to Heathrow for a flight to Dublin. I was then whisked off to a hotel on the Irish border where I was giving one of the opening speeches the next day. Coming from Ireland, it was good to catch up with some old friends although, as is so often the case there, it was disappointing that so few public health professionals were participating.
The conference was on inequalities in health and had been organised (very well) by Owen Metcalfe and Jane Wilde from the Institute of Public Health in Ireland. Unusually, I had gone on holiday without a laptop in the summer, so I missed the e-mail arrived suggesting a title, but adding that if it caused any problems could I say so at once as the programme was about to be printed, until it was too late. As a consequence I had had to spend quite a lot of time trying to discover what does work in reducing inequalities in health! Still, it gave me a chance to update the lecture I give on this topic to my students, which I otherwise might not have done!
This is not an easy question. Perhaps the only think that definitely works is voting, with clear evidence that income inequalities narrow under left wing governments and widen under right wing ones. Otherwise the evidence is hard to come by. One reason is that the causal pathway between interventions and outcomes is slow complex and it takes so long for the results to become apparent. By this time it is almost impossible to separate the intervention from all the other things that had happened.
The usual source of evidence, the Cochrane Collaboration, was not, initially, much help – I got a message that “your search – inequality- did not match any documents”. However, it does contain a wealth of evidence on how to do something about the causes of inequalities, especially smoking. The Campbell Collaboration was much more helpful. This was the first time I had used it to any extent and I was struck by how much valuable material it contained. It has three strands: social welfare, education, and crime. Many of the reviews under these headings have considerable relevance to health.
In the end of the day, however, while it was possible to point to a large amount of evidence that could be used to design a strategy to reduce inequalities, I concluded that what you put in that strategy depended on what inequalities (social, ethnic, gender etc.) you wanted to tackle and what causes them to exist. What the ultimate result of such grand strategies will be is difficult to tell, and I found myself quoting Cho en Lai’s answer when asked whether the French Revolution was a good idea – “It’s too soon to say”. Perhaps the most important takeaway message is that when people do intervene, they should evaluate what they do so that others can learn from their experience.