Tackling health inequalities in the enlarged European Union
Authors: Ilona Koupil
Journal: BMJ (2005)

Inequalities in health refer to a broad range of differences in health experience and health status between countries, regions, and social groups. Health inequities are avoidable inequalities that are unfair and unjust.1 The UK government has launched a national drive to improve social justice,2 and now tackling health inequalities has become a key health theme for the UK presidency of the European Union. To explore the scope for action on social and economic determinants of health the presidency is bringing together European and international experts at the “Tackling Health Inequalities: Governing for Health” summit in London this week.

Earlier this month, the Nobel Assembly at Karolinska Institutet announced its decision to award the Nobel Prize in physiology or medicine for 2005 to Barry J Marshall and J Robin Warren for their discovery of the bacterium Helicobacter pylori, which is associated with chronic disease of the upper gastrointestinal tract.3 The prevalence of H pylori differs greatly both between and within countries, with high rates of infection being associated with low socioeconomic status and poor living and housing conditions in childhood.4

Most infected people have acquired H pylori infection during childhood, and people with low socioeconomic status who have infected family members are at the highest risk.5 In many high income countries, the rate of H pylori infection has fallen markedly over recent decades, and the relatively low rate of infection in young people in developed countries seems to be due largely to improved housing conditions during this century.6

Despite the recent decline in prevalence of infection in the new EU member states,7 the infection is still considerably more common among the populations of central and eastern European countries than in western Europe.8 How to reduce this difference and its accompanying morbidity and mortality is known, and this difference should concern European policy makers as much as those in national governments.

Overall, the citizens of the central and eastern European countries tend to have poorer health and shorter life expectancy than those in western Europe. Compared to the body of evidence on health inequalities within western European countries, however, the social determinants of health in the transition countries of central and eastern Europe have been researched less. The available data provide persuasive evidence for substantial and increasing health inequalities in several of these countries, for instance in Estonia during the transition period after 1991.

The difference in life expectancy at birth between Estonian and Russian men resident in Estonia increased from 0.4 to 6.1 years between 1989 and 2000, mainly owing to increasing differences in alcohol related adult mortality.9 Between 1989 and 2000, differences in total mortality related to educational level among adults increased for all age groups in Estonia: life expectancy at age 25 increased in university educated men and women but declined by more than two years in those educated only to lower secondary school level or below.10 There is some good news. For example, the recent achievements in reducing neonatal and infant mortality in Estonia to levels comparable with many European countries are quite remarkable. But the accompanying increase in health inequality due to disproportionately greater improvements among more advantaged social groups in mean birth weight and reduction in rates of preterm births remains a cause of concern.11

Successful collaborative projects on health inequality across Europe have tended to focus on documenting and monitoring socioeconomic gradients in ill health and mortality. Despite the methodological difficulties in making valid comparisons of inequalities in health between socioeconomic groups defined in various ways, this research has yielded valuable information on the dynamics of health inequalities over time and across countries, showing—to varying degrees in all societies—that health inequalities are not immune to policy intervention.

Now other dimensions of social position such as ethnicity, gender, age, religion, and place of residence are attracting increasing interest, and underlying social and biological mechanisms that are clearly relevant to inequality in specific health outcomes are being uncovered. Evidence on long term effects of early life environment, intergenerational mechanisms in transfer of health and social disadvantage, and the availability of “life course” methodological approaches12 open yet further possibilities for better understanding the aetiology of health inequalities between and within countries.

Health inequalities across Europe as a whole are large, with some regions of Europe increasingly lagging behind. This concerns many citizens in Europe and ought to be tackled by European institutions. Current attempts to promote European links and stimulate concerted action to reduce health inequalities are timely. These efforts should not remain restricted to policies implemented within member states of the European Union and should also stimulate and contribute to tackling health inequality across countries and beyond the union's borders.