BMJ  2008;336 (16 February), doi:10.1136/bmj.39490.460162.DE

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Health, wealth, and politics

The idea that, in a developed country, more equal distribution of wealth is associated with better health is remarkably provocative. Can it be true? Is it a scientific or political theory? Does it have any place in a general medical journal?

The BMJ pitched into this debate more than 10 years ago with a series of articles introduced by Richard Wilkinson, currently professor of social epidemiology in Nottingham (www.bmj.com/cgi/content/full/314/7080/591). Now Tony Blakely and colleagues shed further light on the Wilkinson hypothesis (doi: 10.1136/bmj.39455.596181.25). They examined trends in mortality in a natural experiment in New Zealand during the l980s and 1990s, when economic reforms led to rapidly increasing and then decreasing levels of poverty and unemployment and widening income inequality. Overall, people in all income groups got healthier over time. But the gaps in mortality between people on high, middle, and low incomes widened as social inequalities increased: this was mainly due to cardiovascular disease, although rates tailed off and cancer started catching up in the 1990s. In adults aged 25-44 overall mortality barely improved over the two decades, and the association between relative poverty and early death—mostly from unintentional injury and suicide—strengthened. The authors cautiously conclude that their findings may be consistent with a causal association between social and economic inequalities and mortality, but they do not and cannot go further than that.

The analysis is complex and not easy to interpret. Our decision to publish this paper is at least partly explained by one of the peer reviewers’ comments (on file) that "it is much easier to plough the well-tilled furrows of individual-level analysis of risk factors than to take on the methodological challenges of mapping associations between trends in inequalities in health determinants and in health outcomes. Yet for an evidence-informed debate about policies to tackle widening health inequalities, it is precisely Blakely-style work that we need."

If you’re tempted to write off this week’s BMJ as too political, don’t miss the chance to learn more about survival in stroke (doi: 10.1136/bmj.39456.688333.BE. doi: 10.1136/bmj.39456.470880.80) and the management of anorectal disorders (doi: 10.1136/bmj.39465.674745.80. doi: 10.1136/bmj.39455.393299.AD).

But politics won’t go away. Access to general practitioners has become a deeply politicised issue recently, and, as the BMJ went to press, we knew that the BMA was sending out advice to GPs on the government’s plan to extend their opening hours (doi: 10.1136/bmj.39489.411354.C2). General practitioner Iona Heath writes an open letter to prime minister Gordon Brown and accuses him of offering the public "an unattainable disease-free future [through treating every identifiable risk factor], the satisfaction of every wish, and an impossible availability of individual clinicians" (doi: 10.1136/bmj.39484.540127.59). Heath doesn’t comment specifically on the issue of general practitioners’ hours. Her concerns are about constructive joint working when politicians make promises that clinicians cannot keep.

The assumption that doctors and politicians should work together at all may seem alien to BMJ readers in many parts of the world. Here in the UK, however, every prime minister has to add to Bill Clinton’s 1992 campaign slogan "it’s the economy, stupid . . ." these three words: ". . . and the NHS."

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BMA advises GPs on longer opening hours

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