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Editor's Choice

In search of equity

BMJ 2008; 337 doi: (Published 03 September 2008) Cite this as: BMJ 2008;337:a1554
  1. Fiona Godlee, editor, BMJ
  1. fgodlee{at}

    It’s almost 30 years since the Black report on inequalities in health in England and Wales, commissioned in 1977 by a Labour government but given a cold reception in 1980 by their Conservative successors. In contrast, we have good reason to hope that WHO will embrace Michael Marmot’s far more ambitious report, commissioned by its former director general, Lee Jong-wook, and delivered to his successor Margaret Chan in Geneva last week.

    George Davey Smith has been critical in the past of such reports. His BMJ editorial, with colleagues, about the 1998 Acheson report on health inequalities was less than favourable ( This time around his, and Nancy Krieger’s, praise is fulsome (doi:10.1136/bmj.a1526). At last, he writes, an official report has the honesty and courage to say that social injustice is killing people on a grand scale. The real test, though, will be in what happens next. The report’s scope is enormous, covering a wide range of social determinants of health and diverse local circumstances around the world. Each country will need its own strategy for implementation, and any success will depend on government departments—health, education, employment, urban planning—working across their entrenched silos.

    Bids for equity appear elsewhere in this week’s BMJ. Direct to consumer advertising of prescription drugs turns out to cause disproportionate harm to women, says Barbara Mintzes in her editorial (doi:10.1136/bmj.a985). Campaigners in Canada are using this inequity—partly explained by women’s greater use of prescription drugs—to bolster the country’s consumer advertising ban, which is under assault from media groups as well as cross border advertising from the United States. In their longitudinal study, Michael Law and colleagues found that US television advertisements viewed in Canada caused a rise in prescriptions for tegaserod, a treatment for irritable bowel syndrome that was later withdrawn because of safety concerns (doi:10.1136/bmj.a1055).

    Another call for equity comes in this week’s head to head debate, which asks whether a national qualifying exam would be a fair way to rank medical students. Chris Ricketts and Julian Archer (doi:10.1136/bmj.a1282) argue that the UK’s current system of leaving it to individual medical schools is unfair. They call for more standardisation and a national curriculum to allow comparisons between medical schools. They also think this will improve patient care. Ian Noble (doi:10.1136/bmj.a1279) is not convinced. A national exam would, he says, damage diversity and innovation in medical education, would be hard to implement, and would emphasise knowledge over performance.

    Knowledge alone is clearly not sufficient in making good doctors, but it is necessary. You can test your knowledge in our new educational clinical quiz, Endgames (doi:10.1136/bmj.a107, doi:10.1136/bmj.a196, doi:10.1136/bmj.a207, doi:10.1136/bmj.a1482). Compiled from peer reviewed contributions from readers, it will cover clinical medicine and statistics. Short and long answers are available on There’s also a prize quiz, chosen from the BMJ’s sister product, OnExamination ( We hope you’ll find it educational and entertaining.


    Cite this as: BMJ 2008;337:a1554

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