Since I have worked as a researcher in France, I have seen the topic of health inequalities become increasingly fashionable. But does fashion amount to anything? Is progress being made, or is the political Zeitgeist just jumping on a bandwagon?
Health inequalities in France
There are marked socioeconomic health inequalities in France which are well documented and described. In 2002-2003, the life expectancy at the age of 35 was 5.7 years lower for men at the bottom of the occupational social class gradient versus those at the top (Danet 2010). In comparison with other European countries, inequalities in mortality are higher in France and on a par with the UK (Mackenbach, Stirbu et al. 2008). This tends to be explained by the particularly high mortality rate among men with manual occupations aged between 45-59 years (HCSP 2009). Cancer is the first cause of mortality in France among men, estimations have put cancer mortality as contributing to almost 40% of socioeconomic inequalities in total mortality (Kunst, Groenhof et al. 1998).
Despite universal health coverage, French socioeconomic health inequalities have continued to increase. The usual suspects are lined up to explain the widening gap between rich and poor in terms of health: life style and risky behaviours, occupational exposures, socioeconomic conditions, inequality across the social structure, psychosocial exposures, health selection, primary and secondary access to care etc. None of these culprits can stand alone in explaining health inequalities; instead, they highlight the multifaceted nature of the problem. Results from research highlighting these issues, describing socioeconomic health inequalities and developing theories about causes and prevention has now begun to work its way upstream to the political institutions.
Health inequalities and policy
Reducing health inequalities has taken on a prominent role in French public policy, featuring as a goal in the Plan cancer II 2009-2013, an important policy document outlining the direction of research, preventive action, treatment and patient support in dealing with the first cause of male death in France (INCA 2009). A central aim in the recent creation of the Regional Health Agencies has been to reduce health inequalities using broad-scale as well as specific interventions and health promotion policies (Basset 2008). In 2009, the Haut Conseil de Santé Public published a watershed report where social inequalities in health in France were defined and described, with 16 separate recommendations made to reduce inequalities by setting up interventions, public policies and furthering research (HCSP 2009). The report and its public policy recommendations were strongly influenced by many of the UK department of health policy documents.
Initial projects aiming to reduce health inequalities have focused primarily on vulnerable or at-risk subgroups of the population. However, there has been a shift in the discussion about tackling health inequalities with increased attention on reducing the socioeconomic gradient in health outcomes. This change in rhetoric was suddenly apparent during a conference in Paris in January 2010 where policy makers, NGO representatives and researchers were all referring to the importance of ‘the gradient’. Having attended this conference with some colleagues, we were pleasantly surprised by the apparent banality in referring to the socioeconomic gradient, and the acceptance that health inequalities needed to be addressed in this more complex form. Indeed, in her concluding remarks, Roselyne Bachelot, the French health minister, said that “it is necessary to broaden the issue of social inequalities in health across the social gradient as a whole, without diverting our attention from the specific health problems faced by the most fragile among us”.
As most of us know, favorable political rhetoric does not equate to realistic intervention and effective public health outcomes. However, we are now observing a positive impact downstream in the funding of intervention projects on the ground. Many of the French funding agencies now make money available specifically to projects targetting health inequalities, such as the Agence National de Recherche (ANR), the Institut de Recherche en Santé Publique (IRESP), and the Institut National du Cancer (INCa).
One example of this is the IBISS project, funded by the ANR, aiming to study the biological embedding of the social environment leading to the all pervasive socioeconomic gradient. This project brings together biologists, psychologists, epidemiologists, sociologists, philosophers, ethicists and demographers to answer the question: “how does the social environment get under our skin?”. Another example is the AAPRISS project currently underway in the Midi-Pyrenées region, funded by the ANR and INCA. Its objective is simple: to support projects already underway within local institutions targeting cancer prevention and enable them to incorporate health-inequality reducing mechanisms in their implementation. A close partnership is therefore essential between researchers and those involved in intervention such as the hospital, the city hall, the urban planning department etc. The project has been met with enthusiasm by grass-roots partners.
The topic of health inequalities has been in the limelight thanks to its fashionable status; continued political will is what will facilitate change
The overall picture in France is encouraging, as the preoccupation with understanding and reducing health inequalities seems to have permeated into each structural level from politics to policy via research. The next challenge remains to evaluate interventions, and continue to fund essential research. Above all, to maintain this positive momentum requires continued political will.
-Basset, B., Ed. (2008). Agences régionales de santé; les inégalités sociales de santé. Saint Denis, INPES.
-Danet, S. (2010). “Les caracteristiques des inégalités sociales de santé.” Actualité et dossier en santé publique 73: 8-14.
-HCSP (2009). Les inégalités sociales de santé : sortir de la fatalité. Paris, HCSP (Haut Conseil de la santé publique).
I-NCA (2009). Plan Cancer 2009-2013. Boulogne-Billancourt, Institut National du Cancer, Ministère de la santé et des sports, Ministère de l’enseignement superieur et de la recherche: 140.
-Kunst, A. E., F. Groenhof, et al. (1998). “Socio-economic inequalities in mortality. Methodological problems illustrated with three examples from Europe.” Revue D Epidemiologie Et De Sante Publique 46(6): 467-479.
-Mackenbach, J. P., I. Stirbu, et al. (2008). “Socioeconomic inequalities in health in 22 European countries.” New England Journal of Medicine 358(23): 2468-2481.