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Published on 1 June 2002

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European health: are some more equal than others?

Brian Edwards CBE,
Professor of Healthcare Development,
University of Sheffield, UK

Many governments have targeted variations in health outcomes within their countries for action. The European Economic and Social Committee has recently been considering the problems of insecurity and extreme poverty across the whole of Europe. A recent review by the Chief Medical Officer for England confirmed a continued and marked gap between the north and south of England.(1) Some communities in the north had death rates similar to those seen in the 1950s. This reflects the intense concentration of poverty in the inner cities of the north of England.

Men in professional occupations have similar rates of death wherever they live, whereas rates for unskilled working men vary greatly between north and south. The most
disadvantaged in society have not been able to benefit from the health gains achieved by the most affluent. This supports the proposition that access to better education and employment opportunities, and living in a better quality environment, is associated with better health. While that may be stating the obvious, it has only recently been accepted in England and used as a basis for action.

From a health perspective, the EC looks to be heading in broadly the right direction in its struggle to eradicate poverty. It has targeted social exclusion, creating a genuine right to work for all citizens, sorting out asylum and immigration policies and eradicating illiteracy. The latter problem is now compounded by the additional problem of a skills gap in the area of new technologies.(2) These problems will be particularly acute in the candidate countries.

But while policies targeted at the most deprived will work, the greatest overall impact will come from investment in those communities with large numbers of blue-collar or manual workers. Smoking must be a particular target as it is most highly prevalent among these groups, and smoking cessation is the most powerful public health policy available. Sustained regeneration policies for defined communities seem to work, as do clear targets. The new English targets are:

  • Life expectancy – to reduce the gap in mortality between the areas with the lowest life expectancy at birth by at least 10%, and the population as a whole by 2010.
  • Children – starting with children under one year, to reduce by at least 10% the gap in mortality between manual groups and the population as a whole by 2010.
  • Child poverty – a 50% reduction in child poverty in ten years, looking to eradicate it within a generation.
  • Smoking – to reduce smoking rates among manual groups from 32% in 1998 to 26% by 2010.
  • Teenage pregnancy – to reduce the national under-18-years conception rate by 15% by 2004 and 50% by 2010, and to achieve substantial reductions at the bottom end of the range.

Meeting these targets will need more than action by the health sector. The whole of government has to be committed to them, and therein lies the greatest challenge.

The Spanish presidency will focus principally on economic matters. The budget deficit this year will be around 0.5% of the GDP, but real long-term interest rates should facilitate a relaunching of investment and economic activity. This should take some pressure off hard-pressed health budgets. The Community target of creating 20 million new jobs by 2010 has made some progress (2 million so far), but there is a long way to go. The health sector will benefit only if there is early investment in professional undergraduate training, particularly for pharmacists and nurses, who are in great demand in countries with expanding health sectors. England alone is looking to recruit 20,000 more nurses by 2004. If this training investment does not happen, the Community may find its richer members recruiting health professionals from member countries more in need. This will extend rather than reduce the variations in life expectancy and care.

The community needs a health manpower plan that can be used to set training targets for each country so as to avoid excessive poaching. This is an ethical as well as an economic question.

Brian Edwards CBE, Professor of Healthcare Development, University of Sheffield, UK


  1. Annual report of the Chief Medical Officer of Health for England (
  2. European Economic and Social Committee. Press release 05/2002.

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