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REFERENCES 1. Institute of Medicine. Diseases of importance in developing countries. In: New vaccine development; establishing priorities, vol II. Washington: National Academy Press, 1986. 2. Simanjuntak CH, Hoffman SL, Punjabi NH, et al. Epidemiology of typhoid fever in a semiurban area, Paseh, West Java. Cermin Dunia Kedokteran 1987; 45: 16-18. 3. Budiarso R, Putrali J dan, Muchtaruddin RL, Putrali J dan Muchtaruddin. Household survey 1986. Jakarta: Department of Health, Indonesia, 1986. 4. Hoffman SL. Typhoid fever. In: Strickland GT. Hunters tropical medicine, 6th ed. Philadelphia: WB Saunders, 1984: 282-97. 5. Yugoslav Typhoid Commission. A controlled field trial of the effectiveness of phenol and alcohol typhoid vaccines. Bull World Health Organ 1962; 26: 357-69. 6. Ascroft MT, Singh B, Nicholson VC, Ritchie JM, Sobryan A, William F. A seven-year field trial of two typhoid vaccines in Guyana. Lancet 1967; ii: 1056-60. 7. Polish Typhoid Committee. Controlled field trials and laboratory studies on effectiveness of typhoid vaccines in Poland 1961-64. Bull World Health Organ 1966; 34: 221-22. 8. Tapa S, Cvjetanovic B. Controlled field trial on the effectiveness of one and two doses of acetone-inactivated and dried typhoid vaccine. Bull World Health Organ 1975; 52: 75-80. 9. Yugoslav Typhoid Commission. A controlled field trial of the effectiveness of acetone-dried and inactivated and heat phenolinactivated typhoid vaccines in Yugoslavia. Bull World Health Organ 1964; 30: 623-30. 10. Hejfec LB, Salmin LV, Lejtman MZ, et al. A controlled field trial and laboratory study of five typhoid vaccines in the USSR. Bull World Health Orgn 1966; 34: 321-39. 11. Germanier R, Furer E. Isolation and characterization of gal E mutant Ty21a of Salmonella typhi: a candidate strain for a live, oral typhoid vaccine. J Infect Dis 1975; 131: 553-58. 12. Hornick RB, Du Pont HL, Levine MM, et al. Efficacy of a life oral typhoid vaccine in human volunteers. Dev Biol Stand 1976; 33:
89-92.
13. Wahdan MH, Serie C, Cerisier Y, Sallam S, Germanier R. A controlled field trial of live Salmonella typhi strain Ty21a oral vaccine against typhoid: three-year results. J Infect Dis 1982; 145: 292-95. 14. Levine MM, Ferriccio C, Black RE, Germanier R, Chilean Typhoid Committee. Large-scale field trial of Ty21a live oral typhoid vaccine in entenc-coated capsule formulation. Lancet 1987; i: 1049-52. 15. Ferrecio C, Levine MM, Rodriguez H, Contreras R, Chilean Typhoid Committee. Comparative efficacy of two, three or four doses of Ty21a live oral typhoid vaccine in enteric-coated capsules. A field trial in an endemic area. JInfect Dis 1989; 159: 766-69. 16. Levine MM, Ferreccio C, Cryz S, Ortiz E. Comparison of enteric-coated capsules and liquid formulation of Ty21a typhoid vaccine in randomised controlled field trial. Lancet 1990; 336: 891-94. 17. Hornick RB, Greisman SE, Woodward TE, et al. Typhoid fever: pathogenesis and immunologic control. N Engl J Med 1970; 283: 686-91. 18. Darmowigoto R, Hoffman SL, Soeprawoto, et al. Typhoid and paratyphoid fever in Plaju, Sumatra, 1978-1983. 11th International Congress for Tropical Medicine and Malaria; 1984 Sept 16-22; Calgary, Canada. p 193. 19. Edwards PR, Ewing WH. Identification of enterobacteriaceae, 3rd ed. Minneapolis: Burgess, 1972. 20. Hoffman SL, Punjabi NH, Rockhill RC, et al. The duodenal string capsule culture compared to bone marrow, blood and rectal swab cultures for diagnosing typhoid and paratyphoid fever. J Infect Dis 1984; 149: 157-61. 21. Acharya IL, Lowe CU, Thapa R, et al. Prevention of typhoid fever in Nepal with the Vi capsular polysaccharide of Salmonella typhi. N Engl J Med 1987; 317: 1101-04. 22. Klugman KP, Gilbertson IT, Koornhof HJ, et al. Protective activity of Vi capsular polysaccharide vaccine against typhoid fever. Lancet 1987; ii: 1165-69. 23. Tagliabue A, Nencioni L, Caffarena A, et al. Cellular immunity against Salmonella typhi after live vaccine. Clin Exp Immunol 1985; 62: 242-47. 24. Tagliabu A, Villa L, De Magistris MT, et al. IgA-driven t cell-mediated anti-bacterial immunity in man after live oral Ty21a vaccine. J Immunol 1986; 137: 1504-10.
PUBLIC HEALTH What can be done about
A mountain of evidence has accumulated on the issue of inequalities in health. The existence and the extensive nature of the problem have been described in several European countries,’including lately those in the centre and east of the region.8 This widespread evidence shows systematic and avoidable differences among social, ethnic, and geographic groups in the population in terms of both health status and access to, uptake of, and quality of health care. Many of these differences are also unjust and unfair.9 The debate is no longer about whether inequalities in health exist, but what can be done about them. This is the question asked by many policy-makers and practitioners when faced with the facts. But the solutions may seem so complex that people can easily become frozen into inaction. This is the impression gained from the 1991 draft health strategy for England,l° as well as other policy documents in
Europe. Is this pessimism justified, or can the knowledge and experience gained from around Europe be used to make a start on tackling the issue? Background research carried out for a World Health Organisation discussion paper on the subjectll has convinced us that there are grounds for modest optimism.
inequalities in health?
Changing climate Three general observations can be made on the various responses from different parts of Europe. First, in some places inequality in health has changed from a political non-issue in the 1960s and 1970s to one occupying centre stage in the past few years; in several countries it has become politically feasible and timely to take action. In some places, the medical profession has taken a leading role in raising awareness of the issue and campaigning for action, whereas in others it has been conspicuously silent. Second, where action has taken place it tends to start with small, manageable problems rather than tackling the whole subject in a comprehensive, coordinated plan. Particular issues have been addressed when a cause of public concern is seized upon and used to gain support for a policy initiative. Specific health targets to improve health status among disadvantaged groups can be found in programmes concerned with health care, social services, and working ADDRESSES: The Old School, Ash Magna, Whitchurch, Shropshire SY13 4DR, UK (M. Whitehead, BA), and Institute for Futures Studies, Stockholm, Sweden (G. Dahlgren, MA).
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conditions. Curiously, the impact that wider programmes aimed at improvement of economic or social conditions will have on health is rarely acknowledged explicitly, though undoubtedly it will be substantial. Third, initiatives have been taken at different levels, from national governments to small neighbourhood groups or individual health professionals working through their daily contacts. Successful initiatives often entail cooperative action across sectors on the living and working conditions of socioeconomic groups at high risk of poor health. Such responses show that something can be done about inequalities in health, but there is no universal blueprint for success. On the contrary, effective policy to tackle inequalities in health has to be tailored to suit the systems operating in a specific country or district. However, there are some common factors and much is to be learnt from the varied experiences of other countries.
Options for change Several
starting points
could be considered.
Here,
we
propose four types of action to illustrate some of the options.
A focus on infant health One with a
approach to choosing priorities for action is to start particular health problem or disease that shows disparities between social groups and to tackle the determinants of the health problem either singly or in combination. Since social inequalities in health are evident for most diseases and from birth to old age, there is a wide choice of starting points. We have chosen infant health as an example, because inequalities in infancy are striking and regarded as unacceptable by the public. Attention to infant health also represents an investment in the future health of the nation, and it is an issue on which health services can take an active lead. Disparities in health are evident in perinatal and infant mortality and morbidity, in birthweight, in infectious diseases and accidents, in height (an indicator of nutrition in childhood), and in dental health. The pattern continues throughout childhood. If all children in the United Kingdom enjoyed the same survival chances as the children of professionals and managers, over 3000 child deaths a year might be prevented .12 A national strategy to tackle these differences comprehensively would recognise first the need for an adequate income for parents, as well as improvements in child care and housing. But more specific actions can be taken, particularly within health service policy. It has been estimated, for instance, that perinatal mortality in the UK could be reduced by 20% if all antenatal screening tests of proven value were fully implemented.13 Several of the tests seek disorders with strong social gradients, and uptake of antenatal care is lower in less advantaged social groups; action to improve implementation, access, and uptake would therefore have a positive effect not only on the overall perinatal mortality but also on the gap between social groups. The same could be said for other maternal and child health services: if we ensured that all sections of the community had access to contraception and abortion services, for instance, the prevalence of undesirable factors such as early and unwanted pregnancies, high parity, and insufficient spacing between births would decline. Similarly, if immunisation services reached every child, death and disability from infectious diseases, which at
in infants living in the poorest The Netherlands health would be reduced. circumstances, authorities have improved immunisation rates among babies of Moroccan and Turkish immigrants through changes in clinic times and schedules to take account of cultural barriers to services use.14 Inequalities in the dental health of children have been decreased by local measures such as fluoridation of the water supply.ls Also, there are individual doctors and nurses who make sure that the pregnant women and mothers with small babies in their care receive all their social security entitlements and nutritional
present
are commonest
supplements. Enhanced social and psychological support from caregivers is also important, since it can affect the health of mothers and babies on a range of morbidity and quality-ofcare indicators.16,17 Since there is strong evidence that maternal smoking reduces average birthweight, there is a place for sensitive support and advice on quitting smoking in pregnancy; such action would have an effect on inequalities in those countries where there is a social gradient in maternal smoking. However, education is likely to be effective in this context only if offered with some understanding of the way some women use smoking as a means of coping with difficult social conditions.18 In successful schemes sponsored by statutory and voluntary agencies women from disadvantaged communities have given each other support to recover from depression, to overcome social isolation, and to reduce child behaviour problems.19 The point is that, if the health sector made a concerted effort to ensure universal access to the essential services under its control, it could make a valuable contribution to reducing inequalities in infant and child health. Health professionals would then be in a much stronger position to press for the necessary improvements outside the health care
sector.
The approach of choosing a disease or health problem as a starting point has the advantage that effort is concentrated on a single issue. The World Health Organisation’s programme on immunisation, for example, has very effectively mobilised effort to reduce or even eradicate specific infectious diseases in Europe. However, a drawback of the disease-oriented approach is the risk that there will be a predominantly medical response when wider strategies are
also needed.
Improvement of working conditions Another approach is to choose one or more of the health-damaging factors related to the conditions in which people live and work. Conditions that restrict opportunities for people to achieve their full health potential include poverty, unemployment, inadequate or unsafe housing, stressful or dangerous working conditions, and restricted nutritious diet. Richard Smith has set out wide-ranging proposals on what the medical profession could do in relation to unemployment and health .20 There have been several calls lately for a response from public health professionals to the problems of housing and homelessness.21-23 In this article, we focus on working conditions to illustrate that a range of possibilities is available at different levels of organisation. In addition to accidents at work and designated occupational diseases, common work-related disorders include musculoskeletal disorders and stress-related illness linked to the workplace. Working conditions play an important role in inequalities in health-the lower the occupational class the more likely are people to experience access to a
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poor working conditions, including physical strain, serious injury, greater noise and air pollution, shift-work, a monotonous job, and a forced pace of work with fewer voluntary pauses.1 In Sweden, poor working conditions were judged to be the main determinant of inequalities in somatic diseases among occupational groups .24 Since workrelated migration has escalated across Europe, some appalling conditions have arisen for migrant and other low-paid workers, and there are instances of international companies applying different standards in different countries and of children working in unprotected
conditions. So what can be done? Despite achievements made over centuries to improve working conditions and reduce risks of serious accidents, there is obviously a need for further countermeasures. There have been some promising initiatives that point to several types of action. Firstly, governments could experiment with incentive schemes in addition to traditional safety legislation, though this will always be important. In Sweden, for example, a special fund was created by the Government by means of a short-term tax on business from September to December, 1990. The substantial sum of money raised is being paid back over 5 years in grants to companies that put forward good proposals for improvement of working conditions. Such a fund can be raised in other ways-the state of Victoria in Australia uses a levy on tobacco products to create a substantial health promotion fund each year. Secondly, people in the workforce could become more active in investigating and putting forward ideas for improvements in their own immediate surroundings, with encouragement and help from researchers and occupational health personnel. When the Swedish Labour Organisation (LO; the national confederation representing over two million manual workers in the country) realised that its members had an above-average risk of ill health, it initiated a 5-year programme to improve health and narrow the gap between the members and other groups. Although the programme was centrally funded and coordinated, people in each separate branch decided their own priorities for action. The workers of one company near Stockholm, for instance, chose to focus on the reduction of heart disease, but to include not only changes in personal behaviour but also negotiated improvements in the factory canteen, better provision for shift-workers, changes in working hours, and more appropriate training for safety delegates.2s There is also scope for much more cooperation between researchers and people in the workforce, so that workers survey their own working conditions and health problems and put forward ideas for improvements, based on their experience
of the job.26-27 Thirdly, environmental
and public health professionals could become more skilled at identifying work-related illness and could press harder for improvements in the workplace. In the UK, four projects have been initiated to identify work-related illnesses more effectively in primary health care settings. Occupational health workers are employed jointly by family health services authorities and general practitioners to build up occupational histories in patients’ notes. Patients are interviewed at the doctor’s surgery and hearing and lung function are tested. Individual patients are then advised on their right to compensation and social security benefits and put in touch with self-help support groups. In addition, the database on patients is used to look at patterns of illness and to relate diseases to specific industries or hazards.28
The approach of choosing a risk factor in the environment has the advantage that some of the clearly inequitable root causes of ill health are tackled. Several diseases could be affected by action on one risk factor. On the other hand, health is rarely a prime consideration in decisions on housing, employment, and trade and industry policy. Trade-offs over priorities have to be made which mean that rapid progress is unlikely.
Adding equity to the policy equation A third approach is to make sure that in any health policy more attention is paid to how health status, health hazards, and health services are distributed within a population. All too often at present, policies rely solely on overall rates of health indices and risk factors and the distribution is overlooked. Perhaps this point is easiest to illustrate in the context of preventive services, such as cervical cytology. Many schemes aim to achieve uptake rates of 90% or more and thus the prevention of a substantial number of deaths. However, if no attention is paid to the fact that cervical cancer is more prevalent in certain social groups, which also tend to have low uptake of preventive services, an uptake rate of 90% may not secure the predicted saving of life-the people at highest risk of the disorder are likely to be within the 10% of the population who do not take up the service. Here is what we propose in this case: that targets are set to reach all sections of the population; that use of services by social group and geographic area is monitored; and that additional plans are made to increase use in low-uptake areas (for example, by means of mobile screening clinics, by active case-finding and opportunistic screening in general practice, or by employing extra nurses for home visits). These general principles could be applied to most of the priority targets in national health strategies around Europe-the reduction of smoking-related diseases, accident prevention, improvement in nutrition and rates of physical activity, pollution control, and so on. Action on smoking-related diseases, for example, should recognise the heavier burden of such illness among less privileged groups and their poorer survival chances.129 Action to reduce such inequalities could include: tobacco pricing policy, known to have the strongest influence on consumption in low-income and younger age groups;30° restrictions on tobacco advertising and sponsorship, particularly those forms aimed at groups at high risk; the use of educational techniques, which are most effective in the less educated groups;31 more sensitive advice and support for those living in stressful, disadvantaged conditions;and action on inequalities in referral and specialist investigations by different groups of doctors--oncologists, cardiologists, public health specialists, and general practitioners, for example-auditing their referral and treatment procedures. This approach has been adopted by Finland, which has set national health goals on both the level and the distribution of health and health care.32 In Sweden, a parliamentary bill adopted in June, 1991, requires all national public agencies and authorities to report to Parliament on specific goals to reduce inequalities in health in different social and occupational groups and to analyse the health impact of all national policies. An Institute of Population Health has been set up to develop policies to improve health-related conditions for disadvantaged groups and to make sure these are scientifically sound. Thus, formal mechanisms are now in place for monitoring of, reporting
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on, and
planning action on inequalities in health across Government departments in Sweden. In the Netherlands, a national research and policy development committee on inequalities in health has also been set up to inform policy decisions.33 Evidence from the committee was available when a new health insurance system was being discussed and the possible effects of the proposed changes on equity were fully aired. The efficiency and effectiveness of health strategies in general would improve as the problems of those at greatest risk were taken into account, and also the health gap would decline in the long term as improvements raised the level of health of the most disadvantaged groups.
Auditing European policy The dramatic changes happening in Europe provide unique opportunities to address the issue of inequalities in health, not only within countries but also between them. increasing health divide between the east and west of Germany is now one nation’s problem, impossible to ignore. For countries already in the European Community and the many that may join, decisions made in Brussels will have an increasingly important effect on living and working conditions around the region. Policy decided at the Community level has a strong influence in each member state on, for example: price, availability, and quality of food; production, pricing, and promotion of tobacco; availability and price of alcohol; water safety standards; working conditions; pollution control; and transfer of health personnel between countries. Furthermore, the economic policy of the European Community aims to even out the differences between countries; large amounts of money are redistributed towards less developed regions to foster development. The Social Fund also concentrates effort in the most disadvantaged areas, giving priority to unemployed people, people with disabilities who wish to join the labour market, and migrant workers and their families. The European Commission is working on common policies for immigration and refugee asylum, and looking at the different benefits obtainable from The
health and social services. Although there is great potential for these policies to affect health in general and health inequalities in particular, health impact is not explicitly taken into consideration in any of these decisions and there are many anomalies-the funding of tobacco growing in one part of Europe and restriction of tobacco promotion in the rest, for example. What is needed at the Community level is a health impact approach to assess as far as possible the effect on health inequalities of European policy decisions. In the long term, the aim would be to have explicit health objectives for all policies affecting the health status of the population. Although the European Community has no official remit on health matters, people interested in public health in each member state can press for action on such issues through several channels-for example, by lobbying the healthrelated committees of the European Parliament; by briefing each member state during its six-month term holding the presidency of the Community; and by liaising with the umbrella organisations that represent non-governmental agencies from different countries. After the revision of the Treaty of Rome in December, 1991, the Community may have a little more authority to take action on major health issues. In the long term, however, the power of the Community to reduce inequalities in health could be enhanced by the appointment
of a senior member of the Commission to coordinate the actions of the ten departments that currently cover healthrelated matters. Alternatively, a separate public health directorate could be created with a major focus on equity in health. Within the context of European action, it would also be logical to implement the resolution unanimously adopted by the World Health Assembly in 1986 which called on all member states of the World Health Organisation "to use the health status of the population and in particular its changes over time among disadvantaged groups as an indicator for assessing the quality of development". Acceptance of this recommendation would mean the introduction of an indicator of social development alongside the grossnational-product index of economic development. The use of social inequalities in health as an indicator for social progress and quality of development would also reinforce the understanding of the economic and social roots of the health divide. To change European policy in this way is obviously a long-term challenge, but it has the potential for great influence on inequalities.
Conclusion These are just some of the available ways in which to start taking action on inequalities in health. We argue that national and local health strategies would be more efficient and more likely to achieve their targets if more attention were paid to the issue of equity. The gains could be even greater if efforts at different levels and in different sectors were coordinated into soundly based national and European policies. But the strongest arguments of all for doing something about inequalities are still those concerned with fairness and basic human rights.9 Substantial sections of the community are prevented from achieving their full health potential, which is surely unacceptable for Europe in the 1990s. We thank Anna Ritsatakis and Erio Ziglio for their advice and the World Health Organisation for financial and technical support in researching this
subject. REFERENCES 1. Fox J. Ed. Health inequalities in European countries. Aldershot: Gower, 1989. 2. Illsley R, Svensson P-G, eds. The health burden of social inequities. Copenhagen: WHO Regional Office for Europe, 1986. 3. Kohler L, Martin J, eds. Inequalities in health and health care. Gothenberg: WHO/Nordic School of Public Health, 1985. 4. Department of Health and Social Security. Inequalities in health: report of a research working group (The Black report). London: DHSS, 1980. 5. Whitehead M. The health divide. London: Penguin, 1988. 6. Gunning-Schepers LJ, Spruit IP, Krijnen JH, eds. Socio-economic inequalities in health: questions on trends and explanations. The Hague: Ministry of Welfare, Health, and Cultural Affairs, 1989. 7. Vogel J, Andersson L-G, Davidsson U, Häll L, eds. Inequality in Sweden: report no 58. Stockholm: Statistics Sweden, 1988. 8. Wnuk-Lipinski E, Illsley R, eds. Social equity and health in non-market economies. Soc Sci Med 1990; 31: 833-89. 9. Whitehead M. The concepts and principles of equity and health. Copenhagen: WHO Regional Office for Europe, 1990. 10. Department of Health. The health of the nation: a consultative document for health in England. London: HMSO, 1991. 11. Dahlgren G, Whitehead M. Policies and strategies to promote equity and health. Copenhagen: WHO Regional Office for Europe (in press). 12. Whitehead M. Deaths foretold. Guardian, 7 Dec 1988. 13. Wald NJ, ed. Antenatal and neonatal screening. Oxford: Oxford University Press, 1984. 14. Gunning-Schepers L. A policy response to socio-economic differences in health. Paper presented to the meeting of the European Community project on socio-economic factors in health and health care, Lisbon.
May, 1991.
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CL, French AD, Rugg-Gun AJ, Furness AJ. The relationship between social class and caries experience in five year old
15. Carmichael
children in Newcastle and Northumberland after 12 years of fluoridation. Community Dent Health 1984; 1: 47-54. 16. Oakley A, Rajan L, Grant A. Social support and pregnancy outcome. Br J Obstet Gynaecol 1990; 97: 155-62. 17. Enkin M, Keirse M, Chalmers I. Guide to effective care in pregnancy and childbirth. Oxford: Oxford University Press, 1990. 18. Graham H. Women and smoking in the United Kingdom: the implications for health promotion. Health Promotion 1989; 3: 371-82. 19. Pound A. Newpin and child abuse. Child Abuse Rev 1991; 5: 7-10. 20. Smith R. Unemployment and health. Oxford: Oxford University Press, 1987. 21. Morris JN. Inequalities in health: ten years and little further on. Lancet 1990; 336: 491-93. 22. Acheson ED. Edwin Chadwick and the world we live in. Lancet 1990;
336: 1482-85. 23. Roderick P, Victor C, Connelly J. Is housing a public health issue? A survey of directors of public health. Br Med J 1991; 302: 157-60. 24. Lundberg O. Den ojämlika ohälsan. Om klass—och konsskillnader i sjuklighet (Inequities in health-differences in class and gender morbidity). Stockholm: Almqvist and Wiksell International, 1990. 25. Lundberg B. The LO health project: trade union health promotion in
Sweden. Paper presented to the European Conference on Health Promotion in the Workplace. Barcelona: April, 1991. 26. Reich M, Goldman R. Italian occupational health: concepts, conflicts and implications. Am J Public Health 1984; 74: 1031-41. 27. Lundberg B, Starrin B. Fighting health hazards at work: experiences from participatory research on workplace-related health issues. Research report no 1. Karlstad, Sweden: Centre for Public Health Research, 1990. 28. Sheffield Occupational Health Project. Occupational health workers in primary health care. Sheffield: Sheffield Occupational Health Project, 1989. 29. Kogevinas M, Marmot MG, Fox AJ, Goldblatt PO. Socio-economic differences in cancer survival. J Epidemiol Community Health 1991; 45: 216-19. 30. Townsend J. Cigarette tax, economic welfare and social class patterns of smoking. Appl Economics 1987; 19: 355-69. 31. Jamrozik K, Vessey M, Fowler G, Wald N, Parker G, Van Vunakis H. Controlled trials of three different anti-smoking interventions in general practice. Br Med J 1984; 288: 1499-503. 32. Ministry of Social Affairs and Health. Health for all by the year 2000: the Finnish national strategy. Helsinki: Ministry of Social Affairs and Health, 1987. 33. Gunning-Schepers L. How to put equity in health on the political agenda. Health Promotion 1989; 4: 149-50.
VIEWPOINT Obstacles to brain death and organ
transplantation
in
Japan
The modernisation of Japanese society took place after the 1960s, when rapid economic growth was achieved, and fundamental shifts in culture must have occurred since then.
perish.
My studies in the late 1980s showed that Japanese funeral rituals longer involve the complex and prolonged commitment of relatives or neighbours. They have become momentary events managed by commercial agencies, supplanting family and community bonds. A similar change has occurred in burial practices, where the tradition was for extended-family graves. A poll conducted by the Prime Minister’s office in 1990 showed that 86-8% of 3000 respondents living in urban areas wanted to share
no
Japan neither the concept of brain death nor the practice of organ transplantation are accepted.1 I would like to explain the cultural background to this resistance. In seeking social consensus on the desirability of medical interventions affecting life and death it is important to understand what is meant by "person". Is the notion individual or collective? In American society for example, the concept of personhood arises from the Judaeo-Christian view of the soul: "soul" and "personhood" clearly identify human life as individualistic, occurring and perishing within individuals.2 Traditionally, the Japanese view of life and death has regarded personhood as a collective reality. Birth In
and funeral rites in traditional communities show that a newborn baby was not considered a person until he or she had been made a member of the community through a variety of familial and communal rituals. Until then the baby was not named. Nor was a person’s death recognised until communal rituals were completed. These processes usually took several years.3 Thus the traditional Japanese notion of person had a communal, not an individual, basis-a notion incompatible with a brain-oriented definition of death. Many of these traditional "rites of passage" remain in Japan today. This does not mean that contemporary Japanese culture or religion is fixedly opposed to advances in medical techniques and to treatments related to life and death. The important point is that the traditional view of life and death in Japan relied on ad hoc rituals by family and community not on a particular religion with an established canon or teaching such as Buddhism. Consequently, if the bonds of the traditional community are weakened or disappear as the result of fundamental social change the collective view of life incompatible with brain death will also
their grave with a spouse and 71 -0% with their own children while only 47-6% preferred to share a grave with their own parents. Only 38-5% of female respondents wanted to be buried in their husband’s parents’ grave. Only 10-15 years earlier graves were shared by grandparents, parents, children, and grandchildren, and women had to be buried in the grave of their husband’s family. Today Japanese people prefer to share their graves with members not of the traditional extended family but of the nuclear family, in which most of them now live. No more than 30% of Japanese people today practise traditional death rituals. The collective view of the life and death of a person is no longer widely held. Change is also seen in individual freedom from familial or communal control over disposal of the body. More people now sign consent forms for anatomical body gifts-a practice long thought to be abnormal, even dishonourable. Such freedom could not exist when disposing of the dead was a family and community duty. Relatives and neighbours had a social and religious responsibility for taking care of the body,3 and the right to dispose of the dead belonged to the family, not the individual. This tradition too is weakening; the number of people consenting to anatomical body gifts rose from 30 149 in 1980 to 72 770 in 1988. Public attitudes towards organ donation are shifting too. In a 1990 poll 40% of respondents agreed with donation of their brain-dead kin’s organs while only 16% would refuse. Another 11 % would donate to known recipients only. The number of "don’t
ADDRESS: Life Science and Society Programme, MitsubishiKasei Institute of Life Sciences, 11 Minamiooya, Machida 194,
Japan (J. Nudeshima, PhD).
REFERENCES 1. Institute of Medicine. Diseases of importance in developing countries. In: New vaccine development; establishing priorities, vol II. Washington: National Academy Press, 1986. 2. Simanjuntak CH, Hoffman SL, Punjabi NH, et al. Epidemiology of typhoid fever in a semiurban area, Paseh, West Java. Cermin Dunia Kedokteran 1987; 45: 16-18. 3. Budiarso R, Putrali J dan, Muchtaruddin RL, Putrali J dan Muchtaruddin. Household survey 1986. Jakarta: Department of Health, Indonesia, 1986. 4. Hoffman SL. Typhoid fever. In: Strickland GT. Hunters tropical medicine, 6th ed. Philadelphia: WB Saunders, 1984: 282-97. 5. Yugoslav Typhoid Commission. A controlled field trial of the effectiveness of phenol and alcohol typhoid vaccines. Bull World Health Organ 1962; 26: 357-69. 6. Ascroft MT, Singh B, Nicholson VC, Ritchie JM, Sobryan A, William F. A seven-year field trial of two typhoid vaccines in Guyana. Lancet 1967; ii: 1056-60. 7. Polish Typhoid Committee. Controlled field trials and laboratory studies on effectiveness of typhoid vaccines in Poland 1961-64. Bull World Health Organ 1966; 34: 221-22. 8. Tapa S, Cvjetanovic B. Controlled field trial on the effectiveness of one and two doses of acetone-inactivated and dried typhoid vaccine. Bull World Health Organ 1975; 52: 75-80. 9. Yugoslav Typhoid Commission. A controlled field trial of the effectiveness of acetone-dried and inactivated and heat phenolinactivated typhoid vaccines in Yugoslavia. Bull World Health Organ 1964; 30: 623-30. 10. Hejfec LB, Salmin LV, Lejtman MZ, et al. A controlled field trial and laboratory study of five typhoid vaccines in the USSR. Bull World Health Orgn 1966; 34: 321-39. 11. Germanier R, Furer E. Isolation and characterization of gal E mutant Ty21a of Salmonella typhi: a candidate strain for a live, oral typhoid vaccine. J Infect Dis 1975; 131: 553-58. 12. Hornick RB, Du Pont HL, Levine MM, et al. Efficacy of a life oral typhoid vaccine in human volunteers. Dev Biol Stand 1976; 33:
89-92.
13. Wahdan MH, Serie C, Cerisier Y, Sallam S, Germanier R. A controlled field trial of live Salmonella typhi strain Ty21a oral vaccine against typhoid: three-year results. J Infect Dis 1982; 145: 292-95. 14. Levine MM, Ferriccio C, Black RE, Germanier R, Chilean Typhoid Committee. Large-scale field trial of Ty21a live oral typhoid vaccine in entenc-coated capsule formulation. Lancet 1987; i: 1049-52. 15. Ferrecio C, Levine MM, Rodriguez H, Contreras R, Chilean Typhoid Committee. Comparative efficacy of two, three or four doses of Ty21a live oral typhoid vaccine in enteric-coated capsules. A field trial in an endemic area. JInfect Dis 1989; 159: 766-69. 16. Levine MM, Ferreccio C, Cryz S, Ortiz E. Comparison of enteric-coated capsules and liquid formulation of Ty21a typhoid vaccine in randomised controlled field trial. Lancet 1990; 336: 891-94. 17. Hornick RB, Greisman SE, Woodward TE, et al. Typhoid fever: pathogenesis and immunologic control. N Engl J Med 1970; 283: 686-91. 18. Darmowigoto R, Hoffman SL, Soeprawoto, et al. Typhoid and paratyphoid fever in Plaju, Sumatra, 1978-1983. 11th International Congress for Tropical Medicine and Malaria; 1984 Sept 16-22; Calgary, Canada. p 193. 19. Edwards PR, Ewing WH. Identification of enterobacteriaceae, 3rd ed. Minneapolis: Burgess, 1972. 20. Hoffman SL, Punjabi NH, Rockhill RC, et al. The duodenal string capsule culture compared to bone marrow, blood and rectal swab cultures for diagnosing typhoid and paratyphoid fever. J Infect Dis 1984; 149: 157-61. 21. Acharya IL, Lowe CU, Thapa R, et al. Prevention of typhoid fever in Nepal with the Vi capsular polysaccharide of Salmonella typhi. N Engl J Med 1987; 317: 1101-04. 22. Klugman KP, Gilbertson IT, Koornhof HJ, et al. Protective activity of Vi capsular polysaccharide vaccine against typhoid fever. Lancet 1987; ii: 1165-69. 23. Tagliabue A, Nencioni L, Caffarena A, et al. Cellular immunity against Salmonella typhi after live vaccine. Clin Exp Immunol 1985; 62: 242-47. 24. Tagliabu A, Villa L, De Magistris MT, et al. IgA-driven t cell-mediated anti-bacterial immunity in man after live oral Ty21a vaccine. J Immunol 1986; 137: 1504-10.
PUBLIC HEALTH What can be done about
A mountain of evidence has accumulated on the issue of inequalities in health. The existence and the extensive nature of the problem have been described in several European countries,’including lately those in the centre and east of the region.8 This widespread evidence shows systematic and avoidable differences among social, ethnic, and geographic groups in the population in terms of both health status and access to, uptake of, and quality of health care. Many of these differences are also unjust and unfair.9 The debate is no longer about whether inequalities in health exist, but what can be done about them. This is the question asked by many policy-makers and practitioners when faced with the facts. But the solutions may seem so complex that people can easily become frozen into inaction. This is the impression gained from the 1991 draft health strategy for England,l° as well as other policy documents in
Europe. Is this pessimism justified, or can the knowledge and experience gained from around Europe be used to make a start on tackling the issue? Background research carried out for a World Health Organisation discussion paper on the subjectll has convinced us that there are grounds for modest optimism.
inequalities in health?
Changing climate Three general observations can be made on the various responses from different parts of Europe. First, in some places inequality in health has changed from a political non-issue in the 1960s and 1970s to one occupying centre stage in the past few years; in several countries it has become politically feasible and timely to take action. In some places, the medical profession has taken a leading role in raising awareness of the issue and campaigning for action, whereas in others it has been conspicuously silent. Second, where action has taken place it tends to start with small, manageable problems rather than tackling the whole subject in a comprehensive, coordinated plan. Particular issues have been addressed when a cause of public concern is seized upon and used to gain support for a policy initiative. Specific health targets to improve health status among disadvantaged groups can be found in programmes concerned with health care, social services, and working ADDRESSES: The Old School, Ash Magna, Whitchurch, Shropshire SY13 4DR, UK (M. Whitehead, BA), and Institute for Futures Studies, Stockholm, Sweden (G. Dahlgren, MA).
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conditions. Curiously, the impact that wider programmes aimed at improvement of economic or social conditions will have on health is rarely acknowledged explicitly, though undoubtedly it will be substantial. Third, initiatives have been taken at different levels, from national governments to small neighbourhood groups or individual health professionals working through their daily contacts. Successful initiatives often entail cooperative action across sectors on the living and working conditions of socioeconomic groups at high risk of poor health. Such responses show that something can be done about inequalities in health, but there is no universal blueprint for success. On the contrary, effective policy to tackle inequalities in health has to be tailored to suit the systems operating in a specific country or district. However, there are some common factors and much is to be learnt from the varied experiences of other countries.
Options for change Several
starting points
could be considered.
Here,
we
propose four types of action to illustrate some of the options.
A focus on infant health One with a
approach to choosing priorities for action is to start particular health problem or disease that shows disparities between social groups and to tackle the determinants of the health problem either singly or in combination. Since social inequalities in health are evident for most diseases and from birth to old age, there is a wide choice of starting points. We have chosen infant health as an example, because inequalities in infancy are striking and regarded as unacceptable by the public. Attention to infant health also represents an investment in the future health of the nation, and it is an issue on which health services can take an active lead. Disparities in health are evident in perinatal and infant mortality and morbidity, in birthweight, in infectious diseases and accidents, in height (an indicator of nutrition in childhood), and in dental health. The pattern continues throughout childhood. If all children in the United Kingdom enjoyed the same survival chances as the children of professionals and managers, over 3000 child deaths a year might be prevented .12 A national strategy to tackle these differences comprehensively would recognise first the need for an adequate income for parents, as well as improvements in child care and housing. But more specific actions can be taken, particularly within health service policy. It has been estimated, for instance, that perinatal mortality in the UK could be reduced by 20% if all antenatal screening tests of proven value were fully implemented.13 Several of the tests seek disorders with strong social gradients, and uptake of antenatal care is lower in less advantaged social groups; action to improve implementation, access, and uptake would therefore have a positive effect not only on the overall perinatal mortality but also on the gap between social groups. The same could be said for other maternal and child health services: if we ensured that all sections of the community had access to contraception and abortion services, for instance, the prevalence of undesirable factors such as early and unwanted pregnancies, high parity, and insufficient spacing between births would decline. Similarly, if immunisation services reached every child, death and disability from infectious diseases, which at
in infants living in the poorest The Netherlands health would be reduced. circumstances, authorities have improved immunisation rates among babies of Moroccan and Turkish immigrants through changes in clinic times and schedules to take account of cultural barriers to services use.14 Inequalities in the dental health of children have been decreased by local measures such as fluoridation of the water supply.ls Also, there are individual doctors and nurses who make sure that the pregnant women and mothers with small babies in their care receive all their social security entitlements and nutritional
present
are commonest
supplements. Enhanced social and psychological support from caregivers is also important, since it can affect the health of mothers and babies on a range of morbidity and quality-ofcare indicators.16,17 Since there is strong evidence that maternal smoking reduces average birthweight, there is a place for sensitive support and advice on quitting smoking in pregnancy; such action would have an effect on inequalities in those countries where there is a social gradient in maternal smoking. However, education is likely to be effective in this context only if offered with some understanding of the way some women use smoking as a means of coping with difficult social conditions.18 In successful schemes sponsored by statutory and voluntary agencies women from disadvantaged communities have given each other support to recover from depression, to overcome social isolation, and to reduce child behaviour problems.19 The point is that, if the health sector made a concerted effort to ensure universal access to the essential services under its control, it could make a valuable contribution to reducing inequalities in infant and child health. Health professionals would then be in a much stronger position to press for the necessary improvements outside the health care
sector.
The approach of choosing a disease or health problem as a starting point has the advantage that effort is concentrated on a single issue. The World Health Organisation’s programme on immunisation, for example, has very effectively mobilised effort to reduce or even eradicate specific infectious diseases in Europe. However, a drawback of the disease-oriented approach is the risk that there will be a predominantly medical response when wider strategies are
also needed.
Improvement of working conditions Another approach is to choose one or more of the health-damaging factors related to the conditions in which people live and work. Conditions that restrict opportunities for people to achieve their full health potential include poverty, unemployment, inadequate or unsafe housing, stressful or dangerous working conditions, and restricted nutritious diet. Richard Smith has set out wide-ranging proposals on what the medical profession could do in relation to unemployment and health .20 There have been several calls lately for a response from public health professionals to the problems of housing and homelessness.21-23 In this article, we focus on working conditions to illustrate that a range of possibilities is available at different levels of organisation. In addition to accidents at work and designated occupational diseases, common work-related disorders include musculoskeletal disorders and stress-related illness linked to the workplace. Working conditions play an important role in inequalities in health-the lower the occupational class the more likely are people to experience access to a
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poor working conditions, including physical strain, serious injury, greater noise and air pollution, shift-work, a monotonous job, and a forced pace of work with fewer voluntary pauses.1 In Sweden, poor working conditions were judged to be the main determinant of inequalities in somatic diseases among occupational groups .24 Since workrelated migration has escalated across Europe, some appalling conditions have arisen for migrant and other low-paid workers, and there are instances of international companies applying different standards in different countries and of children working in unprotected
conditions. So what can be done? Despite achievements made over centuries to improve working conditions and reduce risks of serious accidents, there is obviously a need for further countermeasures. There have been some promising initiatives that point to several types of action. Firstly, governments could experiment with incentive schemes in addition to traditional safety legislation, though this will always be important. In Sweden, for example, a special fund was created by the Government by means of a short-term tax on business from September to December, 1990. The substantial sum of money raised is being paid back over 5 years in grants to companies that put forward good proposals for improvement of working conditions. Such a fund can be raised in other ways-the state of Victoria in Australia uses a levy on tobacco products to create a substantial health promotion fund each year. Secondly, people in the workforce could become more active in investigating and putting forward ideas for improvements in their own immediate surroundings, with encouragement and help from researchers and occupational health personnel. When the Swedish Labour Organisation (LO; the national confederation representing over two million manual workers in the country) realised that its members had an above-average risk of ill health, it initiated a 5-year programme to improve health and narrow the gap between the members and other groups. Although the programme was centrally funded and coordinated, people in each separate branch decided their own priorities for action. The workers of one company near Stockholm, for instance, chose to focus on the reduction of heart disease, but to include not only changes in personal behaviour but also negotiated improvements in the factory canteen, better provision for shift-workers, changes in working hours, and more appropriate training for safety delegates.2s There is also scope for much more cooperation between researchers and people in the workforce, so that workers survey their own working conditions and health problems and put forward ideas for improvements, based on their experience
of the job.26-27 Thirdly, environmental
and public health professionals could become more skilled at identifying work-related illness and could press harder for improvements in the workplace. In the UK, four projects have been initiated to identify work-related illnesses more effectively in primary health care settings. Occupational health workers are employed jointly by family health services authorities and general practitioners to build up occupational histories in patients’ notes. Patients are interviewed at the doctor’s surgery and hearing and lung function are tested. Individual patients are then advised on their right to compensation and social security benefits and put in touch with self-help support groups. In addition, the database on patients is used to look at patterns of illness and to relate diseases to specific industries or hazards.28
The approach of choosing a risk factor in the environment has the advantage that some of the clearly inequitable root causes of ill health are tackled. Several diseases could be affected by action on one risk factor. On the other hand, health is rarely a prime consideration in decisions on housing, employment, and trade and industry policy. Trade-offs over priorities have to be made which mean that rapid progress is unlikely.
Adding equity to the policy equation A third approach is to make sure that in any health policy more attention is paid to how health status, health hazards, and health services are distributed within a population. All too often at present, policies rely solely on overall rates of health indices and risk factors and the distribution is overlooked. Perhaps this point is easiest to illustrate in the context of preventive services, such as cervical cytology. Many schemes aim to achieve uptake rates of 90% or more and thus the prevention of a substantial number of deaths. However, if no attention is paid to the fact that cervical cancer is more prevalent in certain social groups, which also tend to have low uptake of preventive services, an uptake rate of 90% may not secure the predicted saving of life-the people at highest risk of the disorder are likely to be within the 10% of the population who do not take up the service. Here is what we propose in this case: that targets are set to reach all sections of the population; that use of services by social group and geographic area is monitored; and that additional plans are made to increase use in low-uptake areas (for example, by means of mobile screening clinics, by active case-finding and opportunistic screening in general practice, or by employing extra nurses for home visits). These general principles could be applied to most of the priority targets in national health strategies around Europe-the reduction of smoking-related diseases, accident prevention, improvement in nutrition and rates of physical activity, pollution control, and so on. Action on smoking-related diseases, for example, should recognise the heavier burden of such illness among less privileged groups and their poorer survival chances.129 Action to reduce such inequalities could include: tobacco pricing policy, known to have the strongest influence on consumption in low-income and younger age groups;30° restrictions on tobacco advertising and sponsorship, particularly those forms aimed at groups at high risk; the use of educational techniques, which are most effective in the less educated groups;31 more sensitive advice and support for those living in stressful, disadvantaged conditions;and action on inequalities in referral and specialist investigations by different groups of doctors--oncologists, cardiologists, public health specialists, and general practitioners, for example-auditing their referral and treatment procedures. This approach has been adopted by Finland, which has set national health goals on both the level and the distribution of health and health care.32 In Sweden, a parliamentary bill adopted in June, 1991, requires all national public agencies and authorities to report to Parliament on specific goals to reduce inequalities in health in different social and occupational groups and to analyse the health impact of all national policies. An Institute of Population Health has been set up to develop policies to improve health-related conditions for disadvantaged groups and to make sure these are scientifically sound. Thus, formal mechanisms are now in place for monitoring of, reporting
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on, and
planning action on inequalities in health across Government departments in Sweden. In the Netherlands, a national research and policy development committee on inequalities in health has also been set up to inform policy decisions.33 Evidence from the committee was available when a new health insurance system was being discussed and the possible effects of the proposed changes on equity were fully aired. The efficiency and effectiveness of health strategies in general would improve as the problems of those at greatest risk were taken into account, and also the health gap would decline in the long term as improvements raised the level of health of the most disadvantaged groups.
Auditing European policy The dramatic changes happening in Europe provide unique opportunities to address the issue of inequalities in health, not only within countries but also between them. increasing health divide between the east and west of Germany is now one nation’s problem, impossible to ignore. For countries already in the European Community and the many that may join, decisions made in Brussels will have an increasingly important effect on living and working conditions around the region. Policy decided at the Community level has a strong influence in each member state on, for example: price, availability, and quality of food; production, pricing, and promotion of tobacco; availability and price of alcohol; water safety standards; working conditions; pollution control; and transfer of health personnel between countries. Furthermore, the economic policy of the European Community aims to even out the differences between countries; large amounts of money are redistributed towards less developed regions to foster development. The Social Fund also concentrates effort in the most disadvantaged areas, giving priority to unemployed people, people with disabilities who wish to join the labour market, and migrant workers and their families. The European Commission is working on common policies for immigration and refugee asylum, and looking at the different benefits obtainable from The
health and social services. Although there is great potential for these policies to affect health in general and health inequalities in particular, health impact is not explicitly taken into consideration in any of these decisions and there are many anomalies-the funding of tobacco growing in one part of Europe and restriction of tobacco promotion in the rest, for example. What is needed at the Community level is a health impact approach to assess as far as possible the effect on health inequalities of European policy decisions. In the long term, the aim would be to have explicit health objectives for all policies affecting the health status of the population. Although the European Community has no official remit on health matters, people interested in public health in each member state can press for action on such issues through several channels-for example, by lobbying the healthrelated committees of the European Parliament; by briefing each member state during its six-month term holding the presidency of the Community; and by liaising with the umbrella organisations that represent non-governmental agencies from different countries. After the revision of the Treaty of Rome in December, 1991, the Community may have a little more authority to take action on major health issues. In the long term, however, the power of the Community to reduce inequalities in health could be enhanced by the appointment
of a senior member of the Commission to coordinate the actions of the ten departments that currently cover healthrelated matters. Alternatively, a separate public health directorate could be created with a major focus on equity in health. Within the context of European action, it would also be logical to implement the resolution unanimously adopted by the World Health Assembly in 1986 which called on all member states of the World Health Organisation "to use the health status of the population and in particular its changes over time among disadvantaged groups as an indicator for assessing the quality of development". Acceptance of this recommendation would mean the introduction of an indicator of social development alongside the grossnational-product index of economic development. The use of social inequalities in health as an indicator for social progress and quality of development would also reinforce the understanding of the economic and social roots of the health divide. To change European policy in this way is obviously a long-term challenge, but it has the potential for great influence on inequalities.
Conclusion These are just some of the available ways in which to start taking action on inequalities in health. We argue that national and local health strategies would be more efficient and more likely to achieve their targets if more attention were paid to the issue of equity. The gains could be even greater if efforts at different levels and in different sectors were coordinated into soundly based national and European policies. But the strongest arguments of all for doing something about inequalities are still those concerned with fairness and basic human rights.9 Substantial sections of the community are prevented from achieving their full health potential, which is surely unacceptable for Europe in the 1990s. We thank Anna Ritsatakis and Erio Ziglio for their advice and the World Health Organisation for financial and technical support in researching this
subject. REFERENCES 1. Fox J. Ed. Health inequalities in European countries. Aldershot: Gower, 1989. 2. Illsley R, Svensson P-G, eds. The health burden of social inequities. Copenhagen: WHO Regional Office for Europe, 1986. 3. Kohler L, Martin J, eds. Inequalities in health and health care. Gothenberg: WHO/Nordic School of Public Health, 1985. 4. Department of Health and Social Security. Inequalities in health: report of a research working group (The Black report). London: DHSS, 1980. 5. Whitehead M. The health divide. London: Penguin, 1988. 6. Gunning-Schepers LJ, Spruit IP, Krijnen JH, eds. Socio-economic inequalities in health: questions on trends and explanations. The Hague: Ministry of Welfare, Health, and Cultural Affairs, 1989. 7. Vogel J, Andersson L-G, Davidsson U, Häll L, eds. Inequality in Sweden: report no 58. Stockholm: Statistics Sweden, 1988. 8. Wnuk-Lipinski E, Illsley R, eds. Social equity and health in non-market economies. Soc Sci Med 1990; 31: 833-89. 9. Whitehead M. The concepts and principles of equity and health. Copenhagen: WHO Regional Office for Europe, 1990. 10. Department of Health. The health of the nation: a consultative document for health in England. London: HMSO, 1991. 11. Dahlgren G, Whitehead M. Policies and strategies to promote equity and health. Copenhagen: WHO Regional Office for Europe (in press). 12. Whitehead M. Deaths foretold. Guardian, 7 Dec 1988. 13. Wald NJ, ed. Antenatal and neonatal screening. Oxford: Oxford University Press, 1984. 14. Gunning-Schepers L. A policy response to socio-economic differences in health. Paper presented to the meeting of the European Community project on socio-economic factors in health and health care, Lisbon.
May, 1991.
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CL, French AD, Rugg-Gun AJ, Furness AJ. The relationship between social class and caries experience in five year old
15. Carmichael
children in Newcastle and Northumberland after 12 years of fluoridation. Community Dent Health 1984; 1: 47-54. 16. Oakley A, Rajan L, Grant A. Social support and pregnancy outcome. Br J Obstet Gynaecol 1990; 97: 155-62. 17. Enkin M, Keirse M, Chalmers I. Guide to effective care in pregnancy and childbirth. Oxford: Oxford University Press, 1990. 18. Graham H. Women and smoking in the United Kingdom: the implications for health promotion. Health Promotion 1989; 3: 371-82. 19. Pound A. Newpin and child abuse. Child Abuse Rev 1991; 5: 7-10. 20. Smith R. Unemployment and health. Oxford: Oxford University Press, 1987. 21. Morris JN. Inequalities in health: ten years and little further on. Lancet 1990; 336: 491-93. 22. Acheson ED. Edwin Chadwick and the world we live in. Lancet 1990;
336: 1482-85. 23. Roderick P, Victor C, Connelly J. Is housing a public health issue? A survey of directors of public health. Br Med J 1991; 302: 157-60. 24. Lundberg O. Den ojämlika ohälsan. Om klass—och konsskillnader i sjuklighet (Inequities in health-differences in class and gender morbidity). Stockholm: Almqvist and Wiksell International, 1990. 25. Lundberg B. The LO health project: trade union health promotion in
Sweden. Paper presented to the European Conference on Health Promotion in the Workplace. Barcelona: April, 1991. 26. Reich M, Goldman R. Italian occupational health: concepts, conflicts and implications. Am J Public Health 1984; 74: 1031-41. 27. Lundberg B, Starrin B. Fighting health hazards at work: experiences from participatory research on workplace-related health issues. Research report no 1. Karlstad, Sweden: Centre for Public Health Research, 1990. 28. Sheffield Occupational Health Project. Occupational health workers in primary health care. Sheffield: Sheffield Occupational Health Project, 1989. 29. Kogevinas M, Marmot MG, Fox AJ, Goldblatt PO. Socio-economic differences in cancer survival. J Epidemiol Community Health 1991; 45: 216-19. 30. Townsend J. Cigarette tax, economic welfare and social class patterns of smoking. Appl Economics 1987; 19: 355-69. 31. Jamrozik K, Vessey M, Fowler G, Wald N, Parker G, Van Vunakis H. Controlled trials of three different anti-smoking interventions in general practice. Br Med J 1984; 288: 1499-503. 32. Ministry of Social Affairs and Health. Health for all by the year 2000: the Finnish national strategy. Helsinki: Ministry of Social Affairs and Health, 1987. 33. Gunning-Schepers L. How to put equity in health on the political agenda. Health Promotion 1989; 4: 149-50.
VIEWPOINT Obstacles to brain death and organ
transplantation
in
Japan
The modernisation of Japanese society took place after the 1960s, when rapid economic growth was achieved, and fundamental shifts in culture must have occurred since then.
perish.
My studies in the late 1980s showed that Japanese funeral rituals longer involve the complex and prolonged commitment of relatives or neighbours. They have become momentary events managed by commercial agencies, supplanting family and community bonds. A similar change has occurred in burial practices, where the tradition was for extended-family graves. A poll conducted by the Prime Minister’s office in 1990 showed that 86-8% of 3000 respondents living in urban areas wanted to share
no
Japan neither the concept of brain death nor the practice of organ transplantation are accepted.1 I would like to explain the cultural background to this resistance. In seeking social consensus on the desirability of medical interventions affecting life and death it is important to understand what is meant by "person". Is the notion individual or collective? In American society for example, the concept of personhood arises from the Judaeo-Christian view of the soul: "soul" and "personhood" clearly identify human life as individualistic, occurring and perishing within individuals.2 Traditionally, the Japanese view of life and death has regarded personhood as a collective reality. Birth In
and funeral rites in traditional communities show that a newborn baby was not considered a person until he or she had been made a member of the community through a variety of familial and communal rituals. Until then the baby was not named. Nor was a person’s death recognised until communal rituals were completed. These processes usually took several years.3 Thus the traditional Japanese notion of person had a communal, not an individual, basis-a notion incompatible with a brain-oriented definition of death. Many of these traditional "rites of passage" remain in Japan today. This does not mean that contemporary Japanese culture or religion is fixedly opposed to advances in medical techniques and to treatments related to life and death. The important point is that the traditional view of life and death in Japan relied on ad hoc rituals by family and community not on a particular religion with an established canon or teaching such as Buddhism. Consequently, if the bonds of the traditional community are weakened or disappear as the result of fundamental social change the collective view of life incompatible with brain death will also
their grave with a spouse and 71 -0% with their own children while only 47-6% preferred to share a grave with their own parents. Only 38-5% of female respondents wanted to be buried in their husband’s parents’ grave. Only 10-15 years earlier graves were shared by grandparents, parents, children, and grandchildren, and women had to be buried in the grave of their husband’s family. Today Japanese people prefer to share their graves with members not of the traditional extended family but of the nuclear family, in which most of them now live. No more than 30% of Japanese people today practise traditional death rituals. The collective view of the life and death of a person is no longer widely held. Change is also seen in individual freedom from familial or communal control over disposal of the body. More people now sign consent forms for anatomical body gifts-a practice long thought to be abnormal, even dishonourable. Such freedom could not exist when disposing of the dead was a family and community duty. Relatives and neighbours had a social and religious responsibility for taking care of the body,3 and the right to dispose of the dead belonged to the family, not the individual. This tradition too is weakening; the number of people consenting to anatomical body gifts rose from 30 149 in 1980 to 72 770 in 1988. Public attitudes towards organ donation are shifting too. In a 1990 poll 40% of respondents agreed with donation of their brain-dead kin’s organs while only 16% would refuse. Another 11 % would donate to known recipients only. The number of "don’t
ADDRESS: Life Science and Society Programme, MitsubishiKasei Institute of Life Sciences, 11 Minamiooya, Machida 194,
Japan (J. Nudeshima, PhD).
