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One could envisage a taxation system where taxes are partly paid according to how much one’s behaviour has negative consequences for the environment and to what extent one expects to need the health-care system to cure self-inflicted health problems. For example, at the same time as the Alma-Ata Declaration professed its concern for the unacceptable health conditions found among the hundreds of millions among the world’s poor, it also advocated primary health care because of its potential ‘to close the gap between the “haves” and the “have-nots” ‘, i.e. The previously cited World Health Report 1995 (WHO 1995), which had a great deal to say about the health of the poor, was subtitled Bridging the Gaps, referring to the inequalities between poor and rich.

This process does not necessarily operate from people with the disease to the non-diseased, and often the mechanism taks place via more distant determinants of the disease. American Journal of Epidemiology, 139, 856 (1994).) Olschwang, S., Hamelin, R., Laurent-Puig, P., et al. Alternative genetic pathways in colorectal carcinogenesis. Proceedings of the National Academy of Sciences of the United States of America, 94, 12122–7. For instance, the well-known 1980 Black Report in the United Kingdom was entitled Inequalities in Health (Department of Health and Social Security 1980), as was the exercise that produced its successor, the 1998 Acheson Report (Department of Health 1998).

Eliminating risk factors for those at highest risk who benefit the most from this intervention will only have limited impact at population levels as the majority of these diseases come from people with moderate risk who will personally benefit very little by avoiding the risk determinants in question. Absolute poverty The first, based on what is often called ‘absolute poverty’, takes a universal perspective and defines poverty in terms of a given level of income or consumption, which is equally relevant for people wherever they may be.

Furthermore, all individual-based health programmes are expected to have limited immediate effect and may increase social inequalities in health as the well educated are probably more likely to adapt to evidence-based disease prevention and health care than non-educated people. This is usually done by defining a ‘poverty line’ as the lowest amount of money sufficient to purchase the amount of food necessary for a minimally adequate diet (and still have enough left over to buy other essentials).

Non-communicable diseases increase when clean drinking water is provided, poverty has been reduced, and malnutrition is gradually eliminated. Relative poverty The second approach, which is more country-specific, deals with what is frequently referred to as ‘relative poverty’.

Basic health care will lead to good-quality treatment of infections, and implementation of vaccination programmes will increase life expectancy; therefore the lifelong incidence of cancer, and probably of cardiovascular diseases, will increase. The practice here is to define the poverty line in terms of relevance for a specific society. One way, analogous to the international approach just described, is to determine how much income one needs to live decently according to some locally established definition of decency.

There is no magic treatment that will make arteriosclerosis go away and it is unlikely that any cancer treatment will ever be able to eliminate the excess cancer mortality associated with smoking. However, others feel that relative poverty and deprivation are just as important, if not more so.

Cancer treatment may in time be able to cure a growing number of cancer diseases, but many opportunities for prevention have been lost because we have waited in vain for this to happen. Inequality in health While a concern for improving the health of the poor is widespread, it is by no means universally preferred.Accepting non-smokers’ right to avoid passive smoke will reduce smoking habits as role models will have less influence when smoking is not performed in public places. To say that the focus has been exclusively on inequality would be to overstate the case, for it is possible to cite expressions of concern for poverty in prominent international health documents from at least the time of the Alma-Ata Declaration (1978) onwards.Subsidizing healthy food or taxation on alcohol, tobacco, fat, and sugar may also facilitate a change towards a more prudent diet. However, it is rare for a prominent international health statement not to give at least equal, if not more, weight to inequality reduction.Prevention has to do with avoiding diseases at a premature stage, not necessarily preventing the diseases from occurring at any stage in life. The consumption level of about 1200 million of the world’s population lies below this line.In addition, the incidence of non-communicable diseases will increase with increasing life expectancy. Almost all these people—who constitute just under a quarter of the world’s total population—live in South Asia, sub-Saharan Africa, and China (World Bank 2000).The shift from communicable to non-communicable diseases in many developing countries is an achievement that cannot and should not be prevented as it is largely driven by forces that prevent premature death. Moderate alcohol intake and lower risk of coronary heart disease: meta-analysis of effects on lipids and haemostatic factors. The second approach is simply to define the national poverty line as some proportion—often arbitrarily determined—of a society’s average per capita income or expenditure.

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