Vallin J
Popul Bull UN. 1980(13):26-41.
In the early 1950s, it was generally considered that social mortality differentials appeared during the 1st stages of industrialization and would be resolved with the socialization of health services. Admittedly, at that time, the spectacular progress achieved through antibiotics encouraged the belief that health was merely a matter of medicine and that the institution of a social security scheme would suffice for minimizing the risks of death that were not directly involved in the natural differences between individuals. 30 years have passed and the expectation of life has lengthened (although less than anticipated), but the social differences remain. They are, in fact, by no means attributable to lack of medical science. The elimination of the most discriminating causes of death (alcoholism, accidents, suicide, tuberculosis, etc.) is less dependent on further scientific progress than on a complete change in living conditions and behavior. The reduction in the excess mortality of the poorer classes from other causes (cancer, cardiovascular diseases, etc.) again calls more for a thorough cultural transformation of the least privileged social categories than for the discovery of new therapies or increased expenditure on hospitals. Faced with a mortality that is already very unequal (selection, differential risks), the various social categories behave in basically different ways, which, while aggravating the real inequities, lead to an apparent morbidity that is inversely proportional to true morbidity and to a more prompt and frequent use of medical care among the social categories in which true morbidity is lowest. Inequality with respect to death is only 1 dimension of social inequality. It was an illusion to imagine that 1 could be eliminated without the other. Today that illusion has been destroyed. That does not mean that the present situation must be accepted. Inequality with respect of death is still 1 of the most disgraceful consequences of social inequality and its abolition must still be our aim. Obviously, however, this aim cannot be achieved through the health services alone.
在20世纪50年代初，人们普遍认为社会死亡率差异出现在工业化的第一阶段，并将随着卫生服务的社会化而得到解决。诚然，当时抗生素取得的惊人进展使人们相信，健康仅仅是医学问题，建立社会保障计划就足以将与个体自然差异无直接关联的死亡风险降至最低。30年过去了，预期寿命延长了（尽管低于预期），但社会差异依然存在。事实上，这些差异绝不能归因于医学科学的不足。消除最具歧视性的死因（酗酒、事故、自杀、结核病等）与其说依赖于进一步的科学进步，不如说依赖于生活条件和行为的彻底改变。减少贫困阶层因其他原因（癌症、心血管疾病等）导致的过高死亡率，更多地需要对最弱势群体进行彻底的文化变革，而不是发现新的疗法或增加医院支出。面对已经非常不平等的死亡率（选择、不同风险），不同社会阶层的行为方式基本不同，这在加剧实际不平等的同时，导致明显的发病率与真正的发病率成反比，并使真正发病率最低的社会阶层更迅速、频繁地使用医疗服务。死亡方面的不平等只是社会不平等的一个维度。想象可以消除其中一个而不消除另一个是一种错觉。如今这种错觉已被打破。这并不意味着必须接受现状。死亡方面的不平等仍然是社会不平等最可耻的后果之一，消除它仍然必须是我们的目标。然而，显然仅靠卫生服务无法实现这一目标。
