Socio-economic determinants of mortality in industrialized countries.

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.