Published online before print October 30, 2003, doi: 10.1161/01.STR.0000101664.02943.69
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(Stroke. 2003;34:2628.)
© 2003 American Heart Association, Inc.
Original Contributions |
Editorial Comment—Down With the Class Society!
Department of Medicine, University Hospital, Umeå, Sweden
In industrialized countries, people with a low level of education and those who have unskilled manual work are clearly at higher risk for being afflicted by stroke than people with university education or nonmanual employment.1–5 As convincingly demonstrated in a study from Glasgow in this issue of Stroke, this is at least partly due to a more unfavorable risk factor profile (such as higher blood pressure and more smoking) among people living in deprived areas.
It comes as no surprise that there is a social patterning of risk factors for stroke.6,7 An important question is if this is entirely due to personal factors or if societal factors also contribute. Multilevel analyses have shown that the area/community a person is living in has an influence on risk factors for cardiovascular disease that goes above and beyond the individual level of education.8
Once a stroke has occurred, are affluent and deprived people treated equally? The Glasgow investigators report that early case fatality does not differ by degree of deprivation, a finding similar to what has been observed in the Scandinavian countries.2,3 However, a Canadian study showed reduced early survival after stroke in low-income people.9 Worse long-term survival after stroke in people of low social class has been reported from Finland3 and, now, from Scotland.
In the Canadian study, the effect of socioeconomic status was not small: each $10 000 increase in median neighborhood income was associated with a 9% reduction in the hazard of death at 30 days. In that study, patients with the lowest incomes were less likely to receive in-hospital rehabilitation and they had to wait much longer for carotid surgery.9 Similar observations have been made in the United States.10
The Glasgow example emphasizes that there may be remarkably large gradients of stroke between communities within one and the same city. Socioeconomic factors explain also many of the differences across ethnic groups, such as the excess stroke mortality among black Americans in the United States.11 The scenario is even bigger: stroke mortality rates between countries vary markedly with economic conditions, as exemplified in the Figure. General economic indicators seem to explain more of the variation of stroke mortality than population levels of classic cardiovascular risk factors do.12
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If the risk of stroke is greater in low-income people and their survival after stroke is worse, we would expect higher stroke mortality rates (deaths per 100 000 population). Indeed, when data from a large number of countries have been compiled, manual classes consistently have higher stroke mortality rates than nonmanual classes. This social gradient is relatively large in the United Kingdom, Ireland, and Finland; intermediate in the United States, France, and Switzerland; and relatively small in Sweden, Norway, Denmark, Italy, and Spain.13 In most countries, inequalities are much larger for stroke mortality than for ischemic heart disease mortality.13
So, what to do? The Glasgow investigators conclude: 
Tackling health inequalities in stroke should focus on stroke primary prevention by tackling deprivation, including promoting changes in lifestyle.
The most radical interpretation of this message is: Down with the class society!
Another interpretation, lukewarm enough to be attractive to many, is that more health education is needed, with a special focus on deprived people. In fact, it is very common for scientific articles on inequity in health to end with a plea for better health education for the poor and deprived. But does it work?
In rich countries, well-educated people are the first to adopt messages about a healthy lifestyle and they are more prone to change their health behavior (see Shaper et al14). It would seem that health education is, in itself, driving inequity. A social patterning emerges, so that people with a high level of education have more leisure-time physical activity; are leaner; have lower levels of blood pressure, cholesterol, and fibrinogen; are less often smokers; and are less likely to have diabetes.14–16 Some of this general pattern is shown also in the Glasgow study.
This is one expression of what public health experts call epidemiologic transition. This translates also into major clinical events. As the overall mortality from cerebrovascular disorders declined in Australia over 3 decades, the differences in stroke mortality rates between social classes increased considerably.17
This general model seems to apply not only to individuals but also to nations. The decline in stroke mortality in most Western countries in face of unchanged or even increasing stroke mortality in Russia and other former USSR countries has resulted in a rapidly increasing gap in the burden of stroke between East and West Europe.18
If the concept of epidemiologic transition is valid, there is cause for optimism. The theory tells that there are early and late adopters of lifestyle messages (and a large majority of modestly enthusiastic people in between).19 As messages about healthy lifestyle habits are spreading, they will ultimately also make the late adopters change. A caveat: this development, attractive as it seems, must be an oversimplification. Many late adopters of a healthy lifestyle are in fact early adopters of new unhealthy habits.
The safest and most desirable road to combat stroke as a public health problem seems to be social and economic development going hand in hand. All information available suggests that improved education and less poverty will, in itself, reduce the risk of stroke. Waiting for such wishes to come true, we as stroke physicians can start to eliminate apparent inequities in the detection and management of cardiovascular risk factors and in the treatment of stroke patients.
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