Socioeconomic Factors in CHD Prevention
Michael Marmot Amanda Feeney University College -- London Medical School
Coronary heart disease (CHD) is the leading cause of death in industrialized societies, and it is rapidly becoming a major cause of death in developing countries, imposing an enormous burden on the social and economic welfare of each country ( 1, 2). There are two striking features of the epidemiology of CHD that are of major scientific and practical significance. The first is the marked contrast between the countries of Western Europe, where CHD is now showing welcome declines in mortality, and those of Central and Eastern Europe, where CHD rates are rising dramatically. Figure 3.1 shows that countries of the West, with the exception of Ireland, all show decreases; the countries of Central and Eastern Europe, which were at the time all under communist governments, all show increases ( 3). The second feature is the sharp socioeconomic gradient in CHD (higher rates in lower socioeconomic groups) that is now seen in most Western industrialized countries, but may be different in the countries of Central and Eastern Europe. Understanding reasons for the variations in the socioeconomic gradient in CHD mortality is crucial to public health.
The social gradient in CHD mortality is far from stable. In England and Wales in the 1930s and 1950s, CHD mortality was higher in the more affluent classes, but in the 1970s this gradient reversed toward the lower social classes ( 4). A similar change has been documented in The Netherlands. One hypothesis is that the social gradient in CHD is related to the stage of development of society. The overall
This chapter is an abridged version of a chapter in Society and Health, edited by Amick Levine B S Tarlov A, and Walsh D (in press). It is included here by permission of Oxford University Press.