Simon Capewell and Hilary Graham have an important new article out in PLoS Medicine (full-text open access) entitled Will Cardiovascular Disease Prevention Widen Health Inequalities?
Here are the summary points:
- The primary prevention of cardiovascular disease (CVD) is dependent on the effective reduction of the major risk factors for CVD, particularly tobacco control and a healthier diet.
- The high-risk approach to prevent CVD typically involves population screening. Those exceeding a risk threshold are then given lifestyle advice and/or tablets to reduce blood cholesterol and blood pressure.
- Evidence suggests this high-risk approach typically widens socioeconomic inequalities. Such inequalities have been reported in screening, healthy diet advice, smoking cessation, statin and anti-hypertensive prescribing, and adherence.
- The alternative approach is population-wide CVD prevention. For example, legislating for smoke-free public spaces, banning dietary transfats, or halving daily dietary salt intake. Such strategies are generally effective and cost-saving; there is also increasing evidence that they can reduce health inequalities.
- We conclude that screening and treating high-risk individuals represents a relatively ineffective CVD prevention approach that typically widens social inequalities
This is a critical article. It addresses one of the thorniest problems in public health ethics, Sir Geoffrey Rose's prevention paradox. Namely, while many (most?) ethical frameworks would suggest health interventions be directed to the most disadvantaged, population health will be maximized by a directing interventions to the larger low-risk population. In addition, targeting interventions at high-risk groups may widen inequities.
Big problems, obviously. Because I have some work I am preparing for submission on these issues, I won't comment much more here. But the article is highly recommended and the issue itself could barely be of greater significance to public health ethics and policy, in my view.