Exercer la médecine sans prendre en compte les inégalités n'est pas juste...

Calendrier de l'Avent médical 2019 : Jour 7

L'exercice de la médecine est une activité qui, à l'inverse des mathématiques ou de la physique, ne peut se pratiquer dans une tour d'ivoire où les patients seraient des individus sans histoire, sans passé, sans famille, sans différence de revenus, de classe sociale ou de sexe, sans interactions avec le réel, et cetera.

Il est bon que certaines études le recherchent et le rappellent. L'une d'elles est parue dans le Lancet, journal qui n'est pas connu pour ses idées révolutionnaires et avec l'aide du National Institute of Health Research et une fondation privée, le trust Welcome.

C'est LA

Le contexte : 

Low socioeconomic position is consistently associated with increased risk of premature death. The aim of this study is to measure the aggregate scale of inequality in premature mortality for the whole population of England.

(Des conditions socio-économiques défavorables sont constamment associées à un risque accru de mort prématurée. Le but de cette étude est de mesurer le spectre complet des inégalités entraînant une mortalité prématurée dans toute la population anglaise.

Les résultats : 

35·6% (95% CI 35·3–35·9) of premature deaths were attributable to socioeconomic inequality, equating to 877 082 deaths, or one every 10 min. The biggest contributors were ischaemic heart disease (152 171 excess deaths), respiratory cancers (111 083) and chronic obstructive pulmonary disease (83 593). The most unequal causes of death were deaths due to tuberculosis, opioid use, HIV, psychoactive drugs use, viral hepatitis, and obesity, each with more than two-thirds attributable to inequality. Inequality was greater among men and peaked in early childhood and at age 40–49 years. The proportion of deaths attributable to inequality increased during the study period, particularly for women, because mortality rates among the most deprived women (excluding cardiovascular diseases) plateaued, and for some diseases increased. A mean of 14·4 months of life before age 75 years are lost due to socioeconomic inequality.

Interprétation :

One in three premature deaths are attributable to socioeconomic inequality, making this our most important public health challenge. Interventions that address upstream determinants of health should be prioritised.

(Une mort prématurée sur trois est attribuable à des inégalités socio-économiques,  ce qui est notre défi de santé publique le plus important. Les actions qui agissent en amont sur les déterminants de santé doivent être privilégiées.

Valeurs ajoutées de ce travail : 

Added value of this study

We use two indicators of socioeconomic inequality: mortality attributable to inequality (referred to as MASI: the number and proportion of premature deaths that can be attributed to socioeconomic differences), and the years of life lost to socioeconomic inequality (the reduction in life expectancy before 75 years attributable to inequality). We applied these indicators to the whole population of England over the period 2003–18, allowing direct reporting of aggregate numbers of death and avoiding selection bias. Our study uses an index of inequality that combines data on income, employment, education levels, crime, availability of services, and the local environment in individuals' neighbourhoods, providing insight into health inequalities associated with upstream socioeconomic circumstances. We studied cause-specific inequality in much greater detail than in previous studies, including 156 causes of death. Our findings showed little or no inequality in some diseases such as cancers of the skin, blood, breast, eye, and brain, and for cystic fibrosis, whereas three-quarters of premature deaths caused by tuberculosis, HIV, and illicit drugs were attributable to socioeconomic inequality. We studied inequality in premature mortality by age, sex, and deprivation, showing that three-quarters of deaths among men aged 35–49 years in the poorest areas were attributable to inequality. Although mortality reduced over the study period, the proportion attributable to inequality increased, particularly for women. Inequalities were tempered by converging rates of cardiovascular mortality between deprivation groups, whereas inequalities in other diseases, including respiratory diseases among women, plateaued or even worsened.

Bon, c'est une étude non randomisée, rétrospective, bla bla bla. Mais c'est tout à fait important à prendre en compte, non seulement lors des choix à faire pour l'allocation des budgets pour les politiques de santé publique mais aussi, pour les praticien.ne.s dans la façon d'aborder chaque patient.e individuellement au cabinet.

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