Objective: To examine any possible links between exposure to DDE (1,1-dichloro-2,2-bis (p-chlorophenyl)ethylene), the persistent metabolite of the pesticide dicophane (DDT), and breast cancer. Design: Multicentre study of exposure to DDE by measurement of adipose tissue aspirated from the buttocks. Laboratory measurements were conducted in a single laboratory. Additional data on risk factors for breast cancer were obtained by standard questionnaires. Setting: Centres in Germany, the Netherlands, Northern Ireland, Switzerland, and Spain. Subjects: 265 postmenopausal women with breast cancer and 341 controls matched for age and centre. Main outcome measure: Adipose DDE concentrations. Results: Women with breast cancer had adipose DDE concentrations 9.2% lower than control women. No increased risk of breast cancer was found at higher concentrations. The odds ratio of breast cancer, adjusted for age and centre, for the highest versus the lowest fourth of DDE distribution was 0.73 (95% confidence interval 0.44 to 1.21) and decreased to 0.48 (0.25 to 0.95; P for trend = 0.02) after adjustment for body mass index, age at first birth, and current alcohol drinking. Adjustment for other risk factors did not materially affect these estimates. Conclusions: The lower DDE concentrations observed among the women with breast cancer may be secondary to disease inception. This study does not support the hypothesis that DDE increases risk of breast cancer in postmenopausal women in Europe.

The high burden levels at the moment the decision to institutionalise the patient is taken put a heavy claim on the energy needed to continue to care during the ensuing waiting period. More social support and formal home care may reduce the level of burden of caregiving.

Study objective-To assess the size of mortality diVerentials in men by social class in Scotland as compared with England and Wales, and to analyse the time trends in these diVerentials. Socioeconomic mortality diVerences in England and Wales have increased over the past 40 years. Subjects-Men from England and1-5 Recently, increased attention has been given to the international variation in the size of mortality diVerences associated with socioeconomic position. Kunst and Mackenbach show that countries diVer in the size of their socioeconomic mortality diVerences, with small diVerences being observed in Norway and Denmark and large diVerences in France. 6 Scotland is known to have higher death rates than England and Wales. Carstairs and Morris argued that this higher mortality around the 1981 census is because of the much higher levels of deprivation in Scotland as compared with England and Wales.7 In another study it was shown that the mortality diVerentials between the west of Scotland and the south of England were largely explained by age, height, lung function, socioeconomic status, and smoking. 8 The relative magnitude of socioeconomic mortality diVerentials within Scotland and England and Wales has not been examined previously, however.The purpose of this study is to assess the magnitude of the mortality diVerences by social class in Scotland as compared with England and Wales over the period 1951 to 1981, to determine whether the higher overall mortality rate in Scotland is accompanied by greater socioeconomic mortality diVerentials within Scotland. We investigate which causes of death have contributed to increasing social class mortality diVerences and whether these were diVerent in Scotland than in England and Wales. MethodsAll analyses were restricted to men aged 15 to 64 years of age because of diYculties in comparing social class measures in women, based on their own or their spouses occupation, over time. The population of 65 years and older was excluded, because the meaning of social class coded on death certificates for

Conclusions-Building up a systematic knowledge base on the effectiveness of interventions to reduce socioeconomic inequalities in health will be a major enterprise. Elements ofa strategy to increase learning speed are discussed. Although the guidelines and design recommendations developed in this paper apply to the evaluation of specific interventions where rigorous evaluation methods can often be used, they may also be usefuil for the interpretation of the results of less rigorous evaluation studies, for example ofbroader policies to reduce socioeconomic inequalities in health.

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Objective-To examine the relation between trends over time in mortality and hospital morbidity caused by various cardiovascular diseases in the Netherlands. Design-Trend analysis by Poisson regression of national data on mortality and hospital admissions from 1975 to 1995. Subjects-The Dutch population. Results-All cardiovascular diseases combined were responsible for 39% of all deaths and 16% of all hospital admissions in 1995. From 1975 to 1995, age adjusted cardiovascular mortality declined by an annual change of −2.0% (95% confidence intervals (CI) −2.1% to −1.9%), while in the same period age adjusted discharge rates increased annually by 1.3% (95% CI 1.1% to 1.5%). Around 60% of the gain in life expectancy in this period was related to lower cardiovascular mortality. For mortality, major reductions were seen in coronary heart disease (annual change −2.9%) and in stroke (−2.1%), whereas the increase in hospital admissions was mainly caused by chronic manifestations of coronary heart disease (5.1%), heart failure (2.1%), and diseases of the arteries (1.8%). In recent years, the gap between men and women at risk of dying from coronary heart disease became smaller for those aged < 65 years. Conclusions-Our findings of a decrease in cardiovascular mortality and an increase in admission rates for chronic conditions such as heart failure, chronic coronary syndromes, and diseases of the arteries, support the hypothesis that the longer survival of many patients with heart diseases is leading to a growing pool of patients at increased risk for subsequent cardiovascular complications in Western countries. (Heart 1999;82:52-56)

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Policy measures to reduce socioeconomic health differences (SEHD) must be preceded by an analysis of the possibilities and desirability of a reduction. This paper argues that it is necessary to pursue equality in health, conceived as equal opportunities to achieve health. This principle is justified as part of the principle of maximizing Individual freedom of choice, and requires that everyone has the opportunity to be as healthy as possible. By means of this principle a distinction can be made between unjust, unavoidable, and acceptable health inequalities. The determinants of SEHD which lead to inequalities considered unjust must be subject to policy. These are living conditions (physical and social environment and health care) and conditions of choice (e.g. the knowledge of an individual about the health risks of a certain behaviour). Even if SEHD are considered inequities, sometimes conflicting interests will make it difficult to propose a health policy to redress these Inequities. These are partly the consequence of the intersectoral character of a policy aimed at equality of opportunities to attain health, in which the importance of hearth has to be weighed against other goals. Moreover the impact of such a policy on the individual free choice has to be critically weighed. Finally in the context of health care policy, conflicts between the principle of equality and maximizing health can be expected.Key words: equity in health, health policy, socioeconomic factors TK ere is no doubt that socioeconomic differences in health (SEHD) exist, even in welfare states. Empirical studies in different countries show higher morbidity and mortality rates among people with a lower education, lower income, or a lower classified occupation, compared to people in higher socioeconomic groups (Wilkinson 1986, Fox 1989, Illsley &. Svensson 1990. Now that the association between socioeconomic position and health seems to be established, a call for a policy response can be observed. Whitehead and Dahlgren (1991), who elaborated policy measures to reduce existing inequalities, summarize this trend as follows: The debate is no longer about whedier inequalities exist but what can be done about them." (p.1059). In the current debate about the policy measures to be taken to reduce SEHD, two important issues have rarely been discussed. The first concerns the justification of a policy aimed at reducing SEHD: why is it necessary to reduce socioeconomic inequalities in health? This question must precede the development of policy measures. Most often the desirability of such measures is simply assumed, even though the justification of policy measures is not necessarily selfevident. We will argue that is necessary to give arguments for the government's responsibility to reduce SEHD and to specify the socioeconomic inequalities in health to which this responsibility applies. ' If one can show that (some) socioeconomic inequalities should be reduced, die second question is what possibilities exist to achieve this. Given die intersectoral cha...