The pathways that lead from conditions of life and work to health disparities, by way of multiple exposures and vulnerabilities (Diderichsen

et al., 2001), are if anything more complex and less predictable than those involved with the operation of environmental risks. As in the case of environmental risks, both researchers and those seeking to use their findings for policy and advocacy must therefore make or understand multiple “methodological value judgments” (Shrader-Frechette and McCoy, 1993: 84–101). These begin with the choice of outcomes for study. Bcl-2 inhibitor Over a time frame that permits effective policy response Selleck Bosutinib or intervention design, changes in mortality rates and causes of death may be too crude an indicator of the consequences of social and economic inequalities

except in the case of catastrophic disruptions like the collapse of the former Soviet economy and the parallel collapse of social supports and health systems (Frank and Haw, 2011). In less extreme situations, changes in mortality data or the prevalence of other adverse outcomes may, given the accumulation of effects of disadvantage over the life course (Blane, 2006), take decades to become evident. This effect has been described as “epidemiological inertia” (Frank and Haw, 2011: 676) and raises problems similar to those associated with the long latency associated with many health outcomes attributable to environmental risks. Against this background of uncertainty, how long is too long to wait to see whether “dead bodies” appear? Assuming that the choice has been made not to wait for the epidemiological Godot of data not on mortality or other health outcomes, should evidence of (for instance) changes in risk factors like obesity, which contributes

to a broad range of adverse health outcomes, or allostatic load, which is a basic concept in the physiology of chronic stress (McEwen and Gianaros, 2010 and Seeman et al., 2010), be sufficient to justify initiating an intervention or to consider it successful? Or should the net be cast wider still? Support for this latter position comes from an important literature review on overweight and obesity: “Many strategies aimed at obesity prevention may not be expected to have a direct impact on BMI, but rather on pathways that will alter the context in which eating, physical activity and weight control occur. Any restriction on the concept of a successful outcome, to either weight-maintenance or BMI measures alone, is therefore likely to overlook many possible intervention measures that could contribute to obesity prevention” (Mooney et al., 2011: 22).