Global oral health inequalities: task group--implementation and delivery of oral health strategies

Oral health workforce planning part 2: figures, determinants and trends in a sample of World Dental Federation member countries

BACKGROUND AND AIM

A range of factors needs to be taken into account for an ideal oral health workforce plan. The figures related to dentists, specialists, auxiliaries, practice patterns, undergraduate and continuing dental education, laws/regulations, the attitudes of oral health-care providers and the general trends affecting the practice patterns, work conditions and preferences of oral health-care providers are among such determinants. Thus, the aim of the present study was to gather such information from a sample of World Dental Federation (FDI) member countries with different characteristics.

METHODS

A cross-sectional survey study was carried out among a sample of FDI member countries between March 2, 2012 and March 27, 2012. A questionnaire was developed addressing some main determinants of oral health workforce, such as its structure, involvement of the public/private sector to provide oral health-care services, specialty services, dental schools, trends in workforce and compliance with oral health needs, and a descriptive analysis was performed. The countries were classified as developed and developing countries and Mann-Whitney U-tests and chi-square tests were used to identify potential significant differences (P > 0.05) between developed and developing countries. All data were processed in SPSS v.19.

RESULTS

In the18 questionnaires processed, the median number of dentists (P = 0.005), dental practices (P = 0.002), hygienists (P = 0.005), technicians (P = 0.013) and graduates per year (P = 0.037) was higher in developed countries. Only 12.5% of developed and 22.2% of developing countries reported having optimal number of graduates per year. It was noted that 66.7% of developing countries had more regions lacking enough dentists to meet the demand (P = 0.050) and 77.8% lacked the necessary specialist care (P = 0.015). Although developing countries reported mostly an oversupply of dentists, regardless of the level of development most countries did not report an oversupply of specialists. Most developed countries did not feel that their regulations (87.5%) complied with the needs and demands of the population and most developing countries did not feel that their undergraduate dental education (62.5%) complied. Migrating to other countries was a trend seen in developing countries, while, despite increased numbers of dentists, underserved areas and communities were reported.

DISCUSSION

The cross-sectional survey study suggests that figures related to optimum or ideal oral health workforce and fair distribution of the available workforce does not seem to be achieved in many parts of the world. Further attention also needs to be dedicated to general trends that have the capacity to affect future oral health workforce.

The ethical imperative of addressing oral health disparities: a unifying framework

Health disparities are preventable differences in the burden of disease or opportunities to achieve optimal health that are experienced by socially disadvantaged population groups. Reducing health disparities has been identified as an ethical imperative by the World Health Organization's Commission on Social Determinants of Health and numerous other national and international bodies. Significant progress has been made over the past years in identifying vulnerable groups, and 'distal' factors including political, economic, social, and community characteristics are now considered pivotal. It is thus unsurprising that the remarkable advances in the science and practice of dentistry have not led to notable reductions in oral health disparities. In this review, we summarize recent work and emphasize the need for a solid theoretical framing to guide oral health disparities research. We provide a theoretical framework outlining pathways that operate across the continuum of oral health determinants during the lifecourse and highlight potential areas for intervention. Because oral health disparities emanate from the unequal distribution of social, political, economic, and environmental resources, tangible progress is likely to be realized only by a global movement and concerted efforts by all stakeholders, including policymakers, the civil society, and academic, professional, and scientific bodies.

The research agenda on oral health inequalities: the IADR-GOHIRA initiative

The World Health Organization asserts that oral health is a basic human right, yet this is a right enjoyed by few. Oral disease is a major problem in high-income countries, where the cost of treating oral diseases often exceeds that for major non-communicable diseases. In low-to-middle income countries, oral diseases are a severe and growing public health problem. Furthermore, major inequalities exist both within and between countries in terms of disease severity and prevalence, and major social gradients exist in the prevalence of oral disease. The International Association for Dental Research (IADR) has responded to the challenge of poor oral health and oral health inequalities through the Global Oral Health Inequalities: the Research Agenda (GOHIRA) initiative. In a Call to Action it has set out the priorities for research that can lead to a reduction in oral health inequalities. Three key challenges have been identified, namely gaps in knowledge and an insufficient focus on social policy, the separation of oral health from general health, and inadequate evidence-based data. Ten key research priorities have been identified with due regard to the differing needs of the variety of global health care systems, and a set of prioritized outcomes and a timeline for implementation have been defined. In the wider context of the proposals set out above, five immediate priorities for action have been proposed.

Determinantes individuais e contextuais da cárie em crianças brasileiras de 12 anos em 2010

OBJETIVO: Estimar a prevalência e gravidade de cárie em crianças brasileiras e sua associação com fatores individuais e contextuais. MÉTODOS: Foram utilizados os dados da Pesquisa Nacional de Saúde Bucal (SBBrasil 2010), em uma amostra de 7.247 crianças de 12 anos. Os dados foram coletados por meio de exames clínicos e entrevistas. As variáveis dependentes foram as prevalências de cárie (dentes permanentes cariados, perdidos ou obturados [CPOD] ≥ 1 e CPOD ≥ 4). Foram realizadas análises bivariadas (teste de Rao-Scott) e multinível (regressão de Poisson). As variáveis individuais foram sociodemográficas, condição periodontal e relato de incômodo ao escovar os dentes. Os fatores contextuais foram a presença de água fluoretada, a porcentagem de domicílios ligados à rede de abastecimento de água e a renda mediana do município. RESULTADOS: A prevalência de CPOD ≥ 1 foi 56,0%. O CPOD médio foi igual a 2,04 (IC95% 1,76;2,31) e 22,2% das crianças tinham CPOD ≥ 4. A experiência de cárie foi significantemente mais elevada em crianças de cor de pele preta, parda e amarela; em famílias com renda mais baixa; em crianças com cálculo dentário ou sangramento gengival; e naquelas que relataram incômodo ao escovar. Viver em cidades sem água fluoretada, com menor cobertura da rede de abastecimento de água e com renda mediana baixa foram fatores contextuais associados à doença. CONCLUSÕES: A prevalência de cárie em crianças brasileiras de 12 anos foi baixa, de acordo com os critérios da Organização Mundial da Saúde. Houve significantes desigualdades geográficas e socioeconômicas nos níveis da doença.

Socioeconomic and family influences on dental treatment needs among Brazilian underprivileged schoolchildren participating in a dental health program

BACKGROUND

The objective of this study was to compare the socioeconomic and family characteristics of underprivileged schoolchildren with and without curative dental needs participating in a dental health program.

METHODS

A random sample of 1411 of 8-to-10 year-old Brazilian schoolchildren was examined and two sample groups were included in the cross-sectional study: 544 presented curative dental needs and the other 867 schoolchildren were without curative dental needs. The schoolchildren were examined for the presence of caries lesions using the DMFT index and their parents were asked to answer questions about socioenvironmental characteristics of their families. Logistic regression models were adjusted estimating the Odds Ratios (OR), their 95% confidence intervals (CI), and significance levels.

RESULTS

After adjusting for potential confounders, it was found that families earning more than one Brazilian minimum wage, having fewer than four residents in the house, families living in homes owned by them, and children living with both biological parents were protective factors for the presence of dental caries, and consequently, curative dental needs.

CONCLUSIONS

Socioeconomic status and family structure influences the curative dental needs of children from underprivileged communities. In this sense, dental health programs should plan and implement strategic efforts to reduce inequities in oral health status and access to oral health services of vulnerable schoolchildren and their families.

Are obesity and overweight associated with gingivitis occurrence in Brazilian schoolchildren?

AIM

This cross-sectional study aimed to assess the relationship between weight status and gingival inflammation in Brazilian schoolchildren aged 8- to 12-year old, when controlling for potential confounders.

METHODS

Overall, 1211 children aged 8- to 12-year old from public and private schools in Southern Brazil were selected by a two-stage cluster method. Questionnaires were used to assess socio-demographic data and oral hygiene habits. Oral examination evaluated presence of plaque and gingival bleeding. Anthropometric measures were collected to obtain body mass index. Multivariate Poisson regression was used for data analysis (Prevalence Ratio/95% Confidence Interval).

RESULTS

Prevalence of gingivitis was 44.0%. Mean and median values of gingival bleeding sites were 3.10 and 2.0 respectively. Obese/overweight children totalized 34.6%. In multivariate adjusted analysis, sex (PR 0.86; 95%CI 0.75;0.98), maternal schooling (PR 1.09; 95% CI 1.01;1.18), plaque (PR 1.37; 95% CI 1.26;1.50), dental caries experience (PR 1.16; 95% CI 1.01;1.36) and bleeding during tooth brushing (PR 1.27; 95% CI 1.11;1.48) were associated with the outcome. In the sex-stratified analysis, overweight/obese boys presented a greater risk for gingivitis (PR 1.22 95% CI 1.01;1.48).

CONCLUSIONS

Gingivitis was not associated with obesity/overweight in the total sample. Gender differences seem to influence the relationship between gingivitis and obesity/overweight; a stronger association was noted among boys than girls.

Perception of toothache in adults from state capitals and interior cities within the Brazilian geographic regions

Background

Studies emphasizing toothache in adulthood are scarce in Brazil. A greater understanding of both the prevalence and the self-perception of pain among individuals in this age group (35 to 44 years old) is important, especially considering that this is an economically active population. To describe reports of oral pain and oral pain-related aspects in from Brazilian state capitals and interior cities.

Methods

The sample comprised 9779 adults residing in the state capitals and interior cities from each Brazilian region in the SB Brazil 2010 report, regarding reports of oral pain and their intensity in the last 6 months. The descriptive analysis comparing pain reports between and within the regions and regression analysis of pain related to socioeconomic aspects per region were performed considering α=0.05 difference.

Results

The highest prevalence of pain was found in the Southeast region (p<0.01), and there was also difference between the state capitals and interior cities in the South (p<0.01), where the prevalence was higher in the capitals, and in the Southeast, where the higher prevalence was in the interior cities (p=0.03). The Northern region had lower pain intensity than the Southeast and Midwest. Comparing pain intensity, only the Northeast region showed statistical difference between state capitals and the interior cities for pain intensity, where the interior cities had higher pain intensity than the three state capitals. Regarding dental office visitations, the Southeast capitals have the highest prevalence (100%) compared to the North and South. The toothache impact on daily activities was as follows: eating difficulty (29.8% to 72.7%), uncomfortable teeth brushing (over 50%), and sleep disturbance (above 13%). Between the Brazilian regions the socioeconomic aspects differ in relation to the pain; the exception being the association between pain, dental care and income, which occurred in the 5 regions. Users of public dental care services were more likely to present pain, comparing to private dental services, OR ranging from 1.72 in the Northeast to 2.85 in the Southeast.

Conclusion

The prevalence of pain was higher among Brazilian adults, impacting some of the daily activities. The data also showed many differences in the prevalence and intensity of pain among both the Brazilian regions and the cities within the same region.

Oil Essential Mouthwashes Antibacterial Activity against Aggregatibacter actinomycetemcomitans: A Comparison between Antibiofilm and Antiplanktonic Effects

The aim of this work is to determine the antibacterial activity of three marketed mouthwashes on suspended and sessile states of Aggregatibacter actinomycetemcomitans. The efficacy of two commonly used products in clinical practice, containing essential oils as active ingredients (menthol, thymol, methyl salicylate, and eucalyptol) in association with or without alcohol, has been evaluated in comparison with a chlorhexidine-based mouthwash. The microtiter plate assay, in order to obtain a spectrophotometric measurement of bacterial responses at growing dilutions of each antiseptic, was used for the study. The analysis revealed that a good antibacterial activity is reached when the abovementioned mouthwashes were used at concentration over a 1/24 dilution and after an exposure time of 30 seconds at least. In conclusion, the alcoholic mouthwash appears to have a better biofilm inhibition than its antiplanktonic activity while the nonalcoholic product demonstrates an opposite effect with a better antiplanktonic behavior.

Oil Essential Mouthwashes Antibacterial Activity against Aggregatibacter actinomycetemcomitans: A Comparison between Antibiofilm and Antiplanktonic Effects

The aim of this work is to determine the antibacterial activity of three marketed mouthwashes on suspended and sessile states of Aggregatibacter actinomycetemcomitans. The efficacy of two commonly used products in clinical practice, containing essential oils as active ingredients (menthol, thymol, methyl salicylate, and eucalyptol) in association with or without alcohol, has been evaluated in comparison with a chlorhexidine-based mouthwash. The microtiter plate assay, in order to obtain a spectrophotometric measurement of bacterial responses at growing dilutions of each antiseptic, was used for the study. The analysis revealed that a good antibacterial activity is reached when the abovementioned mouthwashes were used at concentration over a 1/24 dilution and after an exposure time of 30 seconds at least. In conclusion, the alcoholic mouthwash appears to have a better biofilm inhibition than its antiplanktonic activity while the nonalcoholic product demonstrates an opposite effect with a better antiplanktonic behavior.

Inequalities in oral health and oral health promotion

This article offers a critical review of the problem of inequalities in oral health and discusses strategies for disease prevention and oral health promotion. It shows that oral health is not merely a result of individual biological, psychological, and behavioral factors; rather, it is the sum of collective social conditions created when people interact with the social environment. Oral health status is directly related to socioeconomic position across the socioeconomic gradient in almost all populations. The main priority for dental interventions is that they be integrated collaboratively and enable research and policies that address the main proximal determinants of oral diseases, i.e., sugars, smoking, hygiene, and risk behaviors. Adopting a mixed approach, these interventions should also reduce inequality, focusing on the socioeconomic determinants, to change the slope of the social gradient. The cornerstone of this approach is the Integrated Common Risk Factor Approach (CRFA).

Measuring socio-economic inequalities in edentate Scottish adults--cross-sectional analyses using Scottish Health Surveys 1995-2008/09

OBJECTIVES

To investigate the appropriateness of different measures of socio-economic inequalities, in relation to adult oral health in Scotland, utilizing data from a series of large, representative population surveys.

METHODS

The Scottish Health Surveys (SHeS) (1995; 1998; 2003; 2008/09) are cross-sectional national population-based surveys used to monitor health status in those living in private households. The age groups included in this study are as follows: 45-54; 55-64 years: all survey years; 65-74: 1998 onwards; 75+: 2003 onwards. Primary outcome was no natural teeth (edentulism). Three measures of socio-economic position: Occupational social class, Education, Carstairs deprivation score (2001) were used. Simple (absolute/relative differences) and complex measures (Slope Index, Relative Index, Concentration Index and c-index) of inequality were produced for each age group across all four surveys.

RESULTS

Simple and complex (absolute) measures of inequality have both demonstrated narrowing disparities in edentulism over time in the 45- to 64-year-old group, a levelling off in those aged 65 and above, and a rise in those aged 75+. Complex relative measures (RII, Concentration Index and c-index), however, show an increasing trend in inequalities over time for all age groups, suggesting that rates of improvement in edentulism rates are not uniform across all social groups.

CONCLUSIONS

Simple absolute inequality provides a quick and easy indication of the extent of disparities between extreme groups, whereas complex measures (absolute and relative) consider the gradient in health across all social groups. We have demonstrated that both are useful measures of inequality and should be considered complementary to one another. The appropriate choice of complex measure of inequality will depend on the audience to whom the results are to be communicated. This methodological approach is not confined to oral health but is applicable to other health outcomes that are socially patterned.

Oral diseases affect some 3.9 billion people

DATA SOURCES

Medline, Embase, Lilacs.

STUDY SELECTION

Published and unpublished observational population-based studies presenting information on the prevalence, incidence, case fatality and cause-specific mortality related to untreated caries, severe periodontitis and severe tooth loss between January 1980 and December 2010. There were no language restrictions. Study quality was assessed using the STROBE checklist (http://www.strobe-statement.org/).

DATA EXTRACTION AND SYNTHESIS

Prevalence estimates were calculated on the database for all age-gender-country-year groups using a specifically developed Bayesian meta-regression tool. Disability-adjusted life-years (DALYs) and years lived with disability (YLDs) metrics were used to quantify the disease burden. Disability weights were calculated based on population-based surveys in five countries (USA, Peru, Tanzania, Bangladesh and Indonesia) and an open Internet survey. Uncertainties in estimates were examined using Monte Carlo simulation techniques with uncertainty levels presented as the 2.5th and 97.5th centiles, which can be interpreted as a 95% UI.

RESULTS

Oral diseases remain highly prevalent in 2010 affecting 3.9 billion people. Untreated caries in permanent teeth was the most prevalent condition evaluated for the entire GBD (Global Burden of Disease) 2010 Study with a global prevalence of 35% for all ages combined. Severe periodontitis and untreated caries in deciduous teeth were the 6th and 10th most prevalent conditions, affecting, respectively, 11% and 9% of the global population. Oral conditions combined accounted for 15 million DALYs globally (1.9% of all YLDs and 0.6% of all DALYs), implying an average health loss of 224 years per 100,000 people. DALYs due to oral conditions increased 20.8% between 1990 and 2010, mainly due to population growth and aging. While DALYs due to severe periodontitis and untreated caries increased, those due to severe tooth loss decreased.

CONCLUSIONS

The findings highlight the challenge in responding to the diversity of urgent oral health needs world-wide, particularly in developing communities.

Inequality in oral health-care utilisation exists among older Thais despite a universal coverage policy

AIM

To assess socioeconomic-related inequality in oral health-care utilisation among older Thais.

METHOD

The data on 8951 and 11,402 older Thais (≥60 years) from national representative Thailand Health and Welfare Surveys (HWS) of 2003 and 2009, respectively, were analysed. Descriptive analyses were performed on oral health-care utilisation, and a concentration index (CI) quantified the extent of socioeconomic-related inequality in oral health-care utilisation.

RESULTS

Analyses indicated that socioeconomic-related inequalities in oral health-care utilisation among older Thais existed, and tended to favour those of higher socioeconomic status. However, the older poor were more likely to utilise oral health care at public facilities, particularly primary care facilities, than those of higher socioeconomic status.

CONCLUSION

Despite universal coverage policy, socioeconomic-related inequalities in oral health-care utilisations exist among the older Thais. To alleviate these, strengthening the primary health-care system deserves particular attention.

Setting oral health goals that include oral health-related quality of life measures: a study carried out among adolescents in Thailand

The aim of this study was to assess the association between oral diseases and condition-specific oral health-related quality of life (CS-OHRQoL) as a basis for proposing OHRQoL-based goals for the population of 15-year-olds in Thailand. Oral examinations and OHRQoL interviews were conducted with 871 15-year-olds as part of the Sixth Thailand National Oral Health Survey. The severity of oral impacts was categorized using "intensity". Associations between oral diseases and CS-OHRQoL were analyzed using chi-square and logistic regression. Thirty-nine percent of 15-year-olds experienced moderate/higher levels oral impacts on quality of life. Compared to those individuals with no tooth decay, adolescents with one or four or more decaying teeth were three and seven times more likely to experience moderate/higher impacts, respectively. Adolescents with extensive gingivitis in 3 or more mouth sextants were twice as likely to experience moderate/higher CS-impacts. Based on these findings, it is proposed that goals should focus on untreated decaying teeth and extensive gingivitis. Oral health goals for 15-year-olds should include specific OHRQoL measures.

Social determinants of health in Canada: are healthy living initiatives there yet? A policy analysis

INTRODUCTION

Preventative strategies that focus on addressing the social determinants of health to improve healthy eating and physical activity have become an important strategy in British Columbia and Ontario for combating chronic diseases. What has not yet been examined is the extent to which healthy living initiatives implemented under these new policy frameworks successfully engage with and change the social determinants of health.

METHODS

Initiatives active between January 1, 2006 and September 1, 2011 were found using provincial policy documents, web searches, health organization and government websites, and databases of initiatives that attempted to influence to nutrition and physical activity in order to prevent chronic diseases or improve overall health. Initiatives were reviewed, analyzed and grouped using the descriptive codes: lifestyle-based, environment-based or structure-based. Initiatives were also classified according to the mechanism by which they were administered: as direct programs (e.g. directly delivered), blueprints (or frameworks to tailor developed programs), and building blocks (resources to develop programs).

RESULTS

60 initiatives were identified in Ontario and 61 were identified in British Columbia. In British Columbia, 11.5% of initiatives were structure-based. In Ontario, of 60 provincial initiatives identified, 15% were structure-based. Ontario had a higher proportion of direct interventions than British Columbia for all intervention types. However, in both provinces, as the intervention became more upstream and attempted to target the social determinants of health more directly, the level of direct support for the intervention lessened.

CONCLUSIONS

The paucity of initiatives in British Columbia and Ontario that address healthy eating and active living through action on the social determinants of health is problematic. In the context of Canada's increasingly neoliberal political and economic policy, the public health sector may face significant barriers to addressing upstream determinants in a meaningful way. If public health cannot directly affect broader societal conditions, interventions should be focused around advocacy and education about the social determinants of health. It is necessary that health be seen for what it is: a political matter. As such, the health sector needs to take a more political approach in finding solutions for health inequities.

Do schools put children's oral health at risk owing to lack of a health-promoting policy?

BACKGROUND

To achieve a healthy school environment with good nutrition as recommended by World Health Organization, health-promoting policies are needed.

AIMS

To ascertain whether Finnish schools had oral-health-promoting policies and whether the presence of the policy was associated with practical actions related to oral-health promotion. Another aim was to determine if and how the policy and the actions had changed in 2007-09.

METHODS

This longitudinal survey was implemented in Finnish upper comprehensive school classes 7-9 (n=970) in 2007-09. The questionnaire contained 32 questions concerning selling of sweet- and healthy products, school policy, and decision-makers of the policy. From the nine items on the questionnaire, three variables were formed by weighting the response categories: Policy, Exposure, and Enabling. The mean values of each variable were calculated and the statistical significances of the changes were analysed using nonparametric Friedman's test. The correlations between the variables were investigated by Spearman's correlation coefficients.

RESULTS

The majority of schools did not have clearly defined oral-health-promoting policies, then they improved in making them, decreased exposure of pupils to sweet products, and offered more oral-health-enabling factors (p<0.041). In 2009, the oral-health-promoting policy and enabling factors of the schools correlated positively (r=0.200; p=0.001) and pupil exposure to selling of sweet products and oral-health-enabling factors correlated negatively (r=-0.176; p=0.005).

CONCLUSIONS

As even a national recommendation do not seem to have a major effect in changing oral-health-promoting policies, schools need more support on their way towards healthier school environment.

Distribution of caries in children: variations between and within populations

The rapid changes in social and economic conditions in many populations may have significant impacts on health, including child oral health. Understanding trends and variations between and within countries will assist in the development of effective preventive programs. This review aims (1) to document time-trends in child caries experience of countries with different levels of social and economic development, and (2) to compare factors affecting the caries experience of children in two contrasting countries. A time-trend analytical approach of ecological data from countries with different levels of social and economic development and individual data of the two contrasting Vietnamese and Australian child populations were used. The analysis found a significant decline in caries experience of children, mostly driven by the improvement in populations with high social and economic development. Significant variations in caries experience and in associations with risk factors between and within countries were observed. Socio-economic inequality in child oral health existed within developed countries and between countries with different levels of development. Population programs aimed at improving upstream factors are of priority in further improving child oral health in different populations.

Using interviews to construct and disseminate knowledge of oral health policy

OBJECTIVES

Policymakers worldwide are challenged by the problem of oral health inequities. The goal of an interprovincial partnership in Canada was to guide policy aimed at improving the oral health of vulnerable populations. Insights regarding barriers and enablers to developing such policy in one province (Newfoundland & Labrador, Canada) were required to enhance collaboration between decision makers and researchers and to contribute to the evidence informing policy development.

METHODS

Snowball technique identified fourteen key informants. Semistructured audio-recorded interviews were conducted in person or by telephone. Two researchers independently conducted the analyses of the transcribed interviews, one using NVivo software and the second, manual coding. Triangulation of the analyses confirmed the findings.

RESULTS

Agreement between the two approaches showed that most key informants believed that oral health is an important policy issue; however, most felt it was not a high priority among the general public and most were unable to articulate the policy process. Barriers to oral health becoming a governmental priority were related to resource allocation and to poor communication among some groups including dentists and dental hygienists. Current government programmes and initiatives were praised but considered weak in health promotion strategies. Recommendations for enhancing oral health priority varied.

CONCLUSIONS

Attention to the methodological considerations of qualitative research enhanced the credibility of the method and confidence in the findings. Leveraging of existing programmes and improving communication were recommended to contribute to raising the priority of oral health within the government, thereby increasing their commitment to address oral health care, particularly for vulnerable populations.

Global oral health inequalities in incidence and outcomes for oral cancer: causes and solutions

The mouth and oropharynx are among the ten most common sites affected by cancer worldwide, but global incidence varies widely. Five-year survival rates exceed 50% in only the best treatment centers. Causes are predominantly lifestyle-related: Tobacco, areca nut, alcohol, poor diet, viral infections, and pollution are all important etiological factors. Oral cancer is a disease of the poor and dispossessed, and reducing social inequalities requires national policies co-ordinated with wider health and social initiatives - the common risk factor approach: control of the environment; safe water; adequate food; public and professional education about early signs and symptoms; early diagnosis and intervention; evidence-based treatments appropriate to available resources; and thoughtful rehabilitation and palliative care. Reductions in inequalities, both within and between countries, are more likely to accrue from the application of existing knowledge in a whole-of-society approach. Basic research aimed at determining individual predisposition and acquired genetic determinants of carcinogenesis and tumor progression, thus allowing for targeted therapies, should be pursued opportunistically.