Response to: ‘Small numbers, big impact: making a utilitarian case for the contribution of inclusion health to population health in England’ by Zhang et al

Building on a recent meta-analysis of mortality in high-income countries,1 Zhang et al calculated population attributable fractions to estimate that people who have experienced incarceration, homelessness, or a substance use disorder in England accounted for 12% of premature deaths, despite comprising less than 1% of the population.2 Their findings provide persuasive evidence that investment in the health of these socially excluded groups can yield substantial benefits for population health.

We agree with Zhang et al that multisectoral ‘top-down’ policy change and ‘bottom-up’ individually tailored interventions are required to address social exclusion. However, the potential impact of such interventions remains to be established.3 The population attributable fraction calculated by Zhang et al represents an upper limit of the potential mortality reduction under the assumption that social exclusion has a direct causal effect on mortality. However, increasing evidence suggests that poor health is normative both before and…

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