In Reply: I agree with virtually everything that Drs van Hoyweghen and Bartholomée state, as noted in my other writings.1 The evidence clearly supports the position that the environment for all classes of people in society plays a large role in determining how healthy they are.2
In my Commentary, I indicated that responsibilities should begin not with the poor, but with the rich and middle class. I distinguished those responsibilities for which an individual is mostly responsible from those (such as cigarette smoking, exercising substantially, and controlling weight) for which social determinants play a major role. Thus, for the middle class my Commentary focused on diagnostic testing that would identify diseases while they were curable and taking medication that would prevent the occurrence of serious diseases, such as myocardial infarction. These actions are under the control of the individual, as opposed to the environment in which he or she lives, especially if care is easily available and is free of charge.