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Social Determinants of Health AK/HLST 3010
School of Health Policy and Management
Dennis Raphael
Societal Approaches to Understanding How Income and Income Inequality
Affect Health
York UniversityOctober 28, 2002
Overview• Health differences among nations• Health differences among US states and
cities• Various explanations for these effects • Social policy and population health• Social policy, health determinants and
health in Canada today• Social policy, health, and the welfare state
PYLL(0-74) by Cause, Urban Canada, 1996
30.9
19.2
17.6
5.3
4.9
4.8
3.8
13.5
23.1
0 5 10 15 20 25 30 35
Neoplasms
Income-Related
Injuries
Circulatory
Infectious
Perinatal
Ill-defined
Congenital
All other
%
Source: Wilkins et al., 2002
Excess PYLL(0-74) by Cause, Urban Canada, 1996
21.6
16.9
14
12.2
8.3
7.1
5.4
14.5
0 5 10 15 20 25
Circulatory
Injuries
Neoplasms
Infectious
Ill-defined
Perinatal
Digestive
All other
%
Source: Wilkins et al., 2002
Poverty and Health: MechanismsPoverty can affect health in a number of ways:• income provides the prerequisites for health, such
as shelter, food, warmth, and the ability to participate in society;
• living in poverty can cause stress and anxiety which can damage people’s health;
• low income limits peoples’ choices and militates against desirable changes in behaviour.
- Benzeval, Judge, & Whitehead, 1995, p.xxi, Tackling Inequalities in Health: An Agenda for Action.
Critical Periods of the Life Course• Fetal development• Birth• Nutrition, growth and health in adulthood• Educational Career• Leaving parental home• Entering labour market• Establishing social and sexual relationships• Job loss or insecurity• Parenthood• Episodes of illness• Labour market exit• Chronic sickness• Loss of full independence -- Shaw et al., The Widening Gap, 1999, p. 106.
Health Differences Among Nations
0.18 0.20 0.22 0.24Median Share of Income
300
425
550
675
800
Ra
te p
er
10
0,0
00
Po
pu
latio
nWorking-Aged Male (25-64) Mortality by Median Share
U.S. States and Canadian Provinces
WAMWeightedCan&US June 16, 1999 2:40:26 PM
Mortality Rates Standardized to the Canadian Population in 1991
U.S. States with weighted linear fit (from Kaplan et al., 1996)Canadian Provinces with weighted linear fit (slope not significant)
MSLA
AL
CA
TX
FL
NH
MN
PEI
NFLDNB
SASK
ONT
ALTABC
MAN
QUE NS
SC
ME
0.15 0.19 0.23 0.27Median Share of Income
200
300
400
500
600
Rat
e pe
r 10
0,00
0 P
opul
atio
nWorking Age (25-64) Mortality by Median ShareU.S. and Canadian Metropolitan Areas
U.S. cities (n=282) with weighted linear fit (from Lynch et al. 1998)Canadian cities with weighted linear fit (n=53) (slope not significant)
Mortality Rates Standardized to the Canadian Popluation in 1991
FlorenceSC
JacksonvilleNC
SiouxCityIA
MonroeLA
ChicagoIL
TuscaloosaAL
Prince George
WashingtonDC
Oshawa
NewYorkNY
LosAngelesCA
NewOrleansLA
BryanTX
McallenTX
SiouxCityIA
AppletonWI
PortsmouthNH
PineBluffAR
FlorenceSC
MonroeLA
AugustaGA
Montreal
Vancouver
Toronto
Barrie
Oshawa
Shawinigan
WAWeightedCan&US June 29, 1999 12:53:18 PM
USA, Canada, and Sweden Rankings Compared to Other Industrialized Nations
(Ranking, 1 is best)
Measure USA Canada SwedenIncome Inequality (1990) 18 of 18 11 3Child Poverty (1990) 17 of 17 14 2Infant Mortality (1996) 24 of 29 17 2Youth Suicide (1992-1995) 15 of 22 16 10High School Drop-Outs (1996) 17 of 17 16 10Youth Homicide (1992-1995) 22 of 22 19 5Wages (1996) 13 of 23 15 6Unemployment (1996) 2 of 10 7 8Elderly Poverty (1990) 15 of 17 4 5Life Expectancy (1996) 20 of 29 4 3
Health Differences Among US States and Cities
Economic Inequality: Explanations
• Economically unequal societies have greater levels of poverty (individual poverty explanation)
• Economically unequal societies have greater hierarchy and weaker social cohesion (social comparison explanation)
• Economic unequal societies provide fewer social safety nets and social investment (neo-materialist explanation)
Economic Inequality and Health
• What matters in determining mortality and health in a society is less the overall wealth of that society and more how evenly wealth is distributed. The more equally wealth is distributed the better the health of that society.
• Editorial: The big idea. British Medical Journal, April 20, 1996, 312, 985.
Economic Inequality and Health
• Inequality may make people miserable long before it kills them.
• Editorial: Income inequality and mortality: Why are they related? British Medical Journal, April 20, 1996, 312, 987-988.
Neo-Materialist Viewpoint I• Income inequality has generally been associated
with differences in health
• A psychosocial interpretation of health inequalities, in terms of perceptions of relative disadvantage and the psychological consequences of inequality, raises several conceptual and empirical problems
• Income inequality is accompanied by many differences in conditions of life at the individual and population levels, which may adversely influence health
• - Lynch et al., BMJ, 2000
Neo-Materialist Viewpoint II• Interpretation of links between income inequality
and health must begin with the structural causes of inequalities, and not just focus on perceptions of that inequality
• Reducing health inequalities and improving public health in the 21st century requires strategic investment in neo-material conditions via more equitable distribution of public and private resources
• - Lynch et al., BMJ, 2000
Higher income inequality is associated with lots of things
Kaplan, BMJ (1996)
-0.42Library books per capita
-0.71High School graduation
-.67Per capita medical spending
0.45No health insurance
0.69Welfare
0.48Unemployment
0.74Homicide
0.65Low birth weight
Source: Lynch et al., BMJ, 2000
Increasing Inequality and Longevity in UK