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