Societal Approaches to Understanding. How Income and Income Inequality Affect Health. Part I

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 University October 28, 2002 • 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 Overview PYLL(0-74) by Cause, Urban Canada, 1996 0 Neoplasms Income-Related Injuries Circulatory Infectious Perinatal Ill-defined Congenital All other 5 10 15 20 25 30 % 30.9 35 23.1 19.2 17.6 5.3 4.9 4.8 3.8 13.5 Source: Wilkins et al., 2002 Excess PYLL(0-74) by Cause, Urban Canada, 1996 0 Circulatory Injuries Neoplasms Infectious Ill-defined Perinatal Digestive All other 5.4 14.5 8.3 7.1 12.2 14 16.9 5 10 15 20 21.6 25% Source: Wilkins et al., 2002 Poverty and Health: Mechanisms Poverty 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 Working-Aged Male (25-64) Mortality by Median Share U.S. States and Canadian Provinces 800 U.S. States with weighted linear fit (from Kaplan et al., 1996) Canadian Provinces with weighted linear fit (slope not significant) Rate per 100,000 Population MS 675 LA SC AL FL 550 TX CA ME PEI 425 MN SASK QUE NH NS NB MAN BC ALTA ONT NFLD Mortality Rates Standardized to the Canadian Population in 1991 300 0.18 0.20 0.22 0.24 WAMWeightedCan&US June 16, 1999 2:40:26 PM Median Share of Income Working Age (25-64) Mortality by Median Share U.S. and Canadian Metropolitan Areas 600 NewOrleansLA AugustaGA PineBluffAR 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) FlorenceSC Rate per 100,000 Population 500 NewYorkNY MonroeLA 400 BryanTX LosAngelesCA Shawinigan SiouxCityIA PortsmouthNH 300 McallenTX Montreal Vancouver Toronto AppletonWI Barrie Oshawa Mortality Rates Standardized to the Canadian Popluation in 1991 200 0.15 0.19 0.23 Median Share of Income 0.27 WAWeightedCan&US June 29, 1999 12:53:18 PM USA, Canada, and Sweden Rankings Compared to Other Industrialized Nations (Ranking, 1 is best) Measure Income Inequality (1990) Child Poverty (1990) Infant Mortality (1996) Youth Suicide (1992-1995) High School Drop-Outs (1996) Youth Homicide (1992-1995) Wages (1996) Unemployment (1996) Elderly Poverty (1990) Life Expectancy (1996) USA 18 of 18 17 of 17 24 of 29 15 of 22 17 of 17 22 of 22 13 of 23 2 of 10 15 of 17 20 of 29 Canada 11 14 17 16 16 19 15 7 4 4 Sweden 3 2 2 10 10 5 6 8 5 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 Low birth weight Homicide Unemployment Welfare No health insurance Per capita medical spending 0.65 0.74 0.48 0.69 0.45 -.67 High School graduation Library books per capita -0.71 -0.42 Kaplan, BMJ (1996) Increasing Inequality and Longevity in UK Source: Lynch et al., BMJ, 2000