Determinants of Health in Rich Countries Hserv 482 Session 2/3

"For years, the life expectancies of both men and women in the United States have lagged behind those of their counterparts in most other industrialized nations. … In 1998 the United States also ranked 28th in infant mortality among 39 industrialized nations. In the area of chronic disease, reported incidence rates in 1990 for all cancers in males and females were highest in the US among a group of 30 industrialized nations." National averages mask serious disparities [Black IMR 2.5 Whites] Pg 20-1

SUMMARY FIRST CLASS Discussed what we do to produce health for an individual, family, possibly a country How to consider a country's health, and where does US stand among countries in health outcomes? DID NOT GET TO CONSIDER Epistemology: how do we come to believe things or know things are true?

NYT

Learning Objectives Describe the various studies that associate hierarchy and health among rich countries Describe associations between measures of income and various health-related outcomes in the United States HAND IN QUIZ ANSWERS

United Nations Human Development Report 2007

1st & 4th yr US medical student knowledge of Population Health (2002) QuestionFirst Year INCORRECT Fourth Year INCORRECT US has higher life expectancy than any other nation? 28.3%34.4% US has lower infant mortality than any other nation? 40.6%30.2% Agrawal et. al. (2005)

Wilkinson 1992 BMJ MORE EQUALITY BETTER HEALTH Income inequality and health

Where is our health? Female Life Expectancy by County 1990 C. Murray, Harvard, 1998 Female Life Expectancy 70.0 to to to to to to to to 90.0

Kaplan 1996 BMJ BETTER HEALTH MORE EQUALITY

Violence Related to gap between RICH and poor

*Austria, Finland, Ireland, Norway, Sweden and Switzerland had fewer than 20 deaths reported and therefore rates were not calculated. Youth violence Olympics—Homicide rates among youth aged (most recent year available) from the World Health Organizations’ World Report on Violence and Health, 2002*

VIOLENCE AND INEQUALITY MORE EQUALITY Higher HOMICDE Rates

SCF State of the World's Mothers 2004 A fifth of 20-yr old women In the US gave birth in their teens In Phillips County,Arkansas, the birth rate among teenage girls in 2000 was 127 births per 1,000 women aged 15 to 19 - a rate higher than in 94 developing countries.

Figure 1b: Mean births per 1000 teens aged Counties divided into tertiles of poverty and income inequality County tertiles by per capita income County tertiles of income inequality Mean births per 1,000 teens Rachel Gold Maternal Child Health Jr 2001

Pickett AJPH 2005 Violence and Teen Birth Rates related Higher TEEN BIRTHS Higher HOMICDE Rates

Pickett et. al. AJPH 2005 Teenage births MORE EQUALITY Higher TEEN BIRTHS

"more egalitarian societies (i.e., those with a less steep differential between the richest and the poorest) have better average health" pg. 59

What does INEQUALITY mean? relative deprivation…..

How might income distribution affect health? Directly Indirectly

Student Comment on personal examples of this relationship relatives friends your travels personal experience with being sick

Poorer people have poorer health is the most consistent finding in epidemiologic research Inequality kills

(last paragraph) "The primary determinants of disease are mainly economic and social, and therefore its remedies must also be economic and social. Medicine and politics cannot and should not be kept apart."

Summary Socioeconomic disparities are most important determinants of health status including: -mortality measures (life expectancy, infant mortality, homicides -teen births (and many others) A gradient (slope), not a dichotomous (them/us) relationship