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

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 % Source: Wilkins et al., 2002

Excess PYLL(0-74) by Cause, Urban Canada, 1996 % 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

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USA, Canada, and Sweden Rankings Compared to Other Industrialized Nations (Ranking, 1 is best) MeasureUSA Canada Sweden Income Inequality (1990)18 of Child Poverty (1990)17 of Infant Mortality (1996)24 of Youth Suicide ( )15 of High School Drop-Outs (1996)17 of Youth Homicide ( )22 of Wages (1996)13 of Unemployment (1996)2 of 1078 Elderly Poverty (1990)15 of 1745 Life Expectancy (1996)20 of 2943

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,

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