1. Societal Approaches to Understanding How Income and Income Inequality
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

2. 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

3. PYLL(0-74) by Cause, Urban Canada, 1996%
Source: Wilkins et al., 2002

4. Excess PYLL(0-74) by Cause, Urban Canada, 1996%
Source: Wilkins et al., 2002

5. 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.

6. 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.

7. Health Differences Among Nations

8. Working-Aged Male (25-64) Mortality by Median Share
0.18
0.20
0.22
0.24
Median Share of Income
300
425
550
675
800
Rate per 100,000 Population
Working-Aged Male (25-64) Mortality by Median Share
U.S. States and Canadian Provinces
WAMWeightedCan&US June 16, :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) MS LA AL CA TX FL NH MN
PEI
NFLD NB
SASK
ONT
ALTA BC
MAN
QUE NS SC ME

11. USA, Canada, and Sweden Rankings Compared to
Other Industrialized Nations
(Ranking, 1 is best)
Measure USA 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
Elderly Poverty (1990) 15 of
Life Expectancy (1996) 20 of

12. Health Differences Among US States and Cities

13. Mortality rate and median share of income in U.S.states
Source: BMJ 312: p

21. 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)

22. 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.

23. 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,

24. 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

25. 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

26. Higher income inequality is associated with lots of things
Kaplan, BMJ (1996)
-0.42
Library books per capita
-0.71
High School graduation
-.67
Per capita medical spending
0.45
No health insurance
0.69
Welfare
0.48
Unemployment
0.74
Homicide
0.65
Low birth weight

27. Increasing Inequality and Longevity in UK
Source: Lynch et al., BMJ, 2000