Upstream and Downstream
Approaches to Inequalities in Health:
Challenges and Opportunities
George A. Kaplan
Center for Social Epidemiology and Population Health
University of Michigan
©Ken Light
CSEPH
Upstream and Downstream Approaches
to Inequalities in Health
• The Context
– The 800 lb. genome gorilla, health, and health inequalities
– Social Epidemiology and Population Health
– Socioeconomic inequalities in health
• Some current explorations (briefly)
–
–
–
–
The downstream/bloodstream side of inequality
The life course and cumulative disadvantage
Communities as crucibles for growing health inequality
Economic equity and health
CSEPH
1
Upstream and Downstream Approaches
to Inequalities in Health
• Challenges and Opportunities
–
–
–
–
–
–
–
Metaphors and Models
Need for Theory
Analytic and Methodologic Pitfalls
Perils and Promise of Interdisciplinarity
Personalizing Populations
Moderating Essentialism
Lost Opportunities
CSEPH
At the end of a century in which the average life
expectancy in the United States has increased by
nearly thirty years, victory over disease and
disability has become an understandably popular
and realistic goal. (emphasis added)
Harold Varmus, 1999
2
More than 150 years ago Rudolf Virchow, the great
German pathologist, journeyed to Upper Silesia to
investigate a great typhus epidemic. In his report to the
Prussian government he focused not on a search for the
critical bacilli, or the necessary animal vectors for
transmission to humans. Instead, he called attention to the
social, economic, and cultural factors responsible for the
epidemic. In education and full employment, he argued,
lay the cures for the prevention of future epidemics..
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.
Geoffrey Rose, The Strategy of Preventive Medicine, 1992
3
Stearns Co, MN
LE= 83
41 year range in life expectancy between the
shortest (AI males in 6 counties in SD) and the
longest (A/PI females in Bergen County, NJ) is Baltimore Co,
equal to 90% of the global range in life
MD LE=73
expectancy (males in Sierra Leone vs. females in
Japan)
(Murray et al.,1998)
4
1991
1994
<10%
10% to 15%
>15%
N/A
1996
1998
Prevalence of Obesity (+30 lbs) Among
U.S. Adults: BRFSS, 1991-1998
Source: Mokdad et al. JAMA 1999; 282(16):1519-1522
Heart Disease Death Rates, Age 25-64
Average Annual 1979 - 1989, Men
Income
1980$
White
Black
B/W
Ratio
Less than $10,000
324.1
390.8
1.21
$10,000 - $14,999
255.4
292.8
1.15
$15,000 - $24,999
136.9
142.2
1.04
Source: Health, United States, 1998
5
Determinants of Population Health
and Health Inequalities
Social and Economic Policies
Institutions (including medical care)
Life
cour
se
Living Conditions
Social Relationships
Individual Risk Factors
Genetic/Constitutional
Factors
Pathophysiologic
pathways
Individual/Population
Health
P
vi
En
l
ica
hys
nt
me
n
ro
l
Upstream and Downstream Approaches
to Inequalities in Health
• The Context
– The 800 lb. genome gorilla, health, and health inequalities
– Social Epidemiology and Population Health
– Socioeconomic inequalities in health
• Some current explorations (briefly)
–
–
–
–
The downstream/bloodstream side of inequality
The life course and cumulative disadvantage
Communities as crucibles for growing health inequality
Economic equity and health
CSEPH
6
Publications with Social Epidemiology in title,
abstract, or descriptors: MEDLINE, 1966-2002
300
P u b lica tio n s/ye a r
250
200
150
100
50
02
20
98
00
20
96
19
94
19
19
90
92
19
88
19
86
19
19
82
84
19
80
19
78
19
19
74
76
19
72
19
70
19
68
19
19
19
66
0
What Do we Mean by Inequalities in
Health?
Inequality
Disparity
Inequity
There are many potential types of inequality/disparity/inequity
In what follows I will focus on socioeconomic inequalities
7
Socioeconomic Position and Health
•
•
•
•
Widespread
All age groups affected
Affects multiple organs and risk factors
Not fixed in time
CSEPH
Davey Smith et al.
8
Fatality Rates for Women Passengers on the Titanic
50
Fatality Rate (%)
45
40
35
30
25
20
15
10
5
0
1st Class
2nd Class
3rd Class
Cabin Class
Lord, 1955
17
Number of publications per month with social class,
socioeconomic factors, income or poverty listed as
descriptors: MEDLINE search, 1969 through mid-2000.
240
P u b lic a tio n s/M o n th
220
200
180
160
140
120
100
1969-72
1973-76
Kaplan and Lynch, AJPH, 1997 +
update 6/03/2000
1977-80
1981-84
1985-88
Year
1989-92
1993-96
1997-2000
18
9
All-cause Mortality by Income
NLMS, 25+ Years
Income Group
$15-19,999
< $5,000
$20-24,999
$5-9,000
$25-49,999
AfricanAmerican Male
White Female
$10-14,999
> $50,000
140
120
SMR
100
80
60
40
20
0
White Male
Rogot et al., 1992
AfricanAmerican Female
19
Relative Risk of Death by Income & the Distribution of
Income: USA, NLMS
2.5
Relative risk of death compared to mean income
2.0
1.5
Population
Income Density
distribution
RR = 1
1.0
Relative Risk (RR) +/95% Confidence
Interval for beta
Mean
Income
0.5
0
0
50,000
Mean
50,000
100,000
150,000
100,000
200,000
150,000
200,000
Household Income
Wolfson, Kaplan,Lynch, Ross, Backlund, BMJ, 1999
10
Deaths/10,000 in 300,685 Men: MRFIT, Age 35-57
120
Median Zip Code Family Income ($1,000s)
100
91.8
<10
10-12
12-14
14-16
16-18
18-20
20-22
22-24
24-26
26-28
28-30
87.6 86.5
30-32
32-34
34+
78.9 78.2
80
70.1 68.1
60
64.5
61.9
59
56.5 58.2
51.9 51.4
40
20
0
Davey Smith et al.,
1996
Socioeconomic Position and Health
•
•
•
•
Widespread
All age groups affected
Affects multiple organs and risk factors
Not fixed in time
CSEPH
11
Infant Mortality Rates by Years of Education:
United States, 1995, Mother 20+ years of age
20
17.3
18
<12
16
12
14
>15
12.7
12.3
11.4
12
10
13-15
14.8
9.9
8
7.9
6.5
6
6.0 5.9
5.1
5.7
5.4
5.7 5.5
4.2
5.1
4.0
4
2
0
White, NH
Black, NH
Hispanic
AmInd/AKNat
Asian/PI
Stunting* by Age and Poverty Status
16.0
Percent
14.0
Poverty
Non-Poverty
12.9
12.0
10.0
8.0
7.4
6.8
6.0
5.2
3.9
4.0
3.7
2.0
0.0
2-5
6-11
12-17
Age
USDHHS, 1986
*height<5th percentile
12
Asthma Hospitalization Rate among children 1-4 years:
U.S,.1989-91
8
<$20K
$20-29.9K
$30-39.9K
$40K+
7
6
5
4
3
2
1
0
All
White
Af-Am
Survival from Age 65 by Pre-Retirement Earnings Quintile
546,759 Canadian Males in Canada Pension Plan
1.00
Survival Probability
0.95
0.90
0.85
Income Quintile (Earnings)
1 (<$14,494)
2 ($14,494-$22,278)
3 ($22,279-$27,990)
4 ($27,991-$35,986)
5 (>$35,986)
0.80
0.75
5
4
3
2
1
0.70
65
66
67
68
69
70
71
72
73
74
Age
Wolfson et al., 1993
26
13
Socioeconomic Position and Health
•
•
•
•
Widespread
All age groups affected
Affects multiple organs and risk factors
Not fixed in time
CSEPH
Chronic Conditions more Prevalent among those with < 12
Years of Education: NHIS, 1989, 65+ years
14
4-Year Change in Max IMT (mm)
4-year Progression of Plaque Height by
Education and Income Level
0.32
0.3
0.28
0.26
0.24
0.22
0.2
<High
School
Some
High
School
Education
Lynch et al., 1997
High
School+
I(Lowest)
I
III
IV
Income
30
15
Upstream and Downstream Approaches
to Inequalities in Health
• Some current explorations (briefly)
– The downstream/bloodstream side of inequality
– The life course and cumulative disadvantage
– Communities as crucibles for growing health
inequality
– Economic equity and health
CSEPH
SES
Psychosocial
Factors
Smoking
High pro-oxidants
to antioxidants ratio
Diet
Low PA
High LDL
Lipid
peroxidation
Atherosclerosis
Angina
Pectoris
Low HDL
Obesity
Insulin
resistance
Other
mechanisms
Thrombosis
Myocardial
Infarction
Hypertension
16
Fibrinogen and TPA by Income Quartiles
Kuopio Ischemic Heart Disease Risk Factor Study
Tissue Plasminogen Activator
Fibrinogen
T P A I U /m l
F ib r in o g e n g /l
3.2
3.1
3.0
2.9
2.8
2.7
1 (low)
2
3
0.3
0.3
0.2
0.2
0.1
1 (low)
4 (hi)
Income Quartile
2
3
4 (hi)
Income Quartile
Total Serum Cholesterol and LDL by Income Quartiles
Kuopio Ischemic Heart Disease Risk Factor Study
LDL Cholesterol
S e r u m C h o le s t e r o l
m m o l/l
Total Serum Cholsterol
4.3
L D L m m o l/ll
6.1
6.0
5.9
5.8
5.7
5.6
5.5
4.0
3.8
3.5
1 (low)
2
3
Income Quartile
4 (hi)
1 (low)
2
3
4 (hi)
Income Quartile
17
Systolic Blood Pressure and Fasting Glucose by Income
Quartiles
Kuopio Ischemic Heart Disease Risk Factor Study
Fasting Blood Glucose
SBP m m H g
B lo o d G lu c o s e
m m o l /l
Systolic Blood Pressure
136.0
5.0
134.0
4.8
132.0
130.0
4.5
1 (low)
2
3
4 (hi)
1 (low)
Income Quartile
2
3
4 (hi)
Income Quartile
Income and Whole Blood Serotonin in the KIHD Study
160
WBS (ng/mL)
155
150
145
140
135
130
Income Quintiles
Everson-Rose et al., in progress
18
Behavioral Risk Factors by Level of Education
Kuopio Ischemic Heart Disease Risk Factor Study
100
90
80
70
60
50
40
30
20
10
0
Primary or less
Some High School
High School or more
Pack-years(-100)
% Drunk>2-3/mo
% Sedentary
Lynch, Kaplan & Salonen, 1997
Dietary Consumption by Income Quartiles
Kuopio Ischemic Heart Disease Risk Factor Study
Vegetables
Fruits & Berries
1 (low)
100
200
50
150
0
1 (low)
3
4 (hi)
2
3
100
50
4 (hi)
0
Income Quartile
Income Quartile
Sodium
P/S Ratio
3400
3300
3200
3100
3000
2900
2800
P/S ratio
Na (mg)
2
250
g/d
g/d
150
1 (low)
2
3
Income Quartile
4 (hi)
0.3
0.29
0.28
0.27
0.26
0.25
0.24
0.23
0.22
1 (low)
2
3
4 (hi)
Income Quartile
19
Age adjusted Prevalence (%)
Prevalence (%) of Psychosocial Factors by Education
Kuopio Ischemic Heart Disease Risk Factor Study: 42-60 year-old men
30
Low
Medium
High
25
20
15
10
5
fC
oh
er
en
ce
li t
y
Se
ns
eo
Ho
s ti
s
Ho
pe
le s
sn
es
De
pr
es
sio
n
0
Lynch, Kaplan & Salonen, 1997
Prevalence of Depressive/Hopelessness Symptoms by Income Tertiles
30
Low
Middle
High
25
20
15
10
5
0
Consumers
Survey
Detroit Study
Alameda Study
Kuopio Study
Everson et al., 2000
20
4-Year Progression of Carotid
Atherosclerosis by Hopelessness
Adjusted for Age and Baseline IMT
Prevalence of Hopelessness by
Income Quintiles
0.34
Maximum Change in Intima-Media Thickness (mm
25
Prevalence of Hopelessness (%)
20
15
10
5
0.32
0.30
0.28
0.26
0.24
0.22
0.20
es
t)
(H
ig
h
4t
h
3r
d
d
2n
Quintiles
5t
h
1s
t(
Lo
we
s
t)
0
Kuopio Ischemic Heart Disease Study,
Low/Moderate Differing Leves High Levels at
at Baseline
at Baseline
Baseline
4 Year Follow-Up of Hopelessness
Everson et al., 1997
41
Upstream and Downstream Approaches
to Inequalities in Health
• Some current explorations (briefly)
– The downstream/bloodstream side of inequality
– The life course and cumulative disadvantage
– Communities as crucibles for growing health
inequality
– Economic equity and health
CSEPH
21
“The childhood shows the man, As the morning shows the day”
John Milton. Paradise Lost (1667), Line 220-221.
Adult Health
Birth Outcomes
Risk Factors &
Environment
Child Health
Coronary Heart Disease Mortality in Hertfordshire
Adults by Weight at Birth (lbs)
Heart Disease Mortality re: <5.5
1.2
Birth Weight
1
<5.5
6-
7-
8-
9-
>10
0.8
0.6
0.4
0.2
0
Males
Females
Osmond et al. , 1993
22
Mother’s
Education
Mother’s
Occupation
Childhood
Socioeconomic
Position
Education
Adult
Cognitive
Function
Father’s
Occupation
Father’s
Education
Early Environmental Events and Later Development
Various studies indicate the following more common for
poor children:
Homelessness
Poor and unaffordable housing
Residential mobility
Inadequate heating
Crowding
Cold, dampness, mold
Cockroaches, rats, mice
Poor quality child care
Decreased verbal interactions with adults
Inadequate schools
Fewer educational opportunities at home
Few stimulating activities at home
Parental stress and depression
23
Cognitive Function at Age 58 & 64 and Life Course
Socioeconomic Disadvantage
190
T r a il-m a k e r T e st (se c s)
worse
173.5
170
150
137.5
130
110
113.1
90.8
90
70
better
50
0
1
2
3
Increasing Life Course Economic Disadvantage
Increase re: 0 tim es
29-year Cumulative Impact of Economic Disadvantage
on Five Health Outcomes
6
No.of Times <200%
5
of Poverty
0
1
2
3
4
3
2
1
0
Disability Depression Pessimism Hostility
Cognitive
Problems
Lynch, Kaplan & Shema, NEJM, 1997
24
Grandmothers of the Current Generation
New York City, 1952
Washington, DC 1952
Barrington, 2003
Childhood and Adult SES and Mortality from All Causes
Kuopio Ischemic Heart Disease Risk Factor Study
OR: re High/High
3.5
3.0
2.93
Childhood SES
High
Mid
Low
2.55
2.5
2.39
2.0
1.5
1
1.0
1.14
0.88
0.5
0.0
High
Low
Adult SES
Lynch et al., 1994
25
Upstream and Downstream Approaches
to Inequalities in Health
• Some current explorations (briefly)
– The downstream/bloodstream side of inequality
– The life course and cumulative disadvantage
– Communities as crucibles for growing health
inequality
– Economic equity and health
CSEPH
Proportion Surviving
Age-adjusted Survival by Poverty Area Residence:
Alameda County Study, 1965-1974
1.00
0.95
Non-Poverty Area
0.90
Poverty Area
0.85
Survival curves from Cox model,
estimated at age=60
0.80
0
Haan et al., 1987
1000
2000
Days
3000
4000
52
26
Those who lived in the poverty area over
the next 9 years:
• had twice the decrease in physical activity
• were more likely to become depressed
• were twice as likely to become disabled
• were less likely to be “successfully” aging
Those in the Poverty neighborhoods
• Were 5.8-8.0 lbs (M and F) heavier and gained
2.4-3.0 lbs (M & F) more over the next 9 years
(after adjustment for age, race, education &
income)
• They were 3-8 times (depending on gender, race,
and income) to develop NIDDM over the next 34
years
27
Diabetes Mortality Differences between Whites and African-Americans
before and after adjustment for Median Income of Area of Residence:
MRFIT: 320,909 men aged 35-47
3
2.63
75% reduction in risk
with adjustment for
median income of area
Mortality Risk re: White
2.5
2
1.43
1.5
1
1.00
1.00
0.5
0
Age
Age+Income
Upstream and Downstream Approaches
to Inequalities in Health
• The 800 lb. genome gorilla and health inequalities
• Socioeconomic inequalities in health
• Some current explorations (briefly)
– The downstream/bloodstream side of inequality
– The life course and cumulative disadvantage
– Communities as crucibles for growing health
inequality
– Economic equity and health
CSEPH
28
U.S. Income Inequality
“The gap between rich and poor has grown into
an economic chasm so wide that this year the
richest 2.7 million Americans, the top 1 percent,
will have as many after-tax dollars to spend as
the bottom 100 million.”
NY Times, Sept 5, 1999
29
Income Inequality and Mortality in US States, 1990
(adjusted for State Median Income)
1000
LA
MS
Age-adjusted Total Mortality
950
AL WV
KY
GA
NV
TN
AR
900
SC
IL
DE
NC
PA
OH
MI NJ VA
Between
1980 OK
and 1990, statesINthatMDhad the
NY
biggest TX
increaseMO
in income inequalityAK
had the
ME
VT
smallest decreaseCAin mortality
rates
MT RI ORWY
850
NM
800
MA
FL
AZ
NE
KS
CT
750
CO
SD
ND
r = - 0.62
WA
NH
WI
IA
ID
MN
UT
700
HI
650
17
18
19
20
21
22
23
24
Kaplan et al. BMJ (1996) Income Share Held by Poorest 50% of the Population
Income Inequality and Selected Educational Indicators
r
% < High School Diploma
-0.71
% High School Dropout
-0.50
4th Grade Reading Scores
-0.58
4th Grade Math Scores
-0.64
Education / Total Spending
-0.32
Library Books Per capita
-0.42
30
High Inequality &
Low Income
926
Low Inequality &
High Income
950
Mortality
Rate per
100,000
900
812
895
1st (Low)
850
2nd
786
800
3rd
4th (High)
750
4th (High) 3rd
2nd
Per Capita
Income
Quartiles
1st (Low)
Income Inequality Quartiles
Lynch, Kaplan, Pamuk,
Pamuk, et al. AJPH (1998)
How large are these mortality effects ?
High Income Inequality
Low Income Inequality
Low Average Income
High Average Income
925.8 per 100,00
785.9 per 100,00
140 deaths per 100,000
Equivalent to the combined loss of life from
lung cancer, diabetes, motor vehicle crashes,
HIV infection, suicide and homicide in 1995.
Lynch, Kaplan, Pamuck, et al, AJPH, 1998
31
Income Inequality and Working Age Mortality
USA, Canada, Australia, Sweden Metropolitan Areas
1990/91
US metro areas n=282
CAN metro areas n=53
AUS metro areas n=18
SWE metro areas n=40
Working-Age (25-64) Mortality Rate per 100,000
600
500
400
DO
300
Source:
T
O
N
E
T
I
C
Canada: Ross, Dunn, Wolfson
US: Lynch and Kaplan
200
Australia: Glover
Sweden: Henricksson
0.15
0.20
0.25
0.30
Median Share of Income
Ross et al., in progress
Upstream and Downstream Approaches
to Inequalities in Health
• Challenges and Opportunities
–
–
–
–
–
–
–
Metaphors and Models
Need for Theory
Analytic and Methodologic Pitfalls
Perils and Promise of Interdisciplinarity
Personalizing Populations
Moderating Essentialism
Lost Opportunities
CSEPH
32
Social and Economic Policies
Life
cour
se
Institutions (including medical care)
Neighborhoods and Communities
Living Conditions
Social Relationships
Individual Risk Factors
Genetic/Constitutional
Genetic/Constitutional
``
Factors
Factors
``
Pathophysiologic
pathways
Individual/Population
Health
ys
Ph
lE
i ca
nv
nt
me
n
ir o
Political Economy
Discrimination
History
Institutions
Culture
Organizational Connections
Neighborhood
Distal Social
Connections
Community
Family
Proximal Social
Connections
Behavioral
Individual
Characteristics
Work
Friends
Socioeconomic
Psychosocial
Human Biology
Genetics
Genetic
Characteristics
Pathological Biomarkers
Pathobiology
Health Status
Conception
Structural
Macrosocial
Factors
Life Course
Old Age
Lynch, 2000
33
Material, Psychosocial
Social Structure
CNS
Work
Psychological Neuroendocrine
Social
Environment
Immune
Health
Behavior
Pathophysiology
Organ Impairment
Early Life
Culture
Genes
DM
CHD
Wellbeing
Marmot, 2001
RaceEthnicity
Socioeconomic
Status
Gender
EXPLANATORY VARIABLES
Social, Political, and
Economic Conditions
and Policy
Health Outcomes
1.
Mortality
2.
Institutionalization
3.
Morbidity (Chronic)
4.
Functional Limitations
5.
Self-rated Health
6.
Cognitive Function
7.
Depression
Medical Care and Insurance
Psychosocial Risk Factors
1. Health Behaviors
2. Social Relationships
and Supports
3. Chronic and Acute
Stress
4. Psychological
Dispositions
5. Social Roles and
Productive Activities
Physical/Chemical and Social
Environmental Hazards
House, 2002
34
Upstream and Downstream Approaches
to Inequalities in Health
• Challenges and Opportunities
–
–
–
–
–
–
–
Metaphors and Models
Need for Theory
Analytic and Methodologic Pitfalls
Perils and Promise of Interdisciplinarity
Personalizing Populations
Moderating Essentialism
Lost Opportunities
CSEPH
35
Upstream and Downstream Approaches
to Inequalities in Health
• Challenges and Opportunities
–
–
–
–
–
–
–
Metaphors and Models
Need for Theory
Analytic and Methodologic Pitfalls
Perils and Promise of Interdisciplinarity
Personalizing Populations
Moderating Essentialism
Lost Opportunities
CSEPH
Upstream and Downstream Approaches
to Inequalities in Health
• Challenges and Opportunities
–
–
–
–
–
–
–
Metaphors and Models
Need for Theory
Analytic and Methodologic Pitfalls
Perils and Promise of Interdisciplinarity
Personalizing Populations
Moderating Essentialism
Lost Opportunities
CSEPH
36
Upstream and Downstream Approaches
to Inequalities in Health
• Challenges and Opportunities
–
–
–
–
–
–
–
Metaphors and Models
Need for Theory
Analytic and Methodologic Pitfalls
Perils and Promise of Interdisciplinarity
Personalizing Populations
Moderating Essentialism
Lost Opportunities
CSEPH
Upstream and Downstream Approaches
to Inequalities in Health
• Challenges and Opportunities
–
–
–
–
–
–
–
Metaphors and Models
Need for Theory
Analytic and Methodologic Pitfalls
Perils and Promise of Interdisciplinarity
Personalizing Populations
Moderating Essentialism
Lost Opportunities
CSEPH
37
Upstream and Downstream Approaches
to Inequalities in Health
• Challenges and Opportunities
–
–
–
–
–
–
–
Metaphors and Models
Need for Theory
Analytic and Methodologic Pitfalls
Perils and Promise of Interdisciplinarity
Personalizing Populations
Moderating Essentialism
Lost Opportunities
CSEPH
In a world of science in which the proximal
and molecular explanation is seen as the
“best,” a complete, satisfying, and useful
understanding of inequalities in health may
require the methodologic lens of complex
systems and systems biology (even), the
sensitivity and insights of the historian, poet
and ethnographer, the knowledge of the
biologist and ecologist, and the tools of the
policy analyst and public health practitioner.
38
While there are many challenges, the study
and remediation of inequalities in health
coiuld serve as a model for a new scientific
paradigm– bridging the social and the
biological.
A tall order, but an exciting one that holds
promise for breaking the link between the
social divides in society and the health
divides, and in doing so perhaps (???) even
helping to decrease the social divides……..
Social and Economic Policies
Life
cour
se
Institutions (including medical care)
Neighborhoods and Communities
Living Conditions
Social Relationships
Individual Risk Factors
Genetic/Constitutional
Genetic/Constitutional
``
Factors
Factors
``
Pathophysiologic
pathways
Individual/Population
Health
ys
Ph
lE
i ca
nv
ent
m
n
ir o
78
39
40
Upstream and Downstream Approaches
to Inequalities in Health
• The 800 lb. genome gorilla and health inequalities
• Socioeconomic inequalities in health
• Some current explorations (briefly)
– The downstream/bloodstream side of inequality
– The life course and cumulative disadvantage
– Communities as crucibles for growing health
inequality
– Economic equity and health
– Globalization and health
– How do we understand?
• 1.2 billion people (20% of world’s population) are
estimated to live on less than $1 per day
• 3 billion (49% of world’s population) on less than $2
per day
• 110 million primary school age children are out of
school (60% of them girls)
• Many more live without adequate food, shelter, safe
water, and sanitation.
WHO, Global Poverty Report, July, 2000
41
Social Impacts of 1998 Asian Financial Crisis in Thailand
Increases in:
• poverty
• unemployment
• divorce rates
• child abandonment
• drug use
Shivakumar et al., 2000
Debt Service vs. Other Expenditures in Pakistan
Debt
Service
(350B)
Development
Health
Budget
Bhutta, 2000
42
Cash Flow in and out of Pakistan from World Bank and
IMF, 1999-2000
Into
World Bank
IMF
Out of
Net
250
514.2
-264.2
0
329.1
-329.1
Bhutta, 2000
Globalization of the Economy
Capital Concentration
Leveraged buy-outs, etc.
Social Resources
Other Risk Factors
Real Wages
Stress &
Time Pressure
Work Hours
Changes in
Occupational Structure
Downsizing/Job Losses
Deforestation
Meat Production
Flue-curing of
tobacco
Job Insecurity
Income and
Wealth
Inequality
Convenience &
Fast Food
Cardiovascular
Disease
Poor Nutrition
Farming
Migration
High-strain,
minimum wage jobs
Social
Cohesion
Blood Pressure
Smoking
Obesity
Epidemiologic Transition
in Developing Countries
43
Upstream and Downstream Approaches
to Inequalities in Health
• The 800 lb. genome gorilla and health inequalities
• Socioeconomic inequalities in health
• Some current explorations (briefly)
– The downstream/bloodstream side of inequality
– The life course and cumulative disadvantage
– Communities as crucibles for growing health
inequality
– Economic equity and health
– Globalization and health
– How do we understand?
44
45
New Urbanism
Small, self-contained neighborhoods
with the center no more than a quarter
of a mile from the edge -- a reasonable
walking distance. Improved public
transit systems and greater integration
of different types of land uses at the
neighborhood level.
vs
46
9-10 fo
differe
$137 vs $13,995
100-fold
difference!!
47
Interactions Between Neighborhood and Individual
Risk Factors for Low Birth Weight
Neighborhood Level
Per Capita
Crime
Unemployment
Wealth
Low Per
Capita
Income
Individual Level
Low Maternal
Education
Maternal Age
Prenatal
Care
LBW
Health
Insurance
O'Campo et al 1997
48
9-10 fo
differe
Historical Factors
Civic Culture
Political
Social Values
Economy
Political Institutions
1
Neo-Material Context
Education System
Working Conditions
Industry Base
Public Health Services
Environmental Controls
Land Use & Zoning
Recreation Facilities
Transportation Systems
Affordable Quality Housing
Access to Optimal Nutrition
Child Care
Advertising - cigarettes, etc
Discrimination
Distribution
of Income
2
Perception of Place
in the Social Hierarchy
Disrespect
Lack of Trust
Ð Social Cohesion
Ð Social Capital
3
Individual
Income
Smoking
Diet
Exercise
Hostility
Isolation
Morbidity
Mortality by
Cause
49
Trends in Inequality and Child Poverty 1967-1992
%Change in
Inequality
UK
USA
Sweden
Australia
Denmark
Canada
Finland
Spain
Israel
W. Germany
%Change in
Child Poverty
+ 30
+ 15 - 29
+ 15 - 29
+ 10 - 15
+ 10 - 15
0
0
0
0
0
+ 30
+ 30
-5
0
-5
-5
-5
0
+ 5 - 10
+ 5 - 10
How large are these mortality effects ?
High Income Inequality
Low Income Inequality
Low Average Income
High Average Income
925.8 per 100,00
785.9 per 100,00
140 deaths per 100,000
Equivalent to the combined loss of life from
lung cancer, diabetes, motor vehicle crashes,
HIV infection, suicide and homicide in 1995.
Lynch, Kaplan, Pamuck, et al, AJPH, 1998
50
Historical Factors
Civic Culture
Political
Social Values
Economy
Political Institutions
1
Education System
Working Conditions
Industry Base
Public Health Services
Environmental Controls
Land Use & Zoning
Recreation Facilities
Transportation Systems
Affordable Quality Housing
Access to Optimal Nutrition
Child Care
Advertising - cigarettes, etc
Discrimination
3
Distribution
of Income
Neo-Material Context
Individual
Income
2
Perception of Place
in the Social Hierarchy
Disrespect
Lack of Trust
Ð Social Cohesion
Ð Social Capital
Smoking
Diet
Exercise
Hostility
Isolation
Morbidity
Mortality by
Cause
Trends in Inequality and Child Poverty 1967-1992
%Change in
Inequality
UK
USA
Sweden
Australia
Denmark
Canada
Finland
Spain
Israel
W. Germany
+ 30
+ 15 - 29
+ 15 - 29
+ 10 - 15
+ 10 - 15
0
0
0
0
0
%Change in
Child Poverty
+ 30
+ 30
-5
0
-5
-5
-5
0
+ 5 - 10
+ 5 - 10
51