Johan Mackenbach
Department of Public Health, Erasmus MC
Rotterdam, Netherlands
Life
Health
expectancy expectancy
Neighbourhood (men, 2007) (men, 2007)
Nesselande
78,8
71,9
Ommoord
77,2
69,0
Oosterflank
76,7
68,7
Prinsenland
77,8
69,1
Kralingen-Oost
78,4
70,1
Kralingen-West
75,9
67,7
Stadsdriehoek
76,5
67,7
Cool
76,0
67,0
Delfshaven
74,3
65,3
Spangen
74,9
65,5
Jonker e.a., 2013
Contributions (in years) of causes of death and age-groups to inequalities in life
expectancy between educational groups, men, 1998-2007
0.6
0.5
other
0.4
extern
respir
othercancer
0.3
capros
calung
0.2
colorect
othercvd
0.1
cervas
ischae
0.0
-0.1
30-34
35-39
40-44
45-49
50-54
55-59
60-64
65-69
70-74
75-79
Kulhanova et al., submitted
The great paradox of
public health:
despite prosperity,
more equal income
distribution, welfare
state, equal access to
health care, …
health inequalities
persist, and even are
widening

Zooming in: individuals, and how they differ in
socioeconomic position, specific risk factors, and
health outcomes
e.g. Whitehall, GLOBE, birth cohort studies, …

Zooming out: societies, and how they differ in social
structure, risk factor distribution, and health
inequalities
e.g. international comparative studies

Socioeconomic inequalities in mortality are
universal and substantial – not smaller in Northern
but in Southern Europe

Socioeconomic inequalities in mortality are
widening – not responsive to policies aiming to
reduce inequalities

Lifestyle risk factors play important role – with
variability illustrating robustness of socioeconomic
position as “fundamental cause”
Relative Risk (age-adjusted, 30-79 years)
Relative Risks of all-cause mortality
low vs. high education, men, 2000s
3.5
3.5
3.0
3.0
2.5
2.5
2.0
2.0
1.5
1.5
1.0
1.0
0.5
0.5
0.0
0.0
Mackenbach et al., submitted
Relative Risk (age-adjusted, 30-79 years)
Relative Risks of all-cause mortality
low vs. high education, men, 2000s
3.5
3.5
3.0
3.0
2.5
2.5
2.0
2.0
1.5
1.5
1.0
1.0
0.5
0.5
0.0
0.0
Mackenbach et al., submitted
Relative Risk (age-adjusted, 30-79 years)
Relative Risks of all-cause mortality
low vs. high education, men, 2000s
3.5
3.5
3.0
3.0
2.5
2.5
2.0
2.0
1.5
1.5
1.0
1.0
0.5
0.5
0.0
0.0
Mackenbach et al., submitted
Relative Risk, age-adjusted, 30-79 years
Relative Risks of all-cause mortality
low vs. high education, women, 2000s
2.5
2.5
2.0
2.0
1.5
1.5
1.0
1.0
0.5
0.5
0.0
0.0
Mackenbach et al., submitted
Relative Risk, age-adjusted, 30-79 years
Relative Risks of all-cause mortality
low vs. high education, women, 2000s
2.5
2.5
2.0
2.0
1.5
1.5
1.0
1.0
0.5
0.5
0.0
0.0
Mackenbach et al., submitted
Relative Risk, age-adjusted, 30-79 years
Relative Risks of all-cause mortality
low vs. high education, women, 2000s
2.5
2.5
2.0
2.0
1.5
1.5
1.0
1.0
0.5
0.5
0.0
0.0
Mackenbach et al., submitted
Relative Risks by cause of death
Spain vs. Northern Europe, men, 2000s
Prostate cancer
Colorectal cancer
Cerebrovasc. dis.
Stomach cancer
Falls
Oth. heart dis.
Suicide
Road accidents
Hypertensive dis.
Isch. heart dis.
Pneumonia
Lung cancer
Diabetes
Alcohol abuse
COPD
Homicide
Total
3 Spanish regions
4 Nordic countries
0
0.5
1
1.5
2
2.5
3
3.5
4
4.5
Relative Risk (age-adjusted, 0-79 years)
Unpublished data from EURO-GBD-SE project
Current smoking
Spain vs. Nordic countries, men, 2000s
0.7
Prevalence of smoking
0.6
0.5
Spain, Low
0.4
Spain, High
Nordic, Low
0.3
Nordic, High
0.2
0.1
0
30-44
45-59
60-69
70-79
Unpublished data from EURO-GBD-SE project
Current smoking
Spain vs. Nordic countries, men, 2000s
0.7
Prevalence of smoking
0.6
0.5
Spain, Low
0.4
Spain, High
Nordic, Low
0.3
Nordic, High
0.2
0.1
0
30-44
45-59
60-69
70-79
Unpublished data from EURO-GBD-SE project
Current smoking
Spain vs. Nordic countries, women, 2000s
0.6
Prevalence of smoking
0.5
0.4
Spain, Low
Spain, High
0.3
Nordic, Low
Nordic, High
0.2
0.1
0
30-44
45-59
60-69
70-79
Unpublished data from EURO-GBD-SE project
Current smoking
Spain vs. Nordic countries, women, 2000s
0.6
Prevalence of smoking
0.5
0.4
Spain, Low
Spain, High
0.3
Nordic, Low
Nordic, High
0.2
0.1
0
30-44
45-59
60-69
70-79
Unpublished data from EURO-GBD-SE project
Rate Ratios of all-cause mortality
low vs. high education, 1990s and 2000s, men
Rate Ratio (age-adjusted, 30-74 years)
3.5
3
2.5
2
1.5
1
1990s
2000s
0.5
0
Mackenbach et al., submitted
Rate differences of all-cause mortality
low vs. high education, 1990s and 2000s, men
Rate difference (age-adjusted, 30-74 years)
1800
1600
1400
1200
1000
800
600
1990s
2000s
400
200
0
Mackenbach et al. submitted
Rate differences of all-cause mortality
low vs. high education, 1990s and 2000s, men
Rate difference (age-adjusted, 30-74 years)
1800
1600
1400
1200
1000
800
600
1990s
2000s
400
200
0
Mackenbach et al. submitted
13 YEARS OF LABOUR
GOVERNMENT
UNIQUE POLICY
EXPERIMENT
IF THIS DID NOT
WORK, WHAT WILL?
Absolute inequalities in all-cause mortality
1981-2010, men
Difference between low and high educated
(deaths per 100000)
900
800
700
600
Finland
500
Norway
400
England & W
Italy, Turin
300
200
100
0
1981-85
1986-90
1991-95
1996-00
2001-05
2006-10
Unpublished data from DEMETRIQ project
Absolute inequalities in Cardiovascular disease mortality
1981-2010, men
450
Difference between low and high educated
(deaths per 100000)
400
350
300
Finland
250
Norway
200
England & W
Italy, Turin
150
100
50
0
1981-85
1986-90
1991-95
1996-00
2001-05
2006-10
Unpublished data from DEMETRIQ project
Absolute inequalities in smoking-related mortality
1981-2010, men
Difference between low and high educated
(deaths per 100000)
250
200
150
Finland
Norway
England & W
100
Italy, Turin
50
0
1981-85
1986-90
1991-95
1996-00
2001-05
2006-10
Unpublished data from DEMETRIQ project
Hu et al., in preparation
Relative Risk (age-adjusted, 30-79 years)
Ischemic heart disease
Relative Risks, low vs. high, 2000s, men
3.5
3.5
3.0
3
2.5
2.5
2.0
2
1.5
1.5
1.0
1
0.5
0.5
0.0
0
Mackenbach et al. submitted
Percent contribution to inequalities in mortality
by education, 2000s, men
Percentage reduction of excess risk
35
30
25
20
15
10
Smoking
Overweight
5
0
Eikemo et al., submitted
Percent contribution to inequalities in mortality
by education, 2000s, women
Percentage reduction of excess risk
35
30
25
20
15
10
Smoking
Overweight
5
0
Eikemo et al., submitted
Median Mortality Relative Risk
19 European populations, 2000s, men
Cancer of larynx B)
Alcohol abuse (B)
Chronic Obstructive Pulmonary Disease (B)
Cancer of trachea, bronchus and lung (B)
Pneumonia / influenza (M)
Appendicitis, hernia and peptic ulcer (M)
Cancer of buccal cavity, pharynx, and oesophagus (B)
Diabetes mellitus (B)
Other liver and gall bladder diseases (N)
Suicide (I)
Road traffic accidents (I)
Cancer of stomach (N)
Ischemic heart disease (B/M)
Cerebrovascular disease (B/M)
Accidental falls (I)
Hypertensive disease (B/M)
Cancer of liver (N)
Cancer of kidney and bladder (N)
Cancer of pancreas (N)
Cancer of colorectum (N)
Cancer of prostate (M)
Hodgkin's disease and leukemia (M)
0.0
0.5
1.0
1.5
2.0
2.5
3.0
3.5
4.0
4.5
RR (low vs. high education)
Mackenbach et al. submitted
Median Mortality Relative Risk
19 European populations, 2000s, men
Cancer of larynx B)
Alcohol abuse (B)
Chronic Obstructive Pulmonary Disease (B)
Cancer of trachea, bronchus and lung (B)
Pneumonia / influenza (M)
Appendicitis, hernia and peptic ulcer (M)
Cancer of buccal cavity, pharynx, and oesophagus (B)
Diabetes mellitus (B)
Other liver and gall bladder diseases (N)
Suicide (I)
Road traffic accidents (I)
Cancer of stomach (N)
Ischemic heart disease (B/M)
Cerebrovascular disease (B/M)
Accidental falls (I)
Hypertensive disease (B/M)
Cancer of liver (N)
Mackenbach et al. submitted
Median Mortality Relative Risk
19 European populations, 2000s, men and women
Men
All causes
of death
All preventable
causes
Amenable to behaviour
change
Amenable to medical
intervention
Amenable to injury
prevention
All non-preventable
causes
Women
Obs.
Median RR
Obs.
Median RR
385
1,90
343
1,67
276
2,15
244
1,90
161
2,35
146
2,30
118
1,82
127
1,90
51
1,94
38
1,40
109
1,53
99
1,43
Mackenbach et al. submitted
Median Mortality Relative Risk
19 European populations, 2000s, men and women
Men
All causes
of death
All preventable
causes
Amenable to behaviour
change
Amenable to medical
intervention
Amenable to injury
prevention
All non-preventable
causes
Women
Obs.
Median RR
Obs.
Median RR
385
1,90
343
1,67
276
2,15
244
1,90
161
2,35
146
2,30
118
1,82
127
1,90
51
1,94
38
1,40
109
1,53
99
1,43
Mackenbach et al. submitted
ROBUSTNESS OF
HEALTH
INEQUALITIES
=
ROBUSTNESS OF
SOCIAL
INEQUALITY

Inequalities in access to material and immaterial
resources have not been eliminated by the
welfare state

Social mobility has become more sensitive to
personal characteristics that are associated with
health (mental health, cognitive ability, …)

Welfare state is not effective against
determinants of disease that are linked to
consumption behavior
Mackenbach 2012
1200
1000
800
600
Before govt. redistr.
400
After govt. redistr.
200
0
Basic
Lower sec.
Higher sec.
Lower voc.
Higher
voc.
University
Lifetime wages before
government intervention,
vs. lifetime welfare after
tax, cash transfers and
non-cash benefits, in
thousands of Euros,
Netherlands, ca. 2002
Ter Rele 2007
40
35
30
25
University
20
Higher voc.
15
Higher sec.
10
Lower sec.
5
Basic
0
1914-39
1940-49
1950-59
1960-69
RMO 2011
Schaap et al. 2008

Magnitude of socioeconomic inequalities in mortality
varies substantially between countries, suggesting
great potential for reduction – but smaller
inequalities do not reflect more effective policies

Recently, absolute mortality inequalities have started
to decline in some countries – but do not reflect
success of national programs to reduce health
inequalities, and relative inequalities continue to rise

Health inequalities are remarkably robust across time
and place – we need better ideas for addressing
inequalities in consumption behavior and/or their
fundamental causes





Mackenbach JP. The persistence of health inequalities in
modern welfare states: The explanation of a paradox. Soc
Sci Med 2012;75:761-769.
Eikemo TA et al. How can inequalities in health be
reduced? A study of 6 risk factors in 21 European
populations. Submitted for publication
Kulhanova I et al. Why does Spain have smaller
inequalities in mortality? Eur J Publ Health (in press)
Mackenbach JP et al. Widening inequalities in mortality in
mortality: a study of 3.2 million deaths in 13 European
countries. Submitted for publication
Mackenbach JP et al. Variations in the relation between
education and cause-specific mortality in 19 European
populations: a test of the “fundamental causes” theory of
social inequalities in health. Submitted for publication