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 050515
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)
Question
First 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)
BETTER HEALTH
Income inequality
and health
MORE EQUALITY
Wilkinson 1992 BMJ
Female Life Expectancy by County 1990 C. Murray, Harvard, 1998
Female Life Expectancy
70.0 to 77.1
77.1 to 78.1
78.1 to 78.6
78.6 to 79.1
79.1 to 79.6
79.6 to 80.1
80.1 to 80.8
80.8 to 90.0
Where is our health?
BETTER HEALTH
MORE EQUALITY
Kaplan 1996 BMJ
Violence
Related to gap
between
RICH and poor
Youth violence Olympics—Homicide rates among youth aged 10-29 (most
recent year available) from the World Health Organizations’ World Report on
Violence and Health, 2002*
US A
New Zealand
Korea
Canada
Poland
Australia
Netherlans
Denmark
Italy
Hungary
Belgium
Portugal
Czech Republic
UK
Greece
S pain
Germany
France
Japan
0
2
4
6
8
10
12
*Austria, Finland, Ireland, Norway, Sweden and Switzerland had fewer than 20 deaths reported and therefore
rates were not calculated.
Higher HOMICDE Rates
VIOLENCE AND INEQUALITY
MORE EQUALITY
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.
A fifth of 20-yr old women
In the US gave birth in their teens
SCF State of the World's Mothers 2004
Figure 1b: Mean births per 1000 teens aged 15-17
Counties divided into tertiles of poverty and income inequality
60
54
46
50
37 39
35
40
30
30
38
28
County
tertiles of
income
inequality
Low
Medium
High
19
20
10
0
High
Medium
Low
County tertiles by per capita income
Rachel Gold
Maternal Child Health Jr 2001
Higher HOMICDE Rates
Violence and Teen Birth Rates related
Higher TEEN BIRTHS
Pickett AJPH 2005
Teenage births
Higher TEEN BIRTHS
Pickett et. al. AJPH 2005
MORE EQUALITY
"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
H
I
E
R
e g Al i t a r i a n
R
C
H
I
C
A
L
horizontal
respect, equality, friendship, support
cooperation, community, sociability
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