1. One starting point: Health Inequalities There are inequalities in health between countries and within countries; these are often linked to the wealth of a country, or to a person’s social position within a society. Because we have so much data on inequalities, they form a convenient starting-point. Our goal is to describe these patterns of health, and then seek explanations for them.

2. Some terms Health inequality: generic term referring to systematic differences in health between groups of people, including those that arise naturally and others whose origins lie in social disadvantage. Health disparity: subset of inequalities that are probably systematic & arise from social or other disadvantage that may in theory be correctable. Health inequity: subset of disparities that are deemed unfair or that stem from an injustice. (Differences in health across age groups may be an inequality; differences across racial groups could be an inequity) (Note you will find somewhat different usage between US & British literature)

3. Inequalities between countries Source: 1998 World Bank Report Among poorer countries, infant mortality is very sensitive to variations in GNP, but does not vary above about GNP $10,000 per year. Different processes operate in poor and rich countries.

4. Major Finding: Our health is certainly improving! Crude and age-standardized mortality rates, Canada, 1920-2000 Deaths per 1000 population

5. 1 2 3 4 5 1 2 3 4 5 Income adequacy quintiles Men Women But health still varies along a social gradient in rich countries: Lower-income Canadians live shorter lives than rich ones. Remaining life expectancy at age 25 in Canada by sex and income quintile, non-institutionalized population, 1991 to 2006

6. This is not new: Potential Years of Life Lost (All Causes) England & Wales, 1971 – 1991 Message: overall mortality rates fell over the 20 years, but the class inequality remained. There is a gradient, but the major deficit is for the lowest class. Occupational Class V IV III n, m II I

7. Why? Maybe occupation influences health? Unemployment & health – RR 2.1 for unemployment with 5-year total mortality (Morris) – 10% rise in unemployment → 1.2% rise in mortality (Brenner) Some occupations imply direct exposures & hazards; behaviors also implicated (not wearing protective gear) Stress & Strain? Karasek’s hypothesis: Low control over work + high demand → strain – Whitehall study: low perceived job control gave OR = 1.9 for CVD

8. Yes, but it’s not only occupation: same pattern holds for income & education – whatever indicator you use. The gradient is more general.

9. Cumulative fetal and infant mortality over time, by maternal education, Québec, 1990-91 M essage: there is an almost two-fold gradient across educational groups. Weeks since conception Deaths per 1000 total births Source: Russ Wilkins, Statistics Canada

10. Absolute, or relative wealth? The previous slides showed levels of health by levels of social status. But what is important: absolute status (amount of wealth, prestige, power) that counts, or is it relative status? Note that in a society where few people are actually starving, there is still a SES-health gradient, so does one’s rank order (as opposed to actual $$ wealth) somehow matter? This is the theme of income inequality: maybe societies with unequal wealth are hazardous to our health?

11. One measure of Income Inequality: Gini Coefficient L(s) lies below line of equality when income inequality favours the rich Gini coefficient is twice the area between the curve and the line of equality It is about 0.32 for Canada (2006) % of income % of population L(s) 0100

12. Source: Wikipedia http://en.wikipedia.org/wiki/File:Gini_Coefficient_World_CIA_Report_2009.png Gini coefficients for the World (Note that China and Russia are quite unequal…)

13. Income Inequality and Life Expectancy in 23 wealthy countries (Data from Equality Trust www.equalitytrust.org.uk) CH–Switzerland D–Germany Is–Israel NL-Netherlands NZ–New Zealand UK–United Kingdom USA-United States of America Japan Sweden Finland Norway D Belgium Spain Austria Canada NL CH F Denmark Greece Ireland Australia Portugal USA Singapore Is Italy UK NZ (r = –0.4)

14. Occupational Class Differences in IMR in England & Wales, Compared to Sweden OK: so what on earth is Sweden doing differently? Sweden England & Wales Deaths per 1000 live births

15. Conceptual issues to be discussed in the course Technical: which health indicators to use? Which indicators of social status? Scale of analysis seems very important: individual, community, or societal? Is SES merely a proxy for familiar risk factors (poorer people smoke more and have worse diets)? What constitutes an explanation? How much is random? How to blend the narrative and the scientific? The hierarchy of disciplines: how to harmonize perspectives from different disciplines studying different aspects of the overall picture?