Social Inequalities and Health

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Social Inequalities and Health Inequalities and
Addictions Summer School Adelaide, 2004
John Lynch Department of Epidemiology Centre for
Social Epidemiology and Population Health Centre
for Human Growth and Development Institute for
Social Research Center for Research on Ethnicity,
Culture and Health University of Michigan, USA
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• Some objectives of this Summer School
• To establish a common understanding of what is
  meant by inequalities (e.g., social inequalities
  and health inequalities)
• Explore and establish the links between
  inequalities and addictions

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Social inequalities
Health inequalities
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• Social inequalities and health inequalities

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Australia - Number of published empirical studies
on social inequalities in health (179 studies
published between 1971 and 1996)
Number of studies
Turrell, G. et al. Socioeconomic determinants of
health towards a national research program and a
policy and intervention agenda, Apr. 1999
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Australian research articles relating to SES and
health outcomes studied
Number of studies
Turrell, G. et al. Socioeconomic determinants of
health towards a national research program and a
policy and intervention agenda, Apr. 1999
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Australian research articles relating to SES and
health populations studied by health outcome
Number of studies
Turrell, G. et al. Socioeconomic determinants of
health towards a national research program and a
policy and intervention agenda, Apr. 1999
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UPSTREAM (MACRO) FACTORS
MIDSTREAM (INTERMEDIATE) FACTORS
DOWNSTREAM (MICRO) FACTORS
Physiological Systems
Health Care System
Government
Demand/Strain Control
Perceptions Stress
Expectations Networks
Depression Self
Esteem
Hostility Isolation
Attachment Anger
Coping Social Support
Endocrine Immune
Access Availability Affordability Utilisation
Policies
Determinants of Health (social, physical,
economic, environmental)
Economic Welfare Health Housing Transport Taxation

Psychosocial Factors
Global Forces
Health
Education Employment Occupation
Income Housing Area of Residence
Mortality Morbidity Life Expectancy etc.
Health Behaviours
Working Conditions
Diet/Nutrition Smoking Alcohol Physical
Activity Self Harm/Addiction Preventative Health
Care Use
Biological Reactions
Hypertension Fibrin Production Adrenalin Suppresse
d Immune Function Blood Lipids BMI Glucose
Intolerance etc.
Culture
Culture
Culture
Priority Groups
Life-Course Stages
Settings Contexts
Low Income Low Education Single
Parents Indigenous Unemployed Ethnic
Groups Disabled Homeless
Work/Employment Community Home Education (school,
vocational, tertiary) Other Community Settings
(clubs, church, recreation, voluntary
organisations)
Infants Children Adolescents Working-Aged
Adults Retired/Elderly
QUT, School of Public Health (Centre for Public
Health Research )
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Determinants of Population and Individual Health

• Society Structural level
• Riksdag government
• International cooperation
• Public organizations
• The economy
• Technical development
• Economic conditions
• War
• Refugee currents
• Natural disasters

• Environment
• Work
• Living
• Free time
• Physical environment
• .

• Group
• Social class
• Education
• Occupation
• Origin
• Family
• Friends

• Individual
• Genes
• Gender
• Age
• Lifestyle
• Vulnerability
• .

Health
Public health
Persson et al. Scandinavian Journal of Public
Health (2001)
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International National State Local Policy
Structural Conditions
Social Determinants
Socioeconomic Behavioral Psychosocial
Individual Characteristics
Blood pressure Cholesterol Infection Inflammation
Biological Characteristics
CVD Cancer Depression
Individual and Population Health Health
Inequalities
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Health Inequalities Socioeconomic Groups
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Socioeconomic Position is a Powerful Risk Factor
Smoking
Income
Relative Hazard CVD Mortality
KIHD Study, 1984-1996
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Age standardised mortality rates for CVD by area
disadvantage, males aged 2564 years, Australia,
198587 19982000
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Trends in Male Total Mortality by Social Class,
Britain 1921-1991
Aged 25-34
Aged 35-44
SClass V
- 56
- 62
SClass I
Log Mortality Rate
- 79
- 85
RR1.9
RR4.8
RR1.8
RR3.8
Aged 45-54
Aged 55-64
- 19
SClass V
- 39
Log Mortality Rate
SClass I
- 58
- 69
RR1.5
RR3.0
RR1.4
RR2.6
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The Standard View of Socioeconomic Health
Disparities
Socioeconomic status is a strong and consistent
predictor of mortality and morbidity. Individuals
lower in the SES hierarchy suffer
disproportionately from almost every disease
This association is found with each of the key
components of SES income, education and
occupational status.
Adler, et. Al., JAMA (1993) p. 3140
Throughout history SES has been linked to
health. Individuals higher in the socioeconomic
hierarchy typically enjoy better health that do
those below SES differences are found for rates
of mortality and morbidity from almost every
disease and condition.
Adler, et. al., Am Psychologist (1994) p. 15
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Life Expectancy at Birth - Britain (1540-1901)
Social Advantage ? LE
Aristocracy
LE
Total Population
Kunitz, (1987)
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Causes of death and median income of Zip Code
area of residence in the men screened for MRFIT
relative risk for 10,000 lower income
RR gt 1.50 RR 1.21-1.50 RR 1.00-1.20 RR lt
1.00 AIDS Infection Aortic aneurysm Blood
disease Diabetes Coronary Heart Suicide Motor
neurone Disease disease Rheumatic Stroke Nervous
system Flying accidentsHeart Disease disease He
art failure Cirrhosis Oesophageal Lymphoma cance
r COPD Genitourinary Stomach cancer Hodgkins
disease disease Pneumonia/ SR Symptoms Pancreatic
cancer MelanomaInfluenza Homicide Accidents Pros
tate cancer Bone/connective tissue
cancer Lung cancer Bladder cancer Liver
cancer Kidney cancer Colorectal cancer Brain
cancer Myeloma Leukaemia
Davey Smith (1996)
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More Common Among Poor
Incidence
Mortality
Mouth/Pharynx ? ? Oesophagus ?
? Stomach ? ? Liver ? ? Nasal
? ? Larynx ? ? Lung
? ? Cervix ? ?
IARC (1997)
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Parental Occupation and Relative Risk for Injury,
Sweden, 1990-1994
Ages 15-19
Traffic Injuries
Falls
OR
Engerström, Diderichsen, Laflamme. Injury
Prevention (2002)
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Health Inequalities race, ethnic, indigenous
groups
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US Trends in Life Expectancy at Birth over the
20th Century
White Female
Black Female
White Male
Black Male
LE
NCHS (2001)
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Mortality Unrelated to Race, 1979-89
Howard et al., Annals of Epidemiology, 2000 10
214-223
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Mortality Related to Race, With and Without
Adjustment for SEP, 1979-89
Howard et al., Annals of Epidemiology, 2000 10
214-223
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Change in the Disparity in Life Expectancy if
Selected Diseases were Eliminated
Change in Disparity in Life Expectancy (years per
person)
Homicide Hypertension HIV 35 of the racial
disparity
Change racial disparity
Wong et al., New England Journal of Medicine,
2002 Vol.347, No.20 1585-1592
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Higher Burden of Mortality Among Indigenous
Australians at All Ages, 1997-99
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Higher Burden for Many Causes of Death Among
Indigenous Australian, 1997-99
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Infant Mortality Indigenous Mothers vs Other
Australian Mothers, 1996-98
15 30 per 1,000
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Health Inequalities place
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Mortality according to Class of Street and House,
Manchester (1844)
Class of the Streets
1st
2nd
3rd
Mortality Proportion
No Houses
Class of the Houses
Engels (1845)
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Australia Differences in Life Expectancy
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79 years Manningham
72 years Yarra
10 km
City of Melbourne, Australia
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Hetzel et al. Sth Aust. PHIDU (2004)
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the evidence on SES and health in Australia
is unequivocal those who occupy positions at the
lower levels of the socioeconomic hierarchy fare
significantly worse in terms of their health.
Turrell, G. et al. Socioeconomic determinants of
health towards a national research program and a
policy and intervention agenda, QUT, 1999.
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The Language and Meaning of Health
Inequalities
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Terminology of health inequalities
Disparities Variations Inequalities Inequities
Health
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Defining Health Disparity

• What are health disparities?
• Health disparities are differences in the
  incidence, prevalence, mortality, and burden of
  diseases and other adverse health conditions that
  exist among specific population groups in the
  United States.
• NIH Strategic Plan to Reduce and Ultimately
  Eliminate Health Disparities, 2001

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Inequality a difference Two quantities that
are not equal
Rate A ? Rate B
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Whats the difference between health
inequality and health inequity ?

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Inequalities in health are based on observed
differences

• Poor people die younger than rich people
• Low social class infants have lower birth weight
• Smokers get more lung cancer than non-smokers
• Women live longer than men

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Inequities in health are based on ethical
judgements about those differences

• Should poor people die younger than rich people?
• Should low social class infants have lower birth
  weight?
• Should smokers get more lung cancer?
• Should women live longer than men?

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Everyone Vote
Are all health inequalities inequitable? Are
all differences in health unfair?
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For those who said no
Which health inequalities are fair? Is there
some level of health inequality that is
acceptable?
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Epidemiologists can measure health
inequality However, some process of
socio-political discourse is required to assess
which inequalities are an affront to social
justice and thus require intervention
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How do we rank health inequities in terms of
their importance in regard to policy
intervention? What criteria do we use to decide
that one inequity is more important than
another and therefore more deserving of policy
attention?
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Efforts to monitor and eliminate health
inequalities assume

• A scientifically rigorous and transparent
  strategy for measuring health inequalities
• Across multiple dimensions of the population
• Across multiple health indicators
• Across time
• Data Sources

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How should we measure health inequalities?

• Issues to consider
• 1. Relative vs. absolute difference

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Your MP wants to know which inequality should be
given policy priority What will you advize?
77 deaths absolute difference 18 30
- relative difference 250
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Black White Inequality in Infant Mortality
over the 20th Century, USA
Relative Inequality
Black
White
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Which age group deserves policy attention to
reduce health inequalities?
Rate Ratio Relative Risk
Poorest 20
RR
Mortality Rate per 1000
Richest 20
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An epidemiological perspective

• Social inequalities as indicated by differences
  in income, education, ethnicity, gender,
  geography are linked to differences in a wide
  range of health indicators, but not all health
  indicators at all points in time
• Important to understand the difference between
  health inequality and health inequity
• We have to first be able to measure health
  inequality accurately over time and then
  prioritize which inequities we see as most unfair
  and deserving policy priority

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A sociological perspective

• That brings us to a consideration of how much a
  society can and should do via policy to create
  changes in the structural / social determinants
  of these health inequities.
• Resonates with the familiar sociological
  arguments about the relative roles of structure
  and agency of nature and nurture

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there has been a lack of attention to the
development of concepts which will help explain
why individuals and groups behave the way they do
in the context of wider social structures to
link agency and structure.
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Social inequalities
Health inequalities
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2. Social Inequalities and Addiction
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A Definition of Addiction
The state of being given up to some habit,
especially strong dependence on a
drug Tobacco Alcohol Illicit drugs Gambling Pres
cription medications
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Smoking
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International Differences in Per Capita Cigarette
Consumption 1998
17 8 billion net revenue
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Age and Daily Smoking, Australia 2002
20-25
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Trends in Daily Smoking, Australia 2002
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Smoking status and average number of cigarettes
per week, persons aged 14 years and over,
Australia. (2001 National Drug Survey)
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Less than High School Education Among Current
Smokers according to tar level of cigarettes
smoked in 1982
Men
Women
Educated to high school ()
Tar level (mg)
Harris, E. et al. Cigarette tar yields in
relation to mortality BMJ Volume 328 10
January 2004
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Educational Trends in Current Smoking, Australia
1989-2001
Females
Males
"Health Inequalities in Australia morbidity,
health-behaviours, risk factors, and health
service utilisation" (in press)
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Smoking prevalence of parents with infants 1995
National Health Survey (Turrell et al 2002)
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Hetzel et al. Sth Aust. PHIDU (2004)
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Relative Excess Expenditure on Cigarettes by
Household Income Groups Australia (1999)
50 more
Reference
Siapush. JECH (2003)
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Education and Phases of Smoking Behaviour,
Australia 1995
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Education and Income and Attempts to Quit
Smoking, NHIS 2000
Education
Income
Barbeau. et al. AJPH ( 2004)
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Lifecourse Processes
Smoking Initiation
Progression to Regular Smoking
Quitting
Gilman et al. JECH (2003)
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Cognitive Test Scores at Ages 22, 42, 60 and 120
months by Parents SEP and early score
High Scores
Low Scores
Feinstein (2003)
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Summary - smoking

• Overall prevalence of 20-25 regular smoking,
  declining somewhat
• Strong, stable trends in social inequalities in
  smoking
• Higher prevalence among lower socioeconomic
  groups - 40
• No social differences in attempts to quit but
  higher SEP better at quitting
• Especially high among indigenous Australians -
  50
• Among smokers, there is good evidence for
  greater addiction to smoking among the less
  advantaged
• Evidence for the importance of lifecourse
  processes in the initiation, progression and
  addiction to smoking

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Alcohol
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International Differences in Per Capita Alcohol
Consumption 1998
19 2.7 billion net revenue
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Trends in Liver Disease and Alcohol Consumption
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Trends in Alcohol Consumption, Australia
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Consumption of more than 29 drinks (males) and 15
drinks (females) At risk of long-term harm -
Australia, 2001
10
81
40
30
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Educational Trends in Long-term Risk Alcohol
Behaviour, Australia 1989-2001
Females
Males
"Health Inequalities in Australia morbidity,
health-behaviours, risk factors, and health
service utilisation" (in press)
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Lifecourse predictors of binge drinking in
adulthood
Mutually adjusted associations
Yang, Lynch et al. (2004)
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Interactions in the Relative Risk of Diagnosis of
Alcoholism Sweden 1975-1983
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RR
Reference
Hemmingsson, et al. Soc Sci Med (1998)
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Summary - alcohol

• Alcohol consumption is a normative behaviour in
  Australia 50 drinking regularly unusual to
  not drink
• Higher prevalence of beneficial drinking style
  among higher socioeconomic groups
• Higher prevalence of short and long-term risk
  drinking among more disadvantaged - 15
  long-term risk
• But opposite gender patterns of social
  inequality in risky alcohol consumption more
  advantaged females at higher risk
• Evidence for the importance of lifecourse
  processes in the initiation, progression and
  addiction to alcohol

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Illicit Drugs
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Recent Illicit Drug Use, Australia, 2001
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Trends in Illicit Drug Use, Australia 1991-1998
lt1
18
lt1
lt3
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Trends in Illicit Drug Use, Australia 1991-1998
lt1.5
lt4
lt3
lt1
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Social Differences in Recent Illicit Drug Use,
Australia, 2001
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Demographic Characteristics of Injecting Drug
Users - Australia, 1998
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Social Group Differences in Recent Substance Use
- Australia, 1998
Indigenous
Non-Indigenous
Non-English Speaking
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Summary - illicits

• Relatively low prevalences - lt 5, except
  marijuana 15
• More common among males and unemployed
• Somewhat more prevalent among urban dwellers
• No striking pattern of social group differences
  in use of illicit drugs as was seen for alcohol
  and tobacco
• Small differences among Indigenous and
  Non-indigenous people
• Lifecourse processes may be important but
  perhaps not those associated directly with social
  disadvantage

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Gambling
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Australia Gambling Addiction means that it is
possible to enjoy a real betting environment from
the comfort of your own home. This is a top
quality and fun betting experience to suit
everyone.

• The gambling industry has experienced an annual
  growth rate of 10 1995-2000 with 400 increases
  in revenue.
• Australia now has 21 of the worlds gambling
  machines
• Industry claims this is a leisure pursuit but
  prevalence of problem gambling increased markedly
  during the 1990s and is highest in NSW
• The industry spends more than 500 million
  annually on advertising

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Gambling

• Accounts for about 2 of national revenues
• But for states in 1997 it accounted for more 11
  and is growing
• Overall government revenues are up 20-fold since
  1973
• Some have argued states are addicted to
  gambling revenues
• Expenditure on legalized gambling exceeded 11
  billion in 1998
• As a proportion of household expenditures it has
  increased from 1.7 in 1982 to 3.2 in the late
  1990s
• Estimated losses in 1998 were 820 per head for
  every Aust. adult

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Gambling Some Social Issues

• Productivity Commission (1999) found that 2.3
  (330,000) Australians had significant gambling
  problems with 140,000 experiencing severe
  problems. They estimate that these 330,000 lost
  nearly 12,000 per year.
• NSW statistics suggest 42 of all profits from
  poker machines come from people experiencing
  gambling problems
• Australia has a high intensity gambling
  environment. Machines are faster and take bigger
  bets. The average loss rate per hour is
• New Zealand 156
• UK 130
• Japan 52
• US 705
• Australia 720

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Problem Gamblers

• 50 male and female
• Aged 40
• Married with kids
• Sales or personal services employment
• Earn between 15,600 36,400

Breaking Even Problem Gambling Services (South
Australia). Client Data (2003)
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• A new SA report by Hetzel et al (2004) will
  demonstrate strong socioeconomic patterning of
  gambling losses with about 1.7 times higher
  losses in the most disadvantaged areas of
  Adelaide.
• In an environment in which governments have a
  direct stake in boosting gambling revenues, the
  vast transfer of wealth from the poorest sections
  of the population to the gambling corporations
  will continue unabated.
• 
  (Harrison, 2000)

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Social inequalities
Health inequalities
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3. The Contribution of Addiction to Population
Health and Health Inequalities
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Burden of Disease Study Australia (1996)
Mathers, et al. Bulletin of WHO (2001)
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15-20
Mathers, et al. Bulletin of WHO (2001)
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Contribution of Different Causes of Death to
Socioeconomic Inequality Sweden, 1988-95
Females
30 unequal burden
Ljung, et al. Bulletin WHO (in press)
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Contribution of Different Causes of Death to
Socioeconomic Inequality Sweden, 1988-95
Males
37 unequal burden
Ljung, et al. Bulletin WHO (in press)
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A Model for Policy Intervention To Reduce
Social Inequalities in Health
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1. The nature of social stratification
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Social structure and social position
2. Social position affects exposure distribution
2
Specific Risk Factors
3. Social position affects susceptibility to
exposure
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Disease, injury and morbidity
4. Social position affects the consequences of
disease or morbidity
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Social Consequences (handicap)
Diderichsen, et al. (2001)
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Policy Interventions
Social Cultural Context Policy
Social structure and social position
Specific Exposures and Risk Factors
Disease, injury and morbidity
Social Consequences (handicap)
Diderichsen, et al. (2001)
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UPSTREAM (MACRO) FACTORS
MIDSTREAM (INTERMEDIATE) FACTORS
DOWNSTREAM (MICRO) FACTORS
Physiological Systems
Health Care System
Government
Demand/Strain Control
Perceptions Stress
Expectations Networks
Depression Self
Esteem
Hostility Isolation
Attachment Anger
Coping Social Support
Endocrine Immune
Access Availability Affordability Utilisation
Policies
Determinants of Health (social, physical,
economic, environmental)
Economic Welfare Health Housing Transport Taxation

Psychosocial Factors
Global Forces
Health
Education Employment Occupation
Income Housing Area of Residence
Mortality Morbidity Life Expectancy etc.
Health Behaviours
Working Conditions
Diet/Nutrition Smoking Alcohol Physical
Activity Self Harm/Addiction Preventative Health
Care Use
Biological Reactions
Hypertension Fibrin Production Adrenalin Suppresse
d Immune Function Blood Lipids BMI Glucose
Intolerance etc.
Culture
Culture
Culture
Priority Groups
Life-Course Stages
Settings Contexts
Low Income Low Education Single
Parents Indigenous Unemployed Ethnic
Groups Disabled Homeless
Work/Employment Community Home Education (school,
vocational, tertiary) Other Community Settings
(clubs, church, recreation, voluntary
organisations)
Infants Children Adolescents Working-Aged
Adults Retired/Elderly
QUT, School of Public Health (Centre for Public
Health Research )
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Conclusions
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Influencing behavioural risk factors
A key finding from this evidence is that health
promotion efforts are not as effective with
people from low SES and disadvantaged
backgrounds. One reason given is that
socioeconomically disadvantaged persons face much
greater pressures in dealing with their everyday
living and working conditions which makes it more
difficult for them to effect behavioural change.
Turrell, G. et al. Socioeconomic determinants of
health towards a national research program and a
policy and intervention agenda, Apr. 1999
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Social class differences in beliefs about future
health, UK (2000)

Wardle and Steptoe. JECH (2003)
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we need to go beyond the enumeration of, and
the attribution of direct causation to, variables
in social epidemiology. The variables used in
social epidemiology represent social relations
rather than objectified concepts. What is missing
is a discussion of the relationship between
agency (the ability for people to deploy a range
of causal powers), practices (the activities that
make and transform the world we live in) and
social structures (the rules and resources in
society). Frohlich et al. Soc Health
Illness (2001)
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Smoking and drinking and drug taking. I put it
down to one thing until money is spent on these
areas there doesnt seem to be much point in
trying to stop people smoking and what else. As
long as the environment is going down the pan
people will go down with it Lay narrative,
quoted in Williams et al. Soc Health Illness
Monograph (1995)
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The failings of the workers in general may be
traced to an unbridled thirst for pleasure, to
want of foresight, and of flexibility in fitting
into the social order, to the general inability
to sacrifice pleasure of the moment to remoter
advantage. But is that to be wondered at? When
a class can purchase few and only the most
sensual pleasures by its wearying toil, must it
not give itself over blindly and madly to those
pleasures?
Friedrich Engels (1845)