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THE PERSISTENCE OF HEALTH INEQUALITIES IN MODERN WELFARE STATES
Johan MackenbachDepartment of Public Health, Erasmus MCRotterdam, Netherlands
INEQUALITIES IN LIFE EXPECTANCY ALONG ROTTERDAM’S METROLINES
Jonker e.a., 2013
Neighbourhood
Life expectancy (men, 2007)
Health expectancy (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
INEQUALITIES IN LIFE EXPECTANCY IN THE NETHERLANDS
30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79-0.1
0.0
0.1
0.2
0.3
0.4
0.5
0.6
Contributions (in years) of causes of death and age-groups to inequalities in life expectancy between educational groups, men, 1998-2007
other
extern
respir
othercancer
capros
calung
colorect
othercvd
cervas
ischae
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
TWO RESEARCH STRATEGIES
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
WHAT DO VARIATIONS BETWEEN COUNTRIES TELL US?
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”
VARIATIONS IN MAGNITUDE OF INEQUALITIES IN MORTALITY (M)
Mackenbach et al., submitted
Finland
Sweden
Norway
Denmark
England & W
Netherlands
BelgiumFrance
Switzerla
nd
Austria
Barcelona
Basque C
MadridTurin
Tuscany
Hungary
Czech
Rep
Poland
Estonia
0.0
0.5
1.0
1.5
2.0
2.5
3.0
3.5
0.0
0.5
1.0
1.5
2.0
2.5
3.0
3.5
Relative Risks of all-cause mortalitylow vs. high education, men, 2000s
Rela
tive
Risk
(age
-adj
uste
d, 3
0-79
yea
rs)
VARIATIONS IN MAGNITUDE OF INEQUALITIES IN MORTALITY (M)
Mackenbach et al., submitted
Finland
Sweden
Norway
Denmark
England & W
Netherlands
BelgiumFrance
Switzerla
nd
Austria
Barcelona
Basque C
MadridTurin
Tuscany
Hungary
Czech
Rep
Poland
Estonia
0.0
0.5
1.0
1.5
2.0
2.5
3.0
3.5
0.0
0.5
1.0
1.5
2.0
2.5
3.0
3.5
Relative Risks of all-cause mortalitylow vs. high education, men, 2000s
Rela
tive
Risk
(age
-adj
uste
d, 3
0-79
yea
rs)
VARIATIONS IN MAGNITUDE OF INEQUALITIES IN MORTALITY (M)
Mackenbach et al., submitted
Finland
Sweden
Norway
Denmark
England & W
Netherlands
BelgiumFrance
Switzerla
nd
Austria
Barcelona
Basque C
MadridTurin
Tuscany
Hungary
Czech
Rep
Poland
Estonia
0.0
0.5
1.0
1.5
2.0
2.5
3.0
3.5
0.0
0.5
1.0
1.5
2.0
2.5
3.0
3.5
Relative Risks of all-cause mortalitylow vs. high education, men, 2000s
Rela
tive
Risk
(age
-adj
uste
d, 3
0-79
yea
rs)
VARIATIONS IN MAGNITUDE OF INEQUALITIES IN MORTALITY (W)
Mackenbach et al., submitted
Finland
Sweden
Norway
Denmark
England & W
Netherlands
BelgiumFrance
Switzerla
nd
Austria
Barcelona
Basque C
MadridTurin
Tuscany
Hungary
Czech
Rep
Poland
Estonia
0.0
0.5
1.0
1.5
2.0
2.5
0.0
0.5
1.0
1.5
2.0
2.5
Relative Risks of all-cause mortalitylow vs. high education, women, 2000s
Rela
tive
Risk
, age
-adj
uste
d, 3
0-79
yea
rs
VARIATIONS IN MAGNITUDE OF INEQUALITIES IN MORTALITY (W)
Mackenbach et al., submitted
Finland
Sweden
Norway
Denmark
England & W
Netherlands
BelgiumFrance
Switzerla
nd
Austria
Barcelona
Basque C
MadridTurin
Tuscany
Hungary
Czech
Rep
Poland
Estonia
0.0
0.5
1.0
1.5
2.0
2.5
0.0
0.5
1.0
1.5
2.0
2.5
Relative Risks of all-cause mortalitylow vs. high education, women, 2000s
Rela
tive
Risk
, age
-adj
uste
d, 3
0-79
yea
rs
VARIATIONS IN MAGNITUDE OF INEQUALITIES IN MORTALITY (W)
Mackenbach et al., submitted
Finland
Sweden
Norway
Denmark
England & W
Netherlands
BelgiumFrance
Switzerla
nd
Austria
Barcelona
Basque C
MadridTurin
Tuscany
Hungary
Czech
Rep
Poland
Estonia
0.0
0.5
1.0
1.5
2.0
2.5
0.0
0.5
1.0
1.5
2.0
2.5
Relative Risks of all-cause mortalitylow vs. high education, women, 2000s
Rela
tive
Risk
, age
-adj
uste
d, 3
0-79
yea
rs
WHY DO NORDIC COUNTRIES HAVE LARGER INEQUALITIES THAN SPAIN?
TotalHomicide
COPDAlcohol abuse
DiabetesLung cancerPneumonia
Isch. heart dis.Hypertensive dis.
Road accidentsSuicide
Oth. heart dis.Falls
Stomach cancerCerebrovasc. dis.
Colorectal cancerProstate cancer
0 0.5 1 1.5 2 2.5 3 3.5 4 4.5
Relative Risks by cause of deathSpain vs. Northern Europe, men, 2000s
3 Spanish regions4 Nordic countries
Relative Risk (age-adjusted, 0-79 years)
Unpublished data from EURO-GBD-SE project
INEQUALITIES IN SMOKING (M)
30-44 45-59 60-69 70-790
0.1
0.2
0.3
0.4
0.5
0.6
0.7
Current smokingSpain vs. Nordic countries, men, 2000s
Spain, LowSpain, HighNordic, LowNordic, High
Prev
alen
ce o
f sm
okin
g
Unpublished data from EURO-GBD-SE project
INEQUALITIES IN SMOKING (M)
30-44 45-59 60-69 70-790
0.1
0.2
0.3
0.4
0.5
0.6
0.7
Current smokingSpain vs. Nordic countries, men, 2000s
Spain, LowSpain, HighNordic, LowNordic, High
Prev
alen
ce o
f sm
okin
g
Unpublished data from EURO-GBD-SE project
INEQUALITIES IN SMOKING (W)
30-44 45-59 60-69 70-790
0.1
0.2
0.3
0.4
0.5
0.6
Current smokingSpain vs. Nordic countries, women, 2000s
Spain, LowSpain, HighNordic, LowNordic, High
Prev
alen
ce o
f sm
okin
g
Unpublished data from EURO-GBD-SE project
INEQUALITIES IN SMOKING (W)
30-44 45-59 60-69 70-790
0.1
0.2
0.3
0.4
0.5
0.6
Current smokingSpain vs. Nordic countries, women, 2000s
Spain, LowSpain, HighNordic, LowNordic, High
Prev
alen
ce o
f sm
okin
g
Unpublished data from EURO-GBD-SE project
Finl
and
Swed
en
Norway
Denm
ark
Engl
and
& W
Belgi
um
Fran
ce
Switz
erla
nd
Barce
lona
Basqu
e C
Mad
ridTu
rin
Hunga
ry
Lith
uani
a
Esto
nia
0
0.5
1
1.5
2
2.5
3
3.5
Rate Ratios of all-cause mortalitylow vs. high education, 1990s and 2000s, men
1990s2000s
Rate
Ratio (
age-a
dju
sted, 30-7
4 y
ears
)WIDENING RELATIVE INEQUALITIES (M)
Mackenbach et al., submitted
Finl
and
Swed
en
Norway
Denm
ark
Engl
and
& W
Belgi
um
Fran
ce
Switz
erla
nd
Barce
lona
Basqu
e C
Mad
ridTu
rin
Hunga
ry
Lith
uani
a
Esto
nia
0
200
400
600
800
1000
1200
1400
1600
1800
Rate differences of all-cause mortalitylow vs. high education, 1990s and 2000s, men
1990s2000s
Rate
diff
ere
nce
(age-a
dju
sted, 30-7
4 y
ears
)VARIABLE TREND ABSOLUTE INEQUALITIES (M)
Mackenbach et al. submitted
Finl
and
Swed
en
Norway
Denm
ark
Engl
and
& W
Belgi
um
Fran
ce
Switz
erla
nd
Barce
lona
Basqu
e C
Mad
ridTu
rin
Hunga
ry
Lith
uani
a
Esto
nia
0
200
400
600
800
1000
1200
1400
1600
1800
Rate differences of all-cause mortalitylow vs. high education, 1990s and 2000s, men
1990s2000s
Rate
diff
ere
nce
(age-a
dju
sted, 30-7
4 y
ears
)VARIABLE TREND ABSOLUTE INEQUALITIES (M)
Mackenbach et al. submitted
DID ENGLAND HAVE MORE NARROWING OF ABSOLUTE INEQUALITIES?
1981-85 1986-90 1991-95 1996-00 2001-05 2006-100
100
200
300
400
500
600
700
800
900
Absolute inequalities in all-cause mortality1981-2010, men
FinlandNorwayEngland & WItaly, Turin
Diff
eren
ce b
etw
een
low
and
hig
h ed
ucat
ed
(dea
ths
per
1000
00)
Unpublished data from DEMETRIQ project
DID ENGLAND HAVE MORE NARROWING OF ABSOLUTE INEQUALITIES?
Unpublished data from DEMETRIQ project
1981-85 1986-90 1991-95 1996-00 2001-05 2006-100
50
100
150
200
250
300
350
400
450
Absolute inequalities in Cardiovascular disease mortality1981-2010, men
FinlandNorwayEngland & WItaly, Turin
Diff
eren
ce b
etw
een
low
and
hig
h ed
ucat
ed
(dea
ths
per
1000
00)
DID ENGLAND HAVE MORE NARROWING OF ABSOLUTE INEQUALITIES?
Unpublished data from DEMETRIQ project
1981-85 1986-90 1991-95 1996-00 2001-05 2006-100
50
100
150
200
250
Absolute inequalities in smoking-related mortality1981-2010, men
FinlandNorwayEngland & WItaly, Turin
Diff
eren
ce b
etw
een
low
and
hig
h ed
ucat
ed
(dea
ths
per
1000
00)
ISCHEMIC HEART DISEASE (M)
Finlan
d
Swed
en
Norway
Denmark
Engla
nd & W
ales
Netherl
ands
Belgium
France
Switz
erlan
d
Austria
Barcelo
na
Basque C
ountry
Madrid
Turin
Tusca
ny
Hungary
Czech Rep
ublic
Poland
Estonia
0.0
0.5
1.0
1.5
2.0
2.5
3.0
3.5
0
0.5
1
1.5
2
2.5
3
3.5
Ischemic heart diseaseRelative Risks, low vs. high, 2000s, men
Rela
tive
Risk
(age
-adj
uste
d, 3
0-79
yea
rs)
Mackenbach et al. submitted
ROLE OF SMOKING AND OVERWEIGHT (M)
Finla
nd
Sweden
Norway
Denm
ark
Engla
nd/W
Scotla
nd
Nethe
rland
s
Belgi
um
Franc
e
Switzer
land
Austri
a
Barce
lona
Basqu
e Cou
ntry
Mad
ridTur
in
Tusca
ny
Czech
Rep
.
Hunga
ry
Polan
d
Lith
uani
a
Estoni
a0
5
10
15
20
25
30
35
Percent contribution to inequalities in mortalityby education, 2000s, men
SmokingOverweight
Perc
enta
ge re
ducti
on o
f exc
ess r
isk
Eikemo et al., submitted
ROLE OF SMOKING AND OVERWEIGHT (W)
Finla
nd
Sweden
Norway
Denm
ark
Engla
nd/W
Scotla
nd
Nethe
rland
s
Belgi
um
Franc
e
Switzer
land
Austri
a
Barce
lona
Basqu
e Cou
ntry
Mad
ridTur
in
Tusca
ny
Czech
Rep
.
Hunga
ry
Polan
d
Lith
uani
a
Estoni
a0
5
10
15
20
25
30
35
Percent contribution to inequalities in mortalityby education, 2000s, women
SmokingOverweight
Perc
enta
ge re
ducti
on o
f exc
ess r
isk
Eikemo et al., submitted
PREVENTABLE VERSUS NON-PREVENTABLE CAUSES (M)
Hodgkin's disease and leukemia (M)Cancer of prostate (M)
Cancer of colorectum (N)Cancer of pancreas (N)
Cancer of kidney and bladder (N)Cancer of liver (N)
Hypertensive disease (B/M)Accidental falls (I)
Cerebrovascular disease (B/M)Ischemic heart disease (B/M)
Cancer of stomach (N)Road traffic accidents (I)
Suicide (I)Other liver and gall bladder diseases (N)
Diabetes mellitus (B)Cancer of buccal cavity, pharynx, and oesophagus (B)
Appendicitis, hernia and peptic ulcer (M)Pneumonia / influenza (M)
Cancer of trachea, bronchus and lung (B)Chronic Obstructive Pulmonary Disease (B)
Alcohol abuse (B)Cancer of larynx B)
0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 4.0 4.5
Median Mortality Relative Risk19 European populations, 2000s, men
RR (low vs. high education)
Mackenbach et al. submitted
PREVENTABLE VERSUS NON-PREVENTABLE CAUSES (M)
Hodgkin's disease and leukemia (M)
Cancer of prostate (M)
Cancer of colorectum (N)
Cancer of pancreas (N)
Cancer of kidney and bladder (N)
Cancer of liver (N)
Hypertensive disease (B/M)
Accidental falls (I)
Cerebrovascular disease (B/M)
Ischemic heart disease (B/M)
Cancer of stomach (N)
Road traffic accidents (I)
Suicide (I)
Other liver and gall bladder diseases (N)
Diabetes mellitus (B)
Cancer of buccal cavity, pharynx, and oesophagus (B)
Appendicitis, hernia and peptic ulcer (M)
Pneumonia / influenza (M)
Cancer of trachea, bronchus and lung (B)
Chronic Obstructive Pulmonary Disease (B)
Alcohol abuse (B)
Cancer of larynx B)
0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 4.0 4.5
Median Mortality Relative Risk19 European populations, 2000s, men
RR (low vs. high education)
Mackenbach et al. submitted
PREVENTABLE VERSUS NON-PREVENTABLE CAUSES
Men Women
Obs. Median RR Obs. Median RR
All causesof death 385 1,90 343 1,67
All preventablecauses 276 2,15 244 1,90
Amenable to behaviour change 161 2,35 146 2,30
Amenable to medical intervention 118 1,82 127 1,90
Amenable to injury prevention 51 1,94 38 1,40
All non-preventable causes 109 1,53 99 1,43
Median Mortality Relative Risk19 European populations, 2000s, men and women
Mackenbach et al. submitted
PREVENTABLE VERSUS NON-PREVENTABLE CAUSES
Men Women
Obs. Median RR Obs. Median RR
All causesof death 385 1,90 343 1,67
All preventablecauses 276 2,15 244 1,90
Amenable to behaviour change 161 2,35 146 2,30
Amenable to medical intervention 118 1,82 127 1,90
Amenable to injury prevention 51 1,94 38 1,40
All non-preventable causes 109 1,53 99 1,43
Median Mortality Relative Risk19 European populations, 2000s, men and women
Mackenbach et al. submitted
WHY HEALTH INEQUALITIES PERSIST DESPITE THE WELFARE STATE
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
REDISTRIBUTIVE EFFECTS OF THE WELFARE STATE, NETHERLANDS
0
200
400
600
800
1000
1200
BasicLower sec.
Higher sec.Lower voc. Higher
voc. University
Before govt. redistr.
After govt. redistr.
Ter Rele 2007
Lifetime wages before government intervention, vs. lifetime welfare after tax, cash transfers and non-cash benefits, in thousands of Euros, Netherlands, ca. 2002
RISE OF INTERGENERATIONAL SOCIAL MOBILITY
0
5
10
15
20
25
30
35
40
1914-391940-49
1950-591960-69
University
Higher voc.
Higher sec.
Lower sec.
Basic
RMO 2011
SOBERING CONCLUSIONS
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
THANK YOU!
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