SDOH-Listserv Bulletin No. 2, February 2, 2004
Income and Health: Theories, Evidence and Debates
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In this Bulletin, I present some recent information concerning income and
income distribution, and information on their effects upon health. This
Bulletin does not specifically address issues of poverty, but poverty is
clearly implicated in this material. It also doesn't cover in detail,
policy responses to income inequality. This will be the subject of later
SDOH Bulletins.
You will also note that there is little discussion of the economic and
social forces that create income inequality and greater numbers of low
income people in the first place. For example, the USA has the second
highest per capital GDP (Luxembourg is first), but one of the highest rates
of absolute and relative poverty and the greatest proportion of low-income
wage earners among developed nations. The political economy of income and
wealth inequalities is the subject of a later Bulletin.
Finally, income is the subject of attention in Canada and Australia while
socioeconomic position [class?] is the favoured variable in UK and Finnish
studies. Some argue that use of class measures open up analyses to the role
played by social structure and a myriad of issues that income simply
doesn't capture. Another topic for further discussion later!
I. Why Income?
"Income is a contextual variable of interest since it is a prime health
determinant in itself and one that affects the presence and quality of
many other determinants of health. Income is a key determinant within
the population health models outlined by the Canadian Institute for
Advanced Research (Health Canada, 1998) and the World Health
Organization (1986). Indeed, any list of social determinants of health
usually lists income or its proxy, socioeconomic status, first
(Wilkinson and Marmot, 1999, Marmot and Wilkinson, 2000). Income and
its distribution appears to be a major determinant of health among
citizens of industrialized nations such as Canada (Kawachi et al.,
1999) as well as globally (Deaton, 2001). Since income appears to be
such a strong determinant of health, further understanding of its role
has the potential to both improve the health of Canadians [and others]
and reduce differentials in health that currently exist in a variety of
areas between Canadians of varying income levels." (Raphael, Labonte,
Colman, Macdonald, Torgerson, and Hayward, 2003)
There are two key issues related to the income and health relationship.
The first is the specific effects that income has on individuals. The
second is whether income inequality ? by itself ? has health effects above
and beyond the effects associated with amount of income available to
individuals and families. The data from within the USA strongly supports
the latter view. States and cities with greater income inequality have
especially poor health. But is this due to the effects of social
comparison and perceived lower place by lower income people in the
hierarchy, or is it a result of high income gap jurisdictions investing
little in the public's health?
See my chapter, Raphael, D. (2003). A society in decline: The political and
economic determinants of health inequalities in the USA, in R. Hofrichter
(ed.) Health and Social Justice: A Reader On Politics, Ideology, And
Inequity In The Distribution Of Disease, pp. 59-88. San Francisco: Jossey
Bass/Wiley as well as the other readings described in this Bulletin for
analyses of these issues.
The paper by Judge and Paterson on income inequality in New Zealand is one
of the best reviews of these arguments, Judge, K. and Paterson, I. (2002),
Treasury Working Paper: Poverty, Income Inequality and Health, New Zealand
Treasury Board: Wellington, NZ. On line at
http://www.treasury.govt.nz/workingpapers/2001/twp01-29.pdf.
II. Conceptualizations of How Income Influences Health (from Raphael et
al., 2003)
"A. Materialist models -- Individual income as a determinant of health:
The materialist explanation for the income and health relationship is that
individuals of differing incomes are exposed to varying degrees of positive
and negative exposures to health risk factors/conditions over the course of
their lifetimes. These exposures accumulate to produce positive or negative
health outcomes. The findings of steeped differences among social classes
and incomes groups results since: "[T]he social structure is characterized
by a finely graded scale of advantage and disadvantage, with individuals
differing in terms of the length and level of their exposure to a
particular factor and in terms of the number of factors to which they are
exposed" (Shaw et al., 1999).
B. Neo-materialist approach -- Individual income and social infrastructure
as determinants of health: Many jurisdictions with inequitable income
distributions show poorer population health. These jurisdictions have both
greater numbers of people with low incomes and also invest less resources
in public infrastructure (Lynch et al., 2000), in addition to the greater
incidence of poverty that is typical of unequal jurisdictions: "[T]he
effect of income inequality on health reflects a combination of negative
exposures [to risk factors/conditions] and lack of resources held by
individuals, along with systematic under investment across a wide range of
human, physical, health, and social infrastructure" (Lynch et al., 2000).
C. Social comparison approach -- Hierarchy and social distance as
determinants of health: In this approach health effects related to income
are not primarily due to material deprivation, but rather to citizens'
interpretations of their standings in the social hierarchy (Kawachi and
Kennedy, 2002). For individuals, psychosocial effects of perceived
position in the hierarchy produces stress and poor health. These
perceptions also lead to overspending, additional employment
responsibilities that threaten health, and coping behaviours such as
overeating and use of alcohol and tobacco. At the communal level, the
widening and strengthening of hierarchy weakens social capital and social
cohesion. Increasing distrust and suspicion of others weakens support for
communal structures such as education and social service systems, thereby
weakening population health."
III. Specific Mechanisms Associated With Individual Health Outcomes."(from
Raphael, 2004)
"Material conditions of life associated with income influence health
by determining the quality of individual development, family life and
interaction, and community environments. Material conditions of life result
in differing likelihood of physical (infections, malnutrition, chronic
disease and injuries), developmental (delayed or impaired cognitive,
personality, and social development,) educational (learning disabilities,
poor learning, early school leaving), and social (socialization,
preparation for work and family life) problems.
Second, differences in material conditions of life lead to
differences in the experience of psychosocial stress (Brunner and Marmot,
1999). The fight and flight reaction -- chronically elicited in response to
continuing threats such as income, housing and food insecurity, among
others ? threatens health. Such threats lead to weakening of the immune
system, increased insulin resistance, and greater incidence of lipid and
clotting disorders and other biomedical injuries that serve as precursors
of disease in adulthood.
Third, adoption of health-threatening behaviours is a response to
material deprivation and stress (Jarvis and Wardle, 1999). Social and
economic environments determine whether individuals take up tobacco, use
alcohol, have poor diets, and engage in physical activity. Tobacco use,
excessive alcohol use and carbohydrate-dense diets result from lack of
material resources and are also means of coping with such circumstances."
See also Benzeval et al., 1995, Lynch et al., 1997, Wilkinson, 1996,
Hertzman, 2001, Hertzman, 2000 at
http://www.isuma.net/v01n02/hertzman/hertzman_e.pdf, Brooks-Gunn et al.,
1998, Keating and Hertzman, 1999.
Not New! Compare the above with what Frederich Engels wrote in 1845:
All conceivable evils are heaped upon the poor?They are given damp
dwellings, cellar dens that are not waterproof from below or garrets
that leak from above? They are supplied bad, tattered, or rotten
clothing, adulterated and indigestible food. They are exposed to the
most exciting changes of mental condition, the most violent
vibrations between hope and fear... They are deprived of all
enjoyments except sexual indulgence and drunkenness and are worked
every day to the point of complete exhaustion of their mental and
physical energies?(Engels, 1845/1987)p. 129)
IV. International Comparisons
One of the most useful and amusing websites is that run by Kenji
Suzuki, Assistant Professor at the European Institute of Japanese Studies,
Stockholm School of Economics. He provides an incredible wealth of data
about OECD nations and Asian nations ranging from various social
determinants of health and health outcomes to the number of MacDonald's
restaurants per 100,000 residents. The graphics are wonderful. Visit his
site at http://web.hhs.se/personal/suzuki/. You will not be disappointed!
Not surprisingly, differences in availability of income to citizens
within a nation are strongly related to overall population health. The
Innocenti Report Card on Child Poverty in Rich Nations compares numerous
nations on both incidence of relative and absolute poverty rates (Innocenti
Research Centre, 2001) at
http://www.unicef-icdc.org/research/ESP/CIIC1.html.
Smeeding and Rainwater in "Poor Kids Living in a Rich Country"
provide an extensive analysis of how income is distributed among 15
developed nations including the US, Canada, UK, Australia, and various
European nations (Rainwater and Smeeding, 2003).
Child Benefits Levels in 2003 and Beyond: Australia, Canada, UK and
US is a new report from the Caledon Institute to be found at
http://www.caledoninst.org/PDF/553820533.pdf
[Thanks, Ross Smith]
Is Income Inequality the Key?
Concerning the income inequality and health argument, see Lynch et
al., 2001, Lynch, 2000, Lynch et al., 2000 for discussion of whether it is
income inequality per se or other factors influencing health, and
Wilkinson's Unhealthy Societies: the Affliction of Inequality (Wilkinson,
1996) and Mind the Gap (Wilkinson, 2001) as well as numerous papers at
http://www.bmj.com.
V. Important National Publications on Income, Income Inequality and Health
AUSTRALIA
1. Clarke P, Smith L. More or less equal? Comparing Australian
income-related inequality in self-reported health with other industrialised
countries. Australian & New Zealand Journal of Public Health.
2000;24(4):370-373.
Concludes Australia's level of health inequalities similar to US & UK but
significantly greater than most other European countries.
2. Walker A. Health Inequalities and Income Distribution, Australia: 1977
to 1995. Presented at the 7th Annual National Health Outcomes Conference;
Canberra; 2001.
http://www.natsem.canberra.edu.au/pubs/cp01/2001_002/cp2001_002.pdf
3. Harding A. Growing apart: Further analysis of income trends in the
1990s. NSW Public Health Bulletin. 2002;13(3):51-53.
This report shows how income inequalities in Australia worsened during
1990s.
http://www.health.nsw.gov.au/public-health/phb/HTML2002/march02html/incometrends.html
4. Department of Health HaCS. Enough to Make you Sick: How Income and
Environment Affect Health. National Health Strategy Research Paper No 1.
Melbourne: Department of Health, Housing and Community Services, 1992.
http://www.health.gov.au/archive/nhs/documents/nhs21.pdf
[Thanks, Sallie Newell]
The Australian Institute of Health and Welfare has a report called
Australia's Health 2002 has sections on socioeconomic status and health as
well as other health equity issues. The URL is:
http://www.aihw.gov.au/publications/index.cfm?type=detail&id=7637 [Thanks,
Andrew Gow]
1. Turrell, G.; Oldenburg, B.; McGuffog, I. & Dent, R. (1999).
Socioeconomic Determinants of Health: towards a national research program
and a policy and intervention agenda. Queensland University of Technology,
School of Public Health. Ausinfo: Canberra.
2. Turrell, G & Mathers, C 2001, 'Socioeconomic inequalities in all-cause
and specific-cause mortality in Australia: 1985-1987 and 1995-1997',
International Journal of Epidemiology, vol. 30, pp. 231-239, viewed 14
January 2004, http://ije.oupjournals.org/cgi/content/full/30/2/231.
3. A Social Health Atlas of Australia at
http://www.publichealth.gov.au/atlas.htm
"The information in this atlas adds to a convincing body of evidence built
up over a number of years in Australia on the striking disparities in
health that exist between groups in the population. People of low
socioeconomic status (those who are relatively socially or economically
deprived) experience worse health than those of higher socioeconomic status
for almost every major cause of mortality and morbidity. The challenge for
policy makers, health practitioners and governments is to find ways to
address these health inequities."
[Thanks, Melissa Raven]
Australian Public Health Association (2002). Socio-economic Inequality and
its Negative Health Impact for Children and their Families.
http://www.phaa.net.au/policy/CHPoverty.htm
West Moreton Public Health Unit, Ipswich, (Statewide Health Promotion Unit
Public Health Services), Queensland Health. (nd). Social Determinants of
Health: Income Fact Sheet
http://www.health.qld.gov.au/phs/Documents/sphun/20399.pdf
CANADA: Dennis Raphael, Ron Labonte, Ron Colman, Jennifer Macdonald, Renee
Torgerson, and Karen Hayward carried out an extensive analysis for CIHR of
how income is conceptualized as a relevant variable in Canadian health
research (Raphael et al., 2003). We systematically analysed all 241 recent
Canadian studies that included income as a relevant variable. The final
report of the project contains an analysis and bibliography of all 241
Canadian studies as well as 40 exemplary UK and 40 Finnish studies. It is
available at:
http://quartz.atkinson.yorku.ca/QuickPlace/draphael/Main.nsf/$defaultview/8B76BCE8BEC72C6085256D09004E9361/$File/FinalReportapril7.pdf?OpenElement
For an example of an interactive website with income data, see the
'demographics' section of the RCIP Rural Report at
http://www.ruralnovascotia.ca/RCIP/RuralReport.htm
[Thanks to Todd Barr].
Other Canadian reports concerned with income, income distribution, and
income and health:
Canadian Institute on Children's Health, 2000 [Children and Health]
Colman, 2001 at http://www.gpiatlantic.org/pr_socialexclusion.shtml
[Income Inequality in Atlantic Canada]
Curry-Stevens, 2001 [Growing Income Gap] at
http://www.fcm.ca/english/communications/igfull.pdf
Dunn et al., 2002 [Widening Income Inequality and Health] at
http://www.opha.on.ca/publications/income_inequalities.pdf.
Federation of Canadian Municipalities, 2003 [Growing Income
Inequality] at http://www.fcm.ca/english/communications/igfull.pdf
Jackson and Robinson, 2000 [Working Class Income in Canada]
Raphael, 2000 [Income Inequality, Health, and Public Health in
Canada] at
http://quartz.atkinson.yorku.ca/QuickPlace/draphael/Main.nsf/$defaultview/B7D198DB9A7D964185256CE40002FA99/$File/critical.pdf?OpenElement
,
Raphael, 2002 [Income and Health in Canada] at
http://www.socialjustice.org/pubs/income&Health.pdf
Raphael, 2001 [Income Inequality and Health]
Ross et al., 2000 [Income and Children's Health] at
http://www.isuma.net/v01n02/ross/ross_e.pdf
Wilkins et al., 2002 [Income and Death by Disease] at
http://www.statcan.ca:80/english/freepub/82-003-SIE/2002001/pdf/82-003-SIE2002007.pdf
Wilkins et al., 2000 [Income and Children] at
http://www.isuma.net/v01n02/wilkins/wilkins_e.pdf
Yalnizyan, 1998 [Growing Income Gap]
Yalnizyan, 2000 [Growing Income Gap] at
http://www.socialjustice.org/pdfs/canadasgreatdivide.pdf
Donner, L., Busch, A. & Fontaine, N. (2000). Women, Income and Health in
Manitoba: An Overview and Ideas for Action at
http://www.womenshealthclinic.org/resources/wih/wih.html
[Thanks to Lissa Donner.]
Stephen Bezruchka's CMAJ article on Canada represents the views of a
Canadian living in the USA (Bezruchka, 2001)
http://www.cmaj.ca/cgi/reprint/164/12/1701.pdf.
See also Andrew Jackson's comparison of the USA, Canada, and Sweden on a
number of SDOH and other indicators (Jackson, 2002)
http://www.ccsd.ca/pubs/2002/olympic/indicators.htm.
UNITED KINGDOM has been the scene of some of the best work on health
inequalities and the sources of their differences. In addition to
references from Bulletin #1, see the following:
Shaw et al., 1999, Townsend et al., 1992, Mitchell et al., 2000, Bartley et
al., 1998;
Acheson Inquiry into Health Inequalities, 1998 at
http://www.official-documents.co.uk/document/doh/ih/contents.htm, Graham,
2001, Benzeval et al., 2001, Gordon et al., 1999, Gordon and Townsend,
2000.
NEW ZEALAND: This paper by Judge and Paterson (2002) is an excellent
analysis of the issues related to income, income distribution, and health.
http://www.treasury.govt.nz/workingpapers/2001/twp01-29.pdf.
USA: The USA is catching up with world research primarily on the basis of
the authors whose work is noted below. Also, see the book by Hofrichter,
Social Justice and Health, highlighted in Bulletin #1. See Kawachi and
Kennedy, 2002, Kawachi et al., 1999, Institute of Medicine, 2002, Rainwater
and Smeeding, 1995, Heywood, 2000, Auerbach and Krimgold, 2001, US
Department of Health and Human Services, 1998 at
http://fluoride.oralhealth.org/papers/pdf/hus98ncb.pdf, Kaplan et al.,
1996, Lynch et al., 1998, Wolff, 1995.
VI. Best Journals for Income and Health Articles: 1) Social Science and
Medicine; 2) International Journal of Epidemiology; 3) Journal of
Epidemiology and Community Health; 4) British Medical Journal.
References
Acheson, D. (1998), Independent inquiry into inequalities in health,
Stationary Office, available at
http://www.official-documents.co.uk/document/doh/ih/contents.htm.
Auerbach, J. A. and Krimgold, B. (Eds.) (2001), Income, Socioeconomic
Status, and Health: Exploring the Relationships. National Policy
Association, Washington, DC.
Bartley, M., Blane, D. and Davey Smith, G. (Eds.) (1998), The Sociology of
Health Inequalities. blackwell Publishers, Oxford UK.
Benzeval, M., Dilnot, A., Judge, K. and Taylor, J. (2001), "Income and
health over the lifecourse: Evidence and policy implications" in
Graham, H. (Eds.), Understanding Health Inequalities, Open University
Press, Buckingham, UK.
Benzeval, M., Judge, K. and Whitehead, M. (1995), Tackling Inequalities in
Health: An Agenda for Action, Kings Fund, London.
Bezruchka, S. (2001), "Societal Hierarchy and the Health Olympics",
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Colman, R. (2001), Health Impacts of Social Exclusion in Atlantic Canada.
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Curry-Stevens, A. (2001), When Markets Fail People, Centre for Social
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http://www.fcm.ca/english/communications/igfull.pdf.
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