- Preston looks at levels of mortality among US children by fathers’ occupation in 1895, 1905, and 1922/4

- In 1895, farmers and manufacturing managers’ kids have lowest mortality

- Farm and manufacturing laborers’ kids have highest

- In 1922/4, doctors and teachers’ kids have lowest

- Overall in 1922/4, higher educated classes have lower mortality than lower educated classes

           - Shows differential dissemination of information

            - More educated ppl can read and adopt public health info

- Segregation of population along class lines also probably contributed to differential death rate

Kitagawa and Hauser (1973) paved the way for studies of SES differences in mortality by estimating cause-specific mortality differences by education, income, occupation, marital status, etc.

Find evidence of an educational health gradient in the US

Whitehall Studies

shed light on the modern relationship between poverty and inequality

- This longitudinal study began in 1960 and examined the health of British civil service workers

- None of the workers were poor

- Nevertheless, their mortality still varied according to their position in the occupational hierarchy

- Ex: members of the lowest pay grade had 2 times the rates of cardiovascular disease as members of the highest pay grade

- This suggests that among populations above the poverty level, position in social hierarchy, rather than income per say, predicts health

- This may be due to psychological factors related to relative, rather than absolute, deprivation

- Income inequality in a country is a better predictor of health than mean income

“Routes to low mortality in poor countries.” Population and Development Review, 12(2), 171-220.

- Is economic development a prerequisite for mortality decline?

           - Caldwell says no

Examines 3 countries that have much lower levels of mortality than would be predicted based on SES: Kerala, Sri Lanka, and Costa Rica

- All three of the countries examined went through a “breakthrough” period in the mid 20^th century in which mortality, especially child mortality, declined quickly

- Argues that the provision of health care services can markedly reduce mortality, but that certain prerequisites must be met before good and efficient health care can be achieved

1. Public must demand education

     - Religious background of these three countries place value on  achieving enlightenment

    - Furthermore, in these countries girls’ education is valued as much as boys’, which increases the demand for good schooling

    - Educated population → ability to make informed decisions, later marriage, protection of indigenous cultures

2. Female autonomy

- Women must have ability to do as they please and to play a key role in decision-making

- This allows mothers to better care for their child’s health

- Furthermore, women who are better educated are able to make more informed decisions regarding their child’s health

- Ex: In Sri Lanka, British government instituted universal suffrage in 1928 with the express purpose of lowering child mortality

- Increased female autonomy also leads to higher levels of participation in labor force and delayed age of marriage

- Furthermore, when women’s position in society is good, so usually is that of children

- Sons and daughters more likely to be treated equally

- Parents more willing to send children to school rather than have them work

3. Political activity

- Political participation leads to increased social reform

- In all 3 of these countries, grass-roots social movements paved the way for social change, especially in the areas of health and education

- These three laid the groundwork for each country’s mortality breakthrough

- Sri Lanka’s breakthrough occurred 1946-53, Kerala’s breakthrough occurred 1956-71, and Costa Rica’s breakthrough 1970-1980

- During these periods, Sri Lanka’s life expectancy increased 12 years, Kerala’s increased 12 years, and Costa Rica’s increased 7 years

- These breakthroughs corresponded with dramatic improvements in health care

- All countries developed a greater density of health care clinics

- Improved efficiency of health care

- Increase in household health visits (esp. in antenatal period)

- Developed “nutritional floors” for all people (Ex: via school lunch programs)

- These developments allowed new medical technology to move seamlessly through entire population

- Caldwell emphasizes that the interaction of better health care and an educated population is what allowed for these health breakthroughs Having only one or the other doesn’t afford nearly the same benefits

- In sum, unusually low mortality can be achieved if the following inputs hold:

 - Female autonomy

 - Government inputs into health services and education for males and females

 - Health services available to all

 - Health services work efficiently

 - Basic nutrition provided to all

 - Universal immunization

 - Concentration of health care on periods right before and after birth

- Caldwell advocates that investing in education (particularly female education) and health is the route to lower mortality for all

  - Low mortality will not come as a spinoff from economic growth

ASDR in 1890-1910

Lowest for forestry, fisherman, and agriculture professionsal

Increased for labourers and servicemen

Next highest in transportation and communication.

“Socioeconomic status and health: The challenge of the gradient.” American Psychologist, 49(1), 15-24.

drift hypothesis- health influences ses and causes downward sociomobility rejects this as likely cause of the full graident – downward social mobility after health shock

suggests that health influences ses and causes downward sociomobility rejects this as likely cause of the full graident

- Health differentials by socioeconomic status are not just about material deprivation; they occur at all levels of the SES hierarchy

- This article reviews evidence for the existence of an SES-health gradient and considers factors that might account for it, paying particular attention to psychosocial variables

Evidence for the gradient

- Whitehall studies (Matmot et al. 1984) find evidence of an occupational gradient in the UK

- Kitagawa and Hauser (1973) find evidence of an educational gradient in the US

- Furthermore, it appears as though the SES-health gradient has gotten steeper over time

3 possible explanations of this association are

1) it’s spurious (various factors related to both SES and health),

2) health causes SES,

3) SES causes health

- Authors consider various mechanisms by which SES might affect health

- Health risk behaviors such as smoking, physical inactivity, poor diet, and substance abuse

- Despite the close ties of these factors to both SES and health, the association between SES and health is reduced but not eliminated when these variables are controlled

- Psychological factors such as depression, hostility, and stress, all of which are more common among low SES and have been linked to poor health outcomes

- SES may be linked to stress in 2 ways:

1) higher SES may diminish chances of encountering negative events and

2) high SES may afford people more social and psychological resources with which to cope with stressful events

- One relative position in the social hierarchy may also explain link between SES and health

- These effects may be moderated by the amount of mobility in a society; studies on animals suggest that living in closed society may negatively affect people with low SES whereas living in an open society may negatively affect people with high SES

- Past research on SES and health has been limited by failure to consider the full range of the SES hierarchy (too much emphasis on low levels of SES), examining only one variable as a proxy for SES (ex: education or income or occupation), and failing to consider the context  in which people live (having low income in a low income area might be better/worse for health than having low income in a high income area)

“Socioeconomic differences in adult mortality and health status.” In Demography of Aging. Eds. Linda Martin and Samuel Preston. Pp. 279-319.

- Purpose of chapter is to review recent evidence about the extent and sources of socioeconomic differences in health and mortality among older people in the US .

Trends in mortality by education

- Education differentials in mortality increased between 1960 and 1971-1984

- More pronounced differentials for men than women, especially in the prime working ages

- Education differentials in mortality by education smaller at older ages (basically completely gone by 85+ years)

Trends in health by education

- Education differentials in disability and ill health are quite large by middle age

- At ages 45-54, more than one-third of ppl with 0-8 yrs of schooling are in “fair” or “poor” health, compared with less than 5% of those who finished college

- Differences by education get smaller at older ages (just like mortality)

- Potential sources of socioeconomic differentials in health and mortality

 Income/wages/education

- People with higher SES are able to purchase more health-enhancing goods and services (healthier foods, gym membership, larger living space, less polluted residence)

- This is sometimes referred to as the “deprivation” model: poor people suffer ill health and premature death because they are poor

Price of health related goods and services

- The market price of seeing a doctor may be much higher for a poor person who lacks health insurance

- Opportunity cost of seeing doctor for hourly employees

- Knowledge of medical knowledge and technique

- Poorer classes may not be aware of treatments that are available

Personal endowments from childhood

- Children of higher status may have a healthier disposition, may have

 good health habits, may have parents with good genes, etc.

Tastes

 - Members of higher classes may have a preference for deferring gratification that affects both class and health

 “The daily struggle of poor people to meet their basic needs for food, clothing, and shelter causes them to place lower priority on more distance dangers.” (p. 302)

- Empirical studies reveal that the behavior to which the largest number of excess deaths in the US are attributable is smoking, which is much more prevalent among low SES individuals

-Nevertheless, even accounting for many variables that are believed to account for SES differences in health and mortality typically fails to explain more than 40% of the variance

- Some researchers suggest that some generalized factor or fundamental cause may be responsible for the differences

-Racial differences in health seem primarily attributable to differences in income and education

 “Child mortality differences, personal health care practices, and medical technology.”

- Purpose of paper is to examine the role of behavioral factors (as opposed to economic development and public health measures) in changes in child mortality

- Begin with finding that French-Canadians had highest rates of child mortality and Jews had the lowest; why?

- Most likely attributable to differences in childcare, cleanliness, and medical knowledge

            - Diarrheal diseases were the most common cause of child mortality

- In the early 1900s health officials began educating mothers on taking proper care of kids

- Medical experts were unsure about exactly what caused young children and infants to contract diarrhea (was it a direct effect of heat or something caused by heat?)

- Debate over whether or not germs caused disease

- Nevertheless, many of the treatments and precautions recommended to mothers were effective at reducing kids exposure to bacteria, even though medical experts were unaware that this is what was happening

- Areas of advice given to mothers included 1) advice on feeding infants, especially the promotion of hygiene among those who were not breastfeeding, 2) Advice on isolating children from sick family members, 3) advice on handwashing and general hygiene, and 4) advice on when to consult a physician

- Authors conclude that decrease in child mortality was primarily due to advances in disease prevention rather than disease treatment

Unmarried versus married men’s mortality risk has widened since 1960

Looked at height of veteran of war and modern norwegians.

The taller have lower mortality.

Age 45-64

gradient with increased risk of death at lower incomes

even when age, sex, race, family size, period are controled.

“Sociodemographic differentials in adult mortality: A review of analytic approaches.” Population and Development Review, 24(3), 553-578.

Some trends in adult mortality differentials

- SES differentials have gotten steeper since 1960 (Pappas et al. 1993)

- Kitagawa and Hauser (1973) paved the way for studies of SES differences in mortality by estimating cause-specific mortality differences by education, income, occupation, marital status, etc.

- Since then, there has been much debate over which SES indicator(s) to use in studies of health and mortality (income vs. education vs. occupation vs. wealth)

- Unmarried versus married men’s risk has widened since 1960 (Smith 1996)

- Racial and gender differentials have at least persisted, and may have gotten stronger, since 1960

- Two repeatedly documented patterns of racial differences in mortality are the

epidemiological paradox (Hispanic populations tend to have lower mortality than non-Hispanic whites despite their lower SES; Markides and Coreil 1986), and the

racial mortality crossover (blacks tend to have lower mortality than whites at oldest ages; Nam 1995)

One major shortcoming of the demographic literature on mortality differentials is that it fails to explain why such differences exist

- Human agency doesn’t play the same role in studies of mortality as it does in studies of migration or fertility, because it is assumed that all people are motivated to avoid death

- One explanatory finding has been that gender differences in mortality are largely due to differences in heart disease

- Biodemographers are paving the way for a theory of human mortality by studying the limits to human life expectancy

- One fundamental assumption of studies of differences in mortality across subgroups is that such differences are social, rather than biological, in origin

A second shortcoming of this work is that without understanding the proximate determinants of mortality differentials, policy questions remain unanswerable

A third shortcoming is that even when proximate determinants have been studies, point in time estimates of risk factors limits their explanatory power

 - Researchers must find a way to incorporate time into studies of the proximate determinants of health and mortality, either by cohort studies, longitudinal studies, or retrospective questions

Some further challenges to this line of work

 - Different causes of death likely have different proximate determinants

- People often die of more than one thing, even though only one cause is listed on death certificate

- Macro-level factors often play a role (e.g. access to health care, dangerous inner-city neighborhoods, etc.)

- However, it is difficult to quantify what role macro-level factors might play on individual health due to processes like selection into certain neighborhoods, variation in utilization of services etc.

More inequity in income in a state or provience (in US or Canada) they higher mortality in the working age men in the poorest 50% of hhs in the state.

May be because of status or income is a proxy for race.

Premature Death in Easter Europe

-Young men espeically ___ to communist policies in Eastern Europe (pre-1990)

Leading cause of increased mortality is Injuries and violence, CVD,

-High alcohol comsumuption esp. binge drinking

-Smoking and nutrition are also a part of it.

Men who experience a rapid ecoomic transition who have the least social support are most effected.

-not uniqure pattern of premature mortality - it's seend in Western Europe too.

Big difference in LE between women and men

“The influence of income on health: Views of an epidemiologist.” Health Affairs, 21(2), 31-46.

- Marmot assesses two ways in which income might affect health:

1) through a direct effect on the material conditions necessary for survival and

2) through an effect on social participation and opportunity to control life circumstances

- In more developed countries, most individuals have moved beyond the threshold where they don’t have enough money to secure material conditions necessary for survival

- The Whitehall studies (Marmot et al. 1984) shed light on the modern relationship between poverty and inequality

- This longitudinal study began in 1960 and examined the health of British civil service workers

- None of the workers were poor

- Nevertheless, their mortality still varied according to their position in the occupational hierarchy

- Ex: members of the lowest pay grade had 2 times the rates of cardiovascular disease as members of the highest pay grade

- This suggests that among populations above the poverty level, position in social hierarchy, rather than income per say, predicts health

- This may be due to psychological factors related to relative, rather than absolute, deprivation

- Income inequality in a country is a better predictor of health than mean income

- Even in the US, income inequality at the state level is associated with higher mortality rates

- Evidence suggests that the relationship between income and mortality is curvilinear, which means that although the rich gain from income inequality and the poor lose, the health advantage to the rich will be less than the disadvantage to the poor

- Marmot argues that this evidence suggests that wealth in and of itself may be standing in as a placeholder for other variables that more directly affect health

- Wealth ascribes benefits and social power

- Social participation, alienation from work, and stress may be reasons why health declines along a gradient related to social class

- In light of these findings, Marmot suggests that public policies should redistribute income, not for the purpose of addressing material deprivation, but rather for allowing all people to participate fully in society

- Presumably, government providing more goods and services so that access is not so dependent on income would also be beneficial

 “Cumulative disadvantage and health: Long-term consequences of obesity?” American Sociological Review, 68, 707-729.

Paper investigates the long-term risks of obesity on health inequality in adulthood, drawing on cumulative disadvantage theory

Cumulative disadvantage theory proposes that early advantages or disadvantages are critical to how individuals within cohorts become differentiated over time

- A theoretical consideration that has typically been overlooked is that health disadvantages are potentially reversible

- Are there compensatory mechanisms that can reduce the effects of previous disadvantages?

- A second limitation of empirical work is the issue of selective survival

4 research questions addressed in paper:

1) Is obesity associated with physical disability?

2) If obesity is related to disability, is the effect of obesity more substantial during certain periods of the life course?

3) Does the timing of obesity influence health inequality?

4) Can compensatory mechanisms reduce or eliminate the effects of obesity on health decline?

Findings

- Evidence for both lagged and immediate effects of obesity on lower body disability

- Only modest effects of obesity on upper body disability

- Transitioning from the obese to the non-obese state between waves 1 and 2 did not reduce the risk of lower body disability compared to those who did not transfer

- No evidence for exiting risk on health

- However, regular exercise did reduce the effect of obesity on disability

- Evidence for compensatory mechanism that occurs via exercise but not via weight loss

- Effects of obesity reduces the independent effects of socioeconomic status on health measures

    looks at how health events and the onset of health conditions affect earnings in a given year and over future years

negative effect?

Different cohorts have different smoking rates by gender. 

In the past there was a large different >10 years, now it's much smaller difference about 2 years.

Likewise in the past, smoking increase mortaltity of men at much greater levels than women, now the difference is shrinking.

Authors estimate that large increase in the numbe who survive from 50-85 if smoking is reduced/eliminated. 

Also the ratio of women surviving to old age vs. men surviving to old age would decrease and there would only be a small difference if there was no smoking.

Determinants of reduction in maternal mortality in Bangledesh - 30 yr cohort study

Found a decrease in maternal moraltiy in a 30 yr periods with international and gov't interventions.

Better health care, midwives, safer abortions helped

But women's education and financial assitance for the poor and poverty reduction are essential.

“Chronic conditions and the decline in late-life disability.” Demography, 44(3), 459-477.

- Recent evidence suggests that the prevalence of late-life disability has been declining

- Objective of paper is to determine the extent to which declines in late-life disability are due to declines in the prevalence of chronic conditions that cause disability versus declines in the risk of disability among those that have these conditions

- Measured disability by looking at the Activities of Daily Living (ADLs) and the Instrumental Activities of Daily Living (IADLs)

General trends

- Find that between 1997 and 2004, the percentage of Americans living with disability declined by about 11%

- Prevalence of many of the potentially debilitating conditions increased significantly

- Cancer, heart and circulatory conditions, diabetes, obesity, and arthritis all increased

- Only severe mental distress and visual impairments decreased

- The probability of disability given a chronic condition was lower in 2004 than in 1997

Decomposition of these trends

- Declines in heart and circulatory conditions as causes of disability were the largest contributors to the disability decline

- Expanding medical and rehabilitative treatments have limited the amount of disability resulting from these conditions

- Declines in overall prevalence of sensory impairments were next

- Increases in the prevalence of obesity contributed to increases in reported disability

- The gender gap in disability declined over this period; women were experiencing less disability relative to men

 - This could perhaps reflect increases in women’s ses relative to men’s

- Education had a mixed effect on disability

- Increased proportion of elderly with more than a high school education contributed to decreased disability

- However, the disadvantage of having less than a high school education increased over this period, which caused overall shifts in education to push disability upward over this period

“Is poverty or wealth driving HIV transmission?” AIDS, Supplement 7, S5-S16.

Literature review of recent findings on the relationship between wealth and HIV infection in sub-Saharan Africa

- Some researchers theorize that in the early stages of the HIV epidemic, the wealthy were more likely to contract the disease due to higher rates of partner change stemming from greater personal autonomy and spatial mobility

- In later stages of the epidemic it has been argued that the poor are more likely to contract the disease due to increased sexual risk taking and decreased immune function (less resistant to the disease in the event of an unprotected sexual encounter)

Some key patterns from recent literature

- At the national level, income inequality is associated with HIV prevalence, but poverty rates are not

- Poor women and wealthy men are particularly likely to engage in transactional sex and to have more sexual partners

- In fact, gender inequality at the population level may lead to riskier sexual behaviors

Two key problems with cross-sectional studies

- Cannot determine whether poverty causes HIV infection or vice versa

- Unable to control for the fact that individuals from richer households may survive longer with HIV, and are thus more likely to be in the population

- Education has a strong negative relationship with HIV infection

- This association changed over time; at the early stage of the epidemic there was little association between education and HIV, but later in the epidemic education was significantly negatively correlated with HIV (similar to association between wealth and infectious diseases over time as discussed by Preston)

- Individuals with more education tend not to engage in risky behaviors, which reduces their chance of HIV infection

- The urban poor appear to have higher rates of HIV than the rural poor

- Authors speculate that this may be due to reduced privacy in urban slums, which allows children to view sexual activity and thus become sexually active at a much earlier age

- In sum, income and gender inequality are particularly predictive of HIV at the national level

- Educational attainment predictive at the individual level

gap in disability-free LE of blacks and whites narrows at older ages, note this may be consistent with the robust hypothesis, notion that the mortality cross-over betwene blacks and whites is real

Steenland et al 2000s-

what are trends in US health inequality by ses in the United States over the 20th century

find ses inequalities at adult and child levels pretty consistent over the 20th century

suggests that since the 1970s there have been fairly constant mortality levels in counties