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Socioeconomic inequalities in morbidity and mortality in western Europe

1997; Elsevier BV; Volume: 350; Issue: 9076 Linguagem: Inglês

10.1016/s0140-6736(05)63105-4

1474-547X

Richard G. Wilkinson,

Employment and Welfare Studies

The unexpectedly large relative differences in morbidity and mortality in Nordic countries reported by Johan Mackenbach and colleagues1Mackenbach JP Kunst AE Cavelaars AEJM Groenhof F Geurts JJM EU Working Group on Socioeconomic Inequalities in HealthSocioeconomic inequalities in morbidity and mortality in Western Europe.Lancet. 1997; 349: 1655-1659Summary Full Text Full Text PDF PubMed Scopus (936) Google Scholar demand some rethinking. Part of the difficulty is likely to involve the relation between educational, occupational, and income-related dimensions of inequality. Mackenbach (personal communication) informed me that he found that average mortality among men 45–59 years was closely correlated (r=0·89) with age-specific income inequality in the same age-group among the few countries for which data were available; this is consistent with the view that income inequality may be a powerful determinant of average mortality rates.2Wilkinson RG Unhealthy societies:the afflictions of inequality. Routledge, London1996Crossref Google Scholar But why then was there no relation between income inequality and relative mortality difference between manual and non-manual occupations? It is hard to imagine greater income equality reducing national mortality rates unless it does so largely by reducing the burden of relative deprivation on mortality. In the UK, for example, the median pay among full-time non-manual workers is only 42% higher than that of manual workers, whereas even in data that exclude the part-timers and non-employed, there is a 90% difference in income across the interquartile range among non-manual men.3Office for National Statistics. New earnings survey 1996. Stationary Office, London1997Google Scholar By reducing the burden of relative deprivation, income inequality may therefore have a bigger impact on mortality among both manual and non-manual occupations than it does on the mortality differences between them. Narrower income differences in countries such as Sweden and Norway are therefore likely to be associated with both lower manual and non-manual death rates and larger relative, but smaller absolute, differences in death rates between them—as Mackenbach et al reported.1Mackenbach JP Kunst AE Cavelaars AEJM Groenhof F Geurts JJM EU Working Group on Socioeconomic Inequalities in HealthSocioeconomic inequalities in morbidity and mortality in Western Europe.Lancet. 1997; 349: 1655-1659Summary Full Text Full Text PDF PubMed Scopus (936) Google Scholar Their inclusion of estimates of mortality for the economically inactive would tend to strengthen this pattern. The picture is also consistent with their research finding of smaller income-related inequalities in morbidity in Sweden, and may indeed be consistent with the view that both national standards of health and the scale of health inequalities within countries are strongly influenced by the scale of relative deprivation in each country.2Wilkinson RG Unhealthy societies:the afflictions of inequality. Routledge, London1996Crossref Google Scholar In a sense, the difficulty is related to matched and unmatched records. Another study which used income and morbidity data collected from the same individuals showed a close correlation (r=0·87) between international inequalities in income and in morbidity.4van Doorslaer E Wagstaff A Bleichrodt H et al.Income-related inequalities in health: some international comparisons.J Health Economics. 1997; 16: 93-112Crossref PubMed Scopus (443) Google Scholar Age-specific income inequality can be related to overall mortality in the same age group without matching because including the total population in an age group leaves little chance of miss-specification. However, relating income inequality in the whole population to inequalities in unmatched data on occupational or educational mortality may produce misleading results. Mackenbach's finding of a relation between age-specific mortality and age-specific income inequality suggests that some of the difficulty experienced in identifying the international relation between societal income distribution and mortality in recent international data may be attributable to the changing age-distribution of relative deprivation.5McIsaac SJ Wilkinson RG Income distribution and cause-specific mortality.European J Publ Health. 1997; 7: 45-53Crossref Scopus (64) Google Scholar Socioeconomic inequalities in morbidity and mortality in western EuropeAuthor's reply Full-Text PDF