Inequalities in Health

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It is natural for there to be considerable variation in health status in any population. Some people die young; some suffer chronic disease or disability; others live to a ripe old age. It is not these differences per se that comprise the theme of inequalities in health, however. Instead, it is the finding that such contrasting experiences do not occur at random. Health levels have been analyzed by region; by race, gender, and age; and by social indicators such as income, education, and occupation. All of these show systematic patterns in the distribution of health within and between societiespatterns that clearly show that at birth not every person shares an equal prospect for a long and healthy life. Among the most striking of these inequalities in health is the almost universal tendency for people in lower socioeconomic groups to die younger and to suffer more illness during their lifetime when compared to those in higher socioeconomic groups.

Because of the contrasts in income, climate, and natural resources between countries, it is perhaps not surprising that there are international inequalities in health. What is striking (and politically unacceptable) is both the level of the disparities, and the fact that improvements in the world economic situation have not greatly diminished the health gap between rich and poor nations. To illustrate the type of international inequalities that exist, Table 1 shows statistics on wealth, life expectancy, and infant mortality from seven countries. While the data on the comparison is drawn from the different years, the rates shown generally remain stable from year to year.

Table 1

GNP and Life Expectancy
CountryGross national product per capita in U.S. dollars (1997)Life expectancy (1999)Infant mortality rate per 1,000 births (1996)
sources: Economic information and infant mortality from the World Bank's World Development Report, 1998/99. Life expectancy data from the World Health Organization's World Health Report, 2000.
New Zealand16,48073.979.36

As seen in the table, infant mortality rates decline steeply as a nation's gross national product (GNP) rises to about $5,000 (U.S.) per capita, then decline more slowly until about $10,000, and remain low thereafter. There is also a marked rise in life expectancy as a nation's GNP increases. Although the GNP dollar values have changed, the essential pattern of this relationship has remained unaltered over the past fifty years. There have, however, been some changes in international inequalities in health, commonly reflecting political and social changes. For example, Central and Eastern European nations currently have a shorter life expectancy than countries in Western Europe, although there was a period after the second World War when the life expectancy in these areas converged.

If some differences between countries may be expected, the level of health inequalities within countries are less readily accepted. Inequalities exist between the genders (e.g., women live longer than men on average) and between racial groups. Whether these differences represent biological or genetic, as opposed to environmental, factors is open to debate. Much of the contrast, however, can be attributed to social status and inequalities in wealth. However social status and health are measured, the general pattern remainspoorer people die younger and experience less adequate health status than wealthier people. To illustrate

Table 2

Annual age-adjusted rate of years of potential life lost per 1,000 men aged 2064 in England and Wales
Occupational class197072197980, 198283199193
source: Blane and Drever (1998). British Medical Journal.
I (professional)48.736.528.0
II (intermediate)51.942.231.6
III (skilled non-manual)65.053.945.7
III (skilled manual)
IV (partly skilled)75.667.752.8
V (unskilled)103.0105.893.3

the typical pattern, Table 2 shows data from England and Wales summarizing years of potential life lost for different types of occupation. This statistic counts deaths, but also reflects how prematurely a person died. In this instance the data refer to men aged 20 through 64, so a death occurring at age 40 would contribute 25 years of potential life lost (the choice of 65 is arbitrary, but raising it would not alter the essential pattern of results). In 19701972, men in occupational class I lost an average of 48.7 years of potential life per 1,000 population for men aged 20 to 64 while unskilled workers lost an average of 103 years per 1,000 men. The results indicate a clear gradient across the occupational groups, but perhaps even more provocative is the finding that, although premature deaths are declining, the improvement is greatest among the socially advantaged, so the social inequality in years of potential life lost is actually increasing. The inequality ratios across the occupational groups rose from 2.1 in 19701972, to 3.3 in 19911993.

In an extension of such analyses, mortality has been compared not against the average wealth in a community, but against the level of dispersion of wealth in the communitythe gap between rich and poor. Both R. G. Wilkinson and I. Kawachi have shown that mortality is highest in those communities with the greatest disparities in wealth; this relationship is stronger than that between mortality and the actual level of wealth.

To what may such inequalities be due? For the most part, occupation or income themselves are not the causes, although they may suggest directions for investigating the root causes. Potential explanations consider a broad range of factors, including social and political environments, cultural factors, nutrition, and patterns of health behaviors. Aspects of individual psychology are also often cited, leading to new disciplines of study that lie at the interface between psychology and biology; such as psycho-neuro-immunology.

However they may be explained, inequalities are politically significant in that they point to a failure of national health planning. Socioeconomic disparities cannot readily be dismissed as biological facts or historical inevitabilities. Furthermore, those who are disadvantaged are often motivated to demand better access to health. Democratic societies view good health as a right to which all persons should have access, and principles of equity and justice demand that inequalities be reduced. In addition, economists note a triple benefit to addressing inequalities: Expenditures on medical care would be reduced if all groups were to share the experience of those currently most favored; the drain on disability insurance and pensions would be reduced; and a healthier workforce would bring greater economic prosperity.

Ian McDowell

(see also: Access to Health Services; Cultural Factors; Economics of Health; Equity and Resource Allocation; Ethnicity and Health; Gender and Health; Health; Infant Mortality Rate; International Health; Life Expectancy and Life Tables; Poverty and Health; Race and Ethnicity )


Blane, D., and Drever, F. (1998). "Inequality among Men in Standardised Years of Potential Life Lost, 19701993." British Medical Journal 317:255.

Kawachi, I.; Kennedy, B. P.; Lochner, S. M.; and Prothrow-Stith, D. (1997). "Social Capital, Income Inequality, and Mortality." American Journal of Public Health 87:14911498.

Power, C. (1994). "Health and Social Inequality in Europe." British Medical Journal 308:11531156.

Wilkinson, R. G. (1996). Unhealthy Societies: The Afflictions of Inequality. London: Routledge.