“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

“Social conditions as fundamental cause of disease.” Journal of Health and Social Behavior, 35, 80-94.

- Most research on SES and health has focused on identifying proximal factors through which SES might affect health, such as diet, cholesterol, hypertension, and exercise

- Purpose of present paper is to highlight the past accomplishments of medical sociologists and social epidemiologists in advancing understanding of the social conditions that cause disease and to offer a conceptual framework to enhance this research

- One downside of examining intervening mechanisms is that researchers may neglect to study the social conditions that produce the intervening mechanisms in the first place

- One way to counteract this trend is to contextualize risk factors

- By contextualizing the authors mean understanding way people come to be exposed to risk or protective factors and to determine the social conditions under which individual risk factors are related to disease

- For instance, without understanding why poor people tend to have a poor diet, providing information about a healthy diet is unlikely to have the intended positive impact

- A second approach to enhancing the study of social conditions rather than proximal conditions is to consider social conditions as “fundamental causes of disease”

- The term “fundamental causes” is meant to imply that the health effects of social conditions cannot be eliminated by addressing the mechanisms that appear to link them to disease

- As certain diseases among the poor have been eradicated, new ones have taken their place

- SES is a fundamental causes of disease because it regulates access to resources such as money, knowledge, power, prestige, and interpersonal networks

- Furthermore, SES influences multiple risk factors and multiple disease outcomes

- Considering social conditions as fundamental causes of disease suggest 3 criteria for policymakers to use when evaluating proposed health interventions

1) Does the intervention contain an analysis of factors that put people at risk of certain behaviors?

2) Does the intervention target just one disease or does it target a fundamental cause that will impact many diseases?

3) Does the intervention claim to address broader social conditions even though it only focuses on intervening variables?

Critical period approach suggests that negative events during developmentally salient periods may alter later life health trajectory

Looked at height of veteran of war and modern norwegians.

The taller have lower mortality.

Children born in the Harvest Season in Gambia have better survival rates at every age.

This is slight until 20-25 when it gets larger and widens for the rest of the lifespan.

“The significance of socioeconomic status in explaining the racial gap in chronic health conditions.” American Sociological Review, 65(6), 910-930.

- According the 1996 estimates, life expectancy of Black men in the US was 66 years compared to 74 years for white men

- Although evidence suggests that the black-white mortality gap converges at older ages (beyond age 65), blacks still remain disadvantaged (Elo and Preston 1994)

2 main questions addressed in paper

1. Are blacks consistently disadvantaged relative to whites across all major chronic diseases and disabling conditions?

2. How do fundamental social conditions affect the racial gap in health?

- Association between race and prevalence is assumed to reflect the historical relationship between SES and health conditions by the time of middle age

- Whereas association between race and incidence is assumed to reflect the occurrence of health problems during middle age

- Include a wide array of covariates in their models because race is assumed to represent the confluences of biological factors, geographic origins, cultural, economic, political, and legal factors, and racism

- For any particular disease, race differences are likely to be the result of differences in combinations of experiences over the life cycle

- Use 1992 and 1994 waves of HRS (respondents 51-61 years old) to assess 1992 prevalence and 1992-1994 incidence of diseases and conditions

- Dependent variables include major fatal chronic diseases (heart disease, hypertension, stroke, diabetes, COPD, and cancer), arthritis and mental diseases, and disability at work and home

- Independent variables include race, gender, educations, mid-life ses, life stressors, social support, health behaviors, and health insurance

Results

- Greater prevalence of all health problems in blacks

- Also higher incidence, but not as substantial

- The greater prevalence of health problems among blacks at middle age is likely to result of cumulative disadvantage over the life cycle, rather than simply the result of the simple bifurcation of health at middle age

- Particularly bad health among black women

- Education and social structure, rather than risk behaviors, explain most of the racial disparities in health (lends support to Link and Phelan’s “fundamental causes of disease” argument)

- It is also important to recognize that health disparities may increase ses disparities between blacks and whites

- Prior to this research, health differences by race were believed to be biological

- This study suggests that health is a product of social variables

- Health results from economic inequality, educational inequality, lifestyle differences, etc.

“The hidden penalties of gender inequality: Fetal origins of ill-health.” Economics and Human Biology, (1), 105-121.

Missing Women

- Main argument is that gender inequality harms the health of the entire population

 poor maternal health -> increased risk of low birth weight

- Overlapping health transitions in the developing world describe a regime in which both communicable diseases and chronic diseases are prevalent simultaneously

- Communicable diseases tend to affect children in poorer segments of the population whereas chronic diseases tend to affect adults in relatively better-off segments of the population

- Authors argue that both of these patterns are exacerbated by the common factor of maternal deprivation operating via fetal deprivation

- In Southeast Asia, mortality rates of women much higher than men

- Estimate 37 million “missing women” in India alone (women that would be alive if it were not for gender inequality)

- 100 million missing women worldwide

- Systematic biases against women -> higher mortality rates among women and averting of women that would have been born

- Authors suggest that gender bias -> maternal undernutrition -> low birthweight -> both child malnutrition and adult poor health

Two types of pathways link low birthweight to adult ill health

- Low birth weight babies may suffer from malnutrition and growth retardation in childhood and typically grow up to be adults of short stature and low BMI

- Barker Hypothesis: Low birthweight infants have bodies and organs that expect to be in a nutrient-poor environment for the rest of their lives

- Babies born with a low birthweight may be better-off in a nutrient poor environment than babies born at normal birthweight because their bodies adapted in the womb

- Babies born with a low birthweight that grow up in a normal or nutrient-rich environment may have more health problems than if they had grown up in a nutrient poor environment because they are more likely to suffer from hypertension, type II diabetes, cardiovascular disease, lung disease, and renal damage

- This hypothesis is supported by the fact that Indian adults have the highest rates of diabetes in the world

- In sum, gender inequality essentially leads to a double jeopardy—simultaneously aggravating both regimes of communicable and chronic diseases and raising the economic cost of the overlapping health transition

- Policies aimed at reducing gender inequality might be the most effective means of preventing these health problems

“Trajectories of functional health: The ‘long arm’ of childhood health and socioeconomic factors.” Social Science and Medicine, 66, 849-861.

examines how circumstances associated with early life may shape the level and progression of functional limitations among older adults

- 2 theories suggest how events earlier in the life course affect later life health

1. Critical period approach (Kuh and Ben-Shlomo 1997) suggests that negative events during developmentally salient periods may alter later life health trajectory

2. Cumulative insult approach suggests that exposures accumulate over the life course and alter an individual’s risk of disease

- Present study uses a combination of prospective and retrospective data between 1994 and 2002 (5 waves) waves of the HRS to study the effects of childhood health and SES on adult health trajectories

- Find that poor health in childhood and disadvantaged social background are associated with both increased baseline limitation and steeper trajectories over time, net of adult chronic conditions and SES

- More proximate health and SES partially mediate childhood impacts on functional health

- This suggests that upward social mobility may partially counteract the effects of poor childhood circumstances on adult health

- Currents SES is only associated with baseline level of limitation (not with trajectories over time); this may be because the effect of SES on health plays out over a longer period of time

Haas’s proposed model

- Childhood SES impacts childhood health, adult SES, and adult health

- Childhood health impacts adult SES and adult health

- Adult SES impacts adult health