Five American authors on wealth, poverty, and inequality

There is much to be gleaned from novels concerning the links between wealth and power, inequality and corruption, poverty and illness. A student of social epidemiology will profit as much from close reading of these classics as from consulting textbooks on social stratification.     

Neighborhood poverty and the resurgence of tuberculosis in New York City, 1984-1992

OBJECTIVES: The resurgence of tuberculosis (TB) in NewYork City has been attributed to AIDS and immigration; however, the role of poverty in the epidemic is unclear.We assessed the relation between neighborhood poverty and TB at the height of the epidemic and longitudinally from 1984 through 1992. METHODS: Census block groups were used as proxies for neighborhoods. For each neighborhood, we calculated TB and AIDS incidence in 1984 and 1992 with data from the Bureaus of Tuberculosis Control and AIDS Surveillance and obtained poverty rates from the census. RESULTS: For 1992, 3,343 TB cases were mapped to 5,482 neighborhoods, yielding a mean incidence of 46.5 per 100,000. Neighborhood poverty was associated with TB (relative risk = 1.33; 95% confidence interval = 1.30, 1.36 per 10% increase in poverty).This association persisted after adjustment for AIDS, proportion foreign born, and race/ethnicity. Neighborhoods with declining income from 1980 to 1990 had larger increases in TB incidence than did neighborhoods with increasing income. CONCLUSIONS: Leading up to and at the height of the TB epidemic in New York City, neighborhood poverty was strongly associated with TB incidence. Public health interventions should target impoverished areas.     

Income inequality,area-level poverty,perceived aversion to inequality,and self-rated health in Japan

In this study we conduct a multilevel analysis to investigate the association between regional income inequality and self-rated health in Japan, based on two nationwide surveys. We confirm that there is a significant association between area-level income inequality and individual-level health assessment. We also find that health assessment tends to be more sensitive to income inequality among lower income individuals, and to degree of area-level poverty, than income inequality for the society as a whole. In addition, we examine how individuals are averse to inequality, based on the observed association between inequality and self-rated health.     

Disadvantage, inequality, and social policy

Eliminating disparities in health is a primary goal of the federal government and many states. Our overarching objective should be to improve population health for all groups to the maximum extent. Ironically, enhancing population health and even the health of the disadvantaged can conflict with efforts to reduce disparities. This paper presents data showing that interventions that offer some of the largest possible gains for the disadvantaged may also increase disparities, and it examines policies that offer the potential to decrease disparities while improving population health. Enhancement of educational attainment and access to health services and income support for those in greatest need appear to be particularly important pathways to improved population health.     

Aggregation and the measurement of income inequality: effects on morbidity

This is a cross-sectional study using records from the National Health Interview Survey linked to Census geography. The sample is restricted to white males ages 25-64 in the United States from three years (1989-1991) of the National Health Interview Survey. Perceived health is used to measure morbidity. Individual covariates include income-to-needs ratio, education and occupation. Contextual level measures of income inequality, median household income and percent in poverty are constructed at the US census county and tract level. The association between inequality and morbidity is examined using logistic regression models. Income inequality is found to exert an independent adverse effect on self-rated health at the county level, controlling for individual socioeconomic status and median income or percent poverty in the county. This corresponding effect at the tract level is reduced. Median income or percent poverty and individual socioeconomic status are the dominant correlates of perceived health status at the tract level. These results suggest that the level of geographic aggregation influences the pathways through which income inequality is actualized into an individuals' morbidity risk. At higher levels of aggregation there are independent effects of income inequality, while at lower levels of aggregation, income inequality is mediated by the neighborhood consequences of income inequality and individual processes.     

山西省运城市学生肺结核发病情况分析

目的了解山西省运城市学生肺结核发病情况,为进一步做好学校结核病防治工作提供依据。方法收集运城市13县(市、区)2002年4月1日至2008年12月31日期间接受疾病预防控制中心结核病防治门诊治疗和管理的患有肺结核的大中专院校与中小学校在校学生相关情况,并对确诊学生的就诊途径、检出分类、年度发病及不同文化程度发病情况进行分析。结果此期间运城市大中专院校与中小学在校学生肺结核确诊人数为872例,其中涂阳肺结核病人454例(新发409例),涂阴肺结核病人418例。因症就诊被诊断为肺结核的学生占发病人数的97.59%(851人)。学生肺结核发病率呈逐年上升趋势,其中初中、高中和小学生发病人数占学生肺结核发病人数的前3位,分别为287人(32.91%)、277人(31.77%)和238人(27.29%)。结论运城市学生肺结核发病情况不容乐观,尤其中学生和小学生发病人数较多,应加强学生结核病健康教育,进一步做好新生入学结核病筛查及体检工作,提高学校结核病控制工作的力度。     

Reproduction of social inequality: access to health services in Mexico City

Statistics of disease and mortality rates in Mexico paint afamiliar picture: a high birth rate coincides with a rapidlyfalling death rate, giving a high rate of population increase;the most prevalent diseases are ones which are caused by poorliving conditions and poverty. Yet the orientation of healthcare policies is still largely curative: the primary healthcare approach, which would be the most suitable for tacklingthe health problems of Mexico, receives lip-service, but littleconcrete support. The coverage with basic health care facilitiesis better in Mexico City than elsewhere in the country, butthere are considerable inequalities within the urban areas.This shows up clearly when the location of health service facilitiesis considered. Although all those living in the irregular settlementsin the poorer areas of Mexico City are eligible for care eitherby one of the social security institutes or by the state, ahigh proportion elected to pay for private care. The evidencesuggests that this is due, not to a dissatisfaction with thequality of the public health care, but rather to the inconvenienceand cost of attending public health facilities many of whichare located far away from the poorer, irregular settlements.For minor ailments requiring inexpensive treatment, many wouldrather pay for private treatment. The richer areas of the city,in contrast, are well served with public health care facilities.     

Psychosocial risk factors, inequality and self-rated morbidity in a changing society

The aim of this study was to analyse the interaction of social, economic, psychological and self-rated health characteristics of the Hungarian population in representative, stratified nation-wide samples during the period of sudden political-economic changes. In 1988 20,902 and in 1995 12,640 persons, representing the Hungarian population over the age of 16 by age, sex and place of residence were interviewed. Self-rated morbidity characteristics, shortened Beck Depression Inventory, hopelessness, hostility, ways of coping, social support, control over working situation and socioeconomic characteristics were examined. Age dependent changes could be observed between 1988 and 1995 with increasing depressive symptomatology, hopelessness, lack of control over working situation in the population above 40 years, while in the younger population improvements in depressive symptomatology could be seen. According to hierarchical loglinear analysis, depressive symptom severity mediates between relative socioeconomic deprivation and higher self-rated morbidity rates, especially among men. Depressive symptomatology is closely connected with hostility, low control in working situation, low perceived social support and emotional ways of coping. A vicious circle might be hypothesised between socially deprived situation and depressive symptomatology, which together has a major role in higher self-rated morbidity rates.     

Trends in the association between average income, poverty and income inequality and life expectancy in Spain

In this paper, we study the relation between life expectancy and both average income and measures of income inequality in 1980 and 1990, using the 17 Spanish regions as units of analysis. Average income was measured as average total income per household. The indicators of income inequality used were three measures of relative poverty-the percentage of households with total income less than 25%, 40% and 50% of the average total household income-the Gini index and the Atkinson indices with parameters alpha=1, 1.5 and 2. Pearson and partial correlation coefficients were used to evaluate the association between average income and measures of income inequality and life expectancy. None of the correlation coefficients for the association between life expectancy and average household income was significant for men. The association between life expectancy and average household income in women, adjusted for any of the measures of income inequality, was significant in 1980, although this association decreased or disappeared in 1990 after adjusting for measures of poverty. In both men and women, the partial correlation coefficients between life expectancy and the measures of relative income adjusted for average income were positive in 1980 and negative in 1990, although none of them was significant. The results with regard to women confirm the hypothesis that life expectancy in the developed countries has become more dissociated from average income level and more associated with income inequality. The absence of a relation in men in 1990 may be due to the large impact of premature mortality from AIDS in regions with the highest average total income per household and/or smallest income inequality.     

The demographic and social class basis of inequality in self reported morbidity: an exploration using the Health Survey for England

STUDY OBJECTIVEs: To assess the relative contribution of age and social class to variations in the prevalence of a selection of self reported health problems. To examine the implications of observed variations for research on health inequalities. DESIGN: Secondary analysis of the Health Survey for England (1991-1997) using morbidities that are particularly prone to class effects. A statistical measure of the "relative class effect" is introduced to compare the effects of adjusting for social class and age. MAIN RESULTS: There is substantial variation in the relative importance of the age and class distributions of different diseases. Age effects often overshadow those of class even for conditions where an apparently strong social gradient exists. Only for self reported mental health among women does the social gradient exceed the age gradient. Within the context of a dominating age gradient, social gradients are relatively high for mental health and general health for both sexes. Variation in the relative strengths of the social gradients between the sexes are observed for angina symptoms. CONCLUSIONS: Given variations in the "relative class effect", analysis recognising the distinct contributions of age, sex, and social class to specific morbidities is advocated as a transparent and robust approach to the assessment of morbidity based inequality.     

Inequalities in mortality by social class in men in Barcelona, Spain

Most of the studies of inequalities in mortality carried out in Spain have been ecological, due to the difficulty of obtaining good quality socioeconomic information at individual level. The objective of this study was to describe inequalities in mortality by social class, based on occupation, among men residents of Barcelona in 1993. A representative sample was obtained of men residents of Barcelona who died during the year 1993, aged between 15 and 65 years. It was a retrospective interview given to relatives of the deceased, or other closely related persons. The variables analysed were: age, education level, underlying cause of death, and social class based on occupation (manual and non-manual workers). Rates, relative risks (RRs) and their 95% confidence intervals (95% CIs) are presented by age groups and cause of death. The main results show that among young people, the excess of mortality due to infectious diseases is notable (RR: 1.9; 95% CI: 1.6–2.2), and also due to external causes (RR: 2.1; 95% CI: 1.8–2.4) among manual workers with respect to non-manual workers, mainly due to AIDS and drug overdose. No significant differences were found in mortality due to tumours. For respiratory and cardiovascular causes, there is an increase in mortality in the less favoured social classes, as also occurs for mortality due to diseases of the digestive system, particularly among young manual workers, with an RR: 2.6 (95% CI: 1.5–3.6) compared to non-manual workers. This study shows that it is necessary to continue exploring inequalities in health, but above all it is necessary to implement efficient preventive measures addressed mainly at young people in situations of disadvantage, in order to avoid the excess of avoidable mortality which is found.     

Health promotion, health promoting education and social inequality

Health promotion should consider social equality more strongly in order to maintain its credibility. The school is an appropriate setting for such interventions. Social-epidemiological studies prove that the school setting has a great homogenising influence. Because of its education programmes it also reaches fringe groups. Experiences from two German pilot projects on Health Promoting Schools offer concepts which can be effectively used for these interventions. It is recommended that interventions take place on different levels (school level, curriculum, teacher in-service training, political level), so the HPS can completely unfold its influence. The chance for realisation is seen in linking the orientation to different life domains and basic principles of education. The more critical processes of changing of society and the growing pressure in schools are seen as risk factors for a healthy balance of the school and for the students as well as teachers.     

Income inequality, poverty, and population health: evidence from recent data for the United States

In this study, state-level US data for the years 2000 and 1990 are used to provide additional evidence on the roles of income inequality and poverty in population health. Five main points are noted. First, contrary to the suggestion made in several recent studies, the income inequality parameter is observed to be quite robust and carries statistical significance in mortality equations estimated from several observation sets and a fairly wide variety of specificational choices. Second, the evidence does not indicate that significance of income inequality is lost when education variables are included. Third, similarly, the income inequality parameter shows significance when a race variable is added, and also when both race and urbanization terms are entered. Fourth, while poverty is seen to have some mortality-increasing consequence, the role of income inequality appears stronger. Fifth, income inequality retains statistical significance when a quadratic income term is added and also if the log-log version of a fairly inclusive model is estimated. I therefore suggest that the recent skepticism articulated by several scholars in regard to the robustness of the income inequality parameters in mortality equations estimated from the US data should be reconsidered.     

Cultural capital and social inequality in health

Economic and social resources are known to contribute to the unequal distribution of health outcomes. Culture-related factors such as normative beliefs, knowledge and behaviours have also been shown to be associated with health status. The role and function of cultural resources in the unequal distribution of health is addressed. Drawing on the work of French Sociologist Pierre Bourdieu, the concept of cultural capital for its contribution to the current understanding of social inequalities in health is explored. It is suggested that class related cultural resources interact with economic and social capital in the social structuring of people's health chances and choices. It is concluded that cultural capital is a key element in the behavioural transformation of social inequality into health inequality. New directions for empirical research on the interplay between economic, social and cultural capital are outlined.     

Neighbourhood social fragmentation and the mental health of children in poverty

Using data from 7,776 Millennium Cohort Study children in England, we examined the role of neighbourhood social fragmentation in trajectories of emotional/behavioural problems at ages three, five and seven, and in moderating the association of children׳s emotional/behavioural problems with neighbourhood poverty, family poverty and adverse family events. Allowing for key background characteristics, social fragmentation generally added little to explain child outcomes, but there were fewer conduct problems among children in poor neighbourhoods with less fragmentation. Surprisingly, in less fragmented neighbourhoods poor families tended to feel less safe and more distressed, which was associated with children׳s conduct problems.     

Human capital, social capital and social exclusion: impacts on the opportunity of households with youth to leave poverty

Based on a sample survey, this paper, analyzes the impact of human capital, social capital and social exclusion on the opportunity of Hong Kong families with youth members to leave poverty. Educational attainment of the youth members and adult family members, as well as the quantity and quality of social networks were found to have significant positive impacts, while social exclusion from the labor market of the adult members was found to have significant negative impact on their opportunity to leave poverty. Among all factors, quality of social network is the most influential. The author suggests that in order to help families out of poverty and enable positive development of youth members, poverty alleviation policies or programs should be targeted to help the youth in poor families to build up a quality social network.