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PAPERS: Merete Osler, Eva Prescott, Morten Grønbæk, Ulla Christensen, Pernille Due, and Gerda Engholm Income inequality, individual income, and mortality in Danish adults: analysis of pooled data from two cohort studies BMJ 2002; 324: 13 [Abstract] [Full text]

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Factors other than income inequality explain mortality differences in rural Australia

Andrew M Thornett   (5 January 2002)

Income inequality and primary care

Barbara Starfield, I   (18 January 2002)

Factors other than income inequality explain mortality differences in rural Australia 5 January 2002
Andrew M Thornett, Deputy Head Adelaide University Rural Clinical School, Whyalla Norrie, South Australia 5608 Send response to journal: Re: Factors other than income inequality explain mortality differences in rural Australia	Several papers in this week’s BMJ have demonstrated the importance of factors other than population income in explaining mortality differences. In Denmark, adjustment for individual risk factors made an apparent effect on area income inequality on all cause mortality disappear,1 while in Japan, individual income has a stronger association with self-rated health than income inequality at a community level,2 and in the USA lack of high school education accounted for a significant proportion of the income inequality effect.3 Data from rural and remote Australia also support this finding. In particular, racial differences play an important part in explaining differences in mortality rates. Although Aboriginal and Torres Strait Islander death rates are declining, they have failed to keep pace with declines in the Australian population as a whole.4 Based on 1992-94 mortality data, life expectancy for Indigenous peoples is still much less than for their non-Indigenous counterparts, with a difference in life expectancy at birth of 14-18 years between Indigenous and non-Indigenous males. The leading cause of death for Indigenous peoples continues to be cardiovascular disease, with death rates at more than three times those obtained in the non-Indigenous population.4,5 Diabetes-related mortality is higher in remote areas of Australia than in urban and rural areas, which is explained by the fact that Indigenous Australians account for two-thirds of diabetes-related deaths in remote areas. Indigenous Australians are twice as likely to die from diabetes- related deaths as non-Indigenous Australians.6 This difference is substantially higher among the 35-44 age group, where the proportion of deaths among Indigenous Australians is six times that of non-Indigenous Australians. Similarly, deaths from respiratory diseases were seven times more common than for the non-Indigenous population in 1992-1994, and did not reduce significantly from 1985 to 1994, and deaths from diabetes rose significantly during the 1985-94 period, with increases of 10% per year in males and 5% per year in females. Indigenous men were 12 times more likely to die from diabetes than non-Indigenous men, and Indigenous females were 17 times more likely to die of the disease. By concentrating on income, the risk is that more important differences between communities will be missed. If we are to improve the health status of our most disadvantaged groups then we must address their needs and take care not to use preconceived notions of disease causation. 1 Osler, M., Prescott, E., Gronbaek, M., Christensen, U., Due, P., Engholm, G. Income inequality, individual income, and mortality in Danish adults: analysis of pooled data from two cohort studies. BMJ 2002, 324, 1- 4. 2 Shibuya, K., Hashimoto, H., Yano, E. Individual income, income distribution, and self-rated health in Japan: cross sectional analysis of nationally representative sample. BMJ 2002, 324, 1-5. 3 Muller, A. Education, income inequality, and mortality: a multiple regression analysis. BMJ 2002, 324, 1-4. 4 Anderson, P., Bhatia, K., 1996. Cunningham, J. Mortality of Indigenous Australians. Australian Bureau of Statistics. 5 Mathur, S., Gajanayake, I., 1998. Surveillance of cardiovascular mortality in Australia 1985 – 1996. AIHW cat. No. CVD 3. Canberra: Australian Institute of Health and Welfare (Cardiovascular disease series no. 6). 6 Mathur S, Gajanayake I & Hodgson G 2000. Diabetes as a cause of death, Australia, 1997 and 1998. AIHW Cat. No. CVD 12. Canberra: AIHW (Diabetes Series no. 1).
Income inequality and primary care 18 January 2002
Barbara Starfield, University Distinguished Service Professor Johns Hopkins University School of Public Health, 624 North Broadway, Baltimore, MD 21205, USA, I Send response to journal: Re: Income inequality and primary care	To Editor: None of the four research reports on income inequalitiy1-4 or the commentary5 mentioned some important research findings regarding the relationship between income inequality, primary care, and various measures of health, even though existing studies6-9 were carried out on various levels of aggregation (states, metropolitan areas, communities) with a variety of variables, both individual and ecological. Our studies have consistently found a modest relationship of income inequality and health, but a much greater relationship of primary care physicians to population ratios. Thus, a measure that reflects a specific health policy component and a material explanation for health effects is strongly suggested. We also found a larger effect of primary care in areas where income inequality is greatest. In concert with the recommendations of several authors, we encourage the consideration of alternative conceptual frameworks for path effects, and inclusion of a broader range of specific characteristics suggested by them as likely to have an impact on health, including, but not necessarily limited to, primary care resources, access, and use. Sincerely, Barbara Starfield, MD, MPH, FRCGP Johns Hopkins University School of Public Health, 624 North Broadway, Room 452, Baltimore, MD 21205, USA e-mail address: bstarfie@jhsph.edu 1. Osler MO, et al. Income inequality, individual income, and mortality in Danish adults: analysis of pooled data from two cohort studies. BMJ 2002: 324: 13. 2. Shibuya K, et al. Individual income, income distribution, and self rated health in Japan: cross sectional analysis of nationally representative sample. BMJ 324: 16. 3. Sturm R, Gresenz CR. Relations of income inequality and family income to chronic medical conditions and mental health disorders: national survey. BMJ 2002; 324: 20. 4. Muller A. Education, income inequality, and mortality: a multiple regression analysis. BMJ 2002; 324: 23.) 5. Mackenbach JP. Income inequality and population health. BMJ 2002: 324: 1-2. 6. Shi L, et al. Income inequality, primary care, and health indicators. J Fam Pract 1999; 48: 275-84. 7. Shi L, Starfield B. The effect of primary care physician supply and income inequality on mortality among Blacks and Whites in US metropolitan areas. Am J Public Health 2001; 91: 1246-50. 8. Shi L, Starfield B. Primary care, income inequality, and self-rated health in the US: mixed-level analysis. Int J Health Serv 2000; 30(3): 541 -55. 9. Shi L, Starfield B, Politzer R. Primary care, self-rated health, and reduction in social disparities in health. Health Serv Res 2002; in press.