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RESEARCH: Danny Dorling, Richard Mitchell, and Jamie Pearce The global impact of income inequality on health by age: an observational study BMJ 2007; 335: 873 [Abstract] [Full text]

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Inequality, exploitation and damaging health

Dirk Van Duppen   (28 October 2007)

The Less Privileged Poor Have Poor Access To Health Care System Than The Rich.

Robert James   (7 November 2007)

Social solidarity can compensate for income inequalities: the case of the public Italian healthcare service.

Giampiero Favato   (11 November 2007)

The problem of aggregated analysis: the need for a multilevel methodology in evaluating the relative income hypothesis

Min Hua Jen, Moon Graham and Ron Johnston   (19 November 2007)

Inequality, exploitation and damaging health 28 October 2007
Dirk Van Duppen, GP B-2100 Antwerp Belgium Send response to journal: Re: Inequality, exploitation and damaging health	Dorling at al confirm that income inequalities seem to be most damaging to health during working adult ages.(1) There could be one more hypothesis why this is happening. Inequality means a gap between rich and poor people in a given society. Rich and poor are not independent variables, on the contrary. The rich become richer, because the poor becomes poorer. They become richer because there is a transfer of value of the poor to the rich. That means for the poor harder work, in worse working circumstances and lower remunerations or in other words: increased exploitation. That exploitation takes place at the working adult ages. Exploitation means more then increasing subjective psychosocial stress. Increased exploitation is associated with objective worsening of the working conditions and decreasing of income and affluence, which have both a bad influence on health. (1) Dorling D at al. The global impact of income inequality on health by age: an observational study. BMJ 2007;335:873 Competing interests: None declared
The Less Privileged Poor Have Poor Access To Health Care System Than The Rich. 7 November 2007
Robert James, MD Medicine Christian Medical College and Hospital, LDH, Pb, In. Send response to journal: Re: The Less Privileged Poor Have Poor Access To Health Care System Than The Rich.	One thing is true from all the above references. The rich have better access to health care system, whereas at the same time the poor struggle to find basic health care to stay alive. The rich can seek health care in hospitals and also have the luxury of visiting their physician in private opd's where definitely the doctor devotes more time on one patient examining him/her. Rich can also have the luxury of calling the doctor at home at the dial of a ph call. So the doctor is a ph call away for them. Whereas for the poor, even if they need basic health care they have to travel relatively longer distances, maybe they will have to wait a longer time in queue’s for getting a simple medical care, maybe the best doctor available won’t be seeing them in the first instance. Because of financial constraints, the poor can’t afford the best of the medicines, hence there is a compromise when medication is prescribed to them. Eg a poor patient may be prescribed a cheaper trimethoprim- sulphamethoxazole combination for fever where as the rich would be prescribed a costly 3rd or 4th generation cephalosporin, that would act faster and cover a broader spectrum of organisms. So the chances of recovery increase with better antibiotic selection. In India a daily wage worker with a family of 10 to support, earning 40-50 rupees a day won’t be able to afford costlier forms of treatment for certain medical conditions, like thrombolytic therapy in acute myocardial infarction, or he won’t go for laproscopic surgery for acute appendicitis, or he would decide against seeking treatment for cancer, or he may not be able to afford to vaccinate his children against preventable diseases. At the same time incidence of illiteracy, overcrowding, poor hygiene, poor diet are seen more amongst the poor population. These again predispose the poor to more illnesses and hence increased mortality. I think more stress needs to be laid for government health organizations and other non profit organizations to look into this problem more deeply to narrow this gap between treatment of rich and poor. Competing interests: None declared
Social solidarity can compensate for income inequalities: the case of the public Italian healthcare service. 11 November 2007
Giampiero Favato, Academic Fellow Henley Management College, Greenlands, RG9 3AU UK Send response to journal: Re: Social solidarity can compensate for income inequalities: the case of the public Italian healthcare service.	The Italian public healthcare service is rapidly evolving from a state centric model to one based upon the equilibrium of central governance of demand and regional funding. The state has exclusive power to define the basic level of coverage, which must be uniformly provided across the country, while each Regional Health Authority (ASSR) is responsible for funding its cost. Equity of access based upon clinical need alone remains the central principle of the national healthcare system, raising the issue of an equitable distribution of resources in proportion to the population needs. Large differences in disposable income per capita can be observed among Italian Regions: the families living below the threshold of poverty varies from 3.9% in Emilia-Romagna to 28.9% in Sicily (1). An efficient distribution of healthcare resources, based on weighted capitation models, would account for a number of determinants of patients demand for health, ignoring the long-term impact of income inequalities on the Regional supply of healthcare services. Underprivileged patients would have access to the basic level of coverage, but the total amount of healthcare available to them would be largely dependent on the Region where they live. Regions with higher income from local taxes would necessarily supply a higher amount of better quality healthcare service. The principle of social solidarity recognises large historical inequalities, allowing Regions with lower per-capita income to spend more on welfare. As an example, in 2006 the annual average per-capita public pharmaceutical spending in Emilia-Romagna was €188, while in Sicily was €302, showing a 61% difference in favour of the Region with the higher poverty rate (2). Patients with severe chronic conditions are allowed to migrate to centres of excellence located in a different Region. The migration rate of cancer patients from Emilia-Romagna to other Regions was only 6%, compared to 16% from Sicily (3). The social solidarity principle is pushing the public cost of healthcare to exceed the 10% threshold of the Italian Gross Domestic Product, and it is possibly economically inefficient. In return, a socially responsible allocation of public healthcare funding can minimise the negative impact of income inequalities on mortality rates. This valuable outcome has been achieved by the Italian health service, since poverty and mortality at Regional level show an extremely weak correlation (r-square = 0.094). Life expectancy at birth is almost identical for Emilia-Romagna and Sicily, respectively 77.5 and 76.7 years, in spite of the large difference in per-capita disposable income, supporting the relevance of solidarity in public healthcare funding. References. (1) ISTAT, Italian National Institute of Statistics (2007), Consumi e poverta’, Anno 2005. Available online at: http://www.istat.it/ (2) AIFA, Agenzia Italiana del Farmaco (2007), L’uso dei farmaci in Italia. Rapporto OSMED 2006. Available online at: http://www.agenziafarmaco.it/wscs_render_attachment_by_id/111.272708.118250656748298dd.pdf?id=111.251385.1182344815039 (3) Balzi D, Geddes M, Lispi L (2002), La “migrazione sanitaria” per tumore della mammella fra le regioni italiane. Available online at: www.ministerosalute.it/programmazione/resources/documenti/migrazionesanitaria.doc (4) ISS, Istituto Superiore di Sanita’ (2007), La mortalita’ per causa in Italia: 1980-2002. Available online at: http://www.iss.it/site/mortalita/ Competing interests: None declared
The problem of aggregated analysis: the need for a multilevel methodology in evaluating the relative income hypothesis 19 November 2007
Min Hua Jen, Research Associate Department of epidemiology, public health and primary care, Imperial College London, London SW7 2AZ,, Moon Graham and Ron Johnston Send response to journal: Re: The problem of aggregated analysis: the need for a multilevel methodology in evaluating the relative income hypothesis	Wilkinson’s relative income hypothesis has generated considerable debate and many papers support, develop or criticise his work.1 2 3 4 5 Much of this interest derives from there being a great deal at stake in policy terms, between the competing demands for policies aimed at material disadvantage and those aimed at social cohesion. However, empirical evidence for the income inequality hypothesis is largely based on the results of aggregated data analyses in developed countries. Dorling et al.6 have similarly used ecological data in their study of associations between countries’ age-sex mortality rates and both GDP (as a measure of wealth) and income inequality. There are two problems with the study by Dorling et al.6 First its design is sub-optimal. Their data set has a multilevel structure in which age-sex specific mortality is nested within countries. Within a country, people are more similar to each other than they are between countries. To ignore this is to violate the assumption of standard regression that all observations are independent. Therefore, their results may be biased. A multilevel binomial model should be able to handle this dataset by treating the mortality outcome as a function of age/sex cells nested within countries, with the absolute and relative income measures at the country level. Second, in pursuing an ecological study design, Dorling et al.6 neglect the possibility that the effect of country level relative (and absolute) inequality is confounded by individual income. We have pursued an alternative approach to testing Wilkinson’s hypothesis using individual data from the World Values Survey (170k respondents nested within 4 waves and within 69 countries)7. Morbidity (self-rated health) was related to age, sex, individual absolute income and national income inequalities in a multilevel framework to take account of within-country autocorrelation. We found no evidence supporting a Wilkinson hypothesis for self-rated health once individual income was taken into account. Even when interactions were allowed between individual income and inequality, poor people in the most unequal counties do not appear to experience the worsened poor health predicted by Wilkinson. References 1.Gravelle H. How much of the relation between population mortality and unequal distribution of income is a statistical artefact? British Medical Journal 1998;316: 382-5. 2.Kawachi I, Kennedy B.P. Income inequality and health: pathways and mechanisms. Health service research 1999; 34: 215-217. 3.Wagstaff A, van Doorslaer E. Income inequality and health: what does the literature tell us? Annual review of public health 2000; 21: 543- 67. 4.Macinko J, Shi L, Starfield B, Wulu J. Income inequality and health: a critical review of the literature. Medical Care Research and Review 2003; 60: 407-52. 5.Lynch J, Davy-Smith G, Harper S, Hillemeier M, Ross N, Kaplan G, Wolfson M. Is income inequality a determinant of population health? Part 1: a systematic review. The Milbank Quarterly 2004; 82: 5-99. 6.Dorling D, Mitchell R, Pearce J. The global impact of income inequality on health by age: an observational study. British Medical Journal 2007; 335: 873-7. 7.Jen M. Health outcomes and income inequality: a multilevel analysis of the Wilkinson hypothesis. 2006; PhD thesis. University of Bristol, UK. Competing interests: None declared