Intended for healthcare professionals


Inequality in income and mortality in the United States: analysis of mortality and potential pathways

BMJ 1996; 312 doi: (Published 20 April 1996) Cite this as: BMJ 1996;312:999

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  1. George A Kaplan, chiefa,
  2. Elsie R Pamuk, health statisticianb,
  3. John W Lynch, research associatea,
  4. Richard D Cohen, senior research associatea,
  5. Jennifer L Balfour, graduate assistanta
  1. a Human Population Laboratory, California Department of Health Services, Berkeley, CA 94704, USA
  2. b National Center for Health Statistics, Centers for Disease Control and Prevention, Hyattsville, MD 20782, USA
  1. Correspondence to: Dr Kaplan.
  • Accepted 9 January 1996


Objective: To examine the relation between health outcomes and the equality with which income is distributed in the United States.

Design: The degree of income inequality, defined as the percentage of total household income received by the less well off 50% of households, and changes in income inequality were calculated for the 50 states in 1980 and 1990. These measures were then examined in relation to all cause mortality adjusted for age for each state, age specific deaths, changes in mortalities, and other health outcomes and potential pathways for 1980, 1990, and 1989-91.

Main outcome measure: Age adjusted mortality from all causes.

Results: There was a significant correlation (r=0.62, P<0.001) between the percentage of total household income received by the less well off 50% in each state and all cause mortality, unaffected by adjustment for state median incomes. Income inequality was also significantly associated with age specific mortalities and rates of low birth weight, homicide, violent crime, work disability, expenditures on medical care and police protection, smoking, and sedentary activity. Rates of unemployment, imprisonment, recipients of income assistance and food stamps, lack of medical insurance, and educational outcomes were also worse as income inequality increased. Income inequality was also associated with mortality trends, and there was a suggestion of an impact of inequality trends on mortality trends.

Conclusions: Variations between states in the inequality of the distribution of income are significantly associated with variations between states in a large number of health outcomes and social indicators and with mortality trends. These differences parallel relative investments in human and social capital. Economic policies that influence income and wealth inequality may have an important impact on the health of countries.

Key messages

  • There was a significant correlation (r=0.62) between the proportion of total household income received by the less well off 50% of households and variation between states in death rates for the United States

  • Income inequality was also significantly related to changes in mortality with smaller declines between 1980-90 in those states with greater income inequality

  • Income inequality was associated with a large number of other health outcomes and with measures related to investments in human and social capital

  • Economic policies that increase income inequality may also have a deleterious effect on population health


  • Funding None.

  • Conflict of interest None.

  • Accepted 9 January 1996
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