Income and Health

Professor M. Omar Rahman, AB,MPh,DSc

(Harvard University), MD (Northwestern University)
Professor of Public Health and Demography
Road Map
● Data on Health and income within and across countries
● Health Spending and Health Status
● Broader Social Dets of Health-Woolf et al-Urban Institute and VCU
● Income and Health-Marmot
● Absolute vs Relative Deprivation
Life Expectancy vs GDP per capita
Life Expectancy GDP relationship

❑ Life Expectancy increases with per-capita GDP

❑ Linear initially but then flattens out
❑ For the same per capita GDP some countries do better or worse
❑
Bangladesh, Vietnam, Cuba over performer
❑
Nigeria, Russia under performer
Health Status and Health Spending
● Health improves with increased health spending initially but the flattens Out
● Initially big changes as public health infrastructure upgraded ( water, sanitation,
vaccination, basic/essential health care access; adequate nutrition)
● Later most health problems are NCDs and prevention more important than
treatment.
○ depends on lifestyle modification- health services not particularly beneficial.
● Lot of wasteful spending on expensive technology
https://www.patientnavigatortraining.org/chronic_disease/
module1/3_healthdisparityexamples2.htm
Woolf et al. How are income and wealth linked to health and longevity ?

! Less able to afford Health Care Services and Health Insurance Rich can
! afford healthy lifestyles
! Nutritious food vs Fast Food
! Afford Gym memberships; More free time for exercise
! Help with smoking cessation and other addictions
! Rich benefit from place effects
! Ellen and Turner (1997) identified six ways in which neighborhood conditions
can influence the health of individuals: (1) quality of local services, (2)
socialization, (3) peer influences, (4) social networks, (5) exposure to crime
and violence, and (6) physical distance and isolation.
Woolf -et al continued-2: Why the poor
have worse health
!
Jobs and Health Care
!
Family Structure
!
Education
!
Access to healthy food
!
Adverse childhood events—long term influence
!
Culture, Health Beliefs
!
Built environment
!
Advertising
!
Housing
!
Transportation
!
School Systems
!
Environmental Pollution
!
Disinvestment in poor neighborhoods
Marmot: The influence of Income on Health:

➢ Income related to Health in 3 ways

! Levels of individual income-can afford services
! Better infrastructure/services
! (sanitation, pollution control, vaccination, health personnel, hospitals)
! Income inequality-
! unequal access to infrastructure; services
! Unequal social capital
Marmot: How national income affects Health Status
● Higher per capita GDP means more health and other infrastructure available:
○ Hospitals, Clinics, Doctors, Nurses, Health Technology (Medicines, surgery)
○ Roads, water, sanitation, cleaner air
● Higher individual wealth means that more people can access services from
those that are available
● Inequality is another dimension separate from per capita GDP
○ Two countries with the same per capita GDP will vary in health status depending on which
country is more equal with regard to distribution of access to services
○ Social Capital under recognized source of health improvement
Marmot: How individual income affects health?
● Not Having enough money to afford available health and other services
● Having enough money but spending it on the wrong things-maldistribution of
spending
● Having enough money but relatively worse off than poor--Relative Deprivation
How does Income Affect Health
Causally- Marmot
! Improvement of material conditions necessary for survival—clean water, proper
sanitation, adequate nutrition, physical environment, healthcare
! Factors other than individual income matter:
! Individuals no matter how rich need Community investments in Public Health
Infrastructure to improve health
!
Threshold Effect. Over threshold no difference in health with inc income—flattening out
of per capita GDP LE curve. However there still may be differences based on social
capital differences
! Improvement in social capital:
! Participation
! Control
Marmot

! After a certain threshold of material resources other factors matter

! Social capital
! Peer groups
! Education
! Neighborhood differences in access to grocery stores, nutritious food, exercise
opportunities
!
STRESS
! Black White Differences in Mortality (not ind income related)
! HIV
! Homicide
! Cardiovascular Deaths
Redrawing the Preston Curve: onlinelibrary.wiley.com
Marmot: INEQUALITY rather than Absolute
POVERTY- matters for health
! Whitehall study: SOCIAL POSITION or RELATIVE DEPRIVATION Matters
! Twofold difference in Mortality among Civil Servants-mostly middle class:
!
No threshold effect-continuous gradient of mortality
!
Direct impacts of Income:
! Comparisons across Countries: LE and per capita GDP: 2 POINTS-
!
flattening out after $5,000 and
!
secular shift at all PC income levels in 20th Century
!
Something other than income made a difference in improving health status
!
Policies of support and sharing-Amartya Sen (UK 1910-1920; 1940-1950). In developing countries—spending on Public Goods—
Education, Public Health-
!

Unlike across countries where per capita GDP and LE relationship flattens out after a threshold, Within
! Countries more robust relationship but gradient is highest for the really poor. The Rich do better than the
middle class who do much better than the poor.
Implications: Modest redistribution from rich to poor helps poor a lot without making much of a difference to
the rich
Lecture Objectives
● Understanding of improvements of health with increasing income within
countries and across countries
○ Under vs Over Performance
● Understanding of threshold effects in the income Health relationship and its
implication for income redistribution policies
● Understanding the importance of community investments/social support in
health (Environmental Conditions; Vaccinations,Transport infrastructure)
● Understanding the importance of social capital on health.
● Understanding the difference between Absolute and Relative
Income/Deprivation (INEQUALITY) and its relationship with health
Bibliography
1. Woolf et al. How Are Income and Wealth Linked to Health and Longevity?
a. https://www.urban.org/sites/default/files/publication/49116/2000178-How-are-Income-and-Wealt
h-Linked-to-Health-and-Longevity.pdf
b. Ellen IG, Turner MA. Does neighborhood matter? Assessing recent evidence. Housing Policy
Debate 1997;8(4):833-865.
2. Michael Marmot. The Influence Of Income On Health: Views Of An
Epidemiologist. Does money really matter? Or is it a marker for something
else?
a. https://www.healthaffairs.org/doi/full/10.1377/hlthaff.21.2.31