Abstract
BackgroundDebates exist as to whether, as overall population health improves, the absolute and relative magnitude of income- and race/ethnicity-related health disparities necessarily increase—or derease. We accordingly decided to test the hypothesis that health inequities widen—or shrink—in a context of declining mortality rates, by examining annual US mortality data over a 42 year period.Methods and FindingsUsing US county mortality data from 1960–2002 and county median family income data from the 1960–2000 decennial censuses, we analyzed the rates of premature mortality (deaths among persons under age 65) and infant death (deaths among persons under age 1) by quintiles of county median family income weighted by county population size. Between 1960 and 2002, as US premature mortality and infant death rates declined in all county income quintiles, socioeconomic and racial/ethnic inequities in premature mortality and infant death (both relative and absolute) shrank between 1966 and 1980, especially for US populations of color; thereafter, the relative health inequities widened and the absolute differences barely changed in magnitude. Had all persons experienced the same yearly age-specific premature mortality rates as the white population living in the highest income quintile, between 1960 and 2002, 14% of the white premature deaths and 30% of the premature deaths among populations of color would not have occurred.ConclusionsThe observed trends refute arguments that health inequities inevitably widen—or shrink—as population health improves. Instead, the magnitude of health inequalities can fall or rise; it is our job to understand why.
Highlights
Between 1960 and 2002, as US premature mortality and infant death rates declined in all county income quintiles, socioeconomic and racial/ethnic inequities in premature mortality and infant death shrank between 1966 and 1980, especially for US populations of color; thereafter, the relative health inequities widened and the absolute differences barely changed in magnitude
One new debate appearing in the public health literature is: as population health improves, do relative and absolute social inequalities in health widen or shrink [1,2,3,4,5,6,7]? An increasingly common view, typically drawing on recent data from the United States, is that relative, if not absolute, health disparities are bound to increase as mortality rates decline, largely because groups with the most education and most resources are most able to take advantage of new knowledge and technology [1,2,3]
The question as to choice of relative or absolute measures arises because as rates for any given health outcome decline, it is conceivable that faster-falling rates in one group compared to another could lead to an increase in the relative risk for that outcome, albeit reflecting a smaller absolute difference compared to when rates in both groups were higher
Summary
One new debate appearing in the public health literature is: as population health improves, do relative and absolute social inequalities in health widen or shrink [1,2,3,4,5,6,7]? An increasingly common view, typically drawing on recent data from the United States, is that relative, if not absolute, health disparities are bound to increase as mortality rates decline, largely because groups with the most education and most resources are most able to take advantage of new knowledge and technology [1,2,3]. The relationship between population health and the magnitude of health inequities is more variable, it would imply that resources are needed to tackle both concerns Reflecting this tension between needing to address both the level of overall population health and the magnitude of health inequities are the twin objectives of Healthy People 2010, which are to both ‘‘increase years and quality of healthy life’’ and ‘‘eliminate health disparities’’ [10]. Debates exist as to whether, as overall population health improves, the absolute and relative magnitude of income- and race/ethnicity-related health disparities necessarily increase—or derease. Within populations are often persistent differences (usually called ‘‘disparities’’ or ‘‘inequities’’) in the health of different subgroups—between women and men, different income groups, and people of different races/ethnicities, for example Researchers study these differences so that policy makers and the broader public can be informed about what to do to intervene. If one group’s average income level increases from $1,000 to $10,000 and another group’s from $2,000 to $20,000, the relative inequality between the groups stays the same (i.e., the ratio of incomes between the two groups is still 2) but the absolute difference between the two groups has increased from $1,000 to $10,000
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