Inequality and Health UCLA Fielding School of Frederick J. - - PowerPoint PPT Presentation

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Inequality and Health UCLA Fielding School of Frederick J. - - PowerPoint PPT Presentation

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Inequality and Health UCLA Fielding School of Frederick J. Zimmerman Public Health Policy Making is like a symphony "Even in Constantinople or Grand Cairo where plague and cholera are decimating the population, it is doubtful

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Inequality and Health

Frederick J. Zimmerman

UCLA Fielding School of Public Health

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Policy‐Making is like a symphony

  • "Even in Constantinople or Grand Cairo where plague and cholera are

decimating the population, it is doubtful whether [publicly organized sewerage] would be desirable." — signed, "A. Ratepayer.”

  • "Suffering and evil are nature’s admonitions; they cannot be got rid of;

and the impatient efforts of benevolence to banish them from the world by legislation, before benevolence has learned their object and their end, have always been more productive of evil than good.” — The Economist Magazine, 1848, on the advisability of a public sewer system

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Policy‐Making is like a symphony

  • In a democracy, nobody wants to be a jerk.
  • Ethics is like the bass section of the symphony
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1: Inequality is a social phenomenon. + 2: Inequality has big effects

  • n human health.

= 3: We can improve health by changing inequality.

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What has happened to Inequality?

And why?

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50 100 50% 70% 30% Two Decades of Global Income Growth Percentile of Global Income Distribution

Percent Real Income Growth

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50 100 50% 70% 30% Two Decades of Global Income Growth Percentile of Global Income Distribution

China’s Middle Class US Lower Middle Class

Percent Real Income Growth

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50 100 50% 70% 30% Two Decades of Global Income Growth Percentile of Global Income Distribution

This is economic

Percent Real Income Growth

This is political

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Income Inequality — outcome or input?

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10 1960 1960 1970 1980 1990 2000 20 30 40 50 60

Cuba United States United States Canada Canada Germany Germany France France

Evolution of Gini Over Time

(post Tax and Transfer)

Source: OECD, Dawson (2014), Latin America Since Independence

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The New York Times

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The New York Times

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DiNardo and Tobias, Journal of Economic Perspectives, 2001.

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Income Inequality is a policy variable.

So what is the right level?

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Productive Inequality Destructive Inequality

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Health as a Measure of Well‐Being

Part of Gross National Well‐Being Correlates with Happiness Both Instrumental and Intrinsic Easily Measured

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Davies and Sherriff. (2012). The gradient evaluation framework (GEF)

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Finding: The range

  • f inequality

within the OECD corresponds to a rough doubling of health risks. That’s about 1.5 years of lost life expectancy.

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What about Inequality causes Poor Health?

And how?

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Inequality directly reduces average health

Wagstaff & van Doorslaer (2000) ARPH.

hi = fI(y i) f′ >0, f′′<0 => hP = fP(y P,y P)

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Inequality directly reduces individual health

Wagstaff & van Doorslaer (2000) ARPH.

hi = fI(y i, Ip) => hP = fP(y P,y P)

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Income Inequality is a symptom of a set of rules that works for the few and not for the many.

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I. Control Over Resources

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Artibonite Dam Artibonite Dam Unprotected livelihood Unprotected livelihood Unprotected Sex Unprotected Sex HIV/AIDS HIV/AIDS Acéphie dies of dehydration brought on by diarrhea Acéphie dies of dehydration brought on by diarrhea

Medical Connection Public Health Connection Economic Connection Structural Connection

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$29,00 Annual Pay Gap

Male MDs Female MDs

50% Due to Specialties

Compensation for New Physicians

LoSasso et al. 2011 Health Aff

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This Committee Controls Medical Compensation

Specialists Primary Care Technical

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Price of Generic Drugs in US relative to OECD average, adjusting for GDP/capita:

1:1

Price of Patent Drugs in US relative to OECD average, adjusting for GDP/capita:

2:1

Laugesen & Glied (2011). Health Affairs. Schweitzer & Comanor (2011) Health Affairs.

Compensation for Primary Care Physicians, net of practice & training costs in US relative to OECD average, adjusting for GDP/capita:

1:1

Compensation for Specialty Physicians, net of practice & training costs in US relative to OECD average, adjusting for GDP/capita:

2:1

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$750

Billion/year

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Medical spending in the US crowds out

  • ther expenditures on

social goods including primary, secondary and higher education, economic development and maintenance of critical infrastructure.

  • V. Fuchs and A. Milstein (2011) New England Journal of Medicine
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Bradley, EH et al BMJ Qual Saf 2011;20:826e831.

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McCullough, Zimmerman, Fielding, Teutsch. (2012). AJPM

$750

Bn/year

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Excessive Inequality in Control Over Resources Impairs Health

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II. Control Over Discourse

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Stephen Moore, Heritage Foundation

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Moore:

“Stampede of rising healthcare costs”

Jonathan Chait, Daily Intelligencer, Feb. 2015

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Stephen Moore, Heritage Foundation

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4 million people not covered

=

7,000 — 17,000 Deaths Annually

Dickman et al, Health Affairs Blog 1/30/14

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Thousands Protest Global Warming

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Scott Clement, Washington Post blog, 4/22/13

Guardian: $120 million

  • ver 8 years

to deny climate change Guardian: 300,000 deaths per year due to climate change

Goldenberg, Guardian UK, 2/14/13; Vidal, Guardian UK, 5/29/09

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Excessive Inequality in Control Over Discourse Impairs Health

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III. Control Over Preferences

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Food Marketing and Diet

  • Promotion
  • Price
  • Place
  • Product
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Yes, it’s a growing phenomenon

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Advertising Study

Car Ad Food Ad

Reference 1.28 (0.007)

Results

Rate Ratio of Unhealthy Foods Taken (p-value)

Zimmerman & Shimoga (2014). BMC public health

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Advertising Study

Car Ad Food Ad

Reference 65 (0.020)

Results

Calories Taken (p-value)

Zimmerman & Shimoga (2014). BMC public health

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Obesity Trends over 50 years

Ljungvall & Zimmerman (2012). Social Science & Medicine

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Excessive Inequality in Control Over Preferences Impairs Health

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Control Over Resources Control Over Discourse Control Over Preferences

Money flows through the body toward power.

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Income Inequality is a symptom of a set of rules that works for the few and not for the many.

Policy can both reduce and buffer the harm.

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1: Inequality is a social phenomenon. + 2: Inequality has big effects

  • n human health.

= 3: We can improve health by changing inequality.

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