The Income–Health Relationship is Bi-Directional
Eventhough all Europeans can on average expect increasingly long and healthy lives, there are still considerable differences between European countries, when it comes to mortality rates or the distribution of health. Economic factors do play an important role, but there is no simple causal relationship. Population Europe asked Pekka Martikainen about main European disparities, and how policies could respond to them.
Question: Where do we currently find the largest health inequalities in Europe: between countries, between men and women, or between rich and poor?
Pekka Martikainen: All of these three dimensions of health inequalities have been really persistent in western European countries over the last 100 years or so. The differences between the rich and poor in the same country but also between countries are easily 5 years and in some cases up to 10 years in life expectancy. That is equivalent to being a lifelong smoker in comparison with a lifelong non-smoker – so these are large and significant mortality differences.
Q: Has there really been no change over the last 100 years?
PM: When you look at differences across countries there has been a dramatic increase in health inequalities between eastern and western Europe in the last 25 years. But if you look at differences between the rich and poor within countries, those inequalities have also increased. As an example, in Finland inequalities in mortality have increased over the past 30 or 40 years.
Q: Is low household income a cause of bad health, or is it actually the other way around?
PM: I would say there is a consensus that the association goes both ways, particularly at working age. If people have to leave the labour market and enter disability retirement because of health problems they receive lower incomes, and the same applies to unemployment to some extent. So the income–health relationship is really bi-directional, and more so than some of the other associations like that between education and health. In fact, people with low incomes tend to be also those least educated, and this might be one of the drivers behind the association of low income and health. It is education, and the skills and knowledge that education brings that are partly behind the income-health association. However, income does provide individuals with significant health promoting resources and when mortality is studied the causal effects of income appear to be particularly strong for mortality from accidental and violent causes.
Q: Income inequalities are on the rise in many European countries. Will this automatically result in increasing inequalities in health?
PM: There does not seem to be an easy and straightforward relationship, in the sense that an increase in income differences would be behind an increase in social health inequalities. In Finland for example, like in many other high-income countries, the restructuring of the welfare state and changes in the economy have been driving increasing income inequalities since the 90s. But social inequalities in mortality had already begun to increase 10 to 15 years before that; they increased particularly rapidly in the 1980s. So there does not seem to be an easy and straightforward link between the two phenomena.
Q: What do you see as the main reason for the increasing social inequalities in health?
PM: This is partly a puzzle and the reasons also likely vary between countries. In Finland increasing social inequalities in mortality are observed at a time when life expectancy has increased in all socioeconomic groups, but more rapidly in the higher strata. Among men, this has been partly because of a more rapid decline in mortality attributable to cardiovascular disease and smoking in the higher groups, and stagnant and even increasing mortality from alcohol-related causes in the lower groups. The role of alcohol has probably increased in recent years due to a change in taxation in 2004 that brought about a significant reduction in alcohol prices. But the trends seem to be largely unaffected by the massive recession in Finland in the early 1990s.
Q: Where could policies intervene: Is it just health policies that matter in this context?
PM: It is certainly not just a question of intervening in the healthcare delivery system, like primary care, hospital care and specialised care or in health related behaviours. There are also other policies that can and will affect social inequalities in health. Some might relate to school reforms, or changes in taxation, housing policies or workplace policies – there is a large spectrum of things that could potentially be influential. However, the evidence base is weak in many fronts and it is unclear which policies could be most effective.
Q: What is your explanation for this?
PM: There is a lack of research in this area, but there are also certain disappointments, or unintended consequences of policies: When new interventions are introduced and they are not specifically targeted to those of lower social standing, the people who benefit the most are normally those who need it the least. Media campaigns on the harmfulness of smoking for example, or the gradual introduction of cardiovascular care that began in the early 80s; although these were effective overall, they may have even increased social differences. Those with higher incomes and better education have better skills to reap the benefits from such initiatives.
A more positive view of this development is that well educated people and those in higher social classes are the forerunners of healthy behavioural change and later other segments of the population might follow.More upstream interventions like the taxation of tobacco and alcohol could provide more benefits for the health of the lower social classes.
Q: Are there any “best practice” countries you can name?
PM: Social inequalities in health are much smaller in some of the southern European countries like Italy. One of the big reasons for that is the much smaller social differences in cardiovascular diseases. That appears to be due to the fact that there are smaller differences in some of the behaviours that define these diseases. Social inequalities in healthy diets and smoking are significantly smaller there than in northern Europe.
But these are more likely to reflect the long-term historical development of the smoking epidemic and long established dietary traditions, rather than a policy or intervention that has been devised to achieve this. For the future it is of course a challenge to reduce smoking among men, but at the same time to not increase social differentials in smoking - something that has happened in many northern European countries.
Pekka Martikainen is Professor at the Population Unit of University of Helsinki. He is involved in cross-national comparisons of health inequalities, and part of an EU-funded project on living arrangements and care in ageing populations.
Interview: Sigrun Matthiesen / Population Europe