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

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 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

Policy ‐ Making is like a symphony • In a democracy, nobody wants to be a jerk. • Ethics is like the bass section of the symphony

1: Inequality is a social phenomenon. + 2: Inequality has big effects on human health. = 3: We can improve health by changing inequality.

What has happened to Inequality? And why?

Two Decades of Global Income Growth Percent Real Income Growth 70% 50% 30% Percentile of Global Income Distribution 0 50 100

Two Decades of Global Income Growth China’s Middle Class Percent Real Income Growth 70% 50% US Lower 30% Middle Class Percentile of Global Income Distribution 0 50 100

Two Decades of Global Income Growth Percent Real Income Growth This is political 70% 50% 30% This is economic Percentile of Global Income Distribution 0 50 100

Income Inequality — outcome or input?

Evolution of Gini Over Time (post Tax and Transfer) 60 Source: OECD, Dawson (2014), Latin America Since Independence 50 France Cuba United States 40 United States Canada France Germany 30 Canada Germany 20 10 1960 1960 1970 1980 1990 2000

The New York Times

The New York Times

DiNardo and Tobias, Journal of Economic Perspectives , 2001.

Income Inequality is a policy variable. So what is the right level?

Productive Inequality Destructive Inequality

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

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

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

What about Inequality causes Poor Health? And how?

Inequality directly reduces average health Wagstaff & van Doorslaer (2000) ARPH . h i = f I ( y i ) f ′ >0, f ′′ <0 => h P = f P ( y P ,y P )

Inequality directly reduces individual Wagstaff & van Doorslaer (2000) ARPH . health h i = f I ( y i, I p ) => h P = f P ( y P ,y P )

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

I. Control Over Resources

Structural Artibonite Dam Artibonite Dam Connection Unprotected livelihood Unprotected livelihood Economic Connection Unprotected Sex Unprotected Sex Public Health Connection HIV/AIDS HIV/AIDS Medical Connection Acéphie dies of dehydration brought on by Acéphie dies of dehydration brought on by diarrhea diarrhea

Compensation for New Physicians 50% $29,00 Due to Annual Specialties Pay Gap LoSasso et al. 2011 Health Aff Male MDs Female MDs

Specialists Primary Care This Committee Controls Technical Medical Compensation

Compensation for Primary Care Price of Generic Drugs in US Physicians, net of practice & training relative to OECD average, costs in US relative to OECD average, adjusting for GDP/capita: Schweitzer & Comanor (2011) Health Affairs . adjusting for GDP/capita: Laugesen & Glied (2011). Health Affairs . 1:1 1:1 Compensation for Specialty Physicians, Price of Patent Drugs in US relative net of practice & training costs in US to OECD average, adjusting for relative to OECD average, adjusting for GDP/capita: GDP/capita: 2:1 2:1

$750 Billion/year

V. Fuchs and A. Milstein (2011) New England Journal of Medicine Medical spending in the US crowds out other expenditures on social goods including primary, secondary and higher education, economic development and maintenance of critical infrastructure.

Bradley, EH et al BMJ Qual Saf 2011;20:826e831.

Bn/year $750 McCullough, Zimmerman, Fielding, Teutsch. (2012). AJPM

Excessive Inequality in Control Over Resources Impairs Health

II. Control Over Discourse

Stephen Moore, Heritage Foundation

Jonathan Chait, Daily Intelligencer , Feb. 2015 “Stampede of rising healthcare costs” Moore:

Stephen Moore, Heritage Foundation

4 million people not covered = Dickman et al, Health Affairs Blog 1/30/14 7,000 — 17,000 Deaths Annually

Thousands Protest Global Warming

Guardian : $120 million Goldenberg, Guardian UK , 2/14/13; Vidal, Guardian UK , 5/29/09 over 8 years Scott Clement, Washington Post blog, 4/22/13 to deny climate change Guardian : 300,000 deaths per year due to climate change

Excessive Inequality in Control Over Discourse Impairs Health

III. Control Over Preferences

Food Marketing and Diet • Promotion • Price • Place • Product

Yes, it’s a growing phenomenon

Advertising Study Results Zimmerman & Shimoga (2014). BMC public health Rate Ratio of Unhealthy Foods Taken (p-value) Car Ad Reference Food Ad 1.28 (0.007)

Advertising Study Results Zimmerman & Shimoga (2014). BMC public health Calories Taken (p-value) Car Ad Reference Food Ad 65 (0.020)

Obesity Trends over 50 years Ljungvall & Zimmerman (2012). Social Science & Medicine

Excessive Inequality in Control Over Preferences Impairs Health

Control Over Resources Control Over Discourse Control Over Preferences Money flows through the body toward power.

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.

1: Inequality is a social phenomenon. + 2: Inequality has big effects on human health. = 3: We can improve health by changing inequality.