Academic journal article Federal Reserve Bank of New York Economic Policy Review

Economic Inequality and Social Differentials in Mortality

Academic journal article Federal Reserve Bank of New York Economic Policy Review

Economic Inequality and Social Differentials in Mortality

Article excerpt

INTRODUCTION

Nationally, the age-adjusted relative risk of death for people at the bottom of the distributions of education, income, and occupational standing is two to three times as high as it is for people at the top of such distributions (Sorlie et al. 1995). The association between socioeconomic position and mortality shows a gradient such that each increment in level of education, occupational status, or income is associated with a reduced risk of death (Adler et al. 1993; Sorlie et al. 1995).

However, at least with respect to income, the relationship to health is not linear: Health improves rapidly as one moves from the lowest levels of income to average or median levels, with increasingly diminishing returns to health from gains to income above that level. In addition, there are marked racial differences in health that are not wholly explained by income (Williams et al. 1997). Racialized stress and high levels of racial and economic segregation also appear deleterious to the health of AfricanAmericans (Williams et al. 1997; Polednak 1996). Recent advances in social epidemiology suggest the importance of aspects of residential areas more broadly as modifiers of the effects of individual socioeconomic characteristics on health (Davey Smith et al. 1998; Geronimus et al. 1996). Thus, the health of equally low-income individuals varies across locales.

Taken together, the above findings suggest that general patterns of the relationship between economic inequality and health may mask extremes for those isolated by persistent poverty and segregation or those exposed to a full range of hazards in their social and physical environment. Furthermore, over the last twenty-five years, the absolute and relative economic circumstances of those in the lower economic strata in the United States have generally stagnated and deteriorated rather than improved (Karoly 1993). Thus, the relative health of those in poverty-lowincome African-Americans in particular-may have worsened in recent decades.

In this paper, I draw on analyses that aimed to determine whether impoverished U.S. locales varied by race or urban/rural location in their rates and causes of excess mortality, and whether mortality gaps between impoverished and other U.S. populations widened over the decade from 1980 to 1990. The focus on urban versus rural areas reflects the fact that in the first half of the Twentieth Century, rural Americans enjoyed longer life expectancies than urban dwellers (Fox et al. 1970). Evidence based on more recent cohorts is mixed and suggests little, if any, mortality advantage for rural residents compared with urban dwellers in young and middle adulthood (Kitagawa and Hauser 1973; Miller et al. 1987; Elo and Preston 1996). However, with some resurgence of infectious disease entities as important causes of death in urban areas and general perceptions of central cities as having become more dangerous and unhealthy in the most recent decades (Wilson 1987; Brown 1993), the fortunes of rural dwellers-even those in poverty-may have again increased relative to their urban counterparts. In addition, recent comparisons of rural and urban dwellers do not focus on those in poverty. Important interactions between race, poverty, and rural/ urban residence may exist, but may be unobserved in analyses of national data sets where only the main effects of residence are estimated as a product of averaging across all rural versus urban dwellers.

In the analyses, we also examined what causes of death were the primary contributors to excess mortality among the poor and whether these varied across locales or time periods. We focused, in particular, on how the HIV/ AIDS epidemic and homicide may have influenced changes in mortality over the decade.

To address these questions, we limited our analyses to mortality among young and middle-aged adults. Social differentials in morbidity and mortality are pronounced at these ages (Geronimus 1992; House et al. …

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