Medical Sociology Exam 3

Life Expectancy by Neighborhood Income

- As your neighborhood income goes up, so does your life expectancy - shown by Marmot curves - Marmot was an English epidemiologist

what about relative status?

- Some have argued that standing in the social order affects health directly - Some evidence links position on the ladder to self-rated health - Relative status - not based on material status - related to where you sit compared to other people - Maybe the comfort of "being at the top" helps a person to live a little longer - maybe it's not what high SES buys you that helps you - maybe it's what high SES feels like - We need to think about status in the context of a perceived hierarchy - How do other people see you? The status is different from the amount of wealth you have or your education - Status is the ladder - where do you stand in relation to other people in the United States? - People tend to place themselves one rung above the midpoint - Most of them consider themselves middle class - Some people might think that once you account for SES then this ladder status shouldn't matter, but there actually is a correlation: ex. Lower blood pressure, better lipid profile, etc

different contributions at different times

- Specific health innovations became more important as time passed by - Public health interventions like new sewer systems definitely help, but they work on a broad scheme - Specific health innovations attacked new problems after public health and personal health practices spread - See Lecture 10, Slide 28 for charts on developed countries vs developing countries

survival among Academy Award winners

- These people have good SES - Predicting survival mortality based on whether or not you are an Academy Award winner - Winners do better than those who were nominated - Limiting comparison to actors - Even if you compare to nominees, there is a 20 percent difference - Boosting longevity by ~20 percent - That's like doing well in terms of exercise

importance of preventability

Fundamental causes should be more powerful in preventing deaths from preventable disease - For both high and low preventability diseases, SES is correlated with mortality - Knowing about a disease helps to prevent and combat it

newer evidence for the association

Gap between life expectancies of high education and low education people is growing Why is education so powerful? Why is its influence growing over time?

contextual effects

Pay attention to income of the state a person grew up in as well as income inequality Places that have more income inequality have higher mortality Utah has good mortality rates - Mormons are healthy - no drinking, that kind of thing

age patterns between 1840 and 1900

Significant declines in mortality happened for those between the ages of 0 and 4 While older people died more frequently in the given time period, infant mortality and juvenile mortality were decreasing Pay attention to infectious disease in general but also to the reduction of infectious disease among young people

mortality trends in the 20th century

Slowing of mortality declines in the 1980s Men improved faster than women, in large part because of smoking After 1960, men's life expectancy improved quickly because smoking rates dropped Mortality improvements have slowed

is it our behavior?

- Behaviors are the leading contributor to the global burden of disease - Especially so in high income countries - Consider actual causes of death, where about 50% is behavioral - About half of American deaths are related to behavior - Extrapolate this data across other countries - Behaviors are the leading contributor to the global burden of disease - health care systems cannot account for a lot of what happens to people US smokes less than a lot of other countries US takes unnecessary risks though - US isn't doing particularly well seatbelt-wise - France may smoke more, but they wear their seatbelts when in the front of the car more often - US has low percentages for motorcyclists wearing helmets - motorcycles are not as common in the US though - US has a relatively high rate for road traffic deaths due to alcohol - US may not smoke as much, but they take other risks that can very possibly lead to death US gun ownership - The percentage of US households with firearms seems to be going down - However, houses with firearms seem to be accumulating more/multiple firearms

childhood origins of the gradient

- Children do not ordinarily contribute to income of household - Professor used to work on a farm at the age of 12 - "That sucked. This job is so much better than that. I will never forget that." - Lower family income - worse health as a child - Relationship between income and health gets stronger as a person gets older - Kids living in poverty are more likely to develop certain conditions, and conditions are also more consequential for them since they often don't have the resources to address their problems

Trends Among Middle-Age Whites

- Decades of progress reversed between 1999 and 2013 among white men and women - Paralleled by rise in morbidity - Evidence of growing distress - In all peer countries, mortality continued to decline - For US Hispanics, they continued to go down too - Hispanic immigrants tend to be healthier - Salmon bias - lots of data may be lost to biostatistics - Many of their deaths are probably not recorded, but even if you adjust for that, the data suggests that US Hispanics have better mortality rates than US whites - Rise in morbidity: diseases in distress - Part of this has to do with self-harm and suicide, also things like cirrhosis from drug or alcohol use, "accidental" suicides from drug overdose - all of these are categorized as diseases in distress Table 2 - Percent of those reporting excellent/very good physical health went down, fair/poor (as well as many conditions like neck pain, facial pain, etc) went up - Depression has been going up over time - Obesity going up over time - A lot of this is related to mental health, but other things are contributing as well Figure 2 Lung cancer decreasing - Continuation of declines in smoking - There are cohorts of men entering that age group that just haven't smoked Chronic liver disease - Seen as a proxy for drinking - Poisoning and suicides as well as drinking diseases of distress Table 1 - White folks with college education are following the decrease in mortality, but not white folks with less education

reverse causality

- Exploiting health shocks: new health problems - Poor health is costly - Initial income losses persist over time - Follow people over time - watch their SES and health - see how both change - does one change first and a change in the other follows? - The out of pocket expenses for a major health shock are costly - significant for (up to 4?) years. Minor health shocks are less costly - Health shocks push people out of the labor force - 26.8 percent drop in work probability after a major health shock, 10.7 percent drop in work probability after a minor health shock - Health shocks lead to income losses that are often not temporary - they persist over time - To go with reverse causality, think about the costs associated with health problems

the complexity of health behavior

- Health behaviors do not cluster - Very little of the variation in health behavior is explained by education, income, or even health beliefs (no more than 14%) - Dominance of situational factors - If education predicts certain health behaviors, maybe those health behaviors are a package deal - a person who eats right might also be more inclined to exercise regularly - There is little correlation between certain health behaviors though - as a set, health behaviors are not very strong ways of explaining health differences based on SES

Importance of Contingencies

- Higher stress for lower-ranking but also for those who are high-ranking - High ranking have to fight to maintain their position - sometimes your position has to be defended (hmmm GPA much) - when society is unstable, high ranking experience stress - apply to humans - if you can avoid those irritations (ex. avoiding spaces where people brag about GPAs) your stress will go down

why does life keep getting longer?

- Life expectancy continues to go up - What forces are propelling the increase? - What will happen in the future? - Life expectancy among women is higher than life expectancy among men - Notice that there are spikes downward in life expectancy - ex. 1918 - Spanish flu - ex. 1945ish - WWII decreases life expectancy for men - Notice that lines are converging as they approach modern times - life expectancies were more different among countries in the past - 1960-2000 - not much fluctuation - trendlines are very straight - treatments are being propagated - treatments in one country are being communicated to other countries - 1850-1900 - viruses and infectious disease are more lethal at this time - if viruses and infectious diseases cause a lot of deaths, that explains why there are spikes in life expectancy - viruses and infectious diseases are not always common in populations - Nowadays, chronic diseases like heart disease and cancer cause a lot of death

record life expectancy

- Record female life expectancy has been going up in a more or less linear fashion - People's guesses at the finite limits of life expectancy have time and again been proven wrong pretty quickly - Life expectancy can be forecast by considering the gap between national performance and the best practice level - The U.S. disadvantage varied from a decade in 1900 to less than a year in 1950 and about 5 years in 2000 - There is no evidence that record human life expectancy is flattening out - we don't seem to be near the finite limit - might take another century to figure out

adult health

- SES experienced as a child has a lasting impact on health as an adult - SES of parents can be used to predict health of a person when they are 21ish and when they are about 42ish - There is a great deal of continuity between the SES of parents and their offspring - Parents' SES resources have a significant bearing on their kids' health - SES has a causal relationship with health - and the effect seems to start at an early age - during childhood - Low birth weight children tend to be less healthy and have lower income as adults

urban-rural differences

- Urban-rural differences in life expectancy can be up to ten years - As income improves, mortality improvements are offset by movement to urban areas - Only with purposeful interventions can this be stopped People living in urban areas live shorter lives than those living in rural areas Urban areas - more exposure to pathogens, improperly disposed waste products, unsanitary conditions Economic growth leads to movement to urban areas Purposeful interventions - ex. Paris authorities realize they need to fix the disposal of human waste - "If it smells bad, it probably isn't great for humans"

associations have grown

- based on data from Pappas, Queen, Hadden, & Fisher (1993) - Widening differentials, especially for men, between 1960 and 1986 - Mortality has improved over time. However, mortality has improved faster for high education people than for low education people - greater gap is developing in spite of overall improvements

Where do we lose years?

- unintentional injuries especially - unintentional injury rate is more than double the mean of other countries

two lingering issues

1. Age-specific mortality is increasing again - before, it was decreasing, but now, there's something going on in the US that is making it increase 2. The US remains well behind other comparable countries in terms of health and longevity

mortality and population trends in Sweden

1710 to 1950 - population of Sweden is growing - as mortality improves, population grows Crisis mortality - deaths from crises like pandemics Less children dying means birth rate decreases Aging population - life expectancy goes up - birth rate goes down - these two points cause an aging population - Crisis mortality is diminished (as indicated by declining volatility) - Population grows exponentially Other countries move at their own pace ex. Japan - changes are subsequent to WWII - Japan makes concerted effort to improve population health to move forward as a country - also receives help from other countries

Shifting of Causes of Death in a Gradual and Fast Transition

1860 - dominant cause of death is infectious disease By 1960, dominant cause of disease is heart disease rather than infectious disease - also, death by cancer is starting to grow Cancer rate rising - at certain ages, risk of cancer increases - also, habits like smoking increase the risk of cancer

what about job characteristics?

A well-balanced job - Demand/control - Effort/reward Control at work helps to explain some of the gradient among Whitehall workers, but not all. - Maybe its not status, but rather the quality of your job - Highest paying jobs are likely to have good characteristics - If you want to maximize your health: If you have successes, you are responsible for them, and when bad things happen, it's your boss's fault - Good jobs might tell you that you have control over things, you can apply this to other things in your life - Why do you control for height? Tall people tend to do better in life; with better income, better childhoods - With Whitehall what's most important is how much control you have over your job: Your job matters

poor health and employment

About 60 to 70 percent of married men below the age of 65ish who are not working report poorer health - case of reverse causality - they probably are not working even though they have wage-earning ages because they have poor health Poor health has consequences on income and work probability

Overweight Among the Young

Americans are heavier than people in other countries Overweight rates in the US are significantly higher than in other countries BMI: US people are heavier starting early on in life, and that persists later into life We eat more: - Americans don't exercise as much as other countries? That doesn't seem to be true - Americans live a more sedentary lifestyle? More driving rather than walking? - The above are speculations - Think about calorie consumption - The US relative to most of the globe gets more calories - However, other countries get a lot of calories too - ex. Italy - but Italians are still healthier than people in the US - Maybe their meals have different nutrition - maybe Italians burn more calories

Disability-Free Life Expectancy

As you successfully live to a certain age, your life expectancy continues to go up. Ex. 1985: If you live to 20, you will probably live to at 73ish. If you live to 65, you will probably live to 80ish. Improvements in disability free life expectancy seem to be smaller than improvements in general life expectancy Work is being done to push back disability in life

the US is not behind at all ages

At age 65, the US rockets to the top rank depends a lot on the age that we're talking about you should spend most of your time in Japan, then move to US at age 65 if you want to be healthy What could be behind this? 1. Once you get on Medicare, situation improves - Limited access to health care for younger ages is what leaves us behind 2. The US might focus a disproportionate amount of its medical care on older people - this interpretation would not be related to limited access - it's a problem with the behavior of the health care system itself - its access and quality of care - maybe the failure of success is emphasized in the US - maybe we're treating older people more aggressively - US works hard to extend the lives of those with cancer, for example

disease prevalence

But some conditions have become more prevalent There has been a greater decline in cardiovascular mortality than in the incidence of cardiovascular disease, which results in more persons with heart disease specifics: - Prevalence of heart disease went up for both men and women - Prevalence of hypertension went up for men but down for women - Prevalence of stroke went up - also a higher chance to survive a stroke - Prevalence of cancer went up in men - one thing to consider is that we are detecting more cancers compared to the past - Prevalence of diabetes went up - Prevalence of arthritis went up - arthritis is particularly significant to women - Prevalence of osteoporosis went up for women - doubled

is it health behavior?

Can the correlation between education and mortality be related back to health behavior? Do educated people just have better health behaviors? Is education related to alcohol consumption, smoking, BMI, and physical activity for example? Well-educated people on average tend to be less likely to smoke, drink only moderately, and have a normal weight. Well-educated folks also tend to exercise more than less educated people health behavior doesn't explain mortality differences by income: about 9 - 14% Note the effects of race, gender, residence between Models 1 and 2 Health behaviors only explain a fraction of the differences Health behaviors are actually quite complicated, and they change over time

What About Macroeconomic Conditions?

Can the socioeconomic conditions of a society affect individuals net of their individual socioeconomic position? How do you identify effects of society-level factors? When does SES explain things for countries? When does it fail?

death rates

Charts are age adjusted because people in other countries like Italy and Japan are older We do better in terms of digestive diseases, malignant neoplasms, etc, but these don't contribute to a lot of deaths; but we are doing much worse in most diseases - Unintentional and intentional injuries especially Suicides more prevalent in the US Japan has higher communicable diseases than US - they are in the stage in which they are dying from old age and infection - they are a high achieving country with different causes of death

importance of institutions and knowledge

Controlling disease requires new institutions - Public health infrastructure - aims to promote good health - Knowledgeable public who engage in consistent practices - ex. they know to wash their hands for example - Shifting focus from external causes (e.g., God) to internal ones (e.g., how I prepare food) ex. 1800s - health is matter of fate - that's God's will - it's out of your hands - to promote health, this mindset must be dismissed - show that tangible things like food prep processes matter In absence of this, everyone suffers

interactions with age

Cumulative advantage: - growing significance of risk factors Age-as-leveler - declining significance of risk factors Disadvantaged spend more years with disability - Maybe the relationship between SES and health starts pretty small at age 25 and then gets bigger with age - then at some point biology takes over and everyone's health starts to plummet, at like age 80 - Idea: pit SES against biology and the aging process - how much does SES really matter? - Age is the great equalizer - as people get older, decline is inevitable - Functional limitation - ex. Being able to walk up stairs - Very few 25-year-olds have functional limitations - as you get older, functional limitations start to pop up - like around the age of 45 - At younger ages, education does not have that much of an impact - as people get older, though, education becomes more significant - well-educated people have less functional limitations than other people at older ages - Around 75, the difference starts shrinking again (age is a leveler), but it does not shrink to the smallness of the gap at the age of 25

caveats

Deviations in pace - Japan went through the stages quickly - Some developing countries have yet to fully move through them Deviations from linear and unidirectional change - Counter transitions: age-specific mortality rates rise, rather than fall - Age-specific transitions: the epidemiological transition occurs at all ages, but is more pronounced among the young Some reverse transitions - cases in which life expectancy actually drops to some extent

what about detection?

Education may shape the detection of conditions, as well as successful management One health behavior - visiting a doctor Often people visit a doctor when they are sick - therefore, maybe more educated, healthier people are less likely to visit a doctor Survey asks people to report things about their health - and then they use their tools to check what people report - figure out how people judge their own health, how much people actually know about how they are doing - ex. Maybe find undiagnosed diabetes Over time, the percent of men with undiagnosed diabetes declined. The gap between people of different levels of education also increased. Less educated people became significantly more likely to have undiagnosed diabetes More highly educated people know more about their health For checking the indicators for diabetes, well-educated people are doing better than less educated people. Well-educated people get the disease diagnosed and are also in a better position to manage the disease once it is diagnosed.

four transitions

External injuries to infectious disease - Larger populations, higher density, longer periods in the same location Infectious to degenerative disease - Reductions in crisis mortality (e.g., 1918 pandemic) - Gradual decline in infectious disease - Population ages Cardiovascular to cancer - Accelerated in the 1970s - Factors: better preservation and less salt, anti-hypertensives, better detection Cancer to ?? - In the 1990s some countries witnessed a decline in total cancer mortality Timeline 1. Humans are killed by animals and kill each other - external injuries 2. When farming happens and people settle down, there's less external conflict, but people living near each other increases threat of infectious disease 3. infectious diseases have spikes in prevalence sometimes - pandemics - when people learn how to deal with this, aging presents its own issues 4. Cardiovascular disease is especially prevalent among older people 5. Correlation between cancer and age is high 6. As cancer mortality rates fall, we don't know what will cause death - maybe infectious diseases that older people are more vulnerable to - maybe cognitive diseases

The US is an outlier

Great wealth, and great healthcare spending, but shorter life expectancy and worse health than peer countries This is true even among highly advantaged Americans Consider the facts, the actual determinants of health, and the political and social environment in which risk factors are embedded - We don't live as long as people in Sweden, Norway, Japan, etc - We still have worse health even after the Affordable Care Act - Sometimes data with no health disparities is compared to the data from other countries

Although Healthcare is More of a Commodity in the US

Healthcare decommodification is based on three things: 1. Private expenditures on health as a % of GDP 2. Private hospital beds as a % of total beds 3. % of the population covered by insurance decommodification - take away commodities - ex. A Lexus is a commodity - there are cheaper options that are still functional Private hospital bed - bed in a private hospital US has a low decommodification rate - health care is better if you pay more in the US - more benefits for private health care

critiques: why diet?

Height is responsive to nutritional improvements, but is only weakly correlated with life expectancy. - In the past, height was often affected by their nutrition in early ages - Life expectancy went up during this time period - Height was going up - life expectancy was not going up as much - height is heavily related to diet - therefore, diet was not a big driving force for raising life expectancy

disrespect and female mortality

Higher political participation reduces all-cause mortality Does so among men as well as women. - Women's work may benefit families There are indicators of women's power in certain states As more women enter office, health in the state gets better - health of both men and women improve This has implications about culture and politics and economy Culture - more opportunities are offered to people - better care - put people in positions of power in a way that improves the health of everyone Politics and economy - female politicians might align themselves more effectively with improvement of health and the welfare state with their policies

types of infectious disease and their contributions between 1850 and 1900

Idea: primary driver of decline in mortality had to do with tuberculosis - around 42 percent of the decline was related to tuberculosis Other infectious diseases were significant - ex. Scarlet fever with 20ish percent - however, tuberculosis was especially important

associations between SES and health are general

Importance of generality Importance of distinctions among features of SES and among specific diseases - Convenience and dominance of schooling - Interactions between features of SES - Diseases amenable to care Found for clinical and self-report measures - Well-educated or high income people are less likely to smoke - SES is pervasive across different kinds of mortality - The above trends are not entirely driven by poverty though - Improvements in SES progressively lead to better health - We cannot alleviate the relationship between SES and health by just getting people out of poverty though - there's more to it than that

infant mortality

In 1960, we were doing better than the other countries But ~1975, we really started to fall behind Infant mortality is very amenable to health care We focus on it as an indicator of the quality of health care and its accessibility - So there's this injury aspect and then an access to care issue - What did Medicare change?

age structure and mortality

In Sweden, death rate per age group is lower than in Kazakhstan - this observation is why age standardization is important - standardization allows figures to be more comparable

The Epidemiological Transition

In progressing from high to low mortality, all populations experience a shift in the major causes of illness. These changes are associated with socioeconomic improvements—as total mortality declines and income rises, communicable disease mortality declines the problems of Infectious disease, Nutritional Health, and Reproductive Health are better dealt with over time, and a new focus emerges on the following problems: Chronic Disease, Degenerative Disease, "Man-Made" Disease As people live longer, they start dying from different things "Man-Made" disease - heart disease, cancer - kinda just develops from the body itself

associations between SES and health are gradual

Income gradient in health Same is true of GDP and mortality Schooling and mortality (among men) - "years of formal schooling completed is the most important correlate of good health" (Grossman, 2003, p. 32). - Some evidence for credentialing effect, but not overwhelming - Partly but not entirely mediated by income It is difficult to find inverse relationships between diseases and SES - you have to dig deep for something strange - ex. More educated people are more likely to develop brain cancer SES - implies that status matters SEP - socioeconomic position - position in relation to other people - some people think this is a better term than SES There is convenience to reducing SES to education level - education seems to help longevity Health may influence income - ex. Poor health, poor income Education is pretty set by about 25 - convenient to consider because it's a factor that doesn't change much for most people when other factors need to be studied Of all the components of SES, education seems to dominate with regard to health - more educated people are healthier even when they have just a median income Well-educated people might report their health a little lower bc they have the knowledge to see how their health could be better There is more of a drop in mortality after 12 and 16 years of schooling - those are time when people get degrees - high school and college There are still improvements in non-milestone years though - just not as significant

culture and health

Income inequality leads to ambient mistrust which leads to worse health - people do better when they are surrounded by good social support More suspicion of other people means more mistrust - more mistrust leads to election of people who do not help the welfare state Less effective welfare state means less resources to draw on during rough times

disability trends

There are lots of things that have been created that make living with disability easier. Health problems still cause disability in spite of technological advancements. Overall, disability seems to be declining over time declines in disability: - Older people are doing better - ex. Walking more - Since the population is aging, the average age of people over 70 is higher now than it was in the past

Innovation and Disparities

Innovation often increases disparities, even as it decreases mortality overall. The case of cholesterol - As a country, our cholesterol has been going down over time - In the past, wealthier people had higher cholesterol - Over time, the correlation changed so that wealthier people had lower cholesterol. What changed? - Medicines that treated cholesterol were made. - Wealthier people had better access to those medicines when they came out. - In the past, wealthier people probably had higher cholesterol because they had the money to buy food that had a lot of cholesterol - ex. Steaks - Over time, more education about maintaining healthy cholesterol and the invention of medicines to treat high cholesterol made it so that wealthier people ended up having better cholesterol levels than people with less resources

evidence for causation

Instruments -Exploiting the bull market of the 1990s -Conditions well prior to onset Adult income is inconsistently related to health, but education virtually always is and childhood SES often is - The above study tries to predict shocks and analyze sources of income that are independent from health - Lotteries are unusual so it's hard to understand how lottery money relates to health - High income seems to predict lower risk for minor health shocks but not much difference for major health shocks - Education has a strong relationship with adult health - Childhood SES seems to exert a lasting impact on health - this could be a reverse causality situation

Social Conditions as Fundamental Causes

Key Elements - Cause affects multiple disease outcomes - Cause operates through multiple risk factors - Cause involves "resources" that minimize risk for onset or minimize its consequences once disease occurs - Causal relationship persists over time, as disease conditions and risk factors change - Education will improve your mortality for a variety of different reasons - Correlated with lots of different forms of health and morbidity, operates through different risk factors - Income is a fundamental cause for exactly the same reasons - Big caveat is that all this presumes that there is a causal relationship - If I were to give you a Penn degree/a lot of money today, then those who get it today would do better - What is being considered is correlations But what about causality? - Does health affect social position? How much? How do you distinguish 1 from 2?

shorter lives

Life expectancy is often compared using women US is at the bottom rankings 6 year difference between Japan and the US - it sounds like only a little, but it takes ~10 years for life expectancy to increase by 6 years over time

Is It Healthcare? Consider Medicare

Medicare was enacted in 1968 But our ranking was already high in 1965 and, if anything, has deteriorated over time Medicare does not seem to be driving the difference between the US and other countries

Failure of Success (Gruenberg)

Medicine puts emphasis on causes of death rather than on causes of non-fatal chronic diseases. We are living longer only to live for longer periods of time with disease and disability - Medicine focuses on preventing death but not as much on healthy living - There are lots of chronic diseases that we cannot treat very well - medicine may be able to alleviate some pain but not much more than that - Failure despite success - rise of chronic conditions even though we live longer

poverty and health

More severe conditions are more common among poor children They are also of more consequence -Asthma, diabetes, epilepsy It's not clear why -Insurance is only part of the issue -Maternal health literacy is another small part - Poor kids suffer from conditions that hinder their academic performances - hard to study with troublesome symptoms - Maternal health literacy is a small part bc really, poor mothers have a good idea of how to take care of the conditions of their children like not poor mothers

risk factors

Obesity: going up - weight analysis can be biased though - people report to be taller and thinner than they really are sometimes Smoking: down Diastolic BP: down - Diastolic BP has improved - systolic BP has gotten worse Total Cholesterol: down - Pharmaceutical treatments seem to be lowering total cholesterol Mixed picture - we aren't necessarily at a lower risk of heart disease than we were at in the past

linear improvements

Once you remove the effects of smoking, improvements in senescent life expectancy are linear from there, we can extrapolate

where are we heading?

Optimism and pessimism - Optimism: life expectancy will continue to go up - we are okay - life expectancy might not be rising as fast as it did in the past, but it will probably keep going up in a linear fashion - Pessimism: we've exhausted everything at our disposal - life expectancy will eventually hit a wall - life expectancy rise will slow down and we should consider the possibility of a natural limit on lifespan Consider life expectancy (LE) - Juvenile mortality (LEj): mortality under 25 - drops as kid gets older - Background mortality (LEb): risks of mortality that do not change with age - do not have anything to do with the aging of the body - equal risk for everyone - ex. Accidents - Senescent mortality (LEs): level of mortality that increases with age, due to deterioration. Assume that a new born survives to 25 and is not subject to background mortality Pessimists are really behind the model that over time, things fall apart

trends: 1850 to 2000

Over time we've caught up with senescent life expectancy Life expectancy was propelled by improvements in juvenile mortality especially - Imagine a place that only accounts for senescent mortality - 20th century - big time for life expectancy increases - Big improvement from reduced juvenile mortality - smaller improvements from reduced senescent mortality

model of chronic disease

Over time, conditions are prevented or postponed, even though everyone is subject to risk for disease Some of the most important illnesses are, thus, universal You have things going on in your body, but you only experience them as issues once they pass a certain threshold After symptoms pass the threshold, deterioration can eventually lead to death Apparently, the later symptoms become troublesome, the later someone dies Simultaneous movements in mortality - live longer - and movements in morbidity - experience of symptoms

effects of policies and social values in the US

Policies and social values are harder to quantify, but they likely inform the social and environmental processes that lead to shorter lives and worse health. What are the values that policies reflect? - Obligation to address inequality - Emphasis on individual freedom and personal choice - Self-reliance - Free enterprise - Federalism - Religious objections to contraception * More income inequality may mean less longevity * More emphasis on personal freedom/choice - ex. Less pushing people to do certain things - seatbelts, smoking? No hard restrictions

Senescent Mortality

Reducing juvenile mortality is a big factor, but as time goes by, improvements in senescent mortality become more significant in influencing life expectancy Current trends depend more on improvements in senescent mortality The treatment of chronic disease

empirical critiques

Relationship disappears if: - Use different years - Use more countries Weaker evidence at lower levels of aggregation In places where there is more equality, life expectancy is longer - it's not absolute income that necessarily pushes life expectancy Using more countries affects the relationship - trends are not consistent among all countries Relationship is stronger at the level of the nation than at the level of the state - get closer to individuals, relationship gets weaker - ex. We are more affected by income inequality of Pennsylvania than we are by income inequality of Philadelphia - counterintuitive since you would think things closer to you would affect you more

control for race composition

Relationship is most robust in US studies But often disappears with controls - Education levels, % black - Regional fixed-effects Multilevel studies still find evidence, especially for homicide - If it's not income inequality per se, what's in the black box? There's something about the culture of a place that affects health - this is a factor aside from income inequality One may make a connection that states with more income inequality are also more discriminatory culture-wise

what about social intervention

Revealing the importance of health-specific action The Preston Curve: the improvement in life expectancy can be viewed as due to either of two components: (1) that arising from a movement along what economists call an aggregate 'health production function', relating life expectancy to real GDP (2) that due to an upward shift in the function caused by 'technological change', the ability to use given resources more productively to control disease and lengthen life It's difficult to record everything that is relevant 1) economic growth leads to higher life expectancy 2) whole function shifts and has an effect (?) more on the Preston Curve: - Entire function is moving up over time in 20th century - Countries' life expectancies can improve independent of income changes - ex. The spread of medical innovation can still help poorer countries - Note that smaller GDP changes have larger effects on poorer countries than on wealthier countries

when medicine matters

See Lecture 10, Slide 11 Smallpox vaccination came earlier than TB vaccination Immunization effectively eliminated polio - forced it down by 1970 Innovations in medicine obviously matter according to the above, but innovations were not the primary driver of combating infectious diseases

It's Not All Income: Consider Life Expectancy Take-Offs

See Lecture 10, Slide 15 What's happening in Japan around 1950 to cause a life expectancy take-off? Japan's government actively started focusing on raising life expectancy - Japan was lagging in the earlier part of the 20th century but around 1950, life expectancy really started to take off

Improvements in Mortality and the Sex Switch in Mortality Levels

See Lecture 10, Slide 24 As life expectancy goes up, mortality goes down Hit a wall - maybe improvements to life expectancy can't be made once people get into their hundreds age-wise E-subscript-0 - life expectancy at birth (age 0) Even at birth girls are more likely to live than boys Mortality obviously gets worse with age At each age interval, men have higher mortality than women Sharp increase in mortality around 13 - sharper for boys than for girls - attributed to risky actions taken as teenagers - boys do more stupid things as teens than girls do

estimated life expectancy

See Lecture 11, Slide 21 US Social Security Administration assumes that there will be a slowing in the rise of life expectancy - pessimistic - American health isn't great - the future will not have as many elderly people as we might think A more optimistic view says that senescent life expectancy will continue to improve over time - continuing rise in life expectancy might mean that the US Social Security Administration estimates are at least 5 years off - this could be consequential for social security budgeting

An Example: Two Lives

See Lecture 11, Slide 5 The stacking of chronic illness increases mortality risk The after effects of intense problems can continue to trouble a person late into life Postponing chronic disease can lead to longer lives but also healthier lives - person won't have to deal with lingering effects of past problems

US cancer death rates by site among males

See Lecture 11, Slide 9 - In our stage of the epidemiological transition, we deal with cardiovascular disease and cancer mortality - Some forms of cancer have actually increased - Colon and rectum and prostate cancer are dropping thanks to early diagnosis and treatment - As cancers are being treated, we wonder what else there is to learn to treat after cancer. Once improvement is no longer possible, if there is a finite life expectancy, we should discover it.

consider other awards

Selection is minimal when we look exclusively at high status people Life circumstances: -Baseball: elected to the hall of fame well after retirement -Presidents: high stress and risk of assassination some results of awards - Emmy award winners have reduction in mortality - Baseball hall of fame leads to no difference - mortality for those elected to be president is considerably higher, even when adjusting for assassination

self-reported health

Self-reported health has improved, especially as fewer report poor health People are pretty good at reporting their self-rated health - people have a good sense of and are pretty honest about their own health How has self-rated health changed over time? The percentage of people reporting good health is rising. The percentage of people reporting poor health is dropping.

Some Explanations and Disciplinary Differences

Sociologists' explanations - Fundamental causes Economists' explanations - Less incentive to preserve health Psychologists' explanations - Psychosocial stress/culture - Hierarchy Statisticians' explanations - Selection: Childhood health conditions affect adult SES - Contamination: Personal characteristics underlie both health and SES - Reverse Causation: Adult health determines adult SES Reverse causality - taking the cause arrow and flipping it towards the other direction Correlation is not causation - things are related but don't necessarily cause one another Maybe there are good genes that promote education and health - these genes would be a greater cause behind the correlation of education and health Maybe some people have a personality that is just more forward-looking - ex. They eat certain foods for the sake of their health - they study in advance for their exams Contamination - personal characteristics underlie both health and SES, so it's hard to examine those concepts in isolation There may be something about SES that requires good health to begin with Sociologists and psychologists guess at a causal relationship but with different factors - economists trace the idea of incentives related to health

mortality rates in 19th century England

Some forces - Industrial revolution - Early science - ex. put aside concepts like the four humors in favor of techniques closer to modern medicine - Environmental improvement - ex. Effective sewer systems in Paris Decline in mortality in the late 1800s was attributable almost entirely to infectious disease Decline in mortality in the late 1800s was attributable almost entirely to infectious disease : there's nothing in play regarding things like cancer and heart disease - what is being addressed is how infectious disease transmission works

In the End, Medical Care Probably Plays a Minimal Role

Some key causes of death are only minimally related to health care, like homicide and suicide, which account for 23% of extra years of life lost among US males relative to other countries US outcomes with respect to myocardial infarction and ischemic stroke are better than the OECD average Even conditions that are treatable are influenced by things outside of healthcare, such as smoking and obesity - Maybe in the US, people show up bc of worse heart attacks - however, the data above assumes that heart attacks are mostly pretty similar - The US case mortality rate makes it not the worst performer and not the best performer for heart attacks - in this case, the data seems to imply that the differences may not be as related to health care system structures as one might think - There is some behavioral component here - what Americans do, not just what physicians do

tuberculosis

Specific medical innovations mattered little Improvements in mortality started well before municipal hygiene became important When science made progress in identifying and treating tuberculosis (1880ish), mortality from tuberculosis declined, but specific medical innovations mattered little because decline in mortality was already happening before certain things came into play

conclusions

The 1970s - Longer life and worsening health - Disease and disability are linked The 1990s - Higher disease prevalence overall, but better health - Disease is no longer closely linked with disability The 2000s - Growing morbidity and mortality among middle-aged (non-Hispanic) white men and women

increasing mortality

The age-adjusted death rate increased 1.2% from 724.6 deaths per 100,000 standard population in 2014 to 733.1 in 2015. - Overall, mortality increased a bit from 2014 to 2015 - Usually in consecutive years you don't get data of this sort - At age 65, no changes, so something is going on under the age of 65

many major causes of death

The data cuts across many major causes of death - There is no one specific cause In the US, leading causes of death are heart disease and cancer The death rate increased for heart disease, but continued to decrease for cancer But many other conditions are also increasing in mortality

possible mortality paradox

The death rate in 1992: - Sweden: 10.55 per 1,000 - Kazakhstan: 7.42 per 1,000 But the age-specific mortality rate in Kazakhstan is higher for every age group Is this a paradox? Mortality goes down - that means there are relatively fewer younger people There is no paradox - there are simply more older people in Sweden than there are in Kazakhstan - those older people are more likely to die, hence a higher death rate

disrespect and black mortality

The ecology of discrimination - "most blacks have less in-born ability to learn" - "most blacks just don't have the motivation or will power" - "mainly due to discrimination" - "don't have the chance for education" All matter net of poverty And all affect white mortality as well Disrespect in states - ex. Black people lack ability and will power - lead to higher mortality for black people - also higher mortality for other kinds of people actually - bigot states overall suffer mortality-wise from their disrespectful ideas

Compression of Morbidity (Fries)

The lifespan is finite - there are only so many years a human can live The compression of morbidity occurs if the age at first appearance of chronic disease increases more rapidly than life expectancy. The survival function is shifting to the right. As time goes by, more people are surviving into old age. Rectangularization of lower graph might imply that nature is preventing life expectancy from moving further to the right - finite lifespan Finite lifespan would be cleanly indicated if the graph became a rectangle - ex. Line has people surviving until 95ish - then the line drops straight down bc that's the lifespan limit

trends in women and children

The most profound changes occur among women and children -Their susceptibility to infection is high Females' risk of dying is less than that for males in the post-reproductive period at all life expectancy levels, but females have a higher probability of death during the adolescent and reproductive age intervals at low life expectancy levels. Women outlive men

consider the timing of mortality improvements

The timing of the take-off doesn't always correspond to the timing of economic growth There's no obvious lag period that is necessary between growing economy and growing life expectancy This can be used as a point against the idea that standard of living improves life expectancy

How far behind is the US?

The trend of the US lagging is more or less continuous - It would take the US 8 years to catch up - At 2005, it would take 50 years to catch up

Relative Standing

Three types of evidence 1. Whitehall 2. Income inequality has a health association 3. Primate studies Higher rank has better health (e.g., cortisol levels) Primate Case - Overall, higher standing in the group leads to lower levels of cortisol - Non-human primates have a status hierarchy similar to our status - There are different statuses - the status you have in Penn, your specific class, your family. There's not one status we can agree on—we chase status in lots of different directions - Those who drive fancier cars tend to live a little longer Imagine that your status is determined entirely by your GPA - We need to think about the behaviors that go along with status - With monkeys, maybe the amount of grooming is that behavior - Maybe humans need to maintain their status

Transportation-Related and Violent Mortality

Transportation-related mortality is relatively high in the US but is declining - think seat belts, airbags, innovations regarding car technology, drinking and driving decreases Despite the decline, US transport-related mortality is still relatively high US violent mortality rates are very high compared to other countries - like quadruple the rates of other countries Even with significant improvements though, US is still much higher in terms of violent mortality rate

population health change

Trends in one box need not be related trends in another box Neither Fries nor Gruenberg is entirely correct - Some do not think that we are anywhere close to a finite limit on life expectancy - Other argument: look at different forms of morbidity - you need to think about population health change in stages - Functioning - going up stairs, balancing checks - ex. Lose hand - Disability - affects productivity - note: if you lose a hand but get a prosthetic, you don't really have a disability regarding that

standard of living debate

Two sides to the argument 1) the standard of living propels improvements in life expectancy - medical innovation is not as important as standard of living improvements like better diets - market is beneficent means that if a country's standard of living improves, life expectancy should also improve Standard of living as the causal engine - Incomes improved, which lead to an improved diet - Specific medical intervention mattered little - The market is beneficent 2) purposeful action is the causal engine - health-focused interventions matter a great deal for improvements - purposefully spreading technology and knowledge about health over a population significantly helps that population Purposeful action as the causal engine - The market is not beneficent: we must intervene - Health-focused interventions matter a great deal - Technology and knowledge are important

social explanations

US has a relatively high poverty rate according to the graph in Lecture 11, Slide 51 US has relatively low educational achievement according to Lecture 11, Slide 52 - US isn't in the top 10 for educational achievement in reading, science, or math

US has fewer general practitioners

US has different organization of care even at the level of providers Idea: best health care is present where there are a lot of general practitioners available to help people 12 percent of physicians in the US are general practitioners - meanwhile in other countries, like half of physicians are general practitioners General practitioners are Swiss army knives of medicine

are we getting healthier?

We can cure many diseases, but some we can only treat Individuals now survive longer with conditions that were once fatal The environment has become more accommodating to functional limitations Two theories (but only theories—we'll look at data later) - Does living longer mean we are healthier nowadays? - Note that individuals are now surviving longer with suboptimal health bc of our medical resources. - Functional limitations are also better accommodated these days - through infrastructure, architecture, and the like

other psychosocial risk factors

What is most striking and important about socioeconomic status is the degree to which it shapes exposure to, and perhaps also the impact of, a wide range of psychosocial and environmental risk factors for health. Risks associated with individual factors are small but add up High education and higher income are doing better When men marry, they tend to live longer because they change their health behaviors Attend more meetings, have more responsibility

Evidence Regarding Quality is Inconclusive

While specialization in the US is important, the fact that it means that people have to work harder to navigate their health care means that high specialization rates may end up being detrimental to a person's health Certain things should be avoidable - people should be equipped to deal with asthma and diabetes on their own most of the time - they shouldn't have to rush to the hospital - asthma people should have inhalers Diabetes hospital admissions indicate that the US in that case actually has a pretty good conditional health care system set up - conditional means that the effectiveness depends on circumstance though

importance of heart disease

Widening differentials by heart disease mortality Similar increases in mortality differentials found in England and Wales, so it's not entirely health insurance - There is no difference in heart attack risk for high education and low education people in 1960. That has changed by 1984 - Care for heart disease improved, but only high education people had access to it - There was no relationship in 1960 because high education wouldn't give someone anymore info about heart disease. By 1984. a high education person could get diagnosed with hypertension and seek out a treatment based on their condition - education yielded something regarding heart disease - There's more to it than just heart disease though

Study of Whitehall Civil Servants

by Michael Marmot Sparked the psychosocial revolution Whitehall Civil Servant jobs are examined because they are good jobs - good organization, good wages, good health care The Whitehall Civil Servants do well compared to a lot of other English people. There is still stratification among the Whitehall Civil Servants - bosses and subordinates idea: health has to do with psychosocial conditions of work People higher up on the totem pole of the Whitehall Civil Servants had better health than those lower on the totem pole

McKeown Thesis

declining mortality owed little if anything to medicine or targeted public health intervention, and almost everything to economic growth and rising standards of living, especially improved nutrition Eliminating potential explanations 1. Decline in organism virulence 2. Immunization 3. Urban hygiene improvements 4. Nutritional improvements Negative finding: 1 through 3 don't work Positive finding: 4 does, but it's hard to prove