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The Social Shaping of Health Disparities: The Fundamental Cause
Hypothesis
Bruce LinkHeron
April 7, 2011
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U.S. All Cause Age-adjusted Death Rates Per 100,000 by Race – 2005
785.3
1016.5
0
200
400
600
800
1000
1200
whiteblack
National Center for Health Statistics – Health United States 2008
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U.S. All Cause Age-adjusted Death Rates Per 100,000 People Ages 25-
64 by Education -- 2005821
606
249
472
352
165
0100200300400500600700800900
Males Females
< 12 years12 years13+ years
National Center for Health Statistics – Health United States 2008
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U.S. Percent Fair or Poor Self-Reported Health by Poverty Level
and Race/Ethnicity
21
14
6
21
14
6
26
17
10
20
15
9
0
5
10
15
20
25
30
Overall White Black Hispanic
Below 100%100%-less than 200%200% or more
National Center for Health Statistics – Health United States 2006 – From NHANES Surveys
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Age Standardized Mortality Rates by SES Classification (NS-SEC) in the North East and
South West, Men 25-64, 2001-2003
210
700
195
400
0
100
200
300
400
500
600
700
North East South West
Hi Manager Prof.
Lo Manager Prof.
Intermediate
Small Employers
Lower supervisory andtechnicalSemi-Routine
Routine
NS-SEC= National Statistics Socioeconomic Classification
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SES,Race
MechanismsSmoking, Diet, Exercise, Stress,
Etc, etc. ?
MortalityMorbidity
?
What Are the Mechanisms that Account for the Association?
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Deaths Per 1000 Among Taxpayers andNon-Taxpayers in Rhode Island 1865
Age Categories Taxpayers Non-Taxpayers(examples)
Under 1 93.4 189.8
30-39 4.5 15.5
60-69 15.1 39.5
Chapin AJPH 1924
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Deaths per 1000 (age adjusted) by SESof Census Tract -- Chicago 1930
SES Males Females
1--Lowest 15.1 12.3
2 11.6 10.2
3 10.2 9.0
4 9.2 7.9
5--Highest 8.7 6.8
Coombs, Medical Care, 1941
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What is the point?• Imagine yourself back in Rhode island in 1865
and doing what we just did for the current data – we might have asked what were the mechanisms involved?
• Contaminated water, poor sanitation, crowded substandard housing – the diseases were cholera, TB, small pox…
• We did something about the risk factors, we developed vaccines, and people don’t die of TB, small pox and cholera in Rhode Island any more.
• But the SES association is resilient.
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The Concept of Fundamental Social Causes
Fundamental social causes involve resources such asknowledge, money, power, prestige and beneficial social connections that determine the extent to which people areable to avoid risks and adopt protective strategies so as toreduce morbidity and mortality.
Because such resources can be used in different ways in different situations, fundamental causes have effects ondisease even when the profile of risk and protective factors and diseases changes radically.
It is their persistent effect on health in the face ofdramatic changes in mechanisms that leads us to call them“fundamental.”
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How Social and Economic Resources Affect Health – The Importance of Contexts
• Resources operate at the individual level – people use their knowledge, money, power, prestige and beneficial social connections to obtain healthy outcomes.
• But resources also provide access to generally salutary contexts – neighborhoods, occupational conditions, marriages – access to health consequential circumstances comes with access to contexts in a sort of “package deal.”
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US Life Expectancy at Birth 1900-2000
47
55
61
7074
77
40
45
50
55
60
65
70
75
80
1900 1920 1940 1960 1980 2000
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US: Heart Disease -- Age-adjusted Death Rates Per 100,000 People
587559
493
412
321 293258
40
140
240
340
440
540
640
1950 1960 1970 1980 1990 1995 2000
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Cancer (green) and Stroke (Yellow) -- Age-adjusted Death Rates Per 100,000 People
181 178
148
96
65 63 6150
194 194 199208
216 210200
186
406080
100120140160180200220240
1950 1960 1970 1980 1990 1995 2000 2004
National Center for Health Statistics – Health United States 2006
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US : Flu (blue) and HIV (green) -- Age-adjusted Death Rates Per 100,000 People
1016
5
4854
42
3137
33
24
0
10
20
30
40
50
60
1950 1960 1970 1980 1990 1995 2000
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Percentage Self Reporting Health as Excellent or Good by Age Group (40-49 yellow and 60-69 blue)
and Decade of Birth using 1972 to 2004 General Social Surveys
74%76%
82% 82%84%
52%
57.00%
63%
74%
82%
50.00%
60.00%
70.00%
80.00%
90.00%
1900's 1910's 1920's 1930's 1940's 1950's 1960's
Age40-49
Age60-69
Adapted from: Robert Warren and Elaine Hernandez (In Press) Journal of Health and Social Behavior, Table 2
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Something is Driving these Dramatic Improvements in Health
X ?
Shouldn’t whatever “x” is be an important part of our explanations of health disparities?
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Do Key Explanatory Variables in Theories of Disparities Account for Trends Toward Improvement
in Health Over Time?• How about genetic factors?
• Social involvement and participation?
• How about income inequality?
• Relative position on hierarchies?
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Of course, X is not any one thing but many things
• The discovery of the germ theory is a strong candidate for declines in rates of infectious diseases in the first half of the 20th century.
• Recent declines in age adjusted rates of death from lung cancer are probably influenced by the lagged effects of declines in smoking rates in earlier decades.
• The rapid decline in HIV/AIDS mortality is probably related to the new anti-retroviral drugs that were developed and disseminated in the late 1990’s
• And then screening for disease, public health efforts to increase the consumption of fruits and vegetables, promote exercise, eradicate smoking, and smog control, flu shots, seat belts, angioplasty, screening for early detection of cancer, etc. etc.
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• So X is clearly not just one thing and is likely different things for different diseases…and probably different things at different times….But the confluence of all of these things has clearly had an enormously positive impact on population health.
• Clearly human beings have dramatically increased their capacity to control disease and death.
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Fundamental Cause Reasoning Concerning the Sources of Disparities: The Core Proposition
• Our enormous capacity to control disease and death combined with social and economic inequality creates health disparities.
• It does so because of a very basic principle – When we develop the ability to control disease and death, the benefits of this new found capacity are not distributed equally throughout the population, but are instead harnessed more securely by individuals and groups who are less likely to be exposed to discrimination and who have more knowledge, money, power, prestige and beneficial social connections.
• People who are more advantaged with respect to resources such as these and who are less likely to be held back by discrimination benefit more and have lower death rates as a consequence. Disparities are the result.
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Explanations for Race and SES Disparities that Have Different Emphases than a Social
Shaping Fundamental Cause Approach
• Genetic Differences• Health Selection• Relative Deprivation• Job Control• Stress of Lower Position
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Test #1 -- SES Associations with More and Less Preventable Causes of
Death
• We say that SES differences arise because people of higher SES use flexible resources to avoid risks and adopt protective strategies
• it follows that the SES gradient should be more pronounced for diseases that we can do something about… for which there are known and modifiable risk and protective factors…
• Our first test involves ratings of the preventability of death from specific causes
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US National Longitudinal Mortality Survey
• Very large study of a nationwide sample of over 350,000 people.
• Interviewed as part of the US Current Population Survey (assesses unemployment etc.) and followed for 9 years with National Death Index for mortality and cause of death
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Relative Risks of Death by Income -- NationalLongitudinal Mortality Study
Income (1980 $) Men 45-64Women 45-64
< 5000 2.32 3.13
5000-9999 1.79 2.63
10000-14999 1.56 2.03
15000-19999 1.35 1.69
20000-24999 1.21 1.47
25000-49999 1.09 1.28
50000+ (reference category) 1.00 1.00
Sorlie et al. AJPH 1995
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The Rating Task
• Thinking of both our ability to prevent a disease from occurring and to treat it once it occurs, to what degree was it possible, in the early 1990’s to prevent death from this disease?
• Rated on a 5 point scale from “virtually impossible to prevent death” to “virtually all deaths preventable”
• Inter-rater reliability .85. Correlation with Rutstein independent ratings .57.
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Examples of Hi and Lo Preventability Diseases
• Low Preventability:brain cancer, ovarian cancer,
gallbladder cancer, multiple sclerosis, pancreatic cancer,
• High Preventability:lung cancer, ischemic heart disease,
colon cancer, pneumonia
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National Longitudinal Mortality Study Percent Dying During 9 Year Follow-Up:
Men and Women 45-64
4.15
8.2
1.8 1.8 2.1
0123456789
Hi Preventability Lo Preventability
16+ Years12 -15 years< 12 Years
Phelan, Link, Diez-Roux, Kawachi and Levin. 2004 JHSB
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Test # 2 Evidence Bearing on the Hypothesis Trends Over Time
• If the core proposition is true we should find that disparities by SES and race emerge when new health enhancing information or technology is obtained: – E.g. Heart disease, Hodgkins Disease, Colon Cancer
• If death from a disease remains unpreventable – disparities will not change dramatically with time– E.G. Brian cancer, Ovarian Cancer, Pancreatic Cancer
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Trends by County-Level SES and Race in the US
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Brain Cancer -- Age-adjusted Death Rates Per 100,000 1950-1999 (Males) US
2.843.21
2.91 3.1 3.08
3.864.18
4.54.81 4.97 5.17 5.04 5.26 5.47
0
1
2
3
4
5
6
50-54 55-59 60-64 65-69 70-74 75-79 80-84 85-89 90-94 95-99
White Males
Black Males
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Ovarian Cancer -- Age-adjusted Death Rates Per 100,000 1950-1999 (Females) US
7.216.66 6.56 6.43 6.72
8.358.91 8.9 9.03 8.88 8.58
8.11 8.08 8.13
0123456789
10
50-54 55-59 60-64 65-69 70-74 75-79 80-84 85-89 90-94 95-99
White Females
Black Females
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Pancreatic Cancer -- Age-adjusted Death Rates Per 100,000 1981-2002 US
1112.3
11.712.3 12.1
11.5 11.3 11
8.4 8.3 8.2 8.2 8.2 8 8.2 8.2
0
2
4
6
8
10
12
14
1981 1984 1987 1990 1993 1996 1999 2002
White
Black
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Heart Disease -- Age-adjusted Death Rates Per 100,000 1950-2000 US
586.7548.3
512
455.3
391.5
324.8
584.8559
492.2
409.4
317
253.4
200
250
300
350
400
450
500
550
600
1950 1960 1970 1980 1990 2000
White
Black
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Breast Cancer-- Age-adjusted Death Rates Per 100,000 1950-2000
25.327.9 28.9
31.7
38.134.5
32.232.4 32 32.5 32.1 33.2
26.323.9
0
5
10
15
20
25
30
35
40
45
1950 1960 1970 1980 1990 2000 2004
White
Black
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Colon, Rectum and Anus -- Age-adjusted Death Rates Per 100,000 1960-2000 US
22.8
26.1
28.3
30.6
28.2
30.9
29.2
27.4
24.1
20.320
22
24
26
28
30
32
34
1960 1970 1980 1990 2000
White
Black
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Age-, sex-, race-adjusted pancreatic cancer mortality per 10,000 persons 45 or more years, 1968-2005
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Age-, sex-, race-adjusted pancreatic cancer mortality per 10,000 persons 45 or more years, 1968-2005
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Age-, sex-, race-adjusted lung cancer mortality per 10,000 persons 45 or more years, 1968-2005
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Age-, sex-, race-adjusted lung cancer mortality per 10,000 persons 45 or more years, 1968-2005
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Age-, sex-, race-adjusted lung cancer mortality per 10,000 persons 45 years and over by county SES percentile, 1968-2005
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What do These Tests Tell Us?
• This is consistent with the social shaping perspective and it says that the scope of problem is large… BUT
• The link to new knowledge and technology is not as direct we would like. Let me turn now to three stories where the linking is somewhat better….
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Income Disparities in Cholesterol
• Chang and Lauderdale use data on cholesterol levels from NHANES before (1976-1980) and after the introduction of highly effective statins (1999 -2004)
• Income is assessed as the poverty income ratio
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Income Gradients for Total Cholesterol 1976-80 and 1999-2004: Predicted Lipid Levels from NHANES
for Women
213
216
195
200
194
199
204
209
214
219
0 1 2 3 4 5
1976-1980
1999-2004
Chang, Virginia and Diane Lauderdale. 2009. Journal of Health andSocial Behavior 50:245-260
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Income Gradients for Total Cholesterol 1976-80 and 1999-2004: Predicted Lipid Levels from NHANES
for Men
212
218
200
205
194
199
204
209
214
219
0 1 2 3 4 5
1976-1980
1999-2004
Chang, Virginia and Diane Lauderdale. 2009. Journal of Health andSocial Behavior 50:245-260
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Medical Advances and Race/ Ethnic Disparities in Cancer Survival
• Tehranifar, Neugut, Phelan, Link, Liao, Desai and Terry. 2009. Cancer Epidemiology Biomarkers Prevention.
• Cancer cases (N=580,225) in SEER ages 20+ diagnosed with one invasive cancer in 1995-1999.
• Used 5-year relative survival rates to measure degree to which mortality from each cancer is amenable to medical interventions (early detection and treatment) – ranged from 5% for pancreatic cancer to 99% for prostate cancer.
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Do Racial/Ethnic Differences in Survival Increase as Cancers become more amenable to medical interventions?
0 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 95 100
0.80
1.00
1.20
1.40
1.60
1.80
American Indian/Alaska Na-tive
Asian or Pacific Islander
African American
Hispanic
Haz
ard
Rat
io
<<<<<Less Amenable More Amenable >>>>>
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HIV Mortality
• One potentially dramatic example might be HIV-AIDS mortality.
• In particular Highly Active Anti-Retroviral Therapy (HARRT) as a new life saving technology.
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HIV Mortality 1987-2005• Rubin, Colen and Link. 2010. American Journal of Public
Health• HIV mortality in every county in the United States from
the National Center for Health Statistics by Age, Race and Gender.
• Constructed rates for every year using mortality data for the numerator and census data for the denominator.
• Constructed SES measures for each county using indicators of education, income, occupation and poverty.
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• We identified a pre (1987-1994), a peri (1995-1998) and a post (1999-2005) HARRT period.
• We expect an interaction between SES and period and between race and period such that the benefit HAART is more pronounced in high SES counties and among Whites as opposed to low SES counties and among Blacks
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HIV Deaths among Whites per 100,000 by Age
0
5
10
15
20
25
30
35
40
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
Year
Dea
ths
per 1
00,0
00 15-24 years25-34 years35-44 years45-54 years55-64 years
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HIV Deaths among Blacks per 100,000 by Age
0
20
40
60
80
100
120
140
160
1987
1989
1991
1993
1995
1997
1999
2001
2003
2005
Year
Deat
hs p
er 1
00,0
00 15-24 years
25-34 years
35-44 years
45-54 years
55-64 years
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Incidence Rate Ratios – Blacks Versus Whites Before (Pre), During (Peri) and After (Post) the Introduction of Highly Active Anti-Retroviral Therapy in the United States
1
3.66
1
5.64
1
7.84
0123456789
10
Pre HAART Peri HAART Post HAART
WhiteBlack
IRRs adjusted for age, sex, and SES and urbanicity of county of residence.
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Incidence Rate Ratios – Comparing a County at the 95th Percentile of SES to a County at the 5th Percentile of SES Pre, Peri and Post the Introduction of Highly Active Anti-Retroviral Therapy (HAART) in the United States
11.41
1
1.91
1
2.72
0
0.5
1
1.5
2
2.5
3
3.5
4
Pre HAART Peri HAART Post HAART
High SES County (5thpercentile)Low SES County (95thpercentile)
IRRs adjusted for age, sex, race, and urbanicity of county of residence
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010
2030
1985 1990 1995 2000 2005Year
95% CI Fitted Values for WhitesFitted Values for Blacks
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Conclusions• When we examine Race and SES disparities in mortality
by particular diseases we find dramatic evidence that such disparities are created over time.
• Groups with more resources and who face less discrimination benefit more greatly from our new found capacity and disparities emerge
• This means that explanations that propose relatively unchanging causes of disparities like genes, health selection due to health induced disability, relative deprivation, job control etc. cannot be the main reasons for health disparities.
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Colon, Rectum and Anus -- Age-adjusted Death Rates Per 100,000 1950-2000
22.8
26.1
28.3
30.629.3
28.2
30.929.2
27.4
24.1
2220.320
22
24
26
28
30
32
34
1950 1960 1970 1980 1990 1995 2000
White
Black
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Age-, sex-, race-adjusted lung cancer mortality per 10,000 persons 45 years and over by county SES percentile, 1968-2005
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Puzzles • Combinations of SES and gender, race, ethnicity,
immigration status and sexual preference sometimes produces “paradoxes.” Understanding these paradoxes can be a door to newer and deeper knowledge.– Women disadvantaged compared to men but live
longer.– African Americans disadvantaged with respect to SES
but have lower rates of major depression.– Some immigrants groups --though disadvantaged with
respect to SES -- enjoy longer life.
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Conclusion
• Many prominent disparities are created when the benefits of new knowledge about disease causation and new approaches to prevention and cure are distributed unequally in populations.
• The HERON’s Gaze needs to be fixed on these unequal distributions and it needs tobe ready to strike when the processes that enable their emergence are evident.