Deborah Prothrow-Stith

Social capital, income inequality, and mortality.

OBJECTIVES Recent studies have demonstrated that income inequality is related to mortality rates. It was hypothesized, in this study, that income inequality is related to reduction in social cohesion and that disinvestment in social capital is in turn associated with increased mortality. METHODS In this cross-sectional ecologic study based on data from 39 states, social capital was measured by weighted responses to two items from the General Social Survey: per capita density of membership in voluntary groups in each state and level of social trust, as gauged by the proportion of residents in each state who believed that people could be trusted. Age-standardized total and cause-specific mortality rates in 1990 were obtained for each state. RESULTS Income inequality was strongly correlated with both per capita group membership (r = -.46) and lack of social trust (r = .76). In turn, both social trust and group membership were associated with total mortality, as well as rates of death from coronary heart disease, malignant neoplasms, and infant mortality. CONCLUSIONS These data support the notion that income inequality leads to increased mortality via disinvestment in social capital.

Income distribution and mortality : cross sectional ecological study of the Robin Hood index in the United States

Abstract Objective: To determine the effect of income inequality as measured by the Robin Hood index and the Gini coefficient on all cause and cause specific mortality in the United States. Design: Cross sectional ecological study. Setting: Households in the United States. Main outcome measures: Disease specific mortality, income, household size, poverty, and smoking rates for each state. Results: The Robin Hood index was positively correlated with total mortality adjusted for age (r=0.54; P<0.05). This association remained after adjustment for poverty (P<0.007), where each percentage increase in the index was associated with an increase in the total mortality of 21.68 deaths per 100000. Effects of the index were also found for infant mortality (P=0.013); coronary heart disease (P=0.004); malignant neoplasms (P=0.023); and homicide (P<0.001). Strong associations were also found between the index and causes of death amenable to medical intervention. The Gini coefficient showed very little correlation with any of the causes of death. Conclusion: Variations between states in the inequality of income were associated with increased mortality from several causes. The size of the gap between the wealthy and less well off—as distinct from the absolute standard of living enjoyed by the poor—seems to matter in its own right. The findings suggest that policies that deal with the growing inequities in income distribution may have an important impact on the health of the population. Key messages The size of the gap between the wealthy and less well off—as distinct from the absolute standard of living enjoyed by the poor—seems to be related to mortality Policies that deal with the growing inequities in income distribution may have a considerable impact on the health of the population

Income distribution, socioeconomic status, and self rated health in the United States: multilevel analysis

Abstract Objective: To determine the effect of inequalities in income within a state on self rated health status while controlling for individual characteristics such as socioeconomic status. Design: Cross sectional multilevel study. Data were collected on income distribution in each of the 50 states in the United States. The Gini coefficient was used to measure statewide inequalities in income. Random probability samples of individuals in each state were collected by the 1993 and 1994 behavioural risk factor surveillance system, a random digit telephone survey. The survey collects information on an individuals income, education, self rated health and other health risk factors. Setting: All 50 states. Subjects: Civilian, non-institutionalised (that is, non-incarcerated and non-hospitalised) US residents aged 18 years or older. Main outcome measure: Self rated health status. Results: When personal characteristics and household income were controlled for, individuals living in states with the greatest inequalities in income were 30% more likely to report their health as fair or poor than individuals living in states with the smallest inequalities in income. Conclusions: Inequality in the distribution of income was associated with an adverse impact on health independent of the effect of household income.

Women's status and the health of women and men: a view from the States

We examined the status of women in the 50 American states in relation to womens and mens levels of health. The status of women in each state was assessed by four composite indices measuring womens political participation, economic autonomy, employment and earnings, and reproductive rights. The study design was cross-sectional and ecologic. Our main outcome measures were total female and male mortality rates, female cause-specific death rates and mean days of activity limitations reported by women during the previous month. Measures of womens status were strikingly correlated with each of these health outcomes at the state level. Higher political participation by women was correlated with lower female mortality rates (r = -0.51), as well as lower activity limitations (-0.47). A smaller wage gap between women and men was associated with lower female mortality rates (-0.30) and lower activity limitations (-0.31) (all correlations, P < 0.05). Indices of womens status were also strongly correlated with male mortality rates, suggesting that womens status may reflect more general underlying structural processes associated with material deprivation and income inequality. However, the indices of womens status persisted in predicting female mortality and morbidity rates after adjusting for income inequality, poverty rates and median household income. Associations were observed for specific causes of death, including stroke, cervical cancer and homicide. We conclude that women experience higher mortality and morbidity in states where they have lower levels of political participation and economic autonomy. Living in such states has detrimental consequences for the health of men as well. Gender inequality and truncated opportunities for women may be one of the pathways by which the maldistribution of income adversely affects the health of women.

The Epidemic of Youth Violence in America: Using Public Health Prevention Strategies to Prevent Violence

Violence is exacting an increasingly heavy toll on individuals across the country, causing a marked rise in fear and frustration. However, historical attempts to address violence have been both episodic and inconsistent. There has not been a comprehensive and coordinated, prevention-oriented approach. Many law enforcement experts now agree that violence must be met with solutions from disciplines other than law enforcement, those of public health included. These experts acknowledge that social conditions such as family stability, education, and other societal institutions directly affect the behavior of juveniles and thereby the safety of communities. No single strategy, institution, or discipline can create the changes needed to reduce violence in America. Preventing violence demands not only a long-term commitment but a comprehensive set of strategies and new partnerships. These combined efforts must focus on prevention and not solely on aggressive responses to violence.

Dying Is No Accident: Adolescents, Violence, and Intentional Injury

Violence and its consequences are a major issue to be addressed by the health care community. The magnitude and characteristics of the problem cry out for new, creative approaches and provide for some insight into the direction that needs to be taken. Some of the components related to violence are societal in scope and will require long-term strategies well beyond the immediate realm of the health care system. Others provide direction that more clearly present a role for health providers and public health planners. Although there will be no easy answers or solutions to this problem, it is essential that support be developed for experimental efforts. The health community cannot ignore this problem and can in fact make a real contribution to its resolution through prevention, treatment, and research.

Can physicians help curb adolescent violence

Some of the factors associated with such violence, notably racism and poverty, clearly demand societal solutions. Other factors, however, may respond to public health intervention strategies. Emergency room workers can practice secondary intervention, as they do with victims of child abuse, sexual assault, or attempted suicide. Family physicians can refer adolescents for appropriate help.

Adolescent interpersonal assault injury admissions in an urban municipal hospital.

To extend the study of the epidemiology of interpersonal violence into the area of nonfatal intentional injury, a retrospective study was undertaken of patients admitted to a major city hospital for intentional injury during a single year (1984–1985). This study focused on interpersonal assaultive injury, excluding sexual assault, child abuse, and self-inflicted injuries. Relevant injuries made up three-quarters of all admitted intentional injuries and represented a total of 671 patients (4.5% of all hospital admissions). The intentionally injured were compared to the catchment area population and to the remaining admitted hospital population, by age, sex, and race. Medical records of intentionally injured adolescents (n = 133) were reviewed and compared to a sample of adolescent homicide victims regarding the circumstance of the event and the relationship of victim to assailant. Relevant findings are that: (1) in the area served by this hospital, male adolescents are at relatively high risk for nonfatal intentional injury; (2) among adolescents, the majority of these intentional injuries are the result of interpersonal conflicts between acquaintances, paralleling the etiology of homicide; (3) a prevalence of missing data in the medical records of older male adolescents is symptomatic of the lack of attention that has been paid to understanding and preventing intentional injury among adolescents. It is concluded that: (1) more area-specific and hospital-based studies of intentional injury are needed as a guide to such preventive efforts; and (2) medical personnel providing acute care to victims of intentional injury are an important resource for this research and prevention effort.

School-based interventions can play a critical role in enhancing children's development and health in the developing world.

Early interventions are critical to improving the health, nutrition and development of young children. A recent review in the Lancet makes a forceful case for pre-primary school interventions (Engle et al. 2007). However, the potential of school-based interventions to promote children’s health and development should not be underestimated. These are important because a considerably higher percentage of children in developing countries are enrolled in school than in pre-school (World Bank 2006; Engle et al. 2007). While the most marginalized children may not have access to pre-school, the increasing universality of primary education makes for high accessibility and attendance (World Bank 2006). Furthermore, school teachers have more training and qualifications than those in pre-schools. This enables them to deal better with the emotional, behavioural and developmental needs of children, and creates potential for good-quality, teacher-delivered school-based interventions. Teachers are well placed to liaise with caregivers to support children, and strategies and interventions can be taught at relatively low cost during formal teacher training. The 2007 World Development Report, focusing on ages 12–24, states that ‘decisions during five youth transitions have the biggest long-term impact on how human capital is kept safe, developed and deployed . . .’ and that ‘policies and institutions affect the risks, the opportunities and the outcomes of youth and their families (World Bank 2006). Emotional difficulties among children in deprived settings are common and interfere with learning (Abdel-Fattah et al. 2004; Cluver & Gardner 2006). While difficulties for vulnerable children may be reduced with pre-school interventions, many of the emotional problems associated with traumatic experiences (e.g. depression and anxiety) may only become apparent later and increase in prevalence with age (Ford et al. 2003). This may be because older children are better able to express themselves but, in developing countries, it may be attributable to the cumulative impact of chronic adversity. In sub-Saharan Africa, 12.3 million children have lost one or both parents to AIDS and an estimated 18 million will do so by 2010 (UNAIDS, UNICEF, & USAID 2004). In high HIV settings, ongoing exposure to chronic illness and bereavement suggests the need for interventions in schools even in settings with pre-school programmes. In sub-Saharan Africa, 70% of infected mothers survive for the first 5 years of their child’s life – a figure likely to increase with Editorial doi:10.1111/j.1365-2214.2007.00820.x

Strengthening the collaboration between public health and criminal justice to prevent violence.

Over the last two decades in the United States, I, public health practitioners, policy makers, and researchers have charted new territory by increasingly using public health strategies to understand and prevent youth violence, which has traditionally been considered a criminal justice problem. The utilization of public health approaches has generated several contributions to the understanding and prevention of violence, including new and expanded knowledge in surveillance, delineation of risk factors, and program design, including implementation and evaluation strategies.