Income inequality and population health: A review and explanation of the evidence

Abstract

Whether or not the scale of a society's income inequality is a determinant of population health is still regarded as a controversial issue. We decided to review the evidence and see if we could find a consistent interpretation of both the positive and negative findings.

We identified 168 analyses in 155 papers reporting research findings on the association between income distribution and population health, and classified them according to how far their findings supported the hypothesis that greater income differences are associated with lower standards of population health. Analyses in which all adjusted associations between greater income equality and higher standards of population health were statistically significant and positive were classified as “wholly supportive”; if none were significant and positive they were classified as “unsupportive”; and if some but not all were significant and supportive they were classified as “partially supportive”. Of those classified as either wholly supportive or unsupportive, a large majority (70 per cent) suggest that health is less good in societies where income differences are bigger.

There were substantial differences in the proportion of supportive findings according to whether inequality was measured in large or small areas. We suggest that the studies of income inequality are more supportive in large areas because in that context income inequality serves as a measure of the scale of social stratification, or how hierarchical a society is.

We suggest three explanations for the unsupportive findings reported by a minority of studies. First, many studies measured inequality in areas too small to reflect the scale of social class differences in a society; second, a number of studies controlled for factors which, rather than being genuine confounders, are likely either to mediate between class and health or to be other reflections of the scale of social stratification; and third, the international relationship was temporarily lost (in all but the youngest age groups) during the decade from the mid-1980s when income differences were widening particularly rapidly in a number of countries. We finish by discussing possible objections to our interpretation of the findings.

Introduction

Whether or not the extent of income inequality in a society is a determinant of population health remains a controversial issue despite a large body of research. Although the findings of a substantial majority of studies suggest that more egalitarian societies do have better health and longevity (Lynch, Smith, & Harper, 2004a; Subramanian & Kawachi, 2004), a minority conclude otherwise and several authorities remain skeptical as to whether inequality has any implications for population health (Deaton, 2003; Lynch et al., 2004a). To gain a clearer understanding of the evidence and the nature of the disagreement, we decided to review all the research reports published in peer reviewed journals, and then to see if we could arrive at an interpretation of them which made sense of both the supportive and unsupportive findings.