Response to BMJ Mackenback editorial and papers

[Stephen Bezruchka]

This letter has appeared, along with one from Richard Wilkinson in the
electronic BMJ.  Stephen
(http://bmj.com/cgi/eletters/324/7328/1#18579)


"Hierarchy and Health are related"
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<P>  Dear Editor,

<P>  Mackenbach's editorial [1] suggests that individual income rather
than income distribution is the more important determinant of population
health.  That issue of the BMJ presents four studies that appear to
challenge the original hypothesis put forth by Wilkinson that posits an
independent effect of the level of hierarchy in a society and health.

<P>  The studies presented do not deny a relationship between hierarchy
and health, but the results suggest that income distribution may not
always be a good measure of that hierarchy. Non-income aspects of social
rankings operating in specific cultures may overpower single economic
measures such as income distribution.  In addition, high levels of
inequality, as Shibuya suggests, may be required before effects are
demonstrated.  [2]   However given that a perfect measure of inequality or
hierarchy does not exist, the lack of such a measure does not refute the
possibility of a significant relationship between hierarchy and health.

<P>  There is much external evidence regarding the studies in this issue
that conflict with their findings.  In Japan the poorest region (Okinawa)
appears to have the lowest mortality [3], a finding that is at odds with
Mackenback's individual income hypothesis.  Shibuya's study looked at self
-rated health, but this measure has been validated as related to mortality
measures in Japan by only one study, compared to 13 on US populations.
[4]  Only 0.8% of Shibuya's sample rated their health as poor, in contrast
to studies in other populations with higher rates such as 4.8% in a US
study.   [5]

<P>  Osler's study [6] only confirms previous evidence that  "there is
something rotten in the state of Denmark."  Denmark is the only rich
country that has worse health, as measured by life expectancy, than the
United States of America, the world's richest and most powerful country.
[7]  Unlike the USA, the Danish government has an official web site
(http://www.sum.dk/health/sider/print.htm) that calls attention to its
relatively poor health status compared to other European countries, and to
not having had the same secular time improvements as other countries.
This site also shows Denmark's poor life expectancy ranking, an unusual
admission by a country.

<P>  Muller's finding of a strong relationship of education with US state
mortality overlooks other findings relating social capital to mortality
found by Kawachi that support an inverse correlation between hierarchy and
health.   [8]

<P>  If individual income, rather than its distribution is so important,
then why does Kerala, one of India's poorest states, have a life
expectancy approaching that of the United States? [9]   The usual cry from
any research is that more studies are needed.  The key piece of evidence
required would be that the health of the richer is better where hierarchy
is decreased and everyone shares more in the fruits of society.

<P>  Stephen Bezruchka

<P>  Department of Health Services

<P>  School of Public Health and Community Medicine

<P>  Box 357660

<P>  University of Washington

<P>  Seattle, Washington 98195-3576

<P>  USA

<P>  1.	Mackenbach, J.P., Income inequality and population health. BMJ,
2002. 324(7328): p. 1-2.

<P>  2.	Shibuya, K., H. Hashimoto, and E. Yano, Individual income, income
distribution, and self rated health in Japan: cross sectional analysis of
nationally representative sample. BMJ, 2002. 324(7328): p. 16-19.

<P>  3.	Cockerham, W.C., H. Hattori, and Y. Yamori, The social gradient in
life expectancy: the contrary case of Okinawa in Japan . Soc Sci Med,
2000. 51(1): p. 115-22.

<P>  4.	Idler, E.L. and Y. Benyamini, Self-rated health and mortality: a
review of twenty-seven community studies. J Health Soc Behav, 1997. 38(1):
p. 21-37.

<P>  5.	Kawachi, I., B.P. Kennedy, and R. Glass, Social capital and self-
rated health: a contextual analysis. Am J Public Health, 1999. 89(8): p.
1187-93.

<P>  6.	Osler, M., et al., Income inequality, individual income, and
mortality in Danish adults: analysis of pooled data from two cohort
studies. BMJ, 2002. 324(7328): p. 12-15.

<P>  7.	UNDP, Human Development Report. 2001, New York: Oxford University
Press.

<P>  8.	Kawachi, I., et al., Social capital, income inequality, and
mortality. Am J Public Health, 1997. 87(9): p. 1491-8.

<P>  9.	Sen, A., Development as Freedom. 2000, New York: Knopf.