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WIDER Angle Newsletter World Institute for Development Economics Research No. 2/2006 WIDER Conference 2006 WIDER Annual Lecture Advancing Health Equity Global Patterns of Income and Health by Angus Deaton Inequalities in income and inequalities in health lobal inequality takes many dimensions. Not only is there great inequality across Gthe peoples of the world in material standards of living, but there are also dramatic ehtikuva / Reuters /Supri 2002 IMAP 2002 /Supri / Reuters ehtikuva inequalities in health. The inhabitants of poor L countries not only have lower real incomes, but they are also more often sick, and they live shorter lives. These international correlations between income and health should affect the way that we think about the level and distribution of global WIDER recently launched its research on health with an wellbeing. They also need to be understood if international conference entitled Advancing Health Equity, we are to be effective in reducing global poverty, held on 29–30 September 2006. Health is increasingly in incomes, or in health. Wellbeing should never recognized as an important indicator of a country’s be thought of only in terms of income, or only in standard of living as well as a measure of the wellbeing terms of health. Health scientists and economists of its citizens. Substantial and widespread improvement in need to come together if we are to fully understand health outcomes has taken place during the past century, yet global poverty and inequality and if we are to this progress has been highly uneven both within and across design policies that will be effective in making countries. This has resulted in health outcomes in many the world a better place, particularly for its most countries falling far short of commonly accepted levels. deprived inhabitants. For instance, in sub-Saharan Africa significant numbers of children now face more risk of dying than those ten years Income, life expectancy, and ago. Though these are important issues very little has been global wellbeing done to understand the root causes of the widening gap in health outcomes and even less has been done to address In a justly celebrated paper, Samuel Preston them through appropriate policies. drew a graph of life expectancy against national income, showing that, in the poorest countries, The conference, attended by over 100 experts, focused on small changes in average income were associated issues of health inequality and deprivation, specifically with large improvements in life-expectancy, in the context of developing countries. Papers presented while among the rich countries, the protective at the conference examined the causes and consequences effects of income, although still present, were less of this inequality, analyzed the patterns and trends in the pronounced. Figure 1 shows the relationship for outcomes, and evaluated policies with a particular focus the year 2000. Life expectancy is on the vertical on public health programmes. axis, and per capita national income in purchasing power parity dollars is on the horizontal axis; Papers presented at the conference and other details: the diameter of each circle is proportional to the www.wider.unu.edu population of each country. The point at which the slope flattens out, at an income per capita United Nations University of around $5,000 in 2000, is the ‘epidemiological transition’, where deaths from the ‘diseases of the bowels and lungs of children’ are replaced by deaths from ‘diseases of the arteries of the elderly’. Preston also showed that income is not the only factor at work. Even countries with stagnant incomes typically have increases in life expectancy, which he attributed to the adoption of new methods of public health, or more precisely in most cases, to the new adoption of old methods of public health. If we were to make an adjustment to income to take into account life chances, scaling down for those with poor health, and scaling up for those with good health, the and, after the Second World War, countries are mostly the lives of world distribution of this compound were rapidly brought to the rest of babies, and these reductions in of income and health would be the world. As a result of this diffusion infant mortality have a dramatic much more unequal than the world of health knowledge, cross national effect on increasing life expectancy. distribution of either health or inequality in life expectancies fell Indeed, in the years immediately income taken separately. The case quite sharply in the years after 1950. after the Second World War, in the for humanitarian action to improve If, for example, we take a simple heyday of malaria eradication and the lot of the world poorest is compound measure of income and child vaccination, some countries stronger once we recognize that the health by multiplying income by increased their life expectancies poor are doubly deprived, not only life-expectancy, then inequality by several years each year. By in material living standards, but also over countries declined for most of contrast, the current increase in in lower chances of living a long and the post-war period, driven not by life expectancy in rich countries healthy life. any reduction in income inequality is largely driven by reductions in between countries, but by the the mortality rates of the middle- The joint distribution of global convergence of life-expectancy. aged and elderly, partly through health and income has undergone reductions in smoking, partly remarkable changes over time. Things fell apart after 1990. HIV/ through improvements in medical Before the industrial revolution, AIDS in sub-Saharan Africa undid prevention and treatment, particularly there was relatively little inequality almost all of the increases in life- for cardiovascular disease, and between countries in either health or expectancy of the previous 40 years partly from improvements in the income, although there was a great and there was a significant, although health and nutritional standards deal of inequality within countries. smaller, reduction in life expectancy of children 50 years ago. It is far As the material living standards of in the countries of the former Soviet from clear how we should compare the countries of northwest Europe, Union. Huge gaps in life expectancy the value of mortality reductions particularly Britain, began to pull opened up again between many at different ages. Focusing on the away from the rest of the world, so African countries and the rich, effects on life expectancy is one did their life expectancy rates. This healthy countries of the world, way of comparing the two, but this growth in cross-country inequality of and health (and total) inequality essentially arbitrary ‘solution’ gives incomes that began in the eighteenth increased once again. If, as we much higher weight to reductions century shows no sign of reversal might hope, the AIDS pandemic is in infant and child mortality, and to this day, but the same is not a historical anomaly, international requires a better justification than true of health. The sanitary and health convergence will resume. habit and the convenient availability preventive measures associated with of information on life expectancy. an understanding of the germ theory The cross-country convergence in of disease spread to the countries of health is arguably overstated by One important consideration is that southern and eastern Europe in the focusing on life expectancy. The fertility falls with infant mortality, early years of the twentieth century lives that are being saved in poor albeit with a lag. If parents adjust 2 their fertility so that the number of In the ‘high income’ countries, less education which is more important surviving children is the same after than 1 per cent of deaths are deaths for child mortality and health than is the reduction in infant mortality as it of children. Worldwide, there are either economic growth or poverty was before, the new age structure of around four million deaths a year reduction. Better educated women the population will eventually settle from acute respiratory infections, are better caregivers to their children, down to the previous one, except for nearly two million from diarrheal as well as more effective users of and the absence of those young children disease, and more than a million lobbyists for better health services. who were previously destined to die. from diseases that are preventable In the new demographic equilibrium, by childhood immunization. How Economic growth is much to be the babies who used to cease to exist to prevent or cure these diseases is desired because it relieves the very soon after they were born, well-known, and often long known, grinding material poverty of much of because of lack of vaccinations or so that these deaths come not from the world’s population. But economic clean water, are now not born at all lack of knowledge, but because of growth, by itself, will not be enough or, to use parallel language, now some other factor, among which to improve population health, at cease to exist immediately before poverty is clearly a leading suspect. least in any acceptable time. Instead, they are born. Before the health In further support of the poverty governments must tackle the often improvement, these now unborn hypothesis, it has long been known difficult task of increasing education, children would have been born, and that countries whose economies and of providing better public health most would have led lives beyond have grown faster have had the and health services, particularly in infancy. These possibly good lives are largest (proportionate) reductions the poorest and least served areas. lost. While not everyone accepts the in infant and child mortality. (What As far as health is concerned, the legitimacy of including the potential happens to adult mortality is not market, by itself, is not a substitute lives of unborn children in welfare something that we know with any for collective action.
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