“Social change and mortality decline.” In Women’s Position and Demographic Change.  Edited by Federici, Mason, and Sogner.  New York: Oxford University Press.  Pp. 190-212.

- Women have a mortality advantage in most developed countries

- The excess mortality of men is believed to be largely biological

- Demographers and scientists have attempted long attempted to quantify this “natural” mortality advantage among women;

- Most common estimate is that women can expect to live 2 years longer than men

However, in developing countries, as well as in developed countries in the past, women’s mortality is often higher than men’s

- Lots of excess mortality for women during the reproductive years due to the hazards of childbirth

- Also excess mortality of female children perhaps due to lower valuation of girls compared to boys (girls given less access to nutrition, hygiene, and medical facilities)

- In these countries more girls die of infectious diseases than boys

- Economic and social progress has been accompanied by a reduction of the difference between the social status of men and women and allowed them to gain a mortality advantage over men

This advantage is even greater than what we would expect if men and women behaved in identical ways

- In the period 1974-1978, men had greater mortality than women at every age

- In infancy, boys more likely than girls to die of genetic defects

- In young adulthood, boys more likely than girls to die of accidental causes

- In late adulthood, men more likely than women to die of degenerative diseases, neoplasms, and malnutrition

However, it is difficult to say to what extent the current mortality advantage of women is due to social or biological factors

- However, women’s participation in certain behaviors that have long been characteristic of men, such as smoking, drinking, driving cars, and working outside the home, should have caused their mortality to converge with men’s; why hasn’t this happened?

- Women are still given “protected status” in society more so than men

- Although more women are engaging in risky, masculine behaviors, they do so to lesser degree than men

- Women less likely to perform manual labor than men

- Women tend to utilize medical services more and take better care of their health than men

“Socioeconomic differences in adult mortality and health status.” In Demography of Aging. Eds. Linda Martin and Samuel Preston. Pp. 279-319.

- Purpose of chapter is to review recent evidence about the extent and sources of socioeconomic differences in health and mortality among older people in the US .

Trends in mortality by education

- Education differentials in mortality increased between 1960 and 1971-1984

- More pronounced differentials for men than women, especially in the prime working ages

- Education differentials in mortality by education smaller at older ages (basically completely gone by 85+ years)

Trends in health by education

- Education differentials in disability and ill health are quite large by middle age

- At ages 45-54, more than one-third of ppl with 0-8 yrs of schooling are in “fair” or “poor” health, compared with less than 5% of those who finished college

- Differences by education get smaller at older ages (just like mortality)

- Potential sources of socioeconomic differentials in health and mortality

 Income/wages/education

- People with higher SES are able to purchase more health-enhancing goods and services (healthier foods, gym membership, larger living space, less polluted residence)

- This is sometimes referred to as the “deprivation” model: poor people suffer ill health and premature death because they are poor

Price of health related goods and services

- The market price of seeing a doctor may be much higher for a poor person who lacks health insurance

- Opportunity cost of seeing doctor for hourly employees

- Knowledge of medical knowledge and technique

- Poorer classes may not be aware of treatments that are available

Personal endowments from childhood

- Children of higher status may have a healthier disposition, may have

 good health habits, may have parents with good genes, etc.

Tastes

 - Members of higher classes may have a preference for deferring gratification that affects both class and health

 “The daily struggle of poor people to meet their basic needs for food, clothing, and shelter causes them to place lower priority on more distance dangers.” (p. 302)

- Empirical studies reveal that the behavior to which the largest number of excess deaths in the US are attributable is smoking, which is much more prevalent among low SES individuals

-Nevertheless, even accounting for many variables that are believed to account for SES differences in health and mortality typically fails to explain more than 40% of the variance

- Some researchers suggest that some generalized factor or fundamental cause may be responsible for the differences

-Racial differences in health seem primarily attributable to differences in income and education

racial mortality crossover:

blacks tend to have lower mortality than whites at oldest ages

“The significance of socioeconomic status in explaining the racial gap in chronic health conditions.” American Sociological Review, 65(6), 910-930.

- According the 1996 estimates, life expectancy of Black men in the US was 66 years compared to 74 years for white men

- Although evidence suggests that the black-white mortality gap converges at older ages (beyond age 65), blacks still remain disadvantaged (Elo and Preston 1994)

2 main questions addressed in paper

1. Are blacks consistently disadvantaged relative to whites across all major chronic diseases and disabling conditions?

2. How do fundamental social conditions affect the racial gap in health?

- Association between race and prevalence is assumed to reflect the historical relationship between SES and health conditions by the time of middle age

- Whereas association between race and incidence is assumed to reflect the occurrence of health problems during middle age

- Include a wide array of covariates in their models because race is assumed to represent the confluences of biological factors, geographic origins, cultural, economic, political, and legal factors, and racism

- For any particular disease, race differences are likely to be the result of differences in combinations of experiences over the life cycle

- Use 1992 and 1994 waves of HRS (respondents 51-61 years old) to assess 1992 prevalence and 1992-1994 incidence of diseases and conditions

- Dependent variables include major fatal chronic diseases (heart disease, hypertension, stroke, diabetes, COPD, and cancer), arthritis and mental diseases, and disability at work and home

- Independent variables include race, gender, educations, mid-life ses, life stressors, social support, health behaviors, and health insurance

Results

- Greater prevalence of all health problems in blacks

- Also higher incidence, but not as substantial

- The greater prevalence of health problems among blacks at middle age is likely to result of cumulative disadvantage over the life cycle, rather than simply the result of the simple bifurcation of health at middle age

- Particularly bad health among black women

- Education and social structure, rather than risk behaviors, explain most of the racial disparities in health (lends support to Link and Phelan’s “fundamental causes of disease” argument)

- It is also important to recognize that health disparities may increase ses disparities between blacks and whites

- Prior to this research, health differences by race were believed to be biological

- This study suggests that health is a product of social variables

- Health results from economic inequality, educational inequality, lifestyle differences, etc.

 “The 1918 influenza epidemic’s effects on sex differentials in mortality in the United States.” Population and Development Review, 26(3). 565-581.

- Authors suggest that the 1918 flu had a strong and long-lasting effect on differential mortality by sex, reducing the female advantage

- Operated through a selection effect whereby young men with TB were particularly likely to die from the flu, reducing the number of male deaths to TB in the years following 1918

- By selection effect, the authors mean the increased robustness of a cohort over age and time due to a shift in the unobserved heterogeneity among mortality risk factors

            - 4 aspects of the 1918 flu epidemic that set it apart from other flu epidemics

                        - It’s magnitude

                        - It’s high mortality rate

- It’s W-shaped mortality profile (infants, the elderly, and young adults were all especially likely to die from the flu)

- It’s unique molecular composition

- Just after the 1918 flu, TB death rates experienced their steepest decline of the century, and the decline was much more pronounced for males than females

- TB infection was a key risk factor for contracting and dying from the flu

- The authors find that if pre-1918 trends in male and female ASDRs had continued through 1932, the number of deaths to TB in the US would have been 500,000 greater than actually occurred and the majority of deaths would have occurred among males

 Black/White mortality differs across place and across the life course, and his main contribution was to look at where black men live. In urban areas the difference are different, but in low-income areas, less of a difference in mortality by race.

Also finds in high poverty areas black-white functional limitations almost reach a convergence find while blacks at younger ages have more functional limitations than whites by around decades but significant heterogeneity with rural blacks having an advantage over urban black.

“The hidden penalties of gender inequality: Fetal origins of ill-health.” Economics and Human Biology, (1), 105-121.

Missing Women

- Main argument is that gender inequality harms the health of the entire population

- Overlapping health transitions in the developing world describe a regime in which both communicable diseases and chronic diseases are prevalent simultaneously

- Communicable diseases tend to affect children in poorer segments of the population whereas chronic diseases tend to affect adults in relatively better-off segments of the population

- Authors argue that both of these patterns are exacerbated by the common factor of maternal deprivation operating via fetal deprivation

- In Southeast Asia, mortality rates of women much higher than men

- Estimate 37 million “missing women” in India alone (women that would be alive if it were not for gender inequality)

- 100 million missing women worldwide

- Systematic biases against women -> higher mortality rates among women and averting of women that would have been born

- Authors suggest that gender bias -> maternal undernutrition -> low birthweight -> both child malnutrition and adult poor health

Two types of pathways link low birthweight to adult ill health

- Low birth weight babies may suffer from malnutrition and growth retardation in childhood and typically grow up to be adults of short stature and low BMI

- Barker Hypothesis: Low birthweight infants have bodies and organs that expect to be in a nutrient-poor environment for the rest of their lives

- Babies born with a low birthweight may be better-off in a nutrient poor environment than babies born at normal birthweight because their bodies adapted in the womb

- Babies born with a low birthweight that grow up in a normal or nutrient-rich environment may have more health problems than if they had grown up in a nutrient poor environment because they are more likely to suffer from hypertension, type II diabetes, cardiovascular disease, lung disease, and renal damage

- This hypothesis is supported by the fact that Indian adults have the highest rates of diabetes in the world

- In sum, gender inequality essentially leads to a double jeopardy—simultaneously aggravating both regimes of communicable and chronic diseases and raising the economic cost of the overlapping health transition

- Policies aimed at reducing gender inequality might be the most effective means of preventing these health problems

“Inequality in life spans and a new perspective on mortality convergence across industrialized countries.” Population and Development Review, 31(4), 645-674.

- Authors want to know whether the age pattern of mortality has converged across industrialized countries as life expectancy has

- Examine the standard deviation of ages at death past age 10 (S₁₀)

- Also examine within-group versus between group variation

- Analysis of 7 industrialized countries reveals only a slight decrease in the variation of death rates since 1960

  - The US has the highest S₁₀ of the countries examined

- What accounts for high S₁₀ in the US?

- Increasing differentials in life expectancy for males and females

- In addition, males have greater variation in mortality rates than females

- Race doesn’t seem to be driving high US S₁₀

- However, blacks have greater variation than whites

- SES (measured by dichotomized education and income) doesn’t account for higher US S₁₀

- However, disadvantaged groups have higher variance than advantaged ones

- Although authors did not find clear patterns of what’s driving S₁₀, they argue that it remains a useful measure for revealing life-span inequality (which may be the most fundamental form of inequality in the human population), as well as for forecasting future mortality, planning for work, saving, and investing, and for determining Old Age Support policies

“Rethinking gender differences in health: Why we need to integrate social and biological perspectives.” Journals of Gerontology, 60B, 40-47.

Review of the literature on gender differences in mortality and morbidity

- Although women have lower rates of mortality than men, they have higher rates of morbidity    

Men are more likely to die of CVD at every age, but more women ultimately die of CVD

- This is because women outlive men

- Women have higher rates of auto-immune disorders

- Women have higher rates of depression, especially in middle age

- Biological and social explanations alone are incapable of explaining these gender differences in health

Authors argue that different constraints placed on men and women by social policies, community actions, work, and family affect the social and health-related choices they make, and ultimately result in health differences

- For instance, workplace policies regarding on-site childcare affect stress levels and lifestyle decisions of men and women differently

- Such a policy might affect how long a woman decides to breastfeed her child, which impacts her hormones and risk of breast cancer

- Obviously, such a policy would not have the same effect on men

- A focus on constrained choices brings much-needed attention to the contribution of multiple levels of contextual effects on men’s and women’s health

Black - white crossover (@ 82 for women)

Frality effect

The "frailer blacks die earlier and at older ages the most robust are still alive

“Sex differences in morbidity and mortality.” Demography, 42(2), 189-214.

- The gender paradox in health refers to the fact that women have worse self-rated health and more hospitalization episodes than men in early and middle age, but are less likely to die at each age

-Researchers examine whether or not this paradox is true, and if so, why

Some possible explanations

1. Sex differences in the distribution of chronic conditions;

-women may be more likely to suffer from conditions, such as headaches and arthritis, that result in poorer self-rated health but contribute relatively little to mortality,

-whereas men may be more likely to have conditions such as cardiovascular disease that have relatively large effects on the probability of death

2. Women may simply report worse health than men on surveys

Findings

Use data from the National Health Interview Survey (1986-1994; 1997-2001)

- Women do indeed report worse self-rated health than men but are less likely to die

- Men and women with the same health conditions report similar self-rated health

- This suggests that differences in self-reports are due to differing distributions of disease, rather than reporting differences

- Women are more likely to get chronic but not fatal conditions (headaches, arthritis, depression) whereas men more likely to get fatal conditions

- Men are also more likely to die from smoking-related diseases than women with the same diseases

- Specifically, 50% of sex difference in mortality explained by 14 chronic health conditions,

with 25% of this difference explained by men being more likely than women to have conditions that have larger effects on mortality and

75% of it explained by men having greater probability of dying than women with same chronic conditions

“The exceptionally high life expectancy of Costa Rican nonagenarians.” Demography, 45(3), 673-691.

 2 major hypotheses exist for why mortality rates are declining and the death rates of the oldest-old are decelerating

1. The heterogeneity in frailty hypothesis suggests that frail people die off when conditions are harsh at younger ages, leaving only the hearty among the oldest old

- Past improvements in health conditions at early ages may be benefiting today’s elderly

2. The heterogeneity in frailty hypothesis suggests that poor conditions early in life may strengthen a cohort at older ages

- Absence of accurate data about old-age mortality in low-income populations has been a major obstacle to examining this hypothesis

- Author hopes to shed some light on this theory using data from Costa Rica

- Costa Rica has notoriously good vital statistics and exceptionally high old-age longevity

Results

- Costa Rica does have significantly higher life expectancy at age 90 than low-income countries

- A comparison with the US and Sweden suggests that this advantage is mostly due to lower cardiovascular disease mortality among Costa Ricans

- Costa Ricans also have much lower prevalence of obesity

- Government emphasis on health care may also contribute to advantage

- The Costa Rican advantage (compared to high-income countries) is particularly large for males, although male life expectancy at age 90 is still 0.3 years less than that of females

- Although this analysis cannot really get at why these patterns occur, author suspects it may be due to a heterogeneity of frailty effect, in light of the fact that this cohort of individuals survived exceptionally high infant mortality rates due to infectious diseases

- If this is the case, the exceptional longevity of Costa Ricans may decline as new, less hearty cohorts age

The greatest change in projected LE would be if everyone were non-smokers and had normal BMI.

However the smoking rates declining would lead to more LE than constant BMI.

discusses disparities and the reasons behind higher risk of mortality for blacks.

Discuss medical access

 health behaviors

working

and early life conditions may cause black-white differences

Frisby et al 2007

from 1980 -2001 infant mortality ratio of blacks to whites? - increased from 2.0 to 2.4 indicating less favorable conditions for blacks