Income Inequality and Health: A Critical Review of The Literature

ARTICLE
MCR&R 60:4
10.1177/1077558703257169
Macinko et al.(December
/ Income Inequality
2003) and Health
Review
Income Inequality and Health:

A Critical Review of the Literature
James A. Macinko
New York University Steinhardt School of Education
Leiyu Shi
Johns Hopkins Bloomberg School of Public Health
Barbara Starfield
Johns Hopkins Medical Institutions
John T. Wulu, Jr.
Bureau of Primary Health Care, HRSA/DHHS
This article critically reviews published literature on the relationship between income
inequality and health outcomes. Studies are systematically assessed in terms of design,
data quality, measures, health outcomes, and covariates analyzed. At least 33 studies
indicate a significant association between income inequality and health outcomes, while
at least 12 studies do not find such an association. Inconsistencies include the following:
(1) the model of health determinants is different in nearly every study, (2) income
inequality measures and data are inconsistent, (3) studies are performed on different
combinations of countries and/or states, (4) the time period in which studies are con-
ducted is not consistent, and (5) health outcome measures differ. The relationship
between income inequality and health is unclear. Future studies will require a more com-
prehensive model of health production that includes health system covariates, sufficient
sample size, and adjustment for inconsistencies in income inequality data.
Keywords: income inequality; health determinants; social epidemiology; health

inequalities
Over the past decade, there has been an ongoing debate over the role of
income inequality as a determinant of population health. The debate contin-
Medical Care Research and Review, Vol. 60 No. 4, (December 2003) 407-452
DOI: 10.1177/1077558703257169
© 2003 Sage Publications
407
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408 MCR&R 60:4 (December 2003)
ues, with evidence both for and against what has become known as the rela-
tive income hypothesis—the proposition that the distribution of income
within societies (independent of absolute levels of income or wealth) is an
important determinant of that population’s health. This document presents a
critical examination of the public health and social science literature describ-
ing the relationship between income inequality and health status. It reviews
the numerous empirical studies in the area, assesses the strength of study
designs and data sources, presents a summary of the major theories describ-
ing the observed relationship, and proposes a comprehensive conceptual
framework and specific considerations that should be taken into account for
future studies.
NEW CONTRIBUTION
This review differs from previous efforts (see Wagstaff and van Doorslaer
2000; Lynch, Smith, et al. 2000) because it looks at a comprehensive range of lit-
erature, both within and outside of the public health field. This review exam-
ines nearly 50 studies on income inequality and health, including the follow-
ing: (1) studies aiming to demonstrate or refute the relationship between
income inequality and health, (2) theoretical and empirical literature on the
pathways through which income inequality could influence health, and (3)
social science literature on the production of income inequalities within and
between countries. This review also emphasizes the role of the health system
as a potential mediator of the relationship, a factor largely unexplored in the
existing literature. Finally, this review proposes a comprehensive conceptual
framework for ordering and understanding the relationships among political,
economic, social, and biological factors proposed as causes, consequences, or
confounders of the relationship between income inequality and health out-
comes. Such a framework is intended not only to organize this review but also
to suggest a more conceptually sound model for exploring the relationship
between income inequality and health outcomes.
METHOD
This integrative literature review was conducted between October 2001
and January 2002. It utilized methods identified by Shi (1996) and Fink (1998).
The search used the following electronic databases: PubMed, OVID (in-
This article, submitted to Medical Care Research and Review on April 22, 2002, was revised and ac-
cepted for publication on October 23, 2002. This study was partially funded by a grant (T32 HS
00029) from the Agency for Healthcare Research and Quality.
Macinko et al. / Income Inequality and Health 409
cluding all sociological, political science, psychology, education, and econom-

ics journals), and dissertation abstracts. Each database was searched for arti-
cles that contained the phrase “income inequality AND health” in either the
title or abstract. The search was not limited by date but only included articles
written in English, French, or Spanish. This process revealed 327 potential
articles. In addition, individual journals that publish frequently on the topic
were each searched from 1990 to the present. This revealed an additional 30
relevant articles. All articles were then culled to identify another 18 references.
Finally, to ensure that the search parameters were wide enough, an additional
search for the terms income inequality and health AND inequality was conducted
through the Library of Congress catalog, which, after inspection of titles and
descriptions, revealed 17 relevant books. After inspection of abstracts and
evaluation of methodologies, 47 key articles were retrieved and abstracted
(see the appendix). Only articles published in peer-reviewed journals and rep-
resenting empirical studies or literature reviews were abstracted, although
other articles, books, and editorials are discussed throughout this document.
The theoretical literature was used to supplement empirical studies to
develop the conceptual framework and assess the adequacy of the empirical
models reviewed, especially in terms of the plausibility of results and the
inclusion of a minimum set of covariates used in multivariate models.
CONCEPTUAL FRAMEWORK
To organize this review and to attempt to integrate the many strands of lit-
erature examining the relationship between income inequality and health, we
propose a multidimensional conceptual framework, as presented in Figure 1.
The framework is based on the work of Starfield and Shi (1999) and others but
has been modified based on findings of the literature reviewed here. Thus, the
framework is an outcome and a method of organizing this review.
Figure 1 describes distal and proximal determinants of health at the macro
and micro levels. It organizes these determinants into four main columns.
Beginning at the left, Panel Arepresents national political, cultural, and histor-
ical factors that produce income inequality and influence all other health
determinants. Examples include systems of governance, legal and institu-
tional factors governing union formation and health financing, cultural atti-
tudes toward welfare and charity, and historical patterns of social relations.
Panel B shows income inequality. It is important to note that previous stud-
ies have positioned income inequality in different places within the frame-
work. Our review of the sociology and economics literature suggests that it is
most appropriately viewed as a consequence of political and cultural factors,
and a potential modifier of macro- and microlevel health determinants. The
C.1 D.1
B.1 Income Physical Exposures
Inequality
Environment
C.2 D.2
A.1 National Politics
Macro Economic
& Policies
Economics Resources E.1
Health
Outcomes
A.2 C.3 Social D.3
National Culture & Relations/ Social
History Cohesion Resources
C.4 Health D.4

& Other Access/Use
Services of Services
FIGURE 1 A Simplified Conceptual Framework of the Relationship between

Income Inequality and Health Outcomes
literature reviewed here does not suggest that there is any direct effect of
income inequality on health outcomes. Instead, income inequality is hypothe-
sized to work through one or more health determinants.
Panel C shows macrolevel determinants of health. In the literature
reviewed here, none of these factors (with the possible exception of social
cohesion) is hypothesized to have a direct impact on health, but all are none-
theless important precursors to the factors presented in Panel D. Macrolevel
health determinants include the physical environment (e.g., air and water pol-
lution, community or neighborhood characteristics, and infrastructure), mac-
roeconomic environment (e.g., employment, gross national product [GNP],
cost of living), social relations and cohesion (e.g., social class structure, com-
munity-level social capital), and health and welfare services (e.g., primary
care services, educational institutions, welfare programs). Note that the
framework does not attempt to describe the relationships among factors
within each panel.
Panel D describes microlevel health determinants. These include expo-
sures and risk factors (e.g., exposure to pollutants and external causes of inju-
ries, and unhealthy behaviors such as drinking and smoking), economic
resources (e.g., income), social resources (e.g., social networks, coping
abilities), and access and use of services (e.g., ability to use health services,
obtain medicines, and join Women, Infants, Children [WIC] programs when-
ever needed). It is clear that these factors are often interrelated (e.g., availabil-
ity of income can help determine whether one will use health services), but we
make no attempt to tease out the relationships among the separate variables.
Finally, Panel E represents health outcomes. These include life expectancy,
mortality, self-rated health, morbidity, mental health, and others. It is likely
that a more detailed look at the causes of these outcomes would necessitate
modifications to the conceptual framework; however, for the purposes of this
review, we do not make such distinctions.
The framework presented above organizes this review. First, this review
describes the literature examining simple associations between income
inequality and health. Then, it examines studies that propose a pathway
between income inequality and health outcomes. It then reviews criticism of
these approaches and presents alternative explanations for the observed rela-
tionship between income inequalities and health. Finally, we present an analy-
sis of the empirical evidence and provide suggestions for future studies on
this topic.
INCOME INEQUALITY AND HEALTH

The health and social science literature is replete with studies of the impact
of income, poverty, and social policies on the health of individuals (see over-
views by Rodriguez-Garcia and Goldman 1992; World Bank 1993; Basch
1990). Numerous studies have supported the hypothesis that individual
socioeconomic status (Antoft, Gadegaard, and Lind 1974; Blaxter 1987;
Hollingsworth 1981; Mackenbach et al. 1997; Marmot et al. 1991) or its compo-
nents of income (Blackburn 1994; Grant 1977; Salkever 1975; Wilkins, Adams,
and Brancker 1989), education (Christenson and Johnson 1995), and occupa-
tion (Chandola 1998; Robinson 1984) have profound effects on an individual’s
health. Similar results have been found for social class (Antonovsky 1967;
Bunker 1983; Dougherty, Pless, and Wilkins 1990; Gregory and Piche 1983;
Soderfeldt, Danermark, and Larsson 1989).
In the mid-1970s, researchers began to doubt whether national income con-
tinued to play a role in determining population health within industrialized
countries (Fuchs 1974; Preston 1976). It appeared that at a certain level of
development, additional increases in income had little effect on increasing
national life expectancy (Preston 1976). This coincided with Omran’s epide-
miological transition theory that stated that as countries move toward
increased levels of economic prosperity, two things can be expected to hap-
pen. First, an epidemiological transition will take place: the cause of deaths
will shift from infectious to chronic diseases. Second, a demographic transi-

tion will take place: the burden of mortality will become increasingly made up
of the old rather than the very young, and overall life expectancy will increase
(Omran 1971).
Although the literature search revealed several early studies on the distri-
bution of health within countries (see Antoft, Gadegaard, and Lind 1974;
Mathers 1974; Smith and Kaluzny 1974), it was with the 1980 publication of
Britain’s Black Report on health inequalities that intense research efforts began
to focus less on aggregate income and health measures and more on the distri-
bution of economic and health benefits across different social and economic
groups within and across societies (Black et al. 1980). Consequently, research
on variations in health status among people with different socioeconomic sta-
tus has intensified over the past two decades.
An unexpected and important finding has been that better health outcomes
appear to be positively correlated not only with absolute levels of income but,
in some cases, even more strongly correlated with the equitable distribution of
income within society. Wilkinson (1994, 61) summarized this position by stat-
ing that “mortality rates are no longer related to per capita economic growth,
but are related instead to the scale of income inequality in each society.”
The earliest studies on the relationship between income inequality and
health stressed associational measures between health outcomes and levels of
income distribution. Referring to our framework in Figure 1, these studies
assess the association between income inequality (B.1) and a variety of health
outcomes (E.1) and occasionally control for other health determinants such as
GNP (C.2) or health system resources (C.4).
Rodgers (1979) found that in multiple regressions using 56 countries, the
level of income inequality (as measured by the Gini coefficient) was a signifi-
cant predictor of life expectancy. The study estimated that differences in life
expectancy between an egalitarian and nonegalitarian country might be as
much as 5 to 10 years. This relationship held for all countries studied but was
less pronounced among a sample of developing countries with a GNP per
capita of less than US$1,000.
Further cross-sectional ecological studies by Waldman (1992) conducted
with 1960 and 1970 data from 56 countries showed that a rise of 1 percent of
national income held by the richest 5 percent of a given population could
result in an increase in the infant mortality rate (IMR) of about 2 infant deaths
per 1,000 live births. Consistent with Rodgers (1979), this effect was somewhat
reduced in developing countries but also significant, even after controlling for
GDP per capita, total number of physicians and nurses per 1,000 population,
percentage of the country that was urban, levels of primary school enrollment,
female literacy, and the gross reproductive rate.
Wilkinson (1992, 33) made the claim that few countries having achieved a
life expectancy of 70 years or more had a GNP of less than US$5,000 per year
and that beyond that threshold “there is little systematic relation between
gross national product per head and life expectancy.” This led Wilkinson to
posit what has become known as the relative income hypothesis. According to
Wilkinson,
the sense of relative deprivation, of being at a disadvantage to those better off,

probably extends far beyond conventional boundaries of poverty. A shift in em-
phasis from absolute to relative standards indicates a fall in the importance of di-
rect material circumstances relative to psychosocial influences. The social conse-
quences of people’s differing circumstances in terms of stress, self-esteem, and
social relations may now be one of the most important influences on health.
(p. 34)
More sophisticated research designs offered support for the relative in-
come hypothesis. For example, several studies suggested that the relationship
held for units of analysis smaller than countries. One study found a strong
gradient in mortality related to the gap between the rich and poor within Eng-
lish wards/counties (Ben-Schlomo, White, and Marmot 1996). The authors
suggested that the effect of relative income is primarily an ecological or
contextual phenomenon.
Kaplan et al. (1996) found a statistically significant correlation between the
percentage of income received by the less well-off and all-cause mortality
among U.S. states. Variations in states’ income inequality were also signifi-
cantly associated with homicides, crime, low birth rate, educational attain-
ment, disability, expenditures on health care, imprisonment, and lack of
medical insurance.
Kennedy, Kawachi, and Prothrow-Stith (1996) found that inequality in the
distribution of income explains a significant proportion of cross-state variance
in several causes of mortality in the United States, independent of poverty and
smoking. The size of the gap in income between rich and poor—distinct from
the average income level of the poor—was related to mortality within U.S.
states. They used the Robin Hood Index (the percentage of income of the rich-
est 50 percent of the population necessary to transfer to the poorest 50 percent
of the population to have total income distributed equally between the two
population halves) as an alternate measure of income inequality. This mea-
sure is thought to be less sensitive to outliers in the highest and lowest income
categories.
Lynch et al. (1998) suggested that excess mortality within U.S. metropolitan
statistical areas (MSAs) attributable to income inequality could be as high as
64.7 to 95.8 deaths per 100,000, depending on the income inequality measure
used. The authors concluded that if U.S. states with the highest income
inequality could redistribute their income to the level of those U.S. states with
the lowest income inequality, then the high income inequality states could
reduce their overall mortality by as much as 139.8 deaths/100,000. This mor-
tality difference was similar in magnitude to the combined loss of life from
lung cancer, diabetes, motor vehicle accidents, HIV, suicide, and homicide in
1995.
Several studies present evidence that the relative income hypothesis also
holds for health outcomes other than mortality. For example, Diez-Roux, Link,
and Northridge (2000) found that state inequality was associated with several
cardiovascular disease risk factors (body mass index, hypertension, and
sedentarism). Income inequality was also found to be associated with higher
abdominal weight gain among a representative sample of U.S. men (Kahn et
al. 1998).
Soobader and LeClere (1999) showed that income inequality exerts an inde-
pendent adverse effect on self-rated health at the county level. Kahn et al.
(2000) found that women in the lowest income categories were more likely to
report depressive symptoms or fair/poor health. Among women in the lowest
income quintiles, those women who lived in states with higher income
inequality were more likely to report depressive symptoms or fair/poor
health status than comparable women who live in states with lower income
inequality, even while adjusting for individual characteristics such as age,
marital status, education, race/ethnicity, and household size. The relation-
ship was consistent for women in the three lowest income quintiles.
Multilevel designs have been used to measure the individual and contex-
tual effects of income inequality on population health. For example, Kennedy
et al. (1998) found that inequalities in income at the state level had an inde-
pendent, negative effect on an individual’s risk of reporting fair or poor
health. Inequalities in statewide income distribution were found to be associ-
ated with self-rated fair or poor health, even while controlling for individual
income and other risk factors. Lochner et al. (2001), using a prospective multi-
level design, also found that individuals living in states of higher income
inequality had a 12 percent increased relative risk of mortality, even after
adjusting for age, gender, race/ethnicity, marital status, and annual income.
Studies on non-U.S. populations include those by Duleep (1995), who con-
firmed the relationship between income inequality and mortality for a sample
of the Organization for Economic Cooperation and Development (OECD) and
former Soviet states. Humphries and van Doorslaer (2000) found that income-
related health inequality in Canada was between that of the United Kingdom
and the United States.
Chiang (1999) provided evidence from Taiwan that income distribution

may become a more important determinant of mortality than absolute income
as a country develops economically. In 1976, absolute income (GNP) was a
powerful and significant predictor of under-5 mortality in Taiwan. By 1995,
the distribution of income (Gini) had become a more significant predictor of
mortality in Taiwan than GNP per capita.
PATHWAYS THROUGH WHICH INCOME

INEQUALITIES INFLUENCE POPULATION HEALTH
Several possible explanations have been offered for how income inequali-
ties might affect health. These explanations are summarized in Table 1.
PSYCHOSOCIAL PATHWAYS
The first set of explanations is based on individual and society-level
psychosocial characteristics, such as levels of interpersonal trust and social
cohesion. The theoretical basis for these explanations comes from the work of
Emile Durkheim. Referring to Figure 1, these studies primarily explore the
relationships between income inequality (B.1), macrolevel (C.3) or microlevel
(D.3) social factors, and health (E.1).
At the individual level, the psychosocial explanation posits that “cognitive
processes of social comparison” work to increase individuals’ levels of stress
that concomitantly lead to poorer health status. Stress, poor social support,
and lack of control over one’s work are related to poor health and have a
greater effect on those at the bottom of social hierarchies (Wilkinson 1996,
1998). This hypothesis is supported by the Whitehall study that shows a con-
tinuous social gradient in health, that is, within a social (or economic) hierar-
chy, individuals at a given level in a hierarchy tend to exhibit poorer health
than individuals in the next highest level of the hierarchy. This relationship
holds for individuals at each and every level of the hierarchy (Marmot et al.
1991).
Interestingly, Adam Smith also discussed the idea of relative income and its
impact on social functioning and well-being. Sen (1999, 71) reminds us of
Smith’s concern that what counts as a necessity in one society is not absolute
but is determined by social norms and expectations. For example, to be able to
appear in public and to carry out one’s social functioning may require a higher
standard of clothing or other forms of conspicuous consumption in a richer
society than in a poorer one, and “the same parametric variability may apply
to personal resources needed for fulfillment of self-respect.”
TABLE 1 Explanations for the Relationship between Income Inequality

and Health
Explanation Synopsis of the Argument
Psychosocial (micro): Income inequality results in “invidious processes of social

Social status comparison” that enforce social hierarchies causing
chronic stress leading to poorer health outcomes for those
at the bottom.
Psychosocial (macro): Income inequality erodes social bonds that allow people to
Social cohesion work together, decreases social resources, and results in
less trust and civic participation, greater crime, and other
unhealthy conditions.
Neo-material (micro): Income inequality means fewer economic resources among
Individual income the poorest, resulting in lessened ability to avoid risks,
cure injury or disease, and/or prevent illness.
Neo-material (macro): Income inequality results in less investment in social and
Social disinvestment environmental conditions (safe housing, good schools,
etc.) necessary for promoting health among the poorest.
Statistical artifact The poorest in any society are usually the sickest. A society
with high levels of income inequality has high numbers of
poor and consequently will have more people who are
sick.
Health selection People are not sick because they are poor. Rather, poor
health lowers one’s income and limits one’s earning
potential.
The psychosocial explanation has its correlate at the macro level. Advo-
cates of the relative income hypothesis have theorized that income inequality
may lead to changes in society by creating a climate of mistrust, reduced coop-
eration, and decreased propensity to join voluntary organizations. Several
authors have variously termed this concept social cohesion, social trust, and
social capital. In spite of difficulties with the definitions and measurement of
these concepts (see Macinko and Starfield 2001), all suggest a social mecha-
nism that is related to psychosocial stresses associated with the status and
power differentials caused by income inequalities. This explanation is based
on the role of social relations and networks in determining individual and
population-level health (Berkman and Kawachi 2000; Berkman and Syme

1979; Durkheim 1951).
For example, Kawachi et al. (1997) found that income inequality within
states (as measured by the Robin Hood Index) was correlated with group
membership and lack of social trust. Aggregated rates of social mistrust (the
percentage of respondents who answered that “you can’t be too careful in
dealing with other people”), perceived lack of fairness (the percentage of
respondents who answered that “most people would try to take advantage of
you if they got the chance”), and per capita membership in voluntary organi-
zations were associated with total state all-cause mortality while adjusting for
poverty and income inequality. Path analysis suggested that income inequal-
ity leads to a lowering of social trust that then leads to increased mortality.
Kawachi, Kennedy, and Glass (1998) expanded on these findings. They
used General Social Survey (GSS) measures of civic trust, reciprocity (helpful-
ness of others), and civic engagement. Using a multilevel model, they found
that a person living in a state with low levels of social trust was 40 percent
more likely to report lower self-assessed health status than someone living in
an area of higher social trust. Similar results were found for those living in
states characterized as having low and medium group membership and low
and medium reciprocity (Kawachi, Kennedy, and Glass 1998).
Kawachi, Kennedy, and Wilkinson (1999) further expanded on the mean-
ing of social capital by proposing that among U.S. states, inequalities in envi-
ronmental and social characteristics help to predict geographic variation in
crime. The results suggested that state-level income inequality (as measured
by the Robin Hood Index) was highly associated with violent crime such as
homicide. Low levels of interpersonal trust and the number of female-headed
households were correlated with higher homicide rates. Health status mea-
sures were not included in the study. These studies follow others showing
associations between income inequality, crime, and other unfavorable social
conditions (see Chiu and Madden 1998; Sampson, Raudenbbush, and Earls
1997; Walberg 1998).
Kawachi, Kennedy, and Brainerd (1998) applied measures of social capital
to explain increased mortality in Russia after the fall of the Soviet Union. They
used voting rates and trust in government as social capital measures and also
included a number of variables related to what the authors term social cohe-
sion. These include crime, divorce rates, and conflicts in the workplace. Each
of these social indicators was strongly associated with all cause age-adjusted
mortality and life expectancy for men and women.
NEO-MATERIAL PATHWAYS
The second main set of explanations emphasizes neo-material and eco-
nomic factors and stems from either a Marxist or rational choice orientation.
These studies primarily explore the relationships among income inequality
(B.1), macroeconomic factors (C.2), individual economic resources (D.2), and
health (E.1). They also occasionally incorporate measures of the physical envi-
ronment (C.1) and individual exposures (D.1).
In many ways, the neo-material approach developed out of critiques of the
psychosocial pathway literature. It is founded on the proposition that material
factors, such as income and living conditions, are the most important
determinants of health. In contrast to the Durkheimian theories of psychosocial
stress and social cohesion, the individual-level income hypothesis holds that
aggregate-level associations between income inequality and health reflect
only the individual-level associations between absolute income and health.
The neo-material explanation incorporates the individual-level health
hypothesis but goes further by claiming “health inequalities result from the
differential accumulation of exposures and experiences that have their
sources in the material world” (Lynch, Smith, et al. 2000, 1202). The effect of
income inequality on health is thought to be the result of negative exposures,
lack of resources, and systematic underinvestment in human, physical, health,
and social infrastructure. Thus, it incorporates individual- and contextual-
level factors but emphasizes that accumulated exposures resulting from
poorer physical conditions and reduced quality of education and other social
services adversely affect the life chances and health outcomes of those at the
lowest end of the social spectrum. As an illustration of this concept, Kaplan et
al. (1996) found that U.S. states with high income inequality also had lower
rates of medical care expenditures and higher rates of unemployment.
Muntaner and Lynch (1999) argued that the psychosocial explanation is
flawed because of the following: (1) Class relations are ignored, (2) interna-
tional economic relations are not analyzed, (3) politics are not included as a
determinant of population health, (4) social cohesion is not well defined, (5)
the role of medical care is underemphasized, and (6) there is little evidence
that social cohesion and equality are related.
Lynch, Due, et al. (2000, 406) offered an alternative explanation for the role
of social capital and income inequality on population health. They claimed
that “absolute and relative income differences may represent the unequal dis-
tribution of the material conditions that structure the likelihood of possessing
and accessing health protective resources; of reducing negative health expo-
sures; and of facilitating full participation in the society.” Essentially, they
argued that disturbed social relations are the effect of health and social
inequalities, not their cause.
Lynch, Smith, et al. (2000) asserted that data for the association between
psychosocial pathways and income inequality are ambiguous at best. Their
objections include the following: (1) the macrolevel social cohesion hypothe-
sis ignores structural causes of the inequality, (2) it oversimplifies the role of
social cohesion, and (3) the data do not clearly show that as income inequality
increases, social indicators also uniformly decrease. Instead, they suggested
that systematic differences in material conditions (at the individual and con-
textual levels) better explain the observed relationship between income
inequality and health. Lynch, Smith, et al. suggested specific public policy
interventions such as investments in schooling, health care, social welfare,
and working conditions and more equitable distribution of public and private
resources as ways to address inequalities in health. A similar argument was
presented by Bobak et al. (2000).
Lynch et al. (2001) conducted an ecological study that was improved over
previous studies because it used income inequality measures from the Lux-
embourg Income Survey (LIS)—widely considered to be the most accurate
and consistent income data available (Atkinson, Rainwater, and Smeeding
1995)—and tested a wide range of health outcomes. The authors found that in
a sample of 16 OECD countries, higher income inequality was consistently
associated with higher infant mortality. Associations between income
inequality and all-cause mortality decreased with age, and actually reversed
in populations older than 65 years. Cause-specific mortality showed no clear
relationship. Psychosocial variables (trust, organizational membership, vol-
unteering) showed weak and inconsistent relationships. They concluded that
overall, psychosocial pathways seem to play little role in the relationship
between income inequality and health (Lynch et al. 2001). The study did not
include any measures of the medical or social services system.
THE ROLE OF HEALTH SERVICES

AND PRIMARY CARE
In general, the studies reviewed here did not incorporate the role of health
services in the analysis of the relationship between income inequality and
health. In our conceptual framework, there are two main levels at which the
health system may influence the relationship between income inequality and
health: through the structure and availability of health and other social ser-
vices (C.4) and individual access and use of specific services (D.4).
Although the literature indicates some skepticism as to the overall contri-

bution of medical care to the improvement of population health worldwide
(McKeown 1976; McKeown, Record, and Turner 1975; McKinlay and McKin-
lay 1977), there is evidence that access to certain types of medical care may be
more beneficial than others in reducing a country’s overall burden of disease
(Starfield 1996). For example, Bunker (2001) has suggested that in some coun-
tries, as much as half of the 7.5 years of increased life expectancy since 1950 is
the result of improved medical care. Another study on the determinants of
decline in mortality rates in the Netherlands from 1875 to 1924 likewise high-
lighted the historical role of medical care—particularly public health inter-
ventions and health education provided through primary care settings—in
contributing to long-term improvements in population health (Wolleswinkel
et al. 2001).
Other authors have suggested that at least some of the historical differences
in health status between the rich and poor may be in part due to differential
access to basic health services (Mackenbach, Stronks, and Kunst 1989). In par-
ticular, primary care, defined as “that level of a health service system that pro-
vides entry into the system . . . provides person-focused care over time, pro-
vides care for all but very uncommon or unusual conditions, and coordinates
or integrates care provided elsewhere or by others” (Starfield 1998, 8-9), has
been shown to have an important impact on health outcomes for some of the
most common medical problems (Starfield 1996). Furthermore, several stud-
ies have demonstrated that the extent of primary care orientation (as opposed
to a system based on physician specialists) has a statistically significant effect
on improving life chances, particularly among the disadvantaged (Shi 1994).
Among the studies abstracted in the appendix, there were contradictory
findings as to whether access to health services was associated with health sta-
tus and income inequalities. Flegg (1982) found that the number of physicians
and nurses per capita had a statistically significant effect on health outcomes
in models including income inequalities, while Judge, Mulligan, and
Benzeval (1998a, 1998b) and van Doorslaer et al. (1997) found no consistent
association. One possible explanation for this discrepancy is that Flegg’s anal-
ysis included primarily developing and middle-income countries, while
Judge et al. and van Doorslaer et al. included only wealthy OECD countries in
their analysis. This choice of countries is important because generic measures
of medical care may be stronger predictors of overall population health status
in developing countries than in more wealthy ones. Moreover, none of these
authors differentiated between primary care and specialty care, which is a
particularly important distinction when examining the impact of health care
on outcomes in wealthy OECD countries (Shi and Starfield 2000; Starfield and
Shi 2002).
Other health and social services indicators, such as overall social expendi-
tures (Gustafsson and Johansson 1999) and investments in medical care
(Kaplan et al. 1996), have been found to be associated with lower income
inequality, but these same expenditure variables have not always been found
to be associated with mortality (Judge, Mulligan, and Benzeval 1998a; van
Doorslaer et al. 1997).
Shi et al. (1999), in an ecologic study in the United States, found that income
inequality and primary care (measured by primary care physicians per 10,000
population) exerted a strong and statistically significant influence on state-
level mortality and life expectancy. Path analysis suggested that primary care
might overcome some of the adverse health impacts of income inequality on
population health.
In a multilevel model including individual-, community-, and state-level
variables, Shi and Starfield (2000) present stronger evidence for the ability of
primary care to partially attenuate the adverse health effects of income
inequalities. In multivariate analyses, income inequality and primary care
were significantly associated with self-rated health. Primary care significantly
attenuated the effects of income inequality on self-reported health status.
Adding individual-level socioeconomic status variables somewhat reduced
the magnitude of the association between income inequality, primary care,
and self-reported health. The study found that while controlling for all
covariates, an increase of one primary care physician per 10,000 population
was associated with a 2 percent increase in the odds of reporting excellent/
good health.
Although the authors do not propose any specific mechanisms, there may
be several possible explanations for the observed relationship between
income inequality, primary care, and health. One mechanism for such an
influence is that access to a regular source of primary care may improve health
promotion and early detection of diseases such as complications of hyperten-
sion (Shea et al. 1992). Primary care is conceived of as that aspect of the health
care system where the majority of care is provided through its role of first con-
tact with the health system and its attributes of providing comprehensive,
coordinated, and longitudinal care (World Organization of National Colleges,
Academies and Academic Associations of General Practitioners/Family
Physicians [WONCA] 1991).
Second, there is evidence that strong primary care can lead to appropriate
and more efficient secondary and tertiary care (Casanova, Colomer, and
Starfield 1996; Casanova and Starfield 1995).
Third, because primary care implies person-oriented, longitudinal, and
first-contact care, it is expected that in the best of circumstances, individuals
living in areas with high levels of primary care providers may develop an
important social tie with their primary care provider.
Finally, primary care may function as an important measure of social trans-
fer that could compensate individuals for their relative income deprivation
with an essential social service.
CRITIQUES OF THE RELATIVE

INCOME HYPOTHESIS
Although much of the early literature on income inequality and health con-
firmed the findings that such a relationship existed, there is now a growing
body of literature that questions the validity of the relative income hypothesis
and its explanatory theories. The studies reviewed here consist of critiques of
the relative income hypothesis, negative findings, and alternative explana-
tions for the observed relationship. These studies are organized into several
categories to aid analysis and describe trends in the intellectual development
of this literature. These categories include discussions of data quality, method-
ological discussions, and alternative explanations for the observed relation-
ship. Taken as a whole, these studies cast doubt on several features of the rela-
tive income hypothesis and argue that the role of income inequality on health
may be modest and perhaps limited to only certain societies and certain health
outcomes.
MEASURING INCOME AND INCOME INEQUALITY

Income and income inequality are notoriously difficult to measure. Table 2
provides a summary of the major measures of income inequality and their
advantages, disadvantages, and most common data sources. In addition to
differences in the construction and interpretation of the income inequality
measures, the household income data on which inequality indices are derived
can differ significantly from study to study. Two key concepts are disposable
(net) versus total (earned) income, and income that has been equivalized for
household size. Disposable income refers to household income that is net of
taxes and other income transfers. The idea is that disposable income is a more
valid and comparable income measure because different households will
have different purchasing power, depending on the taxes and social transfers.
Such differences in real purchasing power would not be captured by using
total (gross) family income. This distinction can be important. For example, in
a country with a highly progressive tax system, using gross household income
to assess income distribution may indicate high levels of inequality, while
using a posttax and transfer measure of income to calculate the income
TABLE 2 Commonly Used Measures of Income Inequality
Example
United United
States, Kingdom,
Measure Definition Advantage Disadvantage Data Source 1994 1995
Gini coeffi- Ranges from 0 (perfect Most commonly Comparability LIS; World Bank 0.355 0.344
cient equality) to 1 (perfect used; simple problems; not (Deininger and
inequality); ratio of interpretation always constructed Squire 1996);
area between Lorenz identically; lack of WIID; U.S.
curve and a line of good data; not census
perfect income available for many
equality countries/years
Income Ratio of income of Easily interpreted; Lack of good data; LIS; World Bank 90:10, 90:10,
shares person at the xth can examine a not available for (Deininger and 5.85; 4.87;
percentile (often the range of extreme many countries/ Squire 1996); 80:20, 80:20,
90th) to a person at distributions years WIID; U.S. 3.11 2.84
the yth percentile census
(often the 10th)
Atkinson Ranges from 0 to 1; Weighs the relative Not commonly used; LIS; World Bank e = 1, e = 1,
Index relative position of position of the no consensus on (Deininger and 0.214; 0.204;
the poorest is weighted poorest; allows best value for e; lack Squire 1996); e = 0.5, e = 0.5,
by parameter e that for a range of e of good data; not U.S. census 0.105 0.100
measures society’s weights available for many
aversion to inequality countries/years
(continued)
423
424
TABLE 2 (continued)
Example
United United
States, Kingdom,
Measure Definition Advantage Disadvantage Data Source 1994 1995
Theil Index Ranges from 0 (complete Weighs relative po- Not commonly used; University of Texas .0280 .0189
equality) to infinity; a sition of poorest; not easily inter- Inequality Project
member of the entropy reliable data sets preted; based on (UTIP)
class of inequality mea- available wages, not income
sures
Robin Hood Ranges from 0 to 1; per- Intuitively appeal- Ignores the distribu- U.S. census NA NA
Index centage of income ing; less sensitive tion of income
needed to transfer from to highly skewed within each 50 per-
the richest 50 percent to distributions cent share; not avail-
the poorest 50 percent able for many coun-
to obtain equality tries/years
Note: LIS = Luxembourg Income Survey; WIID = World Income Inequality Database.
distribution in the same population could reveal a more egalitarian society.

The World Income Inequality Database (UNU/WIDER 2000) suggests that
Gini coefficients calculated from gross income are 5 to 10 points higher than
those calculated from net income.
Another distinction in terms of household income data is whether such
data have been “equivalized” for household size. Dividing household income
by family size (often the square root of family size) is considered good practice
because a family of four does not necessarily need twice the income of a family
of two to live equally well. Failure to make this adjustment may render
interhousehold comparability significantly less reliable, because the unit of
analysis (the household) is in reality composed of a number of different units
(the family) that vary in size and composition. Atkinson, Rainwater, and
Smeeding (1995), Judge and Paterson (2002), and Coulter (1989) provide more
detailed discussions of income inequality measurement issues.
Judge (1995) presented a critique of Wilkinson’s early work that addresses
some of the problems inherent in many income inequality measures. Judge
pointed out that Wilkinson and others used measures of income inequality
(the Gini coefficient) that were derived from household surveys conducted
independently in each country. One of the key difficulties in comparing
household income studies is that they often differ in how they solicit total
income from the households they interview. It is therefore possible that
reported differences in income distribution between countries could be biased
because each country did not measure income the same way (Galbraith,
Conceição, and Kum 2000). Second, some income inequality databases (such
as the World Bank’s “Deininger and Squire” or the United Nations’ “WIDER”
databases) include a mix of Gini coefficients calculated from household data
that differ not only in how income was measured but also in whether the final
Gini coefficients are adjusted for taxes or other income transfers (Deininger
and Squire 1996). Although within such data sets one can select income
inequality data that have more or less consistent definitions, this is not always
done in practice because data are rarely available for every country and year
of interest. Third, not all income inequality measures were calculated by using
equivalized family income.
Judge (1995) used the LIS as a source of internationally comparable, stan-
dardized measures of income inequality. The LIS income inequality measures
are based on a similar household income data collection methodology, are
based on net income, and are equivalized for family size. Using the LIS income
inequality measures, Judge did not find a relationship between life expec-
tancy and the distribution of income. He concluded that the previously
reported relationship was in large part due to the weaknesses of the income
data used to calculate the income inequality measures.
METHODOLOGICAL CRITIQUES
Judge, Mulligan, and Benzeval (1998a) provided a critique of the methodol-
ogy used in much of the income inequality and health literature. Their objec-
tions included the observations that (1) authors generally used small sample
sizes so their conclusions are prone to error, (2) some studies used data on
developing and developed countries but then generalize the results only to
the developed countries, (3) many studies used bivariate analyses only and
thus fail to control for other health determinants, and (4) income inequality
data were generally unreliable, are not available for a wide range of years, and
were not consistently adjusted for taxation and family size.
Judge, Mulligan, and Benzeval’s (1998a) critique, although pertinent to
much of Wilkinson’s work, is not a generalizable critique; multilevel and time-
series studies in the United States (see Blakely et al. 2000; Kennedy et al. 1998;
Lynch et al. 1998; Wolfson et al. 1999), studies using a variety of outcome vari-
ables (Soobader and LeClere 1999), studies conducted in Canada (Cairney and
Wade 1998) and Australia (Clarke and Smith, 2000), and studies using equiva-
lent disposable income to construct inequality data (Humphries and van
Doorslaer 2000; Shi and Starfield 2000) provide much stronger evidence for
the relative income hypothesis and address each of Judge, Mulligan, and
Benzeval’s objections.
However, more sophisticated research designs have also resulted in nega-
tive findings. For example, Fiscella and Franks (1997) used a U.S.-based longi-
tudinal cohort study (National Health Examination Survey and its follow-up
components) and a multilevel model to test the relationships between individ-
ual income, neighborhood-level income inequality, and an individual’s risk of
dying. Their results showed that although there seems to be a bivariate rela-
tionship between survival rates and community income inequality, after
adjustment for household income, no significant relationship was found
between neighborhood income inequality and mortality. They suggested that
previous ecological-level studies using larger geographical units may have suf-
fered from the confounding influence of the interrelations between contextual-
level income inequality measures and individual-level family income. They
concluded that poverty, rather than income inequality, determines mortality
at the community level.
Wagstaff and van Doorslaer (2000, 543) conducted a literature review of
individual-level studies on the impact of income inequality on health. In their
review of six major studies, they found that the literature “reveals strong sup-
port for the absolute income hypothesis and little or no support for the income
inequality hypothesis.” The authors concluded that many of the individual-
level studies conducted in the United States suffer from methodological flaws
in the income inequality measures used, do not account for fixed state and
year effects, and are not generally consistent with several hypothetical path-
ways through which income inequality is posited to influence individual
health.
Several individual-level international studies further called into question
the universality of the relative income hypothesis. Research conducted in
Japan (Shibuya, Hashimoto, and Yano 2002) and Denmark (Osler et al. 2002)
showed that individual-level health (measured by self-rated health status and
mortality risk, respectively) was not associated with income inequality mea-
sured at the level of prefectures (states) in Japan, or smaller areas of aggrega-
tion (parishes) in Denmark. Both studies suggested that individual income is a
more important predictor of health outcomes at the individual level than
income inequality. The authors of both studies also suggested that features of
the Japanese and Danish welfare state may protect people from the adverse
effects of income inequality in ways that social protections in countries such as
the United States, Taiwan, and the United Kingdom do not. Finally, another
study reported that income inequality is not significantly related to mortality
in Canada at either the regional or metropolitan level, although there was a
relationship between income inequality and health in the United States (Ross
et al. 2000).
Sturm and Gresenz (2001) present a further methodological critique of the
literature. The authors argue that associations between self-rated health and
income inequality became nonsignificant when adjusted for other individual-
level covariates (income, age, gender, race/ethnicity, family size). Further-
more, they found a strong gradient in the relationship between better health
and improved levels of education and absolute (not relative) family income.
Perhaps the most comprehensive study to date is that by Mellor and Milyo
(2001). Their study examined the country-level relationship between income
inequality (measured by the Gini coefficient and income ratios of the bottom
20th percentile to the top 20th percentile) and aggregate health outcomes (life
expectancy at birth, infant mortality) across 30 countries over a four-decade
span. It also examined 48 U.S. states over five decades using the Gini coeffi-
cient to measure income inequality and all-cause mortality, infant mortality
rates, low-weight births, homicides, suicides, and six different specific causes
of death as dependent variables. At the international and state levels, the
authors found that contrary to previous literature, there was no consistent
relationship between income inequality and health outcomes. The analysis
controlled for demographic variables such as median income, educational
levels, and year-specific effects. The state-level analyses also controlled for
percentage of population that is urban, black, and college educated. In the 54
regression equations reported, income inequality was significantly associated
with poorer aggregate health outcomes in only 11 cases but was significantly
associated with better health outcomes in 15 cases.
ALTERNATIVE HYPOTHESES
Gravelle (1999) presented an alternative explanation for the observed rela-
tionship between income inequality and health outcomes. He claimed that the
relationship between individual income and mortality is curvilinear—
beyond a certain point, increases in income have little effect on mortality.
Because of this relationship, he argued that a statistical artifact might explain
the observed relationship between income inequality and health. His logic
was that if one population has a more equal distribution of income than
another, then there are more individuals at the middle income levels and
fewer outliers at the high and low ends. This means, in general, better health
status for those at the lowest income groups (especially since more people at
the higher end of the income distribution will not be expected to influence
health outcomes because of the curvilinear relationship between income and
health). The average poor person can thus appear to be better off in a more
egalitarian society because he or she is likely to have a higher individual
income, which will reduce the risk of mortality. Therefore, the relative income
hypothesis is simply an artifact of absolute income.
Gravelle, Wildman, and Sutton (2001) then reexamined Rodgers’s (1979)
study using more consistent income inequality data derived from the LIS. In
multivariate regression analyses using data from 56 countries at two time
periods (1980-1982 and 1988-1990) and controlling for GDP and several trans-
formations of average national income, the relationship between income
inequality and life expectancy was not significant. Box-Cox and
nonparametric estimations also revealed no significant association between
life expectancy and income inequality. They concluded that the relationship
between income inequality and health was indeed a statistical artifact.
Other alternate explanations for the observed relationship between income
inequality and health include the hypothesis that racial and ethnic minority
populations within countries (which often have a poorer health profile and
represent a larger share of the lower income quintiles) may explain the higher
mortality among lower income deciles. Wilkinson (1992) showed that minor-
ity groups have a small impact on health in England (one of the more ethni-
cally diverse countries in Europe), implying that the scale of income inequal-
ity was too large to be accounted for by ethnic minorities alone (Wilkinson
1992). However, studies in the United States showed a different pattern.
Deaton and Lubotsky (2002) examined the impact of race on the relation-
ship between income inequality and mortality among U.S. states and MSAs in
1980 and 1990. They found that “once the fraction [of the state or MSA that is]
black is controlled for, income inequality has no effect” (p. 11). Their findings
are significant even after stratifying by age groups and gender and after con-
trolling for income, education, and state fixed effects. The authors argue that
the association between income inequality and health in the United States
might be the result of confounding with race, since those areas with a higher
proportion of black population also have higher income inequality and higher
mortality—for whites as well as for the entire population. They proposed that
the social cohesion argument made to explain the impact of income inequality
on health might be applied to segregation based on race. Muller (2002) found
similar results. While Shi and Starfield (2001) found that in an ecological study
of U.S. MSAs in 1990, income inequality was a significant predictor of mortal-
ity for both black and white populations; even while conditioning on per
capita income, education, unemployment, urban residence, and primary care
in both combined and race-stratified analyses.
Other authors suggested that the health selection hypothesis might be at
work. This hypothesis holds that ill health precedes poor educational or work
performance. That is, sicker people are more likely to be poorer because of the
economic consequences of their illness (West 1991).
Finally, Judge and Paterson (2002) discussed the possibility that income
inequality might also have a negative impact on the health of those at the high-
est income levels. This is supported by Weich, Lewis, and Jenkins (2001), who
found an association between regional income inequality and self-reported
mental health in Britain. This relationship was statistically significant only
among individuals in the wealthiest income quintile, and held when control-
ling for a range of individual-level health determinants, including social class,
employment status, age, gender, income, and physical health status.
COMPARISON OF EMPIRICAL STUDIES

The appendix presents an analysis of the main peer-reviewed studies on
the relationship between income inequality and health. Forty-five empirical
studies and two literature reviews are included in the table. Criteria for com-
parison include the type of income inequality measure; main outcome vari-
able(s); whether the study controlled for at least the following covariates—
GDP per capita or mean/median income for ecological studies and income,
age, and gender for individual-level studies; unit of analysis (ecological, indi-
vidual, mixed); study population and time period; which pathway (if any)
was tested; and whether income inequality was found to be associated with
health outcomes.
Table 3 presents a summary of the findings and main characteristics of the

studies reviewed. The table presents the study results according to three over-
all classifications—by health outcome, income inequality measure, and level
of analysis. This table is not meant to present results of a formal meta-analytic
method. Instead, it is intended to facilitate analysis of the results of the many
studies contained in the appendix. It is also important to note that publication
bias is likely to have limited the number of studies published that showed no
relationship between income inequality and health. Therefore, we caution
against a simple comparison of number of studies that found or failed to find
an association between income inequality and health, particularly when
examination of the authorship of the articles points to a group of less than 10
researchers being responsible for the vast majority of the studies reviewed.
Instead, we constructed the table to see if there might be patterns in the study
design, health outcomes tested, or country analyzed that were more likely to
find positive or negative results. The results of this analysis follow.
Several conclusions can be drawn from an examination of Table 3. First,
there are contradictory findings based on the health outcomes measure used.
Overall, 33 analyses showed a statistically significant relationship between
income inequality and health outcomes, while 12 studies generally showed no
relationship. For each health outcome (life expectancy, infant mortality, all-
cause adult mortality, and self-rated health), there is evidence both for and
against an effect of income inequality.
Studies also differed by the measure of income inequality used. The most
prevalent measure of income inequality was the Gini coefficient, followed by
different combinations of income shares. For each type of income inequality
measure, there is evidence both for and against its association with health out-
comes. There was little consistency even among studies using the same mea-
sure of income inequality. For example, among those studies using the Gini
coefficient, some calculated it by using household as opposed to family
income, while others used gross (pretax) instead of net (posttax) income. By
and large, international studies using the LIS Gini measures (adjusted for
taxes and household size) did not find an association between income
inequality and health, while studies using other Gini measures did find an
association. But it is important to note that not all of these studies used exactly
the same countries, the same years, the same control variables, or even the
same outcomes measures, rendering comparison among even seemingly
similar studies inconclusive.
In terms of level of analysis, evidence is also mixed. Ecological studies were
the most prevalent, and the results, often conducted on the same unit of analy-
sis (U.S. states or OECD countries), varied. Individual-level and multilevel
studies all revealed positive and negative findings. This was the case even
TABLE 3 Summary of Literature Review Findings

Association between Income
Inequality and Health
Study Characteristic Significant Not Significant
Outcomes
Life expectancy 3 4
Infant mortality rate (IMR) 5 0 (2)a
Mortality 9 5
Self-rated health 9 3
Other 7 0
Total 33 12
Income inequality measure
Gini 15 7
Robin Hood 3 0
Income decile ratios 10 4
Other 5 1
Total 33 12
Level of analysis
Individual 10 5
Ecologic 17 6
Multilevel 6 1
Total 33 12
Countries studied
United States only 17 3
Non–United States (single country) 5 3
International (multicountry) 11 6
Total 33 12
a. Some studies examined multiple outcomes, including IMR. Although only the study’s main
findings are presented in the table, at least two studies additionally present evidence of no statisti-
cal association between income inequality and IMR.
when the same outcomes, data sets, and units of analysis were used. For exam-
ple, Lochner et al. (2001) found a significant relationship between income
inequality and mortality using a multilevel design with the U.S. National
Health Interview Survey, while Fiscella and Franks (1997), using a similar
design and the same data set, did not find a relationship.
Some authors have suggested that there is more evidence of a relationship
between income inequality and health within the United States than within
(or between) other countries (Judge and Paterson 2002). This review only par-
tially supports such a conclusion. Some individual-level within-country
studies conducted at the individual or state level provide limited evidence

that income inequality may affect health in Australia, New Zealand, Taiwan,
and the United States, and there is evidence both for and against an associa-
tion within Canada. There are also mixed findings regarding multicountry
studies. Even though recent literature (see Deaton 2002; Mellor and Milyo
2001) has called into question the validity of conclusions drawn from
Wilkinson’s (1992) and Rodgers’s (1979) international (multicountry) ecologi-
cal studies, several more sophisticated analyses (see Lynch et al. 2001) did find
an association across countries between income inequality and some, but not
all, categories of health outcomes.
DISCUSSION
The literature review has described the wide range of studies exploring the
relationship between income inequality and health. We have attempted to
provide structure to the literature by describing its historical development,
outlining its major theoretical and empirical basis, and categorizing the many
criticisms, alternative explanations, and negative findings presented in the
literature.
This review suggests that there are inconsistent findings on the relationship
between income inequality and health. The most frequently reported associa-
tions seem to be in studies based in the United States (primarily using self-
rated health and measuring income inequality at the state level) and interna-
tional studies that use infant mortality as an outcome. But even within these
studies there is variation. For example, in studies conducted within the United
States, many that find a relationship between income inequality and health
create categories of income inequality and then rank the unit of analysis (usu-
ally U.S. states) by categories of high, medium, or low income inequality,
rather than using the actual value of the income inequality measure (such as
the Gini coefficient) in the analysis. This is in contrast to many of the studies
that do not find a relationship: they usually use the value of the income
inequality measure itself in multivariate analyses.
In light of these findings, the main conclusion from this review is that the
lack of consistency in the study design, data used, measures constructed, con-
ceptual models employed, and unit of analysis makes it difficult to draw a
definitive conclusion about the relationship between income inequality and
health. For nearly each empirical study reviewed, another mostly similar
study produces a negative finding. Then, a new publication appears to chal-
lenge the negative finding and reassert the original study’s conclusions. Nor-
mally, such disputes could be resolved by analyzing of the strength of differ-
ent study designs, but even prospective, multilevel designs controlling for a
variety of relevant covariates revealed contradictory results often because

they used similar (but not identical) income inequality measures. The lack of
systematic replication of results has certainly increased the number of articles
published on this topic, but it has done little to address the central question of
whether (and if it is, to what extent and how) income inequality is related to
health outcomes.
To answer these questions, we make several suggestions that we believe
would facilitate future studies and ultimately help shape future policies and
programs designed to address the impact of income and other social inequali-
ties on health.
First, although the majority of studies control for covariates thought to be
associated with health, the actual model of health production specified is dif-
ferent in nearly every study. Our conceptual framework shows that although
multiple pathways have been mentioned in the literature, few studies test
competing pathways. Almost none have placed analyses within a larger
socioeconomic framework that considers the causes of income inequality as
well as its potential impacts on health and other population outcomes. As part
of the conceptual framework of health determinants, future studies should
include, at the very least, a macro-level measure such as GDP per capita and
health systems and services, as well as micro (or aggregate) measures of indi-
vidual income, socioeconomic status (SES) measures of education or occupa-
tional prestige (or social class), and racial/ethnic composition.
Second, the link between the theoretical literature and the empirical model
used to test hypotheses is often weak. At the very least, the range of covariates
and the specific theoretical framework for each study should be better justi-
fied in terms of the health outcome being evaluated. In addition, issues of
proximal determinants of income inequality and health outcomes are rarely
(if ever) addressed. Here, the economics and sociology literatures present
numerous studies of how (and why) income and other social disparities
develop within nations (see Alderson and Nielson 1999; Chase-Dunn 1975;
Gradstein and Milanovic 2000; Gustafsson and Johansson 1999; Lipset 1959).
Few studies in the literature reviewed have attempted to analyze the role of
macropolitical effects through techniques such as instrumental variables or
structural equation modeling. Doing so could enrich the health literature
enormously by building on the rich theoretical and empirical traditions in
fields that have long studied the distribution and consequences of inequalities
on populations.
Third, there is a need to improve the framework and analyses by sorting out
the various levels of health determinants, that is, ecological and individual,
and the need to assess at which ecological levels (nation, state, MSA, county,
city, neighborhood, etc.) that income inequality makes most sense in
influencing health. We have attempted to provide a basic framework for

ordering these analyses in our conceptual framework. The literature reviewed
here suggests that different results can be obtained by examining the same
populations at different levels of analysis. Further work will be necessary to
satisfactorily explain such discrepancies and justify the level of analysis used
in future studies.
Fourth, there are great differences in the measure of income inequality, the
data used to calculate income inequality measures, and the years for which
data are derived. These inconsistencies greatly impede study comparability.
At the very least, income inequality measures should contain some weight or
identify the position of the poorest in the income distribution. This is why
income share ratios, concentration curves, and Atkinson and Theil indices
should be preferred to the Gini or the Robin Hood Index. Moreover, house-
hold inequality data must be consistent. The economics literature suggests
that household income used for calculating income inequality measures
should be net of taxes and other transfers and should be equivalized for family
size. Future studies will need to be explicit about the income data used to
derive the inequality index and discuss the implications of the limitations of
the income data they employ.
Fifth, very few of the studies reviewed included health system compo-
nents. Those studies that do incorporate health system variables, particularly
measures of primary care, found that they are important determinants of
health outcomes and in some cases reduce the impact of income inequality
and other socioeconomic measures on health outcomes. The finding that
aspects of the health system can interact in some way with social or economic
determinants of health offers what Starfield and Shi (2002) term a “palliative
strategy” to partially reduce the negative effects in inequalities on health in
the absence of more comprehensive efforts to tackle the root causes of such
inequalities. Greater efforts should be taken to ensure that the health system is
included not only in further research but also in the design of policies and pro-
grams meant to address social disparities.
Sixth, because of the complexity of the analyses required, methodological
problems continue to plague most published studies. Time lags (Blakely et al.
2000), data quality (Judge 1995; Judge, Mulligan, and Benzeval 1998a; Wag-
staff and van Doorslaer 2000), controlling for median versus mean income
(Blakely and Kawachi 2001)—just to name a few issues—have all been found
to influence results. Moreover, issues such as multicolinearity among eco-
nomic variables are rarely dealt with systematically. To date, no single study
has comprehensively addressed each of these potential limitations. For this
reason, it is difficult to compare different studies since each contains its own,
often unique, flaws. Although it will be a challenging task, if we are to satisfac-
torily investigate the impact (if any) of income inequalities on health,
resources should be directed at designing a thorough, rigorous, and replicable
study that addresses each of these methodological issues.
CONCLUSIONS
Some authors have recently asserted that “evidence favoring a negative
correlation between income inequality and life expectancy has disappeared”
(Mackenbach 2002, 1). Based on the analysis of the literature reviewed here,
this conclusion appears premature. It is difficult to draw a firm conclusion
about the true nature of the relationship between income inequality and
health because a combination of limited data of questionable quality,
noncomparable study designs, radically different conceptual frameworks,
and different analytical methodologies has complicated rather than clarified
our understanding of this relationship.
Moreover, none of the studies or editorials discussing the relationship
between income inequality and health has claimed that income inequality
itself has a direct influence on health. Instead, income inequality is viewed as a
proxy for something else—some other psychological, social, economic, politi-
cal, or environmental determinant of health. Based on the literature reviewed
here, it appears that income inequality performs rather poorly as a proximate
cause of health.
Finally, regardless of the relationship between income inequality and
health detected, nearly every study has confirmed the importance of individ-
ual income on health outcomes—even within countries with universal insur-
ance and relatively generous social welfare policies. This suggests that one
benefit of research on income inequality is that it has highlighted the role of
economic and social resources and their impact on health inequalities
(Mackenbach 2002). We also believe another important contribution has been
a reexamination of the role of the health system, particularly primary care, as
an important determinant of population health in advanced industrialized
nations, an area that deserves further thought, analysis, and action.
436
APPENDIX
Literature Review
Income Main Hypothesis/ Income
Inequality Outcome Controlled Unit of Study Design, Pathway Inequality Related
Author Measure Variable for Covariates Analysis Population Explored to Health?
Ben-Schlomo, Townsend All-cause Yes (using Ecological Cross-sectional; Material Yes

White, and Index (IQ mortality Townsend (wards) England only, 1981
Marmot range) younger Index) and 1985 data
(1996) than age 65
Blakely et al. Gini (state- Self-rated Yes (gender, age, Individuals Cross-sectional with Time lag Yes
(2000) level) health race, median time lag; U.S. Current
household Population Survey
income, state (1979-1981, 1983-1985,
income) 1987-1989, 1991-1993,
1995-1997)
Blakely, Gini (high, Self-rated Yes (individual Multilevel Cross-sectional; U.S. Individual health Yes (but not after
Lochner, medium, low health and Current Population and metropolitan controlling for
and categories) metropolitan Survey data, 1996- area (MA) income household
Kawachi area) 1998; census data inequality income and not
(2002) 1990 for income at county level)
Bobak et al. Gini (country- Self-rated Yes (material Individuals Cross-sectional study; Material and No (not after
(2000) level) health deprivation = representative psychosocial controlling for
food, clothing, samples of adults in material
heating; control, 1996/1998 in Russia, deprivation
education, Estonia, Czech, score)
income) Lithuania, Poland,
Latvia, Hungary
Chiang Income All cause Yes (median Individuals Ordinary least squares Income inequality, Yes
(1999) received by mortality, household (OLS) regression mortality, eco-
poorest 50 younger than income, share model comparing nomic
percent of age 5 of household) three time periods: development
population mortality 1976, 1985, 1995
Clarke and Health Self-reported Yes Individuals Cross-sectional study; Magnitude of Yes
Smith Concentra- Health Australian National health inequality
(2000) tion Index Concentra- health survey, 1990/ due to income
tion Index 1995
Diez-Roux, Robin Hood Smoking, Yes Multilevel U.S. state- and Income inequalities Yes (BMI,
Link, and Index (by Body Mass individual-level and risk factors hypertension,
Northridge state) Index (BMI), indicators from sedentarism
(2000) hyperten- Behavioral Risk strongest effect
sion, Factor Surveillance among poorest)
sedentarism System and census,
1990
Duleep Average Adult male Yes (percentage of Ecological Cross-sectional Mortality and Yes
(1995) income mortality industrialization (countries) ecologic study on 38 income
received by and average industrialized inequality
lowest income) countries; Internal
income Revenue Service,
decile International Labor
Organization, and
other data sources
(mid-1970s compared
to late 1980s)
Fiscella and Lower 50 Mortality Yes (household Multilevel Longitudinal cohort Mortality related No
Franks percent income, study; sample of to individual or
(1997) income demographics, adults included in the community
share in mean National Health and income inequality
community community Nutrition Examina-
income) tion Survey, 1971-
437
1975 to 1987
(continued)
438
APPENDIX (continued)
Flegg (1982) Gini, Theil, Infant Yes (female Ecological Cross-sectional study; IMR and different Yes (with Gini)
coefficient of mortality illiteracy and (country) multivariate and measures of
variation rate (IMR) labor force, bivariate OLS income
physician/nurse regressions for 46 inequality
per 1,000, underdeveloped
GDPpc, income countries, data from
transfers) 1970s
Gravelle Relative and Mortality No Theory Reexamination of the Is the relationship No
(1999) absolute relationship between a statistical
income levels income and mortal- artifact
by income ity; no data used.
shares
Gravelle, Gini Life Yes (GDP, Ecological Cross-sectional 75 Reanalyze Rodgers No
Wildman, expectancy income, and (countries) countries, 1981 and (1979) data
and Sutton (gender- permutations) 1989
(2001) specific)
Hales et al. Gini—not IMR Yes (GNP per Ecological Cross-sectional; 38 Infant mortality, Yes (more
(2000) equivalized capita) (country) countries, 1970; 26 GNP, and income pronounced in
(from countries, 1990 inequalities industrialized
Deininger countries)
and Squire
1996)
Humphries Health Con- Self-assessed Yes (income, Individual Cross-sectional; 1994 Absolute versus Yes (but does not
and van centration health status Health Utility Canadian National relative income explain all
Doorslaer Index Index) Population Health income-related
(2000) Survey health
inequalities)
Judge (1995) Gini, percent- Life No Ecological Cross-sectional study; Is the relative No
age of popu- expectancy (countries) 13 Organization for income hypothe-
lation with Economic Coopera- sis valid?
less than 50 tion and Develop-
percent ment (OECD) coun-
income tries; Luxembourg

Income Survey (LIS)
data, 1994
Judge, Mulli- Share of Life expec- Yes (social secu- Ecologic Literature review and Further critique of No
gan, and income going tancy, infant rity, geographic (country) cross-sectional study; the relative
Benzeval to different mortality region, percent- OLS regression; 16 income
(1998a) income dec- age female OECD countries; LIS hypothesis
iles, Gini, workforce, income inequality
90:10 ratio health data
expenditures)
Kahn et al. Percentage Abdominal Yes Individual Cohort from 21 states; Psychosocial stress Yes (men only)
(1998) total income obesity follow-up of Ameri-
received by can Cancer Nutrition
richest 50 Survey
percent in
each state
Kahn et al. Gini (states Depressive Yes (household Individual Cross-sectional; Income inequality Yes (most pro-
(2000) ranked in cat- symptoms income, age, national sample of and women’s nounced among
egories based and self- marital status, women who gave health lowest income
on Gini) rated health education, race/ birth in 1998 groups)
ethnicity, house- (National Maternal
hold size) and Infant Health
Survey)
(continued)
439
440
Kaplan et al. Income Age-adjusted No (bivariate rela- Ecological Cross-sectional study; Income inequality Yes (also with
(1996) received by all-cause tionships only) (states) U.S. states, 1980, 1990, and mortality homicide, crime,
lowest 50 mortality; 1989-1991; data from insurance,
percent in low birth the National Center imprisonment)
state weight for Health Statistics
(NCHS) and 1980 and
1990 census
Kawachi et Robin Hood Social capital No (only con- Ecological U.S. cross-sectional Components of Yes
al. (1997) Index variables trolled for state (states) ecological analysis; 39 social capital
poverty) U.S. states
Kawachi, State-level Self-rated Yes (income edu- Multilevel Multilevel analysis; Social capital Yes
Kennedy, social capital health cation, smoking, Behavioral Risk Fac-
and Glass (categories of age, gender) tor Surveillance Sys-
(1999) trust, group tem (U.S. adults)
membership
reciprocity)
Kennedy et Gini for states Self-rated Yes (risk factors, Multilevel Cross-sectional; U.S. Is there an effect of Yes
al. (1998) classified by health status demographic, states in 1993 and income inequality
four levels of and socioeco- 1994, data from in individual-
inequality nomic status behavioral risk factor level health?
[SES] factors) survey
Kennedy, Robin Hood Mortality, No (poverty and Ecological Cross-sectional analy- Income inequality Yes
Kawachi, Index, Gini IMR, smoking only) (states) sis; U.S. states, 1990 and mortality
and coefficient coronary census data
Prothrow- disease,
Stith (1996) cancer,
homicide
LeGrand Share of Age at death Yes (GDP, welfare, Ecological Cross-sectional analy- Income inequality Yes
(1987) income for health care) (countries) sis of 17 developed and health
bottom 20 countries; 1980s data
percent
Lochner et al. Gini (state- Individual risk Yes (age, income, Multilevel Prospective design; State-level income Yes (most pro-
(2001) level in five of mortality race, gender, U.S. National Health inequality and nounced for
categories) marital status) Interview Survey risk of death near-poor
linked to National whites)
Death Index, 1991
Lynch et al. Gini, Atkinson, All-cause mor- Yes (per capita Ecological Cross-sectional design; Income inequality Yes (for infant
(1998) Theil, below tality by age income, house- (metropoli- U.S. population using and mortality in mortality and
50, 50:10 and group hold size, 200 tan statistical 1990 census data MSAs in the aged 15-64
90:10 income percent poverty area [MSA]) United States group)
shares rate)
Lynch et al. Gini coeffi- Mortality cate- Yes (GDP and Ecological Cross-sectional; corre- Psychosocial envi- Yes (for IMR
(2001) cient, LIS gories, IMR, population size) (countries) lations only; OECD ronment, health, only), no
data life expec- countries; World income (psychosocial
tancy, dis- Health Organization inequalities variables show
trust, organi- (WHO) and world mixed results)
zational values survey data,
membership, from mid-1990s
control,
union,
women in
government
McIsaac and Decile shares Mortality No Ecological Cross-sectional; corre- Income inequality Yes
Wilkinson of income (multiple cat- (countries) lations only; data and different
(1997) (LIS data) egories), from 12 wealthy health outcomes
IMR, poten- OECD countries
tial years of
life lost
(PYLL)
441
(continued)
442
Mellor and Gini coeffi- Life expec- Yes (income, edu- Ecological Cross-sectional for dif- Income inequality No (relationship
Milyo cient, income tancy, all- cation, year, (countries ferent time periods; and health not consistent,
(2001) ratios cause mortal- urban, black) and U.S. 30 countries, 48 U.S. income inequal-
ity, IMR, states) states, 1960s-1990s ity associated
low-weight with both better
births, homi- and poorer
cide, suicide outcomes)
Muller (1985) Income share Homicide Yes (economic Ecological Cross-sectional study; Mortality from Yes
of upper from political growth, regime, (country) OLS regression and political violence
quartile violence oppression, path analysis, 57
years of countries
democracy)
Osler et al. Median Mortality risk Yes (household Individual Pooled, representative Income inequality, No
(2002) income share income, house- cohort studies (more mortality, and
by parish hold and demo- than 25,000 people individual
graphic followed for 13 years) income
characteristics) in Denmark
Rodgers Gini Life expec- Yes (GNP per Ecological Cross-sectional study, Income inequality Yes
(1979) tancy at birth capita and log (countries) 56 countries, 1973 as a determinant
and age 5 transformations of mortality
and IMR of GNP)
Ross et al. 50 percent Mortality Yes Ecological Cross-sectional study, Income inequality Yes for United
(2000) income share (states and OLS regression and health States, no for
MSAs) model; Canadian Canada
provinces and MSAs,
U.S. states and MSAs;
Census data 1990-
1991
Shi et al. Gini Mortality, post Yes Ecological Cross-sectional study; Primary care Yes
(1999) and neonatal (states) U.S. census and oth-
mortality, life ers, 1990
expectancy
Shi and Gini (state) Self-rated Yes (primary care, Multilevel Cross-sectional study; Primary care Yes (income
Starfield health income, demo- U.S. Community inequality

(2000) graphics, Tracking Survey impact is
employment, (state, MSA/commu- reduced in pres-
wages, poverty, nity, individual), 1996 ence of strong
insurance, primary care)
smoking
Shibuya, Gini Self-rated Yes (individual Individual Cross-sectional analy- Income inequality No
Hasimoto, health income and sis of more than and self-rated
and Yano demographic 80,000 Japanese health
(2002) characteristics) adults in 1995
Soobader and Gini Self-rated Yes (income, pov- Individual Cross-sectional ecologi- Income inequality Yes (at county
LeClere health erty, income-to- cal study; white adult and morbidity level, but
(1999) needs ratio, edu- males in the United reduced at cen-
cation, States, National sus tract level)
occupation) Health Interview Sur-
vey, 1989-1991
Sturm and Gini Self-rated Yes (family Individual Cross-sectional ecologi- Income inequality, No (not after con-
Gresenz health, income, age, cal study; population- family income, trolling for edu-
(2001) chronic med- gender, race/ based survey data and mental health cation and fam-
ical condi- ethnicity, family from nationally rep- ily income—
tions, and size) resentative commu- strong predic-
mental nity tracking study tors of health in
health (United States only) this study)
Turrell and Gini Propensity to Yes (income level, Individual 1995 Australian Health Is income NA (income
Mathers not report occupational Survey; analysis of underreporting underreporting
(2001) income class, gender, data from survey of significant? most prevalent
education, Australian adults, among high
443
income source) 1995 income groups)
(continued)
444
van Health concen- Self-reported Yes (health and Individual Cross-sectional; Fin- Income inequality Yes
Doorslaer tration curve health social land, Germany, Neth- and health in
et al. (1997) expenditures) erlands, Spain, Eng- OECD countries
land, United States,
Sweden, Switzerland;
data from 1982-1992
Wagstaff and NA NA NA Individual Literature review of six Income inequality No consistent
van individual-level and health relationship
Doorslaer studies
(2000)
Waldmann Log income IMR (log- Yes (GDP, doc- Ecological Cross-sectional study; Income distribu- Yes
(1992) share of top 5 transformed) tors/1,000, (countries) 57 countries; data tion and IMR
percent and urban, primary from World Tables,
bottom 20 school, female UN statistics, World
percent literacy, repro- Bank 1960/1970
ductive rate)
Weich, Lewis, Gini (net cur- Self-reported Yes (age, gender, Individual Cross-sectional analy- Income inequality Yes (but only
and Jenkins rent income) mental social class, sis of adults in Eng- and mental health among the
(2001) health employment, land, Wales, and Scot- wealthiest
ethnicity, physi- land; data from early income quintile)
cal health) 1990s
Wennemo Gini IMR Yes (poverty, fam- Ecological Pooled cross-sectional IMR and inequality Yes
(1993) ily benefits, (countries) analysis of 18 OECD
unemployment countries, 1990
insurance,
GDPpc,
unemployment)
Wilkinson Gini (posttax, Life Yes (GDP per Ecological Cross-sectional study; Developed versus Yes
(1994) standardized expectancy capita) (countries) some time-series developing
for house- analyses; 12-22 OECD countries
hold size) countries, 1970-1990
Wilkinson Income decile Life No Ecological Cross-sectional study; Income distribu- Yes
(1992) shares (fam- expectancy (countries) bivariate correlations; tion and life
ily net cash 23 OECD countries; expectancy in
income) data from World developed
Tables, LIS, WHO, countries
OECD, 1975-1985
Wolfson et al. Income shares All-cause Yes (state income Individual Multivariate statistical Relation between Yes
(1999) mortality levels) simulation model; mortality and
data from 1990 U.S. income inequality
census, CDC, and a statistical
national longitudinal artifact?
mortality study
445
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Income Inequality and Health: A Critical Review of The Literature

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ARTICLE

Income Inequality and Health:

Keywords: income inequality; health determinants; social epidemiology; health

cluding all sociological, political science, psychology, education, and econom-

C.4 Health D.4

FIGURE 1 A Simplified Conceptual Framework of the Relationship between

INCOME INEQUALITY AND HEALTH

will shift from infectious to chronic diseases. Second, a demographic transi-

the sense of relative deprivation, of being at a disadvantage to those better off,

Chiang (1999) provided evidence from Taiwan that income distribution

PATHWAYS THROUGH WHICH INCOME

TABLE 1 Explanations for the Relationship between Income Inequality

Psychosocial (micro): Income inequality results in “invidious processes of social

population-level health (Berkman and Kawachi 2000; Berkman and Syme

THE ROLE OF HEALTH SERVICES

Although the literature indicates some skepticism as to the overall contri-

CRITIQUES OF THE RELATIVE

MEASURING INCOME AND INCOME INEQUALITY

Measure Definition Advantage Disadvantage Data Source 1994 1995

Measure Definition Advantage Disadvantage Data Source 1994 1995

distribution in the same population could reveal a more egalitarian society.

COMPARISON OF EMPIRICAL STUDIES

Table 3 presents a summary of the findings and main characteristics of the

TABLE 3 Summary of Literature Review Findings

studies conducted at the individual or state level provide limited evidence

variety of relevant covariates revealed contradictory results often because

influencing health. We have attempted to provide a basic framework for

Author Measure Variable for Covariates Analysis Population Explored to Health?

Ben-Schlomo, Townsend All-cause Yes (using Ecological Cross-sectional; Material Yes

income tries; Luxembourg

Starfield health income, demo- U.S. Community inequality

income source) 1995 income groups)

driguez, G. Sundberg, and O. Winkelhake. 1997. Income-related inequalities in

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