It Breaks a Man's Heart:Socioeconomic Differences in the Onset of Cardiovascular Disease in Contemporary Sweden
In: Hannemann , T 2012 , It Breaks a Man's Heart : Socioeconomic Differences in the Onset of Cardiovascular Disease in Contemporary Sweden . Lund Studies in Economic History , no. 58 , Lund University , Lund, Sweden .
The development of human populations is determined by the demographic dynamics of fertility, mortality and migration. Health and disease patterns are a major component of all three demographic events. Epidemiology, the study of the distribution of disease and mortality as well as their causes and consequences, is therefore a substantial component of public policies and public interest. Researchers have identified global patterns of development in disease and mortality. One of the most fundamental global patterns is the theory of the Epidemiologic Transition by Omran (1971). The theory describes three stages of disease patterns in the transition from a population mainly challenged by pestilence and famines to a population facing primarily degenerative and "manmade" diseases. During the first stage, population growth is limited by Malthusian positive checks, which refer to population stagnation or reduction caused by famines, pandemics and violent deaths. The transition theory goes on to describe how changes in socioeconomic, cultural and political circumstances shifted the demographic pattern (decline and stabilization of mortality and fertility rates, rising life expectancy) to arrive in an era determined by degenerative and "manmade" disease, such as cancer or diseases of the cardiovascular system. The effects of the epidemiological transition are not only noticeable in the size and composition of the population but also in the economic output produced by the population. Decreased mortality and morbidity due to lower prevalence of infectious disease increases economic productivity and labor efficiency (Omran 1971). Through the prolonged survival of adults, the attainment and transmission of knowledge and skills is intensified and supports the development of national economic growth. While leaving behind some obstacles for population growth and economic development, a society whose health status is largely determined by degenerative diseases faces new challenges. With continuously increasing life expectancy in most developed countries, a large share of the population lives not only until the end of their economically active period, but as also well beyond that. Entering the last stage of Omran's Epidemiologic Transition during the middle of the 20th century, the developed world experienced a strong increase in cardiovascular disease (CVD) mortality until the 1980s. From that time, mortality due to cardiovascular diseases began to fall again, while the morbidity rate for CVD was still increasing. These diverging trends in mortality and morbidity are caused by improvements in the treatment of acute cardiovascular events, leading to a higher share of patients surviving an initial event. Alongside high and increasing survival rates among CVD patients, the prevalence of CVD and CVD-related medical problems is also very high. Currently, CVD is the leading cause of death in developed countries, accounting for about 40 percent of all deaths. This thesis examines the case of Sweden, where over 40 percent of all-cause mortality is caused by CVD (Socialstyrelsen 2009). Treatment for diseases of the cardiovascular system is rather intense and therefore costly, because it not only includes medical intervention for acute events but also treatment for risk factors such as diabetes and hypertension, as well as medical management of chronic heart disease. Sweden has a universal healthcare system that is almost entirely tax-financed, implying that the costs associated with CVD account for a substantial share of the overall public healthcare costs in Sweden. In 2010, the direct and indirect costs of CVD amounted to roughly SEK 61.5 billion (~$9.3 billion). Direct costs contain expenditures for physicians, hospitalization, medication and home healthcare. Indirect costs account for costs of lost future productivity caused by premature mortality. The expenditures for healthcare of CVD patients represent around eight percent of the total healthcare expenditures in Sweden in 2010 (Steen Carlsson and Persson 2012). Given the high public costs for treatment of CVD and the economic loss due to premature morbidity and mortality among CVD patients, research on the causes and consequences of CVD has high priority within the field of public health. The prevention of the onset of the disease as well as the prolongation of general good health has become the focus of recent research on CVD. Those efforts are reinforced by the findings of previous research demonstrating that a substantial share of CVD is not inevitable and the onset and course of CVD can be altered by actions of the healthcare system and, more importantly, by the individual itself, through the maintenance of a healthy lifestyle. One important impact factor for CVD was found in socioeconomic status (SES) (Adler et al 1994). SES could be linked to many CVD risk factors and appears to be the origin of major direct and indirect impact pathways to the onset and progress of the disease. A large share of studies in the field of social epidemiology, sociology and public health focus on the relationship between SES and various health outcomes, including CVD. Some large-scale studies have had the specific aim of evaluating the link between SES and CVD such as the Framingham Heart Study (Dawber and Kannel 1958) the Whitehall Study II and the co called "Black report" (Department of Health and Social Security 1980). During recent decades many studies have confirmed the existence of a social gradient, finding better health among individuals in the higher social classes (Cabrera et al 2001; Mackenbach et al 1997; Pocock et al 1987). The link between SES and health is not a straightforward one, however. One reason for the complexity of the relationship between SES and CVD lies in the variety of SES measurements. SES can be operationalized in a number of manners, such as occupation, economic performance, education, labor market attachment or other characteristics, and most of these measurements are highly correlated with each other. Formal education can be expected to lead to occupational success, while both characteristics are the basis for income attainment and labor market participation. While all these forms of operationalization will influence the risk for CVD in a similar way, regarding the direction of the effect, the magnitude of the effect can vary substantially. Furthermore, the effects of SES will vary depending on the demographic characteristics of individual. The individual ethnic background and marital status will shape SES impact on CVD as will the sex and age of a person. This thesis investigates SES differences in the onset of CVD among samples of the population in contemporary Sweden. The overall aim is to achieve a broad picture of SES impact factors and their direct as well as indirect effects on CVD, taking other risk factors and individual characteristics into account. Throughout the papers, included in this thesis, SES is operationalized in different forms. Therefore, each paper investigates a different aspect of the relationship between SES and CVD, emphasizing the complexity of the relationship. The findings from this study will be useful for identifying opportunities for future CVD prevention programs aiming at reducing SES differences and the resulting health impact among the population. For many of the CVD risk factors there is the risk of reverse causality. On the one hand, lower SES could be the reason for unhealthy lifestyles and therefore increase the risk for CVD. On the other hand, the incidence of CVD could cause changes in labor market attachment and income level. This thesis is taking part of the causality problem into account by limiting the analysis to the onset of CVD (only the first CVD event for every person). Furthermore, the empirical part of the thesis focuses on coronary heart disease as the main subgroup of CVD, thereby excluding more rare forms of CVD, mainly incidences of stroke, for which the empirical results of SES impact have been less consistent.Building on established theories and models, this thesis identifies new aspects and impact pathways of SES in relation to the onset of CVD, taking into account a set of additional risk factors and their potential effects on CVD.
