Mortality and socioeconomic status: the vicious cycle between poverty and ill health
Authors: Victoria Pillay-van Wyk, Debbie Bradshaw
Journal: The Lancet Global Health (2017)

The link between mortality and socioeconomic status has echoed through the ages, and was graphically captured by the Preston curve, which showed the relation between life expectancy and income per person at the country level.1Preston SH The changing relation between mortality and level of economic development.Population Studies. July 1975; 29Crossref PubMed Scopus (871) Google ScholarInt J Epidemiol. 2007; 36: 474-490Crossref Google Scholar The Global Burden of Disease Study, which generates global trends in mortality, uses the predictive relation between socioeconomic status and mortality to help fill information gaps in estimates at the regional and country levels.2GBD 2015 Mortality and Causes of Death CollaboratorsGlobal, regional, and national life expectancy, all-cause mortality, and cause-specific mortality for 249 causes of death, 1980-2015: a systematic analysis for the Global Burden of Disease Study 2015.Lancet. 2016; 388: 1459-1544Summary Full Text Full Text PDF PubMed Scopus (4081) Google Scholar In The Lancet Global Health, Chodziwadziwa Kabudula and colleagues3Kabudula C Houle B Collinson MA et al.Socioeconomic differences in the antiretroviral therapy era in Agincourt, rural South Africa, 2001–13: a population surveillance analysis.Lancet Global Health. 2017; 5: e924-e935Summary Full Text Full Text PDF PubMed Scopus (29) Google Scholar have analysed mortality data from Agincourt, a rural region of South Africa, which are gathered through ongoing health and demographic surveillance and made publicly available in the INDEPTH Network Data Repository. The authors quantified socioeconomic disparities in mortality from 2001 to 2013, based on broad cause-of-death groupings and selected mortality indicators relevant to the area. Over this 14-year period, the poorest households consistently had the highest mortality, particularly from HIV/AIDS and tuberculosis. Likewise, Wabiri and Taffa4Wabiri Taffa Socioeconomic inequality and HIV in South Africa.BMC Public Health. 2013; 13: 1037Crossref PubMed Scopus (46) Google Scholar reported from a national household survey done in 2008 that HIV prevalence was highest among the poor in South Africa, and Probst and colleagues5Probst C Parry CD Rehm J Socio-economic differences in HIV/AIDS mortality in South Africa.Trop Med Int Health. 2016; 21: 846-855Crossref PubMed Scopus (17) Google Scholar showed a similar inverse relation between HIV/AIDS mortality and socioeconomic status in a systematic review. Kabudula and colleagues3Kabudula C Houle B Collinson MA et al.Socioeconomic differences in the antiretroviral therapy era in Agincourt, rural South Africa, 2001–13: a population surveillance analysis.Lancet Global Health. 2017; 5: e924-e935Summary Full Text Full Text PDF PubMed Scopus (29) Google Scholar also highlighted that this community will probably be burdened in the future by high mortality associated with non-communicable diseases. This prediction is not a given. Work with our colleagues on national mortality in South Africa has shown a mix of increasing and decreasing trends in non-communicable diseases.6Pillay-van Wyk V Msemburi W Laubscher R et al.Mortality trends and differentials in South Africa from 1997 to 2012: second National Burden of Disease Study.Lancet Global Health. 2016; 4: e642-e653Summary Full Text Full Text PDF PubMed Scopus (196) Google Scholar, 7Nojilana N Bradshaw D Pillay-van Wyk V et al.on behalf of the South African National Burden of Disease teamEmerging trends in non-communicable disease mortality in South Africa, 1997–2010.S Afr Med J. 2016; 106: 477-484Crossref Scopus (45) Google Scholar Monitoring of trends in cause-specific premature mortality and their risk factors will, therefore, be important to inform public health responses that are locally relevant.7Nojilana N Bradshaw D Pillay-van Wyk V et al.on behalf of the South African National Burden of Disease teamEmerging trends in non-communicable disease mortality in South Africa, 1997–2010.S Afr Med J. 2016; 106: 477-484Crossref Scopus (45) Google Scholar The work by Kabadula and colleagues3Kabudula C Houle B Collinson MA et al.Socioeconomic differences in the antiretroviral therapy era in Agincourt, rural South Africa, 2001–13: a population surveillance analysis.Lancet Global Health. 2017; 5: e924-e935Summary Full Text Full Text PDF PubMed Scopus (29) Google Scholar has identified the need to strengthen the health system in their study area. The South African Government has recognised that addressing the challenge of HIV and non-communicable disease nationally needs to focus on ensuring early detection of disease, linkage to care, access and adherence to treatment, and retention in care.8National Department of HealthAdherence guidelines for HIV, TB and NCDS. Policy and service delivery guidelines for linkage to care, adherence to treatment and retention in care.https://www.nacosa.org.za/wp-content/uploads/2016/11/Integrated-Adherence-Guidelines-NDOH.pdfDate: February, 2016Google Scholar South Africa's National Department of Health released adherence guidelines for HIV, tuberculosis, and non-communicable diseases in 2016.8National Department of HealthAdherence guidelines for HIV, TB and NCDS. Policy and service delivery guidelines for linkage to care, adherence to treatment and retention in care.https://www.nacosa.org.za/wp-content/uploads/2016/11/Integrated-Adherence-Guidelines-NDOH.pdfDate: February, 2016Google Scholar These focus on achieving some of the 2030 health objectives in the country's National Development Plan.9National Planning CommissionOur future—make it work. National development plan 2030: executive summary.http://www.gov.za/sites/www.gov.za/files/Executive%20Summary-NDP%202030%20-%20Our%20future%20-%20make%20it%20work.pdfGoogle Scholar The Minister of Health stated8National Department of HealthAdherence guidelines for HIV, TB and NCDS. Policy and service delivery guidelines for linkage to care, adherence to treatment and retention in care.https://www.nacosa.org.za/wp-content/uploads/2016/11/Integrated-Adherence-Guidelines-NDOH.pdfDate: February, 2016Google Scholar that these adherence guidelines aim "to strengthen access to appropriate services and interventions in order to improve clinical outcomes. The guidelines also assist service providers to ensure that people with chronic diseases are linked to care, retained in care and supported in adhering to treatment." The National Department of Health, together with provincial departments of health and district and facility managers, should strive to roll out these guidelines in poorer areas of the country where limited infrastructure and resources are additional constraints, while recognising that extra effort and support would be needed for the roll-out to be successful. The socioeconomic differences in mortality reported in Agincourt highlight that efforts to alleviate the burden of poor health resulting in death among the poor should be prioritised. Probst and colleagues5Probst C Parry CD Rehm J Socio-economic differences in HIV/AIDS mortality in South Africa.Trop Med Int Health. 2016; 21: 846-855Crossref PubMed Scopus (17) Google Scholar have noted the inter-relatedness of illness and poverty: "Overall, one could conclude that persons of low SES [socioeconomic status] face a self-perpetuating cycle of limited resources that complicate dealing with their HIV which in turn diminishes available resources further". Di Cesare and colleagues10Di Cesare M Kang Y Asaria P et al.Inequalities in non-communicable diseases and effective responses.Lancet. 2013; 381: 585-597Summary Full Text Full Text PDF PubMed Scopus (420) Google Scholar underscore the increased risk of dying from non-communicable diseases among the poor and argue that specific actions will be needed to reduce mortality in poorer areas. Apart from those mentioned above, other actions to consider are equitable early childhood development programmes and education, removal of barriers to secure employment, and access to social grants. Reduction in premature mortality and breaking the cycle of poverty and ill health need a multisectoral approach that engages all government departments.9National Planning CommissionOur future—make it work. National development plan 2030: executive summary.http://www.gov.za/sites/www.gov.za/files/Executive%20Summary-NDP%202030%20-%20Our%20future%20-%20make%20it%20work.pdfGoogle Scholar, 10Di Cesare M Kang Y Asaria P et al.Inequalities in non-communicable diseases and effective responses.Lancet. 2013; 381: 585-597Summary Full Text Full Text PDF PubMed Scopus (420) Google Scholar We declare no competing interests. Socioeconomic differences in mortality in the antiretroviral therapy era in Agincourt, rural South Africa, 2001–13: a population surveillance analysisThe poorest people in the population continue to bear a high burden of HIV/AIDS and tuberculosis mortality, despite free antiretroviral therapy being made available from public health facilities. Associations between socioeconomic status and increasing burden of mortality from non-communicable diseases is likely to become prominent. Integrated strategies are needed to improve access to and uptake of HIV testing, care, and treatment, and management of non-communicable diseases in the poorest populations. Full-Text PDF Open Access