New light on the Nordic paradox

Professor Johan Mackenbach, public health researcher from Erasmus MC in Rotterdam, has coined the term “the Nordic paradox” to describe this situation. However, Mackenbach thinks that his research has sometimes been misinterpreted:  The Nordic welfare model does reduce health inequalities, and without the generous welfare system the gaps in health would have been even bigger, he says.

The Nordic welfare system has been a role model for tackling health inequalities among many public health researchers. That health inequalities are not smaller than elsewhere, and that gaps in health by socio-economic position have substantially widened over time, has been a disappointment and raised some doubts about the effectiveness of the Nordic model. But Johan Mackenbach says that the results of his research must be interpreted carefully.

– It´s clear that the Nordic welfare systems reduces inequalities in income and other material factors, and that this makes health inequalities smaller than they would otherwise have been. This probably also explains why inequality in health is more strongly related to education than to income in the Nordic countries.

The role of alcohol and tobacco

However, there are other factors that generate large health inequalities in the Nordic countries, despite their well-developed welfare systems. Most prominent among these factors are smoking and excessive alcohol consumption, for which inequalities between socioeconomic groups are very large.

Mackenbach notes that there, however, is an interesting exception from the general picture. Swedish men seem to be protected from the Nordic paradox: socioeconomic inequalities in mortality among Swedish men are smaller than in the other Nordic countries, and also than in many other Western European countries. One possible explanation, says Mackenbach, is the more extensive use of snus than cigarettes among Swedish men with low education.

Absolute and relative inequality

One aspect, which also needs to be considered in this discussion, is that the widening of the gap in death rates, as seen in the Nordic countries, is generally the result of a difference between socio-economic groups in the speed of mortality decline. While mortality declines in all socio-economic groups, the decline has been proportionally faster in the higher socio-economic groups than in the lower. Because the Nordic countries are often ahead of other Western European countries in reducing mortality, this also explains part of the Nordic paradox.

According to Mackenbach we should focus on absolute inequality rather than relative inequality*.  Mackenbach explains that in his research he has found very few examples of declining relative inequalities in health: relative inequalities tend to increase over time, because whenever a decline in the frequency of health problem occurs, they are larger in percentage terms among the higher socioeconomic groups.

This is unfortunate, but the good news is that the picture is rather different for absolute inequalities in health: here we often see reduced inequalities because absolute declines in the frequency of health problems are larger in lower socioeconomic groups.

– In my view, absolute inequalities are more important than relative inequalities, because absolute inequalities determine the excess cases of disease or premature deaths among lower socioeconomic groups, says Mackenbach.

Educational expansion plays a key role

It´s obvious that everyone has not been able to benefit from the positive development in the society to the same extent and it´s not entirely easy to explain why, says Johan Mackenbach. But there are some factors that can help us to understand this development. Mackenbach explains that educational expansion plays a key role. A high proportion of the population in the Nordic countries have an elevated level of education. This has led to a highly skilled and competitive labour market that offers many opportunities for the well-educated, but less for the ones with lower education.

At the same time society has become more individualised and secular, and the family and the church do not exert the same kind of social control as they used to. This may partly explain why harm from alcohol and tobacco makes such a large contribution to inequalities in health in the Nordic countries. Inequalities in mortality related to alcohol and tobacco are often staggering – especially in Norway and Denmark, and particularly so among women.

What should we do?

Since the patterns of inequality seem to be self-strengthening, actions must be taken to prevent widening gaps between socio-economic groups. Then, what can we do in the Nordic countries to create better prerequisites for a more equal health?  Mackenbach says that this is also a very hard question to answer, but points out the health care system as a key component and says that resources must be put where they are needed the most.

– We know that people from the lower socio-economic groups benefit less from improvements in medical care and prevention, due to a combination of factors including more comorbidity, less health literacy and less compliance with treatments. If the aim would be to have similar outcomes of medical interventions regardless of patients’ socioeconomic position, more effort should go into patients from lower socioeconomic groups. It is not sufficient to have equal access and equal treatment: we need to do more, Mackenbach says.

Another thing that Mackenbach points out is policies regarding alcohol and tobacco.

– It´s very important for the Nordic countries to have more equity-focused alcohol and tobacco control programs. Raising prices through taxes is important – if necessary, by convincing the rest of the EU to embrace the Nordic price levels – as are outreach programs to help people stop smoking and abusing alcohol.

*Absolute and relative inequalities

Absolute inequality refers to the difference in mortality rate between socio-economic groups. Relative inequality is the ratio of mortality rates for different groups. The two measures do not always develop in the same direction.

Example: Two groups have different levels of education. Group A has ≤ 9 years of education and group B has >12 years of education. The absolute difference in mortality rate between the two groups is 650-350 = 300 in year 1991. In 2012 the absolute difference is slightly lower, 450-200 = 250. The relative difference in 1991 is 650/350 = 1.9. In 2012 the relative difference has increased to 450/200= 2.3. Thus, while the absolute difference has decreased the relative difference has increased.

Nordic NGO’s in public health and the Nordic Welfare Centres’ Public Health Arena arranged a seminar on the Nordic welfare model. It took place at the European Public Health Conference in Stockholm in November 217. Professor Johan Mackenbach was the key-note speaker.