It Breaks a Man's Heart: Socioeconomic Differences in the Onset of Cardiovascular Disease in Contemporary Sweden

Research output: Book/ReportBook


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.

Bibliographical metadata

Original languageEnglish
Place of PublicationLund, Sweden
PublisherLund University
Number of pages217
ISBN (Print)978-91-7473-401-0
Publication statusPublished - Nov 2012

Publication series

NameLund Studies in Economic History
PublisherLund University (Media-Tryck)