New light on the Nordic paradox

The Nordic welfare model is strongly connected to the concept of equality. The fact that inequalities in health are larger in the Nordic countries than in many countries with less developed welfare systems has therefore puzzled researchers as well as politicians and policy makers.

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, says Mackenbach.

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, according to Mackenbach. 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, explains Mackenbach. 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.

Read the whole interview with professor Johan Mackenbach!