The socio-spatial inequalities of health status in Hungary Uzzoli, Annamária1 Ph.D. Eötvös Loránd University, Budapest, Hungary Abstract The main object of this study is to examine the socio-spatial aspects of health inequalities, because the general state of health of the Hungarian people is worse than justified by the level of economic development. The marked deterioration in the health status has been going on since the middle of the 1960s. The extremely bad morbidity and mortality situation in Hungary is almost unparalleled among the post socialist countries, worse situation can only be detected in the former states of the Soviet Union. The rate of death caused by malignant neoplasms is the highest here in Europe. The role of the transformation in the deterioration of health is easy to detect, however differences can be experienced in its social and spatial dimensions. As I see social determination is essential in the development of inequalities regarding the health conditions. The difference between the average life expectancy of the counties of the best and the worst values is 2.5 years. However, this difference is about 10 years in the capital Budapest, where the social segregation and poverty can influence the health inequalities among the districts. Considering these data there are significant mortality differentials between the western and the eastern half of the country. Health inequalities in Hungary mostly influenced by health-related quality of life as life conditions, life-style and health-behaviour.

Key-words: health inequalities, socio-spatial dimensions, spatial structure, health-related quality of life, regional indicators Introduction “The mortality situation in Hungary, which had been worsening for decades, developed into an epidemiological crisis by the early 1990s, and it presently hits the whole adult population” (Józan 1991). As the consequence of this process Hungary is lagging behind the countries with more developed health culture. The mortality rate of the relatively younger generations has been rising for years and the rate of premature death is extremely high. Besides, Hungary is still one of the countries in leading position in suicides and people with addictions deleterious to health represents a marked rate in the population. The aim of my research project is to present and explain the spatial inequalities in the state of health in Hungary. The primary objective of the research is to interpret the changes having occurred in the health status in the past 40 years, and to define the socio-spatial dimensions of the health inequalities. The study consist of two major structural parts, the first one is theoretical in nature while the second is based on the empirical research. The theoretical part provides an insight to the literature of the wider topic of health inequalities and its Hungarian references, while the empirical chapters contain statistical data analysis of the Hungarian health status. In the empirical chapters of this essay I look for the answer to the following comprehensive questions: 1. Which regions of Hungary can be typified with the best and the worst health? 2. In what ways has the socio-economic transformation affected the change in the general health state in Hungary? 3. What are the underlying socio-spatial reasons for the development of the marked inequalities in the health conditions in Hungary?

1

The study is supported by OTKA (PF63859).

• •

The basic assumptions are: The general health status in Hungary shows even less favourable features than the already far too unfavourable characteristics of the other East-Central European countries. The economic spatial structure of the country determines the arrangement of the regions with favourable or unfavourable states of health.

The spatial units of the research project examined range by size from the international (mainly European) level to the national (country and county) levels. The temporal scale embraces primarily the second half of the 20th century, the analysed data is mainly based on the period after 1990. The particularly used mortality statistics was the infant and adult mortality rate, the average life expectancy at birth, mortality rate by selected main groups of death causes etc. The empirical part of the study is based on quantitative data analysis. For the analyses of the regional inequalities of the state of health regional inequality indicators were used such as Hoover-index and weighted relative standard deviation. The outcome of this research project can be used in practical planning tasks as background material. On the other hand, the comparative study gives a hand to make preventive and health promotion programmes for (sub)regions and settlements. Review of the literature Two aspects are considered in the theoretical part which was prepared on the bases of the literature: firstly the explanation of the health inequalities problem field, secondly the interpretation of the scientific related literature involves the presentation of the Hungarian research approaches. Health is a complete multi-factoral definition, the WHO defined it as a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity (Sigherist 1948). Examining spatial structure it must be given a complement to make a distinction between inequalities and differences. Inequality means more than difference, because it contains socio-spatial contents of value (Nemes Nagy 2000). The social and spatial distribution of health, diseases and causes of death characteristics is the best described with the term of inequality. Health inequalities can be defined as differences in health status or in the distribution of health determinants between different population groups (www.who.int). The issue of “health inequalities” has been becoming more and more serious social problem and therefore a topical research focus since the 1980s. Moreover health inequalities not only imply socio or spatial inequalities, but also socio-spatial inequalities as a whole (Jones - Moon 1987). It is also important to recognise that social inequalities have spatial aspects that reflect the social context of spatial inequalities (Townsend 1988). From the beginning of the 1980s it became a most studied social problem and research topic, the very first used as a definition was by Black - Morris - Smith - Townsend (1985) in the well-known “Black Report”. The examination of the socio-spatial aspects of the state of health in Hungary looks back on a considerably long history and determinative background. As the consequence of the interdisciplinary character of health research, in the middle of the 20th century various branches of science started to examine the inequalities regarding the Hungarian people’s health and the health care system, therefore various trajectories of health research evolved in the literature. In the 1960s the medical and sociological research projects focused on the examination of relationship between social status and health status while in the 1970 statistical, demographic and epidemiological works came out. In the 1980s the analysis of

individual way of life came to the forefront of research along with the explanation of the reasons of mortality and avoidable mortality. In the 1990s mainly analytical works on the various aspects of critical state of the Hungarian health care system came to light and the same years saw the emergence of the detailed research on the psychological health and health behaviour (e.g. Skrabski – Kopp 1994) with its socio-psychological factors (e.g. Pikó 1998). The overview of the research preliminaries mainly includes the interpretation of the explanation of Hungarian health inequalities. The gradual degradation of the people’s health in Hungary called for more intense research work on the morbidity situation in the country from the 1960s. Since the 1970s the outcomes of morbidity research gave way to the development of a view, which put the blame on the individuals’ irresponsible behaviour for the general trend of health deterioration in Hungary, this way emphasising the importance of life style which is the question of individuals’ choice. Due to the extensive research work the most common causes of premature death were identified as social and spatial inequalities. The examination of social differences manifested in the state of health came to the forefront in literature in the 1980s. The research projects justified that the inequalities in general health status in Hungary in the 1980s was greater than a decade earlier. The interpretation of certain diseases as deprivations is connected to the examination of the socio-cultural dimensions of health (Szalai 1992). The research preliminaries of social inequalities go partly into the analysis of the demographic factors (age, gender, education) and partly into the examination of the effects of death cause structure characteristic of the developed world on the changes in the state of health. In the 1990s papers on the health conditions of the Hungarian population (e.g. Losonczi 1998) and on the critical situation in the functioning of the Hungarian health care system increased in number (e.g. Orosz 1990). Among these works the greatest project is the series of books titled “Hungary in the new Millennium – a strategic research: The factors of quality of life in Hungary” coming out since 1998 under the editorship of the Hungarian Academy of Sciences. The examination of the spatial inequalities of health started to become a major research topic in the 1970s. In the beginning this trajectory meant the examination of the relationship between the development of diseases and presence of certain environmental factors. Such topics were the assessment of the health threatening impact of the toxic materials dissolved in the drinking water of the Southern Great Plain; the relationship between the areas with iodine deficiency and the higher than average incidence rate of goitre; the link between the malignant tumour and tobacco production; the spatial occurrence of tuberculosis etc. From the end of the 1990s the complex health geographical research projects could highlight the socio-spatial dimensions of the Hungarian health status which were applied on various regional levels. For example complex interpretation of the issue were prepared for counties (Pál - Kiss - Tipei 2006). The regional analyses of health dealt with the methodological challenges of the health research on subregional level and also with the examination of case studies (e.g. Uzzoli 2002). On the settlement level health research projects examined health inequalities in the agglomeration of Budapest and within the capital (e.g. Józan – Forster 1999). Meanwhile another view evolved in the complex health geographical research projects from the 1990s, which blamed the health care system for the same situation stating that the system is not prepared for the immediate reaction to the new challenges and therefore has a deterministic role in the worsening of the health situation. In this way I follow the conception to study the relation between health status and socio-spatial differences in this article. Among

the examination levels of health inequalities on environmental perspectives (Elliott 1993) as cellular, individual, local, regional, national, international and global it will be shown regional inequalities on based national data in the international context. Life chances and its regional differences Life expectancy means the average number of years to be lived, calculated from birth or from a particular age, so this is an average number of years that a newborn is expected to live if current mortality rates continue to apply (Johnston et al. 2000). The index reflects the overall mortality level of a population. It summarizes the mortality pattern that prevails across all age groups - children and adolescents, adults and the elderly. The average life expectancy at birth in Hungary was 72.7 years in 2005 which is a lot less than in the European Union (77.2 years) (Fig. 1.). According to the very disadvantageous mortality rate of the middle-aged Hungarian males population (Józan 1996) the country has a very bad situation in the European continent. The average number of males’ life chances is under 70 years and it is so similar to the non-EU member post-socialist countries. Naturally, biomedical relation explains the disparity of life expectancy by sex; females have approximately 2-3 years longer life expectancy at every age than males (Murray et al. 2003). However the gap between the Hungarian male and female life expectancy is now extremely wide (8.6 years). Furthermore, the indicator is also over 6 years in EU. Males

90

Females

66.8

Non-EU members

68.5

Hungary

75.0

77.1

74.0

EU27

80.7

75.1

EU15

81.5

70

50

30

10

10

30

50

70

90

years

Fig. 1. Average life expectancy at birth in comparison in Europe, 2005 Data source: www.workmall.com/wfb2005/ Life expectancy is influenced by death rates, so they are even compound indexes for life chances. In this way. the adult mortality rate in Hungary is one of the worst among the European countries (Table 1): even better values are can be found in the new members of EU as Bulgaria and Romania. Hungary is only ranked 32nd among the 39 European countries by both of the male and female death rates. This rank is very similar to the Baltic Republics. Hungarian men’s health is mainly poor compared with all countries of European Union. It can be explained by the fact that they are increasingly adopting harmful behaviour, such as smoking, alcoholism and drug-addiction. The death rate of the middle-aged male population stands out by global standards, due to this indicator Hungary belongs to the middle-ground countries in the world (Uzzoli 2006).

However by European standards it is among the countries with the worst characteristics regarding general state of health. All the mortality indicators are worse than the average European values and it is especially true about the mortality rate of the middle-aged male and female population. Table no. 1 Adult mortality rate (per 1,000) between ages 15 and 60 years in Europe, 2005 Rank 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39

Country Sweden Iceland Malta Switzerland Netherlands Italy Norway Cyprus Ireland United Kingdom Germany Luxembourg Austria Spain Greece Denmark Belgium France Finland Portugal Slovenia Czech Republic Albania Croatia Serbia and Montenegro

Males 74 81 84 90 93 93 96 99 100 103 115 115 115 116 118 121 125 132 134 150 165 166 167 173 186

Females 50 53 49 50 66 47 58 47 60 64 59 63 59 46 48 73 66 59 57 63 69 74 92 70 99

Bosnia and Herzegovina Poland Macedonia Slovakia Bulgaria Romania Hungary Lithuania Moldova Latvia Estonia Belarus Ukraine Russia

190 202 202 204 216 239 257 302 303 306 319 370 384 480

89 81 86 77 91 107 111 106 152 120 114 130 142 182

Data source: http://globaledge.msu.edu/ibrd/countrystats.asp While the difference of the average life expectancy is approximately 15 years among the European countries, until this gap is 2.5 years between the best and the worst values of the

Hungarian counties (Uzzoli 2003). Male’s and female’s life expectancy is the best in Budapest and Győr-Moson-Sopron county, but is the lowest in Borsod-Abaúj-Zemplén and Szabolcs-Szatmár-Bereg counties (Fig. 2.).

Fig. 2. The average life expectancy at birth by sex in the Hungarian counties, 2005 Data source: Hungarian Demographic Yearbook 2005 The average life expectancy at birth and its changes continuously depended on the improvement or the worsening of the mortality situation in Hungary after the Second World War (Fig. 3.). It could particularly increase during the 1950s and rise over 70 years, but the marked deterioration of life expectancy happened at the end of the 1970s. It reached its bottom in 1985, but this could not be followed by a period of upswing due to the change of regime and the socio-economic transformation. Nevertheless the role of the transition caused another bottom in 1993. The moderation of mortality rate resulted that the life chances could increase again over 70 years from the second half of the 1990s. Now the average number of it is 72.7 years; for males is 68.5 years and for females is 77.7 years in Hungary. The gap between man and women was the widest (about 10 years) in the middle of the 1990s. The life chances and its regional differences within Hungary are influenced by the socioeconomic situation of the counties. The relative position to each other has not or hardly changed in the past 15 years. The most advantaged and the worst disadvantaged counties were the same at the beginning of the 1990s and nowadays, too. The examination of the average number and divergence of life expectancy at birth in the last decade shows us a very typical spatial structure (Fig. 4.). The most favourable life chances include North-West Transdanubia (Győr-Moson-Sopron, Vas and Veszprém counties) and Budapest, while the most disadvantageous area can be found in North-East Hungary (Szabolcs-Szatmár-Bereg and Borsod-Abaúj-Zemplén counties). In this latter case the indicator of these counties always occurred from the average life expectancy of the whole country during the 1990s. On the other hand, the best value of Győr-Moson-Sopron county was at least 1.5 years higher the national average number during the 1990s.

14.8 14.6 14.4

per 1,000

14.2 14.0 13.8 13.6 13.4 13.2 2005.0

2004.0

2003.0

2002.0

2001.0

2000.0

1999.0

1998.0

1997.0

1996.0

1995.0

1994.0

1993.0

1992.0

1991.0

1990.0

1989.0

1988.0

1987.0

1986.0

1985.0

1984.0

1983.0

1982.0

1981.0

1980.0

13.0

Fig. 3. Mortality rate (per 1,000) in Hungary, 1980-2005 Data source: Hungarian Demographic Yearbook 2005

Fig. 4. The life expectancy at birth and its divergence from the national average in Hungary, 1990-1999 Data source: Hungarian Demographic Yearbook 1990-1999 In comparison with Fig. 4.; on Fig. 5. and Fig. 6. it can be seen a very close connection between life expectancy and economic development, and they can have effects on the regional inequalities of life chances. Studying the GDP per capita (Fig. 5.) and the unemployment rate (Fig. 6.) the next relation results: if the income is higher; the life expectancy is also better, however the lower value of life chances follow the higher unemployment rate. In Transdanubia, with better than average economic indicators, Somogy county stands out as a county with the relatively worst conditions. The county with the best indicators in the fairly bad context of the eastern part of Hungary is Csongrád. Budapest in general has favourable values regarding the GDP and unemployment indicators; nevertheless it has a bad reputation for the high rate of deaths caused by malignant neoplasm. This is the main cause for the average life expectancy being a little bit less in the capital than in Győr-Moson-Sopron county for a few years during the last decade. One of the most interesting thing about the widening health gap between the eastern and the western half of Hungary is that it had already evolved during the 1970s and 1980s, but also

has suggested the common origins of the health trends and the uprisings of 1989. Now the mortality levels in the eastern counties are above the average of the whole country.

Fig. 5. GDP per capita (country=100%) in Hungary, 2005 Data source: http://epp.eurostat.ec.europa.eu

Fig. 6. The unemployment rate (total - % of labour force) in Hungary, 2005 Data source: Hungarian Statistical Yearbook 2005 Adult mortality data serve as a standard information resource to guide public health action. This is an important indicator of probability that a 15 year old will die before reaching his/her 60th birthday. Considering the significant mortality and life chances data, it is impossible to disregard the fact that in the eastern part of Hungary the number of people in multiply disadvantaged position is very high, struggling with many economic (e.g. unemployment) and social problems (e.g. ethnical minority groups). In the eastern half of Hungary people belonging to the upper strata of the social hierarchy is mostly low because of these counties’ low incomes. Mortality differentials among the Hungarian counties Mortality data are the most complete and comparable, and they therefore constitute the main component of international comparisons. However, even in this case there is often some doubt

about the completeness of the recording of deaths, especially at very young and old ages, regarding the accuracy of coding of causes of death. There are significant mortality differentials among the Hungarian counties, and according to life expectancies the probability of surviving have most deteriorated over the last decade. This fact is also sincere in adult and infant mortality. The infant mortality rate is the number of children dying under a year of age divided by the number of live births that year. This is an important measure of the well-being of infants, children, and pregnant women because it is associated with a variety of factors, such as maternal health, quality and access to medical care, socio-economic conditions, and public health practices (www.medicinenet.com). I have applied Hoover-index to study the spatial inequalities of the infant mortality (Fig. 7.). The powerful and continuous reduction of the infant mortality in developed countries and of course in Hungary was experienced in the second half of the 20th century, which was influenced by the right organised mother and infant welfare service and centres (Howe 1997). It followed that it must be reduced the premature birth and have organised the welfare centres in the country. This process could also result the decrease of the spatial inequalities among the Hungarian counties. During the examined period the values of Hoover-index were the highest at the beginning of the 1980s (H=21.2%), and from that time it was halved. Despite of the fact, the role of the transition could experience a mild rising period around the transformation years, but it was not a significant difference. Nowadays the value of the regional indicator is approximately 10%, but it comes from the higher rate of premature births mortality which is particularly based on the natal weight as less than 2500g, and it has affects on neonatal deaths between 0-6 days after the birth (Sz. Serfőző 2000).

2005 2000 1995 1990 1985 1980 0.0

5.0

10.0

15.0

20.0

25.0

%

Fig. 7. The values of Hoover-index by the infant mortality rate among the Hungarian counties Many common, in Hungary western diseases remain more prevalent than in Western Europe – as cardiovascular diseases, cancer in general, and lung cancer in particular. Unfortunately, Hungary has the highest high cancer mortality, mainly due to lung cancer. The dominant cause is clearly the consumption of cigarettes (WHO 2002). This is according to developed countries’ cause-specific mortality situation, where more than 90% of deaths are coming from 4 main cause, such as circulatory system (app. 50%), malignant neoplasms (app. 25%), respiratory and digestive system. On the other hand, some causes of mortality are currently less common in Hungary than in Western Europe, mostly respiratory and many infectious diseases (WHO 2002).

The weighted relative standard deviation is a very sensitive indicator to present the spatial inequalities. Among the other 4 main death causes - except for the respiratory mortality there was a significant spatial differentiation in 1990 (Fig. 8.). Mostly it could experience in the digestive diseases and in the malignant tumours. In fact, the role of the social-economic transformation was not just the cause of it around 1990, but even it is the final state of a very long process which started 10-15 years ago. It means the symptoms of these death causes appeared among middle-aged population – mainly at the age of 40-45 years – long time ago, but because of their overworked lifestyle they were not able to go doctors’ to any treatments. The effects of transition from 1989 resulted particular social problems in Hungary, and the “loser social groups” of it cannot adopt the facilities of the new living conditions. They got to so disadvantageous social position, firstly lost their jobs, and even became homeless. The high death rates of these social groups influenced the bottom of the Hungarian mortality situation in 1993 (Fig. 3.). We can see a spatial equalization among the main death causes from the middle of the 1990s. Nevertheless it does not mean an improvement, only a moderated rate in mortality with the connection of the advanced life chances from 1996. On the other hand, the mortality rate is very high in all Hungarian counties, because the majority population most often died in circulatory diseases or malignant neoplasms. 99.0 %

97.0

95.0

93.0

91.0

89.0

Malignant neoplasms

Circulatory system

Respiratory system

2005

2004

2003

2002

2001

2000

1999

1998

1997

1996

1995

1994

1993

1992

1991

1990

1989

1988

1987

1986

1985

1984

1983

1982

1981

1980

87.0

Digestive system

Fig. 8. The weighted relative standard deviation by the main death causes in the county level Besides of the main 4 death causes, I have examined tuberculosis mortality, because it was increasing in the eastern part of Europe and in Hungary, too from the beginning of the 1990s. Thus, it has a typical spatial pattern in the country. Mortality of the tuberculosis is one of those diseases which has renewed during the years of the transition, although it levelled off or began to decrease by the end of the 1990s in Central and Eastern Europe as well as in Hungary too (Fig. 9.). This cause of mortality is very high in all of the former republics of Soviet Union. Prevalence and mortality are direct indicators of the burden of tuberculosis, indicating the number of people suffering from the disease at a given point in time, and the number dying each year. Furthermore, prevalence and mortality respond quickly to improvements in control, as timely and effective treatment reduce the average duration of diseases (thus decreasing prevalence) and the likelihood of dying from the disease (thus reducing disease-specific

mortality) (www.euractiv.com/en/health/health-inequalities/). Mortality of the tuberculosis is one of those diseases which has renewed during the years of the transition, although it levelled off or began to decrease by the end of the 1990s. That is the main point to using the indicator of tuberculosis incidence – as morbidity statistics - to show the inequalities in Hungary.

Fig. 9. Mortality of tuberculosis per 100,000 in Europe, 2003 Data source: www.who.int/whosis/country Tuberculosis had been common in the 19th century and had experienced the highest mortality rates in Hungary among the European countries, therefore called it “morbus hungaricus”. The struggle against tuberculosis in the country had been unique in Europe from the beginning of the 20th century, because had had very good vaccination coverage for it (mainly for infants/children). As the consequence of this process tuberculosis was rare until the 1980s years, however from the end of this decade the number of it started to increase (Fig. 10.). At that time as well as recently the most endangered social groups are homeless and poor people (Makara 1994). Among them the disadvantageous living conditions and alcoholism can cause the deterioration of the general state of health, because it is established that the weakened immune system cannot fight against the bacterial infectious diseases. Nowadays the Central Region and the eastern part of the country have the highest rate of tuberculosis incidence. In Budapest and Pest county live the most homeless people in Hungary (about 8,000), while the highest number of the most unfavourable social groups is in the eastern part of the country. Besides of the cause specific mortality rate, the demographic situation of Hungary can also influence the negative tendency of the health conditions. The Hungarian population is declining from 1981, owing to a combination of high rate deaths exceeding births (negative

natural growth). The demographic situation of decreasing population and increasing ageing index is typically parallel with Western Europe. On the other hand, its mortality position however is more unfavourable rather than in Western Europe. The country experienced particular mortality problems during the social-economic transition of the late 1980s and early 1990s, because the high rates of the middle-aged population (Józan 1998). Throughout the 1990s dramatic demographic changes were associated with low birth rate, falling population, particularly those of working ages, and increased the proportion of elderly (Vukovich 1997).

Fig. 10. Tuberculosis incidence in Hungary in 1980, 1990 and 1999 Data source: Hungarian Demographic Yearbook Conclusion There are determining spatial inequalities in the health status in Hungary, mainly between the western and the eastern halves, and the patterns of these differentials vary considerably among the examined counties. In fact, the Hungarian mortality position however is more unfavourable rather than in Central Europe. We can say, Hungary has one of the worst health status in the European continent.

The Hungarian life expectancies are one of the lowest in Europe and demonstrate a variety of spatial structures in the country. Infant mortality, though falling, is about double than in EU15, and the low birth weight – probably related to the very high rates of teenage pregnancy and those unhealthy habits as smoking and drinking alcoholics during the pregnancy – is a particular problem. These are the main causes of higher levels of maternal mortality, too. Unfortunately, this situation has accompanied by unhealthy lifestyle, low living standards and more prevalent mortality. Relatively high rates of smoking, alcohol consumption, high blood pressure, lack of exercise, a diet high in animal fats and low on fresh fruit and vegetables are direct contributory factors, though the social insecurity of the last decade resulted the unfavourable mortality position of the post-socialist countries in Europe and in the world. From mortality of the circulatory system both of cerebrovascular and cardiovascular mortality are disproportionately higher than levels in Western Europe. Malignant neoplasms, especially lung cancer are an important public health problem in Hungary with high premature mortality among men (though this has been falling generally throughout the 1990s). Mortality for women, though much lower, is still rising. The dominant cause is clearly the consumption of cigarettes (WHO 2002). The mortality situation in Hungary presently hits the whole adult population, but its spatial inequalities differ by the death causes. This spatial differentiation has closer connection with the life chances rather than with the death causes (Table 2). Table no. 2 Pearson’s coefficient of correlation in the county level, 2003 Mortality per 100,000 Population GDP per capita Income Circulatory system -0.18 -0.25 -0.31 Malignant neoplasms 0.29 0.28 0.24 Respiratory system -0.27 0.00 -0.38 Digestive system 0.26 -0.17 0.24 Tuberculosis 0.40 -0.20 0.40

Unempolyment rate 0.20 0.33 0.44 0.50 0.56

In addition to the east-west gap of the Hungarian health, differences in health status between socio-economic groups have increased in many counties as socio-economic determinants such as education, employment and life-style affect the health (health related quality of life). In my opinion papers on health geography can illustrate how new concepts (geographical health inequalities) can be combined to provide an enhanced analysis of a complex relationship between health and place and its socio-spatial dimensions. The geography of area effects in ill-health is not defined purely by its spatial characteristics, but also its social characteristics (Mitchell - Gleave - Bartley 1998). In this article I tried to attend the theory of inequalities researches, but I also used the concept of regional science studies. For that very reason I should say, in methods of analysing of health inequalities it is requiring to adopt both of quantitative and qualitative approaches. In the future is necessary to define and analyse health inequalities in the level of sub-regions and settlements in Hungary, among the districts of Budapest. It will be the next step of my health geographical studies. References 1. Black, D. - Morris, J. N. - Smith, C. - Townsend, P. (1985): Inequalities in health. The Black Report. Penguin Books, Hammondsworth, Middlesex, England 2. Elliott, Paul (1993): Global epidemiology. In: Environmental change and human health. CIBA Foundation Symposium 175. John Wiley and Sons, London pp. 220.

3. Howe, G. M. (1997): People, environment, disease and health. A Medical Geography of Britain Throughout the Ages. University of Wales Press, Cardiff UK 4. Hungarian Demographic Yearbook. Central Statistic Office, Budapest 5. Hungarian Statistical Yearbook. Central Statistic Office, Budapest 6. Johnston, R. J. – Gregory, D. – Pratt, G. – Watts, M. (2000): The Dictionary of Human Geography. Blackwell Publishers Ltd., Oxford UK 7. Jones, K. - Moon, G. (1987): Health, disease and society: A Critical Medical Geography. Routledge and Kegan Paul Ltd.: London – New York. Portsmouth Polytechnic 8. Józan, P. (1991): Some features of mortality in postwar Hungary. The third epidemiological transition. Resarch Reviw, No. 4. pp. 127-137. 9. Józan (1996): Health Crisis East of the Elbe: A consequence of dead-ended modernization. Paper presented at the Sawyer-Mellon Conference on Increasing Adult Mortality in Eastern Europe. Ann Arbor, MI: University of Michigan, pp. 312-134. 10. Józan, P. (1998): Some features of mortality in Hungary between 1980 and 1994. Atlantic Studies on Societies in Change. No. 85. pp. 111-138. 11. Józan, P. – Forster D. P. (1999): Social inequalities and health: ecological study of mortality in Budapest, 1980-3 and 1990-3. British Medical Journal, 318. pp. 914-915. 12. Losonczi, Á. (1998): Utak és korlátok az egészségügyben (Ways and Guards in the Health Care). Magyar Tudományos Akadémia ‘Hungarian Academy of Sciences’, Budapest 13. Makara, P. (1994): The Effect of Social Changes of the Population: Way of Life and Health. The Hungarian Case Study. In: Economic Change Social Welfare and Health in Europe. WHO. R. P. European Series, No. 54. pp. 77-94. 14. Mitchell, R. - Gleave, S. – Bartley, M. (1998): Multilevel analysis of the geography of health inequalities: using better geographies. ESRC Health Variations Programme, Portsmouth (www.geocomputation.org/1998/) 15. Murray, C. J. L. – Ferguson, B. D. – Lopez, A. D. – Guillot, M. – Salomon, J. A. – Ahmad, O. (2003): Modified log it life table system: principles, empirical validation and application. Population Studies 2003, 57 (2): pp. 1-18. 16. Nemes Nagy, J. (2000): The new regional structure in Hungary. In: Petrakos, G. - Maier, G. - Gorzelak, G. (eds.): Integration and Transition in Europe: The Economic Geography of Interaction, Routledge, London, pp. 203-222. 17. Orosz, É. (1990): Inequalities in Health and Health Care in Hungary. Social Science and Medicine, Vol. 31. No. 8., pp. 847-857. 18. Pál, V. – Kiss, J. P. – Tipei, A. (2006): A survey of regional differences in health conditions of Hungarian patients on the basis of hospital admissions. Magyar Epidemiológia ‘Hungarian Epidemiology’, No. 3., pp. 83-96. 19. Pikó, B. (1998): Social support and health in adolescence: A factor analytical study. British Journal of Health Psychology, no. 3., pp. 333-344. 20. Sigherist, H. E. (1948): Definition of well-being. In: Official Records of the WHO, No. 2., pp. 100. 21. Skrabski, Á. – Kopp, M. (1994): Health behaviour, psychiatric symptoms and psychological background factors. Swiss Monographs in Psychology, No. 2., pp. 21-27. 22. Szalai, J. (1992): Child poverty and deprivation. In: Industrialized countries: The Hungarian Case. Florence, Unicef Occasional Papers. 23. Sz. Serfőző, K. (2000): A termékenység változásának néhány jellemzője a legutóbbi nyolc évtizedben (The fertility and its changes during the last eight decades in Hungary). Demográfia ’Demography’, No. 4. pp. 445-478. 24. Townsend, P. (1988): Inequalities in Health. Penguin, London

25. Uzzoli, A. (2002): Social problems in the secondary schools in Budapest. In: Tivadar, B. – Mrvar, P. (eds.): Flying over or falling through the cracks? Young people in a risk society. Ministry of Education, Science and Sport of the Republic of Slovenia. Slovenia, Ljubljana 2002. pp. 268-272. 26. Uzzoli, A. (2003): A magyar népesség egészségi állapota az európai országok körében (The Hungarian health status among the European countries). Földrajzi Közlemények ‘Hungarian Geographical Review’, No. 1-4. pp. 131-156. 27. Uzzoli, A. (2006b): The spatial structure of health inequalities in Europe. Geographical Phorum – Geographical studies and environment protection research 2006/5. University of Craiova, Romania pp. 101-113. 28. Vukovich, Gy. (1997): The demographic situation in Hungary in international perspective. Hungarian Statistical Review. Special Number, pp. 63-75. 29. WHO Regional Office for Europe (2002): Health status overview for countries of Central and Eastern Europe that are candidates for accession to the European Union. European Communities and WHO, July 2002 (Document E76888) 30. WHO (2006): The World Health Report 2006. – Working together for health. World Health Organization, Geneva 2006. Internet sources www.euractiv.com/en/health/health-inequalities/ http://epp.eurostat.ec.europa.eu www.euro.who.int/countryinformation www.medicinenet.com www.who.int www.who.int/whosis/country www.workmall.com/wfb20015/ http://globaledge.msu.edu/ibrd/countrystats.asp