Den ojämlika dödligheten är en studie av främst hjärt–kärldödlighet avseende perioden 1950–2010 i tvillingstäderna Linköping och Norrköping och konsekvenserna av ojämlikhet. Skillnaderna mellan städerna i dödlighet är stora. Under 1970-talet, då jämlikheten stod i focus, minskade dessa. Efterhand som ekonomisk politik och samhällsvärderingar mera anpassades till en global monetaristisk politik ökade också den ojämlika dödligheten mellan städerna. Stora förändringar ägde rum inom respektive stad när det gäller hjärtdödligheten. Miljonprogramområdena i de båda städerna blev relativt sett fattigare och präglades allt mer av flyktinginvandring, samtidigt som städernas centra gentrifierades, inte minst i Linköping. Skillnaderna i dödlighet mellan ytterområdena och centrum ökade under 1990- och 2000-talen. Detta gäller i större utsträckning i Linköping än i Norrköping. Avhandlingen består av tre delar. I licentiatuppsatsen analyseras städernas utveckling från 1950-talet till 2006. Studien gör också ett försök att spåra orsaker till ohälsoskillnader och för tidig död. Artikel 1 handlar om vad som hände med folkhälsan på vägen från ett högindustriellt till ett postindustriellt samhälle. Ett särskilt focus har varit att studera skillnader i hjärtsjuklighet mellan olika stadsdelar i de bägge tvillingstäderna. I artikel 2 analyseras skillnader i hjärt–kärldödlighet på stadsdelsnivå under perioden 1976 till 2010. / Unequal Mortality is primarily a study of coronary heart disease mortality and its consequences during the period 1950–2010 in the twin cities Linköping and Norrköping. The difference in mortality between the two cities was great. During the 1970s, when there was a focus on equality, these differences declined. As economic policies and social values were adapted to a global monetary policy, inequality in mortality between the two cities increased. Large changes took place in the respective cities as far as mortality in coronary heart disease was concerned. In both cities the low cost housing projects became poorer and were increasingly influenced by the influx of refugees, at the same time that the city centres became gentrified, not least in Linköping. The differences in mortality between the out-lying areas and the city centres increased during the 1990s and the first decade of the 21st century. This is true to a greater extent in Linköping than in Norrköping. The dissertation consists of three parts. The licentiate thesis analyses the development of the cities from the 1950s until 2006. The study also attempts to trace the reasons for the differences in health and premature death. Article 1 deals with what happened on the way from a highly industrial to a post-industrial society. It has especially focused on studying the differences in coronary heart disease morbidity among various neighbourhoods in both the twin cities. Article 2 analyses differences in coronary heart disease mortality during the period from 1976 to 2010.

[Truncated abstract] The main objective of this study was to develop and validate a demographic/epidemiologic Markov model for population modelling/forecasting of CARPs as well as CHD deaths and incidence in Western Australia using population, linked hospital morbidity and mortality data for WA over the period 1980 to 2000. A key feature of the model was the ability to count events as individuals moved from one state to another and an important aspect of model development and implementation was the method for estimation of model transition probabilities from available population data. The model was validated through comparison of model predictions with actual event numbers and through demonstration of its use in producing forecasts under standard extrapolation methods for transition probabilities as well as improving the forecasts by taking into account various possible changes to the management of CHD via surgical treatment changes. The final major objective was to demonstrate the use of model for performing sensitivity analysis of some scenarios. In particular, to explore the possible impact on future numbers of CARPs due to improvements in surgical procedures, particularly the introduction of drug eluting stents, and to explore the possible impact of change in trend of CHD incidence as might be caused by the obesity epidemic. ... When the effectiveness of PCI due to introduction of DES was increased by reducing Pr(CABG given PCI) and Pr(a repeat PCI), there was a small decline in the requirements for PCIs and the effect seemed to have a lag. Finally, in addition to these changes when other changes were incorporated which captured that a PCI was used more than a CABG due to a change in health policy after the introduction of DES, there was a small increase in the requirements for PCIs with a lag in the effect. Four incidence scenarios were developed for assessing the effect of change in secular trends of CHD incidence as might be caused by the obesity epidemic in such a way that they gradually represented an increasing effect of obesity epidemic (assuming that other risk factors changed favourably) on CHD incidence. The strategy adopted for developing the scenarios was that based on past trends the most dominant component of CHD incidence was first gradually altered and finally the remaining components were altered. iv The results showed that if the most dominant component of CHD incidence, eg, Pr(CHD - no history of CHD) levelled off and the trends in all other transition probabilities continued into future, then the projected numbers of CABGs and PCIs for 2001-2005 were insensitive to these changes. Even increasing this probability by as much as 20 percent did not alter the results much. These results implied that the short-term effect on projected numbers of CARPs caused by an increase in the most dominant component of CHD incidence, possibly due to an ?obesity epidemic, is small. In the final incidence scenario, two of the remaining CHD incidence components-Pr(CABG - no history of CHD) and Pr(CHD death - no CHD and no history of CHD) were projected to level off over 2001-2005 because these probabilities were declining over the baseline period of 1998-2000. The projected numbers of CABGs were more sensitive (compared to the previous scenarios) to these changes but PCIs were not.

The study Social Change and the Fragile Heart is an analysis of contemporary history in two neighboring Swedish cities, Linköping and Norrköping. The analysis has been made from a special perspective: the changes in deaths due to heart disease in the age group 50-74 years. The differences in mortality between the two cities is a measurable way to study how well a society functions and is governed. These cities in the county of Östergötland differ historically and socially. This has led to clear differences in socio-economic conditions and even variations in health and mortality that have been to Norrköping’s disadvantage. There is an exception, the 1970’s, when the rise in the numbers of deaths due to heart disease was broken in Norrköping, while the figures continued to increase in the neighboring city, especially among men. Uneasiness about the future and opportunities to make a living grew. This may have influenced health negatively, especially among middle-aged men who feared their jobs were threatened. In Norrköping the textile industry had definitely died in the beginning of the 1970’s. The closing of this industry meant at the same time that poor working conditions and low-paid work were phased out. The earlier rising trend in deaths due to heart diseases was broken, and instead a noticeable decline occurred that was especially clear among women. Deaths due to heart disease in ages 50–74 began to decline generally in the 1980’s and sank significantly in the following decade. The difference between the cities, however, grew from the relatively equal situation of the 1970’s. These are the years during which economic and political power shifted from Norrköping to Linköping. As the regional center and a relatively new university town, Linköping survived the recession of the 1990’s rather well. Simultaneously, Norrköping suffered from what might be called a “social exhaustion depression.” During the last decade of the 20th century long-term unemployment and illness affected far more people than in Linköping. The great transformation from an industrial to a post-industrial society left its mark on Norrköping in the form of increased differences between the cities in the case of premature deaths due to heart disease.