The new map of mortality in Spain , the most detailed in history and made with data from 26 cities, reveals brutal inequalities between residents of the same city, sometimes on both sides of the same street. The coordinator of the atlas, statistician Miguel Ángel Martínez Beneito , speaks of “devastating results.”
The highest risk of dying from the 15 causes analyzed is concentrated in the poorest neighborhoods, especially in the case of lung cancer, chronic obstructive pulmonary disease and AIDS, in men; diabetes, in women; and cirrhosis and stomach cancer, in both sexes.
The 26 cities analyzed are home to 25% of the Spanish population. The atlas is part of the Medea 3 project , an initiative coordinated bythe Fisabio Foundation and financed by the Carlos III Health Institute to obtain a photograph of mortality in the neighborhoods.
Martínez Beneito, from the University of Valencia, sums it up like this: “We see the same pattern over and over again, which corresponds to socioeconomic deprivation”. The greatest risks are observed in neighborhoods such as Villaverde, in Madrid; the Raval, in Barcelona; or the Three Thousand Homes, in Seville.
But it is not a problem of marginalized populations. Health inequality is gradual: people tend to fall ill and die earlier than those immediately above them in the job hierarchy .
The authors have analyzed one million deaths in 26 Spanish cities between 1996 and 2015, grouping the deaths by census sections, the small areas where some 1,500 residents live who vote in the same electoral college. The atlas, whose data EL PAÍS has had access to, allows us to visualize the effects of socioeconomic inequality on health like never before.
Poor housing, low wages, social marginalization and unemployment are associated with poorer nutrition, less sporting activity and, especially in the case of men, greater consumption of tobacco and alcohol. Some streets act as a border between two different worlds, one on each side of the sidewalk.
The map that heads this news reflects a value that summarizes all the patterns of causes of death in each census section. The greater or lesser risk in one section versus another can vary a lot simply because a specific disease is much more common than the rest. Next, we show the details of certain diseases in the neighborhoods where they hit the most.
1. The Three Thousand Homes (Seville)
A train track with a wall separates the Sevillian neighborhood of Bami, with swimming pools and green areas, from the Tres Mil Viviendas, one of the poorest neighborhoods in Spain, with just over 5,000 eurosaverage annual income per inhabitant. The rails are a true urban border. In Bami, the risk of death from almost all causes is lower than the Seville average.
Across the railroad track, in the Three Thousand Homes, men’s risk of dying from lung cancer is 112% higher; for cirrhosis, 214%; for chronic obstructive pulmonary disease, 230%; and for AIDS, 590%. The atlas shows relative, not absolute, risks. If an average of 80 deaths per year from lung cancer per 100,000 inhabitants is observed in a city, a 100% increase in risk would translate into a rate of 160 deaths per 100,000.
Pablo Sánchez Villegas , a researcher at the Andalusian School of Public Health and co-author of the atlas, laments: “When we say that poverty kills, we are not referring to images from 30 years ago of children in Ethiopia with fat bellies. We talk about our own cities ”.
2. El Ruedo de la M-30 (Madrid)
More than 300 families from the oldest shanty town in Madrid – El Pozo del Huevo (Villa de Vallecas) – were relocated in 1990 in the so-called Ruedo de la M-30 , a complex of social housing next to the capital’s ring road.
El Ruedo still appears as an island with higher mortality in men from almost all causes: 40% more in lung cancer, 53% more in chronic obstructive pulmonary disease, 84% more in cirrhosis, 194% more in AIDS.
In women there are hardly any differences with the Madrid average. Ana Gandarillas, epidemiologist at the Madrid Regional Ministry of Health and co-author of the atlas, explains: “In women, in general in all cities, mortality patterns are much softer, more homogeneous.”
3. The Paseo de la Castellana (Madrid)
26% of men in Spain smoke, compared to 19% of women, according to the latest National Health Survey . The tobacco epidemic in the 20th century followed a classic pattern of diffusion of innovations : first, wealthy men began to smoke; later, men of lower socioeconomic status; third, women from the wealthy classes; and finally the rest of the women. As lung cancer takes decades to appear, what is seen now are the effects of smoking in the middle stages of that epidemic.
Epidemiologist Ana Gandarillas sums up: “The poorer an area, the more lung cancer in men. The richer an area, the more lung cancer in women ”. It is a mirror pattern that is observed in all large Spanish cities.
The highest risk of death from lung cancer in women in Madrid is detected around Paseo de la Castellana, one of the most privileged areas in Spain, with up to 35,000 euros of average annual income per inhabitant. The risk peak appears in the Paseo de La Habana, with 258% more than the average of the capital.
4. El Corralón (Valencia)
Two triangular blocks of social housing, known as El Corralón, emerge as an island with a higher risk of mortality around Yecla Street , in Valencia. El Corralón stands out for its increased risk in men: 33% more in lung cancer, 40% in chronic obstructive pulmonary disease, 68% in cirrhosis and 300% in AIDS.
The place has been popularized by the video clips of the young Valencian rapper Aloy, raised there . One of his successes begins like this: “I’m just a slum boy , I don’t have money.”
Statistician Miguel Ángel Martínez Beneito navigates the map of his city , Valencia, showing again and again the same pattern: a gradual increase in the risk of mortality from wealthy neighborhoods to the most disadvantaged, with a peak in men from the areas poorer. The highest excess in male lung cancer, 58% above the average, appears in Cabanyal, a coastal neighborhood historically abandoned by the administrations.
“We see that almost all diseases”, affirms Martínez Beneito, “point in the same direction, they go in unison. It has left me out of the game to see to what extent the socioeconomic part dominates in the mortality maps of all cities ”.
The epidemiologist Óscar Zurriaga , from the University of Valencia, criticizes the policies of demolishing marginal homes to simply relocate the population. “It is very gimmicky in the face of public opinion. Then some small trees are planted and it is said that what was once a degraded area is now a green area. Yeah, but where are those people? ”He reflects.
“This has been done constantly, regardless of political color, because the causes are not attacked. The problem is inequality, and therefore the problem of inequality must be solved. If not, all we do is move the problem from one place to another ”, says Zurriaga, vice president of the Spanish Society of Epidemiology.
5. L’Eixample (Barcelona)
Breast cancer, the most common tumor in women in Spain, is another of the few causes of death that usually presents an inverse pattern: the highest risk appears in wealthy neighborhoods . “It’s like seeing the negative of the photo of socioeconomic deprivation,” explains Maica Rodríguez , an epidemiologist at the Barcelona Public Health Agency and co-author of the atlas.
The phenomenon is observed in El Eixample, one of the districts with the highest average income in the Catalan capital. In some of its census tracts, the risk of dying from breast cancer is 78% higher than the city average.
The relationship between socioeconomic status and these tumors is still being investigated, although risk factors such as smoking , certain oral contraceptives, some hormonal therapies during menopause and the fact of having the first pregnancy after the age of 30 are pointed out .
6. San Blas (Madrid)
Epidemiologist Ana Gandarillas walks down the avenue of the Institución Libre de Enseñanza, at number 125. A grandmother speaks from her window with her granddaughter, on the street, about when she will have to get vaccinated against the covid. The avenue is one of the urban borders that separate two worlds in Madrid.
The census section that Gandarillas observes —with 12-story residential towers belonging to the San Blas district— presents a higher risk of death in men of up to 56% from lung cancer, 139% from cirrhosis and 408% from AIDS . The risk of death from diabetes in women is 41% above the Madrid average. On the other side of the avenue, already in the Ciudad Lineal district , all the risks are much lower than those of the city as a whole.
San Blas was devastated by heroin and unemployment in the 1980s, but the area has been transformed since then: where the shanty town of Los Focos was located , one of the largest in Spain, today is the Las Rosas shopping center , inaugurated in 1998.
The mortality atlas, however, continues to show San Blas as a striking exception in the east of Madrid. “Inequalities are a very persistent phenomenon,” reflects Gandarillas.
“When there is a socioeconomic improvement that affects the entire population, such as the economic boom that we had since 2000, it sometimes happens that the gain in health is not the same at all levels. All improve, but the richest improve more, with which inequality may even increase ”, warns the epidemiologist.
It is a paradox detected in many other countries: neighborhoods progress over the years, but health inequality continues to grow. The new mortality atlas confirms that the neighborhoods with the highest mortality in 1996 were still the neighborhoods with the highest mortality 20 years later.
7. Bilbao La Vieja (Bilbao)
More than a decade ago, London scientists showed that if the historic Jubilee tube line was traversed eastward, life expectancy in neighborhoods would drop by more than a year every two stops. The Basque Government’s Department of Health repeated the experiment in the Bilbao metro in 2015.
Its data revealed that life expectancy skyrocketed from the impoverished city center to the outside, increasing by five years in women and almost 10 years in men from the Bilbao La Vieja neighborhood to the Algorta stop, in Getxo, one of the richest municipalities in Spain, with an average annual income of 20,150 euros per inhabitant. The new atlas confirms this mortality pattern in the center of Bilbao and in two of the neighborhoodswith the lowest incomes in the city: Iturrigorri-Peñascal and Uretamendi.
“Life expectancy varies by neighborhood,” laments Elena Aldasoro , epidemiologist at the Department of Health of the Basque Government and co-author of the atlas. The researcher insists on an idea: “Not all people have the same control over our lives to make them healthier.”
Factors such as the stress of not making ends meet and the lack of health education make citizens smoke more, drink more alcohol or consume more ultra-processed food and sugary drinks . “It is not necessary to blame the people, but their situation,” emphasizes Aldasoro.
8. Villaverde (Madrid)
The area of Madrid with the highest risk of death from lung cancer in men – 123% above the average – is in Villaverde , along the Toledo highway, where the ArcelorMittal steel factory , a black dot of pollution in the city
The authors of the atlas caution that specific industrial facilities should not be lightly associated with the increased mortality observed in their environment. In that census section of Villaverde, for example, the excess of lung cancer in women – 27% more than in the capital as a whole – does not stand out as much as that of men.
9. Palma-Palmilla (Malaga)
Diabetes is one of the causes of death most associated with socioeconomic deprivation in women. In Palma-Palmilla – one of the poorest neighborhoods in Spain, with an average annual income of 6,800 euros per inhabitant – the risk of women of dying from diabetes is up to 54% higher than the average in Malaga. The team from the Andalusian School of Public Health has also detected in women a higher risk of death from dementia, heart disease, cerebrovascular diseases and cirrhosis in the most disadvantaged neighborhoods of the eight Andalusian capitals.
10. El Raval (Barcelona)
“In the eighties, the inequalities that existed between the neighborhoods of Barcelona were very wild,” recalls the epidemiologist Maica Rodríguez. Deaths from AIDS or overdoses were then concentrated in highly degraded downtown neighborhoods, such as Raval, and in the north of the city, in Nou Barris, the district where the working class families who arrived in Barcelona in the middle of the twentieth century.
Rodríguez, from the Barcelona Public Health Agency, is optimistic. Its indicators indicate that the city has improved . The Barrios Law, an urban regeneration program launched in 2004 by the Generalitat of Catalonia with European funds, reduced the enormous inequalities in health in the Raval, Nou Barris and other places.
The epidemiologist’s team has also studied another parallel phenomenon: the arrival in the historic center of young immigrants since 2000. “In the Raval there is a 50% foreign population. We have observed that this population change has improved the health of the neighborhood, at least in terms of mortality, ”says Rodríguez.
The atlas, however, continues to show the Raval as a spot of higher mortality, with some census sections with increases in risk of 42% in lung cancer, 147% in cirrhosis and 950% in AIDS, in the case of the men, and 95% in diabetes in women.
The commission on social determinants of health of the World Health Organization released in 2008 a report with recommendations to achieve health equity in a single generation. One of his main guidelines was “to fight against the unequal distribution of power, money and resources.” The new atlas of mortality in Spain shows the lethal effects of this inequality as never before. Now it is the turn of the politicians.
The Congress of Deputies already approved on September 22, 2011, with the vote of the vast majority of the deputies , the General Law of Public Health, a regulation promoted by the Government of the socialist José Luis Rodríguez Zapatero that established that all policies they would include objectives to reduce social inequalities in health.
Two months later, the Popular Party of Mariano Rajoy won the general elections with an absolute majority and the law was never developed . The rule has “remained forgotten for too many years in a drawer,” summarized in June 2020 the then Minister of Health, Salvador Illa. Ministry sources assure that they are working to recover it.
Two public health experts – Joan Benach , from the Pompeu Fabra University in Barcelona, and Carles Muntaner , from the University of Toronto (Canada) – assured in 2005 that “the worst epidemic of our time is social inequality.” In their book Learning to look at health , the two authors sarcastically recalled that reports on social inequalities tend to end up like the Bible: being little read, highly cited and with recommendations that are never put into practice.