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Why Does The Flu Hit The Poor More Than The Rich? A 1931 Social Epidemiology Article Breaking New Ground In The History Of Confounding, Mediation, And Interaction.

In 1931 Edgar Sydenstricker, statistician of the United States Public Health Service, challenged the common belief that the 1918 Flu had affected "the rich and the poor alike." Using data from 112,317 participants of a US national survey on the 1918 Flu he observed that, on the contrary, both the morbidity and mortality from the flu had been higher among the poor than among the rich. To explain these differences Sydenstricker stratified the analyses by two measures of affluence collected in the survey: "economic status" (from "very poor" to "well-to-do") and household crowding (ie, number of people per household room). Economic status was associated with influenza attack rates within categories of crowding, but not the opposite, suggesting that other characteristics of poverty than "household congestion" were the culprit of the poor's higher influenza burden. Risk of influenza in infants and older adults was greater for the poor or very poor. Sydenstricker used a stratification approach to assess confounding, mediation, and interaction before the concepts were formally named. Sydenstricker re-analyzed an already 12-year old dataset in the context of the Great Depression to build the evidence base relating poverty to ill health.