James Macinko

James Macinko
Associate Professor of Public Health, NYU Steinhardt School of Education

James Macinko is Associate Professor of Public Health and Health Policy in the Department of Nutrition, Food Studies, and Public Health and the Robert F. Wagner Graduate School of Public Service. Since 2008, he has directed the NYU Master's program in Global Public Health. Dr. Macinko was formerly a Robert Wood Johnson Foundation Health and Society Scholar at the University of Pennsylvania and a Fulbright Scholar in Brazil. His field experience includes evaluation of primary health care programs and policies in Latin America and the Caribbean; assessment of microenterprise development programs in Africa and Latin America; assisting the US Agency for International Development and the World Health Organization to develop indicators for assessing infectious disease prevention and control programs in Sub-Saharan Africa; coordinating election monitoring in Ethiopia; and working with the Latino communities in Washington DC, Philadelphia and New York City to identify and eliminate barriers to primary health care.

Date Publication/Paper

de Souza, M., de Fatima, M., Macinko, J., Alencar, A.P., Malta, D.C. & de Morais Neto, O.L. 2007. Reductions In Firearm-Related Mortality And Hospitalizations In Brazil After Gun Control Health Affairs, Mar/Apr 2007, Vol. 26 Issue 2, p575-584, 10p.

This paper provides evidence suggesting that gun control measures have been effective in reducing the toll of violence on population health in Brazil. In 2004, for the first time in more than a decade, firearm-related mortality declined 8 percent from the previous year. Firearm-related hospitalizations also reversed a historical trend that year by decreasing 4.6 percent from 2003 levels. These changes corresponded with anti-gun legislation passed in late 2003 and disarmament campaigns undertaken throughout the country since mid-2004. The estimated impact of these measures, if they prove causal, could be as much as 5,563 firearm-related deaths averted in 2004 alone.


Macinko, J. Guanais, F. & Souza, F. 2006. An Evaluation of the Impact of the Family Health Program on Infant Mortality in Brazil, 1990-2002 Journal of Epidemiology and Community Health,
View Publication

Objective: To use publicly available secondary data to assess the impact of Brazil's Family Health Program on state level infant mortality rates (IMR) during the 1990s.

Design: Longitudinal ecological analysis using panel data from secondary sources. Analyses controlled for state level measures of access to clean water and sanitation, average income, women's literacy and fertility, physicians and nurses per 10 000 population, and hospital beds per 1000 population. Additional analyses controlled for immunisation coverage and tested interactions between Family Health Program and proportionate mortality from diarrhoea and acute respiratory infections.

Setting: 13 years (1990-2002) of data from 27 Brazilian states.

Main results: From 1990 to 2002 IMR declined from 49.7 to 28.9 per 1000 live births. During the same period average Family Health Program coverage increased from 0% to 36%. A 10% increase in Family Health Program coverage was associated with a 4.5% decrease in IMR, controlling for all other health determinants (p<0.01). Access to clean water and hospital beds per 1000 were negatively associated with IMR, while female illiteracy, fertility rates, and mean income were positively associated with IMR. Examination of interactions between Family Health Program coverage and diarrhoea deaths suggests the programme may reduce IMR at least partly through reductions in diarrhoea deaths. Interactions with deaths from acute respiratory infections were ambiguous.

Conclusions: The Family Health Program is associated with reduced IMR, suggesting it is an important, although not unique, contributor to declining infant mortality in Brazil. Existing secondary datasets provide an important tool for evaluation of the effectiveness of health services in Brazil.



Shi, L., Macinko, J. Starfield, B. Politzer, R., Wulu, J. & J. Xu. 2005. Primary Care, Social Inequalities, and All-Cause, Heart Disease, and Cancer Mortality in U.S. Counties, 1990. American Journal of Public Health.

We tested the association between the availability of primary care and income inequality on several categories of mortality in US counties. Methods. We used cross-sectional analysis of data from counties (n=3081) in 1990, including analysis of variance and multivariate ordinary least squares regression. Independent variables included primary care resources, income inequality, and sociodemographics. Results. Counties with higher availability of primary care resources experienced between 2% and 3% lower mortality than counties with less primary care. Counties with high income inequality experienced between 11% and 13% higher mortality than counties with less inequality. Conclusions. Primary care resources may partially moderate the effects of income inequality on health outcomes at the county level.

Starfield, B., Shi, L. & Macinko, J. 2005. Contribution of Primary Care to Health Systems and Health Milbank Quarterly, Vol. 83 Issue 3, p457-502, 46p.

Evidence of the health-promoting influence of primary care has been accumulating ever since researchers have been able to distinguish primary care from other aspects of the health services delivery system. This evidence shows that primary care helps prevent illness and death, regardless of whether the care is characterized by supply of primary care physicians, a relationship with a source of primary care, or the receipt of important features of primary care. The evidence also shows that primary care (in contrast to specialty care) is associated with a more equitable distribution of health in populations, a finding that holds in both cross-national and within-national studies. The means by which primary care improves health have been identified, thus suggesting ways to improve overall health and reduce differences in health across major population subgroups.

Starfield, B., Shi, L. & Macinko, J. 2005. Primary care impact on health outcomes: A literature review Milbank Quarterly Volume 83 Number 3, pages 457-502.

Evidence of the health-promoting influence of primary care has been accumulating ever since researchers have been able to distinguish primary care from other aspects of the health services delivery system. This evidence shows that primary care helps prevent illness and death, regardless of whether the care is characterized by supply of primary care physicians, a relationship with a source of primary care, or the receipt of important features of primary care. The evidence also shows that primary care (in contrast to specialty care) is associated with a more equitable distribution of health in populations, a finding that holds in both cross-national and within-national studies. The means by which primary care improves health have been identified, thus suggesting ways to improve overall health and reduce differences in health across major population subgroups.

Shi, L., Macinko, J., Starfield, B., Politzer, R. & J. Xu. 2005. Primary care, race and mortality in the United States Social Science & Medicine Volume 61 Number 1, pages 65-75.

This study used US state-level data from 1985 to 1995 to examine the relationship of primary care resources and income inequality with all-cause mortality within the entire population, and in black and white populations. The study is a pooled ecological design with repeated measures using 11 years of state-level data (n=549). Analyses controlled for socioeconomic and demographic characteristics. Contemporaneous and time-lagged covariates were modeled, and all analyses were stratified by race/ethnicity. In all models, primary care was associated with lower mortality. An increase of one primary care doctor per 10,000 population was associated with a reduction of 14.4 deaths per 100,000. The magnitude of primary care coefficients was higher for black mortality than for white mortality. Income inequality was not associated with mortality after controlling for state-level sociodemographic covariates. The study provides evidence that primary care resources are associated with population health and could aid in reducing socioeconomic disparities in health.

Starfield, B., Shi, L., Grover, A. & Macinko, J. 2005. The Effects of Specialist Supply on Population Health: Assessing the Evidence Health Affairs Volume 5, pages 97-107.

Analyses at the county level show lower mortality rates where there are more primary care physicians, but this is not the case for specialist supply. These findings confirm those of previous studies at the state and other levels. Increasing the supply of specialists will not improve the United States' position in population health relative to other industrialized countries, and it is likely to lead to greater disparities in health status and outcomes. Adverse effects from inappropriate or unnecessary specialist use may be responsible for the absence of relationship between specialist supply and mortality.

Starfield, B., Shi, L., Grover, A. & Macinko, J. 2005. The Need For Real Evidence In Physician Workforce Decision Making: A Reply To Ed Salsberg (3/15/2005) Health Affairs, Jan-Jun 2005 Supplement Web Exclusiv, Vol. 24, pS-7-S-8, 2p.

Presents a letter to Edward Salsberg about the need for real evidence in physician workforce decision making. Opinion that one needs more information before making decisions about specialty composition in the health professions; Notion that primary care physicians could maintain expertise in several specialty areas by greatly limiting their practice size; Information that some health systems are trying to increase the supply of at least certain specialists.


Macinko, J., Almeida, C. & Oliveira, E. 2004. Avaliação das características organizacionais dos serviços de atenção básica em Petrópolis: teste de uma metodologia [Evaluation of the primary care services organization in Petrópolis: a methodological test ] Saude & Debate Volume 65 Number 27, pages 243-256.
View Publication

O objetivo da pesquisa foi adaptar e aplicar um instrumento para medir dimensões organizacionais do sistema de atenção básica no município de Petrópolis (RJ), comparando as dimensões organizacionais selecionadas em dois tipos de unidades: as do Programa Saúde da Família (PSF) e as Unidades Básicas de Saúde (UBS) tradicionais. A pesquisa utilizou a metodologia de informantes-chave. A ferramenta testada foi aplicada de forma rápida o que sugere que ela pode ser empregada nas avaliações regulares do desempenho das unidades. Conclui-se que apesar de Petrópolis ter realizado avanços importantes na atenção básica, enfrenta vários desafios, incluindo: melhorar acesso, reforçar o papel da atenção básica como porta de entrada no sistema, alcançar maior integralidade na atenção à saúde, melhorar a coordenação e aumentar a orientação para a comunidade.

Shi, L. Macinko, J. Starfied, B. 2004. Primary care, social inequalities, and birth outcomes in U.S. states Journal of Epidemiology and Community Health Volume 58 Number 5, pages 374-80.
View Publication

Study objective: The study tests the extent to which primary care physician supply (office based primary care physicians per 10 000 population) moderates the association between social inequalities and infant mortality and low birth weight throughout the 50 states of the USA.

Design: Pooled cross sectional, time series analysis of secondary data. Analyses controlled for state level education, unemployment, racial/ethnic composition, income inequality, and urban/rural differences. Contemporaneous and time lagged covariates were modelled.

Setting: Eleven years (1985-95) of data from 50 US states (final n = 549 because of one missing data point).

Main results: Primary care was negatively associated with infant mortality and low birth weight in all multivariate models (p<0.0001). The association was consistent in contemporaneous and time lagged models. Although income inequality was positively associated with low birth weight and infant mortality (p<0.0001), the association with infant mortality disappeared with the addition of sociodemographic covariates.

Conclusions: In US states, an increased supply of primary care practitioners-especially in areas with high levels of social disparities-is negatively associated with infant mortality and low birth weight.


Macinko, J., Shi, L. & Starfield, B. 2004. Wage inequality, health care, and infant mortality in 19 industrialized countries Social Science & Medicine Volume 58 Number 2, pages 279-292.

This pooled, cross-sectional, time-series study assesses the impact of health system variables on the relationship between wage inequality and infant mortality in 19 OECD countries over the period 1970-1996. Data are derived from the OECD, World Value Surveys, Luxembourg Income Study, and political economy databases. Analyses include Pearson correlation and fixed-effects multivariate regression. In year-specific and time-series analyses, the Theil measure of wage inequality (based on industrial sector wages) is positively and statistically significantly associated with infant mortality rates--even while controlling for GDP per capita. Health system variables--in particular the method of healthcare financing and the supply of physicians--significantly attenuated the effect of wage inequality on infant mortality. In fixed effects multivariate regression models controlling for GDP per capita and wage inequality, variables generally associated with better health include income per capita, the method of healthcare financing, and physicians per 1000 population. Alcohol consumption, the proportion of the population in unions, and government expenditures on health were associated with poorer health outcomes. Ambiguous effects were seen for the consumer price index, unemployment rates, the openness of the economy, and voting rates. This study provides international evidence for the impact of wage inequalities on infant mortality. Results suggest that improving aspects of the healthcare system may be one way to partially compensate for the negative effects of social inequalities on population health.

Shi, L., Macinko, J., Starfield, B., Wulu, J., Regan, J. & Politzer, R. 2003. The relationship between primary care, income inequality, and mortality in US States, 1980-1995. Journal of the American Board of Family Practice Volume 16, Number 5 Sep-Oct 2003; pages 412-22.

OBJECTIVES: This study tests the robustness of the relationships between primary care, income inequality, and population health by (1) assessing the relationship during 4 time periods-1980, 1985, 1990 and 1995; (2) examining the independent effect of components of the primary care physician supply; (3) using 2 different measures of income inequality (Robin Hood index and Gini coefficient); and (4) testing the robustness of the association by using 5-year time-lagged independent variables. DATA SOURCES/STUDY SETTING: Data are derived from the Compressed Mortality Files, the US Department of Commerce and the Census Bureau, the National Center for Health Statistics, the Centers for Disease Control and Prevention, and the American Medical Association Physician Master File. The unit of analysis was the 50 US states over a 15-year period. STUDY DESIGN: Ecological, cross-sectional design for 4 selected years (1980, 1985, 1990, 1995), and incorporating 5-year time-lagged independent variables. The main outcome measure is age-standardized, all-cause mortality per 100,000 population in all 50 US states in all 4 time periods. DATA COLLECTION/EXTRACTION METHODS: The study used secondary data from publicly available data sets. The CDC WONDER/PC software was used to obtain mortality data and directly standardize them for age to the 1980 US population. Data used to calculate the income inequality measure came from the US census population and housing summary tapes for the years 1980 to 1995. Counts of the number of households that fell into each income interval along with the total aggregate income and the median household income were obtained for each state. The Gini coefficient for each state was calculated using software developed for this purpose. RESULTS: In weighted multivariate regressions, both contemporaneous and time-lagged income inequality measures (Gini coefficient, Robin Hood Index) were significantly associated with all-cause mortality (P <.05 for both measures for all time periods). Contemporaneous and time-lagged primary care physician-to-population ratios were significantly associated with lower all-cause mortality (P <.05 for all 4 time periods), whereas specialty care measures were associated with higher mortality (P <.05 for all time periods, except 1990, where P <.1). Among primary care subspecialties, only family medicine was consistently associated with lower mortality (P <.01 for all time periods). CONCLUSIONS: Enhancing primary care, particularly family medicine, even in states with high levels of income inequality, could lead to lower all-cause mortality in those states.

Macinko, J., Shi, L., Starfield, B. & Wulu, J. 2003. Income inequality, primary care, and health outcomes�a critical review of the literature Medical Care Research and Review Volume 60 Number 4, pages 407-52.

This article critically reviews published literature on the relationship between income inequality and health outcomes. Studies are systematically assessed in terms of design, data quality, measures, health outcomes, and covariates analyzed. At least 33 studies indicate a significant association between income inequality and health outcomes, while at least 12 studies do not find such an association. Inconsistencies include the following: (1) the model of health determinants is different in nearly every study, (2) income inequality measures and data are inconsistent, (3) studies are performed on different combinations of countries and/or states, (4) the time period in which studies are conducted is not consistent, and (5) health outcome measures differ. The relationship between income inequality and health is unclear. Future studies will require a more comprehensive model of health production that includes health system covariates, sufficient sample size, and adjustment for inconsistencies in income inequality data.

Shi, L., Macinko, J., Starfield, B. & Politzer, R. 2003. Primary Care, Social Inequality, and Stroke Mortality in U.S. States--a Longitudinal Analysis, 1985-1995 Stroke Volume 34 Number 8, pages 1958-64.

BACKGROUND AND PURPOSE: The goal of this study was to test whether primary care reduces the impact of income inequality on stroke mortality. METHODS: This study used pooled time-series cross-sectional analysis of 11 years of state-level data (n=549). Analyses controlled for education levels, unemployment, racial/ethnic composition, and percent urban. Contemporaneous and time-lagged covariates were modeled. RESULTS: Primary care was negatively associated with stroke mortality in models including all covariates (P<0.0001). The impact of income inequality on stroke mortality was reduced in the presence of primary care (P<0.0001) but disappeared with the addition of covariates (P>0.05). CONCLUSIONS: In the absence of social policy that addresses sociodemographic determinants of health, primary care promotion may serve as a palliative strategy for combating stroke mortality and reducing the adverse impact of income inequality on health.

Macinko, J., Starfield, B. & Shi, L. 2003. The contribution of primary care systems to health outcomes in OECD countries, 1970-1998. Health Services Research Volume 38, Number 3, pages 819-854.
View Publication

To assess the contribution of primary care systems to a variety of health outcomes in 18 wealthy Organization for Economic Cooperation and Development (OECD) countries over three decades.

Data Sources/Study Setting
Data were primarily derived from OECD Health Data 2001 and from published literature. The unit of analysis is each of 18 wealthy OECD countries from 1970 to 1998 (total n=504).

Study Design
Pooled, cross-sectional, time-series analysis of secondary data using fixed effects regression.

Data Collection/Extraction Methods
Secondary analysis of public-use datasets. Primary care system characteristics were assessed using a common set of indicators derived from secondary datasets, published literature, technical documents, and consultation with in-country experts.

Principal Findings
The strength of a country's primary care system was negatively associated with (a) all-cause mortality, (b) all-cause premature mortality, and (c) cause-specific premature mortality from asthma and bronchitis, emphysema and pneumonia, cardiovascular disease, and heart disease (p<0.05 in fixed effects, multivariate regression analyses). This relationship was significant, albeit reduced in magnitude, even while controlling for macro-level (GDP per capita, total physicians per one thousand population, percent of elderly) and micro-level (average number of ambulatory care visits, per capita income, alcohol and tobacco consumption) determinants of population health.

(1) Strong primary care system and practice characteristics such as geographic regulation, longitudinality, coordination, and community orientation were associated with improved population health. (2) Despite health reform efforts, few OECD countries have improved essential features of their primary care systems as assessed by the scale used here. (3) The proposed scale can also be used to monitor health reform efforts intended to improve primary care.



Macinko, J. & Starfield, B. 2002. Annotated bibliography on equity in health Intl J of Equity in Health Volume 1, Number 1, pages 1-20.

The purposes of this bibliography are to present an overview of the published literature on equity in health and to summarize key articles relevant to the mission of the International Society for Equity in Health (ISEqH). The intent is to show the directions being taken in health equity research including theories, methods, and interventions to understand the genesis of inequities and their remediation. Therefore, the bibliography includes articles from the health equity literature that focus on mechanisms by which inequities in health arise and approaches to reducing them where and when they exist.

Rodriguez-Garcia, R., Macinko, J. & Waters, W. 2001. Microenterprise Development for Better Health Outcomes Westport, CT: Greenwood Publishing.

Showing that economic development and public health, often thought of as distinct, are both interdependent and dependent on social and political conditions, this book provides a new appreciation of the close relationship between microenterprise development and health in developing countries. Many of the world's poor earn a living from microenterprises, often outside the formal economy, and international practitioners have recently turned their attention to this underground economy, providing support through group poverty lending and village banking models, but overlooking the potential benefits of linking income generation with public health. This book argues for a conceptual and practical relationship between microenterprise development and household health, nutrition, and sanitation. To support their framework, the authors look at specific actions for harnessing the power of microeconomic development to improve health and human development. They support their argument further with case studies of innovative programs carried out in Latin America, Asia, and Africa. The book challenges the reader to cross disciplinary and professional boundaries to not only understand the interrelationships between health and income generation but to use available tools to enhance those interrelationships.

Macinko, J. & Starfield, B. 2001. The utility of social capital in studies on health determinants Milbank Quarterly Volume 79, Number 3, pages 387-428.

Social capital has become a popular subject in the literature on determinants of health. The concept of social capital has been used in the sociological, political science, and economic development literatures, as well as in the health inequalities literature. Analysis of its use in the health inequalities literature suggests that each theoretical tradition has conceptualized social capital differently. Health researchers have employed a wide range of social capital measures, borrowing from several theoretical traditions. Given the wide variation in these measures and an apparent lack of consistent theoretical or empirical justification for their use, conclusions about the likely role of "social capital" on population health may be overstated or even misleading. Elements of a research agenda are proposed to further elucidate the potential role of factors currently subsumed under the rubric of "social capital."


Rodriguez-Garcia, R., Macinko, J. & Casas, J. (Eds.) 1998. From Humanitarian Assistance to Human Development Washington, DC: Pan American Health Organization/WHO. .

Civil, political and military conflict--Natural and man-made disasters--Poverty and human suffering...As the new millennium approaches, the need for humanitarian assistance in response to these global challenges endures. Complex humanitarian emergencies demand human, financial and material resources on an international scale. This presents the global community, and particularly the health sector, with a formidable and daunting task: Faced with limited resources, how can organizations and actors simultaneously meet immediate humanitarian needs while maintaining their commitment to long term human development? More specifically, how can humanitarian relief and sustainable human development efforts be linked? From Humanitarian Assistance to Human Development responds and reacts to this question by serving as a forum for distinguished members of the health and development arena to present issues, policies and innovative programs in response. Divided into three sections, the book examines the humanitarian assistance-human development continuum within the global-policy context of human development, reviews humanitarian assistance as a social phenomena, highlights country experiences in Rwanda and Bosnia, and discusses means of relieving human suffering and restoring infrastructure and health and social services in the aftermath of conflict. In this thought-provoking, informative volume, the perspectives, experiences and proposals of specialists from academic institutions, national and international agencies and non-governmental organizations are united to help inform future policy, inspire programmatic action and, ultimately, bridge the gap between humanitarian assistance and human development.

In the Press

More alcohol, traffic laws correlate to fewer U.S. traffic deaths
United Press International