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Life sciences · Journal article
BMC Public Health · September 26, 2026
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Subnational health disparities persist in high- and middle-income countries, but the structural mechanisms linking macro-level development to within-country inequality remain under-measured. We quantified the structural inequality footprint of metabolic disease and despair-related mortality in China and the USA – two countries with contrasting development models and compared the inequality-formation mechanisms. We did a retrospective ecological panel study using harmonised longitudinal data from 31 Chinese provinces and 50 US states (2010‑2019; 810 region‑years). The primary outcome was age-standardised despair-related mortality per 100,000 (suicide plus alcohol-attributable deaths in China; also drug-overdose deaths in the USA). Exposures were obesity and type-2 diabetes prevalence. Structural inequality covariates included Gini coefficient, urbanisation rate, GDP per capita and unemployment rate. We estimated two-way fixed-effects panel regressions, decomposed variance into the intraclass correlation coefficient (ICC) – interpreted as structural embedding – and quantified additive interaction using the relative excess risk due to interaction (RERI) with 2000 bootstrap replications. Within-region variation in structural covariates was consistently associated with despair mortality. In China, Gini coefficient (β = -0.22, p = 0.001) and urbanisation rate (β = 0.18, p = 0.08) were the strongest predictors, while obesity–diabetes joint exposure showed no super-additive interaction (RERI = -0.09, 95% CI -0.24 to 0.07). In the USA, joint exposure showed positive additive interaction (RERI = 0.25, 95% CI 0.12 to 0.38). Unconditional ICC was 0.76 (95% CI 0.69–0.82) in China and 0.78 (0.72–0.84) in the USA, indicating roughly three‑quarters of cross-sectional variation was structurally embedded. The inequality–mortality association was strongest in low‑GDP‑per‑capita and high‑Gini provinces (China) and in high‑Gini and high‑opioid‑prescription states (USA). Two contrasting development models leave distinct, measurable fingerprints of structural inequality on subnational mortality. Both countries exhibit high regional embedding of despair mortality, but the leading within-region correlates differ: in China, regional income inequality and uneven urbanisation; in the USA, super‑additive metabolic–behavioural interaction in the most unequal and opioid‑saturated states. Joint reporting of ICC, fixed‑effects coefficients and RERI provides a transferable framework for health inequality monitoring across heterogeneous settings.