The New York Times has some moderately disturbing—if unsurprising—news about the widening health gap between rich and poor in the US.
New government research has found “large and growing” disparities in life expectancy for richer and poorer Americans, paralleling the growth of income inequality in the last two decades…
In 1980-82 … people in the most affluent group could expect to live 2.8 years longer than people in the most deprived group (75.8 versus 73 years). By 1998-2000, the difference in life expectancy had increased to 4.5 years (79.2 versus 74.7 years), and it continues to grow, he said.
Unfortunately, the news that rich Americans are healthier than poor Americans is a bit of a dog-bites-man story at this point—it’s surprising to, well, just about nobody. Same goes for the trends; few will be shocked to learn that health disparities and wealth disparities are widening more or less in tandem. Is it disappointing? Sure. But unexpected? Not so much.
What I do find surprising, though, is the article’s blinkered, incomplete view of how income inequality and health disparities are linked.
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Sure, the Times’ article posits all sorts of possible mechanisms by which poverty leads to ill health and early death. Being poor limits your access to preventive medical care, as the article points out. Just so, poor people tend to live in violent neighborhoods, which raises the risk of homicide and reduces opportunities for safe exercise. And obviously enough, only the wealthy are in a position to buy top notch, cutting edge medical treatments. The Times even quotes a conservative think-tankster bemoaning that, without internet access, lower-income folks simply aren’t as “health literate” as the well-off.
Amid the plethora of theories, there’s bound to be something that’s at least partially right. After all, there really are a lot of ways that income gaps can influence health. Yet the Times’ article, along with just about everything else written in the popular press on the subject, makes no mention of another potent, and well-studied line of causation: the abundant evidence that poverty itself—that is, the experience of being substantially poorer than other people—is a major health risk all by itself.
Put simply: feeling poor in a land of plenty can make us feel miserable, undermining the sorts of attitudes and behaviors that keep us healthy, and even compromising our ability to ward off, and recover from, illness.
As with just about any line of health research, the idea that the psychological experience of inequality is an inherent health risk has its detractors—and reasonably ones, not just ideologues. Still, there’s a ton of research suggesting that the link is real. (I won’t go into the evidence here. But this UW research forum maintains a good lit review of the inequality-health connection.) Still, even though the Times gives room for an “expert” to discuss his pet theories about health literacy and internet access, the much better researched associations between inequality and health—particularly the psycho-social connections—go entirely unmentioned.
Fortunately, a few media outlets have taken the inequality-health link seriously. A few weeks back, for example, PBS aired a series on the social and economic determinants of health—and though I haven’t seen it myself, I have it on good authority that it was worth watching. The gist:
It turns out there’s much more to our well-being than genes, behaviors and medical care. The social, economic, and physical environments in which we are born, live and work profoundly affect our longevity and health—as much as smoking, diet and exercise.
If you have to watch just one segment, watch the last bit—“Not Just a Paycheck“—which compares factory closures in Michigan vs. Sweden. When the Michigan factory closed, workers were basically left to fend for themselves. And as a consequence, hospital visits more than tripled, as alcoholism, depression, and domestic violence spiked. But in Sweden, where both culture and policy emphasize shared responsibility rather than rugged individualism, the plant closure caused barely a ripple in people’s health. Social support and shared sacrifice did more than smooth out an economic hiccup—it kept people out of the doctor’s office.
In Canada, CBC radio ran a 2-part series entitled “Sick People or Sick Societies?” covering much of the same ground. Again, I haven’t listened to it—so if any of you have, let me know if you like it.
Attentive, long-time readers of this blog know that every once in a while I become obsessed with the health-inequality connection. The dynamics of the issue fascinate me. As I see it, there are at least four core facts that are continually reinforced by research—yet get little or no attention in the health section of most papers:
First, the US is the most unhealthy major democracy in the world. We lag on just about every measure of health—life expectancy, healthy life expectancy, infant mortality, you name it. If anything, our status among world nations is actually slipping.
Second, the US spends more on health care than any other nation in the world. We’re the only major industrial democracy without universal health care, yet the US government spends more per resident on health care than any other. (That’s right, we already do have “big government” health care. We just don’t get much from it.) And government spending is only the tip of the iceberg. All in all, about one dollar in seven in the US Northwest—some fifteen percent of all the money we have—is dedicated to medical expenditures.
Third, the link between health and health care isn’t as strong as people assume. This follows somewhat from the first two facts, but it’s reinforced by other data. Among US states, for example, health outcomes and health care spending are essentially unlinked, especially after factoring in demographics. Even the availability of medical specialists—oncologists and so forth—has little bearing on longevity; in fact, visiting a series of specialists may simply increase the risk of a life-threatening medical error. Just so, the evidence suggests that universal health care will provide only a modest boost to lifespans. Right now, about 18,000 deaths each year can be attributed to a lack of health insurance—a drop in the bucket, among the 2.4 million annual deaths nationwide. In the same vein, “medically preventable” deaths are dwarfed by fatalities that doctors are powerless to thwart. Surprisingly, there’s a ton of evidence that health care has less to do with our health than we’d like to think.
Fourth—as described above—the connections between economic inequality and poor health are quite strong. The links are frequently confirmed both by “ecological” studies (comparing real-world inequality and health outcomes in different parts of the world) and by more direct measures linking individuals’ social status and health outcomes. Of course, the inequality-health link isn’t unassailable, and the whole idea has many fair-minded critics. Still, given the evidence on hand: if inequality were a drug, the FDA would almost certainly reject it as too risky for public consumption.
Together, these facts suggest—to me at least—that America’s surprisingly dismal health record isn’t rooted in unequal access to medical care. It’s something much deeper: a society that’s based on the premise that individuals must be sorted into “winners” and “losers” will also sort its citizenry into “healthy” and “unhealthy.” The underlying dynamic is simple: wide disparities in wealth make for poor health.
Yet our current health discourse only hints at this dynamic. Health policy rarely injects itself into questions of economic fairness. Part of this may be intrinsic to a medical system that heaps financial rewards on star physicians: the winners in a winner-takes-all system rarely question whether the status quo is good for society at large.
But I suppose there’s also an unspoken metaphor in play. We view society’s health the same way we view our own health. For both, we hope for a quick fix—a pill, or a painless surgery—that can heal us without forcing us to alter our lifestyles. We hope that one tiny tablet will make us hale; or that a nip and a tuck will restore us to beauty. Likewise, for health policy, we hope for a miracle cure: apply a little health care here, a little internet access there, and health disparities will simply vanish. (Or, at a minimum, whatever disparities remain can be simply attributed to the bad judgment or shaky willpower of the unhealthy.)
To me, though, this is simply magical thinking. Like it or not, quick fixes aren’t always effective, effective fixes aren’t always quick, and the unlucky aren’t always responsible for their plight. So as difficult and necessary as universal health insurance may be, it may be that we’ll need to heal something much more fundamental—a political addiction to economic inequality—before we can make much headway on our health.
Peter Ronai, MD, PhD
Has anyone done a study of the difference in prevalence of smoking between the rich and poor? Despite the relatively high cost of cigarettes, I bet the prevalence of smoking among the poor is very much higher than among the rich. In fact, it wouldn’t surprise me if this factor alone was enough to account for most of the 4.5 year difference in life expectancy between the two groups.
HiI listened to “Sick People or Sick Societies on CBC podcast. It is well worth it, quoting numerous studies on the link between health and wealth. Of course they do not ignore such factors as increased opportunity for medical care when wealthy, but far more important was the factor of personal control—over opportunity, over stress-causing environments and work situations, and so on. Download the podcast from http://www.cbc.ca (follow the link to podcasts). 2 hours of listening.Al
Peter –Possibly so. Interestingly, though, many healthy nations—including Japan—have much higher smoking rates than the US does.See, e.g., here:<blockquote>[T]he prevalence of smoking in Japan is tied with that in China as the highest in the world and 3 times that of the United States; yet, the Japanese do not die of smoking-related diseases to the extent that Americans do. Lung cancer mortality rates in Japan are one half to one third of those in the United States. </blockquote>Still, I think that’s a question that’s definitely worth exploring.
Certainly, differences in diet must contribute to this disparity in health, too. We now have a two-tiered food system in America where the most affluent can buy fresh fruit and vegetables and high quality fish and meats, but many poorer people can only afford to buy poor quality foods (fast foods, preprocessed products made from corn, soybeans and derivative additives) and not the healthier fresh fruits and vegetables. In the poorest neighborhoods, there are even food “deserts,” where convenience stores offer the only foods available. (Imagine subsisting on corn dogs, soda, and candy!) The broad trend of eating poor quality foods has contributed to America’s rising obesity, which is also generally tiered by income—with poorer people more inclined to over-weight. And, of course, obesity is associated with a number of health risks. The push towards cheaper and cheaper (though poorer quality) food has long been justified as a way to help the wage-earning classes, and the “poor and hungry.” But we are now seeing the results of this narrow approach: dismal public health and ever-rising public costs (even in the form of allegedly “private” insurance premiums) for treating a deluge of chronic health problems.
Ironically, those who smoke are generally poorer (least likely to able to afford smoking,)(below the poverty line as a group) than most educated people. Poverty, smoking and access to health care are very much sadly linked. Never mind that this habit robs people of the opportunity to save for retirement.The average smoker starts before 18, when you take in account a smoker who smokes for 48 years a pack a day at retirement then their projected lifespan is reduced by 1 month per year of smoking or nearly 4 years and would forego more $2,000,000 in retirement funds had that money been saved.