The Complex Link between Social Status and HealthPublished May 2013
Is the Wealth Gap Creating a Health Gap?
Income inequality and a rising health underclass in America
By Elaine Meyer
Published December 5, 2012
As the debate rages in Washington over how much rich Americans should pay in taxes, a study released last week by the Center on Budget and Policy Priorities found that the well-off, and especially the very wealthy once again are pulling ahead of everyone else. Although every income group lost ground after the financial crisis in 2008, the rich are the only ones making money again, while incomes at the bottom and middle remain stagnant, according to the study.
Public health experts say this a problem not only for economic reasons, but for the nation’s health.
As income inequality has climbed over the last 30 years to a level not seen since the Gilded Age, the U.S. has dropped below other developed nations on a range of health measures, such as life expectancy, infant mortality, and obesity.
Although some groups, particularly the rich, the well-educated, and white and Asian populations, still score well on various health measures, other groups like black men, the poor, and even members of the middle class are falling behind. For instance, in 2001, Asian women in this country had a life expectancy nearly 21 years longer than poor urban black men.
“America is a very wealthy country, but we have one of the lowest life expectancies in the developed world,” says Dr. Ichiro Kawachi, a professor of social epidemiology and chair of the department of society, human development, and health at Harvard University’s School of Public Health.
That health markers in this country have worsened at the same time the income gap has widened is not a coincidence, says a 2009 book called The Spirit Level: Why More Equal Societies Almost Always Do Better.
The authors, British social epidemiologists Drs. Richard Wilkinson and Kate Pickett, argue that the level of inequality in a nation more than that nation’s wealth is what determines health and other quality of life measures.
Rich but unequal nations like the U.S. and the United Kingdom have much worse health outcomes across the board than other rich countries with narrower differences in income, such as Japan and the Scandinavian nations, the authors say.
Released soon after the financial crisis, The Spirit Level took off across the Atlantic, especially in the U.K., where controversial post-recession austerity measures have been criticized for contributing to the nation’s rising income and race inequality.
Even Tory Prime Minister David Cameron has endorsed the findings of the book.
As the BBC put it in October of 2010: “It is not every day that a future British Prime Minister name checks someone from the rarefied world of social epidemiology.”
In the U.S., on the other hand, discussing the connection between inequality and health has mostly taken place among social epidemiologists and other social scientists.
“It has been totally lost in the current political climate exactly how inequality harms health,” Dr. Yvette Cozier, an assistant professor of epidemiology at Boston University’s School of Public Health, who studies the effects of racial inequality on health.
In the 1990s, policy elites on both sides of the Atlantic, up to U.S. President Bill Clinton and British Prime Minister Tony Blair, believed that “a rising tide lifts all boats,” that income inequality is not a problem if the gains of the rich lift up the middle and working classes. This was the prevailing view into the early 2000s, a period when the rich pulled far ahead of everyone else.
But as a result of the financial crisis of 2008, the sentiment has begun to change and attention is starting to focus on income inequality’s effect on society and social cohesion.
While it is clear there is a strong relationship between income and health, researchers are still trying to understand the “pathways” by which income inequality leads to worse health outcomes.
“The intuition that inequality is divisive and socially corrosive has been around since before the French Revolution,” Dr. Wilkinson says in in a TED talk from July 2011. “What’s changed is we can now look at the evidence. We can compare societies, more and less equal societies, and see what inequality does.”
Mining copious amounts of health and income data and using sophisticated study design methods that allow them to control for various confounding factors, social epidemiologists have found that inequality affects everything from people’s ability to afford adequate healthcare to the inner workings of their endocrine and immune responses.
However, it is impossible to demonstrate a straight-forward cause and effect relationship.
“Inequality is not any one kind of event, like a terrorist attack. It’s very much in the fabric of our daily life. It’s hard to show that there is a direct connection between living in a society like that, and this is why your blood pressure went up today,” says Dr. Kawachi.
One area of research has looked at how markers of inequality lead to psychological and physiological problems. For instance the stress of unequal conditions can lead to unhealthy behaviors like smoking and over-eating, as well as a physiological response that disrupt the endocrine system.
“Inequality in all of its forms, whether it’s in extremely low wages, lack of a safety net, racial or gender discrimination, these types of things, creates a [stress] response. What any organism does toward stress is try to adapt. There’s a big expense of effort that goes into to that,” says Dr. Cozier.
Findings like this could strengthen the case for policies that seek to redistribute income from the one percent to the rest of society.
Inequality research like that presented in The Spirit Level has been criticized by some of Drs. Wilkinson and Picketts peers as singularly focused.
Reducing inequality alone will not suffice if there continues to be, as there is now, a lack of capital investment in social services, says Dr. George Kaplan, an emeritus professor of epidemiology at University of Michigan’s School of Public Health and the founder of the school’s Center for Social Epidemiology & Population Health.
He points to a 2005 study that compares income inequality and health measures across metropolitan areas in the U.S., Canada, the U.K., Sweden, and Australia.
Only in the U.S. and Great Britain was there a significant relationship between inequality and mortality across urban areas, according to the study. The researchers suggest that this is because both nations are organized so that big spending decisions on services like education and health are made at local and state, not federal levels as they are in Canada, Sweden, and Australia.
Dr. Kaplan illustrates that point with the following example: “Does a woman in the lowest tenth percentile economically in the New Orleans metro area have the same chance of having a child with health problems as a woman in the Hartford, Connecticut, metro area [where there is more investment in social services] who’s in the lowest tenth percentile? Everyone knows the answer is no.”
Although awareness of inequality is growing in the U.S.—witness the mainstreaming of the Occupy Wall Street “one percent” versus “99 percent” terms, and surveys finding that a majority of Americans believe the rich need to pay more in taxes—it remains to be seen whether the country’s policymakers are willing to act.
One contention from the The Spirit Level that could persuade them is that unequal societies are not just worse for the poor but for the rich.
This is seen for instance in emergency rooms, where insured and uninsured patients alike encounter long wait times and over- worked staff, conditions created because the E.R. cannot turn away uninsured Americans, of which there are millions.
“It’s the spillover effect of living in an unequal society,” says Dr. Kawachi.
Yet so far “health implications have not mattered to politicians. Other aspects of inequality may have mattered to them,” says Dr. Kaplan.
For this reason, some academics believe that they need to speak up more on the grave health effects of inequality.
“As epidemiologists, our job is to really count and calculate and study these relationships, but the piece that we don’t have is that of advocating,” says Dr. Cozier. “I wish that more of us would be able to advocate and explain and really get out there and push the message that there is inequality.”
Top photo credit: Alane Golden