Cause of Death: Inequality
by Alejandro Reuss
Dollars and Sense magazine, May / June 2001
You won't see inequality on a medical chart or a coroner's
report under "cause of death. " You won't see it listed
among the top killers in the United States each year. All too
often, however, it is social inequality that lurks behind a more
immediate cause of death, be it heart disease or diabetes, accidental
injury or homicide. Few of the top causes of death are "equal
opportunity killers." Instead, they tend to strike poor people
more than rich people, the less educated more than the highly
educated, people lower on the occupational ladder more than those
higher up, or people of color more than white people.
Statistics on mortality and life expectancy do not provide
a perfect map of social inequality. For example, the life expectancy
for women in the United States is about six years longer than
the life expectancy for men, despite the many ways in which women
are subordinated to men. Take most indicators of socioeconomic
status, however, and most causes of death, and it's a strong bet
that you'll find illness and injury (or "morbidity")
and mortality increasing as status decreases.
Men with less than 12 years of education are more than twice
as likely to die of chronic diseases (e.g., heart disease), more
than three times as likely to die as a result of injury, and nearly
twice as likely to die of communicable diseases, compared to those
with 13 or more years of education. Women with family incomes
below $10,000 are more than three times as likely to die of heart
disease and nearly three times as likely to die of diabetes, compared
to those with family incomes above $25,000. African Americans
are more likely than whites to die of heart disease; stroke; lung,
colon, prostate, and breast cancer, as well as all cancers combined;
liver disease; diabetes; AIDS; accidental injury; and homicide.
In all, the lower you are in a social hierarchy, the worse your
health and the shorter your life are likely to be.
THE WORSE OFF IN THE UNITED STATES ARE NOT WELL OFF BY WORLD
You often hear it said that even poor people in rich countries
like the United States are rich compared to ordinary people in
poor countries. While that may be true when it comes to consumer
goods like televisions or telephones, which are widely available
even to poor people in the United States, it's completely wrong
when it comes to health.
In a 1996 study published in the New England Journal of Medicine,
University of Michigan researchers found that African-American
females living to age 15 in Harlem had a 65% chance of surviving
to age 65, about the same as women in India. Meanwhile, Harlem's
African-American males had only a 37% chance of surviving to age
65, about the same as men in Angola or the Democratic Republic
of Congo. Among both African-American men and women, infectious
diseases and diseases of the circulatory system were the prime
causes of high mortality.
It takes more income to achieve a given life expectancy in
a rich country like the United States than it does to achieve
the same life expectancy in a less affluent country. So the higher
money income of a low-income person in the United States, compared
to a middle-income person in a poor country, does not necessarily
translate into a longer life span. The average income per person
in African-American families, for example, is more than five times
the per capita income of E1 Salvador. The life expectancy for
African-American men in the United States, however, is only about
67 years, the same as the average life expectancy for men in E1
HEALTH INEQUALITIES IN THE UNITED STATES ARE NOT JUST ABOUT
ACCESS TO HEALTH CARE.
Nearly one sixth of the U.S. population lacks health insurance,
including about 44% of poor people. A poor adult with a health
problem is only half as likely to see a doctor as a high-income
adult. Adults living in low-income areas are more than twice as
likely to be hospitalized for a health problem that could have
been effectively treated with timely outpatient care, compared
with adults living in high-income areas. Obviously, lack of access
to health care is a major health problem.
But so are environmental and occupational hazards; communicable
diseases; homicide and firearm-related injuries; and smoking,
alcohol consumption, lack of exercise, and other risk factors.
These dangers all tend to affect lower-income people more than
higher-income, less-educated people more than more-educated, and
people of color more than whites. African-American children are
more than twice as likely as white children to be hospitalized
for asthma, which is linked to air pollution. Poor men are nearly
six times as likely as high-income men to have elevated blood-lead
levels, which reflect both residential and workplace environmental
hazards. African-American men are more than seven times as likely
to fall victim to homicide as white men; African-American women,
more than four times as likely as white women. The less education
someone has, the more likely they are to smoke or to drink heavily.
The lower someone's income, the less likely they are to get regular
Michael Marmot, a pioneer in the study of social inequality
and health, notes that so-called diseases of affluence - disorders,
like heart disease, associated with high-calorie and high-fat
diets, lack of physical activity, etc. - are most prevalent among
the Ieast affluent people in rich societies. While recognizing
the role of such "behavioral" risk factors as smoking
in producing poor health, he argues, "It is not sufficient
... to ask what contribution smoking makes to generating the social
gradient in ill health, but we must ask, why is there a social
gradient in smoking?" What appear to be individual "lifestyle"
decisions often reflect a broader social epidemiology.
GREATER INCOME INEQUALITY GOES HAND IN HAND WITH POORER HEALTH.
Numerous studies suggest that the more unequal the income
distribution in a country, state, or city, the lower the life
expectancies for people at all income levels. One study published
in the American Journal of Public Health, for example, shows that
U.S. metropolitan areas with low per capita incomes and low levels
of income inequality have lower mortality rates than areas with
high median incomes and high levels of income inequality. Meanwhile,
for a given per capita income range, mortality rates always decline
as inequality declines.
R.G. Wilkinson, perhaps the researcher most responsible for
relating health outcomes to overall levels of inequality (rather
than individual income levels), argues that greater income inequality
causes worse health outcomes independent of its effects on poverty.
Wilkinson and his associates suggest several explanations for
this relationship. First, the bigger the income gap between rich
and poor, the less inclined the well off are to pay taxes for
public services they either do not use or use in low proportion
to the taxes they pay. Lower spending on public hospitals, schools,
and other basic services does not affect wealthy people's life
expectancies very much, but it affects poor people's life expectancies
a great deal. Second, the bigger the income gap, the lower the
overall level of social cohesion. High levels of social cohesion
are associated with good health outcomes for several reasons.
For example, people in highly cohesive societies are more likely
to be active in their communities, reducing social isolation,
a known health risk factor.
Numerous researchers have criticized Wilkinson's conclusions,
arguing that the real reason income inequality tends to be associated
with worse health outcomes is that it is associated with higher
rates of poverty. But even if they are right and income inequality
causes worse health simply by bringing about greater poverty,
that hardly makes for a defense of inequality. Poverty and inequality
are like partners in crime. "[W]hether public policy focuses
primarily on the elimination of poverty or on reduction in income
disparity," argue Wilkinson critics Kevin Fiscella and Peter
Franks, "neither goal is likely to be achieved in the absence
of the other."
DIFFERENCES IN STATUS MAY BE JUST AS IMPORTANT AS INCOME LEVELS.
Even after accounting for differences in income, education,
and other factors, the life expectancy for African Americans is
less than that for whites. U.S. researchers are beginning to explore
the relationship between high blood pressure among African Americans
and the racism of the surrounding society. African Americans tend
to suffer from high blood pressure, a risk factor for circulatory
disease, more often than whites. Moreover, studies have found
that, when confronted with racism, African Americans suffer larger
and longer-lasting increases in blood pressure than when faced
with other stressful situations. Broader surveys relating blood
pressure in African Americans to perceived instances of racial
discrimination have yielded complex results, depending on social
class, gender, and other factors.
Stresses cascade down social hierarchies and accumulate among
the least empowered. Even researchers focusing on social inequality
and health, however, have been surprised by the large effects
on mortality. Over 30 years ago, Michael Marmot and his associates
undertook a landmark study, known as Whitehall I, of health among
British civil servants. Since the civil servants shared many characteristics
regardless of job classification - an office work environment,
a high degree of job security, etc. - the researchers expected
to find only modest health differences among them. To their surprise,
the study revealed a sharp increase in mortality with each step
down the job hierarchy- even from the highest grade to the second
highest. Over ten years, employees in the lowest grade were three
times as likely to die as those in the highest grade. One factor
was that people in lower grades showed a higher incidence of many
"lifestyle" risk factors, like smoking, poor diet, and
lack of exercise. Even when the researchers controlled for such
factors, however, more than half the mortality gap remained.
Marmot noted that people in the lower job grades were less
likely to describe themselves as having "control over their
working lives" or being "satisfied with their work situation,"
compared to those higher up. While people in higher job grades
were more likely to report "having to work at a fast pace,"
lower-level civil servants were more likely to report feelings
of hostility, the main stress-related risk factor for heart disease.
Marmot concluded that "psycho-social" factors - the
psychological costs of being lower in the hierarchy- played an
important role in the unexplained mortality gap. Many of us have
probably said to ourselves, after a trying day on the job, "They're
killing me." Turns out it's not just a figure of speech.
Inequality kills - and it starts at the bottom.
Alejandro Reuss is co-editor of Dollars & Sense.