By Larry Adelman
Creator and Executive Producer of 'Unnatural Causes: Is Inequality Making Us Sick?'
Real people have problems with their lives as well as with their organs. Those social problems affect their organs. In order to improve public health, we need to improve society.—Sir Michael Marmot, Chair, World Health Organization Commission on the Social Determinants of Health
For all the talk of the growing gap between the rich and the rest of us, one issue has escaped scrutiny. And that’s health. Not health care, but health.
Some 47 million of us have no health care. Inexcusable. But health care, as Canadian health economist Robert Evans points out, is our repair shop, where we take our bodies when they break down. But what’s wearing down our engines and making us sick in the first place? And why is that wear and tear so differentially distributed by race and by class?
That’s where inequality comes into play. We pour billions of dollars into drugs, dietary supplements and new medical technologies, and focus on what we as individuals can do to be healthier. But a growing body of evidence suggests there is much more to our health than bad habits, our meds or unlucky genes.
Written into our bodies is an accumulation of conditions that start in childhood and can lead to a pile-up of risk for some, a cascade of advantage for others. Harvard epidemiologist Nancy Krieger says, “We interact constantly with the world in which we’re engaged. That’s the way in which the biology actually happens. We carry our history in our bodies. How can we not?”
The social, physical and economic environments in which we are born, live and work can actually get under our skin as surely as germs and viruses. Because these conditions are distributed unequally—in the jobs we do, the wealth we enjoy, the schools we attend, the neighborhoods we inhabit, the power we have to manage our lives—so are our patterns of health and disease, particularly stroke, heart disease, asthma, hypertension, diabetes, kidney disease and even some cancers.
The single best predictor of one’s health is not diet, exercise or even smoking but class status. But it’s not only the poverty-stricken who are afflicted—after all, what would be so surprising about that?—but the middle classes as well. At each descending step down the class pyramid, from the rich to the middle to the poor, people tend to be sicker and die sooner. Top executives have, on average, better health than managers, managers fare better than supervisors and technical personnel, supervisors do better than line, service and clerical workers, and the unemployed have the worst health of all. High school dropouts die, on average, six years sooner than college graduates. In other words, it’s not CEOs who are dying of coronary heart disease but those who work for them.
In practically every step on the class pyramid, African Americans are worse off than their white counterparts. In many cases, so are other communities of color. African Americans live on average nearly six years less than white Americans. Among American Indians and Latinos, the prevalence of diabetes is 100 percent higher than among white Americans. Despite the newspaper headlines, there is nothing different about the genes of the less-affluent or people of color.
Much of American health prevention focuses on individual behaviors. Behaviors certainly matter for health. But the choices we make are constrained by the choices we have. It’s hard to eat your five to seven fruits and vegetables a day when your neighborhood is dominated by fast-food joints and mom-and-pops and you have to take two buses to get to a supermarket.
But many health risks have nothing to do with behaviors. Government and business decisions over which individuals have little say can expose us to health threats or health promoters: the location of toxic dumps, the quality of schools, whether plants stay open or shift jobs overseas, where parks and freeways get built, wages and benefits, shifting mortgage rates, even tax policy.
According to the MacArthur Research Network on Socioeconomic Status and Health and the work of Peter Schnall, June Fisher and others, high-demand coupled/low-control jobs in particular create damaging levels of chronic stress. Those who cannot control the pace of their work and have limited opportunity for autonomy and decision making experience higher rates of depression, heart disease, diabetes and premature death even when they face no physical hazards at work.
But if we look overseas, where citizen health and life expectancy are often considerably higher than ours, we can see the importance of national social policies that “treat” not just the individual but the larger environment. One set of policies—such as free universal pre-school, quality schools no matter the neighborhood, paid parental leave, four to six weeks of paid vacation—make sure health promoters are available to everyone, not just the affluent.
The other kind—such as child supports and progressive tax policies—tend to flatten nations’ inequality. Where the United States has a child poverty rate of 21 percent, Sweden, for example, has a child poverty rate of 4.2 percent—even though they have an even higher percentage of single parent families than we do. But the two countries’ social spending is reversed: Sweden spends 18 percent of its GDP on social programs—the United States less than 4 percent. Swedes live on average more than three years longer than Americans. And did I mention that 78 percent of the Swedish workforce belong to unions?
But we’ve improved our health inequities in the past, and we can do so again.
A century ago, during the days of the robber barons and Jim Crow, U.S. life expectancy was about 48 years. Most medical historians attribute much of the 30-year increase since then not to new drugs, hospitals or medical technologies but social change. The abolition of child labor, the eight-hour workday, housing and factory codes, modern sewage systems, collective bargaining, Social Security and other reforms won working Americans a bigger share of our productivity gains and protections against the chaos of an unfettered free market.
The civil rights movement extended some of those gains to African Americans and other people of color. As a result, the health of African Americans improved in absolute and relative terms compared to whites between 1968 and 1978. By 1976, economic inequality, though still large, had reached a 20th century low. Our lives had improved and so did our health.
Then we changed direction—with consequences that remain with us today. In the midst of a recession, the Reagan administration cut taxes on the rich, slashed social programs and deregulated business placing a disproportionate burden on some populations while advantaging others.
So, why the surprise that the United States has slid to 29th in life expectancy and 31st in infant mortality? The United States is far and away the most unequal of all the rich democracies. The richest 1 percent now own more wealth than the bottom 90 percent of us combined. This nation also does less to protect its citizens from the chaos of market forces. We are the only rich country without universal health care and mandated paid vacations. San Francisco is the only city that mandates paid sick leave. Americans now work on average even longer hours than the Japanese. And if we lose our job, we’re basically out on our own. Why wouldn’t our health outcomes reflect that?
Class and racial inequities in the United States and the health disparities they shape are not “natural.” They are the products of decisions that we as a society have made—and can make differently. As we once did.
David Williams, Florence and Laura Norman professor of public health at Harvard University, says: “Increasing opportunities, providing education and training for better jobs, investing in our schools, improving housing, integrating neighborhoods, giving people more control over their work—these are as much health strategies as diet, smoking and exercise.” Economic justice, racial equality and caring communities may be the best medicine of all.
We have a choice. We can address the forces that create and reproduce inequities today, or we can pay to repair the bodies tomorrow. With our over-burdened health care system already gobbling up $2 trillion a year—16 percent of our GDP—(and chronic illness costing business more than $1 trillion in lost productivity) I’m not sure that’s a choice we can afford.
Larry Adelman is creator and executive producer of "Unnatural Causes: Is Inequality Making Us Sick?" broadcast by PBS at the end of March. Find out more at .
