Yves here. The high social cost of inequality – the fact that it shortens the lives of people at the top of the pecking order along with the lower orders – has long been excluded from discussion in polite company in the US. Michael Prowse took note of the lifespan cost of income inequality in the Financial Times in 2007, and this information wasn’t new in public health circles even then:
Those who would deny a link between health and inequality must first grapple with the following paradox. There is a strong relationship between income and health within countries. In any nation you will find that people on high incomes tend to live longer and have fewer chronic illnesses than people on low incomes.
Yet, if you look for differences between countries, the relationship between income and health largely disintegrates. Rich Americans, for instance, are healthier on average than poor Americans, as measured by life expectancy. But, although the US is a much richer country than, say, Greece, Americans on average have a lower life expectancy than Greeks. More income, it seems, gives you a health advantage with respect to your fellow citizens, but not with respect to people living in other countries….
Once a floor standard of living is attained, people tend to be healthier when three conditions hold: they are valued and respected by others; they feel ‘in control’ in their work and home lives; and they enjoy a dense network of social contacts. Economically unequal societies tend to do poorly in all three respects: they tend to be characterised by big status differences, by big differences in people’s sense of control and by low levels of civic participation….
Unequal societies, in other words, will remain unhealthy societies – and also unhappy societies – no matter how wealthy they become. Their advocates – those who see no reason whatever to curb ever-widening income differentials – have a lot of explaining to do.
Sam Pizzigati puts a renewed focus on his post on America’s lagging life expectancy. He makes an argument that some readers may question, namely, that Americans generally lived unhealthier lives in the 1950s than now. I’m not sure I agree. I grew up in the 1960s, and standard work weeks were shorter and kids were much more active (walking to and from school, having much more unstructured play time). Labor saving devices in the home also became more prevalent in the 1950s, which reduced the physical effort associated with being a stay-at-home wife (try beating eggs with a whisk). There were fewer pollutants (some scientists contend that many chemicals interact in the human body, and so much lower doses may have adverse effects in combination than they do when they are tested in isolation). Phthalaes, for instance, are endocrine disruptors and were commonly used in building materials and in furniture cushions, starting in the 1950s. They’ve been linked to childhood obesity. Similarly, when I was young, a soda with all its high fructose corn syrup, was a treat, not a staple. And don’t get me started on our large portion sizes, or how much processed food is in the typical American diet. So while inequality is clearly a big culprit in American’s relatively decline in life expectancy, I’m not so certain I’d write off other lifestyle factors so quickly.
Let’s talk life expectancy.
The stats first. They tell a clear story: Americans now live shorter lives than men and women in most of the rest of the developed world. And that gap is growing.
Back in 1990, shouts a new study published last week in the prestigious Journal of the American Medical Association, the United States ranked just 20th on life expectancy among the world’s 34 industrial nations. The United States now ranks 27th — despite spending much more on health care than any other nation.
Americans, notes an editorial the journal ran to accompany the study, are losing ground globally “by every” health measure.
Why such poor performance? Media reports on last week’s new State of U.S. Health study hit all the usual suspects: poor diet, poor access to affordable health care, poor personal health habits, and just plain poverty.
In the Wall Street Journal, for instance, a chief wellness officer in Ohio opined that if Americans exercised more and ate and smoked less, the United States would surely start moving up in the global health rankings.
But many epidemiologists — scientists who study health outcomes — have their doubts. They point out that the United States ranked as one of the world’s healthiest nations in the 1950s, a time when Americans smoked heavily, ate a diet that would horrify any 21st-century nutritionist, and hardly ever exercised.
Poor Americans, then as now, had chronic problems accessing health care. But poverty, epidemiologists note, can’t explain why fully insured middle-income Americans today have significantly worse health outcomes than middle-income people in other rich nations.
The University of Washington’s Dr. Stephen Bezruchka has been tracking these outcomes since the 1990s. The new research published in the Journal of the American Medical Association, Bezruchka told Too Much last week, should worry Americans at all income levels.
“Even if we are rich, college-educated, white-skinned, and practice all the right health behaviors,” he notes, “similar people in other rich nations will live longer.”
A dozen years ago, Bezruchka published in Newsweek the first mass-media commentary, at least in the United States, to challenge the conventional take on poor U.S. global health rankings.
To really understand America’s poor health standing globally, epidemiologists like Bezruchka posit, we need to look at “the social determinants of health,” those social and economic realities that define our daily lives.
None of these determinants matter more, these researchers contend, than the level of a society’s economic inequality, the divide between the affluent and everyone else. Over 170 studies worldwide have so far linked income inequality to health outcomes. The more unequal a society, the studies show, the more unhealthy most everyone in it — and not the poor alone.
Just how does inequality translate into unhealthy outcomes? Growing numbers of researchers place the blame on stress. The more inequality in a society, the more stress on a daily level. Chronic stress, over time, wears down our immune systems and leaves us more vulnerable to disease.
This same stress drives people to seek relief in unhealthy habits. They may do drugs or smoke — or eat more “comfort foods” packed with sugar and fat.
Inequality has an equally potent impact on policy decisions around health.
“A substantial proportion of our adult health,” as Stephen Bezruchka explained last week, gets programmed in the early years of a child’s life. Given this reality, guaranteeing every child the best possible supports in the early years ought to be priority number one for any society committed to better health for all.
But unequal nations do precious little of this guaranteeing. The nations with the highest ranking for child well-being turn out to be the nations with the most equal distributions of income.
Can the United States change course on health? Will Americans in the future be able to look forward to living lives as long as people in other developed nations?
Japan may offer the most encouraging precedent. In the middle of the 20th century, Japan ranked as a deeply unequal and unhealthy nation. But since the 1950s Japan has become a much more equal society, one of the world’s most equal, and, on life expectancy, Japan now ranks number one globally.
The United States, over the same span of time, has gone in the exact opposite direction. We have become the world’s most unequal major nation, with health outcomes among the developed world’s worst.
So how do we start a turnaround? Most Americans, Stephen Bezruchka notes, already understand the concept of “vital signs.”
“We can sense these vital signs tell us something significant about our individual health,” he notes, “every time we step on a scale at the doctor’s office or feel a blood pressure cuff tighten.”
But societies have “vital signs,” too, with none more important to health than our level of inequality. We need to start recognizing these broader “vital signs.” If we do, Bezruchka believes, we can make a difference.
“Dying so much younger than we should,” he sums up, “can be changed.”