Date: Tue, 17 Feb 1998 10:09:02 -0500
From: Nichols.Nick@epamail.epa.gov
To: p34d3611@jhunix.hcf.jhu.edu, cfleming@agu.org
Subject: Rachel #584: Major Causes of Ill health
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Subject: Rachel #584: Major Causes of Ill health
=======================Electronic Edition========================
.. .
.. RACHEL'S ENVIRONMENT & HEALTH WEEKLY #584 .
.. ---February 5, 1998--- .
.. HEADLINES: .
.. MAJOR CAUSES OF ILL HEALTH .
.. ========== .
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MAJOR CAUSES OF ILL HEALTH
Numerous studies in England and the U.S. have shown consistently
that a person's place in the social order strongly affects health
and longevity.[1] It now seems well-established that poverty and
social rank are the most important factors determining health
--more important even than smoking.[2]
This conclusion has been a long time in the making. A British
study in 1840 observed that "gentlemen" in London lived, on the
average, twice as long as "labourers." Starting in 1911, British
death certificates have been coded for social class based on
occupation. (In the U.S., death certificates are coded for race
or ethnicity without reference to class or occupation.) The
British database of deaths coded by class has allowed many
studies, which have shown consistently that lower social status
is associated with early death.
For example, in 1980, Sir Douglas Black, who was then the
President of the Royal College of Surgeons, published a study
covering the period 1930-1970 in England. The so-called Black
Report concluded that "there are marked inequalities in health
between the social classes in Britain." Specifically, people in
unskilled occupations had a two-and-a-half times greater chance
of dying before retirement than professional people (lawyers and
doctors).[1]
Furthermore, the Black Report showed that the gap in death rates
between rich and poor had widened between 1930 and 1970. In
1930, unskilled workers were 23% more likely to die prematurely
than professional people, whereas in 1970 they were 61% more
likely than professionals to die prematurely.
Several subsequent studies confirmed the findings of the Black
Report and demonstrated that, even within privileged groups,
those with less status lived shorter lives. In other words,
social rank affects health even among those who are well off.
The so-called Whitehall studies in England examined the health of
10,000 British government employees (civil servants) over 2
decades and found a 3-fold difference in death rates between the
highest and lowest employment grades. The Whitehall studies
showed (and later a U.S. study confirmed) that conventional risk
factors such as smoking, obesity, physical activity, blood
pressure and blood-levels of cholesterol could explain only 25%
to 35% of employment-grade differences in mortality.[2] In other
words, social rank was more important a determinant of health
than were all the conventional risk factors. In sum, being lower
in the pecking order makes you sick and shortens your life.
Researchers have examined the opposite hypothesis, that perhaps
health status determines social class --that being sick makes you
poor, instead of the other way around. They have found that this
explains only about 10% of the health disparities between social
ranks.[1]
In the U.S., a study in Chicago during 1928-1932 examined death
certificates in relation to place of residence at time of death.
Chicago was categorized into 5 socioeconomic levels based on
average monthly rental payments. The study showed a fairly
smooth curve: the higher the rent, the lower the death rate for
people of similar ages.
This study was redone in 1973, looking at changes between 1930
and 1960. There had been "no relative gain" in recent decades
for those paying the lowest rents. So even though the general
standard of living may rise, those lower on the income scale die
at younger ages.
In 1986, researchers at the National Center for Health Statistics
showed that Americans with annual incomes of $9000 or less had a
death rate 3 to 7 times higher (depending on gender and race)
than people with annual incomes of $25,000 or more. Furthermore,
they showed that this situation had worsened between 1960 and
1986.[1]
In the U.S., within groups of people having similar incomes,
African-Americans have worse (and worsening) health status,
compared to whites, for many diseases including asthma, diabetes,
hypertension (high blood pressure), major infectious diseases,
and several cancers.[3] Among researchers who have studied these
problems, the basis of these health differences is thought to be
racism, not genetics.[1]
As we have reported previously (REHW #497), several studies have
now revealed two important facts about the relationship of wealth
to health:
1. Between countries, there is no relationship between gross
domestic product (GDP) --a conventional measure of wealth --and
health. In other words, comparing countries at similar levels of
industrialization, it is quite possible for people in poorer
countries to be healthier than people in richer countries. The
absolute level of income does not determine health or longevity.
2. On the other hand, within individual countries there is a
consistent relationship between health and the size of the gap
separating rich from poor. Countries with the longest life
expectancy at birth are those with the smallest spread of incomes
and the smallest proportion of people living in relative poverty.
Such countries (for example, Sweden) generally have longer life
expectancy than countries that are richer but tolerate larger
inequalities, such as the U.S.
Within the U.S., comparisons between states have come to similar
conclusions: it is not the average level of income in a state
that determines health status --it is the size of the gap between
rich and poor in a state that determines health.
George Kaplan and his colleagues at the University of California
at Berkeley measured inequality in the 50 states as the
percentage of total household income received by the less well
off 50% of households.[4] It ranged from 17% in Louisiana and
Mississippi to 23% in Utah and New Hampshire. In other words, by
this measure, Utah and New Hampshire have the most EQUAL
distribution of income, while Louisiana and Mississippi have the
most UNEQUAL distribution of income.
This measure of income inequality was then compared to the
age-adjusted death rate for all causes of death, and a pattern
emerged: the more unequal the distribution of income, the greater
the death rate. For example in Louisiana and Mississippi the
age-adjusted death rate is about 960 per 100,000 people, while in
New Hampshire it is about 780 per 100,000 and in Utah it is about
710 per 100,000 people. Adjusting these results for average
income in each state did not change the picture: in other words,
it is the gap between rich and poor within each state, and not
the average income of each state, that best predicts the death
rate.
Inequality is growing throughout the world, both between
countries and within countries. As of 1996, 89 countries (out of
174) were worse off, economically, than they had been a decade
previously. In 70 developing countries, incomes are lower now
than they were in the 1960s and 1970s.[5] And the level of
inequality is already astonishing. For example, in 1996, 358
billionaires controlled assets greater than the combined annual
incomes of countries representing 45 percent of the world's
population (2.5 billion people).[5] Between 1961 and 1991, the
ratio of the income of the richest 20% of the world's population
to the poorest 20% increased from 30-to-1 to 61-to-1.[2]
Within the U.S., inequality is wider than it has been for 50
years, and it is getting worse. The U.S. now finds itself among
a group of countries, including Brazil and Guatemala, in which
the national per capita income is at least four times as high as
the average income of the poorest 20 percent.[5] In the U.S.
between 1980 and 1990, inequality of income increased in all
states except Alaska.[1] Inequality in the distribution of income
and wealth[6] has been increasing in the U.S. for about 20
years.[7,8,9,10] In 1977 the wealthiest 5% of Americans captured
16.8% of the nation's entire income; by 1989 that same 5% was
capturing 18.9%. During the 4-year Clinton presidency the
wealthiest 5% have increased their take of the total to over 21%,
"an unprecedented rate of increase," according to the British
ECONOMIST magazine.[11]
Inequality in the distribution of wealth in the U.S. is even
greater than the inequality in income. In 1983, the wealthiest
5% of Americans owned 56% of all the wealth in the U.S.; by 1989,
the same 5% had increased their share of the pie to 62%.[10,pg.29]
These tremendous inequalities translate directly into sickness
and death for those holding the short end of the stick.
As Dr. Donald M. Berwick, a Boston pediatrician, said recently,
"Tell me someone's race. Tell me their income. And tell me
whether they smoke. The answers to those three questions will
tell me more about their longevity and health status than any
other questions I could possibly ask."[3]
Isn't it time that the public health community --physicians,
public health specialists, and environmentalists --recognized
that poverty, inequality and racism cause sickness and death?
Given what science now tells us, medical policy --including
medical training --should aim to combat and eliminate poverty,
inequality, and racism just as it now aims to combat and
eliminate infectious diseases and cancer.[2] With U.S. health
care costs now exceeding $1 trillion each year, anti-poverty and
anti-racism initiatives would be economically efficient as well
as humane.
--Peter Montague
(National Writers Union, UAW Local 1981/AFL-CIO)
===============
[1] Oliver Fein, "The Influence of Social Class on Health Status:
American and British Research on Health Inequalities," JOURNAL OF
GENERAL INTERNAL MEDICINE Vol. 10 (October, 1995), pgs. 577-586.
[2] Andrew Haines, Michael McCally, Whitney Addington, Robert S.
Lawrence, Christine Cassel, and Oliver Fein, "Poverty and Health:
The Role of Physicians," ANNALS OF INTERNAL MEDICINE (in press).
[3] Peter T. Kilborn, "Black Americans Trailing Whites in Health,
Studies Say," NEW YORK TIMES January 26, 1998, pg. A16.
[4] George A. Kaplan and others, "Inequality in income and
mortality in the United States: analysis of mortality and
potential pathways," BRITISH MEDICAL JOURNAL Vol. 312 (April 20,
1996), pgs. 999-1003.
[5] Barbara Crossette, "U.N. Survey Finds World Rich-Poor Gap
Widening," NEW YORK TIMES July 15, 1996, pg. A3.
[6] Wealth is the net worth of a household, calculated by adding
up the current value of all assets a household owns (bank
accounts, stocks, bonds, life insurance savings, mutual fund
shares, houses, unincorporated businesses, consumer durables such
as cars and major appliances, and the value of pension rights),
then subtracting the value of all liabilities (consumer debt,
mortgage balances, and other outstanding debt).
[7] Sheldon Danziger and others, "How the Rich Have Fared,
1973-1987," AMERICAN ECONOMIC REVIEW Vol. 79 (May, 1989), pgs.
310-314.
[8] McKinley L. Blackburn and David E. Bloom, "Earnings and
Income Inequality in the United States," POPULATION AND
DEVELOPMENT REVIEW Vol. 13, No. 4 (December, 1987), pgs. 575-609.
[9] Johan Fritzell, "Income Inequality Trends in the 1980s: A
Five-Country Comparison," ACTA SOCIOLOGICA Vol. 36 (1993), pgs.
47-62.
[10] Edward N. Wolff, TOP HEAVY; A STUDY OF THE INCREASING
INEQUALITY OF WEALTH IN AMERICA (New York: Twentieth Century
Fund, 1995). Although this is a study of wealth inequality,
chapter 6 deals with income inequality.
[11] "Up, down and standing still," THE ECONOMIST February 24,
1996, pgs. 30, 33.
Descriptor terms: u.s.; uk; poverty and health; income and
health; wealth and health; inequality; longevity; morbidity
statistics; race and health; african americans; la; nh; ut; ms;
chicago; medical policy; equity; environmental justice; black
report; whitehall studies; brazil; guatemala;
################################################################
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