Inequality: The Root Source of Sickness in America

The United States spends more on health care than any other industrial nation, yet it has the highest infant death rates and the lowest life expectancy.

This problem is attributed to a fragmented, profit-oriented medical system that denies millions of people access to care.1 While a national medical plan that covers everyone is desperately needed, improving the general health of the population requires more fundamental change.

Studies show that social inequality affects the health of populations more than any other factor – more than diet, smoking, exercise, and even more than access to medical care.2

Americans suffer the worst health statistics in the industrialized world because they live in the most unequal society in the industrialized world.

Poor health and lack of access to medical care are both symptoms of social inequality. In 1970 the wealthiest 0.1 percent of Americans took in 100 times the average annual income. By 2001, they were taking 560 times the average annual income. In 1980, U.S. life expectancy ranked 14th in the world. By 2007, it ranked 29th.

Inequality is built into and generated by the capitalist system. Capital is created when employers pay workers less than the value of the goods and services they produce. The resulting profit, or capital, is used to extract more capital. As this process repeats over time, capital accumulates at the top of society and misery accumulates at the bottom.

The strategy of divide-and-rule generates even more inequality: between men and women; White and Black; national and foreign-born; straight and gay; etc.

As social inequality grows, the health of the entire population suffers, not just those on the bottom.3

Inequality Kills

A study of 282 metropolitan areas in the U.S. found that the greater the difference in income, the more the death rate rose for all income levels, not just for the poor.

Researchers calculated that if income inequality could be reduced to the lowest level found in the United States, it would save as many lives as would be saved by eradicating heart disease or by preventing all deaths from lung cancer, diabetes, motor vehicle crashes, HIV infection, suicide and homicide combined!4 We would see even greater benefits if we eliminated social inequality entirely.

Consider the lives that would be saved just by ending racial inequality.

Without racism, death rates for Black and White Americans would be the same. Yet, every year, Black Americans suffer 300 more deaths per 100,000 people than White Americans. Compare these 300 additional deaths with the 2005 U.S. homicide rate of fewer than 6 per 100,000. Do the math. Racism kills 50 times more people than die at the hands of individual murderers.

Inequality kills kids. Forty-two nations have lower infant death rates than the U.S. The infant death rate in the capital of the U.S. is more than double the infant death rate in the capital of China. In 25 nations, people live longer, on average, than they do in America.

Inequality is so destructive that it can even counter the benefit of higher incomes. Studies show that poorer people living in more equal nations tend to be healthier and live longer than more-affluent people living in more unequal nations. For example, middle-income people in Britain enjoy better health than wealthier Americans.5

Men living in Bangladesh, one of the world’s poorest countries, are more likely to reach age 65 than Black American men living in Harlem. Harlem men have higher incomes than Bangladeshi men but live in a more unequal society. Black Americans tend to die prematurely from cardiovascular and other diseases that are linked with class and race inequality.6

How does inequality do so much damage?

Power = Health

A study of the highly-stratified British civil service found that health deteriorated as social status fell. This decline in health could not be explained by smoking, exercise or body weight.7 Income is not the factor, because professionals who earn less than non-professionals still enjoy better health.8

The answer lay in the surprising finding that those near the top of the power structure had worse health than those at the top, even though their life-styles were essentially the same.7 The only difference that could account for this is social power.

People with more control over their lives enjoy better health. Bosses live the longest, healthiest lives because they have the most power. As power diminishes, stress rises and health deteriorates. This relationship between social status and health has been found in every nation studied, including the United States.9

A 2008 study found widening differences in health between income levels in America. (Income level is often used to measure social status.) The nation’s poorest adults were nearly five times more likely to be in “poor or fair” health than the richest, and at every income level the wealthier group was healthier than the next lower one. This trend was seen in all racial groups.10 Michael Marmot, who studies the link between social status and health, explains,

Your position in the hierarchy very much relates to how much control you have over your life…Sustained, chronic and long-term stress is linked to low control over life circumstances.11

Under capitalism, only a few people get to make the important decisions. The rest of us get no say over how work will be organized and how social resources will be used. We don’t get to decide if we will build more schools or more prisons, wage war or make peace.

Exclusion from decision-making is strongly linked with cardiovascular disease,12 and the more powerless a person feels, the faster the disease progresses.13 Oppressed sections of the working-class suffer the highest rates of cardiovascular disease,14 because they have the least social control.

People with little control over demanding jobs are more likely to be overweight and have high cholesterol regardless of age, amount of exercise and smoking habits. By itself, hard work is not bad for your health unless there is also a lack of control. The most health-damaging jobs saddle workers with great responsibility (e.g. caring for patients) while denying them the resources required to meet those responsibilities (enough time to do what is needed).15

In Unhealthy Societies: The Afflictions of Inequality, Richard Wilkinson links inequality with health-damaging stress. Children show rising levels of stress hormones as their social position falls.16 Nurses who work under “unfair and unreasonable” bosses have higher blood pressure.17 Simply speaking with someone with higher social status will raise your blood pressure.18 The greatest damage is done to those who are put down and ordered around their entire lives.

Stress triggers a higher heart rate, a release of adrenaline, glucose and other neurological responses to help the body respond to a short-term threat. But when extended over long periods of time, they can harm the cardiovascular and immune systems, making individuals more vulnerable to a wide range of conditions including infections, diabetes, high blood pressure, heart attack, stroke, asthma and aggression.11

Solidarity is the Best Medicine

Human survival has always depended on the cooperation that flows from strong social bonds. People who pull together enjoy better health and longer lives.19 Strong social ties may explain why Hispanic Americans have lower rates of chronic illness than White Americans, despite having lower incomes.20

Human beings cannot be healthy in class-divided societies. From birth to death, capitalism ranks people on a vertical scale, with those higher up being treated as more worthy than those lower down. The unequal relationship between bosses and workers is maintained by divide-and-rule policies that generate more inequality based on sex, skin color, religion, nationality, etc. These divisions rupture social bonds and generate sickness throughout the population.

Universal access to medical care would reduce some of this inequality. However, even the best medical system cannot eliminate the health-damaging effects of poverty, social discrimination, unsafe work, bad housing, poor schools and being denied the right to make decisions that affect our lives. To end these miseries, we must eliminate class divisions and all the other inequalities that follow.

Human sickness is a product of sick social relationships, and human health is a product of healthy social relationships. Replacing class divisions with a cooperative, socialist society would reduce the burden of disease and raise the level of health more than any other measure.

  1. Hadley, J. (2002). Sicker and poorer: The consequences of being uninsured. Kaiser Family Foundation. []
  2. Wilkinson, R.G. (1992). National mortality rates: the impact of inequality? Am J Public Health, Vol 82:8, p. 1082-1084. See also, PBS (2008). Unnatural Causes: Is Inequality Making Us Sick? []
  3. Rosenthal, S. (2006). POWER and powerlessness, Chapter 11, “Divide and Rule.” []
  4. Lynch, J.W. et. al. (1998). Income inequality and mortality in metropolitan areas of the United States. Am J Public Health Vol. 88, p. 1074-1080. []
  5. Quoted in Bowe, C. (2008). U.S. society helping to make people sicker. The Financial Times Limited, February 29. []
  6. McCord C, Freeman H.P. (1990). Excess mortality in Harlem. New England Journal of Medicine Vol. 322, p. 173-7. []
  7. DHSS (1980). Inequalities in health: Report of a research working group. Middlesex: U.K. Author. [] []
  8. Cited in Schmidt. J. (2000). Disciplined minds: A critical look at salaried professionals and the soul-battering system that shapes their lives. Rowman & Littlefield, p. 103-104. []
  9. A discussion of American studies linking class and heath can be found in Schmidt. J. (2000). Disciplined minds: A critical look at salaried professionals and the soul-battering system that shapes their lives. Rowman & Littlefield, p. 103-104. []
  10. Robert Wood Johnson Foundation. (2008). Overcoming Obstacles to Health. []
  11. Cohen, P. (2004). Forget lonely. Life is healthy at the top. New York Times, May 15. [] []
  12. Raphael, D. (2001), Inequality is bad for our hearts: Why low income and social exclusion are major causes of heart disease in Canada, North York Heart Health Network, Toronto, Canada. []
  13. Everson S, et. al. (1997). Hopelessness and 4-year progression of carotid atherosclerosis. Arteriosclerosis, Thrombosis, and Vascular Biology, Vol. 17:8, p.1490-5. []
  14. Raphael, D. (2002). Poor choice or no choice?: Even more evidence links low income with disease so why keep blaming lifestyle choices like fries? Toronto Star, October 11, p. F6. []
  15. Kivimääki, M., et. al. (2002). Work stress and risk of cardiovascular mortality: prospective cohort study of industrial employees. BMJ October 19. Vol. 325, p. 857. []
  16. Lupien S.J. et al. (2000). Child’s stress hormone levels correlate with mother’s socioeco­nomic status and depressive state. Biol Psychiatry Nov 15. Vol. 48, p. 976-80. []
  17. CBC. (2003). Bad bosses bring blood pressure to boil: Study. June 24. []
  18. Long, J.M, et. al. (1982). The effect of status on blood pressure during verbal communication. Journal of Behavioral Medicine Vol.5, p. 165-71 []
  19. Cacioppo, J.T. et al. (2002). Loneliness and health: Potential mechanisms. Psychosom Med May/June, Vol. 64, p. 407-17. Also, House, J.S. et. al. (1988). Social relationships and health. Science, Vol. 24, p. 540-545. []
  20. Cited in Cohen, P. (2004). Forget lonely. Life is healthy at the top. New York Times, May 15. []

Susan Rosenthal is a socialist, retired physician, union member, and the author of Sick and Sicker: Essays on Class, Health and Health Care (2010), and Power and Powerlessness (2006). She recently launched ReMarx Publishing. She can be reached through her web site or by email: susan@susanrosenthal.com. Read other articles by Susan.

8 comments on this article so far ...

Comments RSS feed

  1. Christophe said on November 3rd, 2009 at 9:26am #

    Indeed, the relation of social power (read: An increase in the options from which one may choose) and morbidity have been postulated in the wild, and with primates in captivity (Alpha-males being less stressed) certainly must also obtain with human communities. The “system” now extant in the U.S. has not fundamentally changed in generations, and I don’t think any changes are forecasted any time soon. There are also stressors that lead to premature death that I think cannot be changed, as so much in the environment cannot be reigned in by political and/or social reform: Stress is ubiquitous. However, again, much of the stress in our polity is really an indication of the functional dysfunction inherent in a dog-eat-dog culture.

  2. Christophe said on November 3rd, 2009 at 9:32am #

    Human sickness is a product of sick social relationships, and human health is a product of healthy social relationships. Replacing class divisions with a cooperative, socialist society would reduce the burden of disease and raise the level of health more than any other measure.

    Who will then re-engineer a society that is marked by conspicuously healthy social relationships? Again, this strikes me as harking back to the antiquarian notions of statism, not unlike Stalinist Russia: science at the employ of social organismal health. It does give one pause when contemplating the manner in which a culture would address so much social inequality, without creating more problems.

  3. Wingnut said on November 3rd, 2009 at 10:17am #

    Excellent report, Susan! You know how I feel about pieces where you divide-up the classes and give them labels, and then try to put them at war with each other. This piece didn’t do that at all, and it appears you are seeing the classes as a “stratification” and something not so easily delineated. Good stuff. The classes wobble around so much because many of us have varying “roles”, or maybe “masks”, or maybe “facets”. Sometimes we’re Christian, sometimes we’re consumer, sometimes we’re capitalist, sometimes we’re politician, sometimes we’re giving, sometimes we’re greedy/ego-centric, etc. etc.. In SOME groups, $24,000/yr is “rich”. In some groups, that’s middle class. In other groups, that’s scraping bottom. It all depends upon the perspective/condition of the person doing the viewing. And example from before… is a local little ol’ lady piano teacher, who practices “whatever the market will bear”… considered “capitalist class”?

    You know how I feel about trying to delineate and label borders between classes and US versus THEM wars. We’ve talked. And i don’t know why I bring it up here, because… this is just a fantastic report… with great statistics. You are (still) one of the best important-statistics gatherers I’ve ever met… and I’ve told you THAT before, too.

    And, its just plain good hearing from you, again. I hope you’re well. On-subject-speaking… yes, monetary discrimination (wellbeing inequality) is killing most of humanity and planet. Its just like the childhood pyramids which always collapse. Upper 1/3… heads in the clouds (enjoyment/luxury junkies)… and lower 2/3… crushed by the weight of the world’s knees in their backs. There’s giant pyramids out in the planet’s sandbox… built by former civilizations… as symbols of what we’re supposed to be studying here. Pyramiding. Or, in other words, capitalism. The ultimate ownershipism rat-race. Yay. (not)

  4. b99 said on November 3rd, 2009 at 12:26pm #

    The war between those who conduct genetic studies and those who look for answers in social class has only just begun. Those who favor the latter for explanations best be prepared for the findings of the former – they will not be easy to digest or counter. Genetic studies are here to stay.

  5. Christophe said on November 4th, 2009 at 11:58am #

    b99: What are you trying to communicate? Are you saying that deterministic-biologistic attempts at understanding complex human behaviour and interactions are the way of the future, full of promise, or, fraught with danger and wrongheaded public health policy? By the way, genetics, in one form or other-reflective of the level of scientific underpinnings-has figured in works as far back as Plato, with no real solutions to some of the more intractible societal problems. No “new” scientific paradigm will in itself be a solution, without honestly considering the “non-scientific” ameliorative approaches.

  6. ajohnstone said on November 4th, 2009 at 11:01pm #

    very insightful article and much appreciated

  7. Ann said on November 5th, 2009 at 1:59pm #

    Biologistic or genetic attempts at understanding our health problems is old story always reviving itself as if it’s something new. Try to find within biomedical circles social solutions, you’d be hard pressed. It almost appears medical researchers have a certain disdain for sociological explanations, despite its over 100 year history. The problem is no can make money on solutions that focus on society.

  8. Wingnut said on November 10th, 2009 at 7:59am #

    That’s right, Ann. The true root cause for MANY of the planet’s problems… is with the using of economies. No other living things on the planet… use such. You’ll never see a deer use a price tag, honor a title of ownership, carry a wallet or purse, or mercantile in any way whatsoever.

    As far as your comment about biomedical folk rarely having solutions for social problems, likely true. But medical people do great reporting and tracking of things they see/deal-with. And if we heed those findings and statistics, we can at least PROVE a social problem exists. It might not be shrugged-off as cock’n’bull, because we will have truth. But will those in power LISTEN to medical reports and statistics? Probably not. With capitalists in charge of power (instead of nuns, nurses, and farm moms)… the objective will be to “grow economy”. Most medical folk know that “economy” is the name for a type of cancerous tumor… and that its not a good idea to grow those. They should be removed from the organism.

    If one looks at things from a certain angle, one can see that $money$ = wellbeing. Wellbeing has been seen as a highly-sought thing, and thus, the capitalists (which SOME label as “we”)… have found that wellbeing sales is a fertile place to harvest some hide-gouge from the wellbeing-desperate general public. Lets itemize a bit. Great vitamins… $$$. Great medical experts… $$$. Great nutrition/food… $$$. Great shelter/clothes… $$$. Entertainment/fun… $$$. Stress-free transportation… $$$. Stress free high-edu child-rearing safety and confidence… $$$. Great insurance/fear-countering-measures… $$$. Getting to set-for-life… $$$.

    All of the above categories of wellbeing… overlap/affect each other. For every category that’s “satisfied”, the general happiness levels of the person… increase (often via a reduction in fear or stress). Relaxation is the opposite of stress/fear… correct? And being able to relax about ANY given issue of concern… increases happiness in all humans… as best I can tell. And I think we’ll all eventually find… that the higher the happiness and the lower the wellbeing worries, the healthier the human. That goes for planets, too. In fact, I’m quite sure that the medical folks have all the statistics to prove that a happier human is a healthier human… and lets hope SOMEBODY is heeding those findings.

    But, it takes money to “cover” (counteract?) the things that are attacking humans. With the rich in charge, THAT group doesn’t really feel the stress of monetary discrimination and wellbeing rationing. Just recently have the middle class areas of pyramids like capitalism… started to feel wellbeing rationing. The low-on-the-pyramid folks have been feeling it since birth. Set-for-lifes are in a much different environment than set-for-servitude/job folks are.

    Remove the man-made-up phenomena of money, ownership, pricetags… and it all goes away. Suddenly EVERYONE is wellbeing-rationed… and we’ll ALL be forced to come up with a new (non-)game plan. A LEVEL plan. No discrimination, not monetary, not ownership, not “have a say”. Just “plane” level stuff. If discrimination is seen or provable… off to jail the perpetrator goes.

    In that world, the position of USA president would be a “role” or “job description” and would not be any more or less powerful than anyone else. Police officer… same same… a role, not an empowerment. Egalitarian! Decision by committee. Everyone has a say and its weighed for smartness! Sure its slow and arduous, but we have the information systems now… to record, track, weigh, and add-to everyone’s great ideas.

    It all sounds good in theory, anyway. :/ It would have to be seriously worked-at by everyone. Economy-less worldwide communes are no free ride, work-wise. The motivations would be of a completely different flavor than money, power, esteem, and ownership. More of a pride and “good name” thing. But even “good name” is dangerous, as its pro-individual and not pro-team.

    Its best to get “spearheaders” like those who come up with ideas and “spirit” to gather a few of the local neighborhood dads (moms too) together… and build a treehouse for all the neighborhood kids. Treehouse Teaming. No wages, no boss, no deadlines, no stress, and yet a wonderful treehouse comes from it, and the folks involved often get together for a potluck supper afterwards, and sit around the fire with Michelobs… patting each other on the back for a job well done. I think that’s called love… but its been awhile, so I’m not sure. :)

    So, in studying alternative ways and “communes”… one should probably study HOW and WHY… treehouse teaming works, and has such excellent results. First, we need to say/believe/know that competition is NOT healthy and NEVER WAS. Cooperation, its opposite, is the healthy thing. Then, as we eliminate competition from our world, money and ownership would be the first to go. Those are the two “big tools” by which capitalists (force-ins and free-joiners) compete.

    Peace and love!