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
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.
- Hadley, J. (2002). Sicker and poorer: The consequences of being uninsured. Kaiser Family Foundation. [↩]
- 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? [↩]
- Rosenthal, S. (2006). POWER and powerlessness, Chapter 11, “Divide and Rule.” [↩]
- 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. [↩]
- Quoted in Bowe, C. (2008). U.S. society helping to make people sicker. The Financial Times Limited, February 29. [↩]
- McCord C, Freeman H.P. (1990). Excess mortality in Harlem. New England Journal of Medicine Vol. 322, p. 173-7. [↩]
- DHSS (1980). Inequalities in health: Report of a research working group. Middlesex: U.K. Author. [↩] [↩]
- 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. [↩]
- 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. [↩]
- Robert Wood Johnson Foundation. (2008). Overcoming Obstacles to Health. [↩]
- Cohen, P. (2004). Forget lonely. Life is healthy at the top. New York Times, May 15. [↩] [↩]
- 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. [↩]
- Everson S, et. al. (1997). Hopelessness and 4-year progression of carotid atherosclerosis. Arteriosclerosis, Thrombosis, and Vascular Biology, Vol. 17:8, p.1490-5. [↩]
- 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. [↩]
- 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. [↩]
- 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. [↩]
- CBC. (2003). Bad bosses bring blood pressure to boil: Study. June 24. [↩]
- 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 [↩]
- 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. [↩]
- Cited in Cohen, P. (2004). Forget lonely. Life is healthy at the top. New York Times, May 15. [↩]