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Meghan J. ClarkOctober 29, 2012

In one neighborhood on the East Side of Manhattan the average household income is $101,000. A few miles away, in a section of the South Bronx, it is $19,800. This troublesome income gap within New York City was highlighted in a statement on poverty issued by Cardinal Timothy Dolan and Bishop Nicholas DiMarzio on Sept. 27, the feast of St. Vincent de Paul. But religious leaders are not the only ones bringing this issue to the fore. The debate over inequality has also become a substantive issue in the 2012 presidential race, in which comments about fairness and social structures of opportunity are often met with accusations of inciting class warfare and envy.

What both sides often overlook, however, are the social and health costs of this growing inequality. In short, inequality is making Americans sick and contributing to premature death. According to public health research, more than 800,000 U.S. deaths can be linked to excessive economic inequality. The Organization for Economic Co-operation and Development found that in 2010 the United States spent 17.6 percent of its gross domestic product on health care ($8,233 per person), nearly double the 9.5 percent average in other developed countries. But the United States ranks 50th in life expectancy and 41st in infant mortality. Americans have a lower life expectancy than residents of South Korea and Bosnia.

New public health research is showing that the economic crisis and the health crisis are linked by far more than just the cost of health care. In 2007, one-third of U.S. deaths—883,914 total, or the equivalent of the population of San Francisco—were deemed “excess deaths.” What are excess deaths? Experts in public health and epidemiology have developed tools to calculate how many people should be expected to die, on average, in a given location and time frame; anything above that number is considered a premature death. These tools are used not only for examining the effects of inequality but also in epidemics and natural disasters. According to the New York City Department of Health’s primer on health disparities, individuals living in the South Bronx are twice as likely to die before the age of 75 as those on the city’s Upper East Side. The neighborhoods themselves are vastly different, and the health disparity between the residents is equally stark. Higher economic inequality translates into higher health disparities for almost everyone in society.

When we think of our health, we usually focus on two things: family history and individual choices. Imagine the questions asked of you on your most recent trip to the doctor: Do you have a family history of cancer? Have you ever smoked? But genetics and personal choices are not enough to explain the health disparities between the rich and the poor, and the reality of your health status is far more complicated. It is common knowledge that smoking increases the risk of lung cancer; but most of us also know at least one person with lung cancer who never touched a cigarette or a smoker who smoked for decades but never got cancer.

Health and well-being are also greatly affected by social determinants of health, like nutrition, education, safe housing, social inclusion or exclusion and poverty. Analyzing and separating the individual social determinants of health is often difficult because they are interrelated. The negative health effects of lack of proper nutrition or safe housing are rather obvious. It is easy to imagine that homelessness causes illness and early death. Economic inequality, however, is a social determinant of health that is difficult to picture but one that public health research is finding has a powerful effect on our individual and social health.

Imagine our society as a ladder. As inequality grows, the gap between the steps grows wider, making the ladder harder and harder to climb. The space between levels is the social or wealth gradient. Climbing up and down the ladder is social mobility. Public health research finds that with each step down the wealth gradient, individuals have a lower life expectancy and increased health concerns. This research, pioneered by Sir Michael Marmot, a professor of epidemiology and public health at University College London, demonstrates significant health differences at each level of the ladder. These differences kick in long before one reaches the poverty line in the United States, as well as in the United Kingdom, and remain when the data is adjusted for personal unhealthy behavior like smoking.

An excellent presentation of this research is the 2009 documentary film series “Unnatural Causes: Is Inequality Making Us Sick?”, which examines in detail the negative health effects of inequality on the health and well-being of Americans. The film follows employees of a hospital—including the chief executive officer, the manager of a laboratory, nurses and janitors—who are at a range of income levels. Where previous assumptions held that a chief executive officer is more likely to have a heart attack, because of a high level of stress and responsibility, the medical research showed that the janitor is more likely to have heart disease and a heart attack, even if he or she is not in poverty. This holds up and down the ladder of the hospital: A greater gap between the C.E.O. and the janitor correlated to a greater health outcome gap affecting every level of society.

The effects of inequality could also be seen when researchers compared health outcomes in states with higher and lower levels of equality. Americans living in states with greater equality live on average four years longer than in those with greater inequality. “Unnatural Causes” walks the viewer through Louisville, Ky., where the total gap in life expectancy between the richest and poorest ward is about 10 years. This research focuses specifically on other developed countries of the Organization for Economic Co-operation and Development (2010 data). The United States has a life expectancy of 78.7 years and an infant mortality of 6.1 per 1,000 births. Japan and Sweden are both developed countries with greater economic equality. Japan has a life expectancy of 83 and infant mortality of 2.3 out of 1,000 births. Similarly, Sweden’s life expectancy is 81.5, with an infant mortality rate of 2.5 out of 1,000. Turkey and Mexico are the only Organization for Economic Co-operation countries with higher infant mortality in 2010 than the United States.

A Threat to the Common Good

How does inequality make us sicker? It contributes to a complex combination of chronic stress (and elevated levels of the stress hormone cortisol), anxiety, housing disparities, poverty and social sins like racism. The intersection of these lead to concrete health effects as well as social division. In its pastoral letter “Economic Justice for All” (1986), the U.S. Conference of Catholic Bishops recognized that “extreme inequality is a threat to the solidarity of the human community, for great disparities lead to social divisions and conflict.” Greater inequality can lead to greater narcissism among those higher on the ladder, a good example of which is the excessive pay and bonuses for Wall Street traders. The extent of fraud in the financial industry, which is becoming more and more apparent with the Libor scandal, exposes the deep levels of social division—one set of rules for the financial sector and another for everyone else.

In their groundbreaking book The Spirit Level: Why Greater Equality Makes Societies Stronger, Richard Wilkinson and Kate Pickett provide an empirical argument connecting health factors like life expectancy, infant mortality and cancer rates to the weakening of community bonds. As the ladder becomes taller, the social anxiety and chronic stress experienced by people at virtually every point on the ladder rise.

Social anxiety to keep up with others or appear successful is overwhelming within American culture. Perhaps the clearest illustration of this is the strong social value placed on having the latest technology. The value associated with having the latest iPad or smart phone is not based on the item’s usefulness but on the social status associated with the item. While the latest edition of technology will have new features, the desire or need for such upgrades is not always rooted in practicality. Too often we consider our value as human beings to be linked to economic status. As the ladder grows taller, the distance separating people grows greater and the likelihood of interacting with those significantly higher or lower than ourselves on the wealth gradient lessens. The resulting economic segregation erodes any broader community bonds. The Spirit Level concludes: “At its most fundamental level, what reducing inequality is about is shifting the balance from divisive, self-interested consumerism driven by status competition, towards integrated and affiliative society. Greater equality can help us develop the public ethos and commitment to working together which we need if we are to solve the problems which threaten us all.”

According to Catholic social teaching, the gap between people—not only between rich and poor but also between those in the middle—is a significant moral issue. At the heart of “Economic Justice for All” is its robust definition of justice as participation: “Basic justice demands the establishment of minimum levels of participation in the life of the community for all persons.” Participation is central to the public health studies that examine the clinical effects of marginalization upon individual and public health. Great disparities in income and wealth are directly related to disparities in power and participation—social, political and economic. In 2007 the top 1 percent of the population received 23.5 percent of the national income, a concentration matched only in 1928 on the eve of the Great Depression. Statistics like this have fueled the battle cries of the Occupy movement. Equality of opportunity and fairness are highly prized values within American culture. But in Catholic social teaching the focus is not only on fairness but on participation and power. This provides a helpful overarching lens through which to begin moral reflection on inequality.

A Presumption Against Inequality

Within the framework of Catholic social teaching, the question of inequality is often addressed tangentially in relation to poverty. The preferential option for the poor has provided a clear and narrow lens through which to view inequality, as evidenced by the criteria in “Economic Justice for All,” which puts a priority on “meeting the basic needs of the poor and increasing [the] level of participation by all members of society in the economic life of the nation.” Both human dignity and the common good require that as a society we meet the basic needs of all. In light of the global financial crisis, we have placed a renewed focus on the effects of inequality. In his encyclical “Charity in Truth” (2009), Pope Benedict XVI noted, “The dignity of the individual and the demands of justice require, particularly today, that economic choices do not cause disparities in wealth to increase in an excessive and morally unacceptable manner.” We have therefore not only a presumption against extreme inequality but a preference for relative equality.

A preference for relative equality is not, as some critics might argue, an attempt to create an egalitarian, socialist society. Few would advocate the elimination of all differences in income or wealth. The goal is not equality of outcome but equality of opportunity, a priority in American culture. But there are distinct social conditions necessary in order to realize this. As the ladder becomes taller through rising inequality, social mobility and equality of opportunity decrease, because what is required to reach the next level grows. President John F. Kennedy said that “a rising tide lifts all boats,” and it was believed that growing an economy addressed the basic needs of all. Research on health and inequality has demonstrated that, in today’s society, this is no longer true.

Inequality can be addressed in two ways: We must achieve greater equality in compensation. As detailed in The Spirit Level, in 2007 the average salary of C.E.O.’s of the top 365 companies was 500 times that of the average worker. While examining the manufacturing industry, the filmmakers found that in the United States the ratio was 44:1, whereas in Japan it was 16:1; in Sweden 21:1; and in the United Kingdom it was 31:1. Sweden achieves greater equality by redistribution of wealth through taxes and benefits. Redistribution is treated as if it is a four-letter word by many in the United States, but from the perspective of public health, this option must also be examined as a way to achieve greater equality. But greater equality is not solely a matter of choosing big government or small government. In both there are ways to achieve good in society. The Occupy movement and the financial crisis have put inequality in the spotlight, and we must not let the issue fade away without taking steps to investigate options, acknowledge the public health concerns and work to find solutions.

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C Walter Mattingly
11 years 9 months ago
Professor Clark's essay is a timely article on an important subject that misses the forest for the trees.
A recent report on factors affecting health and longevity stated that the most important factor accounting for 40% of the problem was the personal choice of the individual. The quality of health care had a fourth of the impact, or 10%. Let's reexamine the countries cited in Clark's report in light of those factors along with another report.
Japan spends far less on health care as a  percentage of GDP than the US or almost any major European country, yet leads in longevity by a wide margin. Why is that?
The obesity rate in the US, 30.6%, is about the highest in the world; the obesity rate in Japan, the lowest of all major industrial nations, 3.2%, almost ten times lower.
Another study about 8 years old ranked nine major nations and their longevity, including Japan, Sweden, France, the US, Germany, and Great Britain. The leader was again Japan, at over 82 years. The 3 nations with longevity under 80 years were, in declining order, Germany, Great Britain, and bringing up the rear, the US, at 78 years.
Germany, like the US, was near the top on dollars spent on health care. But the obesity rates? The 3 greatest, in ascending order were, you guessed it, Germany, with the highest rate in continental Europe; Great Britain, with the highest rate in all Europe, and the US, with far and away the highest rate of the major industrial nations of the world. Bottom line: the personal lifestyle choices of weight control, not money spent, has a far higher correlation with longevity than expenditures or percentage covered by health insurance.
Tragically, Obamacare, drawn up behind closed doors with no opportunity to discuss or incorporate incentivizing/penalizing good and poor personal choices in healthcare, offers little incentive for the individual to reward control of obesity, illegal drug use, casual sex with multiple partners, etc where the US leads. So in the 80-20 rule, Obamacare effectively ignores the 80% of the problem and addresses, or perhaps we should say attempts to address, the 20% of the problem. Therefore it is doomed to failure in its effort to mazimize the quality of life issue while controlling the cost, as we have already seen.

Yet there is one area already in our Medicare formula that does address personal choice: smoking. Anyone filling out a Medicare application must answer this smoker quetion, and a positive reply results in a significantly higher payment for part B. Is there any impact? The numbes would so suggest, as those who smoke daily in the US represent 18% of the population; in Japan, over 30%.
All these problems are especially acute in the inner city minority populations of many of our larger cities. The discipline of self-control and delayed gratification can be learned. Where and how, if not in the home or church? Through the voucher program, proven to provide a better graduation rate for this population. Graduating with your class requires a degree of self-control and delayed gratification, and the results are there for all to see.
If the nation is fortunate enough to see Obamacare ended, it must come up with a health care program that incentivizes good personal health choices and disincentivizes poor ones, or we simply will not make progress on improving the health of the nation at an affordable cost. 
Gerald Beyer
11 years 9 months ago

Mr. Mattingly's comment above points to a salient issue, that of individual responsibility. There is no question that individuals must take responsibility for their own health by making good choices in diet, lifestyle, etc. However, the relationship between individual responsibility and social factors that condition them is a complex one. Long ago the great sociologist Robert K. Merton contended that when individuals cannot achieve the cultural markers of success in their society (e.g. wealth, power, high educational attainment) due to lack of opportunity, they will often resort to unconventional and even illegal means to attain them. This was his famous theory of social anomie. In more recent times evolutionary biologists have talked about this issue. For example, in his book Evolution for Everyone David Sloan Wilson argues that if communities want to reduce rates of early pregnancy and violent crime they must "create a stable social environment with high life expectancy and reliable means of obtaining status without violent conflict." He makes this claim based on a studies done in Chicago neighborhoods that concluded income inequality, not the poverty rate, was the greatest predictor of homicide rates. High homicide rates contributed to lower life expectancy rates, which in turn led to high unintended early pregnancy rates. When the women in the study were asked why they were getting pregnant early, the most frequently reported response was that they wanted their own mothers to be able to see their children. In other words they expected their mothers to die early, given the lower life expectancy rates in their neighborhood. The choices of these women were conditioned by social factors. Economist Amartya Sen writes about this in terms of the relationship between individual freedoms and social responsibility in his Development as Freedom.

This is not to say that individuals are not responsible for their decisions. But we can't ignore the social forces that shape those decisions. If one lives in what is called a "food desert," where access to affordable nutritious food is lacking (explained here by the CDC: http://www.cdc.gov/Features/FoodDeserts/index.html) it is hard to expect that this individual will make the must salubrious dietary choices. Even if there are grocery stores in poorer neighborhoods, healthy foods are far more expensive than junk food.

Mr. Mattingly is right that our society needs to incentivize healthy choices, but I think one important way to do that is to attentuate social and economic inequalities. I think Prof. Clark is right that incomes that rise faster at the bottom than the top would lead to greater health outcomes. Mr. Mattingly's states that "All these problems are especially acute in the inner city minority populations of many of our larger cities. The discipline of self-control and delayed gratification can be learned." Yes, maintaining a healthy weight, diet and lifestyle is a matter of self-discipline, but it is a lot easier when one can afford good food, access to a gym, stress-management programs, etc. And it is a lot easier when one does not have to work two jobs in order to support, often barely, one's family (hence the importance of a living wage). In other words, producing healthy outcomes is a matter of personal and social responsibility.



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