Up Front

   Poverty Kills

   For Want of Resources, Millions Face Early Death and Ill Health

   by Meredith Minkler

   In 1993, a landmark survey calculated the leading causes of
   premature death and disability in the United States not by
   disease



?cancer, heart disease, stroke, and so on?but by actual
   cause. Smoking topped the list, accounting for more than 400,000
   deaths annually, followed by poor diet, lack of exercise, and alcohol.

   Although this article, written by public health leaders William Foege
   and Michael McGinnis, and published in the Journal of the
   American Medical Association provided a refreshingly frank look at
   the prominent role of socio-behavioral factors underlying health
   problems, it unfortunately missed one of the most important.
   Poverty increasingly is recognized as perhaps the single most
   important risk factor for premature death and disability. Indeed, even
   the pronounced race differences in health in the U.S. appear to be
   very largely?though not exclusively?a function of class.

   The pervasive impact of poverty on health is evident regardless of
   how poverty is measured. David Williams and his colleagues at the
   University of Michigan thus found that people with annual incomes
   of under $10,000 had more than three times the risk of dying in a
   given year as those who made more than $30,000. Dozens of other
   studies have produced similar findings, regardless of whether
   income, education, or occupation was used as the marker of low
   socioeconomic status. Finally, and moving the unit of analysis from
   the individual to the community, the now-classic Alameda County
   Study in California demonstrated that residence in a poor
   neighborhood itself, regardless of the individual's income, resulted
   in a risk of dying 40 percent higher than would be expected on the
   basis of age, gender, and even smoking history.

   But might not
   most of the high
   mortality and
   morbidity among
   the poor simply be
   a reflection of the
   high rates of
   smoking, poor
   dietary habits, and
   other unhealthy
   behaviors in this
   group? The
   answer appears to
   be no. One recent national study found that of the threefold excess
   deaths among the poor, at most just 13 percent could be accounted
   for by higher rates of smoking, drinking, diet and exercise, and other
   traditional risk factors. Other studies have corroborated such
   findings, suggesting that there's something about poverty itself
   that is decidedly bad for one's health.

   Chronic Deprivation
   Public health experts debate just how poverty "gets under the skin"
   to so dramatically worsen health, but researchers have identified
   several plausible pathways. For Harvard's Richard Levins, these
   include, but are not limited to:

        chronic deprivation and limited access to resources such as
        food, housing, and education
        exposure to environmental toxins
        physical threats to health and safety
        unsafe jobs, or those involving high demands and low
        resources for coping
        chronic psychological stress

   Two other possible reasons deserve special mention. One of these,
   elucidated by scholars in many parts of the world, suggests that the
   adverse effects of poverty on health are magnified in countries
   where there is a high degree of income inequality. It's not just being
   poor, but being poor in a country where many others are rich, that
   seems to exacerbate the effects of poverty on health. A raft of
   studies demonstrates that the very fact of being around others who
   are higher on the socioeconomic ladder causes individuals to
   experience elevated stress, lower feelings of control over their lives,
   and a lack of trust in society and their surroundings. Researchers
   theorize that these factors contribute to ill health, and that the
   greater the difference between rich and poor (or even rich and
   middle class), the more these factors are exacerbated.

   Still another possibility suggests that people at progressively lower
   levels of socioeconomic status have correspondingly less
   opportunity to control the circumstances and events that affect their
   lives. In the words of epidemiologist S. Leonard Syme, this lack of
   "control over destiny" may be the mediating concept that helps
   explain why the poor are less healthy in almost every disease and
   disability category, regardless of their particular habits and
   behaviors.

   In stressing the profound impact of poverty on health, it is vital not
   to underestimate the importance of other factors, such as racism.
   Racial discrimination's impact on heart disease, depression and
   other illnesses has been well documented, and disturbing studies
   continue to demonstrate the persistence of racism in medical
   decision-making about who gets what kind of care, even when all
   other factors are controlled for. It was in light of these facts that
   when preparing the criteria for the next edition of the nation's
   "health report card," public health officials set as twin goals
   reducing health inequeties by race and class. Neither poverty nor
   race should predict who lives and who dies, who gets ill and who
   remains well in this most blessed of the world's nations.