Dennis,
Thank you for sending and for summarizing this paper. It provides some useful
and readily understandable explanations for the link between poverty, death
and poor health. One of the challenges continues to be "convincing" people in
other fields (our own fields, too!).

I sincerely appreciate this paper and your continuing efforts.

Dennis Raphael wrote:

> 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.

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