Class — The Ignored Determinant of the Nation's Health

Stephen L. Isaacs, J.D., and Steven A. Schroeder, M.D.

 The health of the American public has never been better. Infectious
diseases that caused terror in families less than 100 years ago are now
largely under control. With the important exception of AIDS and occasional
outbreaks of new diseases such as the severe acute respiratory syndrome
(SARS) or of old ones such as tuberculosis, infectious diseases no longer
constitute much of a public health threat. Mortality rates from heart
disease and stroke — two of the nation's three major killers — have
plummeted. It is no wonder that a 2003 Institute of Medicine report
concluded that Americans today, as compared with those in 1900, "are
healthier, live longer, and enjoy lives that are less likely to be marked
by injuries, ill health, or premature death."1

Any celebration of these victories must be tempered by the realization that
these gains are not shared fairly by all members of our society. People in
upper classes — those who have a good education, hold high-paying jobs, and
live in comfortable neighborhoods — live longer and healthier lives than do
people in lower classes, many of whom are black or members of ethnic
minorities. And the gap is widening.

Class, Race, and Health

A great deal of attention is being given to racial and ethnic disparities
in health care.2,3,4,5 At the same time, the wide differences in health
between the haves and the have-nots are largely ignored. Race and class are
both independently associated with health status, although it is often
difficult to disentangle the individual effects of the two factors.6 We
contend that increased attention should be given to the reality of class
and its effect on the nation's health. Clearly, to bring about a fair and
just society, every effort should be made to eliminate prejudice, racism,
and discrimination. In terms of health, however, differences in rates of
premature death, illness, and disability are closely tied to socioeconomic
status. Concentrating mainly on race as a way of eliminating these problems
downplays the importance of socioeconomic status on health.

The focus on reducing racial inequality is understandable since this
disparity, the result of a long history of racism and discrimination, is
patently unfair. Because of the nation's history and heritage, Americans
are acutely conscious of race. In contrast, class disparities draw little
attention, perhaps because they are seen as an inevitable consequence of
market forces or the fact that life is unfair. As a nation, we are
uncomfortable with the concept of class. Americans like to believe that
they live in a society with such potential for upward mobility that every
citizen's socioeconomic status is fluid. The concept of class smacks of
Marxism and economic warfare. Moreover, class is difficult to define. There
are many ways of measuring it, the most widely accepted being in terms of
income, wealth, education, and employment.

Although there are far fewer data on class than on race, what data exist
show a consistent inverse and stepwise relationship between class and
premature death.7,8,9 On the whole, people in lower classes die earlier
than do people at higher socioeconomic levels, a pattern that holds true in
a progressive fashion from the poorest to the richest. This stepwise
pattern is illustrated in Figure 1, which shows that, at the extremes,
people who were earning $15,000 or less per year from 1972 to 1989 (in 1993
dollars) were three times as likely to die prematurely as were people
earning more than $70,000 per year.10 The same pattern exists whether one
looks at education or occupation.11 With few exceptions, health status is
also associated with class.12


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   Figure 1. Adjusted Odds Ratio for Death from All Causes According to
Annual Household Income, 1972–1989.
Data are from McDonough et al.10 The group with an annual household income
of more than $70,000 (in 1993 dollars) is the reference group.


The difference in mortality and morbidity rates is partly attributable to
the fact that people in upper classes have healthier behavior and
lifestyles than do people in lower classes. In Great Britain, where good
data on class are available, the percentage of smokers in the upper class
dropped from 42 percent in 1973 to 17 percent in 1996, even as the rate of
smoking rose from 75 percent to 80 percent among people in the lowest
class.13 In the United States, people without a high-school diploma, as
compared with college graduates, are three times as likely to smoke (Figure
2) 14 and are nearly three times as likely not to engage in leisure-time
physical exercise.15 Partly as a result of a sedentary lifestyle and
unhealthy eating habits (often as a result of conditions in which wholesome
food is unavailable or exorbitantly priced, public recreation is
nonexistent, and exercising outdoors is dangerous), obesity and the
diseases it fosters now characterize lower-class life.


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   Figure 2. Age-Adjusted Prevalence of Current Cigarette Smoking in 2000
among Persons 25 Years of Age and Older, According to Educational Level.
Data are from the National Center for Health Statistics.14 GED denotes
general equivalency diploma.

But unhealthy behavior and lifestyles alone do not explain the poor health
of those in lower classes. Even when behavior is held as constant as
possible, people of lower socioeconomic status are more likely to die
prematurely than are people of higher socioeconomic status. In a study of
white American men (which therefore eliminated the variable of race), when
smoking and other risk factors were taken into account, men earning less
than $10,000 a year (on the basis of data from the 1980 Census) were 1.5
times as likely to die prematurely as were those earning $34,000 or more.16
Similar results were obtained in Great Britain, where the Whitehall study
of British civil servants showed that when smoking and other risk factors
were controlled for, those in the lowest employment category were still
more than twice as likely to die prematurely of cardiovascular disease as
were those in the highest category (Figure 3).17


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   Figure 3. Relative Rates of Death from Cardiovascular Disease among
British Civil Servants According to the Classification of Employment.
Data are from Davey Smith et al.17 The relative rates of death are for
people who did not own cars; the rates were adjusted for age, smoking
status, systolic blood pressure, plasma cholesterol concentration, and
glucose tolerance. In the British civil service, "administrative" positions
are at the high end of the socioeconomic scale and those in "other" jobs
are at the low end.

In sum, people in lower classes die younger and are less healthy than
people in higher classes. They behave in ways that ultimately damage their
health and that take their lives prematurely (by smoking more, having
poorer eating habits, and exercising less). They also have less health
insurance coverage, live in worse neighborhoods, and are exposed to more
environmental hazards. Beyond that, however, there is something about lower
socioeconomic status itself that increases the risk of premature death.

Much the same holds true for blacks in the United States. Having
lower-class status and being black are intertwined to such a degree that it
is difficult to separate the two factors. (We recognize that some other
racial and ethnic groups also have poorer health than whites. In this
article, however, we focus largely on blacks because of the historical
importance of race in the United States and the fact that more data are
available on the health of blacks than on the health of other minority
groups.) Blacks are disproportionately poorer and less educated, and they
are more likely to live in dangerous, unhealthy urban neighborhoods. The
median financial net worth of whites, for example, is 10 times that of
blacks18; 27 percent of black families live in poverty, as compared with 11
percent of white families.19 The life expectancy of blacks is seven years
less than that of whites.20 Blacks have higher rates of cardiovascular
disease, many types of cancer, diabetes, infant mortality, hypertension,
homicide, and unintentional injuries than do whites.21 Are these
differences due primarily to race or socioeconomic circumstances?

Although race and class both have an effect on health, our sense of the
evidence is that of the two, class has a more powerful effect. Blacks have
higher rates of death from heart attack than do whites at all levels of
income, and the poorest people, whatever their race, have substantially
higher rates of heart attack than those who are better off. As Table 1
illustrates, the difference in the rates of premature death from heart
attack between poorer and richer people is far greater than the difference
in the rates of premature death between blacks and whites.22

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   Table 1. Average Annual, Age-Adjusted Rates of Death from Heart Disease
among Persons 25 to 64 Years Old, 1979–1989.



A comprehensive review of the available evidence led Williams and Collins
to conclude, "Socioeconomic differences between racial groups are largely
responsible for the observed patterns of racial disparities in health
status,"23 a conclusion shared by Davey Smith and colleagues, who wrote,
"Socioeconomic position is the major contributor to differences in death
rates between black and white men."24

Policy Implications

Recognizing the importance of class to health does not mean discounting the
importance of race. As Williams has observed, "Racism is still a driving
force in determining economic opportunities for minorities."25 It does
imply, however, that rather than focusing primarily on reducing racial and
ethnic disparities, policymakers should devote the same energy to improving
the overall health of the public. Since the best way to do this is to focus
on those whose health is the poorest, the targets of intervention will
still be poor members of minority groups but will include lower-class
whites as well. This refocusing will require a number of distinct policy
steps.

Collecting Better Data on Class

Far more data regarding mortality and morbidity are available according to
race than according to class, and the paucity of socioeconomic data is a
problem.26 Virtually all of the recent articles on disparities come from
data sets that include information on race and ethnic group but not on
socioeconomic status. This has the unintended result of driving researchers
to focus on race and ethnic background rather than on class.

The United States does not systematically collect mortality or morbidity
data stratified by social class. There are few national or even regional
disease registries, and those that exist do not include socioeconomic
data.27 Of the 58 trend tables on "health status and determinants" that
provide data on race or socioeconomic status in Health, United States,
2003,28 only 8 contain information on socioeconomic status (usually,
educational level), whereas 57 contain information on race. What data there
are on class come primarily from big national surveys, such as the National
Health and Nutrition Examination Surveys.

Death certificates have traditionally included information about race but
not class. Only in 1989 did states begin to include information about a
decedent's educational level; information on a decedent's occupation, in
those states that collect it, often is not coded or reported. In contrast,
starting in 1911 and throughout the 20th century, British death
certificates included the social class of the decedent on the basis of one
of five occupational categories ranging from unskilled to professional.29
Thus, much of what we know about class and health comes from Great Britain,
primarily through three major reports and studies. The first, the Black
report, concluded that there were marked inequalities in health between the
social classes in Britain.30 In the second, the Whitehall study, Marmot and
his colleagues found that mortality rates among British civil servants
followed a gradient: mortality rates among persons in every occupational
class (even white-collar workers) were higher than those in the class
above, and no clear threshold (such as a poverty level) divided persons in
good health from those in poor health.31,32 The third, the 1998 Acheson
report, showed that although death rates had fallen among all social groups
between 1970 and 1990, the decline was substantially greater in the higher
social classes, and the mortality gap was thus growing.33 The Acheson
report proposed 39 policy steps in areas such as taxes, education,
employment, housing, nutrition, and agriculture that were aimed at
improving health (particularly, but not exclusively, that of the poor) and
adoption of a health impact statement, much like our own environmental
impact statement.34

Understanding How Class Influences Health

Although there is wide agreement that people of higher socioeconomic status
live longer and healthier lives than people of lower socioeconomic status,
there is less consensus on why this is so or which factors are most
responsible. Some researchers suggest that education is the critical
variable.35 In this country, education is considered the key to economic
and social advancement, since better-educated people are more likely to get
better jobs and to have higher social status. Schools instill values
(including behavioral ones) in young people and give them knowledge to read
about and understand health information and the capacity to solve problems.
As Deaton noted, "It is time that the educational debate was more cognizant
of [education's] health benefits."36

Others pinpoint income as the single most powerful predictor of
mortality.37 Low income can affect health through a number of mechanisms.
The poorer a person is, the more likely it is that he or she will have to
struggle to meet the basic necessities of life (such as obtaining food,
shelter, and medicine, when necessary), to live in a dangerous
neighborhood, and to endure the hardships of everyday living. As income
increases, people are able to afford more of the things that lead to good
health and to obtain better medical care.

There is a related school of thought that argues that inequitable
distribution of income and wealth itself causes poor health.38 The argument
is based on the comparatively long life expectancy of people living in
nations with a more equitable distribution of wealth, such as Sweden and
Japan, and, domestically, in states with a more equitable distribution of
income.39,40 Wealth and income are distributed less equitably in the United
States than in any other industrialized country, and the gap between the
rich and the poor is widening. (The average annual compensation of the top
100 chief executive officers went from 39 times that of the average worker
in 1970 to more than 1000 times in 1999.41) Insofar as health reflects the
distribution of wealth in a society, these are disturbing indicators. The
explanation of poor health on the basis of inequality, however, has many
critics, who argue that an absolute lack of resources, or poverty, is more
important than a relative lack of resources.42,43

Some analysts suggest that employment is the key socioeconomic determinant
of health.44 Workers such as physicians, attorneys, and senior corporate
executives are highly educated, and their employment brings them both high
income and prestige. Lower-status jobs, on the other hand, can expose
workers to an unhealthy environment and boring, repetitive tasks. Workers
in these jobs often have little job security or control over their work,
which, in turn, leads to increased stress levels and to a greater chance of
illness. Of course, unemployment is in itself stressful.

Recently, researchers have studied the hypothesis that where people live
has an independent influence on health.45 The argument is that poor
neighborhoods — which are often dangerous and have high crime rates, with
substandard housing, few or no decent medical services nearby, low-quality
schools, little recreation, and almost no stores selling wholesome food —
offer residents, no matter what their race, income, or education, little
chance to improve their lives and engage in health-promoting behaviors.46

Whatever the most important elements of class may be, there must be
mechanisms whereby being in a lower class translates into poor health.
Recent research suggests that stress is one such mechanism. Studies have
linked poor health to the constant stress of a lower-class existence — a
lack of control over one's life circumstances, increased social isolation,
and the anxiety brought about by a subjective feeling of being of low
social status (all of which can be compounded by racism). Physiologically,
stress appears to trigger a neuroendocrinologic response that is beneficial
in the short term but over the long run can weaken the body's resistance to
illness.47

Advancing Social and Economic Policies That Will Improve Health

Although there is still much to learn about the relative contributions of
education, income, and occupation to health, the fact that they do have an
influence means that policies affecting these areas must be examined for
their effects on health. This requires broadening the concept of health
policy to include areas not normally considered when thinking about health.
Investments in social and economic policy made upstream can pay health
dividends downstream. Policies regarding education, taxes, recreation,
transportation, and housing cannot be divorced from their effects on
health. Tax policies that benefit people at the top while having little
effect on those on the bottom, for example, should be recognized as
detrimental to the aggregate public health, since revenues that otherwise
could be used for the social good are forgone. Policies that shutter
inner-city recreation facilities affect the health of the residents of
those neighborhoods. Failure to fund inner-city schools adequately not only
hinders the education of the most vulnerable children but also damages
their health. On the basis of what is known about early-childhood
development, improving preschool and elementary education may well be the
most beneficial investment to improve health.

Conclusions

Health reform, to date, has focused primarily on health insurance. Although
finding a way to expand health insurance coverage for Americans must remain
a high priority,48 medical care has been estimated to account for only
about 10 to 15 percent of the nation's premature deaths.49 Thus, ensuring
adequate medical care for all will have only a limited effect on the
nation's health. More important is enabling people in the lower economic
classes to adopt more healthy forms of behavior and attending to those
social and environmental factors that encourage healthy behavior —
abstaining from smoking, drinking alcohol in moderation and not before
driving a car, eating wisely, engaging in regular physical activity,
adopting prudent sexual practices, and reducing exposure to environmental
hazards. However, a nation that is serious about improving the health of
its people will have to go beyond expanding medical care, changing
unhealthy behavior, and improving the environment and give more attention
to social policies that address the class — as well as the racial and
ethnic — differences that underlie illness and premature death.



Supported in part by the Robert Wood Johnson Foundation.

The views expressed in this article are solely those of the authors.

We are indebted to Nancy Adler and Kimberly Lochner for their helpful
comments and to John Rodgers for his research assistance.


Source Information

From the Center for Health and Social Policy (S.L.I.) and the University of
California (S.A.S.) — both in San Francisco.

Address reprint requests to Mr. Isaacs at the Center for Health and Social
Policy, 847 25th Ave., San Francisco, CA 94121.

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