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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