RACHEL'S ENVIRONMENT & HEALTH WEEKLY #497
. ---June 6, 1996---
. HEADLINES:
. ECONOMIC INEQUALITY AND HEALTH
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ECONOMIC INEQUALITY AND HEALTH
It seems obvious that poor people are more likely to be
sick, and to die at an earlier age, compared to rich people.
Several recent studies from the U.S. confirm that this is
the case.[1,2,3,4]
What is not so obvious is that the health of the poor is
harmed in proportion to the size of the gap between rich and
poor. It isn't the absolute level of poverty that matters
so much as the size of the gap between rich and poor. In
other words, "...what matters in determining mortality and
health in a society is less the overall wealth of that
society and more how evenly wealth is distributed. The more
equally wealth is distributed the better the health of that
society," according to an editorial in the BRITISH MEDICAL
JOURNAL April 20th.[5] Two recent studies of the U.S.
indicate that this is so,[6,7] and they are not the first to
make the case.[8,9]
The two recent studies, published in April in the BRITISH
MEDICAL JOURNAL, examine all 50 states within the U.S. Each
study defines a measure of income inequality and compares it
to various rates of disease and other social problems. Both
the studies --one from Harvard and one from University of
California at Berkeley --conclude that the greater the gap
between rich and poor, the greater the chances that people
will be sick and die young. It isn't the absolute level of
wealth in a society that determines health; it is the size
of the gap between rich and poor. Let's look at some of the
details: George Kaplan and his colleagues at Berkeley
measured inequality in the 50 states as the percentage of
total household income received by the less well off 50% of
households.[6] It ranged from about 17% in Louisiana and
Mississippi to about 23% in Utah and New Hampshire. In
other words, by this measure, Utah and New Hampshire have
the most EQUAL distribution of income, while
Louisiana and Mississippi have the most UNEQUAL distribution
of income.
This measure of income inequality was then compared to the
age-adjusted death rate for all causes of death, and a
pattern emerged: the more unequal the distribution of
income, the greater the death rate. For example in
Louisiana and Mississippi the age-adjusted death rate is
about 960 per 100,000 people, while in New Hampshire it is
about 780 per 100,000 and in Utah it is about 710 per
100,000 people. Adjusting these results for average
income in each state did not change the picture: in other
words, it is the gap between rich and poor, and not the
average income in each state, that best predicts the death
rate in each state.
This measure of income inequality was also tested against
other social conditions besides health. States with greater
inequality in the distribution of income also had higher
rates of unemployment, higher rates of incarceration, a
higher percentage of people receiving income assistance and
food stamps, and a greater percentage of people without
medical insurance. Again, the gap between rich and poor was
the best predictor, not the average income in the state.
Interestingly, states with greater inequality of income
distribution also spent less per person on education, had
fewer books per person in the schools, and had poorer
educational performance, including worse reading skills,
worse math skills, and lower rates of completion of high
school.
States with greater inequality of income also had a greater
proportion of babies born with low birth weight; higher
rates of homicide; higher rates of violent crime; a greater
proportion of the population unable to work because of
disabilities; a higher proportion of the population using
tobacco; and a higher proportion of the population being
sedentary (inactive).
Lastly, states with greater inequality of income had higher
costs per-person for medical care, and higher costs per
person for police protection.
The Harvard researchers used a slightly different measure of
inequality, called the Robin Hood index.[10] The higher the
Robin Hood index, the greater the inequality in the
distribution of income. The researchers calculated the
Robin Hood index for all 50 states and then examined its
relationship to various measures of health and well being.
They found that the Robin Hood index correlated with the
overall age-adjusted death rate. Each percentage point
increase in the Robin Hood index was associated with an
increase in total mortality of 21.7 deaths per 100,000
population.
The Robin Hood index was also strongly associated with the
infant mortality (death) rate; with deaths from heart
disease; with deaths from cancer; and with deaths by
homicide among both blacks and whites.
The Harvard team concludes that reducing inequality would
bring important health benefits. For example, if the Robin
Hood index were reduced from 30% to 25% (about where it is
in England), deaths from coronary heart disease would be
reduced by 25%.
These studies are important because they confirm work that
has previously found a relationship between income
inequality and health, using data of good quality from all
50 states.[11]
Inequality in the distribution of income and wealth[12] has
been increasing in the U.S. for about 20 years.[13,14,15,16]
In 1977 the wealthiest 5% of Americans captured 16.8% of the
nation's entire income; by 1989 that same 5% was capturing
18.9%. During the 4-year Clinton presidency the wealthiest
5% have increased their take of the total to over 21%, "an
unprecedented rate of increase," according to the British
ECONOMIST magazine.[17]
Inequality in the distribution of wealth in the U.S. is even
greater than the inequality in income. In 1983, the
wealthiest 5% of Americans owned 56% of all the wealth in
the U.S.; by 1989, the same 5% had increased their share of
the pie to 62%.[16,pg.29]
These trends in inequality in the U.S. are accelerating as
time passes. We now know that these trends have real
consequences for the health of people and society. As a
nation, we have traditionally thought it was acceptable if
the rich got richer, so long as the poor were minimally
provided for. These studies now reveal that such a
situation is not acceptable. As the gap grows between rich
and poor, the health of the nation deteriorates, the social
fabric unravels, and the cost of maintaining community goes
up.
How does the gap between rich an poor harm the health of the
poor? Evidently, the psychological hardship of being low
down on the social ladder has detrimental effects on people,
beyond whatever effects are produced by the substandard
housing, nutrition, air quality, recreational opportunities,
and medical care enjoyed by the poor.[18]
The growing gap between rich and poor has not been ordained
by extraterrestrial beings. It has been created by the
policies of governments: taxation, training, investment in
children and their education, modernization of businesses,
transfer payments, minimum wages and health benefits,
capital availability, support for green industries,
encouragement of labor unions, attention to infrastructure
and technical assistance to entrepreneurs, among others. In
the U.S., government policies of the past 20 years have
promoted, encouraged and celebrated inequality. These are
choices that we, as a society, have made. Now one half of
our society is afraid of the other half, and the gap between
us is expanding. Our health is not the only thing in
danger. They that sow the wind shall reap the whirlwind.
--Peter Montague
===============
[1] George Davey Smith and others, "Socioeconomic
Differentials in Mortality Risk among Men Screened for the
Multiple Risk Factor Intervention Trial: I. White Men,"
AMERICAN JOURNAL OF PUBLIC HEALTH Vol. 86, No. 4 (April,
1996), pgs. 486-496.
[2] George Davey Smith and others, "Socioeconomic
Differentials in Mortality Risk among Men Screened for the
Multiple Risk Factor Intervention Trial: II. Black Men,"
AMERICAN JOURNAL OF PUBLIC HEALTH Vol. 86, No. 4 (April,
1996), pgs. 497-504.
[3] Gopal K. Singh and Stella M. Yu, "US Childhood
Mortality, 1950 through 1993: Trends and Socioeconomic
Differentials," AMERICAN JOURNAL OF PUBLIC HEALTH Vol. 86,
No. 4 (April, 1996), pgs. 505-512.
[4] C. Wayne Sells and Robert Wm. Blum, "Morbidity and
Mortality among US Adolescents: An Overview of Data and
Trends," AMERICAN JOURNAL OF PUBLIC HEALTH Vol. 86, No. 4
(April, 1996), pgs. 513-519.
[5] Editorial, "The Big Idea," BRITISH MEDICAL JOURNAL Vol.
312 (April 20, 1996), pg. [985].
[6] George A. Kaplan and others, "Inequality in income and
mortality in the United States: analysis of mortality and
potential pathways," BRITISH MEDICAL JOURNAL Vol. 312 (April
20, 1996), pgs. 999-1003.
[7] Bruce P. Kennedy and others, "Income distribution and
mortality: cross sectional ecological study of the Robin
Hood index in the United States," BRITISH MEDICAL JOURNAL
Vol. 312 (April 20, 1996), pgs. 1004-1007.
[8] Richard G. Wilkinson, "Income distribution and life
expectancy," BRITISH MEDICAL JOURNAL Vol. 304 (January 18,
1992), pgs. 165-168. See also footnote 11, below.
[9] Robert J. Waldmann, "Income Distribution and Infant
Mortality," THE QUARTERLY JOURNAL OF ECONOMICS Vol. 107
(November 1, 1992), pgs. 1283-1302.
[10] The Robin Hood index (RHI) is calculated by dividing
the population into 10 groups, richest to poorest. The RHI
calculation proceeds by first summing the percentage of
income for each 10% group whose percentage of available
income exceeds 10% and then subtracting the product of the
number of 10% groups that meet this criterion times 10%.
Example: in Massachusetts in 1990, the top 10% received
29.93% of income; the next lower 10% received 16.41% of all
income; the next lower 10% received 13.09% if all income;
the next lower 10% received 10.83% of all income, and the
remaining six 10% groups each received less than 10% of
income and are therefore ignored in the RHI calculation.
The RHI index for Massachusetts in 1990 is therefore
calculated from the top four 10% groups: (10.83% + 13.09% +
16.41% + 29.93%)-(4x10%) = 70.26%-40% = 30.26%. See
Appendix, pg. 1007, of Kennedy, cited above in note 7.
[11] The body of literature linking health to the gap
between rich and poor is reviewed in Richard G. Wilkinson,
"Commentary: A reply to Ken Judge: mistaken criticisms
ignore overwhelming evidence," BRITISH MEDICAL JOURNAL Vol.
311 (November 11, 1995), pgs. 1285-1287, which was written
as a response to Ken Judge, "Income distribution and life
expectancy: a critical appraisal," BRITISH MEDICAL JOURNAL
Vol. 311 (November 11, 1995), pgs. 1282-1285.
[12] Wealth is the net worth of a household, calculated by
adding up the current value of all assets a household owns
(bank accounts, stocks, bonds, life insurance savings,
mutual fund shares, houses, unincorporated businesses,
consumer durables such as cars and major appliances, and the
value of pension rights), then subtracting the value of all
liabilities (consumer debt, mortgage balances, and other
outstanding debt).
[13] Sheldon Danziger and others, "How the Rich Have Fared,
1973-1987," AMERICAN ECONOMIC REVIEW Vol. 79 (May, 1989),
pgs.310-314.
[14] McKinley L. Blackburn and David E. Bloom, "Earnings and
Income Inequality in the United States," POPULATION AND
DEVELOPMENT REVIEW Vol. 13, No. 4 (December, 1987), pgs.
575-609.
[15] Johan Fritzell, "Income Inequality Trends in the 1980s:
A Five-Country Comparison," ACTA SOCIOLOGICA Vol. 36 (1993),
pgs. 47-62.
[16] Edward N. Wolff, TOP HEAVY; A STUDY OF THE INCREASING
INEQUALITY OF WEALTH IN AMERICA (New York: Twentieth Century
Fund, 1995). Although this is a study of wealth inequality,
chapter 6 deals with income inequality.
[17] "Up, down and standing still," THE ECONOMIST February
24, 1996, pgs. 30, 33.
[18] George Davey Smith, "Income inequality and mortality:
why are they related?" BRITISH MEDICAL JOURNAL Vol. 312
(April 20, 1996), pgs. 987-988.
Descriptor terms: wealth; income distribution; equity;
inequality; economy; poverty; morbodity statistics;
mortality statistics; homicide; tobacco use; education;
disabilities; incarceration; robin hood index; harvard;
berkeley;
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