Tuesday, September 16, 2014


Source: CIA World Factbook (life expectancy) and
Wilkinson and Pickett, 2009 (income inequality) 
Higher inequality means poorer health outcomes. The US is a case in point. It has the highest level of income inequality in the industrialised world. And at birth, Americans can typically expect to live shorter lives - around 79 years compared to 82 years in Switzerland (Figure 1) and nearly 90 years in Monaco (not shown in Figure 1). So why is inequality associated with adverse health?

In health, it's all about hierarchies, whether by income, education, social status or race. Those higher up the hierarchy report more favourable health outcomes than those lower down. Even those at the very top report better health than people just a notch below them. There is a 'gradient' effect of your position in society on your health (Adler et al, 1994;  Marmot et al, 1991).

Towards the middle and top of the income distribution, this is attributed to a 'keeping up with the Jones'' mentality. People are under pressure to compete with each other in jobs, wealth and possessions. These behavioural factors cause stress and stress-related illness.    

Towards the bottom, this is attributed to the more straightforward relationship between absolute deprivation and health. Material factors matter. The conditions of modern-day poverty in the US - working two jobs to make ends meet, living in over-crowded accommodation, living in neighbourhoods with few healthy eating options, low probability of having health insurance - all contribute to poor health outcomes. This becomes self-reinforcing for today's working families. Those who suffer from poor health are less likely to be able to hold down a long-term job. It also impacts on tomorrow's workforce. Children born into deprivation are more likely to suffer short and long-term health problems like obesity and asthma.

Healthcare reform will go some way to fixing these problems for the poor and uninsured. By opening up the market for healthcare, expanding government-funded medical programs and subsidising insurance premiums, coverage has already ticked up. The hope is that as more people sign up for medical insurance, they will be able to access timely and cost-effective care [a future blog will provide critique of the US healthcare system].

But tackling the hierarchies that generate unequal health outcomes requires reform of a wider set of institutions. That is because health is simply a window into the world of inequality. We need to flatten structures elsewhere. That might be in our schools and universities, where we need to ensure equality of opportunity. That might also be in our workplaces, where we need to ensure fair pay and progression. That might be in our neighbourhoods, where we lean against the creation of wealthy and less wealthy clusters. All of these actions would help break down the hierarchies that create inequality. Fixing health is only the first step.

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