UNNATURAL CAUSES is inequality making us sick? HEALTH EQUITY research topics and resources to learn more
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Income & Wealth

Background: Perhaps the biggest predictor of one's health is one's wealth. It's not just the poor who are suffering; every step down the class pyramid corresponds to worse health. Study after study has shown that those at the top of the class pyramid live on average longer, healthier lives than the rest of us. The middle classes fare worse than those on the top, and the poor get sick more often and die sooner.

The greater the inequality in a society, the steeper the gradient. Currently, the United States has the greatest inequality among rich countries - and the worst health inequities. People in the middle are twice as likely to die prematurely (before age 65) as those on top; people at the bottom are three times as likely.

The life expectancy of American men in the highest income group is 8 years longer than for men in the lowest income group, two and a half years longer than for the second highest income group. Wealthy women live almost 7 years longer than poor women. Children in low-income families are seven times as likely to be in poor or fair health as those in high-income families. Poorer adults are three times as likely to have a chronic disease that limits their activity; twice as likely to have diabetes, and are nearly 50% as likely to die of heart disease.

Wealth doesn't just bring more material comfort, it also provides financial security and access to resources that promote opportunities for better health. Higher income affects health at every age, from the beginning of life to adulthood and old age. For adults, wealth is tied to neighborhood quality, work conditions, food security, access to medical care, and the availability of buffers against stress.

For children, the impact of advantages or disadvantages is even greater, because the effect on health is cumulative. The greater proportion of life one spends at the upper end of the class spectrum, the more benefits accrue. Children from affluent families are more likely to grow up in a house owned by their parents and to live in a neighborhood with healthy food options, safe places to play, good schools, libraries and other quality public services all of which help set them on the path to a successful, healthy life.

Children from less affluent families not only lack these advantages, they are more likely to experience conditions that limit their health and ultimately their life chances: injuries, inadequate or delayed health care, physical inactivity, poor nutrition, insecure or substandard housing, and exposure to toxins, high lead levels and violence. The influence of wealth on health begins even before a child is born, shaping the quality of prenatal care an expectant woman receives, her level of stress during pregnancy and her likelihood of delivering a premature or low birth weight baby.

Wealth is an important determinant of health because it has such a profound effect on other conditions. Yet at every socioeconomic level, African Americans, Native Americans and other people of color fare worse than their white counterparts. Racism as a stress factor independent of class partially explains this, but racism for example, in the form of residential segregation or job discrimination also directly affects wealth.

Today, the wealth gap in America is growing. The average CEO makes more than 250 times the average workers salary, and the top 1% of American households holds more wealth than the bottom 90% combined. In the last 25 years, the income of top earners has increased 81%, while wages for those on the low end of the pay scale have stagnated or declined.

Our health has followed suit. In 1980, the U.S. ranked 14th in the world for life expectancy. In 2007 we ranked 29th. One out of every five American children lives in poverty. Many of the countries that rank higher than we do have policies that protect workers, support families, and provide a safety net for their citizens. These policies typically address income and wealth inequality in one of two ways: (1) they reduce the overall gap so that everyone has sufficient resources to prosper and maintain control over their lives or (2) they loosen the connection between health and wealth by making certain resources available to everyone, not dependent on a family's individual assets.

Examples of policies to reduce the gap include a guaranteed living wage, earned income tax credits, family supports, guaranteed paid vacation and sick leave, secure pensions, and severance pay and job training for unemployed workers. Examples of policies to loosen the wealth-health relationship include universal preschool, better land use and zoning policies, school financing reform, universal health insurance, and stronger environmental protections and better enforcement.

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Image Thumbnail Health Inequalities among British Civil Servants: the Whitehall II study E-mail to a friend
SCHOLARLY ARTICLE by Marmot, et al., The Lancet, July 1991

Twenty years after the original Whitehall study, which first identified the Health-Wealth gradient in British civil servants, the study was repeated with a new cohort of over 10,000 participants. The study found no decrease in inequality, with those lower on the social gradient still suffering higher rates of chronic disease and mortality.

Image Thumbnail Health Inequities in British Columbia (pdf) E-mail to a friend
DISCUSSION PAPER, Health Officers Council of British Columbia, November 2008

This report and recommendations from the health officers of British Columbia provides one of the clearest and easiest to understand documents on health equity produced thus far. The first half defines terms, sets a health equity framework, and makes policy recommendations that are widely applicable. The second half focuses on outcomes specific to British Columbia.

Image Thumbnail Health Inequities in the Bay Area E-mail to a friend
REPORT from the Bay Area Regional Health Inequities Initiative (BARHII)

This report is an attempt to show how the various forces discussed in UNNATURAL CAUSES influence health in the nine-county California Bay Area, and to suggest the kinds of policy initiatives and activities that will be crucial for both reducing the disparities among populations and improving our health overall.

Image Thumbnail Health Leadership: Action Steps DVD E-mail to a friend
PRESENTATION available from Blue Cross and Blue Shield of Minnesota Foundation

The 2007 Blue Cross Foundation Leadership Award Program and Luncheon featured a keynote by Dr. Anthony Iton, director of the Alameda County (California) public health department, on how race, class, wealth, education, geography and employment affect health status.

Also includes presentations from Atum Azzahir, co-founder, president and executive director of the Powderhorn Phillips Cultural Wellness Center in Minneapolis, and remarks by Marsha Shotley, foundation president; the new Minnesota Health Commissioner, Dr. Sanne Magnan; and Blue Cross and Blue Shield of Minnesota President Colleen Reitan.

Image Thumbnail Health Policy Institute of the Joint Center for Political and Economic Studies E-mail to a friend

With the mission to ignite a Fair Health movement that gives people of color the inalienable right to equal opportunity for healthy lives, this pioneering program of the Joint Center for Political and Economic Studies undertakes research, publications, activities, and projects designed to accelerate progress beyond listing and analyzing a litany of health disparities. Rather, they are directed toward collective strategies that will produce real change—and real opportunities for health.

See also: HPI Place Matters

Image Thumbnail How social injustice becomes embodied in differential disease and mortality rates (pdf) E-mail to a friend
DIAGRAM designed by Richard Hofrichter, National Association of City and County Health Officials

A graphical representation of the complex interactions between history, social structure, policy, personal psychology and behavior, and health. Hofrichter provides the caveat that any attempt to visually represent a complex reality will appear somewhat oversimplified and linear.

Image Thumbnail How U.S. Laws and Social Policies Influence Chronic Stress and Health Disparities E-mail to a friend
SCHOLARLY ARTICLE, Holly Avey, Politics of Race, Culture, and Health Symposium, Ithaca College, Nov. 14, 2002

A clear, thorough overview explaining the stress process (exposures and vulnerabilities to stressors), physiological response to stressors (how stress "gets into the body"), and why people of color and lower socioeconomic status tend to be more negatively affected by stress. Concludes with policy implications.

Image Thumbnail How U.S. Laws and Social Policies Influence Chronic Stress and Health Disparities - A Response (pdf) E-mail to a friend
SCHOLARLY ARTICLE by Thomas C. Shevory, Ithaca College, 2002

A short response to Holly Avey's literature review that provides additional background and references regarding misconceptions of the character traits of "the poor" vs. "the affluent," chronic stressors, and the need for structural policy intervention.

Image Thumbnail How Unemployment Affects Families E-mail to a friend

Job loss doesn't just affect individuals. It impacts families and even whole communities. Stress, uncertainty, and lost income affect children in various ways.

Image Thumbnail Impact of Poverty and Stress on Diabetes among Native Americans E-mail to a friend

As Dr. Donald Warne explains, there is a direct biochemical connection between living in poverty and blood sugar levels. The stress of being poor and of having family members die young creates a complicated web of cultural values and beliefs that make controlling diabetes more difficult. Add to that the lack of availability of healthy food and it's no wonder diabetes rates are high.

Image Thumbnail In the U.S., we don't take enough vacations - really E-mail to a friend
ESSAY by John de Graaf, San Francisco Chronicle, August 2008

De Graaf compellingly makes the case for federally guaranteed paid time off for all employees by laying out the links between vacation, productivity, child-rearing, and health.

Image Thumbnail Inclusion for the United States (pdf) E-mail to a friend
REPORT from Inclusion.org and the Center for Economic Policy and Research

This working paper makes the case for a new, overarching framework—social inclusion—to advance and integrate social policy. It critiques the current poverty framework and the official U.S. poverty measure, and explains why the concept of social inclusion is a better alternative. The paper discusses how the concept of social inclusion is used in the United Kingdom and how it might be adapted for use in the United States.

Inequality in life expectancy widens for men E-mail to a friend
 National Academies of Science, Engineering and Medicine

Wealthier men can expect to live longer than their parents did, while life expectancy for the poor have not changed.

Inequality in life expectancy widens for women E-mail to a friend
National Academies of Science, Engineering and Medicine

Wealthier women can expect to live longer than their parents did, while life expectancy for poor women may have declined.

Image Thumbnail Inequality is Unhealthy: Dr. Stephen Bezruchka on How Economic Inequality is Dangerous to our Health E-mail to a friend
VIDEO INTERVIEW on Democracy Now!

As lawmakers continue to debate healthcare proposals, Democracy Now takes a look at how the economic crisis can impact the health of people in this country. They speak with Dr. Stephen Bezruchka, professor at the University of Washington’s School of Public Health and series advisor, who has written extensively on the impact of societal and economic inequalities on the health of a population and argues that combating inequality might be the best way to ensure improved health.

Image Thumbnail Inequality.org E-mail to a friend
WEB SITE created by Demos and the Institute for Policy Studies

Inequality.org was created to serve as a dependable portal of information. They believe that too much inequality undermines democracy, community, culture and economic health, and they are committed to presenting the best and latest information about this important issue.

Image Thumbnail Inequality: Bad for Your Health E-mail to a friend
INTERVIEW with Ichiro Kawachi, Dollars & Sense, January 2008

Epidemiologist Ichiro Kawachi clearly explains the theory about how relative deprivation from economic inequality, and explores various possible mechanisms for the relationship.

Image Thumbnail Interim first report on social determinants of health and the health divide in the WHO European Region E-mail to a friend
Sir Michael Marmot on behalf of the WHO

Although health has improved for many people, there are major inequalities in health - within and between countries - across the WHO European Region. Evidence shows that these inequalities should be mostly avoidable and has significant human and economic costs. Unless action is taken, the gap between and within countries will increase. The WHO Regional Office for Europe commissioned a regional review of the health divide and inequalities in health from July 2010 to 2012 in order to inform the new health policy for the Region. The first phase of the review is assessing levels of inequalities in health across the European Region and identifying the barriers to and opportunities for reducing these.

Image Thumbnail KIDS COUNT Data Center E-mail to a friend
DATABASE created by The Annie E. Casey Foundation

A database system that contains state- and city-level data for over 100 measures of child well-being. This easy-to-use, powerful online database allows you to generate custom reports for a geographic area (Profiles) or to compare areas on a topic (Ranking, Maps, and Line Graphs).

Image Thumbnail Latina mothers poor in wealth, rich in health (pdf) E-mail to a friend
NEWS ARTICLE by Yvette Cabrera, Milwaukee Journal Sentinel, August 11, 2002

National health records show that Latina women have significantly lower rates of premature and underweight births compared to Americans from other racial/ethnic groups - even than individuals wealthier than them. Cabrera looks at the story of this "Latino epidemiological paradox," and the hypothesis that Latino culture plays a major role in the health advantage.

Image Thumbnail Library of Resources on Social Determinants of Health E-mail to a friend
WEB SITE created and maintained by Dennis Raphael

A great collection of resources on the issues surrounding SDOH, health equity, and the politics of creating real change in the social factors that most affect health outcomes. 

See especially Raphael's "Public policies and the problematic USA population health profile," and "The Politics of Population Health: Why the Welfare State is the Key Social Determinant of Health."

Image Thumbnail Life and Death From Unnatural Causes: Health and Social Inequity in Alameda County E-mail to a friend
REPORT from Alameda County Public Health Department, California

This report takes an in-depth look at health inequities and underlying social inequities in Alameda County based on local data. Part One describes the nature and magnitude of health inequities in the county. Part Two describes social inequities and proposes policies to address social inequities-the root causes of health inequities. Sections include: segregation, income and employment, education, housing, transportation, air quality, food access and liquor stores, physical activity and neighborhood conditions, criminal justice, access to health care and social relationships and community capacity.

Also see Alameda County Public Health Department Director Dr. Tony Iton's comment on press coverage of the study.

Image Thumbnail Life at the Top E-mail to a friend
EDITORIAL by Sir Michael Marmot, New York Times, 2005

"The Oscar winners are a quirky example of a phenomenon that is remarkably widespread: the higher your status in the social hierarchy the better your health and the longer you live..."

Image Thumbnail Life in a Town Without Poverty E-mail to a friend
Dr. Evelyn Forget

Once upon a time in Canada, there was a town where no one was poor.  That might seem like a fairy tale, but it's an historic fact. From 1974 through 1978, as part of a labour market experiment called MINCOME, all of the almost 13,000 citizens in and around Dauphin, Manitoba were guaranteed annual income support to keep them above the poverty line.

With support from CIHR, Dr. Forget has spent three years comparing the administrative health care records of Dauphin's citizens between 1974 and 1978 with those of a control group of people living in similar Manitoba communities at that time. She found that people appear to live healthier lives when they don't have to worry about poverty.

Image Thumbnail Living at an Epicenter of Diabetes, Defiance and Despair E-mail to a friend
NEWS ARTICLE in the New York Times, January 1, 2006

The second in a series of in-depth articles about New Yorkers living with diabetes, this article describes the epidemic of diabetes in low-income neighborhoods like East Harlem.

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