by Susan Rosenthal
(Chapter 1 of SICK and SICKER: Essays on Class, Health and Health Care)
The United States boasts the most expensive medical system in the world, yet consistently ranks behind Australia, Canada, Germany, New Zealand and the United Kingdom in access to care, equity of care, patient safety and patient outcomes.(1)
While the US medical system delivers billions in profits, it delivers little in terms of population health. By the end of 2009, compared with all other nations, the US ranked 50th in life expectancy(2) and 45th in infant mortality.(3)
The relatively poor health of Americans(4) is often blamed on a fragmented, for-profit medical system that denies millions of people access to care. The United States is the only industrial nation(5) without a universal public system, and this must change. However, improving the overall health of Americans requires even more fundamental change.
Social inequality affects the health of populations more than any other factor – more than diet, smoking, exercise and even more than access to medical care.(6)
As we shall see, social inequality generates poor health and inadequate health-care systems.
It is obvious why poor people have worse health than those who are better off. Poor people eat less nutritious food and are more likely to live in substandard housing in more dangerous neighborhoods located closer to industrial pollution. They suffer more unemployment and financial stress and have less access to medical care.
What is not obvious is that inequality hurts the health of the entire population.
A study of 282 metropolitan areas in the United States found that the greater the difference in income, the more the death rate rose for all income levels, not just for the poor.(7)
Researchers calculated that reducing income inequality to the lowest level found in the United States would save as many lives as would be saved by eradicating heart disease or by preventing all deaths from lung cancer, diabetes, motor vehicle crashes, HIV infection, suicide and homicide combined!
Even greater benefits would flow from eliminating class inequality entirely.
Consider the lives that would be saved by ending racial inequality. Without racism, death rates for Black and White Americans would be the same. Yet, every year, Black Americans suffer 300 more deaths per 100,000 people than White Americans. Compare these 300 additional deaths with the national homicide rate of about 6 per 100,000. Do the math. Racism kills 50 times more people than die at the hands of individual murderers.
The health-damaging impact of inequality counters the health benefits of higher income.
Poorer people in more equal nations tend to be healthier and live longer than wealthier people in more unequal nations. Middle-income people in Britain enjoy better health than wealthier Americans.(8) And men in Bangladesh, one of the world’s poorest countries, are more likely to reach age 65 than Black men in Harlem, USA.
Harlem men have higher incomes than Bangladeshi men but live in a more unequal society. Many Black Americans die prematurely from cardiovascular and other diseases that are linked with class and race inequality.(9)
Why is inequality so damaging?
Power = Health
In 1948, the British National Health Service was established to provide universal access to medical care. However, universal access has not eliminated health inequality.
A 1980 study of the highly-stratified British civil service found that health deteriorated as social status fell. This decline in health could not be explained by smoking, exercise, body weight or access to medical care.(10)
A 2008 American study also found health differences between income levels (income level is often used to measure social status in the US). At every income level, the wealthier group was healthier than the one below it. Moreover, this trend was observed in all racial groups.(11)
Every nation studied, regardless of its type of medical system, shows this same link between higher social status and better health.(12)
How can we explain this?
The answer lies in the surprising fact that those at the top of the power structure enjoy better health than those near the top, even though their life-styles are essentially the same. Moreover, professionals enjoy better health than non-professionals, even when the non-professionals make more money.
Michael Marmot, who studies the relationship between social status and health, explains,
“Your position in the hierarchy very much relates to how much control you have over your life…Sustained, chronic and long-term stress is linked to low control over life circumstances.”(13)
Bosses live the longest, healthiest lives because they have the most social power. As social status falls, power diminishes, stress rises and health deteriorates.(14)
Children show rising levels of stress hormones as their social position falls.(15) Nurses who work under “unfair and unreasonable” bosses suffer higher blood pressure.(16)
Just talking with someone with higher social status will raise your blood pressure.(17) The greatest damage is done to those who are put down and ordered around their entire lives.
“Stress triggers a higher heart rate, a release of adrenaline, glucose and other neurological responses to help the body respond to a short-term threat. But when extended over long periods of time, these changes can harm the cardiovascular and immune systems, making individuals more vulnerable to a wide range of conditions including infections, diabetes, high blood pressure, heart attack, stroke, asthma and aggression.”(18)
Hard work is not harmful to health unless there is also a lack of control.
The most health-damaging jobs are those that expose workers to oppressive conditions that they would change if they had the power to do so, and jobs that saddle workers with great responsibilities while denying them the power to meet those responsibilities.
People with little control over demanding jobs are more likely to be overweight and have high cholesterol regardless of age, amount of exercise, smoking habits and access to medical care.(19)
In a class-divided society, only a few people get to make the important decisions. The rest of us get no say over how work is organized and how social resources will be used. We don’t get to decide if society will invest in schools or in prisons, make peace or wage war, develop renewable energy or build more nuclear plants. All of these matters, that affect us so deeply, are decided by an elite whose primary concern is making profit.
Being excluded from decision-making is strongly linked with cardiovascular disease,(20) and the more powerless a person feels, the faster the disease progresses.(21)
Oppressed sections of the working-class have the least social power and the highest rates of cardiovascular disease.(22)
Capitalism: The Root Source of Inequality
Capitalism is based on inequality and generates more inequality.
The unequal relationship between the capitalist and the worker is enshrined in law. The capitalist owns the means of production and the worker does not. The capitalist also owns everything the worker produces. The wages paid to the worker can never equal the value of what the worker produces or there would be no profit.(23)
Profit that is reinvested to make more profit becomes capital. Competition compels capitalists to raise worker productivity (the net value of what workers produce) to generate more capital.
The most effective way to raise productivity is to put workers in charge. Increasing worker decision-making has been shown to raise productivity more than any other factor.(24)
Capitalism cannot give workers any meaningful control over production without making itself redundant, so it raises productivity by intensifying worker exploitation:
- increasing the length of the workday
- increasing the number of days worked per year
- increasing the speed of production
- redesigning the work to increase output-per worker
- using technology and machines to increase output-per-worker
- employing fewer workers to do the same job
- cutting wages and benefits
- lowering the cost of consumer goods
The process of capital accumulation enriches the capitalist at the expense of the worker. The more capital is accumulated, the more inequality is generated between the classes. The United States is a prime example.
The US boasts the world’s richest economy, the world’s largest corporations and the world’s most powerful military. It is also the most unequal nation on the planet, with fabulous wealth existing alongside abject poverty. The two are directly linked.
The American elite reached the pinnacle of wealth and power by stealing native lands and by exploiting African slaves and waged workers. This process is ongoing.
Since the late 1970s, the productivity of American workers has risen steadily, while the median household income has dropped. To compensate for falling wages, people work more hours. By 2000, the average American worker was spending 199 more hours on the job, or five weeks more than in 1973.
In 1991, Juliet Schor calculated,
“Working hours are already longer than they were forty years ago. If present trends continue, by the end of the century, Americans will be spending as much time on their jobs as they did back in the nineteen twenties.”(25)
Most Americans are not only working longer and harder, they are taking home less money.
In the late 1960’s, the minimum wage in America was half of what the average worker earned per hour. By 2003, it had fallen to 34 percent of the average wage. A 2004 report, Working Hard, Falling Short found that,
“More than one out of four American working families now earn wages so low that they have difficulty surviving financially. By 2003, one in five American workers were in occupations where the median wage was less than $8.84 an hour, which is considered to be a poverty-level wage for a family of four. A full-time job at the federal minimum wage of $5.15 an hour would not be enough to keep a family of three out of poverty…In all, more than 14 million, or 21 percent of all kids under 18, still live in poverty — a higher proportion than in 1975.”(26)
Real wages have dropped so low that two people must work to earn the same income that one used to make. By 2000, half of all families were two-earner families. Families that depend on two incomes are less able to care for the young, the sick, and the elderly.
Now, let’s look at the other side of the equation.
Between 1992 and 2000, the incomes of the 400 wealthiest taxpayers in the US increased 15 times faster than the bottom 90 percent, whose income barely kept up with the rate of inflation. In 2005, the New York Times reported,
“The top fifth of earners in Manhattan now make 52 times what the lowest fifth make – $365,826 compared with $7,047– which is roughly comparable to the income disparity in Namibia…Put another way, for every dollar made by households in the top fifth of Manhattan earners, households in the bottom fifth made about 2 cents.”(27)
The growing gap between the classes is often measured by the income differential between top corporate executives (CEOs) and average workers.
In 1980, America’s top CEOs earned 42 times the pay of average workers. By 1998 they were earning 419 times the pay of average workers. To visualize this difference, imagine that the height of the Washington monument (555 feet) represents the average income of the top 500 American CEOs. In 1980, the average American worker’s income would have been only 13 feet tall in comparison. Eighteen years later, the average American worker’s income was only 16 inches tall in comparison.(28)
These comparisons are deceiving because they ignore the fortunes accumulated by America’s wealthiest families, both old (Rockefellers, du Ponts, Vanderbilts, Rothschilds) and new (Buffets, Gates, Waltons). Forty-four percent of America’s richest 25 families trace their fortunes back to the 1800s, and another 36 percent to the first half of the 1900s. In other words, 80 percent of these families were already super-rich more than 60 years ago.(29)
No one knows how rich these families actually are because their financial dealings are a closely-guarded secret and because their wealth is invested in so many different businesses.
We do know that the top one percent of the US population owns more than one-third of the nation’s wealth. We also know that, in 2009, the 400 richest individuals in America had a combined wealth of $1.27 trillion, which is equivalent to 9 percent of the value of all goods and services produced in one year by the entire US labor force.
Sustaining such massive social inequality requires:
- a legal code that protects the right of the capitalist to exploit the worker, to evade taxes, and to pass wealth from one generation to the next
- an education system that trains the majority to be subordinate
- a penal system to contain discontent
- a military to crush open rebellions
- and a mass media that insists there is no alternative.
These functions are provided by the capitalist State. Without such a State, the majority who labor to create the wealth would rise up against the elite who control it.
The extent to which the State serves the rich and protects their wealth is revealed during financial crises, when government treasury doors swing open to save large corporations and slam shut against desperate individuals who have lost life savings, pensions, jobs and homes.
During the savings and loans crisis of the 1980s, the US government spent about $160 billion to float financial institutions. In response to the financial crisis of 2008-2009, the government gave 20 financial giants an estimated $300 billion, even though,
“these executives helped drive the US – and global – economy off a cliff. Their reckless joy ride has brought hardship to tens of millions of families. Yet these executives have emerged, virtually unscratched, out of the accident scene…The 20 US financial firms that received the most bailout dollars from taxpayers awarded their top five executive officers, in the three years through 2008, pay packages worth a combined $3.2 billion…One hundred US workers making the 2008 annual average wage would have to labor over 1,000 years to make as much as these 100 executives made in three.”(30)
Improve Health – End Capitalism
As capital accumulates at the top of society, misery accumulates at the bottom. The more the workers produce, the more the capitalists take. The less workers get in relation to what they produce, the sicker they become.
Americans suffer the worst health in the industrialized world because they live in the most unequal society. They also have the worst medical system because their ruling class, the most powerful in the world, has consistently opposed any universal public system.
National medicare would be a definite improvement. However, even the best medical system cannot eliminate the health-damaging effects of exploitation, poverty, social discrimination, unsafe work, bad housing, poor schools and being denied the right to make the decisions that affect our lives.
We can end these miseries only by ending capitalism and the inequality that it generates.
See also How Inequality is Killing Us
1. K. Davis, et. al. (2007). Mirror, mirror on the wall: An international update on the comparative performance of American health care. The Commonwealth Fund, May.
2. CIA. The World Factbook. Country Comparison: Life expectancy at birth. accessed December, 2009.
3. CIA. The World Factbook. Country Comparison: Infant mortality rate, accessed December, 2009.
4. The term ‘American’ properly describes the residents of North and South America. However, US imperialism has made the term synonymous with residents of the United States.
5. The term ‘industrial nations’ is commonly used to identify those nations that sit at the top of the global power hierarchy.
6. Wilkinson, R.G. (1992). National mortality rates: The impact of inequality? Am J Public Health, Vol 82, pp. 1082-1084. See also, PBS (2008). Unnatural causes: Is inequality making us sick?
7. Lynch, J.W. et. al. (1998). Income inequality and mortality in metropolitan areas of the United States. Am J Public Health. Vol. 88, pp.1074-1080.
8. Quoted in Bowe, C. (2008). US society helping to make people sicker. The Financial Times Limited, February 29.
9. McCord C, Freeman H.P. (1990). Excess mortality in Harlem. New England Journal of Medicine. Vol. 322, pp.173-7.
10. Department of Health and Social Security. (1980). Inequalities in health: Report of a research working group. Middlesex: U.K. Author.
11. Robert Wood Johnson Foundation. (2008). Overcoming obstacles to health.
12. A discussion of US studies linking class and heath can be found in Schmidt. J. (2000). Disciplined minds: A critical look at salaried professionals and the soul-battering system that shapes their lives. Rowman & Littlefield, pp.103-104.
13. Quoted in Cohen, P. (2004). Forget lonely. Life is healthy at the top. New York Times, May 15.
14. Wilkinson, R. (1996). Unhealthy societies: The afflictions of inequality. Routledge.
15. Lupien S.J. et al. (2000). Child’s stress hormone levels correlate with mother’s socioeconomic status and depressive state. Biol Psychiatry. Nov 15. Vol.48, pp. 976-80.
16. CBC. (2003). Bad bosses bring blood pressure to boil: Study. June 24.
17. Long, J.M, et. al. (1982). The effect of status on blood pressure during verbal communication. Journal of Behavioral Medicine. Vol.5, pp.165-71
18. Quoted in Cohen, P. (2004). Forget lonely. Life is healthy at the top. New York Times, May 15.
19. Kivimääki, M. et. al. (2002). Work stress and risk of cardiovascular mortality: Prospective cohort study of industrial employees. BMJ. October 19, Vol. 325, p.857.
20. Raphael, D. (2001). Inequality is bad for our hearts: Why low income and social exclusion are major causes of heart disease in Canada. North York Heart Health Network, Toronto.
21. Everson S, et. al. (1997). Hopelessness and 4-year progression of carotid atherosclerosis. Arteriosclerosis, Thrombosis, and Vascular Biology. Vol. 17, No.8, pp.1490-5.
22. Raphael, D. (2002). Poor choice or no choice?: Even more evidence links low income with disease so why keep blaming lifestyle choices like fries? The Toronto Star. October 11, p.F6.
23. Marx, K. (1898). Value, price and profit.
24. Scientists and Engineers for Social and Political Action. (1973). Chile. Bulletin of Scientists and Engineers for Social and Political Action. 5(6), pp.26-28.
25. Schor, J.B., (1991). The overworked American: The unexpected decline of leisure. HarperCollins, p.1.
26. Waldron, T., Roberts, B. & Reamer, A. (2004). Working hard, falling short: America’s working families and the pursuit of economic security. Baltimore, MD: Annie E. Casey Foundation.
27. Roberts, S. (2005). In Manhattan, poor make 2¢ for each dollar to the rich. New York Times, September 4.
28. Leondar-Wright, B. (1999). CEOs now earn 419 times the pay of average workers, up from 326 in 1997 and 42 in 1980. Common Dreams News Wire, April 8.
29. Greenberg, D. and Thibault, M. (2009). America’s richest families. Forbes.com, posted December 3.
30. Anderson, S., Cavanagh, J., Collins, C. & Pizzigati, S. Executive Excess 2009: 16th annual executive compensation survey. Institute for Policy Studies. Washington, DC.