By Phillip Longman
That poverty is deadly is not hard to understand, at least at the extreme. To be very poor means not having enough to eat, being exposed to the elements, and living in areas where homicide and addiction are leading causes of death or where your access to appropriate health care is minimal or nonexistent. In addition, both historically and today, getting seriously sick is likely to make you seriously poor even if you weren’t before.
But if our goal is to overcome the vast disparities in health that exist in the United States, especially for African-Americans, we have to absorb two more difficult facts. These facts are noncontroversial among epidemiologists, even if they remain unfamiliar to most Americans.
First, it’s not just extreme poverty that is bad for your health; so is having less autonomy and status than others, regardless of your income. Among people who have plenty to eat, have equal access to quality health care, live in safe neighborhoods, and hold down jobs, health and life expectancy declines with socioeconomic position. While it is not hard to understand why truly impoverished people of all races die younger than middle-class people, it’s also true that middle-class people die younger than upper-middle-class people, and that upper-middle-class people die younger than rich people, even though none but the very poor are wanting for the basic necessities of life.
The second fact is just as strange, and equally radical in its implications, both for individuals seeking to maximize their personal health and for societies that are intent on creating just institutions. It is that the wider the disparities in status and power that exist between people within a given workplace, city, county, state, or country, the more premature deaths happen. Crudely put, inequality kills.
It’s a pattern that’s found, in greater or lesser degree, under all forms of government, within rich countries and not-so-rich countries, in the East and in the West. It also holds true in countries with universal health care and those without, and among different U.S. states.
The first place researchers rigorously documented this pattern was in the United Kingdom. There, starting in the 1960s, a team headed by the epidemiologist Michael Marmot began a long-term study of the health of British civil servants. These bureaucrats had much in common with one another. None lived in poverty; none were rich. None had jobs that posed any clear physical danger beyond the risk of paper cuts. All had equal access to the fully "socialized" British health care system.
Yet as the study went on it became clear that these bureaucrats were vastly different from one another in their health and longevity. Specifically, among employees of the same age, those who occupied the bottom of the organization chart as typists, clerks, and the like were four times more likely to die over the next 20 years as were administrators at the top of the hierarchy. Moreover, the differences in death rates did not just exist at the extremes of the organizational ladder. At every step in between, health and life expectancy were better one rung above and worse one rung below.
At first, researchers suspected that this social gradient of disease must be related to lifestyle. People at the bottom of the organization tended to smoke more, for example. But it turned out that if you were an administrator and smoked two packs of day, this was far less dangerous to your health than if you were a clerk who did the same. Similarly, if your blood pressure or cholesterol levels were high, or if you rarely exercised, being higher in the organizational chart made these conditions less threatening to your health than if you were lower. This was true even though people at the bottom of the organization tended to see doctors more frequently.
Since then, similar correlations between health and social rank have been observed just about everywhere researchers have looked. To take just one of the more curious examples, it turns out that Hollywood actors who win the Academy Award live four years longer on average than their costars in the same movie. And they also live four years longer than actors who were nominated for the award but did not win. This four-year difference in life expectancy may not sound like a lot. But to keep the implications for population health in perspective, consider that if all deaths from heart disease were magically eliminated while deaths from other causes remained the same, the improvement in life expectancy for the population as a whole would come to just four years.
One way researchers have tried to explain these and similar findings is to posit that the losers in our society have become losers because they have poor health. This is no doubt true in some cases. Clearly, if you’re in the hospital for months following a car crash, lose the ability to walk, and go through life thereafter with hideous facial scars, it is bound to negatively affect your career prospects. The same would be true if you were born already addicted to narcotics or positive for HIV.
Or to take a less extreme but far more common example, say you are a low-level employee working a dead-end cubicle job and find yourself afflicted at age 30 with prolonged bouts of depression, insomnia, and more than an occasional hangover. It is possible that these conditions will make it less likely that you will rise to the top of the ladder than if you bounced out of bed each morning feeling like the picture of health.
But to conclude in this instance that your lack of upward mobility is because of your poor health is to beg the question of why you have developed these afflictions in the first place. Maybe you would drink in any event. Maybe you’d describe life as stressful regardless. But would you drink as much, and feel so bad about it in the morning, if you also felt (like that famous, highly effective, long-lived alcoholic Winston Churchill) that you were in command and getting important stuff done?
To continue this thought experiment, what if you did not feel slighted and powerless at work; if your boss didn’t make eight times your income but only double; if he didn’t seem to look down on you and "your kind"; if losing your job didn’t mean losing what little control you have over your life? What if you didn’t feel variously envious, intimidated, and infuriated by coworkers, neighbors, and people you see on TV who seem to have it all; if you could point to some way of keeping score in this life by which you were a winner and life had meaning?
The specific biological mechanisms that lead from feelings of relative powerlessness and low status to specific diseases are not well understood at the molecular level. Some researchers have pointed to the role of cortisol, a steroid hormone released by the adrenal gland in response to stress that has the effect of suppressing the immune system. Among people who are overweight, those with high levels of cortisol are more likely to contract diabetes than those with low levels.
More than 200 laboratory studies have also shown that the highest cortisol levels are found in people required to perform tasks outside their control that involve, as the epidemiologist Richard Wilkinson puts it, "threats to self esteem and social status in which others can negatively judge your performance." A hard-charging executive may use the word "stress" to describe his reaction to the burdens of command, but it is his cowering subordinates who are most likely to feel the kind of stress that literally changes body chemistry.
The negative effects may be compounded if those subordinates must also endure the stress and humiliation of either perceived or real racial or class discrimination.