Numerous studies in England and the U.S. have shown consistently that a
person's place in the social order strongly affects health and
longevity. It now seems well-established that poverty and social
rank are the most important factors determining health --more important
even than smoking.
This conclusion has been a long time in the making. A British study in
1840 observed that "gentlemen" in London lived, on the average, twice
as long as "labourers." Starting in 1911, British death certificates
have been coded for social class based on occupation. (In the U.S.,
death certificates are coded for race or ethnicity without reference to
class or occupation.) The British database of deaths coded by class has
allowed many studies, which have shown consistently that lower social
status is associated with early death.
For example, in 1980, Sir Douglas Black, who was then the President of
the Royal College of Surgeons, published a study covering the period
1930-1970 in England. The so-called Black Report concluded that "there
are marked inequalities in health between the social classes in
Britain." Specifically, people in unskilled occupations had a two-and-
a- half times greater chance of dying before retirement than
professional people (lawyers and doctors).
Furthermore, the Black Report showed that the gap in death rates
between rich and poor had widened between 1930 and 1970. In 1930,
unskilled workers were 23% more likely to die prematurely than
professional people, whereas in 1970 they were 61% more likely than
professionals to die prematurely.
Several subsequent studies confirmed the findings of the Black Report
and demonstrated that, even within privileged groups, those with less
status lived shorter lives. In other words, social rank affects health
even among those who are well off. The so-called Whitehall studies in
England examined the health of 10,000 British government employees
(civil servants) over 2 decades and found a 3-fold difference in death
rates between the highest and lowest employment grades. The Whitehall
studies showed (and later a U.S. study confirmed) that conventional
risk factors such as smoking, obesity, physical activity, blood
pressure and blood-levels of cholesterol could explain only 25% to 35%
of employment-grade differences in mortality. In other words, social
rank was more important a determinant of health than were all the
conventional risk factors. In sum, being lower in the pecking order
makes you sick and shortens your life.
Researchers have examined the opposite hypothesis, that perhaps health
status determines social class --that being sick makes you poor,
instead of the other way around. They have found that this explains
only about 10% of the health disparities between social ranks.
In the U.S., a study in Chicago during 1928-1932 examined death
certificates in relation to place of residence at time of death.
Chicago was categorized into 5 socioeconomic levels based on average
monthly rental payments. The study showed a fairly smooth curve: the
higher the rent, the lower the death rate for people of similar ages.
This study was redone in 1973, looking at changes between 1930 and
1960. There had been "no relative gain" in recent decades for those
paying the lowest rents. So even though the general standard of living
may rise, those lower on the income scale die at younger ages.
In 1986, researchers at the National Center for Health Statistics
showed that Americans with annual incomes of $9000 or less had a death
rate 3 to 7 times higher (depending on gender and race) than people
with annual incomes of $25,000 or more. Furthermore, they showed that
this situation had worsened between 1960 and 1986.
In the U.S., within groups of people having similar incomes, African-
Americans have worse (and worsening) health status, compared to whites,
for many diseases including asthma, diabetes, hypertension (high blood
pressure), major infectious diseases, and several cancers. Among
researchers who have studied these problems, the basis of these health
differences is thought to be racism, not genetics.
As we have reported previously (REHW #497), several studies have now
revealed two important facts about the relationship of wealth to
1. Between countries, there is no relationship between gross domestic
product (GDP) --a conventional measure of wealth --and health. In other
words, comparing countries at similar levels of industrialization, it
is quite possible for people in poorer countries to be healthier than
people in richer countries. The absolute level of income does not
determine health or longevity.
2. On the other hand, within individual countries there is a consistent
relationship between health and the size of the gap separating rich
from poor. Countries with the longest life expectancy at birth are
those with the smallest spread of incomes and the smallest proportion
of people living in relative poverty. Such countries (for example,
Sweden) generally have longer life expectancy than countries that are
richer but tolerate larger inequalities, such as the U.S.
Within the U.S., comparisons between states have come to similar
conclusions: it is not the average level of income in a state that
determines health status --it is the size of the gap between rich and
poor in a state that determines health.
George Kaplan and his colleagues at the University of California at
Berkeley measured inequality in the 50 states as the percentage of
total household income received by the less well off 50% of households.
 It ranged from 17% in Louisiana and Mississippi to 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 within
each state, and not the average income of each state, that best
predicts the death rate.
Inequality is growing throughout the world, both between countries and
within countries. As of 1996, 89 countries (out of 174) were worse off,
economically, than they had been a decade previously. In 70 developing
countries, incomes are lower now than they were in the 1960s and 1970s.
 And the level of inequality is already astonishing. For example, in
1996, 358 billionaires controlled assets greater than the combined
annual incomes of countries representing 45 percent of the world's
population (2.5 billion people). Between 1961 and 1991, the ratio of
the income of the richest 20% of the world's population to the poorest
20% increased from 30-to-1 to 61-to-1.
Within the U.S., inequality is wider than it has been for 50 years, and
it is getting worse. The U.S. now finds itself among a group of
countries, including Brazil and Guatemala, in which the national per
capita income is at least four times as high as the average income of
the poorest 20 percent. In the U.S. between 1980 and 1990,
inequality of income increased in all states except Alaska.
Inequality in the distribution of income and wealth has been
increasing in the U.S. for about 20 years.[7,8,9,10] 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.
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%.[10,pg.29]
These tremendous inequalities translate directly into sickness and
death for those holding the short end of the stick.
As Dr. Donald M. Berwick, a Boston pediatrician, said recently, "Tell
me someone's race. Tell me their income. And tell me whether they
smoke. The answers to those three questions will tell me more about
their longevity and health status than any other questions I could
Isn't it time that the public health community --physicians, public
health specialists, and environmentalists --recognized that poverty,
inequality and racism cause sickness and death? Given what science now
tells us, medical policy --including medical training --should aim to
combat and eliminate poverty, inequality, and racism just as it now
aims to combat and eliminate infectious diseases and cancer. With
U.S. health care costs now exceeding $1 trillion each year, anti-
poverty and anti-racism initiatives would be economically efficient as
well as humane.
--Peter Montague (National Writers Union, UAW Local 1981/AFL-CIO)
 Oliver Fein, "The Influence of Social Class on Health Status:
American and British Research on Health Inequalities," JOURNAL OF
GENERAL INTERNAL MEDICINE Vol. 10 (October, 1995), pgs. 577-586.
 Andrew Haines, Michael McCally, Whitney Addington, Robert S.
Lawrence, Christine Cassel, and Oliver Fein, "Poverty and Health: The
Role of Physicians," ANNALS OF INTERNAL MEDICINE (in press).
 Peter T. Kilborn, "Black Americans Trailing Whites in Health,
Studies Say," NEW YORK TIMES January 26, 1998, pg. A16.
 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.
 Barbara Crossette, "U.N. Survey Finds World Rich-Poor Gap
Widening," NEW YORK TIMES July 15, 1996, pg. A3.
 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
 Sheldon Danziger and others, "How the Rich Have Fared, 1973-1987,"
AMERICAN ECONOMIC REVIEW Vol. 79 (May, 1989), pgs. 310-314.
 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.
 Johan Fritzell, "Income Inequality Trends in the 1980s: A Five-
Country Comparison," ACTA SOCIOLOGICA Vol. 36 (1993), pgs. 47-62.
 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
 "Up, down and standing still," THE ECONOMIST February 24, 1996,
pgs. 30, 33.
Descriptor terms: u.s.; uk; poverty and health; income and health;
wealth and health; inequality; longevity; morbidity statistics; race
and health; african americans; la; nh; ut; ms; chicago; medical policy;
equity; environmental justice; black report; whitehall studies; brazil;