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#497 - Economic Inequality and Health, 05-Jun-1996

It seems obvious that poor people are more likely to be sick, and to
die at an earlier age, compared to rich people. Several recent studies
from the U.S. confirm that this is the case.[1,2,3,4]

What is not so obvious is that the health of the poor is harmed in
proportion to the size of the gap between rich and poor. It isn't the
absolute level of poverty that matters so much as the size of the gap
between rich and poor. In other words, "...what matters in determining
mortality and health in a society is less the overall wealth of that
society and more how evenly wealth is distributed. The more equally
wealth is distributed the better the health of that society," according
to an editorial in the BRITISH MEDICAL JOURNAL April 20th.[5] Two
recent studies of the U.S. indicate that this is so,[6,7] and they are
not the first to make the case.[8,9]

The two recent studies, published in April in the BRITISH MEDICAL
JOURNAL, examine all 50 states within the U.S. Each study defines a
measure of income inequality and compares it to various rates of
disease and other social problems. Both the studies --one from Harvard
and one from University of California at Berkeley --conclude that the
greater the gap between rich and poor, the greater the chances that
people will be sick and die young. It isn't the absolute level of
wealth in a society that determines health; it is the size of the gap
between rich and poor. Let's look at some of the details:

George Kaplan and his colleagues at Berkeley measured inequality in the
50 states as the percentage of total household income received by the
less well off 50% of households.[6] It ranged from about 17% in
Louisiana and Mississippi to about 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, and not
the average income in each state, that best predicts the death rate in
each state.

This measure of income inequality was also tested against other social
conditions besides health. States with greater inequality in the
distribution of income also had higher rates of unemployment, higher
rates of incarceration, a higher percentage of people receiving income
assistance and food stamps, and a greater percentage of people without
medical insurance. Again, the gap between rich and poor was the best
predictor, not the average income in the state.

Interestingly, states with greater inequality of income distribution
also spent less per person on education, had fewer books per person in
the schools, and had poorer educational performance, including worse
reading skills, worse math skills, and lower rates of completion of
high school.

States with greater inequality of income also had a greater proportion
of babies born with low birth weight; higher rates of homicide; higher
rates of violent crime; a greater proportion of the population unable
to work because of disabilities; a higher proportion of the population
using tobacco; and a higher proportion of the population being
sedentary (inactive).

Lastly, states with greater inequality of income had higher costs per-
person for medical care, and higher costs per person for police

The Harvard researchers used a slightly different measure of
inequality, called the Robin Hood index.[10] The higher the Robin Hood
index, the greater the inequality in the distribution of income. The
researchers calculated the Robin Hood index for all 50 states and then
examined its relationship to various measures of health and well being.

They found that the Robin Hood index correlated with the overall age-
adjusted death rate. Each percentage point increase in the Robin Hood
index was associated with an increase in total mortality of 21.7 deaths
per 100,000 population.

The Robin Hood index was also strongly associated with the infant
mortality (death) rate; with deaths from heart disease; with deaths
from cancer; and with deaths by homicide among both blacks and whites.

The Harvard team concludes that reducing inequality would bring
important health benefits. For example, if the Robin Hood index were
reduced from 30% to 25% (about where it is in England), deaths from
coronary heart disease would be reduced by 25%.

These studies are important because they confirm work that has
previously found a relationship between income inequality and health,
using data of good quality from all 50 states.[11] Inequality in the
distribution of income and wealth[12] has been increasing in the U.S.
for about 20 years.[13,14,15,16] 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.[17]

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%.[16,pg.29]

These trends in inequality in the U.S. are accelerating as time passes.
We now know that these trends have real consequences for the health of
people and society. As a nation, we have traditionally thought it was
acceptable if the rich got richer, so long as the poor were minimally
provided for. These studies now reveal that such a situation is not
acceptable. As the gap grows between rich and poor, the health of the
nation deteriorates, the social fabric unravels, and the cost of
maintaining community goes up.

How does the gap between rich an poor harm the health of the poor?
Evidently, the psychological hardship of being low down on the social
ladder has detrimental effects on people, beyond whatever effects are
produced by the substandard housing, nutrition, air quality,
recreational opportunities, and medical care enjoyed by the poor.[18]

The growing gap between rich and poor has not been ordained by
extraterrestrial beings. It has been created by the policies of
governments: taxation, training, investment in children and their
education, modernization of businesses, transfer payments, minimum
wages and health benefits, capital availability, support for green
industries, encouragement of labor unions, attention to infrastructure
and technical assistance to entrepreneurs, among others. In the U.S.,
government policies of the past 20 years have promoted, encouraged and
celebrated inequality. These are choices that we, as a society, have
made. Now one half of our society is afraid of the other half, and the
gap between us is expanding. Our health is not the only thing in
danger. They that sow the wind shall reap the whirlwind.

--Peter Montague


[1] George Davey Smith and others, "Socioeconomic Differentials in
Mortality Risk among Men Screened for the Multiple Risk Factor
Intervention Trial: I. White Men," AMERICAN JOURNAL OF PUBLIC HEALTH
Vol. 86, No. 4 (April, 1996), pgs. 486-496.

[2] George Davey Smith and others, "Socioeconomic Differentials in
Mortality Risk among Men Screened for the Multiple Risk Factor
Vol. 86, No. 4 (April, 1996), pgs. 497-504.

[3] Gopal K. Singh and Stella M. Yu, "US Childhood Mortality, 1950
through 1993: Trends and Socioeconomic Differentials," AMERICAN JOURNAL
OF PUBLIC HEALTH Vol. 86, No. 4 (April, 1996), pgs. 505-512.

[4] C. Wayne Sells and Robert Wm. Blum, "Morbidity and Mortality among
US Adolescents: An Overview of Data and Trends," AMERICAN JOURNAL OF
PUBLIC HEALTH Vol. 86, No. 4 (April, 1996), pgs. 513-519.

[5] Editorial, "The Big Idea," BRITISH MEDICAL JOURNAL Vol. 312 (April
20, 1996), pg. [985].

[6] 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.

[7] Bruce P. Kennedy and others, "Income distribution and mortality:
cross sectional ecological study of the Robin Hood index in the United
States," BRITISH MEDICAL JOURNAL Vol. 312 (April 20, 1996), pgs. 1004-

[8] Richard G. Wilkinson, "Income distribution and life expectancy,"
BRITISH MEDICAL JOURNAL Vol. 304 (January 18, 1992), pgs. 165-168. See
also footnote 11, below.

[9] Robert J. Waldmann, "Income Distribution and Infant Mortality," THE
QUARTERLY JOURNAL OF ECONOMICS Vol. 107 (November 1, 1992), pgs. 1283-

[10] The Robin Hood index (RHI) is calculated by dividing the
population into 10 groups, richest to poorest. The RHI calculation
proceeds by first summing the percentage of income for each 10% group
whose percentage of available income exceeds 10% and then subtracting
the product of the number of 10% groups that meet this criterion times
10%. Example: in Massachusetts in 1990, the top 10% received 29.93% of
income; the next lower 10% received 16.41% of all income; the next
lower 10% received 13.09% if all income; the next lower 10% received
10.83% of all income, and the remaining six 10% groups each received
less than 10% of income and are therefore ignored in the RHI
calculation. The RHI index for Massachusetts in 1990 is therefore
calculated from the top four 10% groups: (10.83% + 13.09% + 16.41% +
29.93%)-(4x10%) = 70.26%-40% = 30.26%. See Appendix, pg. 1007, of
Kennedy, cited above in note 7.

[11] The body of literature linking health to the gap between rich and
poor is reviewed in Richard G. Wilkinson, "Commentary: A reply to Ken
Judge: mistaken criticisms ignore overwhelming evidence," BRITISH
MEDICAL JOURNAL Vol. 311 (November 11, 1995), pgs. 1285-1287, which was
written as a response to Ken Judge, "Income distribution and life
expectancy: a critical appraisal," BRITISH MEDICAL JOURNAL Vol. 311
(November 11, 1995), pgs. 1282-1285.

[12] 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
outstanding debt).

[13] Sheldon Danziger and others, "How the Rich Have Fared, 1973-1987,"
AMERICAN ECONOMIC REVIEW Vol. 79 (May, 1989), pgs. 310-314.

[14] 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.

[15] Johan Fritzell, "Income Inequality Trends in the 1980s: A Five-
Country Comparison," ACTA SOCIOLOGICA Vol. 36 (1993), pgs. 47-62.

OF WEALTH IN AMERICA (New York: Twentieth Century Fund, 1995). Although
this is a study of wealth inequality, chapter 6 deals with income

[17] "Up, down and standing still," THE ECONOMIST February 24, 1996,
pgs. 30, 33.

[18] George Davey Smith, "Income inequality and mortality: why are they
related?" BRITISH MEDICAL JOURNAL Vol. 312 (April 20, 1996), pgs. 987-

Descriptor terms: wealth; income distribution; equity; inequality;
economy; poverty; morbodity statistics; mortality statistics; homicide;
tobacco use; education; disabilities; incarceration; robin hood index;
harvard; berkeley;

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