Income inequality is harmful to your health—whether you’re rich, poor, or part of the ever-shrinking population living between those two extremes.
“I’m glad I’m living in the land of the free
Where the rich just get richer
And the poor you don’t ever have to see.”
Randy Newman, “The World Isn’t Fair”
The afterschool art program was done for the day, and the children filed into the van. I went along for the ride as we took them back to their homes in West Baltimore, past blocks of boarded-up row houses.
As we pulled to the curb to drop off one little girl, I saw a man in dirty clothes stumbling down the sidewalk. The girl stepped out of the van right in front of him. He continued his awkward ambling just steps behind her. The longer the man followed the girl, the more I tensed up. She walked in a door. He walked in behind her.
He lives with her, I realized. The door closed. I lived less than two miles away, but the distance felt much greater. Life expectancy in the little girl’s neighborhood is 68 years. It’s 75 years in the neighborhood of well-kept brownstones I went home to later that day. Just a few miles up the road, among the Victorian homes with wide wraparound porches, it’s 83 years.
Look closely at those life expectancy patterns and you’ll see them track with race and class. In America, the numbers will tell you: Whiteness and wealth mean better outcomes on many indicators of health.
But being well-off doesn’t necessarily make you well. Income inequality may be driving Americans further and further apart economically, but their lives continue to intersect through policy and in our communities. The consequences of growing poverty and inequality create tension that can be felt physically by the rich and poor alike. With every effort made to reinforce the social and geographical distance between more well-off Americans and the problems they see in poorer communities, that tension grows. And it’s making us all less well.
Being well-off doesn’t necessarily make you well. The consequences of growing poverty and inequality create tension that can be felt physically by the rich and poor alike.
There’s no question that poverty is bad for poor people, particularly where their health is concerned. There is a growing body of research into the so-called “social determinants of health”—income, access to health care, food security, public school conditions, racial discrimination, and any other social condition, policy, or distribution of economic resources that can affect a person’s health. They’re a priority for the World Health Organization, which recently created a global plan of action to address them, and the Centers for Disease Control and Prevention, which has several initiatives, including the Racial and Ethnic Health Disparities Action Institute. One report cited by the CDC claims that social determinants actually have a greater effect on health than do genes, medical care, and health behavior combined. Poor people are more likely to have low birth weight at the beginning of life, the end of life is likely to come earlier, and they have more asthma, heart disease, and diabetes in between.
Researchers, however, have been investigating not just the effect of poverty on the health of individual poor people, but what happens to the health of entire societies when the rich get richer and the poor get poorer. British epidemiologist Richard Wilkinson has spent three decades studying the effects of income inequality on population health. As income inequality increases in rich nations, he argues, so do other health and social problems, among them infant mortality, low life expectancy, incarceration rates, and social mistrust. And that’s not just among the poor—that’s everybody. “America is one of the most unequal countries in the developed world,” he says. “And it does worst in terms of almost all the health and social problems.”
In The Spirit Level: Why Greater Equality Makes Societies Stronger, published in 2009, Wilkinson and co-author Kate Pickett compare Swedish health to that of England and Wales, the former having a more equal distribution of income than the latter two. He found that lower-class Swedes had lower death rates than those in the upper classes of England and Wales. He also found infant mortality to be lower in Sweden than in England and Wales at all levels.
One theory about the consequences of inequality on population health posits that if you’re at the bottom of the economic ladder with no hope of climbing up, anxiety and resentment can create a lifetime of debilitating stress and lead to coping mechanisms like smoking or drug abuse. Wilkinson cites a 2004 study that found the release of cortisol, a hormone associated with stress, elevated for tasks related to “social evaluative threat”—the feeling of being rejected or judged by others.
Wilkinson sees this effect not just on the poor, though—he says it’s on all rungs of the economic ladder. “In a more unequal society,” he says, “where some people seem so important and other people seem almost worthless, I think we judge each other more by social status. I think we all get more worried about how we’re seen and judged, and there are lots of signs of that. Money becomes even more important, so people work longer hours and get into debt more and save less, because money becomes more important as a way of showing what you’re worth.”
“America is one of the most unequal countries in the developed world. And it does worst in terms of almost all the health and social problems.”
Earlier this year, a Baltimore resident and blogger named Tracey Halvorsen, who lives in one of the city’s recently gentrified neighborhoods by Patterson Park, wrote a post called “Baltimore City, You’re Breaking My Heart.” In response to several brutal crimes in her neighborhood—including a mugger knocking a man’s teeth out with a brick and burglars stabbing a woman to death in her park-front home—Halvorsen wrote that she is now scared to visit the park even during the day. She wanted to stay in the city, she said, and she made a long list of things she loves about living there. But the blog’s subhead made clear what was at stake: “This is why people leave.” The post went viral in Baltimore.
Halvorsen advocated for police to start arresting people in her neighborhood for minor offenses like littering, arguing that the offenders would eventually take their problems elsewhere. Some Baltimoreans criticized her “us versus them” mentality—including me. I pointed out that police had already tried “zero tolerance” quality-of-life policing, which they dropped after a lawsuit pointed out that in one year, they had made 100,000 arrests in a city of less than 650,000 residents. An “us versus them” mentality, I thought, undermined the fact that even people in Baltimore’s poorest neighborhoods care about quality of life and home values.
Yet an “us versus them” mentality prevails, not just in Baltimore, and the problem goes beyond urban environments. Across the country, middle-class neighborhoods—where Americans of a wide range of economic backgrounds go to the same schools, attend the same churches, and socialize in the same civic and fraternal organizations—are disappearing. According to US2010, a peer-reviewed research project on how America is changing in the 21st century, in the 1970s, two-thirds of American families lived in middle-income neighborhoods. Now less than half do. It’s hard to argue that a healthy community is one in which the most “comfortable” residents are actually so uncomfortable that they are retreating to exclusive neighborhoods or, like Halvorsen, are at least hatching escape plans.
Those with the greatest means are increasingly retreating behind locked gates. The number of American housing units in gated communities rose by 4 million between 2001 and 2009. “It used to be that only in the poorest of countries people lived in locked and gated communities,” says Robert Blum, director of the Johns Hopkins Urban Health Institute. “But increasingly, because of the recent economic disparity and the consequent sense of vulnerability, we have a proliferation of locked and gated communities to try to give those of us of higher income the illusion—or delusion—of safety.”
Those with the greatest means are increasingly retreating behind locked gates.
Social epidemiologist Ichiro Kawachi, chair of the Department of Social and Behavioral Sciences at the Harvard School of Public Health, has found that ruptures in the social fabric—memberships in social organizations, a sense that neighbors look out for one another and can be trusted—are correlated with mortality, and that mistrust is higher where income inequality is greater. Amid this social disorganization, his theory goes, mistrust fills the growing chasm between the “haves” and the “have-nots.” As middle-class neighborhoods disappear, so does the common ground upon which social bonds can grow between those on all rungs of the economic ladder.
The idea that social bonds make us healthier—and that a lack of them makes us less healthy—is not necessarily new. A 1999 study published in Sociological Forum by sociologist David Williams and Chiquita Collins, currently associate dean for diversity and cultural competence at the Johns Hopkins University School of Medicine, found that in cities where blacks and whites “had little contact,” both groups’ mortality rates were higher. Citing a collection of 10 studies, a 2001 Russell Sage Foundation review that looked at the way social capital (the benefits of strong social relationships within a community), poverty, and community health all worked together showed that an equitable distribution of resources “translates into a lower burden of mortality for all members of the community.” The review also noted that “the positive contribution to health made by social integration and social support are said to rival in strength the detrimental contributions of several well-established biomedical risk factors” like smoking, obesity, and elevated blood pressure.
In the 1990s, the U.S. Department of Housing and Urban Development used a lottery to offer poor families in several cities housing vouchers to move out to mixed-income areas. A 2012 study of the Moving to Opportunity program found that even though such moves didn’t improve a family’s economic well-being, the program had a positive impact on people’s physical and mental health, including obesity, diabetes, and “self-reports of subjective well-being.”
Thomas LaVeist will tell you that poverty has real economic costs. A Johns Hopkins health policy professor and director of the university’s Center for Health Disparities Solutions, LaVeist co-authored a 2009 report for the Joint Center for Political and Economic Studies called The Economic Burden of Health Inequalities in the United States. He and two other researchers calculated that American health inequalities had a direct medical cost of over $230 billion between 2003 and 2006, plus $1.24 trillion in indirect costs from lower productivity and premature death.
The result, LaVeist says, is a workforce that is less healthy than it should be and an economy that is less productive than it should be, leaving us with what he calls “opportunity costs” affecting everyone. “Resources that are used to try to address inequalities are not available to use for other things,” LaVeist says. “If you’ve got people showing up in the emergency departments with illnesses that shouldn’t necessarily need emergency care, that affects the ability to bring through the system people who really do need emergency care.” Arguments for addressing those inequalities have, for the most part, been focused on social justice, LaVeist says. “‘It’s the right thing to do; it’s a shame; we shouldn’t do that.’ What we wanted to do was to create another strain of argument for why we should devote resources and to move beyond simply tugging at people’s heartstrings to say, ‘No, the cold, hard reality is that it is taking resources out of the economy, and it’s expensive to maintain disparities, and everyone’s affected by them.’”
But the economy is not the only thing at stake. In his book One Nation, Underprivileged: Why American Poverty Affects Us All, Mark Rank acknowledges the inefficiency of money “spent on the back end of the problem rather than on the front end.” But he also believes growing poverty and inequality are incompatible with fundamental American values. “The words ‘liberty and justice for all’ take on a hollow meaning when a significant percentage of the population is economically and politically disenfranchised,” he writes. “This undermines every citizen, for it suggests that the American ideals in which we profess to believe apply to some more than others. This contradicts the very core of the American promise, diminishing us all.”
“If you’ve got people showing up in the emergency departments with illnesses that shouldn’t necessarily need emergency care, that affects the ability to bring through the system people who really do need emergency care.”
At the end of the Economic Burden of Health Inequalities report, LaVeist and the other authors acknowledge that their analysis shows “social justice can be cost-effective.” But, they write, “sometimes the tremendous human suffering of health inequalities can be obscured by analysis such as was conducted for this report.
“It is not our intent that the utilitarian argument replace moral deliberation or the application of social justice,” they continue. “We should address health disparities because such inequities are inconsistent with the values of our society. Addressing them is the right thing to do.”